Course Articles

Editor’s note: This text-based course is a transcript of the webinar, Elder Abuse and Child Abuse: Know the Signs and Your Role, presented by Kathleen Weissberg, OTD, OTR/L.

Learning Outcomes

• After this course, participants will be able to recognize possible clinical, behavioral, and physical indicators of suspected elder and child abuse and neglect.
• After this course, participants will be able to list possible risk factors related to elder and/or child abuse and neglect.
• After this course, participants will be able to describe the reporting procedure for abuse and neglect.
• After this course, participants will be able to list resources that can be utilized for state-specific procedures.

Elder Abuse

Today, we are going to talk about elder abuse and child abuse, and sadly this is more common than you might think. Our goal for today is to learn to spot those warning signs and then to know what your responsibilities are or could possibly be with regard to reporting.

Some Statistics

• According to the U.S. Government Accountability Office (GAO), elder abuse is a widespread and growing problem
• Data reporting is a challenge
• Recent studies indicate that elder abuse incidence rates are far higher than once thought

According to a study by the United States Government Accountability Office, the GAO, elder abuse is really a widespread and growing problem. The data reporting in this area is a challenge, but despite that, recent studies indicate that elder abuse incident rates are far higher than we probably thought. This slide show includes a few different stories that have come up in the public sector.

• In NYS, incidence rates nearly 24X greater than the number of cases referred to authorities who can help (Lifespan of Greater Rochester et al., 2011)
• One in five Americans older than age 65 had been defrauded (Kiplinger’s Personal Finance, 2011)
• In most cases, the adult children of abused elders were unaware that their mother or father had received solicitations for money (Olson, 2011)

A collaborative public-private report on elder abuse in New York State, for example, found an incident rate of elder abuse nearly 24 times greater than the number of cases referred to social service, law enforcement, or legal authorities who have the capacity and the responsibility to assist adult older victims. And, as a nation, our response is disjointed. The minimal federal investment is only about 12 million dollars, give or take, and it is spread sparsely across eight agencies and two departments with very little coordination. I am going to digress for a second and say that recently the Office of Inspector General came out with a report related to elder abuse. I am not going to go through a lot of the details, but basically they found that a lot of individuals were coming into the emergency room and had diagnosis codes or situations indicative of abuse that was never reported to state authorities. I think we are going to see a little more oversight in the near future on this topic and probably some additional training from some of these government agencies. An Investors Protection Trust Survey found that one in five Americans older than the age of 65 had been defrauded. This is something that we are hearing about quite a bit about in the news. The conservative estimates of the personal cost to victims of financial abuse are easily three billion dollars annually. These reported cases only hint at the extent of the problem. We are not hearing a lot of the other stories that are probably out there. And, in a New York Times article, they talked about financial exploitation and the knowledge of adult children. Many are unaware that their mother or father had even received solicitations for money. Even attentive children, as involved as you can be with your parents, sometimes miss the warning signs. In that particular article, they highlighted the story of Dr. Robert Parker. He is the chief of community geriatrics at the University of Texas Health Medical Center in San Antonio. He failed to notice that his own mother was a victim of financial abuse. So, no matter how involved you are, sometimes you still miss some of these things.

A Chilling Example of Neglect

Before we get into some of the definitions, I wanted to share this story. It was a widely publicized case in Michigan. An elderly female nursing home resident began coughing one night. Her caretakers were busy, and she continued to just cough throughout the night. A couple of staff observed "white things" in her sputum and near her trach collar. It was not until the next morning that somebody actually checked into her mouth, and they found maggots. The maggots had created a partial airway obstruction causing her to suffer abnormal blood oxygen levels and labored breathing. The emergency medical services staff said that they could not even suction because of the very active maggots in the airway. This is just a terrible example and there is no evidence that that staff was disciplined for clearly neglecting this woman so severely. 

Definitions

“Acts of omission or commission by a person who stands in a trust relationship that result in harm or threatened harm to the health and/or welfare of an older adult.”

Abuse Defined

• Willful infliction of injury
• Unreasonable confinement/Involuntary seclusion
• Intimidation with resulting physical harm, or pain, or mental anguish
• Punishment with resulting physical harm, or pain, or mental anguish
• Deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, or psychosocial well-being
• Corporal punishment & any physical or chemical restraint not required
• Abuse that includes that which is facilitated or enabled through the use of technology

I think the biggest piece here is that it is willful infliction. It can also include things like unreasonable confinement or involuntary seclusion, and that could happen in the home environment or in an institution. It might be where we are separating an individual from other individuals, from their room, or from another area where they want to go. This can be against their will or even against the will of that person's legal representative. It also could include intimidation or punishment with resulting physical harm, pain, or mental anguish. It could include things like deprivation by an individual, including a caretaker, of goods or services that are necessary to attain physical, mental, or psychosocial well-being. These are all the things that that person needs to be well. It can include corporal punishment or physical or chemical restraints that are not really required to treat that individual's symptoms or their issues. Again, it is anything that would cause pain or an issue, and it can also include things that are enabled through the use of technology. The individual acts deliberately.

• Elder abuse includes physical, emotional, or sexual harm inflicted upon an older adult, their financial exploitation, or neglect of their welfare by people who are directly responsible for their care
• Elder abuse tends to take place where the senior lives: where their abusers are often adult children, other family members such as grandchildren, or a spouse or partner. Elder abuse can also occur in institutional settings.

Now elder abuse includes, as we just said, physical, emotional, sexual harm potentially inflicted upon an older adult. It can also include financial exploitation and neglect of their welfare. It is done by somebody who is directly responsible for their care. And in the United States alone, more than half a million reports of elder abuse reach authorities every year, and many more go unreported. Now as older adults become more physically frail, they are less able to take care of themselves. They cannot stand up to bullying, and they cannot fight back a lot of times if they are attacked in some way.

The mental or physical ailment that they have can make them more trying to companions for those who live with them. They may not see, hear, or think as clearly as they used to. This leaves them open, unfortunately, for unscrupulous people to take advantage of them, and we definitely see that. The other thing to keep in mind is that elder abuse tends to take place where that individual lives. We hear stories of elder abuse that occurs somewhere out in the community, but typically, the senior lives with their abusers. The abusers can be adult children, other family members like grandchildren, a spouse, a partner, or a very good friend. The sad reality is that elder abuse can also occur in institutional settings especially long-term care facilities, that is where we hear about it most.

Forms of Abuse

• Verbal
• Physical
• Sexual
• Mental/Emotional
• Neglect
• Abandonment
• Financial exploitation
• Self-neglect

What are the different forms? Abuse of elders takes a lot of different forms. Some involve intimidation or threats against the elderly, some involve neglect and other financial trickery. The most common types are listed above. We will go through each one of these in a little more detail and look at some of the warning signs.

Verbal Abuse

• Oral, written or gestured language that includes disparaging and derogatory terms to the residents or their families to describe the resident within their hearing distance, regardless of their age &/or ability to comprehend or disability

This is almost like bullying. It is talking about that person in such a negative way so that they overhear it. The person feels, based upon this blame, diminished self-worth, or diminished ego, et cetera. This is, obviously, not something that we would want to do.

Physical Abuse

• The non-accidental use of force against an elderly person that results in physical pain, injury, or impairment. Such abuse includes not only physical assaults such as hitting or shoving but the inappropriate use of drugs, restraints, or confinement.

Physical abuse is pretty straightforward. This does not just include physical assault such as hitting or shoving, but it can also include things like the inappropriate use of drugs or medications, restraints, or even confinement. This can be in an institutional or home setting. The more common types of physical abuse that we see are things like hitting, slapping, pinching, scratching, spitting, holding that person roughly, holding them in their chair, or forcing them into their wheelchair. It also includes controlling behavior through corporal punishment. Unfortunately, we continue to see this in some of our settings. This a corporal type punishment of influence.

Sexual Abuse

• Contact with an elderly person without their consent. Includes but is not limited to humiliation, harassment, coercion, or sexual assault. Activities such as showing an elderly person pornographic material, forcing the person to watch sex acts, or forcing the elder to undress are also considered sexual elder abuse.

Again, you hear these outrageous stories on the news, and it makes you scratch your head. Sexual abuse includes but is not limited to things like humiliation, harassment, coercion, or even sexual assault. It is non-consensual sexual contact of any type with an individual. It is contact with that elderly person without their consent. It can involve physical sexual acts, but it can also involve other things like showing an elderly person pornographic materials and making them watch it or forcing the person to watch other sex acts or something else occurring in the environment. It can even include forcing the elder to undress in front of you. This would not be part of an ADL or helping them to use the restroom. This is forcing them to undress outside of those normal scenarios.

Emotional/Mental Abuse

• The treatment of an older adult in ways that cause emotional or psychological pain or distress, including:
  • Intimidation through yelling or threats
  • Humiliation and ridicule
  • Habitual blaming or scapegoating
  • Ignoring the elderly person
  • Isolating an elder from friends or activities
  • Terrorizing or menacing the elderly person
  • Harassment
  • Threats of punishment or deprivation.

This is the treatment of an older adult in ways that cause emotional or psychological pain or distress. It can be intimidation through yelling or threats, humiliation or ridicule, habitual blaming, or scapegoating. It can also be ignoring that elderly person or ignoring their requests, isolating an elder from their friends or their activities, and terrorizing or menacing the elderly person. You may not think that some of these things are necessarily emotional elder abuse, but they could be under the right set of circumstances. For example, if you take a photograph, and that person does not want to be photographed, that could constitute mental, physical, or some sort of abuse. Again, we should not be doing that in any of our settings or doing anything that might be considered humiliating toward an individual. During the delivery of care, depending on what we are doing with that individual, we need to make sure that we are keeping the person from public view like undressing to do an ADL. We need to make sure that we prevent any unnecessary exposure of body parts. That is what we do all the time normally, but if we did not, it could be potentially considered emotional or mental abuse.

My aunt, who has since passed away, was in a nursing home many years ago. She had dementia but she still knew enough to say I need to use the restroom when she truly needed to go. She had a urinary tract infection at the time was going much more frequently. I remember her saying, "I have to use the bathroom." She did not want me to take her and that was fine. She called for a nurse who came in and said, "Don't you realize you just went about an hour ago? You couldn't possibly need to go again. If you need to go, you're just going to have to go in your diaper." And I sat there and thought, "That's emotional abuse. That's humiliating to say to a person." And, this is in a premier community. There are the things that we need to look out for as they can certainly lead to emotional types of abuse. Whether that mental abuse has occurred or not is really determined by a reasonable person's standard and does not require a specific response from the individual. What I mean by that is a reasonable person would think that that is completely unacceptable. It does not necessarily have to have a response from the individual because that individual may have dementia or something else going on and cannot respond in an appropriate manner. We always use that "reasonable person standard" as our litmus test against whether or not something would be considered emotional or mental abuse.

Medication Diversion

• Knowingly, or intentionally, interrupting, obstructing, or altering the delivery, or administration of a prescription drug.

The next one is medication diversion. This is an interesting one. This is one we are hearing more and more about, but I think particularly in a home environment by a companion or caregiver (not necessarily paid) who might be looking to steal those medications for their own personal or financial gain. We are seeing a little bit more of this out in the community.

Elder Neglect

• Failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. This constitutes more than half of all reported cases of elder abuse. It can be intentional or unintentional.

This is quite simply the failure to fulfill a caretaking obligation. Unfortunately, this constitutes more than half of all reported cases of elder abuse. It can be intentional or unintentional based on factors such as ignorance or denial that an elderly charge needs as much care as they do. Again, it is really just that failure to provide goods and services that are necessary for that person to avoid harm, and we will talk more about that in just a little bit.

Financial Exploitation 

• The unauthorized use of an elderly person’s funds or property, either by a caregiver or an outside scam artist
  • Misuse an elder’s personal checks, credit cards, or accounts
  • Steal cash, income checks, or household goods
  • Forge the elder’s signature
  • Engage in identity theft
  • Scams targeting the elderly

Another one that we are hearing a lot about now in the news is financial exploitation. This is the unauthorized use of an elderly person's funds or property either by a caregiver or by some outside person, a scam artist. It is deliberate misplacement, exploitation, wrongful temporary or permanent use of an individual's belongings or money without their consent. The important distinction is without their consent. An unscrupulous caregiver might do things like misuse a person's personal checks, their credit cards, or their accounts. They may steal cash, income checks, household goods, or get access to their accounts. They may be under the guise of helping the client with their bills, but they are skimming out of their accounts without that elder knowing. Forging the elder's signature and engaging in identity theft is very common. Another example is an announcement of a prize that the elderly person has won, but they have to pay money to claim. There can be phony charities and investment fraud. I have even heard of scammers showing up on an elder's doorstep. They claim to be from the utility company, or what have you, and they tell the homeowner that they need to pay their bill in cash.  

Healthcare Fraud and Abuse

• Not providing healthcare, but charging for it
• Overcharging or double-billing
• Getting kickbacks for referrals
• Overmedicating or under medicating
• Recommending fraudulent remedies for illnesses
• Medicaid fraud

You may not think of this as elder abuse but it really is. This is carried out by unethical individuals like doctors, nurses, hospital personnel, and other professional providers. This includes not providing healthcare but charging for it, overcharging or double-billing from medical care or services, getting kickbacks for referrals to other providers, prescribing certain drugs, over-medicating or under-medicating, or recommending fraudulent remedies for illnesses or other medical conditions. This is anything that benefits the medical professional, not the client.

Elder Self-Neglect

• Physical or mental impairment or diminished capacity can mean that an older adult is no longer able to perform essential self-care
• May lack basic personal hygiene, appear malnourished, live in dirty conditions, be unable to pay bills or manage medications
• Can be a sign of depression, grief, dementia, or other medical problem

We already talked about neglect, but this is self-neglect. This is a common form of elder abuse that we see in healthcare. Physical or mental impairment or diminished capacity can mean that an older individual is no longer able to perform essential self-care, and we see that very commonly with cognitive decline, dementia, et cetera. They may lack basic personal hygiene, appear dehydrated, malnourished, underweight, or what have you. This can be a sign of depression, grief, dementia, some other medical problem, and in many cases, the older person refuses to seek assistance. They, oftentimes, are in denial. They feel ashamed about needing help or feel worried about losing their independence. If you see this self-neglect, this could be indicative of some other larger systemic issue going on with the elder.

Signs of elder abuse can, unfortunately, be very difficult to recognize, mistaken for symptoms of dementia, the elder person's frailty, or again the caregivers may explain them to you in that way and just pass them off. In fact, many of the signs and symptoms of elder abuse do overlap with symptoms of mental deterioration, but that does not mean that we want to dismiss them on the caregiver's say-so.

Warning Signs

If you suspect abuse but you are not sure, look for the warning signs. We are going to go through these quickly as it relates to each of the types of abuse.

Physical Abuse Warning Signs

• Unexplained signs of injury, such as bruises, welts, or scars
• Broken bones, sprains, or dislocations
• A report of drug overdose or an apparent failure to take medication
• Broken eyeglasses or frames
• Signs of being restrained, such as rope marks on wrists
• Caregiver’s refusal to allow you to see the elder alone

These can include unexplained signs of injury such as bruises, welts, scars, especially if they appear symmetrically on both sides of the body, broken bones, sprains, or dislocations, or fractures that are unexplained. Another warning sign is a report of either a drug overdose or an apparent failure to take their medication. When you go in to do your visit, you may see that there is a lot more of that prescription remaining than should be. They may have broken eyeglasses, broken frames, signs of being restrained, like rope marks on their wrists, or things maybe that came from a zip tie. The caregiver may refuse to allow you to see the elder alone. There can also be signs of burns, internal injuries, and abrasions. These are injuries that are unexplained or somebody is giving you an explanation and that explanation is just really not plausible.

Emotional Abuse Warning Signs

• Threatening, belittling, or controlling caregiver behavior
• Behavior from the elder that mimics dementia
• Depression, sleep and appetite disturbances
• Decreased social contact
• Evasiveness, anxiety, hostility

When we look at emotional abuse warning signs, these are things like threatening, belittling, or controlling caregiver behavior. You may observe the caregiver and what they are saying may not ring true. Your "spidey sense" may be alerted. Behavior from the elder that mimics dementia such as rocking, sucking, or mumbling to themselves. Depression, sleep and appetite disturbances, decreased social contact, loss of interest in their own self, apathy, suicidal ideation, evasiveness, anxiety, hostility, or any of those changes can be potential warning signs. This person who has always wanted to go to activities and been very involved suddenly does not want to go and have isolated themselves would be a big red flag.

Sexual Abuse Warning Signs

• Bruises around breasts or genitals
• Unexplained vaginal or anal bleeding
• Torn, stained, or bloody underclothing
• Fear of being touched
• Inappropriate modesty on evaluation

You may notice some of these things while doing an ADL. Other issues would be unexplained vaginal or anal bleeding, torn, stained, bloody underclothing, fear of being touched, or an inappropriate modesty when you are delivering standard treatment or evaluation. You might have draped that person appropriately, but they still just do not want you to see them. 

Neglect Warning Signs

• Unusual weight loss, malnutrition, dehydration
• Untreated physical problems, such as bed sores
• Unsanitary living conditions
• Being left dirty or unbathed
• Unsuitable clothing or covering for the weather
• Unsafe living conditions
• Desertion of the elder at a public place
• Eccentric or idiosyncratic behavior, self-imposed isolation, marked indifference

Elder neglect or even self-neglect have some warning signs. These are things like unusual weight loss without a weight loss program, malnutrition, dehydration, untreated physical problems like bedsores or something else that should be treated, unsanitary living conditions, so dirt, bed bugs, or soiled bedding and clothing. They may be dirty or unbathed, or have unsuitable clothing or covering for the weather. For example, it could be cold outside yet the person has no coat. There may be no heat or running water, faulty electrical wiring, other fire hazards, or maybe they have been deserted at a public place. Another indication is the misuse or the absence of medication or an assistive device. You can also see things like eccentric or idiosyncratic behavior, self-imposed isolation, and a marked indifference to anything that is going on around them. All of those can be signs of neglect.

Financial Exploitation Warning Signs

• Significant withdrawals from the elder’s accounts
• Sudden changes in the elder’s financial condition
• Items or cash missing from the senior’s household
• Suspicious changes in wills, power of attorney, titles, and policies
• Addition of names to the senior’s signature card
• Financial activity the senior couldn’t have undertaken
• Unnecessary services, goods, or subscriptions
• The disparity between assets and appearance and general condition

Some of the warning signs here include significant withdrawals from that person's account, a sudden change in their financial condition, and items or cash missing from their household. Maybe, there have been changes in the will, in the power of attorney, and in titles and policies. They may have signed over these items to someone that just makes you scratch your head. There may be new additions of names to a signature card for the bank or other accounts. There may be financial activity that the person could not have possibly undertaken. For example, an ATM withdrawal when the account holder is bedridden or paying an account online when the person does not even have a computer. There could be unnecessary services, goods, or subscriptions. The client may also display fear, vague answers, or anxiety when asked about their personal finances. You may see a disparity between their assets and their appearance and their general condition. 

Healthcare Fraud/Abuse Warning Signs

• Duplicate billings for the same medical service or device
• Evidence of overmedication or under-medication
• Evidence of inadequate care when bills are paid in full
• Problems with the care facility

Duplicate billings for the same medical service or device, evidence of overmedication or under-medication, evidence of inadequate care when the bills are truly paid in full are some warning signs in this category. All of their medical bills are paid, but they do not look like they are cared for. This could also happen in an institution where there are problems with the care facility. The staff could be poorly trained, poorly paid, insufficient staff, or overcrowding.

Risk Factors

• Caregiver stress
• Depression in the caregiver
• Lack of support from other potential caregivers
• Substance abuse by the caregiver
• The intensity of the elderly person’s illness or dementia
• Social isolation
• The elder’s role, at an earlier time, as an abusive parent or spouse
• A history of domestic violence in the home
• The elder’s own tendency toward verbal or physical aggression

Taking care of a senior who has a lot of different care needs can be difficult. Both the demands of caregiving and the needs of that elder can create situations in which abuse is more likely to occur. Many nonprofessional caregivers, spouses, adult children, other relatives, and friends find taking care of an elder to be really satisfying and enriching, but the responsibilities and demands of caregiving can escalate and cause stress as that person's condition deteriorates. The stress of elder care can lead to mental and physical health problems that leave the caregiver burned out, impatient, and more susceptible to neglecting or lashing out at the elder in their care. Even caregivers in institutional settings can experience that stress that can lead to elder abuse. Nursing home staff particularly may be prone to elder abuse if they lack training, have too many responsibilities, are unsuited to caregiving, or they work under poor conditions. In addition to that caregiver's inability to manage stress, some other significant risk factors for elder abuse include depression in the caregiver and lack of support from other caregivers. The caregiver's perception that taking care of the elder is burdensome without any sort of emotional reward is another problem. Other risk factors include substance abuse by the caregiver, the intensity of the elderly person's illness or their dementia, social isolation, meaning that the elder and the caregiver are alone most of the time together, the elder may have been an abusive parent or a spouse, a history of domestic violence in the home, and the elder's own tendency toward verbal or physical aggression.

Federal Reporting Requirements

• Elder Justice Act (EJA): designed to address crimes committed against older persons, raise national awareness of elder justice issues and apply resources to the efforts of those confronting elder abuse and neglect on the front lines in healthcare settings

These reporting requirements come from the Elder Justice Act. The purpose of that act is to detect, prevent, and prosecute elder abuse, neglect, and exploitation. The Elder Justice Act is designed to address crimes committed against older persons, raise national awareness of elder justice issues, and then apply resources to the efforts of those confronting elder abuse and neglect on the front lines in our healthcare settings. The Elder Justice Act as well adds new elder justice provisions and very specific provider requirements particularly in long-term care by amending various sections of several titles of the Social Security Act.

• Section 1150B of the Social Security Act (the Act), as established by section 6703(b)(3) of the Patient Protection and Affordable Care Act of 2010 (Affordable Care Act), requires specific individuals in applicable long-term care facilities to report any reasonable suspicion of crimes committed against a resident of that facility
• Facilities are required to conspicuously post, in an appropriate location, a notice for its employees specifying the employees’ rights, including the right to file a complaint under this statute. The notice must include a statement that an employee may file a complaint with the SA against an LTC facility that retaliates against an employee.

Section 1150B of the Social Security Act, as established by the Patient Protection and Affordable Care Act, requires that very specific individuals in applicable long-term care facilities report any reasonable suspicion of crimes committed against an individual of that facility. Now, this is required of any facility that receives at least $10,000 in federal funds under the act in the preceding year. That community is required to notify every covered individual of their obligation to report to the Secretary of Health and Human Services, known as the Secretary, and at least one local law enforcement entity, for any reasonable suspicion of a crime. A covered individual, in this case, is an owner, an operator, an employee, a manager, an agent, or a contractor. It includes pretty much everybody. Additionally, communities are required to post in a very conspicuous place a notice for employees specifying their rights including the right to file a complaint, and the notice also has to have a statement in it that an employee can file a complaint with the Secretary and they cannot be retaliated against. 

• You have a duty to report any suspected acts involving mistreatment, neglect, abuse, etc.
• Facilities must report any reasonable suspicion of a crime against a resident or patient to:
  • The Secretary of the U.S. Department of Health and Human Services (HHS), and
  • The law enforcement authorities in the political subdivision where the facility is located.

You do have a duty to report any suspected acts involving individual mistreatment, neglect, abuse, crimes, misappropriation of resident property, injuries of an unknown source, et cetera. Again, these are healthcare facilities again that are receiving federal aid. These facilities need to report any reasonable suspicion of a crime against an individual or a patient, number one, to the Secretary of the United States Department of Health and Human Services, and then also to the law enforcement authorities in the political subdivision where that facility is located. There are two specific federal reporting requirements, and most of these apply to the long-term care segment of the industry as that is where most of our elders reside.

• Two-time limits for the reporting of reasonable suspicion of a crime
  • Serious Bodily Injury – 2 Hour Limit
    • Shall report the suspicion immediately, but not later than 2 hours after forming the suspicion
  • All Others – Within 24 Hours
    • If no serious bodily injury shall report the suspicion not later than 24 hours after forming the suspicion
• “Serious bodily injury” is one involving extreme physical pain or substantial risk of death; or an injury involving protracted loss or impairment of the function of a bodily member, organ, or mental faculty; or an injury requiring medical intervention such as surgery, hospitalization, or physical rehabilitation.

There are two-time limits for reporting reasonable suspicions of crime depending on the seriousness of the event that leads to that suspicion. The first is whether or not there is a serious bodily injury. Now under the Elder Justice Act, serious bodily injury is one involving extreme physical pain, substantial risk of death, or an injury involving protracted loss or impairment of the function of a bodily member, organ, or mental faculty. This is an injury requiring medical intervention such as surgery, hospitalization, or physical rehabilitation. If the events that cause a reasonable suspicion of harm or abuse and there is serious bodily injury, people are required to report immediately but no later than two hours after forming a suspicion to both local law enforcement and the Secretary of Health and Human Services. All others need to be reported within 24 hours. That is federal guidance. 

State Reporting Requirements

• Each state may have specific reporting requirements related to abuse
• It is important that you familiarize yourself with the requirements for the state in which you work/provide services
• Report as required by state law

This is where it gets tricky because every state is different. Each state may have specific reporting requirements related to the abuse. And for you, it is important that you familiarize yourself with the requirements for the state where you work and where you provide the services. If you feel or have a reason to believe that somebody is being abused, you need to report this. As every state is different and you need to report as required by your state law.

Resources

• State Adult Protection Statutes:
  • https://www.stetson.edu/law/academics/elder/home/adult-protection-statutes.php
• State Mandatory reporting Statutes:
  • https://www.stetson.edu/law/academics/elder/home/media/Mandatory-reporting-Statutes-for-elder-abuse-2016.pdf

Here are a couple of resources. One is the State Adult Protection Statutes, and the second link here is for State Mandatory Reporting Statutes. The second one specifically will tell you where to report, how to report, who is required to report, and what those timeframes are for your specific state. Hopefully, you can take the time to look those up as well. 

Child Abuse

Federal Definition of Child Abuse

• Federal Child Abuse Prevention and Treatment Act (CAPTA) (42 U.S.C.A. § 5106g) defines child abuse and neglect 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 act or failure to act which presents an imminent risk of serious harm."

According to the United States Department of Health and Human Services, federal legislation provides guidance to states by identifying a minimum set of acts or behaviors that define child abuse and neglect. The Federal Child Abuse Prevention and Treatment Act or CAPTA, as amended by a Reauthorization Act in 2010, defines child abuse and neglect at a minimum to 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, and an act or failure to which presents an immediate or an imminent risk of serious harm.

Definitions

• A "child" generally means a person who is younger than age 18 or who is not an emancipated minor
• CAPTA does not provide specific definitions for types of maltreatment such as physical abuse, neglect, or emotional abuse
• Federal legislation sets minimum standards for States that accept CAPTA funding, each state provides its own definitions of maltreatment within civil and criminal statutes

Under these definitions, this definition refers very specifically to parents and other caregivers. A child under this definition generally means a person who is younger than the age of 18 or who is not an emancipated minor. And while CAPTA provides definitions for sexual abuse and the special cases of neglect related to withholding or failing to provide medically indicated treatment, it does not provide specific definitions for other types of maltreatment or things like physical abuse, neglect, or emotional abuse. While federal legislation sets those minimum standards for states that accept CAPTA funding, each state is going to go out on its own and provide its own definitions of maltreatment within civil and criminal statutes. 

State Statutes

• Definitions of child abuse and neglect are typically located in two places within each State's statutory code:
  • Civil statutes provide definitions of child maltreatment for mandated reporters
  • Criminal statutes define those forms of child maltreatment subject to arrest and prosecution

The federal definition is out there, but the state has to be accepting CAPTA funding for that federal definition to apply. More often than not, each state is going to have its own set of statutes related to child abuse. We will talk about this on another slide, but that is again where it is up to you to figure out the requirements in your specific state. Are you a mandatory reporter? What are your training requirements? I gave you some resources to do that, and we will talk about that in a minute. The definitions of child abuse are going to be located typically in two places within each state's statutory code. The first statutory code will be the civil statutes, and these will provide those definitions of what is child maltreatment. It also will help to guide the mandatory reporters and other individuals as well as to identify and report suspected child abuse and determine the grounds for intervention by the state child protection agencies and the civil courts. This is the overarching area of what is abuse, who reports, how do you report, and what do we do when you report. The criminal statutes, on the other hand, will define those forms of child maltreatment that can subject an offender to arrest and prosecution in criminal courts. Most of them will list out very specifically the types of things that are absolutely positively against the law and what would warrant an arrest, prosecution, jail time, community service, or whatever it would happen to be.

Types of Abuse

• Many states recognize four major types of maltreatment
  • Neglect
  • Physical abuse
  • Sexual abuse
  • Emotional abuse or neglect

Many states recognize four major types of maltreatment in their definitions and these include neglect, physical abuse, sexual abuse, and emotional abuse or neglect. Let's look at these in a little more detail. I think the first step in helping an abused or neglected child is learning those warning signs. The presence of a single sign does not prove that child abuse is occurring but it could be. But, when you look at the situation a little bit more closely, you may see signs appear repeatedly or in combination. When you see a pattern, that is when you want to take notice. If you do suspect at any time that a child is being harmed, you have to report your suspicions because that is going to help protect that child and get some help for the family. We will talk about reporting in a second, but any person can report suspicions of child abuse and neglect. Mandatory reporters need to report under very specific circumstances defined by the state. Healthcare providers with very few exceptions would be considered mandatory reporters in those states. 

Recognizing Child Abuse

• The Child:
  • Shows sudden changes in behavior or school performance
  • Has not received help for physical or medical problems
  • Has learning problems that cannot be attributed to specific causes
  • Is always watchful
  • Lacks adult supervision
  • Is overly compliant, passive, or withdrawn
  • Comes to school or other activities early, stays late, and does not want to go home

These are the signs in a child that may signal child abuse or neglect. They show sudden changes in behavior or school performance. They were a wonderful student and now they are not. They have not received help for a physical or a medical problem that has been brought to the parent's attention. They have learning problems or difficulty concentrating in the classroom that cannot be attributed to a very specific physical or psychological cause. Or, maybe that child is always watchful as though they are always preparing for something bad to happen. They are looking for that other shoe to drop or looking over their shoulder. They lack adult supervision when they are not of an age to be unsupervised. They are overly compliant or very passive or withdrawn. They say yes ma'am or no sir to all requests. They come to school or to other activities early, they stay late, and they do not really want to go home when it is time for dismissal.

• The Parent:
  • Shows little concern for the child
  • Denies the existence of—or blames the child for—the child’s problems in school or at home
  • Asks teachers to use harsh physical discipline
  • Sees the child as entirely bad, worthless, or burdensome
  • Demands a level of physical or academic performance the child cannot achieve
  • Looks primarily to the child for care, attention, and satisfaction of emotional needs

This parent shows little concern for the child. They pass off some of the things that are happening with their child as not being important. They deny the existence of or even blame the child for the child's own problems in school or at home. They ask a teacher or a caregiver to use harsh physical discipline if that child misbehaves. It is okay to do X, Y, and Z if the child misbehaves. "This is what we do at home." They see the child as bad, worthless, or burdensome. They demand a level of physical or academic performance that the child cannot possibly achieve. This is different from encouraging them to be a better student or athlete. This is forcing something that they could not possibly achieve or do not have the physical or mental capacity to do. They look at the child primarily for care, attention, and satisfaction of their own emotional needs rather than providing the care to the child for the child's needs.

• The Parent and Child:
  • Rarely touch or look at each other
  • Consider their relationship entirely negative
  • State that they do not like each other

We can also look at the parent and child dyad together. They rarely touch each other or look at each other. You do not see that bond or connection between the two of them. They consider their relationship entirely negative, and they may just flat out state that they do not like each other and truly mean that. We talked about the types of maltreatment that are generally defined in the state statute, and now, we are going to go through now some of the signs that are associated with the types of child abuse and neglect. It is important to note however that these types of abuse are typically found in combination rather than alone.

You will not typically just see physical abuse without also some sort of emotional or mental anguish as well. For example, a child who is sexually abused may also be neglected. You want to look for these in combination and look for some of those signs. And again, a lot of these are going to be very similar to what we just talked about with elder abuse. 

Physical Abuse

• Has unexplained burns, bites, bruises, broken bones, or black eyes
• Has fading bruises or other marks noticeable after an absence from school
• Seems frightened of the parents and protests or cries when it is time to go home
• Shrinks at the approach of adults
• Reports injury by a parent or another adult caregiver

They may have unexplained burns, bites, bruises, broken bones, and black eyes. They may be consistently in the emergency room for some sort of treatment. They have fading bruises or other marks that are noticeable after an absence from school. They seem frightened of the parents. They protest or they cry when it is time to go home. They shrink at the approach of an adult and are wary of adults who are around them. They report injuries by a parent or another adult caregiver, or they report an injury and the explanation of that injury is just not plausible. The proverbial "I fell down the stairs" type of excuse.

• Consider physical abuse when the adult:
  • Offers conflicting, unconvincing, or no explanation for the child’s injury
  • Describes the child as “evil,” or in some other very negative way
  • Uses harsh physical discipline with the child
  • Has a history of abuse as a child

We might want to consider physical abuse if they are offering conflicting, unconvincing, or no explanation for the child's injury. "have no idea how that happened." Or, "Don't worry about it. It's no big deal." They describe the child as evil in some way, or they are very negative in their description of the child. They use harsh physical discipline with the child even when it is not warranted. Another one is that they themselves may have a history of abuse as a child. 

Neglect

• The child is frequently absent from school
• Begs or steals food or money
• Lacks needed medical or dental care
• Is consistently dirty
• Lacks sufficient clothing for the weather
• Abuses alcohol/drugs
• States that there is no one at home to provide care

You want to consider the possibility of neglect when the child is frequently absent from school again without a reason. This is when they are not on vacation, not sick and at the physician, and not visiting their grandparents. They may beg or steal food in the cafeteria. They may lack the necessary medical or dental care that they should be having at their age. They may not have their immunizations not necessarily related to the opinions of the parent but because the parent refuses to give them. Maybe they need glasses, but they do not have glasses. They are consistently dirty and do not look well-kept. They have severe body odor or their hair is very dirty. They may have consistent issues with lice or other types of bugs. They may lack sufficient clothing for the weather, again very similar to elder abuse. It is cold outside but they do not have a coat. It is raining but they do not have anything to protect them from the elements. The child may be abusing alcohol, drugs, or other things more consistent in an older child. They may state that there is no one home to provide care for them. They may say, "I cook my own meals all the time." Another clue is, "I take care of a younger sibling." 

• Consider neglect when the adult:
  • Appears to be indifferent to the child
  • Seems apathetic or depressed
  • Behaves irrationally or in a bizarre manner
  • Is abusing alcohol or other drugs

You also want to consider the possibility of neglect again when we look at the parent or the adult caregiver and they are indifferent to that child. They are apathetic and do not seem to care. They themselves are depressed and not in a position to care appropriately for that child. They behave irrationally or in a bizarre type of manner. Or, they may be abusing alcohol or other drugs themselves.

Sexual Child Abuse

• Has difficulty walking or sitting
• Suddenly refuses to change for gym
• Reports nightmares or bedwetting
• Experiences a sudden change in appetite
• Demonstrates bizarre, sophisticated, or unusual sexual knowledge
• Becomes pregnant or contracts a venereal disease
• Runs away
• Reports sexual abuse by a parent or another adult caregiver

Consider the possibility of sexual child abuse when that child has difficulty walking or sitting. You see that they have pain in their genital area. It is observable that they are very uncomfortable. They suddenly refuse to change for the gym, participate in physical activities, or maybe participate in your treatment session. They may report having nightmares or bedwetting. Their appetite may have gone down or up, and they may also have sleep disturbances. They have bizarre, sophisticated, or even unusual sexual knowledge or behavior for their age. Things that they should not know but they do. They may become pregnant or have a sexually transmitted infection, particularly at younger ages. They run away or they report some sort of sexual abuse by a parent or another adult or caregiver. You have to take these comments very seriously. 

• Consider sexual abuse when the adult:
  • Is unduly protective of the child or severely limits the child’s contact with other children, especially of the opposite sex
  • Is secretive and isolated
  • Is jealous or controlling with family members

We also want to consider the possibility of sexual abuse when the parent, adult caregiver, or older sibling is really protective of that child. This severely limits the child's contact with other children or other individuals, especially of the opposite sex. They are secretive and isolated. They look like they have an unhealthy type of family bond. They are very jealous and controlling with other family members.

Emotional Maltreatment

• Shows extremes in behavior
• Is either inappropriately adult or inappropriately infantile
• Is delayed in physical or emotional development
• Has attempted suicide
• Reports a lack of attachment to the parent

Signs of emotional maltreatment is when you see a child showing extremes in behavior. They may be overly demanding, extremely passive, or extremely aggressive. They are either inappropriately adult-like or infantile as examples. They may be delayed in their physical, emotional development, and cognitive development. Perhaps, they have attempted suicide or have even talked about suicide. They feel like their life is not worthy or unsatisfactory. They may report a lack of attachment to the parent. If we interact with that parent or caregiver, we may see that the adult constantly blames, belittles, or berates that child. They are really unconcerned about the child, their whereabouts, their well-being, and those sorts of things. They do not consider the offers of help for the child's problem. 

How to Report Suspicions

• Suspected Child Maltreatment
  • If in serious danger, call 911
  • National and local resources are available to provide assistance and information about reporting suspected maltreatment.
• Suspected child abuse or neglect?
  • Contact your local child protective services office or law enforcement agency
  • Know the statutes if you are a mandatory reporter

If you see suspicions, what do you do? If you or someone else is in immediate danger, call 911. That is the best thing to do because there are both national and local resources that are available to provide immediate assistance to that child and family. You would want to report that information about suspected maltreatment. Again this is very state-specific, but at a bare minimum, you would contact your local Child Protective Services office or law enforcement agency. If you are a mandatory reporter in your state, you are going to need to know what their requirements are. I can tell you that I am licensed in a couple of states, and I look at my licensing requirements. There are very specific rules that you need to follow about timeframes, phone calls, and specific people to contact. Unfortunately, in the scope of this presentation, we cannot go into that level of detail, but you need to know what the statutes are for your specific state. 

Who Can Report?

• Anyone can report suspected child abuse or neglect
• All U.S. States and territories have laws identifying mandatory reporters
• Mandatory reporters may include social workers, teachers, and other school personnel, childcare providers, physicians, and other health-care workers, mental health professionals, and law enforcement officers

Again all states have laws that identify persons who are mandatory reporters like social workers, teachers, school personnel, childcare providers, physicians, mental health professionals, and law enforcement officers. They are all identified in those state statutes, However, any person who suspects child abuse and neglect can and should report.

What Happens Next?

• Report a complete, honest account of what you observed that led you to your suspicion. Any reasonable suspicion is sufficient.
• Reports are sent to child protective services (CPS) for review
• If an investigation is deemed needed, CPS may talk with the family, the child, or others to help determine what is making the child unsafe
• For more information about where and how to file a report, contact your local child protective services agency or police department

You need to provide a completely honest account of what you observed that led you to suspect the occurrence of child abuse or neglect and any reasonable suspicion is sufficient. Do not make up details or leave out details - be clear, be honest about what you saw, what you heard, or what you observed. Do not base that on hearsay. It should only be based on your own report. This report is going to be sent over to Child Protective Services or CPS for review. Generally speaking, again for states, when they receive that report, the worker will review the information and determine if an investigation is necessary. That CPS worker may talk to the family, the child, or other individuals to help determine what possibly is making this child unsafe. They can also help parents and other caregivers get services, get an education, and get other assistance to help them through the situation. 

Resources

• Childhelp National Child Abuse
  • Call or text 1.800.4.A.CHILD (1.800.422.4453). Professional crisis counselors are available 24 hours a day, 7 days a week, in over 170 languages.
• National Center for Missing and Exploited Children’s CyberTipline
  • Report online sexual exploitation of a child or if you suspect that a child has been inappropriately contacted online at the CyberTipline.

There are national resources that are available. For the Childhelp National Child Abuse resource, professional crisis counselors are available 24 hours a day, seven days a week in 170 different languages. Every call that is placed is completely confidential, and the hotline offers things like crisis intervention, information, referrals out to other emergency services, social services, and other sorts of resources that are available in the community. There is also the National Center for Missing and Exploited Children's Cyber. This is an online reporting if you suspect any sort of sexual exploitation of a child, and that would include human trafficking. You can also report if you suspect that a child has been inappropriately contacted online. Information again is made available to law enforcement in order to conduct that investigation.

• State Statutes for Child Protective Services:
  • https://www.childwelfare.gov/topics/systemwide/laws-policies/state/
• State reporting Phone Numbers:
  • https://www.childwelfare.gov/organizations/?CWIGFunctionsaction=rols:main.dspList&rolType=custom&rs_id=5

Here are two resources for your states. The first one is the state statutes for Child Protective Services, and the second is the state reporting phone numbers. Now, these are not necessarily the end all be all. Again go back to your Practice Act, your licensure, etc. But, these are some good starting points so that you can start to read about what is required.

This text-based course is an edited transcript from a live webinar presented by Sophie Nathenson, PhD.

This material is for educational purposes and does not replace clinical judgment or local policy.

Course Overview

This course provides health professionals with a comprehensive framework for understanding and identifying human trafficking in the United States. Grounded in a sociological perspective, the material examines the complex definitions, scope, and societal factors that contribute to trafficking. Participants will learn to recognize the physical, behavioral, and psychological indicators of trafficking in both adult and minor victims, with a specific focus on signs that may present in healthcare settings. The course offers practical guidance on trauma-informed communication, clinical assessment, and the use of national resources to report suspected cases and support vulnerable individuals.

Learning Outcomes

After this course, participants will be able to:

• Describe the different types and venues of human trafficking prevalent in the United States.​

• Explain at least two risk factors and warning signs, including social and systemic factors, of human trafficking for both adult and minor victims.

• Identify five specific indicators of trafficking that can be identified in healthcare settings and appropriate resources and protocols for reporting suspected cases.

Risks/Limitations

• Generalization of Trends: Trends presented change over time and population.

• Limited Cultural Representation: The course may not fully encompass the diversity of experiences with human trafficking or the regional or global scope and differences.

• Research Scope: This course does not contain an exhaustive review of research conducted on these topics.

Definitions of Human Trafficking

Understanding the formal definitions of human trafficking is the first step in distinguishing it from other related criminal activities. These definitions provide the legal framework for identification, reporting, and prosecution, establishing clear boundaries for what constitutes this severe violation of human rights.

Federal Definitions

The primary federal legislation governing human trafficking in the United States is the Trafficking Victims Protection Act (TVPA). First enacted in 2000, this act establishes clear definitions for the main forms of trafficking and provides a framework for prosecution, protection, and prevention (U.S. Department of Justice, 2024).

• Sex Trafficking: This is defined as the recruitment, harboring, transportation, provision, obtaining, patronizing, or soliciting of a person for the purpose of a commercial sex act, where the commercial sex act is induced by force, fraud, or coercion.

• Labor Trafficking: This involves the recruitment, harboring, transportation, provision, or obtaining of a person for labor or services, through the use of force, fraud, or coercion for the purpose of subjection to involuntary servitude, peonage, debt bondage, or slavery.

A critical provision of the TVPA relates to minors. Any individual under the age of 18 who is engaged in commercial sex is legally considered a trafficking victim, regardless of whether force, fraud, or coercion can be proven (U.S. Department of Justice, 2024). This removes the burden of proving manipulation in cases involving children, acknowledging their inherent vulnerability. Beyond these two primary categories, other forms of trafficking exist, including child trafficking for non-sexual labor, bonded labor (debt peonage), forced marriage, and organ trafficking.

Michigan State Law

State laws often provide additional specificity that reflects local priorities and legal structures. For example, the Michigan Penal Code defines human trafficking as the knowing exploitation of an individual, with a particular focus on vulnerable populations (State of Michigan, 1931). The key element in this definition is the concept of "knowingly." A person is not culpable if they are caught in a situation without awareness of the context or details of the exploitation.

The Michigan statute includes specific actions, such as:

• Benefitting financially from the exploitation.

• Controlling an individual's access to controlled substances as a means of coercion (State of Michigan, 1931). This tactic is a common method used to maintain control over a victim, creating a physiological dependency that compounds psychological manipulation.

Distinctions from Other Crimes

Human trafficking is often confused with other serious crimes, but its methods and motivations are distinct. It is not always a violent crime, and the signs of abuse may not be physically visible. While violence can be a component, psychological control is often the primary and most powerful tool.

• Smuggling: This crime involves providing transportation across a border, typically with the consent of the individual being transported. While dangerous and illegal, it is not trafficking unless the relationship transitions into a situation of force, fraud, or coercion after the transport is complete. Smuggling is a crime against a nation's border, whereas trafficking is a crime against a person.

• Kidnapping: This typically involves taking someone against their will for a specific purpose, such as a ransom. The motivation is often a one-time event or payment, whereas trafficking is an ongoing form of exploitation for labor or commercial sex.

Trafficking is far more likely to rely on psychological means of control rather than physical restraint. These tactics include manipulation, defrauding individuals with false promises, and making threats against the victim or their loved ones (Eryarsoy et al., 2024). This sustained psychological pressure paralyzes individuals, preventing them from seeking help even when physical escape appears possible.

Tactics

The methods used by traffickers are often subtle and designed to break down a person's autonomy over time. Psychological means are more common than physical confinement, particularly when a family member is the trafficker, as the pre-existing emotional ties can be powerfully exploited (Eryarsoy et al., 2024).

Common tactics include:

• Fraud: This involves making false promises to lure a victim into a situation of dependency. Examples include offering a good job with a specific salary, a safe place to live, a marriage proposal, or support for their family. Once the victim is isolated, these promises are broken, and the exploitation begins.

• Threats: Traffickers frequently use threats to maintain control. This can include threats of physical violence against the victim, threats of harm to their family members and loved ones, or threats of deportation for undocumented individuals. The fear these threats generate can be a more effective restraint than any physical barrier.

• Debt and Intimidation: Many victims are trapped through debt bondage. A trafficker might withhold pay, create a fraudulent debt for transportation or lodging, hold personal documents like passports or identification as collateral, and use various forms of intimidation to ensure the "debt" can never be repaid (Eryarsoy et al., 2024).

Sociological Perspective

To effectively identify and prevent human trafficking, it is essential to look beyond individual cases and examine the broader societal conditions that allow it to flourish. A sociological perspective focuses on the "upstream" factors—the social and systemic issues that create vulnerability in the first place. This approach studies group differences rather than individual pathologies to understand how belonging to certain demographic groups can increase risk. This view shifts the focus from asking "What is wrong with this person?" to "What is happening in our society that allows this to occur?"

This perspective emphasizes several key areas:

• Social Factors: These include a person's demographics, such as race, gender, sexuality, marital status, and employment status. Analysis of these factors can reveal patterns of vulnerability within a population.

• Prevention Focus: By examining upstream factors, the focus shifts from intervention to prevention. Addressing the root causes of vulnerability—such as poverty, lack of education, and discrimination—can reduce the pool of potential victims.

• Systemic Factors: These are issues embedded within our societal systems, such as healthcare, education, and justice. A lack of access to resources, for example, is a systemic factor that can increase an individual's risk of being trafficked.

• Role of Institutions: This involves analyzing how institutions like schools and hospitals can either contribute to a person's vulnerability or serve as critical points for identification and support.

• Social Environment: A person's environment—including their family, neighborhood, and experiences with discrimination—profoundly affects their psychological and even physiological well-being. A hostile or unstable social environment creates the fertile ground in which traffickers operate.

Role of Behavioral Health Professionals

Behavioral health professionals are uniquely positioned to identify and support victims of human trafficking. The growing awareness of this issue has highlighted the critical role clinicians play in the response system, serving as a potential lifeline for individuals who may not encounter other service providers.

Key responsibilities include:

• Mandatory Reporting: Professionals must be aware of and comply with their state's mandatory reporting laws regarding suspected abuse and trafficking, particularly concerning minors.

• Identifying and Supporting Victims: This involves recognizing the subtle signs of trafficking and understanding the resources available to help victims.

• Addressing Consequences: Clinicians must be prepared to address the specific and severe mental, physical, and emotional consequences of trafficking, which often manifest as complex trauma.

• Providing Trauma-Informed Care: It is crucial to use a trauma-informed approach to avoid re-traumatizing victims during assessment and treatment.

• Collaboration and Coordination: Effective support requires collaboration with specialized organizations, law enforcement, and social services that are equipped to handle trafficking cases. No single provider can meet all of a survivor's needs.

• Empowering Vulnerable Individuals: A key prevention strategy is to empower at-risk individuals by providing them with the support and resources needed to reduce their vulnerabilities before a trafficker can exploit them.

Identification

Identifying victims is a challenging but critical task. Traffickers are skilled at manipulation, and victims often do not self-identify due to fear, shame, or psychological control. It is a misconception that trafficking only occurs in other countries; it is a significant problem within the United States.

Victims who are not believed or are met with inadequate responses from institutions can experience re-victimization, which reinforces their sense of helplessness and distrust of authority. A major barrier to identification is the stigma associated with the circumstances of trafficking. Labeling a victim as a "criminal," "delinquent," or "prostitute" prevents professionals from seeing the underlying coercion and exploitation. Overcoming this stigma is essential for effective identification (Toney-Butler et al., 2017).

Policy

Several key policies have been enacted to address human trafficking at both the national and international levels, creating tools for both law enforcement and victim support services.

• The Trafficking Victims Protection Act (TVPA) of 2000 was a landmark piece of federal legislation. It allows trafficked foreign nationals to be eligible for federally funded benefits, including healthcare and immigration assistance.

• The T Visa is a specific provision that offers immigration relief to victims of human trafficking. It prohibits deportation and provides a pathway to potential permanent residency, which encourages victims to come forward and cooperate with law enforcement without fear of being removed from the country.

• The United Nations Sustainable Development Goals also address this issue, with Goal 8 aiming to promote "decent work and economic growth," directly targeting the exploitative labor conditions that trafficking creates.

Scope of Trafficking

Human trafficking, including domestic servitude, occurs in every region of the world. However, measuring its true prevalence is difficult due to the hidden nature of the crime.

• Global Estimates: The estimated number of people in modern slavery varies widely, with figures ranging from 12.3 million to over 45.8 million worldwide. This vast range reflects the significant challenges in data collection.

• Types of Trafficking: According to the United Nations Office on Drugs and Crime, sex trafficking accounts for approximately 50% of all trafficking cases. The International Labour Organization provides a more conservative estimate of 23%.

• Victim Demographics: Children constitute a large portion of victims, making up around 46% of cases. In high-income countries, child trafficking is often for sexual exploitation, forced criminality, or begging, whereas globally it is more often for forced labor (Trafficking, n.d.). Traffickers disproportionately target the extremely poor, those from dysfunctional homes, and individuals who have been abandoned. Approximately 61% of all victims are women and girls.

• Runaways: In the U.S., the link between running away and trafficking is strong. The National Center for Missing and Exploited Children estimates that one in six endangered runaways is likely a victim of child sex trafficking.

• Trafficker Profiles: Trafficking is not typically perpetrated by lone individuals. The majority of cases (57%) are run by organized criminal enterprises. Other structures include "governance-type" organized crime (18%), opportunistic associations (14%), and individual traffickers (11%). This highlights that trafficking is often a business, and identifying one victim may lead to a much larger network.

National Prevalence

In the United States, several organizations work to track the scope of the problem, providing the best available data on this clandestine activity.

• The Polaris Project: This is a leading research and advocacy organization that has handled over 400,000 contacts related to trafficking since its inception.

• National Human Trafficking Hotline: In 2023 alone, the hotline received over 30,000 "signals"—including calls, texts, emails, and web chats. These signals led to the identification of over 9,600 potential cases involving nearly 17,000 victims.

• Michigan Data: In 2023, Michigan accounted for 779 of these tips, which resulted in 254 confirmed cases and 506 victims. The running total of data for Michigan reflects nearly 10,000 tips, over 3,000 confirmed cases, and more than 6,200 victims since the hotline began collecting data.

Across the U.S., victims of both sex and child trafficking are disproportionately women and girls, with women and girls of color being impacted at even higher rates.

Data Limitations

Despite these numbers, there are major gaps in the research on trafficking prevalence and identification (Barrick & Pfeffer, 2024). The data we have likely represents only a fraction of the true scope of the problem.

Key limitations include:

• Hidden Population: Trafficking is a clandestine crime. Victims are difficult to reach and may not self-identify, making accurate counts nearly impossible (Barrick & Pfeffer, 2024).

• Varied Definitions: Different agencies and jurisdictions may use slightly different definitions of trafficking, leading to inconsistencies in data collection.

• Multiple Data Sources: Data is collected by various entities, including social services, healthcare systems, and the criminal justice system, but these sources are often not integrated.

• Difficulty of Proof: Proving trafficking, especially when it involves psychological manipulation rather than physical confinement, is much harder than proving other crimes. This leads to a significant drop-off between potential cases and official prosecutions. For instance, of 11,500 potential situations identified by the National Human Trafficking Hotline in 2019, federal law enforcement opened only 1,830 cases (U.S. Department of State, 2020).

Social Factors

Certain social factors create and exacerbate the vulnerabilities that traffickers exploit. These factors often relate to instability and a lack of a protective social network.

• Unstable or Insecure Housing: Individuals who are homeless or at risk of homelessness are prime targets. This includes youth aging out of the foster care system, who often lack the support services needed to transition to stable independence.

• Displacement: Displaced populations, such as undocumented migrant workers and refugees, are particularly vulnerable. Language barriers can prevent them from understanding the true nature of a fraudulent offer, and the fear of deportation is a powerful tool of coercion.

• Minority or Disability Status: Individuals belonging to minority groups or those with disabilities often face discrimination and marginalization, which increases their risk.

• Poverty and Marginalization: Poverty creates a desperation that traffickers prey on. When people lack access to basic resources, a false promise of a job or a safe home can be incredibly alluring.

These vulnerable populations are disproportionately impacted because their life circumstances align perfectly with the manipulative tactics used by traffickers.

Systemic Contributors

Beyond individual social factors, broader systemic issues within a society contribute to an environment where trafficking can thrive. These are large-scale problems that increase risk for entire communities.

Systemic contributors include:

• Lack of access to quality healthcare

• Inadequate educational opportunities

• Limited access to stable, living-wage employment

• Shortages of safe, affordable housing

• Harmful cultural norms and attitudes around sex, gender, and labor

These systemic failures create a constant state of precarity for many people, making them more susceptible to the false promises of exploiters.

Previous Trauma as a Risk Factor

A history of trauma is one of the most significant risk factors for becoming a victim of human trafficking. Traffickers specifically target individuals who have already been victimized, as they are often more easily manipulated and controlled.

Key trauma-related risk factors include:

• Adverse Childhood Experiences (ACEs): A high ACE score, which measures experiences like abuse, neglect, and household dysfunction before the age of 17, is strongly correlated with a wide range of negative life outcomes, including vulnerability to trafficking (De Vries & Goggin, 2020).

• Neglect from Caretakers: A history of neglect can leave individuals with a profound need for safety and affection, which traffickers exploit through "loverboy" tactics of feigned love and security.

• Intimate Partner Violence (IPV) and Sexual Abuse: Prior experiences with IPV or sexual abuse can normalize exploitation and make it harder for a victim to recognize and resist a trafficking situation.

• Gender Identity: Transgender individuals face high rates of discrimination, family rejection, and homelessness, leading to increased vulnerability. According to a 2015 survey by the National Center for Transgender Equality, 1 in 25 transgender individuals had engaged in sex work, and 19% had participated in "survival sex" to meet basic needs.

In Hospitals

Healthcare settings are a critical, and often missed, opportunity for intervention. Research indicates that as many as 87% of trafficking victims in captivity seek medical treatment at some point during their exploitation but do not receive assistance (Toney-Butler et al., 2017).

Healthcare professionals should be aware of the following dynamics:

• Use of Translators: If a translator is needed for a suspected victim, it should never be a family member or the person who accompanied them to the appointment. This person could be the trafficker. An independent, professional interpreter is essential (Hachey & Phillippi, 2017).

• Trafficker Behavior: Traffickers often seek the fastest possible care to minimize exposure. They may become aggressive or agitated over long wait times in an emergency department and may "hospital shop" to get in and out quickly.

• Victims from All Backgrounds: While it is important to be aware of risk factors, professionals must remember that victims can come from any social group or economic background. A person who appears to come from a stable home can still be a victim.

In Child Welfare & Juvenile Justice Systems

The child welfare and juvenile justice systems are high-risk environments for trafficking. Youth in these systems are often dealing with the exact vulnerabilities—such as a history of trauma, instability, and lack of a protective family—that traffickers seek out.

Although research in this area is limited, existing studies show a strong overlap. A study in Florida of over 12,000 allegations found that half of the children with a human trafficking abuse allegation were already involved in the child welfare system at the time (Scaggs et al., 2024).

Further findings from this study include:

• Females were more likely than males to be involved in the child welfare system.

• Black children were more likely than white children to be involved in both the child welfare and juvenile justice systems.

• Victims of sex trafficking were more likely than victims of labor trafficking to be involved in both systems (Scaggs et al., 2024).

This data underscores the need for professionals in these systems to shift their perspective. An adolescent who appears to be a "perpetrator" of a crime may, in fact, be a victim of trafficking. Adopting a mindset that views these youth as potential victims first is crucial for breaking the cycle of exploitation.

Signs of Human Trafficking

Recognizing the signs of human trafficking requires a multi-faceted approach that looks at physical, behavioral, and psychological indicators. It is also important to understand the common venues where trafficking occurs and the characteristics of potential victims. However, it is essential to remember that many victims may fall outside of a typical profile (Rambhatla et al., 2021).

Physical Indicators

Physical signs are often the most direct evidence of abuse, though they are not always present.

• Injuries and Neglect: Look for unexplained injuries, signs of physical abuse or neglect, poor hygiene, and signs of malnutrition or dehydration (Rambhatla et al., 2021).

• Specific Wounds: Certain types of injuries are highly suggestive of trafficking, such as abrasions from ropes or belts, scratches, road rash, and small, circular cigarette burns.

• Branding and Tattoos: Research has shown that brandings, tattoos (especially those indicating ownership), and rashes are more common in sex trafficking. In contrast, victims of labor trafficking are more likely to present with burns and deep cuts related to hazardous working conditions (Rambhatla et al., 2021).

Behavioral Indicators

Behavioral indicators often reflect the fear and control that define a victim's experience.

• Demeanor: A victim may appear fearful, anxious, submissive, or hyper-vigilant.

• Reluctance to Share Information: Evasiveness or reluctance to share personal information is a major red flag.

• Detachment: The person may speak about their experiences in the third person, a form of mind-body separation common in trauma survivors.

• Physical State: They may appear sleep-deprived or impaired by substances.

• Inconsistent Stories: Pay close attention to inconsistencies in their stories about their home life, job, or relationships.

• Unexplained Absences: For minors, this can manifest as unexplained absences from school, poor attendance, or runaway behavior.

• Pride in Travel: Paradoxically, a young person might boast about travel, which could be a red flag if the details are vague or do not add up.

Psychological Indicators

The psychological toll of trafficking is immense and often presents with symptoms that overlap with other mental health conditions.

• Trauma Symptoms: Victims frequently exhibit symptoms of Post-Traumatic Stress Disorder (PTSD), such as nightmares, flashbacks, irrational fears, and irritability (Hopper & Gonzalez, 2018; Okech et al., 2018).

• Mood and Anxiety Disorders: Depression and anxiety are extremely common (Hopper & Gonzalez, 2018).

• Other Conditions: Substance abuse and suicidal ideation are also prevalent among survivors (Sidun, 2025).

• Trauma Bonding: Victims may show a strong, seemingly loyal attachment to a controlling or abusive individual. This phenomenon, known as trauma bonding, is a survival mechanism that can be mistaken for a consensual relationship.

• Social Isolation: Traffickers work to isolate their victims from friends and family to maintain control. This isolation becomes a significant psychological indicator (Okech et al., 2018).

Identifying Venues

Trafficking can happen anywhere, but certain venues and industries are known hotspots for recruitment and exploitation.

• Online and Youth-Centered Venues: Recruitment often happens online through social media and chat rooms. After-school programs can also be venues, with traffickers sometimes being other students.

• Advertisements: Job advertisements may contain red flags, such as obscured phone numbers, language over-emphasizing trustworthiness ("this is a safe job"), or specifications about ethnicity or youth.

• High-Risk Activities: Activities such as stripping, pornography, forced begging, and drug sales are often linked to or serve as entry points into trafficking.

• Common Labor Venues: Labor trafficking is common in restaurants, hair and nail salons, domestic work (as nannies or au pairs), and agricultural settings.

• Common Sex Trafficking Venues: Sex trafficking frequently occurs in hotels and motels, on the street, in brothels (which may be disguised as homes or legitimate businesses), through escort services, and at truck stops, bars, and strip clubs.

Clinical Red Flags

In a clinical setting, several red flags can indicate that a patient may be a victim of trafficking.

• Controlling Companion: The person is accompanied by a dominant individual who speaks for them, refuses to let them be alone, or becomes agitated when the patient is addressed directly.

• Lack of Documents: The patient lacks identification documents, such as a driver's license or passport, or is not in control of them.

• Inability to Keep Appointments: They are unable to schedule or attend appointments independently.

• Signs of Control: There are signs that the person is working excessively long hours, is being constantly monitored, or has their movements restricted.

• Health Indicators: Recurrent sexually transmitted infections (STIs), especially in a minor, are a major red flag. Other signs can include signs of addiction and injuries that the patient claims are self-inflicted (Hachey & Phillippi, 2017).

Questions to Ask: Identifying Trafficking Red Flags

Because victims may be afraid to disclose their situation directly, asking indirect questions can help gather information and identify red flags. These questions should be asked in a private, safe setting without anyone else present.

Work and Finances

• Are you being paid the wages that were part of the initial agreement?

• Can you change jobs if you want to? Would anything happen to you if you quit your job?

• Did you pay a fee to get your job? Do you owe a debt to your employer?

• Do you have access to your money and your identification?

Freedom of Movement

• Can you come and go as you please, take bathroom breaks, and eat when you want?

• Have you moved around a lot? Do you know your current address?

• Are there locks on the doors or bars on the windows where you live? Can you leave freely?

Living and Working Conditions

• What are your home conditions like? Do you have your own bed?

• Is it too cold or too hot where you live or work?

• Are you provided with safety equipment for your job, like masks, gloves, or a safety harness?

• Does your employer provide your housing?

Safety and Threats

• Has your employer or anyone else ever threatened you?

• Are you concerned about your safety? What about your family's safety?

(Adapted from the National Human Trafficking Resource Center) 

Trauma-Informed Care

A trauma-informed care approach is essential when working with potential victims of trafficking. This approach is designed to create an environment of safety and trust and to minimize the risk of re-traumatization.

Key principles include:

• Recognize Trauma Signs: Be aware of the signs of trauma, including nonverbal cues, and make appropriate referrals.

• Create a Safe Environment: Use slow, calm speech, maintain respectful eye contact, and position oneself at the same physical level as the client. The physical layout of the room, including the location of the door, should be considered to enhance feelings of safety.

• Empower the Client: The goal is to restore a sense of power and control to the client. Allow them to make choices and lead the conversation where possible. Avoid creating a dynamic where the professional is an authority figure to be feared. It is not enough to say "this is a safe space"; the professional must earn that trust through their actions.

Communicating

The language used with a potential victim is critical for building trust. Communication should be supportive, non-judgmental, and clear.

Here are some suggested phrases:

• "We are here to help you, and our priority is your safety. We can help keep you safe."

• "Everyone has the right to live without being abused or hurt, and that includes you."

• "You deserve to be independent and make your own choices. We can help you with that."

• "We can get you help to protect your family and your children."

• "You have rights, and I will do everything in my power to help you."

• "You can decide what is best for you, but let me give you a number you can call for help 24 hours a day. You don’t even have to tell them your name."

Crucially, do not make false promises. Only offer assistance that can realistically be provided. Offering help and failing to deliver can be deeply re-traumatizing.

(Adapted from the Department of Health and Human Services) 

Cultural Competency

Cultural competency is the ability to work effectively with diverse populations. In the context of human trafficking, it involves understanding how cultural factors can influence a victim's experience and disclosure.

• Avoid Assumptions: Do not write off potential signs of trafficking as mere "cultural differences."

• Recognize Language Barriers: Language barriers can obscure discrepancies in a person's story, causing professionals to miss red flags. As stated previously, always use a professional, independent interpreter.

• Understand Cultural Stigma: A victim's immigration status or cultural stigmas around sex and abuse can be powerful barriers to disclosure.

• Examine Personal Biases: All professionals have biases. It is critical to reflect on these biases and prevent them from interfering with identification and care. For example, a bias that a person "should have known better" can completely shut down a provider's ability to see the coercion involved.

Barriers to Identification

Several factors can prevent the successful identification of trafficking victims.

• Lack of Protocols or Resources: Many organizations lack clear protocols for how to respond to a suspected case of trafficking.

• Stigma, Myths, and Stereotypes: Preconceived notions about what trafficking is and who it affects can blind professionals to the reality in front of them (e.g., the myth that it only happens in other countries).

• Lack of Privacy: It can be difficult to separate a potential victim from their trafficker, both physically and psychologically, due to the strong trauma bond that may exist.

• Incomplete History: A client may not give a full or accurate history, making it impossible to identify them as a victim.

Clinical Applications

To apply this knowledge in a clinical setting, professionals should focus on several key actions:

• Establish Trust: Work actively to identify potential victims by establishing trust and consistently practicing trauma-informed care.

• Know Local Resources: Become familiar with the National Human Trafficking Hotline as well as local shelters, advocacy groups, and other support services. Being able to provide a direct, local referral can make all the difference.

• Understand Reporting Laws: Learn the specifics of the mandatory reporting laws in the applicable state or jurisdiction.

• Pursue Further Education: Take advantage of further training opportunities, such as simulations or role-playing exercises, to build skills and confidence in identifying and responding to trafficking.

Head-to-Toe Assessment, 1

A systematic physical assessment can reveal numerous indicators of human trafficking. The following is a comprehensive guide to potential findings from a head-to-toe evaluation.

• Head/Face: Look for bruising (old, new, or healing), lacerations, hematomas, and signs of acute or chronic head trauma or headache. Check for missing hair or bald spots from hair-pulling.

• Ears/Mouth: Assess for hearing trouble, damage to the auditory canal or eardrum, and trauma to the oropharynx (e.g., lacerations, burns, ulcerations). Note any broken teeth, tooth decay, or gum irritation. The oral mucosa can also show signs of anemia or dehydration.

• Eyes/Neck: Note any visual defects, tattoos or brands hidden in the hairline or on the neck, and any signs of strangulation, such as bruising.

• Chest/Cardiovascular: Check for signs of chest trauma, heart murmurs, cigarette burns, and tattoos that imply ownership. Be aware of stress-related cardiovascular issues like arrhythmias or high blood pressure.

• Respiratory/Environmental: Inhalation injuries may be present from exposure to chemicals, toxic fumes, asbestos, or mold. Meth lab exposure can cause burning to the eyes, nose, and mouth, chest pain, and dizziness. Look for signs of tuberculosis (night sweats, coughing up blood, fever, weight loss) or signs of hypothermia/hyperthermia from poor working conditions.

• Gastrointestinal: Assess for chronic GI issues like nausea, vomiting, or abdominal pain. Check for rectal trauma, bleeding, or parasites.

Head-to-Toe Assessment, 2

The assessment should continue through the rest of the body systems, paying close attention to signs of sexual and physical abuse.

• Back/Genitourinary: Look for bruising or scarring on the back. Sexually explicit tattoos or tattoos implying advertisement in the pubic area are a major red flag.

• Obstetrical/Gynecological: Note any OB/GYN complaints, especially recurrent STIs. An STI in a minor is a powerful indicator of sexual abuse. Other signs include repeated unwanted pregnancies, forced abortions, anogenital trauma, and evidence of retained foreign bodies in the vagina. Inquire about the number of sexual partners and condom use.

• Musculoskeletal: Look for signs of repetitive trauma, work-related injuries, or injuries from forced acts (e.g., back problems from wearing heels for long hours, jaw problems from forced oral sex). Note any fractures (old or new) and contractures.

• Extremities/Skin: Check for cigarette or scald burns. Ligature marks or scars around the wrists and ankles are highly indicative of bondage. Look for skin conditions like scabies, infestations, impetigo, or fungal infections.

• Nutritional: Signs of nutritional deficits can include Vitamin D deficiency (from lack of sunlight), anemia, fine or brittle hair, signs of anorexia or bulimia, and severe electrolyte abnormalities. In children, look for growth abnormalities and poor dental health.

• Neurological: Neurological issues can include unexplained memory loss, inability to concentrate, migraines, vertigo, numbness or tingling, and seizures or pseudo-seizures. Insomnia and nightmares are also common.

Key Resource: National Human Trafficking Hotline

The single most important resource for professionals and victims is the National Human Trafficking Hotline.

• Phone: Call 1-888-373-7888.

• Text: Text "HELP" to 233733.

• Emergency: Call 911 for immediate danger.

• Live Chat: humantraffickinghotline.org

• Email: help@humantraffickinghotline.org

This confidential service does more than take tips. It connects victims and survivors to services in their local area and provides training and technical assistance to professionals. Support is available in English, Spanish, and over 200 other languages through interpreters.

Take-Home Messages

Human trafficking is a complex issue, but awareness and diligence can save lives.

• Be aware of the upstream social factors and community characteristics that make certain groups more susceptible to exploitation.

• Remember that trafficking affects people from all walks of life; do not let stereotypes prevent identification.

• Identification can happen before or during confinement. Recognizing early warning signs is a key part of prevention.

• Do not be afraid to ask direct, non-judgmental questions in a safe and private setting.

• Understand that many victims may not have the capacity or willingness to leave their situation immediately due to intense psychological manipulation and fear. Be patient and persistent in offering support.

References

Barrick, K., & Pfeffer, R. (2024). Advances in measurement: A scoping review of prior human trafficking prevalence studies and recommendations for future research. Journal of Human Trafficking, 10(1), 1–19.

Eryarsoy, E., Topuz, K., & Demiroglu, C. (2024). Disentangling human trafficking types and the identification of pathways to forced labor and sex: An explainable analytics approach. Annals of Operations Research, 335(2), 761–795.

Hopper, E. K., & Gonzalez, L. D. (2018). A comparison of psychological symptoms in survivors of sex and labor trafficking. Behavioral Medicine, 44(3), 177–188.

Okech, D., Hansen, N., Howard, W., Anarfi, J. K., & Burns, A. C. (2018). Social support, dysfunctional coping, and community reintegration as predictors of PTSD among human trafficking survivors. Behavioral Medicine, 44(3), 209–218.

Rambhatla, R., Jamgochian, M., Ricco, C., Shah, R., Ghani, H., Silence, C., ... & Kourosh, A. S. (2021). Identification of skin signs in human-trafficking survivors. International Journal of Women’s Dermatology, 7(5), 677–682.

Scaggs, S. J., Starseed, S. C., Kluckman, M., Tueller, S., & Yu, L. (2024). A state-wide analysis of characteristics and predictors of dual system involvement among child victims of human trafficking. Child Abuse & Neglect, 147, 106530.

Sidun, N. M. (2025). Understanding and combating human trafficking: A psychological perspective. American Psychologist.

State of Michigan. (1931). The Michigan Penal Code (Excerpt), Act 328 of 1931, Chapter LXVIIA: Human Trafficking. https://www.legislature.mi.gov/Laws/MCL?objectName=mcl-328-1931-LXVIIA

Trafficking, W. I. H. (n.d.). Human trafficking of children in the United States: A fact sheet for schools. Retrieved July 1, 2025.

This text-based course is an edited transcript of a live webinar, presented by Benjamin Ampel, MA, PhD candidate.

Introduction

The landscape of substance use disorders is complex, marked by a myriad of contributing factors that range from genetic predispositions to environmental influences. Among these, individual personality traits emerge as a critical dimension, offering profound insights into why certain individuals may be more susceptible to substance abuse, how their patterns of use might differ, and what therapeutic approaches could prove most effective. This article delves into the fascinating intersection of personality and substance use, providing a comprehensive overview of the theoretical frameworks and empirical evidence that illuminate these pathways. The primary focus will be on understanding how personality forms and influences behavior, identifying key personality traits linked to substance abuse, and predicting treatment outcomes of substance abuse based on personality.

The journey into understanding personality begins with a fundamental distinction between temperament and personality. Temperament, often considered the biological foundation, refers to the innate, genetically influenced behavioral and emotional patterns observable from early infancy. It is the raw material, the predispositions with which an individual is born. Personality, on the other hand, is the intricate tapestry woven when this biological temperament interacts with the environment—both the physical surroundings and the social milieu. It represents the consistent patterns of behavior that manifest across various situations and over time, shaping an individual's unique way of perceiving, thinking, and acting.

While the realm of personality is vast and multifaceted, this exploration will primarily center on the Big Five personality traits, a widely accepted and empirically supported model for describing human personality. Within this framework, particular emphasis will be placed on the dimensions of extraversion and introversion, given their significant and often counterintuitive implications for substance use. Furthermore, the discussion will extend to the Behavioral Inhibition System (BIS) and Behavioral Activation System (BAS), two neurobiological systems that offer a deeper understanding of approach and avoidance motivations, which are profoundly relevant to addictive behaviors. By integrating insights from these models, this article aims to provide a nuanced perspective on how personality shapes the trajectory of substance use disorders and how this understanding can inform more targeted and effective clinical interventions.

Disclosures

Presenter Disclosure: Financial disclosures: Benjamin Ampel received an honorarium for presenting this course. Benjamin Ampel has published peer-reviewed articles on emotional regulation and personality, along with understanding the relationship between goal pursuit, self-regulation, and emotional regulation. Non-financial disclosures: Benjamin Ampel has no relevant non-financial relationships to disclose. Content Disclosure: This learning event does not focus exclusively on any specific product or service. Sponsor Disclosure: There is no external sponsor for this course.

Limitations and Risks

Personality is complex and multifaceted this webinar is not inclusive of all personality traits and factors that impact substance use. Practitioners should actively engage in supervision and self-reflection in an effort to reduce biased clinical judgments or reduced empathy for clients due to linking certain personality traits to substance abuse. Practitioners should practice culturally humility and utilize, and/or incorporate culturally responsive frameworks into practice.

Substance Use Disorders and Personality Overview

To begin, it is essential to establish a clear understanding of what constitutes a substance use disorder (SUD). According to the DSM-5 criteria, a diagnosis of SUD is based on a maladaptive pattern of substance use leading to significant impairment or distress. This pattern is manifested by at least two of the following criteria occurring within a 12-month period. The severity of the disorder is determined by the number of criteria met.

The DSM-5 outlines four main domains of criteria for SUD:

1. Impaired Control: This domain encompasses behaviors that indicate a loss of control over substance use. Examples include taking the substance in larger amounts or over longer periods than originally intended, a persistent desire or unsuccessful efforts to cut down or control substance use, spending a great deal of time obtaining, using, or recovering from the substance's effects, and experiencing a strong craving or desire to use the substance. These indicators reflect a diminished capacity to regulate one's own consumption, even in the face of intentions to reduce or cease use.
2. Social Impairment: This domain highlights the negative impact of substance use on an individual's social and occupational functioning. Criteria include a recurrent failure to fulfill major role obligations at work, school, or home due to substance use. It also involves continued substance use despite persistent social or interpersonal problems that are caused or worsened by the effects of the substance. Furthermore, giving up or reducing important social, occupational, or recreational activities because of substance use falls under this category, indicating a narrowing of interests and a prioritization of substance use over other life domains.
3. Risky Use: This domain pertains to the use of substances in situations that pose physical hazards or despite awareness of negative consequences. It includes recurrent substance use in physically hazardous situations, such as driving under the influence or operating machinery while intoxicated. It also involves continued substance use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or worsened by the substance. This criterion underscores a disregard for one's own well-being in favor of continued substance use.
4. Pharmacological Criteria: These criteria relate to the physiological adaptations that occur with repeated substance use. Tolerance is a key indicator, characterized by a need for markedly increased amounts of the substance to achieve intoxication or the desired effect, or a markedly diminished effect with continued use of the same amount of the substance. Withdrawal is the other criterion, involving the development of a substance-specific syndrome due to the cessation of or reduction in substance use, or taking the substance (or a closely related substance) to relieve or avoid withdrawal symptoms. These physiological markers often signify a more entrenched pattern of dependence.

Understanding these diagnostic criteria provides a foundational context for exploring how personality intersects with substance use. As previously mentioned, personality is not merely an inherent trait but a dynamic construct shaped by the interplay of an individual's biological temperament and their environmental experiences. Temperament, the bedrock of personality, refers to the constitutionally based individual differences in emotional, motor, and attentional reactivity and self-regulation. These innate predispositions, evident even in infancy, influence how an individual interacts with and responds to their environment. For instance, some infants may exhibit high reactivity to novel stimuli, while others may be more subdued. These early differences can lay the groundwork for later personality traits, such as introversion or extraversion.

When this biological temperament consistently interacts with the physical and social environments over time, it solidifies into what we recognize as personality. This means that while an individual may be born with a certain predisposition, their experiences—their upbringing, social interactions, cultural context, and significant life events—all contribute to the refinement and expression of their personality traits. For example, a child with a naturally reactive temperament might, in a supportive and nurturing environment, develop coping mechanisms that lead to a resilient personality. Conversely, in a chaotic or unsupportive environment, the same temperament might manifest as heightened anxiety or withdrawal. Therefore, when examining the "personality pathways to substance abuse," it is crucial to consider this interplay, recognizing that both innate predispositions and learned behaviors contribute to an individual's vulnerability and their journey with substance use.

The Essential Trait Approach: The Big 5

To comprehend the profound influence of personality on substance use, it is imperative to first understand the prevailing framework for conceptualizing personality: the essential trait approach, which led to the development of the Big Five personality traits. The essential trait approach represents a scientific quest for a concise yet comprehensively predictive list of traits that can account for the broadest range of human behaviors. The core requirements for such a list are succinctness and non-redundancy, meaning each trait must be independent and contribute unique predictive power without overlapping significantly with others. The goal is to identify a parsimonious set of fundamental dimensions that can describe the vast complexity of human individual differences.

Given the immense vocabulary humans possess to describe personality across virtually every language and culture, a natural starting point for this quest was language itself. This led to the "lexical approach" to essential traits. The lexical hypothesis posits that the most important individual differences in human transactions will eventually become encoded in the natural language. In other words, if a personality trait is truly significant, people will have developed words to describe it. Researchers employing this approach began by sifting through dictionaries and asking individuals to describe people they knew well, identifying adjectives commonly used to characterize personality.

A seminal study illustrating this approach involved 1,300 raters who were given a list of 60 commonly used adjectives for describing people. Each rater was asked to think of a person they knew well and underline the adjectives they might use in a conversational description of that person. By analyzing which words were frequently used and which clustered together, researchers observed recurring patterns. For instance, while "bashful" and "bold" are antonyms, they both clearly describe aspects of the same underlying personality dimension. This systematic analysis of everyday language revealed that despite the seemingly endless array of descriptive terms, a finite set of core dimensions consistently emerged. This empirical process ultimately led to the identification of the Big Five personality traits, often remembered by the acronym OCEAN: Openness to Experience, Conscientiousness, Extraversion, Agreeableness, and Neuroticism.

Let us briefly delineate each of these Big Five traits and their general implications, before delving into their specific connections to substance use:

1. Openness to Experience: This trait, sometimes referred to as intellect or culture, describes an individual's receptiveness to new ideas, experiences, and unconventional thinking. People high in openness are often characterized as original, daring, independent, and artistic. They possess a broad range of interests, are imaginative, and enjoy intellectual pursuits. Conversely, individuals low in openness tend to be more conventional, practical, and prefer routine. Interestingly, openness to experience has been linked to substance use, particularly with hallucinogenic substances. Research has even suggested that the consumption of certain psychedelics, such as psilocybin, can temporarily or even enduringly increase an individual's score on openness to experience. One study, for example, found that participants who took psilocybin mushrooms scored higher in openness to experience six months later compared to a control group.
2. Conscientiousness: This trait encompasses an individual's motivation to achieve goals and their discipline in pursuing them. It reflects a tendency to be organized, persistent, and planful. Individuals high in conscientiousness are typically careful, self-reliant, scrupulous, and goal-directed. They are often seen as responsible and hardworking. While conscientiousness might intuitively appear to be a protective factor against substance use due to its association with self-control and adherence to norms, its relationship is more nuanced. Paradoxically, highly conscientious individuals, when faced with significant professional setbacks, such as job loss, tend to experience more profound negative emotional responses, including increased depression, anxiety, and reduced life satisfaction. This heightened vulnerability to stress can, in some cases, lead to the development of maladaptive coping mechanisms, including substance use, as a means to manage intense emotional distress.
3. Extraversion/Introversion: This dimension describes the degree to which an individual is outgoing and derives energy from social interaction. Extraverts are typically talkative, friendly, spontaneous, and bold, seeking frequent interactions with others and often desiring dominance or leadership roles in groups. Introverts, conversely, are described as quiet, aloof, inhibited, or timid, preferring solitude and finding social interaction energetically draining. This trait is particularly central to the discussion of substance abuse, as it profoundly influences drug preferences and responsiveness to various therapeutic modalities. The intricate biological underpinnings of this dimension, particularly in relation to cortical arousal, will be explored in greater detail.
4. Agreeableness: This trait reflects an individual's tendency towards nurturance, emotional supportiveness, and a desire to maintain harmonious relationships. Agreeable individuals are often described as good-natured, helpful, trusting, and lenient. They tend to inhibit negative emotions for the sake of others and prioritize interpersonal harmony. Conversely, individuals low in agreeableness may be more competitive, skeptical, and less concerned with others' feelings. While not as directly linked to specific drug preferences as extraversion or neuroticism, agreeableness can influence an individual's social environment and their susceptibility to peer influence, which are significant factors in substance use initiation and maintenance.
5. Neuroticism/Emotional Stability: This trait represents an individual's tendency to experience negative emotions. Individuals high in neuroticism are often described as worrying, emotional, insecure, and jealous. They are prone to experiencing anxiety, depression, anger, and other distressing emotions. Conversely, individuals low in neuroticism, or high in emotional stability, are characterized as calm, unemotional, secure, and not easily perturbed. Neuroticism is a well-established risk factor for various mental health conditions, including substance use disorders, as individuals may turn to substances as a means of self-medication to alleviate intense emotional distress. The strong link between negative affect and substance use makes neuroticism a critical personality pathway to explore.

Each of these Big Five traits, in its own intricate way, contributes to an individual's unique vulnerability and trajectory concerning substance use disorders. While some traits may appear to be protective, their interaction with life events and other personality dimensions can create complex risk profiles. This foundational understanding of the Big Five sets the stage for a more focused examination of extraversion and introversion, and the underlying biological mechanisms that drive their distinct relationships with substance use.

Extraversion and Introversion: The Big Five

Extraversion and introversion constitute a fundamental dimension within the Big Five personality framework, yet their complexities often extend beyond common understanding. This trait is not merely about being outgoing or reserved; it delves into the very source of an individual's energy and their optimal level of environmental stimulation. When discussing extraversion and introversion, it is crucial to recognize that these are relative terms, describing an individual's position on a continuum compared to others. The majority of people, approximately 66%, fall within one standard deviation of the mean, exhibiting a blend of both introverted and extraverted tendencies. This middle ground is often referred to as "ambiversion." Ambiverts are not simply neutral; they possess the capacity to draw energy from both social interaction and solitude, adapting their behavior based on the situation. They might enjoy a lively party but also value quiet time for reflection, demonstrating a flexible mix of tendencies. However, for the purpose of understanding the more pronounced effects on substance use, focusing on the extreme ends of this spectrum—the highly introverted and highly extraverted individuals—provides clearer insights.

The concepts of introversion and extraversion were originally coined by Carl Jung and later popularized by Hans Eysenck, who proposed a strong biological basis for these differences. Eysenck's theory posited that introverts and extraverts differ in their baseline levels of cortical arousal, which influences how they restore energy. Introverts, as the prefix "intro" suggests, seek to restore their energy by pulling inward, into themselves. Social interactions, especially prolonged or intense ones, are energetically draining for them, leading to fatigue. They recharge in solitude, in environments with lower external stimulation. Conversely, extraverts, deriving their name from the prefix "extra," restore their energy by reaching outside of themselves, through social interaction and engagement with the external world. They find solitude and a lack of external stimulus to be draining and even boring, which depletes their energy. This fundamental difference in energy restoration is a cornerstone for understanding their distinct behavioral patterns.

As a direct consequence of these differing energy restoration mechanisms, introverts and extraverts exhibit notable differences in sociality, as articulated by Carver and Scheier (2016). Extraverts are inherently more likely to seek out social interactions. They are often drawn to group settings and tend to seek dominance within these groups, frequently assuming leadership roles. Furthermore, and for reasons that are biologically complex, extraverts tend to experience positive emotions more frequently in general. This propensity for positive affect can further reinforce their pursuit of stimulating social environments. For an individual to gauge their own position on this spectrum, a simple self-reflection can be illustrative: consider how you feel after leaving a large social gathering. An extravert might feel energized and even seek further social engagement, while an introvert might feel depleted and crave quiet time alone to recharge. This visceral experience reflects the underlying biological differences in how their brains process and react to external stimuli.

The distinction between introversion and extraversion extends beyond social preferences, manifesting in various aspects of life, including drug preference, communication styles, choice of workplace, and approaches to relationships. These differences are rooted in varying optimal levels of stimulation. Eysenck's arousal theory, further supported by research from Bullock and Gilliland (1993), suggests that introverts have chronically higher levels of cortical arousal, meaning their brains are naturally more active even in low-stimulus environments. In contrast, extraverts have chronically lower levels of cortical arousal, leading them to seek out more external stimulation to reach their optimal arousal level.

Consider a spectrum of stimulation, ranging from low (e.g., lying still in a dark, quiet room) to high (e.g., being yelled at by an angry mob). For an introvert, their optimal level of stimuli might be a quiet conversation with a familiar acquaintance. This level of interaction provides sufficient stimulation without overwhelming their already highly aroused nervous system. For an extravert, however, this same quiet conversation might be understimulating, leading them to seek out environments with louder music, more people, or more intense interactions to reach their preferred level of cortical arousal. Both introverts and extraverts are ultimately seeking an optimal level of brain activity, but they require different amounts of external stimulation to achieve it. An introvert's brain lights up more in response to the same stimulus compared to an extravert's brain. This means that a loud party, which might be exhilarating for an extravert, could be profoundly overwhelming and draining for an introvert, as their neural activity spikes significantly in response to the high sensory input. This fundamental difference in how their brains process and react to stimuli explains their divergent preferences and behaviors across various life domains.

Affect and Arousal

Before delving deeper into the biological underpinnings of personality and its connection to substance use, it is important to clarify two key terms: affect and arousal.

Affect: In psychology, affect refers to an emotion or feeling. It is the experience of emotion, such as joy, sadness, anger, fear, or interest. Affect is a subjective experience, but it can be expressed through observable behaviors, facial expressions, and physiological changes. When discussing personality, affect often refers to an individual's general emotional disposition or their tendency to experience certain types of emotions more frequently.

Arousal: Arousal refers to the level of physiological activation in the body and brain. It is a state of being awake, alert, and responsive to stimuli. Physiologically, arousal is reflected in various bodily responses, including heart rate, blood pressure, breathing rate, and neural activity in the brain. High arousal signifies a state of alertness and readiness for action, while low arousal indicates a state of relaxation or sleepiness. In the context of introversion and extraversion, arousal specifically refers to cortical arousal, or the level of activity in the brain's cerebral cortex. Understanding these terms is crucial for grasping the biological mechanisms that differentiate personality types and influence their interactions with substances.

Introversion-Extraversion: Biological Basis 

The profound differences observed between introverts and extraverts in their preferred levels of stimulation, energy restoration, and social engagement are not merely psychological constructs; they are rooted in distinct biological mechanisms. A compelling perspective on this biological basis comes from Desmond Morris's (1969) concept of the "stimulus struggle," drawing parallels from the animal kingdom. Morris categorized species into specialists and opportunists. Specialists thrive by having a highly efficient, specialized method for obtaining food, which reduces their need to explore diverse environments. Opportunists, conversely, have evolved to specialize in exploration, requiring high levels of environmental stimulation to thrive. Morris posited that humans, as opportunistic animals, also engage in a "stimulus struggle," seeking an optimal balance—not too much, but not too little—of stimulation. This inherent variability in the need for stimulation among humans, Morris suggested, manifests as introversion and extraversion.

This idea aligns with the observation that introverts and extraverts have chronically different levels of cortical arousal in response to stimuli. As previously noted, introverts exhibit higher baseline cortical arousal, meaning their brains are more active even in quiet environments. Consequently, they require less external stimulation to reach their optimal arousal level and can easily become overstimulated. Conversely, extraverts have lower baseline cortical arousal, necessitating more external stimulation to achieve their desired level of brain activity. This difference in preferred stimulus level explains their divergent choices in environments and activities, as both types are ultimately striving for a similar, comfortable level of cortical arousal. For instance, an introvert's brain might experience significant neural activity from a quiet conversation, while an extravert might need the intensity of a loud party to achieve the same level of internal "buzz."

Empirical evidence supports these physiological distinctions. Gray (1970) demonstrated that introverts show an increased brain-stem auditory evoked response (B.A.E.R.) to startling noises. In studies where participants were exposed to static noises of varying decibel levels, introverts consistently exhibited a stronger neural response—more neurons firing—to the same sound intensity compared to extraverts. This means that a car door slamming, or loud music at a party, literally causes more brain activity and a greater sense of overwhelm for an introvert. This heightened reactivity explains why introverts find high-stimulus environments more challenging and why they prefer quieter settings where their brains are not constantly bombarded by excessive sensory input.

The key neurological structure implicated in regulating cortical arousal is the Ascending Reticular Activation System (ARAS). The ARAS is a network of neurons located in the brainstem that connects the cerebral cortex to the rest of the brain. Often referred to as the "ignition system" of the brain, the ARAS is responsible for regulating overall arousal, wakefulness, and the filtering of sensory information. Damage to the ARAS can result in severe states of reduced consciousness, such as a coma, underscoring its critical role in maintaining alertness and responsiveness. The ARAS also plays a vital role in filtering out extraneous sensory information, allowing individuals to focus on relevant stimuli. For example, the constant tactile sensation of clothing on one's skin is typically filtered out by the ARAS, preventing sensory overload. Furthermore, the ARAS regulates sleep and wakefulness, with lower neuronal firing rates during sleep and higher activity levels during waking states. Its regulatory functions are mediated through various neurotransmitter systems, including GABAergic, adrenergic, and dopaminergic pathways, which influence neural activity and arousal levels.

In the context of introversion and extraversion, the ARAS functions differently. For introverts, their ARAS requires less stimulation to become overstimulated, leading to a rapid and significant increase in cortical arousal. This inherent sensitivity means that even moderate levels of external stimuli can quickly push an introvert's brain beyond its optimal arousal threshold, leading to feelings of being overwhelmed or drained. Conversely, extraverts require larger amounts of stimulation to activate their ARAS sufficiently, prompting them to actively seek out more stimulating environments and activities to achieve their desired level of cortical arousal. Recent research further supports this, showing that extraverts exhibit less brain activity in certain areas during memorization tasks and have lower resting brain activity when deprived of stimulation. This under-stimulation is a profoundly uncomfortable feeling for extraverts, driving their continuous pursuit of higher levels of external engagement.

This biological distinction profoundly influences various aspects of an individual's life. For instance, communication styles differ markedly. Extraverts tend to be more blunt, forceful, and prone to pushing social boundaries, such as using nicknames quickly or initiating physical touch, as these behaviors generate stimulating social feedback. Introverts, being chronically overstimulated, are more cautious and less inclined to engage in such boundary-pushing behaviors, as their brains are already working overtime. Workplace preferences also diverge; open-plan offices, designed for constant interaction and stimulation, are often ideal for extraverts but can be detrimental to introverts' cognitive functioning and memory due to sensory overload. Relationship approaches also reflect these differences, with extraverts often seeking broader social networks and introverts preferring deeper, more intimate connections.

Crucially, these biological differences in cortical arousal and ARAS functioning also impact drug preferences. Extraverts, with their chronically under-stimulated brains, tend to gravitate towards stimulants such as caffeine, cocaine, methamphetamine, and MDMA. These substances artificially increase neural firing and cortical arousal, helping extraverts achieve their desired level of internal stimulation. For them, a stimulant can make a quiet conversation feel more engaging or provide the "speed" they naturally crave. Conversely, introverts, who are often chronically overstimulated, tend to prefer depressants and anxiolytics. Substances like alcohol, benzodiazepines (e.g., Valium, clonazepam), and other GABAergic agonists literally slow down neural firing, reducing cortical arousal and helping introverts feel less overwhelmed, particularly in social environments. This allows them to function more comfortably in highly stimulating settings that might otherwise be unbearable. However, this preference also carries the risk of developing dependence on these substances to navigate everyday social interactions or to find solace in solitude, often leading to private and isolated patterns of substance use. Understanding this biological basis is paramount for developing targeted and effective interventions for substance use disorders, recognizing that different personality types may require distinct therapeutic approaches.

Extraversion & Substance Use

The inherent drive for stimulation in extraverted individuals creates distinct pathways to substance use, often mediated by social contexts and positive expectancies. Research consistently highlights several mechanisms through which extraversion is linked to substance abuse.

One significant mechanism is the social-amplification pathway. Extraverts are naturally drawn to social gatherings and environments that offer high levels of stimulation. These settings frequently involve alcohol and other substances, leading to increased exposure and opportunities for use. A longitudinal study of 1,200 first-year undergraduates, for example, found that high extraversion predicted earlier alcohol initiation and a greater number of drinking days throughout their freshman year (Geeraerts & Cooper, 2022). This suggests that the extravert's desire for social engagement and excitement places them in situations where substance use is prevalent, thereby amplifying their risk. Even though alcohol is a depressant, and extraverts generally prefer stimulants, the social context in which alcohol is consumed often provides the stimulating environment that extraverts seek. They are drawn to the party culture, the lively interactions, and the overall buzz of social events where alcohol is a common lubricant. This social aspect can override the physiological effects of alcohol as a depressant, making it appealing for its ability to facilitate social interaction and reduce social anxiety, particularly for extraverts who may also experience neurotic tendencies.

Another crucial mechanism is the positive-expectancy mechanism. Extraverts tend to hold stronger positive expectancies regarding the effects of alcohol and other substances. They anticipate that substance use will enhance their social experiences, increase pleasure, and reduce inhibitions, thereby facilitating the very social engagement they crave. A meta-analysis of 46 studies revealed that extraversion was significantly associated with stronger positive alcohol expectancies, and these expectancies fully mediated the frequency of heavy-episodic drinking (Kuntsche et al., 2021). This means that extraverts are more likely to believe that drinking will lead to desirable outcomes, which in turn drives their higher rates of consumption, particularly in binge drinking scenarios. The expectation of amplified positive social experiences fuels their engagement with substances.

Furthermore, there is a clear drug specificity linked to extraversion. Due to their chronically under-stimulated cortical arousal, extraverts exhibit a pronounced preference for stimulants. These substances, such as caffeine, cocaine, and methamphetamine, artificially increase neural activity, helping extraverts achieve their desired level of internal stimulation. A twin analysis, controlling for shared genetics, found that extraversion was uniquely linked to stimulant and cocaine use (Dash, Martin, & Slutske, 2023). This preference is not merely anecdotal; it is rooted in the biological drive to compensate for lower baseline brain activity. For an extravert, a stimulant can make an otherwise mundane situation feel more engaging and exciting, aligning with their inherent need for high levels of arousal. This explains why they might be more drawn to substances that "speed up" their internal experience, making social interactions and other activities feel more vibrant and stimulating.

It is also important to consider the interplay between extraversion and other personality traits, such as neuroticism. An individual can be a highly neurotic extravert, meaning they are outgoing and seek stimulation but also experience significant anxiety. In such cases, alcohol, despite being a depressant, can function as an anxiolytic, reducing their anxiety in social settings. This dual effect—providing social lubrication and anxiety reduction—can make alcohol particularly alluring, increasing the likelihood of binge drinking episodes. The combination of a desire for high stimulation and a need to manage anxiety can create a complex vulnerability profile for extraverted individuals.

Clinical & Treatment Implications for Extraversion

Understanding the unique characteristics of extraverted individuals has significant implications for tailoring effective clinical interventions for substance use disorders. Treatment strategies for extraverts should leverage their inherent social energy and desire for stimulation, while also addressing their specific vulnerabilities.

1. Leverage Social Energy: Extraverts thrive in environments that offer social interaction and engagement. Therefore, treatment approaches should actively incorporate group-based modalities. This includes group cognitive behavioral therapy (CBT), where the interactive nature of the setting can keep extraverts engaged and motivated. Peer-led recovery meetings, such as Alcoholics Anonymous (AA) or Narcotics Anonymous (NA), can be highly beneficial, as they provide a structured social environment and opportunities for connection. While AA generally works equally well for introverts and extraverts once engaged, extraverts may find the group dynamics and shared experiences particularly appealing, fostering a sense of belonging and accountability. Additionally, organizing "sober socials" or other pro-social, substance-free activities can provide extraverts with the stimulation and social connection they crave without the involvement of substances. These interactive activities can boost attendance and engagement in recovery programs.
2. Watch Party Culture and Protective Behavioral Strategies: Extraverts are often drawn to high-stimulation settings, such as parties, concerts, or sporting events, where substance use might be prevalent. Instead of advocating for complete avoidance of such environments, which may be unrealistic or unsustainable for some extraverts, it is crucial to teach protective behavioral strategies (PBS). These strategies aim to reduce the risks associated with substance use in high-stimulation settings. Examples include pacing drinks, alternating alcoholic beverages with water, setting limits on consumption, avoiding drinking games, and having a designated sober friend. For extraverts, who may get caught up in the excitement and social dynamics of these environments, learning how to navigate them safely is paramount to preventing binge drinking episodes.
3. Use Motivational Incentives: Extraverts are often driven by external rewards and recognition. Incorporating motivational incentives into treatment can significantly enhance their engagement and retention. This could involve public recognition boards for achieving sobriety milestones, offering leadership roles in after-care programs or peer support groups, or providing voucher incentives for adherence to treatment goals. Public acknowledgment and opportunities to lead can tap into an extravert's desire for dominance and social validation, keeping them motivated and invested in their recovery journey.
4. Address Relapse Triggers: For extraverts, common relapse triggers often include loneliness and boredom. When deprived of the external stimulation and social interaction they naturally crave, extraverts can experience significant discomfort and a strong urge to seek out substances as a means of alleviating this under-stimulation. Therefore, during early abstinence, it is critical to help extraverts schedule pro-social, substance-free activities. This proactive approach ensures that their need for engagement and connection is met through healthy outlets, reducing the likelihood of turning back to substances. Therapists should work with extraverted clients to identify and plan for periods of potential boredom or isolation, equipping them with a repertoire of alternative, stimulating activities.

While extraverts generally form rapport easily and are highly engaging in therapy, clinicians should be mindful of their potential for quick boredom. Therapy sessions, particularly those involving deep introspection or slow processing of emotions, might feel less stimulating than what an extravert is accustomed to. Therefore, therapists may need to employ more active, engaging techniques, incorporate varied activities, and maintain a dynamic pace to keep extraverted clients invested. The goal is to channel their natural drive for engagement and reward-seeking into the recovery process, transforming their inherent personality traits into assets for long-term sobriety.

Brain Asymmetry: Hemispheric Dominance and Personality

Beyond the broad dimensions of personality, a deeper understanding of individual differences can be found in the subtle yet significant variations in brain activity, particularly in the concept of brain asymmetry or hemispheric dominance. This area, however, has often been subject to popular misconceptions that warrant clarification. The notion of being "right-brained" (creative, emotional, holistic) versus "left-brained" (logical, verbal, analytical) is a sweeping generalization that lacks scientific accuracy. While certain functions, such as language production (e.g., Broca's area), are predominantly localized in one hemisphere, the brain functions as an integrated whole, with both hemispheres constantly communicating and collaborating. Therefore, it is crucial to distinguish scientific understanding from pop-psychology simplifications. This discussion will not delve into psychological interventions like Eye Movement Desensitization and Reprocessing (EMDR) or neurolinguistic programming, nor will it address outdated concepts of "masculine versus feminine hemispheres."

Instead, brain asymmetry, in a scientifically grounded context, refers to the quantifiable differences in activation levels between the right and left sides of the brain, typically measured through techniques like electroencephalography (EEG). This difference is often expressed as a numerical value: a negative number indicates higher activity on the left side of the brain, while a positive number indicates a higher degree of activity on the right side of the brain. These differences, even at rest, have been found to predict an individual's emotional disposition. Specifically, research has shown that individuals with greater right frontal EEG activity (positive asymmetry) tend to exhibit more pessimistic emotional dispositions. Conversely, those with greater left frontal EEG activity (negative asymmetry) are often characterized by more upbeat or optimistic emotional dispositions.

Further research has refined this understanding by examining brain asymmetry in response to emotional stimuli. When participants were exposed to films designed to elicit specific emotions, individuals with higher left hemisphere activity were more responsive to positive mood films, experiencing and expressing more positive affect. Conversely, those with higher right hemisphere activity showed greater responsiveness to negative mood films, indicating a heightened sensitivity to distressing emotions. This suggests that hemispheric dominance is not merely a static state but influences how individuals process and react to emotional information from their environment.

The initial understanding of total differences in hemispheric dominance was limited by the sensitivity of older EEG technology, which could not pinpoint specific brain regions with precision. However, advancements in neuroimaging have allowed researchers to describe these differences more accurately in terms of approach and avoidance emotional tendencies. This refined perspective posits that distinct neural circuits are responsible for motivating behavior towards desired outcomes (approach) and away from undesired ones (avoidance).

Specifically, left hemisphere activity is associated with approach behaviors and emotions. This includes emotions such as joy, interest, and even anger (when anger is directed towards overcoming an obstacle or achieving a goal). The left prefrontal cortex, in particular, is linked to the Behavioral Activation System (BAS), which drives individuals towards incentives and rewards.

In contrast, right hemisphere activity is associated with avoidance behaviors and emotions. This includes emotions such as distress, disgust, and fear, which motivate withdrawal from perceived threats or negative stimuli. The right prefrontal cortex is linked to the Behavioral Inhibition System (BIS), which is responsible for inhibiting behavior in the face of potential punishment or danger.

This shift in understanding from broad hemispheric dominance to specific approach and avoidance systems provides a more nuanced and clinically relevant framework for understanding how brain asymmetry influences personality and, by extension, vulnerability to substance use disorders. It highlights that emotional disposition is not simply about being generally "positive" or "negative," but rather about the relative strength of one's motivational systems for engaging with or withdrawing from the world.

BIS/BAS: Behavioral Activation System and Behavioral Inhibition System

The Behavioral Inhibition System (BIS) and the Behavioral Activation System (BAS) represent two fundamental neurobiological systems that underpin individual differences in motivation, emotion, and behavior, offering a powerful framework for understanding personality pathways to substance use. These systems, rooted in brain asymmetry, govern an individual's sensitivity to cues of punishment versus reward.

The Behavioral Inhibition System (BIS) is a neurological system in the brain that is primarily responsible for causing individuals to withdraw from undesirable stimuli or potential threats. It is associated with vigilance, anxiety, and a tendency to inhibit ongoing behavior in the face of punishment or non-reward. Individuals with a highly active BIS are more sensitive to cues of punishment and tend to experience emotions like distress, disgust, and fear. Self-reports of high BIS sensitivity are correlated with higher activity levels in the right frontal area of the brain, particularly the right prefrontal cortex. This system is thought to involve serotonin activity, which plays a role in modulating mood and anxiety. Greater BIS activity is characteristic of introversion, neuroticism, and low agreeableness, as these traits are often associated with caution, emotional reactivity to negative stimuli, and a tendency to avoid social conflict or perceived threats.

Conversely, the Behavioral Activation System (BAS) directs individuals toward certain desirable goals or incentives. It is responsible for approach emotions such as joy, interest, and even anger when it serves as a motivator to overcome obstacles. Individuals with a highly active BAS are more sensitive to cues of reward and tend to pursue goals vigorously. Self-reports of high BAS sensitivity are correlated with higher activity levels in the left frontal area of the brain, particularly the left prefrontal cortex. This system is strongly linked to dopamine activity, a neurotransmitter crucial for reward processing and motivation. Greater BAS activity is characteristic of extraversion and openness to experience, as these traits are associated with a drive for novelty, social engagement, and a general pursuit of positive experiences.

It is important to understand that BIS and BAS sensitivities are not mutually exclusive; an individual can be high in both, low in both, or high in one and low in the other. Temperament differences often emerge as a relative balance between positive affect/approach behaviors (BAS) and negative affect/inhibition behaviors (BIS).

• BAS sensitivity (Dornbach-Bender et al., 2020) magnifies an individual's reactions to positive events and correlates with higher self-reported positive affect. These individuals are highly responsive to rewards and are motivated by the anticipation of pleasure.
• BIS sensitivity (Lin et al., 2023) magnifies an individual's reactions to negative events and is strongly related to neuroticism. These individuals are highly responsive to potential punishments and are motivated by the avoidance of pain or negative outcomes.

The interplay of these systems can explain various psychological difficulties:

• Anxiety: Often indicative of an oversensitive BIS activity, where individuals are excessively vigilant to potential threats and prone to worry and avoidance behaviors.
• Depression: Can be associated with high BIS activity (increased sensitivity to negative experiences) coupled with weak BAS activity (reduced motivation to pursue rewards and experience pleasure).
• Antisocial personality: Often characterized by high BAS activity (strong drive for reward and sensation-seeking) combined with low BIS activity (weak responsiveness to punishment or negative consequences), leading to impulsive and reckless behaviors without sufficient inhibition.

Understanding the relative strengths of an individual's BIS and BAS provides a powerful lens through which to view their vulnerability to substance use disorders and to tailor interventions more effectively.

BIS/BAS and Substance-Use Disorders

The Behavioral Inhibition System (BIS) and Behavioral Activation System (BAS) framework provides a robust explanation for distinct pathways to substance use disorders, influencing drug preference, craving, and relapse patterns. The differential sensitivity to reward and punishment cues, mediated by these systems, plays a critical role in shaping an individual's relationship with substances.

High BAS (Reward Sensitivity): Individuals with a highly active BAS are inherently more sensitive to cues of reward and are driven by the pursuit of pleasure and positive experiences. This heightened reward sensitivity has been consistently linked to various aspects of substance use. Research indicates that high BAS is associated with earlier initiation of substance use, higher frequency of use, and greater polysubstance involvement (Loxton & Dawe, 2001; Keough & O’Connor, 2014). This is particularly true for stimulants and alcohol. Stimulants, by their very nature, directly activate the brain's reward pathways, providing the intense positive reinforcement that high BAS individuals crave. Alcohol, while a depressant, is often consumed in social, stimulating environments that offer immediate rewards (e.g., social connection, reduced inhibition), making it appealing to those driven by BAS.

Furthermore, a BAS-dominant profile strongly predicts stronger cue-induced craving and rapid reinstatement after abstinence (Franken & Muris, 2006). This means that individuals with a high BAS are more likely to experience intense cravings when exposed to environmental cues associated with substance use (e.g., seeing a bottle of alcohol, being in a place where they used to use). Their strong drive for reward makes them highly susceptible to these triggers, leading to a quicker return to substance use even after periods of abstinence. The anticipation of pleasure and the memory of past rewards associated with the substance exert a powerful pull, making sustained recovery challenging without targeted interventions.

High BIS (Punishment Sensitivity): Conversely, individuals with a highly active BIS are more sensitive to cues of punishment, threat, and negative emotional states. Their motivation is often driven by the desire to avoid pain, anxiety, or discomfort. This heightened punishment sensitivity influences their drug preference, leading them towards substances that dampen negative affect. High BIS sensitivity is associated with a preference for anxiolytic or depressant drugs, such as opioids and benzodiazepines (e.g., Valium, Xanax), and alcohol (Simons, Wills, & Gibbons, 2009). These substances provide a sense of calm, reduce anxiety, and alleviate emotional distress, offering a temporary escape from the discomfort associated with an overactive BIS. For these individuals, substance use is often a form of self-medication, a means to quiet an agitated internal state or to cope with overwhelming negative emotions.

Moreover, a BIS-dominant profile is strongly associated with relapse under stress or social threat, mediated by worry and avoidance coping (Keough & O’Connor, 2014). When faced with stressful situations, interpersonal conflicts, or perceived social threats, individuals with a high BIS are more likely to experience intense anxiety and engage in avoidance behaviors. Substance use becomes a readily available coping mechanism to escape these uncomfortable feelings, even if it leads to long-term negative consequences. The cycle of stress, anxiety, avoidance, and substance use can be particularly entrenched for BIS-dominant individuals, making stress management and anxiety-focused strategies crucial components of their treatment.

In summary, the BIS/BAS framework highlights that substance use is not a monolithic phenomenon but rather a multifaceted issue driven by distinct motivational pathways. High BAS individuals are drawn to substances for their rewarding, pleasure-enhancing effects, leading to a focus on approach-based motivations. High BIS individuals, on the other hand, are drawn to substances for their anxiety-reducing, pain-dampening effects, driven by avoidance motivations. Recognizing these differential sensitivities is paramount for clinicians to develop personalized and effective treatment strategies that address the unique underlying motivational drivers of each client's substance use disorder.

BIS/BAS-Informed Treatment Implications

The insights derived from the Behavioral Inhibition System (BIS) and Behavioral Activation System (BAS) framework offer invaluable guidance for tailoring treatment interventions for substance use disorders. By understanding a client's predominant motivational system—whether they are primarily driven by reward seeking (BAS) or punishment avoidance (BIS)—clinicians can design more effective and personalized therapeutic strategies.

For High BAS Clients (Reward Sensitivity):

High BAS clients, characterized by their strong drive for reward and sensitivity to incentives, respond best to approach-based interventions that emphasize immediate gains and positive reinforcement.

1. Contingency Management: This is a highly effective approach for high BAS individuals. It involves providing tangible rewards (e.g., vouchers, privileges) for desired behaviors, such as negative drug tests or attendance at treatment sessions. The immediate and consistent reinforcement directly taps into their reward-seeking motivation, making abstinence and treatment adherence more appealing.
2. Voucher Incentives: Similar to contingency management, voucher programs offer monetary or other valuable incentives that can be exchanged for goods or services. This provides a clear, tangible reward system that aligns with the BAS drive for positive outcomes.
3. Goal-Oriented Cognitive Behavioral Therapy (CBT): CBT approaches that frame abstinence as an immediate gain, focusing on the positive rewards of sobriety (e.g., improved health, better relationships, financial stability), are particularly effective. This involves helping clients identify and pursue new, healthy goals that provide a sense of accomplishment and reward, replacing the gratification previously sought from substances.
4. Tailoring Motivational Interviewing Frames: "Possible Selves" (BAS-focused): In motivational interviewing, clinicians can leverage the concept of "possible selves" to highlight a rewarding future self. For high BAS clients, this means emphasizing the "thriving sober self"—a future where they experience increased joy, success, social connection, and personal fulfillment as a direct result of abstinence. This positive vision taps into their intrinsic motivation for reward and achievement.
5. Integrating BIS/BAS Assessments: Utilizing assessments like the Carver-White scale at intake can provide valuable information about a client's BIS/BAS profile. This allows for improved treatment-matching and has been shown to predict treatment retention (Daughters et al., 2008). Knowing a client's motivational tendencies from the outset enables clinicians to select interventions that are most likely to resonate and be effective.

For High BIS Clients (Punishment Sensitivity):

High BIS clients, who are more sensitive to punishment and driven by the avoidance of negative emotional states (like anxiety), benefit most from anxiety-focused strategies that reduce punishment expectancy and provide effective coping mechanisms for distress.

1. Mindfulness: Mindfulness-based interventions, such as Mindfulness-Based Relapse Prevention (MBRP), are highly beneficial. These practices help clients develop a non-judgmental awareness of their internal experiences, including cravings and anxiety, without being overwhelmed by them. By observing thoughts and feelings without reacting impulsively, clients can reduce their reliance on substances as an avoidance strategy. Mindfulness helps to lower craving and improve emotional regulation, offering a quiet coping skill that aligns with an introvert's preference for less external stimulation.
2. Exposure Plus Relaxation: This therapeutic technique involves gradually exposing clients to anxiety-provoking situations or cues (e.g., places where they used to use, stressful social scenarios) while simultaneously teaching and practicing relaxation techniques. This helps to reduce the conditioned fear response and build tolerance to discomfort without resorting to substance use. It directly addresses the avoidance motivation characteristic of high BIS individuals.
3. Safety-Planning: Developing comprehensive safety plans helps high BIS clients identify potential triggers for anxiety and relapse and pre-plan concrete strategies to manage these situations without using substances. This reduces the uncertainty and perceived threat, thereby decreasing punishment expectancy and enhancing their sense of control.
4. Tailoring Motivational Interviewing Frames: "Possible Selves" (BIS-focused): For high BIS clients, motivational interviewing can emphasize the "feared future self" or a "rock-bottom" scenario. This approach leverages their avoidance motivation by highlighting the negative consequences of continued substance use (e.g., health deterioration, loss of relationships, financial ruin). By vividly contrasting their current struggles with a potentially worse future, clinicians can motivate clients to pursue abstinence as a means of avoiding these feared outcomes (Simons et al., 2009).
5. Individualized and Smaller Group Therapies: Introverts, who often characterize high BIS profiles, tend to have a slower alliance formation in therapy. Building rapport and disclosing intimate details can be highly stimulating and overwhelming for them. Therefore, one-on-one motivational interviews or cognitive behavioral therapy in small groups (rather than large ones) are often more effective. In larger groups, extraverts may dominate, causing introverts to withdraw and limit their disclosure, thereby hindering their therapeutic progress. The increased availability of telehealth services, particularly since the pandemic, has also proven beneficial for naturally introverted individuals, allowing them to engage in therapy from the comfort of their own environment, reducing external stimulation.

By integrating BIS/BAS assessments at intake and tailoring interventions accordingly, clinicians can significantly improve treatment-matching and predict retention rates. This personalized approach acknowledges the unique motivational landscape of each client, fostering greater engagement and ultimately leading to more successful and sustainable recovery outcomes.

Conclusion

The journey through the intricate pathways connecting personality to substance use disorders reveals a profound and multifaceted relationship. It underscores that vulnerability to addiction is not a monolithic phenomenon but rather a complex interplay of innate temperament, learned behaviors, and underlying neurobiological systems. By delving into the Big Five personality traits, with a particular focus on extraversion and introversion, and the Behavioral Inhibition System (BIS) and Behavioral Activation System (BAS) framework, this article has illuminated how individual differences shape drug preferences, patterns of use, and responsiveness to therapeutic interventions.

We have seen that personality, as the dynamic outcome of temperament interacting with environmental influences, provides a consistent lens through which to understand an individual's behavioral patterns across time and situations. The Big Five model—encompassing Openness to Experience, Conscientiousness, Extraversion, Agreeableness, and Neuroticism—offers a comprehensive yet succinct framework for categorizing these enduring traits. While each trait contributes uniquely to an individual's risk profile, the dimensions of extraversion and introversion stand out due to their direct links to cortical arousal and the pursuit or avoidance of stimulation.

The biological basis of introversion and extraversion, particularly the role of the Ascending Reticular Activation System (ARAS) in regulating cortical arousal, provides a compelling explanation for divergent preferences. Extraverts, with their chronically under-stimulated brains, gravitate towards stimulants and high-stimulation environments, seeking to elevate their arousal to an optimal level. Their social-amplification and positive-expectancy pathways often lead to earlier initiation and higher frequency of substance use, especially alcohol and stimulants, within social contexts. Conversely, introverts, with their chronically higher baseline arousal, prefer depressants and quieter environments, using substances to dampen overwhelming neural activity and cope with anxiety or social overstimulation.

The BIS/BAS framework further refines this understanding, distinguishing between approach-motivated (BAS) and avoidance-motivated (BIS) individuals. High BAS sensitivity predicts a preference for rewarding substances and a heightened risk of cue-induced craving and relapse driven by the pursuit of pleasure. High BIS sensitivity, on the other hand, is linked to a preference for anxiolytic substances and a greater susceptibility to relapse under stress, driven by the desire to alleviate discomfort and avoid negative emotions.

The clinical implications of this knowledge are profound. Recognizing a client's predominant personality traits and motivational systems allows for the tailoring of interventions, moving beyond a one-size-fits-all approach. For extraverted, high BAS clients, strategies that leverage their social energy, provide positive incentives, and teach protective behavioral strategies in stimulating environments are crucial. Group therapies, peer-led recovery, and goal-oriented CBT that frames abstinence as immediate gain can be highly effective. For introverted, high BIS clients, anxiety-focused strategies, mindfulness, exposure with relaxation, and safety planning are paramount. Individualized therapy or smaller group settings, where they feel less overwhelmed, are often more conducive to building rapport and facilitating disclosure. Tailoring motivational interviewing to emphasize either "thriving sober selves" (for BAS) or "feared future selves" (for BIS) can further enhance engagement.

Ultimately, integrating personality assessments and principles into substance abuse treatment fosters a more empathetic, nuanced, and effective approach. By understanding the unique internal landscape of each client—their inherent drives, sensitivities, and coping mechanisms—clinicians can develop personalized pathways to recovery that resonate with the individual, enhancing treatment retention and promoting long-term sobriety. This holistic perspective not only improves clinical outcomes but also deepens our appreciation for the rich tapestry of human diversity in the journey towards healing.

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Dornbach-Bender, A., Ruggero, C. J., Smith, P., & Schuler, K. (2020). Association of behavioral activation system sensitivity to lower-level facets of positive affect in daily life. Personality and Individual Differences, 152, 109570. https://doi.org/10.1016/j.paid.2019.109570

Franken, I. H. A., & Muris, P. (2006). Gray’s impulsivity dimension and substance use: BIS/BAS personality characteristics and cannabis use in adolescents. Addictive Behaviors, 31(5), 849–854. https://doi.org/10.1016/j.addbeh.2005.06.012

Geeraerts, S. B., & Cooper, M. L. (2022). Extraversion and alcohol use in the first year of college: A daily-diary approach. Addictive Behaviors, 131, 107293. https://doi.org/10.1016/j.addbeh.2022.107293

Gray, J. A. (1970). The psychophysiological basis of introversion–extraversion. Behaviour Research and Therapy, 8(3), 249–266. https://doi.org/10.1016/0005-7967(70)90069-0

Keough, M. T., & O’Connor, R. M. (2014). Clarifying the role of worry in substance-use behaviors using the BIS/BAS framework. Addictive Behaviors, 39(9), 1391–1398. https://doi.org/10.1016/j.addbeh.2014.04.017

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Additional Current References

Please Note: The following resources have been included as additional resources associated with this topic area. These resources were not used by the presenter when creating this course.

Ayhan, C. H., Aktas, M. C., Aktaş, S., & Ali Tarakçi, A. S. (2025). The examination of the relationship between 5-factor personality traits and social anxiety among Iindividuals with alcohol and substance use disorders. Eastern Journal of Medicine, 30(1), 82–90. https://doi-org.ezproxy.uu.edu/10.5505/ejm.2025.98853

Forstmann, M., & Sagioglou, C. (2025). The content, consistency and accuracy of stereotypes about recreational users of various psychoactive substances. European Journal of Social Psychology, 1. https://doi-org.ezproxy.uu.edu/10.1002/ejsp.3162

Jain, T., Patriquin, M., & Sanches, M. (2025). Associations between big five personality dimensions and lifetime use of cannabis. American Journal on Addictions, 34(3), 322–326. https://doi-org.ezproxy.uu.edu/10.1111/ajad.13668

Martínez-Gabaldón, E., & Martínez-Pérez, J. E. (2025). Personality traits and drug use: A longitudinal study using data from the British Cohort Study. European Addiction Research, 30(6), 357–365. https://doi-org.ezproxy.uu.edu/10.1159/000541265

Sharifibastan, F., Erevik, E. K., Morken, K. T. E., & Pallesen, S. (2025). Associations between HEXACO personality traits, substance use disorders, and behavioral addictions: a protocol for a comprehensive systematic review and meta-analysis. Systematic Reviews, 14(1), 1–10. https://doi-org.ezproxy.uu.edu/10.1186/s13643-024-02741-8

Editor’s note: This text-based course is an edited transcript of the webinar, The Psychology Behind the Need for Technology in U.S. Society, presented by Taeler Hammond, MA.

Learning Outcomes

After this course, participants will be able to:

• Describe the feelings they have with and without using technology.
• Identify technology dependencies in ourselves and in others.
• Analyze the behavior that comes along with breaking our technology habits.

Risks and Limitations

The information provided in this lecture is for general informational purposes only and does not constitute medical, psychological, or specific intervention for clinical populations. This lecture is not a substitute for professional medical or psychological advice, diagnosis, or treatment. Individual and population considerations should be explored prior to using specific interventions/change methods. It is recommended that viewers seek medical/clinical consultation if struggling with anxiety, depression, suicidal ideation, or other forms of distress. The information provided comes from an industrial/organizational psychology lens. 

Does the Use of Technology Impact our Mental Health?

I always begin my classes with a quote. Today's quote is from Albert Einstein: "It has become appallingly obvious that our technology has exceeded our humanity." Consider the time when Einstein wrote or spoke these words—a time devoid of iPhones, Androids, social media, and AI. Yet, even then, the trajectory of technology's dominance was evident.

The Impacts of Technology on Our Minds

Our first topic is: does technology affect our mental health? As we explore this, consider your own relationship with technology. We've all become accustomed to using technology. It's normal to wake up and reach for our phones and to spend long hours on our computers. But let's consider the depth of our engagement and dependency on technology.

The impact of technology on our mental well-being often goes unexamined. Our reliance on it is so ingrained that we may avoid acknowledging its role in our daily functioning. A friend, Dr. Crystal McDonald, once said: "Tech health is mental health." This statement reminds us that nurturing mental well-being involves tending to our relationship with technology. However, fostering a healthy tech mindset doesn't mean endless screen time. It requires breaks. Let's reflect on how long we spend using technology in one day and how often we take such breaks amidst our daily tech use.

The average American spends approximately four hours and 25 minutes on their phone each day (Dreibelbis, 2023). This figure solely pertains to phone usage and does not encompass computer, tablet, or television usage. While some may argue for the inclusion of tablets in this discussion, the distinction arises from the unique functionalities they offer compared to smartphones.

Consider the implications of spending over four hours daily hunched over your phone screen. Such prolonged periods of looking down can have adverse effects on your neck and posture. This trend has only intensified with the rise of remote work, where the comfort of home often leads to fewer breaks. It's imperative to recognize the importance of taking breaks from technology. Stepping away from screens momentarily can alleviate strain and provide much-needed relief. Pay attention to the signs indicating when a break is necessary.

This course will not only delve into the consequences of neglecting breaks but also examine the signs that indicate the need for a break, our inclination towards taking breaks, and the repercussions of disregarding these indicators.

How Technology Impacts Our Minds and Bodies

Let's explore how technology affects both our minds and bodies. Increased exposure to technology, whether through prolonged phone usage or extended computer sessions, undoubtedly impacts our physical well-being.

This impact manifests in various ways, influencing our mood and overall bodily sensations. Pay close attention to signs of irritability, insomnia, difficulty concentrating, headaches, and even vision changes or blurriness after extended screen time. The effects can extend to mental health, potentially leading to feelings of depression. Contrary to the belief that extended screen time fosters greater social engagement, it can exacerbate feelings of isolation and loneliness, contributing to depressive symptoms.

Moreover, it can cause physical discomfort, such as neck and back pain, emphasizing the importance of ergonomic work setups, especially in remote or office environments. Maintaining proper posture and comfort during screen use is crucial. Consider your posture as you read this—sitting up straight, with adequate back support, can significantly alleviate strain. Overexposure to technology can also result in concentration issues and brain fog, as our minds juggle multiple stimuli simultaneously. Our attention span becomes compromised when bombarded with notifications, work tasks, and personal thoughts.

Tech Health & Mental Health

Acknowledging the interconnectedness of tech and mental health underscores the necessity of prioritizing tech health as an integral component of mental well-being. Setting boundaries with technology is essential for self-care, and if you haven't made it part of your routine yet, today is an ideal starting point. Let's delve into what tech self-care entails.

Table 1. Tech self-care and not self-care examples.

Often, we disregard warning signs indicating the need for a break—tension in the shoulders, an impending headache, or feelings of stress and overwhelm. When these signals arise, it's crucial to log off. Putting ourselves first allows us to bring our best selves to our tasks. Remember, you can't pour from an empty cup. It's okay to step away when fatigue sets in, even for the day.

I advocate prioritizing self-care by taking breaks and logging off as needed. Whenever stress mounts, I find solace in stepping away, taking a walk, and basking in the sunlight for a dose of vitamin D. Limiting screen time is key. Smartphone users can take advantage of apps that track screen time. These tools aren't merely draining your battery but helping you manage your tech dependency.

In the realm of remote work, the phenomenon of seeing oneself on screen during video calls is a subtle yet significant aspect that warrants attention. It's easy to become distracted from the task at hand when your gaze shifts to your own image. Suddenly, you find yourself fixating on trivial details—perhaps your hair seems disheveled, your glasses slightly askew, or you're concerned about an uninvited blemish stealing the spotlight. These distractions divert focus away from the meeting's purpose. Remember, if the webcam becomes a source of discomfort, exercise your right to turn it off. I advocate against any form of coercion or pressure to remain on camera, known as camera bullying. Your well-being should always take precedence.

Moreover, integrating breaks between meetings is essential for maintaining productivity and mental clarity. Transitioning seamlessly from one task to another requires a moment of respite to decompress. Imagine a challenging meeting filled with conflicts or looming deadlines—it's vital not to carry that stress forward. Taking a brief hiatus from your computer screen offers a chance to rejuvenate. Consider simple actions like stretching, hydrating, or briefly stepping away from your workstation. These small breaks foster a conducive environment for optimal performance and well-being.

Take a moment to engage with your loved ones—a quick chat with your pet, a playful conversation with your kids, or a heart-to-heart with your spouse or significant other can provide a refreshing break between tasks. It's crucial to step away from the intensity of one meeting before diving into the next, allowing yourself to approach each interaction with renewed focus.

Additionally, incorporate regular breaks into your routine by standing up and walking away from your desk every hour. While smartwatches may tether us to technology, they also serve as gentle reminders to prioritize our well-being. Pay attention to these prompts—they're not merely thumping your wrist for the sake of it but nudging you to prioritize self-care.

Consider investing in blue light glasses to protect your eyes from prolonged screen exposure. Whether integrated into prescription lenses or purchased separately, these glasses offer valuable protection against eye strain.

Conversely, neglecting tech health manifests in various detrimental habits. Failing to establish boundaries and working non-stop blurs the line between work and personal life, leading to burnout. Excessive screen time across multiple devices exacerbates eye strain and disrupts sleep patterns. Remember to take breaks from screens, turn off your camera when needed, and avoid overloading your schedule with back-to-back meetings.

Moreover, prolonged sitting can result in discomfort and decreased circulation. Combat this by incorporating movement breaks and stretching into your day. Lastly, don't dismiss signs of eye fatigue or dryness—these are red flags indicating the need for a screen break. Close your eyes, clear your mind, and recharge, even if just for a moment. Your well-being is worth prioritizing.

If you've noticed, your blinking decreases when you're glued to a screen as your brain strains to focus. Consequently, this can exacerbate eye dryness, especially for individuals with existing dry eye conditions or seasonal allergies. While eye drops offer relief, they can only do so much. Prioritize breaks to alleviate strain.

Saying No

As we discuss setting boundaries, it's crucial to normalize the act of saying no and shed any associated guilt. Saying no isn't a rejection of others—it's an affirmation of self-care. By asserting boundaries, particularly during overwhelming or fatiguing periods, you grant yourself the space and time to recharge.

When you take these breaks, pay attention to the difference they make. As you establish mental or physical boundaries, consider the following: Do you feel lighter? These are crucial reflections.

For those observing the Lenten season, consider dedicating time to abstain from traditional indulgences like sweets or alcohol and from excess tech use or social media. Reflect on whether these absences truly affect you. Initially, giving up something may feel raw or different, perhaps due to a fear of missing out. However, after a hiatus, reassess: Do you feel better? Lighter? More energized? If the answer is yes, you'll know what boundaries to set moving forward.

Being Mentally Healthy

Achieving mental health encompasses various aspects, but it does not entail adding stress, anxiety, or overwhelm to your life. Mental health involves nurturing emotional, psychological, and overall well-being, which in turn can positively impact physical health. Stress, for instance, manifests as tension and irritability in the body, leading to ailments like back pain and headaches. Therefore, prioritizing mental health involves alleviating stressors and addressing feelings of anxiety or depression.

Social Media Health

As we transition into discussing social media health, I'd like to share a poignant quote from an unknown author: "When it comes to love and happiness, don't compare your real-life experiences to someone else's seemingly perfect, well-crafted social media posts. The less devices you have to charge, the more you have for your mind. [Social media] is to mental health what fossil fuel is to climate health." This quote resonates because it sheds light on the illusion often presented on social media platforms.

When we scroll through social media feeds, it's crucial to remember that what we see is often curated and edited. Posts are filtered, reshoots are common, and moments are carefully selected to portray a desired image. We rarely witness the moments before or after the snapshot. While social media was intended to foster connection, it's also a source of concern. In 2022, over 4.5 billion people were active on social media, a number likely higher now. Paradoxically, while it has connected millions, it has also contributed to feelings of loneliness and isolation (Cotten, 2022).

Research indicates that increased social media use correlates with heightened feelings of isolation, particularly among young adults. A study conducted in 2017 found that individuals aged 19 to 32 with higher social media usage were three times more likely to feel isolated (Johnson, 2020). Although this study dates back to 2020, its relevance persists. It prompts us to consider whether the trend of social media-induced isolation has intensified over time.

During the pandemic, social media served as a lifeline for many, offering a sense of connection in a time of physical distancing. However, as society reopens, the negative impact of social media on mental health remains prevalent. It can perpetuate feelings of inadequacy, fuel depression, and foster a sense of confinement as individuals compare their lives to carefully curated online personas.

Social Media Limits

With that in mind, it's crucial to establish limits on social media usage, aligning with the broader concept of setting boundaries and learning to say no. Boundaries aren't solely applicable to physical or mental well-being; they also extend to our online interactions. Customizing your social media algorithm is one way to exercise these boundaries, ensuring that the content you encounter aligns with your preferences and values.

Studies show that social media algorithms have warped the way that people learn from each other (Brady, 2023). When scrolling through feeds, we absorb information presented to us, whether true or false. It's essential not to blindly accept everything encountered online. Conducting thorough research ensures informed decision-making regarding the content consumed.

Customizing your algorithm serves multiple purposes. It can filter out content that induces negative emotions, such as feeling uncomfortable or depressed, like comparing yourself to others, and mitigate exposure to misinformation. Remember, comparison is a perilous trap that often leads to feelings of anxiety and inadequacy. It's crucial to recognize that what we see on social media is often a curated snapshot, lacking the full context of reality.

Undivided Attention

When considering the importance of undivided attention, it's striking to note that the average human attention span has dwindled to a mere 8.25 seconds, a decrease of 4.25 seconds since 2000 (Schiller, 2023). This decline coincides with the exponential rise in technology use over the past two decades. The data underscores a concerning reality: we are more susceptible to distractions than ever before. Companies vie for our attention through social media, technology, advertisements, and even billboards that flash along our daily commutes, posing hazards for drivers.

Amidst this backdrop of perpetual distraction, it becomes imperative to introspect and recognize moments of diversion. Are we becoming sidetracked during work meetings due to disinterest or personal preoccupations? Do household chores or conversations with friends lure our attention away? Identifying the root causes of distraction prompts reflection on our present state of focus and engagement.

To mitigate distractions, fostering deeper contemplation and intentional concentration is essential. However, acknowledging that struggles with attention are commonplace offers solace. Granting oneself grace amidst these challenges is crucial. Additionally, recognizing the brevity of the average attention span underscores the importance of clear and concise communication. When sharing stories or information, maintaining relevance and focus aids in personal concentration and facilitating attentiveness in others. Also note that if you are struggling with staying focused and paying attention, so is everyone else. By prioritizing mindfulness and intentional engagement, we can navigate the modern landscape of constant stimuli with greater clarity and purpose.

Know When You've Had Enough

In addition to setting boundaries, recognizing when you've reached your limit is paramount. This entails being attuned to signs of fatigue, irritability, or brain fog. Enter the concept of digital dementia, termed by Dr. Manfred Spitzer, which delineates symptoms indicative of cognitive overload, often associated with dementia but temporarily onset by the overuse of technology. Confusion, forgetfulness, and a pervasive sense of mental (brain) fog characterize this condition.

When afflicted by digital dementia, one may find themselves grappling with tasks, struggling to concentrate, having problems remembering things, and feeling agitated due to cognitive strain. It's akin to reaching the capacity of an elevator; attempting to cram more onto an already overloaded brain is futile. Just as an elevator cannot ascend when it exceeds its weight limit, our minds cannot function optimally under excessive digital stimulation.

Understanding this analogy underscores the necessity of granting our minds respite when inundated. Much like waiting for the elevator to unload before boarding, allowing our brains to decompress from digital overload is essential for restoring clarity and functionality.

Health Effects

Excessive screen time can indeed have adverse effects on our health, akin to the cognitive challenges associated with digital dementia. This cognitive fog can impede our ability to tackle tasks efficiently, leaving us disoriented amidst the mental haze. However, it's essential to recognize that technology isn't all bad. This course isn't an indictment of technology as some nefarious force but rather a call to establish boundaries to prevent overexposure.

Acknowledging the benefits of technology is crucial. Therapists and counselors are utilizing technology to treat patients who may not usually seek help (Bradley University, 2018). Technological advancements allow us to have apps on our phones that help us find someone to talk to and match us to someone who can meet our needs. Technology facilitates connections with individuals and resources previously inaccessible, enabling remote therapy sessions and webinars, among other things. Moreover, technological innovations enhance convenience and efficiency, aiding in various aspects of our lives. Nonetheless, it's imperative to remember our humanity amidst this digital landscape.

We aren't designed to be tethered to screens incessantly, akin to machines. Rather, we thrive when we incorporate breaks, nourishment, and fresh air into our routines. Maintaining a balance between technology use and self-care is key to optimizing our well-being in the digital age.

How Can We Do Better?

To improve our relationship with technology, we can start by establishing clear boundaries. This means recognizing when we've reached our limit and gracefully saying no to excessive screen time. When we feel the onset of irritability or tension headaches, it's perfectly acceptable to take a step back and prioritize our well-being.

Another strategy is to declutter our digital spaces by removing unnecessary content. Customizing our algorithms and timelines can help filter out distractions and negative influences, fostering a more positive online environment. Whether it's reducing exposure to distressing news or eliminating excess social media accounts, curating our online presence can promote mental clarity and reduce digital overwhelm.

To reduce negativity, limiting exposure to content that triggers negative emotions is essential. Whether it's distressing news articles or social media posts that evoke sadness or anger, we have the power to curate our online experiences. Instead of subjecting ourselves to a constant stream of negativity, we can choose to prioritize our mental well-being by selectively consuming content that uplifts and inspires us.

For those accustomed to staying informed through the news, it's important to strike a balance between staying informed and protecting our mental health. While it's crucial to remain aware of current events, we don't need to immerse ourselves in every distressing headline or tragic story. Setting boundaries around our news consumption and limiting exposure to overly negative or sensationalized content can help preserve our emotional equilibrium.

Consolidating accounts, whether they're for personal, professional, or recreational purposes, can streamline our digital experience and minimize cognitive load. Similarly, tidying up our email inboxes by unsubscribing from irrelevant newsletters and promotions can help declutter our minds and enhance focus. By implementing these strategies, we can cultivate healthier habits and better balance our digital lives and overall well-being.

Your Virtual Footprint

Being mindful of your virtual footprint is crucial in today's interconnected world. Just as we leave impressions on people we meet in person, our online presence also shapes how others perceive us. Therefore, it's essential to consider our state of mind before engaging with others in virtual spaces.

If you're feeling emotionally off-balance or mentally drained, it's wise to refrain from interacting with colleagues, clients, or even strangers online. Negativity can easily seep into our digital interactions, impacting the perceptions others have of us and potentially damaging professional relationships.

Moreover, be cautious about what you share online, especially when experiencing heightened emotions. Posting content in the heat of the moment can lead to regret later on. Instead, consider journaling as a private outlet for expressing your thoughts and feelings. Whether you choose to journal digitally or with pen and paper, it provides a safe space to process emotions without the risk of public exposure. By being mindful of your virtual footprint and taking steps to manage it responsibly, you can maintain a positive online reputation and protect your mental well-being.

Disconnecting

In this next section, we'll delve into the history and purpose of social media while exploring the importance of disconnecting and unplugging from it. As we navigate this discussion, it's crucial to emphasize the significance of being well-informed, advocating for ourselves, and cultivating compassion and patience, both for ourselves and others, especially in the realm of human interaction with technology.

Let's start with the concept of getting offline, which encompasses practicing self-care. While self-care aims to promote relaxation and happiness, excessive time spent on social media can ironically lead to heightened anxiety, depression, and negativity, contrary to our intentions for seeking solace online.

Understanding how to advocate for yourself is another vital aspect. It's essential to resist the urge to compare your journey to others', recognizing that each person follows a unique path at their own pace. Peer pressure, often associated with adolescents, can also manifest in adult environments, influencing individuals to engage in activities they may not genuinely desire, such as attending unnecessary webinars.

Furthermore, cyberbullying, typically associated with youth, remains a pervasive issue across all age groups. It involves using technology to terrorize or harass others online. As part of advocating for ourselves, it's crucial to reject cyberbullying and know how to respond effectively if confronted with such behavior, whether by standing up against it, blocking the perpetrator, or disengaging from harmful online interactions altogether. When encountering negativity online or experiencing adverse reactions to content, it's best to disengage and log off rather than engage in fruitless arguments. It's not worth the emotional struggle.

History

Now, let's dive into a bit of history. When was social media invented? Contrary to popular belief, Facebook and MySpace weren't the pioneers. The earliest social media platforms emerged thanks to the efforts of Dan Pelson and Andrew Weinreich in 1996. These platforms, named Bolt and Six Degrees (Ngak, 2011), were officially launched in May of 1997.

Originally, social media served as a means for young people to connect with friends through email, messages, or voice notes. For those who remember AIM, Instant Messenger, or Yahoo Messenger, these platforms facilitated connections with individuals beyond physical proximity, setting the stage for the expansive social media landscape we know today.

Case Study

Let's delve into our case study, "The Intervention: Breaking Loose!" Here, we'll explore Darren's situation and consider strategies like setting boundaries, removing negative content, and managing expectations for oneself and others.

Darren is a project manager at a tech firm. He likes to let people know that he does well for himself by posting photos daily on his social media accounts. Darren likes to communicate with his friends and family and is usually not seen without his phone in his hand. Darren’s brother, Michael, noticed a change in Darren’s behavior as they are roommates. Darren has become obsessed with gaining more followers on social media and has not been sleeping well at night because he is usually doing some sort of research about increasing his followers, excelling in his career, or playing video games. Darren loves video gaming with people online and usually plays several games after work before scrolling endlessly on his social media accounts. Michael has noticed that Darren has become more irritable over the last couple of months and has noticed increased activity on Darren’s social media accounts. Michael decided to have a chat with Darren and ask him why he has been so irritable lately. Darren tells Michael that he feels behind in life because everyone he follows online has nice cars and fancy houses or takes fabulous vacations. Michael suggests to Darren that he stop following those people or take a break from the internet for a while. Darren becomes upset. 

Debrief

This case study highlights the challenges individuals face when navigating social media pressures and the importance of setting healthy boundaries to prioritize mental well-being. To assist Darren in managing his excessive technology and social media use, Michael can take several supportive steps:

1. Be Patient: If Darren opens up and discovers that his addiction to interacting with others online is a problem and contributes to him feeling behind in life because he's comparing himself to others, encourage him to consider seeking professional help from a psychiatrist, psychologist, therapist, or counselor. Being patient and offering a supportive ear can help Darren feel comfortable discussing his addiction and seeking assistance.
2. Set Boundaries: Help Darren recognize the negative effects of his technology addiction on his mental well-being. Encourage him to pinpoint stressors, feelings of depression, or comparisons to others that arise from excessive technology use. Together, they can create strategies to limit screen time, such as taking breaks from the internet, implementing technology detox periods, or setting screen time alerts on devices (Sharma & Palanichamy, 2018).
3. Seek Professional Guidance: Suggest seeking guidance from a therapist to develop a personalized plan of action. This plan may include options like total abstinence from social media or controlled use tailored to Darren's needs and goals.

By offering patience, support, and practical strategies, Michael can play a vital role in helping Darren break free from his excessive technology use and regain control over his mental well-being.

Recap

At times, engaging in face-to-face conversations or communicating over the phone can provide insights into aspects of ourselves that we may overlook. If someone offers feedback that we find challenging to accept, it's essential not to interpret it as an insult or personal attack. Instead, view it as an opportunity for growth and understanding. They're offering assistance in recognizing behavioral patterns and insights that might otherwise elude us. Embracing these conversations marks the initial step towards improving our tech health, mental well-being, and self-care practices.

To recap, we've discovered today that excessive technology use can have undesirable effects on our minds and bodies. This includes feelings of irritability, agitation, and a sense of disconnection from our true selves. Learning to set limits on our technology usage is crucial. It involves saying no without succumbing to guilt or fearing judgment from others. By establishing boundaries, we acknowledge that screen time shouldn't consume our entire day; breaks are necessary for physical and mental well-being.

We've also delved into the concept of tech self-care, recognizing when we've reached our limit and need a mental break rather than merely relying on quick fixes like eye drops for dry eyes. Taking care of our tech mental health involves removing negative content from our online experience and knowing when to disengage from sources of stress or discomfort.

Moreover, setting boundaries tailored to our individual needs is essential. What works for others may not be suitable for us. It's vital to avoid mindless scrolling and ensure we incorporate non-screen activities into our daily routines.

Finally, we've explored the history and purpose of social media, understanding its initial intent as a tool for connectivity. Today, we've emphasized the integral role of tech health in our overall mental well-being, stressing the importance of asserting boundaries and learning to say no, not only to people but also to the demands of technology.

References

Bradley University. (2018, June 15). How does technology affect mental health? Bradley University Online. https://onlinedegrees.bradley.edu/blog/how-does-technology-affect-mental-health/

Brady, W. (2023, August 25). Social media algorithms warp how people learn from each other. Scientific American. https://www.scientificamerican.com/article/social-media-algorithms-warp-how-people-learn-from-each-other/

Cotten, S. (2022, November 28). Is technology use leading to the demise of our mental health and well-being? American Sociological Association, 50(4). https://www.asanet.org/footnotes-article/technology-use-leading-demise-our-mental-health-and-well-being/

Digital dementia is real brain fog from tech. (n.d.). Tech Wellness. Retrieved March 21, 2024, from https://techwellness.com/blogs/expertise/digital-dementia-is-real-10-tips-to-prevent-it

Dreibelbis, E. (2023, May 19). Americans check their phones an alarming number of times per day. PCMag. https://www.pcmag.com/news/americans-check-their-phones-an-alarming-number-of-times-per-day

Exploring the link between technology & mental health | Ohio University. (2019, July 31). WFU Online Counseling. https://counseling.online.wfu.edu/blog/exploring-link-technology-mental-health/

Hines, K. (2022, September 2). The history of social media. Search Engine Journal. https://www.searchenginejournal.com/social-media-history/462643/

Jimenez, A. (2019, October 23). Functional neurology: Why screen time causes brain fog. LinkedIn. https://www.linkedin.com/pulse/functional-neurology-why-screen-time-causes-brain-fog-jimenez-/

Johnson, J. (2020, February 25). Negative effects of technology: Psychological, social, and health. Medical News Today. https://www.medicalnewstoday.com/articles/negative-effects-of-technology

Ngak, C. (2011, July 6). Then and now: A history of social networking sites. CBS News. https://www.cbsnews.com/pictures/then-and-now-a-history-of-social-networking-sites/

Ratliff, S. (2023, April 26). The impact of technology on mental health: Balancing connection and screen time. Citizen Advocates. https://citizenadvocates.net/blog/the-impact-of-technology-on-mental-health-balancing-connection-and-screen-time/

Schiller, J. (2023, October 5). Average human attention span by age: 31 statistics. The Treetop. https://www.thetreetop.com/statistics/average-human-attention-span

Sharma, M. K., & Palanichamy, T. S. (2018). Psychosocial interventions for technological addictions. Indian Journal of Psychiatry, 60(Suppl 4), S541–S545. https://doi.org/10.4103/psychiatry.IndianJPsychiatry_40_18

Additional Current References

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Odgers, C. L., & Hayes, G. R. (2024). Let's stop shaming teens about social media use. Educational Leadership, 81(5), 38–43.

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This is an edited transcript of the webinar, The Opioid Crisis: A Sociological Perspective, presented by Sophie Nathenson, PhD. 

Learning Outcomes

After taking this course, participants will be able to: 

• Describe the social context of the opioid crisis.
• Identify three societal-level contributing factors of the opioid crisis.
• Identify two aspects of a holistic, population health approach to addressing the crisis.

The Sociological Perspective

Let's start by covering the sociological perspective and what sociology entails. Sociology is the study of society as a whole, classified as a social science, focusing on human behavior, similar to psychology. However, in sociology, the focus lies in examining differences between groups rather than individuals. Individuals are grouped together based on various social factors, such as age, race, gender, and socioeconomic status. The objective is to compare these groups in terms of behavior, prevalence of illnesses, and other aspects that shape an individual's life course.

Thus, sociology delves into analyzing social factors and aspects of social life and status, as well as structural factors inherent in communities and societies. Medical sociology places special emphasis on understanding social and structural determinants of health outcomes—identifying how community characteristics and social status contribute to potential differences in health outcomes. This field differentiates between upstream factors, focusing on prevention, midstream factors dealing with illness management, and downstream factors, which involve emergency approaches to illnesses.

The population health perspective is essential in this regard, as it assesses the health of a group and examines health behaviors, such as the use of opiates, from a broader population standpoint.

Rather than solely focusing on understanding why an individual may use, our aim is to identify factors associated with the prevalence of addiction and overdose within a society. Thus, we approach health behaviors within a social context, considering not only individual factors but also broader influences such as social norms, community, family, relationships, and the environment where individuals live, work, engage in recreational activities, and socialize. This perspective allows us to explore the impact of social and structural factors on our position in society and our social status, encompassing elements like race, gender, socioeconomic status, and power imbalances, which affect our access to resources.

Structural factors involve examining societal systems. When comparing different societies or communities and analyzing the prevalence of issues like addiction and overdose, significant differences prompt us to explore the underlying reasons for these variations. In doing so, we broaden our scope to consider the systems and structure of societies. This includes evaluating aspects such as the healthcare system, educational system, industries present in the society, media influence, cultural dynamics, and the overall economic structure, including income levels and wealth distribution. Employment and unemployment rates, educational attainment, and access to education among various groups also play a crucial role in this comprehensive analysis.

In terms of culture and the social environment, that also includes norms, how people are socializing, the degree of social isolation, and where people come together. That's another aspect of a society that could influence health outcomes. At the most top-down or broadest level, factors such as political instability, policy, and laws, are interconnected and can trickle down and affect behavior and collective wellbeing. 

The Opioid Crisis

Now, shifting our focus to the opioid crisis, it was officially declared a national public health emergency in 2017, encompassing both the misuse of prescription opioids and illegal drugs derived from opium, such as heroin.

This crisis has been labeled as the deadliest in American history, with the United States accounting for only 4% of the world's population but experiencing 27% of global drug overdose deaths. However, it's essential to acknowledge that these statistics may change over time. Research and social surveys indicate that pain levels in the United States are comparable to countries like France and Italy, despite the fact that the U.S. consumes a staggering 80% of the world's opioids. This suggests that opioid consumption is not merely linked to pain prevalence or chronic illnesses where opioids are medically necessary for pain management. Rather, there may be underlying societal factors contributing to the crisis. See Katz (2017) for further details.

Trends Over Time

Analyzing trends over time reveals drastic changes in the opioid crisis. Between 1980 and 2008, there was a 600% increase in opioid overdoses, and from 1997 to 2017, the number increased fivefold. Notably, during the pandemic years, from April 2020 to April 2021, drug overdose deaths increased by 28.5%. You can start to think about the context and what may have contributed to this significant rise, such as the social and economic impact of the pandemic.  

When we study populations, societies, and countries, we encounter differences. When we analyze statistics, for example when we look at rates of addiction, overdose, depression, suicide, or suicidal ideation, we can be mislead unless we take into account these real differences between groups.  For example, while overall statistics might indicate improvements in certain areas, specific vulnerable groups might still be experiencing increasing rates. This variation among social groups is a core concern in medical sociology, as it emphasizes that diseases, illnesses, and addictions are not distributed evenly across a population; there are distinct patterns and societal factors at play.

Significant variation is observed not only between states in the U.S. but also between counties within those states and as mentioned, among different countries. Such disparities suggest that societal factors play a substantial role in the opioid crisis. If rates were the same across all states and countries, for example, it might imply that individual factors alone are responsible. However, the substantial variation prompts us to explore how societies are structured, what individuals are exposed to within these societies, and the access to resources available, all of which may contribute to the differences that are observed.

Data Limitations

Research and surveys provide valuable insights into the opioid crisis. Self-reported data, when individuals rate their own health, tends to be reasonably accurate and aligned with objective measures obtained in healthcare settings. However, it is essential to acknowledge the limitations inherent in data collection and analysis in social science research.

Overdose rates, for instance, can be subject to miscoding or misattribution when entered into data systems, leading to potential misinterpretations. For example, an accidental overdose might be categorized as a suice. Non-fatal overdoses are often missing from national surveys, which primarily focus on fatal overdoses, potentially overlooking critical information about near-miss incidents that could provide information about underlying factors and prevention strategies.

Measuring opioid use, especially non-medical use and diversion, poses significant challenges. Household surveys can suffer from low response rates, making it difficult to obtain a comprehensive picture of opioid use within households. Furthermore, national drug lab data might not be fully representative, particularly concerning drugs sold in the social markets or the "black market".  Harm reduction efforts are challenging to quantify. The criminal justice system also poses difficulties when attempting to collect data from arrestees or prisoners due to their vulnerable status. Even hospitalization data might not be captured uniformly or in a standardized manner, which can affect our understanding of the crisis's scope and severity. Finally, assessing access to drug treatment can be hindered by potential under-coverage in insurance data, preventing us from gaining a fully accurate picture of treatment availability and utilization.

While data sources play a pivotal role in comprehending and addressing the opioid crisis, it is vital to approach them with caution, taking into account their potential limitations and biases.

How Did We Get Here?

Understanding how we arrived at the current state of the opioid crisis requires examining the significant changes in statistics over time and the events that contributed to this complex issue.

In the 1980s, there was a notable downplaying of opioid addiction. A report, which was not robust in its scientific basis, was circulated among medical professionals and physicians, indicating that opioids were not labeled as an addictive substance. In the 1990s, a problem was identified: patients were experiencing pain, but it was not always adequately measured or addressed. In response, healthcare professional associations deemed pain as the fifth vital sign, emphasizing its importance and promoting its measurement. In the 2000s, aggressive marketing strategies, educational initiatives, and promotions targeted physicians in a specific and calculated way. There was overpscribing, in part potentially related to patient satisfaction (Fenton, Bertakis, & Franks, 2012). Patients might have demanded opioids for pain relief, and if patient satisfaction was a key outcome for physicians and the healthcare system, it may have played a role in the overprescribing of opioids.  Key 

From Prescription to Illicit

Apart from changes within the healthcare system, various social and economic factors also contributed to the opioid crisis. The opioid crisis can be traced back to both prescription drugs, and also illicit drugs obtained through that social channel. There is both diversion use by healthcare professionals and recreational use. For example, there was a big spike in heroin use because people who were addicted to opioids but ran out of a supply or money for their prescription, would be kind of pushed into buying it through social channels in order to access a similar or same high with heroin. There is a close connection between opioids, prescription drugs, and heroin. A study by Cicero et al. (2014) showed that 75% of heroin users had used analgesics, and that painkiller users were 40% more likely to be addicted to heroin.  In 2017, the CDC found that there was almost equal distribution of opioids from healthcare channels and social channels. Simply addressing the healthcare side of the opioid crisis would not be enough.

Diversion Risks and Signs

According to SAMHSA (Substance Abuse and Mental Health Services Administration), approximately one in 10 healthcare workers may be abusing drugs, though it's important to recognize that this figure might be an undercount due to the challenges of obtaining accurate data in this context.

Fentanyl has been particularly problematic in terms of diversion, as it has caused the most deaths. Detecting opioid diversion within healthcare systems has revealed that this problem exists across different levels and disciplines, not limited to individuals with the most direct patient interactions. It occurs throughout the hierarchy in healthcare.

Several indicators may suggest diversion within a healthcare setting. These include controlled substances being removed without proper authorization, compromised containers that appear tampered with, the use of substitute drugs on patients who were previously prescribed opioids, and verbal orders that have not been appropriately verified. Self-prescription, improper handling or disposal of waste, and instances where health professionals are unusually administering medications can also be red flags indicating potential diversion activities.

Signs of Misuse and Addiction
 

Signs of misuse and addiction can be categorized using the three Cs: Control, Craving and Preoccupation, and use despite negative Consequences.

Regarding Control, there is a loss of control. Indicators may include reporting of stolen or lost medications, seeking early refills, seeking drugs from sources, experiencing withdrawal symptoms, and being unable to control their use of opioids.

Craving and Preoccupation involve increased requests for specific drugs and increased pain without a worsening of disease. This may be related to increased tolerance. In addition, an indicator of craving and preoccupation include dismissing non-opioid pain management methods.

Use despite negative Consequences refers to over-sedation, reduced daily activities and functioning, and experiencing relationship issues due to opioid use.

Social-Ecological Model of Risk Factors

From a sociological and psychological perspective on addiction and overdose, a social-ecological model of risk factors is used. This model encompasses multiple levels of influence.

The broadest level considers aspects of society as a whole. The community level looks at the characteristics of specific communities, such as neighborhoods or cities. Interpersonal factors relate to socialization and relationships within an individual's social circle. Addiction and overdose are multifactorial. At the individual level, these various factors include sociological, psychological, genetic, and environmental factors, to name a few, that come together to contribute to this issue.

Individual and Interpersonal Risk Factors

We cannot simply focus on a single risk factor and address it, as these factors not only contribute independently but also overlap and influence each other, making it difficult to isolate one. Therefore, we will begin by examining individual and interpersonal risk factors.

At the individual level, various factors play a significant role. Socio-demographics, including personal social standing, stress levels, and past or current traumas, all have an impact. Additionally, genetics, family history, pain levels, withdrawal symptoms, and self-stigma, which may be internalized from social environments and norms, are crucial factors to consider.

Self-stigma can lead individuals to judge themselves and believe that seeking help is frowned upon, affecting their willingness to seek assistance. Moreover, their determination level and the presence of other addictions, such as cross-addictions, where individuals may switch from one substance or behavior to another, can complicate the situation.

Moving to the interpersonal level, the influence of family and peers becomes prominent. For adolescents, peer influence can be even more powerful than that of the family. Access to substances can also be influenced by social circles, and the ability to seek and distribute drugs can depend on the level of access one has within their social group.

We also need to consider the influence of family history, particularly when it comes to use among family members and friends. Additionally, the nature of your relationships and associations, especially in romantic relationships, can significantly impact opioid use. Oftentimes, drugs serve as social lubricants within these contexts. Later on, we'll explore studies featuring personal stories of drug users to shed further light on this aspect.

Key literature in this area includes Jalali et al. (2020) and Cragg et al. (2019).

Community and Societal Risk Factors

As we expand our perspective, it becomes evident that differences exist between communities in terms of opioid use and addiction rates. Some communities experience high levels of opioid use, while others have much lower rates. This disparity calls for researchers and health professionals to delve into the underlying reasons behind these variations. Understanding these nuances can either satisfy your curiosity or pave the way for your potential involvement in community work focused on prevention.

Access to treatment plays a pivotal role at the community level. For instance, in the state where I reside, we face one of the highest addiction rates but struggle with limited access to treatment options. This creates a challenging situation for those seeking help. However, it's worth noting that there are also many individuals in recovery, largely due to the prevalence of addiction in our community.

Norms and culture within communities are crucial factors to consider. If drug use is normalized within a community, it can contribute to higher rates of addiction. Let's say a large employer in a community shuts down, leaving large numbers of people out of work.  If drug use is the norm in that community, using drugs may not be perceived of deviant behavior in certain social groups within that community, and drug use may increase. In addition, school and work environments can play into this; whether there is an awareness of the issue and whether or not steps are being taken to address it. Prescribing patterns and prescriber perceptions and attitudes can play a role, as can the quality and level of care in a community. In fact, there are differences according to social status and race when it comes to prescriptions for pain medication.

Societal risk factors include economic conditions, supply, government programs, education, advertising, media, stigma, discrimination and prejudice, law enforcement, and policing. In terms of economic conditions, the distribution of wealth in a society can put a strain on everyone, particularly the most vulnerable. For example, during the pandemic essential workers were working while many other businesses were shut down.  This created a strain on individuals and families. Some children had no access to education during the pandemic. Some teachers told me about half their students had access to the Internet, while half did not.  This is not a complete list of community-level factors but the types of things to consider when examining differences around opioid use and addiction.

Gaining a deeper understanding of these community-level factors can pave the way for resource allocation further upstream. By doing so, we have the potential to prevent opioid addiction or at least address the issue at a population level. While individual interventions play a critical role and can be successful, we need to address the issue comprehensively. Individual interventions may not have the capacity to influence an entire population, especially considering the less than ideal ratios of individuals in need versus the number of available counselors, therapists, behavioral health specialists, and substance abuse and prevention experts.

Documented Variation

Looking at the documented variation in state and country-level statistics, the lowest prevalence of opioid addiction was found in Nebraska, according to the 2017 research (Hedegaard, Warner, & Minino 2017), while West Virginia had the highest rates.

It's important to note that rural areas tend to be more vulnerable to opioid addiction, and there are spikes in these regions that correlate with economic opportunities and changes. In rural areas, the level of investment in the community and the availability of industries can result in shifts in the social demographics, with people potentially leaving the community in search of better opportunities. Moreover, the concept of "deaths of despair" has emerged, referring to deaths that are attributed, either through research or perception, to the profound sense of hopelessness and lack of individual opportunities. These deaths are not caused by illness or natural causes but are driven by the absence of a positive future vision. See Dasgupta, Bletsky, and Ciccarone (2018) for further reading on this topic.

Indeed, disparities in health outcomes based on race and social status are evident across various health issues, including opioid addiction. There is a significant correlation between race and socioeconomic status, which plays a role in shaping the prevalence of addiction within different communities. Gender differences also contribute to the variations seen in opioid addiction rates. The prevalence of mental illness and physical pain can also vary from one community to another, adding further complexity to the issue. All of these factors combined serve as evidence of the intricate web of factors influencing addiction within a community.

The War on Drugs
 

Let's delve into the topic of the "war on drugs." This initiative was launched with the positive intention of combatting drug issues in communities across America. 

The approach of the war on drugs led to increased arrests, but it did not necessarily reduce access to street drugs. Moreover, it influenced the culture, perception, and stigma surrounding drug use and addiction. The focus on punitive measures rather than preventive or supportive efforts may have contributed to the perception of drug use as a moral failing, stigmatizing individuals struggling with addiction.

Unfortunately, the war on drugs didn't fully recognize the role of trauma, both past and new traumas, that individuals experience in society. If the initiative had been framed as a war on addiction, it might have called for investment in addressing underlying community-level issues and potentially reduced the driving force behind people seeking drugs. In addition, it exacerbated the stigma around drug use.

This is not intended to prescribe specific policies or take a political stance. Instead, our focus is primarily on the research on various policies and actions related to drug use and addiction. People hold diverse attitudes and opinions about the root causes of drug use and the characteristics of drug users. These viewpoints, coupled with the considerable size of the drug industry and the prison industrial complex, all contribute to the context in which drug policies are formulated. 

Significance of Root Causes

It is essential to recognize that the relationship between various factors is not linear or one-to-one based purely on availability. Simply addressing one factor, such as prescribing behavior, may not lead to the desired outcome.

A striking study caught my attention, where a 13% drop in prescriptions from 2012 to 2015 was followed by a surge in overdose rates (Dasgupta et al., 2018). This finding challenges the notion that reducing prescription rates alone can effectively combat the opioid crisis. 

When access to prescription opioids decreased, some individuals may have turned to social channels to obtain drugs. This shift in behavior may have led to a greater intermixing of drugs, such as heroin, resulting in more severe health issues for those engaging in recreational use or those who have addiction.

Understanding the contributing causes behind the variations in opioid prevalence based on location and social status is important. This involves looking beyond opioids alone because addiction does not occur in isolation. A multitude of factors, such as socioeconomic conditions, mental health issues, access to treatment, and cultural norms, interact to influence addiction rates. Ignoring all these driving forces and just zeroing in on the opioids alone may not be a successful approach. 

Deaths of Despair
 

The term "deaths of despair" was coined by researchers Case and Deaton (2015) to describe what they observed in their research. They researched people with high mortality rates from suicide, drug overdose, and related causes. The researchers delved into the mental and emotional states of these individuals and found a common thread of hopelessness and economic strain.

This is deeply tied to community-level factors. The sense of hopelessness and lack of opportunity can be associated with mental health issues and economic challenges that individuals face within their communities. Income inequality emerges as a powerful indicator of various social problems, not just in specific regions but across the globe. Researchers have consistently found links between income inequality and a range of social issues, such as decreased social trust, increased rates of teen pregnancy, dangerous adolescent behaviors, and interactions with the criminal justice system. Another key study on this topic is Ezell et al. (2022).

Micro, Meso, Macro Levels
 

Indeed, examining the micro, meso, and macro levels can provide valuable insights into the levels of prevention for addressing opioid addiction. At the micro-level, individual factors such as occupation and job conditions play a significant role. Certain jobs may be more prone to causing physical injuries, while others may have different rates of mortality and injury. Changes in prescribing practices can also have an impact, potentially leading to the illicit use of opioids.

At the meso-level, the focus shifts to the immediate environment of individuals. Limited recreational opportunities may lead some individuals to use opioids as an escape from their reality.

Zooming out to the macro-level, community-wide and societal factors become prominent. The level of investment or divestment in a community can have far-reaching consequences, and economic distress within these communities is often linked to higher mortality rates, particularly in rural areas. These factors can impact mental illness as well. 

The interplay of micro, meso, and macro-level factors creates a framework for understanding the complex nature of opioid addiction and its connection to broader community and societal dynamics.

Levels of Prevention

Levels of prevention can be categorized into primary prevention, secondary prevention, and tertiary prevention, each addressing different aspects. Primary prevention focuses on going upstream and addressing factors at the big-picture level, far from the emergency situation. This includes community education, policy changes, and initiatives to reduce stigma surrounding addiction.

Moving on to secondary prevention, the focus shifts to more immediate interventions. This includes measures like needle exchanges, medication-assisted treatment and safe houses, and proper disposal of unused opioids.

At the tertiary level, the emphasis is on providing support and care for individuals. This involves fostering empathy and caring, introducing evidence-based interventions, establishing psychosocial support structures, and facilitating access to support groups.

Role of Stigma
 

Stigmatizing attitudes towards individuals with opioid addiction can be found not only in the general public but also among law enforcement, health professionals, and emergency services professionals. These negative attitudes can impact how referrals are made and how the issue is addressed, hindering access to care and support.

Health professionals working with individuals facing addiction can experience frustration, disillusionment, burnout, and irritation due to the challenges they witness. Witnessing traumatic experiences, such as domestic violence or deaths resulting from drug use, can take a toll on those in helping professions.

One aspect of stigma is the different assumptions made about prior behaviors of individuals dealing with addiction, such as promiscuity. It's important to recognize that not everyone engaging in drug use necessarily exhibits specific prior behaviors, debunking the misnomer that such behaviors are a prerequisite for addiction.

Stigma has been called the "net absence of empathy" (Ezell et al., 2021), which is an interesting perspective.

Direct Experience v. Role Playing
 

There is research that compares the perspectives of people who use drugs and their experiences (direct experience) and those of behavioral health professionals. Behavioral health professionals may be in a role-playing position, meaning they have to envision the experience of someone who uses drugs or has an addiction, because they do not have a direct experience with drug use themselves. These perspectives are not about any specific individual therapist but rather about broader trends observed in qualitative research comparing groups. It highlights the need to understand the perspective of people who use drugs (prescribed and illicit), and how that relates to empathy.

Behavioral health professionals often examine the causes and conditions that led to addiction in an individual, and some may have personal experience with addiction, which can be beneficial in their work. However, there may also be presumptions based on known risk factors and evidence from research. While it is important to understand the research, each individual has their own unique circumstances which may or may not align with research. While we know from research that economic conditions may drive addiction rates, an individual may not attribute their use of drugs to their economic situation. It's important to look beyond the research on risk factors to look at each person's direct experience, to find out why they are using drugs or struggling from addiction. What are they saying? What is their reasoning or explanations for their circumstances?

One factor that is sometimes downplayed is sensation-seeking, where they seek the psychic or bodily high, or the increased sensations that come with certain behaviors, in terms of relationships and sexual contact. Coping with social and environmental circumstances is another factor, where drugs may be used to facilitate social and romantic relationships.

One poignant finding from direct experiences is that drug use may not always be a premeditated decision. Many individuals do not actively seek drugs; instead, they find themselves in social circumstances where drug use becomes a part of their lives. For example, a person may start using drugs due to the influence of a romantic partner, where pressure or romantic feelings cultivate a sense of trust that can impact behavior. Drug use may also be driven by addressing physical pain.

Sociology of Empathy

From a sociological perspective, empathy challenges the notion that opioid use and addiction are solely the result of predisposition or deviant behavior. Empathy goes against the belief that "it's those kinds of people" who would be involved in opioid use or that it would be "unfathomable." Instead, understanding empathy from a sociological lens allows us to recognize the influence of social norms and circumstances on individuals' behaviors.

By building empathy, we can better comprehend the complexities of addiction and the factors that lead individuals to use opioids. This includes acknowledging the impact of trusting relationships. In a relationship where there is trust, you may be more likely to engage in riskier behaviors. You may not have interest in mountain climbing, but you may do it with a partner if it is important to them. Empathy-building is crucial for behavioral health professionals to establish a more effective therapeutic relationship and to avoid compassion fatigue and burnout.

Moreover, as attitudes among professionals start to shift through empathy and understanding, it can lead to more informed advocacy for policy changes that align with the needs and experiences of those experiencing addiction. We know racial disparities exist in terms of administering and prescribing drugs, and empathy is related to reducing these differences in treatment.

Beyond the Opioid Crisis: A Holistic Approach

Taking a holistic approach to addressing the opioid crisis involves several key steps. 

There should be an expansion of funding and the scope of funding available to tackle the crisis. This funding should not be limited solely to specific interventions or programs targeting opioid users, but rather should consider the broader factors contributing to addiction. 

Acknowledging and addressing social and structural determinants of opioid addiction can be done through policy changes and community organizing. 

Empathy-building plays a crucial role in successful recovery. Behavioral health professionals should continue to develop their ability to understand and empathize with those facing addiction, while also addressing compassion fatigue and maintaining appropriate boundaries while still being able to understand backstories. Creating a supportive environment where seeking help is destigmatized will contribute to more individuals accessing treatment and support.

By adopting a holistic approach that combines evidence-based practices with empathy and an understanding of social determinants, we can better connect the opioid crisis to the broader context of the population being served. 

Why Integrate a Sociological Perspective?

The sociological perspective is crucial when examining addiction, including opioid addiction, as it offers valuable insights into understanding the trends and complexities of this issue at the population level. Addiction is not solely an individual problem; it is deeply influenced by social and cultural factors, and the sociological perspective allows us to recognize and explain these influences.

By taking a sociological approach, we can better comprehend why certain trends in opioid use and addiction change over time, including factors related to initiation and continued use. It acknowledges the significant impact of culture, social norms, social position, geography, and disparities in shaping addiction patterns.

Understanding the social and economic conditions surrounding addiction can help guide research and inform policy development. Through sociological research, we can evaluate the effectiveness of various policies in real-time and retrospectively, allowing for adjustments and improvements in intervention strategies.

Stigma awareness is another crucial aspect addressed through the sociological perspective. By reducing stigma and recognizing contextual factors, we can move beyond seeing addiction as merely an individual choice.

The Mental Health Professional's Role

The role of mental health professionals and behavioral health workers in addressing opioid addiction is essential, and adopting a sociological perspective can further enhance their effectiveness. Understanding the individual within their social and societal context is something we do and this is validation that it is good practice.

Empathy-building and inquiring about personal factors contribute to forming a strong therapeutic relationship and gaining insights into the unique challenges of each individual. Practicing cultural humility allows professionals to set aside assumptions and approach each patient with sensitivity to their cultural background and experiences.

Providing education on non-pharmacological interventions is valuable, as it opens up alternative approaches to managing mental and emotional pain. Integrating these interventions alongside other approaches can have an impact.  

Prioritizing self-care and stress management is vital for mental health professionals dealing with the demands of their work and personal lives. Stress in the workplace and society at large can take a toll on professionals. While there are interventions that need to happen on a larger scale in society and workplaces, engaging in self-care practices on an individual level can be empowering and beneficial for mental health professionals in managing their own well-being and maintaining their capacity to provide effective care to their clients.

Summary

In conclusion, mental health professionals and behavioral health workers play a crucial role in addressing opioid addiction. By integrating a sociological perspective into their practices, they can better understand the complexities of addiction, provide empathetic care, and consider the social and contextual factors that influence an individual's relationship with opioids. Prioritizing self-care further enhances their ability to support people with addiction and promote a holistic approach to addressing the opioid crisis.

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Savage, S. R., Kirsh, K. L., & Passik, S. D. (2008). Challenges in using opioids to treat pain in persons with substance use disorders. Addiction Science & Clinical Practice, 4(2), 4.

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This is an edited transcript of the webinar, Self-Care and Systems Change for Behavioral Health Professionals, presented by Sophie Nathenson, PhD.

Learning Outcomes

After taking this course, participants will be able to: 

• Describe a system-changer is and how it can be applied in a behavioral health setting.
• Identify three factors associated with system-change that contribute to burnout for behavioral health professionals.
• Identify four domains of self-care for behavioral health professionals.

Introduction: Healthcare Systems Change Context

This course will adopt a sociological approach. I hope that you will derive some valuable insights from it, even if it's just the validation of your existing knowledge or the sowing of seeds for new ideas.

In this discussion, we're starting with a focus on the United States, though these concepts can apply globally, particularly in the context of healthcare and behavioral healthcare systems. We're looking at population health, which involves studying the overall well-being of communities and societies, examining the root causes of health issues. These causes include socioeconomic factors and cultural elements. Additionally, we consider the impact of various systems and institutions like government, healthcare, mental health services, media, education, and religion. These systems can significantly influence health outcomes, and understanding their role is crucial in the field of medical sociology.

In this sociological context of population health, our focus isn't on one-on-one approaches. Instead, we emphasize prevention and examine upstream factors - elements of society that have far-reaching impacts on how people handle stress and their health behaviors. Further downstream, we deal with issues that can quickly lead to emergencies or mortality. While it's vital to allocate resources to emergencies, we're also considering the potential of system and community structure adjustments to affect a larger population positively.

A relevant concept here is "structure versus agency." Agency refers to our individual choices, attitudes, motivation, and the extent to which we can make choices. However, agency is somewhat constrained by societal structures or "life chances and life choices." This concept is central to our work in systems-change. For instance, providing education can enhance agency, but if structural barriers prevent individuals from exercising their choices, the success of such educational initiatives may be limited.

In the broader context, legislative changes also play a significant role. For instance, in 2008, we saw the introduction of the Mental Health Parity and Addiction Equity Act, which can greatly affect the ability of individuals and organizations to participate in systems-change efforts. A recurring question in the population health and systems-change realm is: Who bears the responsibility for creating programs and initiatives that can influence the system, whether on a large scale or within a smaller organization or group of individuals?

When it comes to health professionals, especially those in behavioral health like therapists, counselors, and addiction treatment specialists, engaging in system-change work alongside their one-on-one responsibilities can add a significant load to their already demanding work. This process is undeniably collective but challenging because it often requires additional effort beyond the norm. Some of you might already be involved in system-change efforts, while others might be contemplating it. Regardless, it's worth considering, especially in the post-COVID era, as psychology literature increasingly calls for systemic changes. The stress our systems endured during the pandemic spotlighted their broken and inefficient aspects. 

Who is a “System-Changer”?

Now, who qualifies as a "system-changer"? Despite some research, it's unclear who first coined this term. It frequently arises in discussions of social innovation and entrepreneurship, where we explore a spectrum between for-profit, profit-focused organizations and entirely mission-driven ones, rather than seeing it as a strict dichotomy. The notion of a "system-changer" emerges from the idea of shifting organizations along this spectrum, making it a fluid and evolving concept.

A system-changer, when we attempt to define this term, is someone who not only identifies problems within a system but actively embraces this role as a primary focus. Not everyone consistently takes this broad view. Beyond recognizing issues, a system-changer possesses a compelling drive to take action. It's akin to the stages of change in the Theory of Planned Behavior, where the behavior is actively working to adjust a given system, be it on a large or small scale, whether within an organization, group, or at local, regional, national, or international levels. There's a multitude of examples of system-change efforts today, covering a vast array of issues.

Ultimately, system-changers are united by a shared desire and commitment to address broader societal problems. This aspiration leads them to delve upstream, scrutinizing the social, economic, cultural, and political contexts in which these issues manifest within a population.

Characteristics of System-Changers. Expanding on the concept of system-changers, it’s important to recognize the presence of an entrepreneurial mindset in these individuals. This mindset can lead to the establishment of businesses, and many behavioral health professionals have ventured into side businesses. These ventures might involve resource exchanges to provide services that aren’t available within their primary healthcare system or could take the form of nonprofit or grant-funded programs, distinct from their regular work. Importantly, this entrepreneurial mindset involves a willingness to innovate, which doesn’t always mean creating something entirely new; it can also involve revisiting past policies or programs that may have lost funding over time. The ebb and flow of funding in response to legislative changes can significantly impact these initiatives.
Moreover, at the core of being a system-changer is a profound concern for others in society. We’ll delve into how this relates to burnout later, but this sense of being others-centered is what drives these individuals to address the root causes they encounter in their daily work. Often, when providing care, they’re acutely aware of underlying issues that may seem beyond their control but are affecting the effectiveness of the care they provide. This awareness compels them to explore or take action on these matters.

System-changers often possess a visionary outlook, enabling them to perceive alternative possibilities. While recognizing systemic problems is relatively straightforward, these individuals go further by envisioning, independently or collaboratively, how things could be different. They frequently adopt growth-centered thinking, which is essential for their own well-being in the context of system-change. This mindset involves viewing challenges as valuable lessons, embracing feedback, engaging in self-reflection, and maintaining humility when confronted with resistance during change efforts. System-changers can be deeply other-centered and exhibit leadership qualities, not necessarily confined to formal decision-making roles; they lead through example. Additionally, a strong commitment to social justice typically underpins their motivations, a theme we'll explore further in relation to system-change.

What Can or Should Change?  

When considering what can or should change, we confront the question of whether a system is fundamentally broken or if there are opportunities for either cultural or practical change. Practical and procedural changes often become entrenched when cultural shifts don't accompany them. To catalyze change, individuals must envision something different, not merely identifying problems but actively imagining alternatives. This growth-centered thinking is vital for personal well-being amid system-change efforts. It involves viewing challenges as valuable lessons, embracing feedback, self-reflection, and maintaining humility in the face of resistance. System-changers often exhibit a deep concern for others in society, driven by a desire to address root causes that affect the efficacy of care. Recognizing systemic issues typically hinges on noticing trends among clients, patients, or community members that extend beyond random chance.

Change can manifest in various ways. It might involve shifting organizational culture, even if it seems daunting, particularly in situations where divisions like administrators versus employees or employees versus clients persist. Yet, culture is malleable and can transform, even when deeply ingrained. Changes can also stem from shifts in funding structures and performance incentives, influenced by legislative changes such as the Affordable Care Act in 2012. This legislation pushed healthcare systems to prioritize population health outcomes over individual care. The move to electronic health records added to the data available for assessing patient outcomes and identifying issues affecting the majority. Data now includes social determinants of health and disparities among different groups, aiding in targeted interventions. Coordinated care organizations, responsible for a defined population's care and costs, further incentivize population health. Changes in healthcare policies and other policies affecting mental health, addiction services, and drug legalization or decriminalization also play significant roles in system change.

Breaking down silos between sectors is crucial for effective collaboration, as issues often intersect with multiple systems. However, it's essential to be mindful of resource allocation, as an excessive focus on a single problem, like the opioid crisis, can hinder broader, systemic improvements. Collaboration across organizations and sectors is pivotal but demands extra effort. In summary, system-change presents personal and professional challenges, emphasizing the importance of understanding these complexities.

System Change and Social Justice 

System-change is also tied to social justice. For a lot of people, that is a big part of the motivation to engage in system change. So, addressing health disparities. There is a disproportionate prevalence of social problems, social determinants of health, meaning different groups, marginalized populations, disadvantaged and disinvested communities. They have a higher prevalence of mental health issues, behavioral health issues across the board, social problems, interactions with the criminal justice system. So, looking at the social institutions that affect those individuals, looking at the criminal justice system, the healthcare system, behavioral health, those systems are part of the root causes of these disproportionate issues that affect these kind of subpopulations. Looking at networks is also important because networks and social networks are one of the most protective elements that serve as a buffer for interactions with criminal justice, with homelessness, with interactions with behavioral healthcare. 

So looking at those community networks is very powerful and can highlight some of those issues. So, if it's systemic, we're looking at policy, we're looking at culture change, we're looking at social policy to drive some kind of improvement with disparities. Health disparities in some cases are narrowing, in many cases are broadening. And so, we have to ask ourselves if cultural competency is widespread as far as training. And we have all of these initiatives at different levels, the state level, the national level, to reduce health disparities, but we're still seeing them across time, that is really a trend and a set of trends that signals we may not be getting to the roots of those issues. There's also the role of social media, mass media, and we really saw that in COVID, especially when the containment measures were at play and there was a lockdown, we had this interesting situation, it was like a social experiment and we had people across the globe that if they had access to the internet through a computer or phone, they were all tuning in to the same issue, the pandemic. 

And so with all eyes on media during that time, there were a lot of social justice issues that just blew up. And in the field of medical sociology and many other disciplines, disparities have been studied for decades upon decades. So, it wasn't new information to a lot of people, but it was new information to many people in society. And for the first time I was seeing statistics by social factors on the mainstream news outlets. And so, that played a role in highlighting all these issues and spurred this desire to focus on systemic change.

Examples of Systems Change

So now we'll go through some examples of systems-change. These might be familiar to you, they might be new ideas and they represent a range of the small to the large scale. 

"Re-Imagining Mental Health Systems."

The phrase "Re-Imagining Mental Health Systems" encapsulates a notable example of system-change. The COVID-19 pandemic, though not fully in the rearview mirror, has exposed vulnerabilities within healthcare systems, including mental health. This crisis has sparked a renewed interest in system-change efforts, prompting a reevaluation of established models like the bio-psychosocial and ecological frameworks. Researchers are once again turning their attention to the impact of various communities and community characteristics, reinvigorating a research field that had seen a period of relative dormancy.

Addressing the Emotional Capacity of Communities 

Addressing the emotional capacity of communities signifies a significant paradigm shift, moving beyond the conventional individual focus. It entails assessing the potential for change within the social, economic, and political context of a community. This shift prompts us to question the extent of transformation that's achievable, a crucial consideration when engaging in individual therapy and service provision while also participating in group-level initiatives. Understanding how the broader context impacts the effectiveness of treatment is paramount, marking a transition from the traditional individual lens to a broader population-level perspective.

Social Determinants

Social determinants significantly influence mental health disparities among communities, and adopting a population-wide view helps identify key issues. Examining why some communities experience higher addiction rates than others, this analysis extends beyond borders, comparing societies and regions. These disparities are often rooted in social and economic factors like poverty, housing challenges, and racism, both within systems and externally. These stressors can detrimentally affect individuals emotionally, mentally, and physically, highlighting the interconnectedness of mental and physical health. Behavioral health professionals increasingly integrate into healthcare to address these complex challenges, serving as agents of systems change. Collaborative coalitions spanning various sectors work to address social determinants and reduce disparities, providing a platform for behavioral health professionals to advocate for their role and educate other sectors.

Participatory Change

Another example of system change involves participating in participatory change, a practice linked to engaging clients within their communities and obtaining feedback from community members. This approach allows for insights into external issues that might influence the system.

Coalition Driven

System changes often rely on coalitions, as the prevalence of mental health conditions varies significantly from one community or group to another. For instance, a community might show a reduction in suicide rates, but disparities based on race, class, sexuality, or gender identity may reveal an increase in suicidal ideation or attempts among certain groups. Using coalitions with representatives from diverse sectors, including education, local churches, and recreational organizations, provides a way to work collaboratively and establish community priorities and tailored initiatives. This approach to system change is often more effective than applying a one-size-fits-all, evidence-based intervention from one community to another without a nuanced understanding of the population served.

Inclusion of Non-Clinicians

Another critical aspect of system-change, as noted in the literature, is the involvement of non-clinicians as experts within population-serving institutions. The behavioral healthcare landscape comprises numerous fragmented organizations that often lack cohesion. When crafting policy changes, even at the organizational level, it's valuable to engage external experts, community members, individuals from academia, and those within healthcare, considering them as experts. Their input can facilitate the development of novel interventions and drive shifts in how systems operate.

Task Sharing

Embracing the concept of task sharing involves moving away from individual or organizational efforts to impact a particular issue or drive organizational change. Instead, it encourages collaboration where people assume different roles. This approach often aligns with public health and healthcare interventions that involve empowering community health workers to enhance their capacity and incorporating backup care. How does this tie into the broader system? Well, even if a behavioral health organization achieves excellent outcomes, disparities between the demand for behavioral healthcare and the supply of professionals can significantly affect a community's mental health status. This challenge is particularly pronounced in places like Oregon, where there's a substantial gap between the number of professionals and those in need of services. Thus, developing strategies to ensure some level of care reaches those underserved individuals and creating pathways to care becomes imperative.

Prevention

Engaging in system change involves challenging the specialist model, questioning hierarchical decision-making, and expanding beyond excessive medicalization to consider prevention within the system. It also entails addressing systemic issues like racism and sexism, applying an equity lens, and transitioning towards trauma-informed care. This might involve educational efforts to inform individuals. While there are many high-level initiatives advocating for the integration of an equity lens, the question remains: How do we achieve this, and whose responsibility is it to make it happen?

The Suffering of System-Changers

Now, let's address the challenges faced by system-changers, which will tie into the discussion of combining system change and self-care. It's important to note that there's a significant issue of burnout among those passionate about system change, and this can negatively impact their career sustainability and overall well-being. While I don't engage directly with the population served, I work closely with program developers, witnessing their idealism, their efforts for change, and the frustration that can follow. This often leads to taking on too much responsibility, which can lead to burnout and disillusionment. The key question is: How can we prevent burnout and prioritize the well-being of those pushing for systemic change?

• Disillusionment; low autonomy or control/influence
• Alienation; lack of peers or support 
• Feeling overwhelmed and stuck
• Imposter syndrome; hesitancy in stance
• Burnout; frustration, perceived lack of effectiveness 
• Can be compounded by other minority or marginalized statuses

Engaging in system change can be mentally and socially challenging. Feeling unheard or thinking differently from others, especially when administrators are heavily focused on funding, can create social stress. Recognizing the system as broken, ineffective, or unjust, and witnessing a lack of empathy or acknowledgment of social issues, can lead to burnout, exhaustion, cynicism, and even dishonest behavior or alcohol abuse. These issues are common among deeply dedicated individuals. Notably, research shows that independent practitioners experience less burnout compared to those in larger organizations, where clashes between hierarchy levels can be more frequent. It's crucial to protect individuals from burnout and its negative consequences.

Measuring Burnout

To recap, measuring burnout involves assessing a combination of emotional exhaustion, depersonalization (developing a negative attitude towards work or the people you serve), and a sense of reduced personal accomplishment. It's not a binary measure; instead, it exists on a continuum. You can experience varying degrees of these feelings, ranging from a state of well-being and vitality to total burnout and detachment from your work. It's important to recognize that individuals can move along this continuum, and burnout is not necessarily a permanent state.

• Emotional Exhaustion (EE): feeling maxed out and not able to offer emotional support
• Depersonalization (DP): negative/cynical attitude towards/of the patient
• Personal Accomplishment (PA):  is reduced, plus escapism
• NOT dichotomous

Pain Points in Systems Change 

System change in the context of behavioral healthcare often involves shifting culture, paradigms, and approaches, which can be challenging and sometimes seen as counter to the traditional medical model, particularly when it involves changing how we view the root causes of mental health issues. These shifts can contribute to the factors related to burnout among system-changers.

Job scope, Time Constraints

Burnout in the context of system change can also be related to short-term coping with workload and feelings of ineffectiveness. It may increase with years of experience and is influenced by the scope of your job and time constraints when taking on extra responsibilities related to system change. Additionally, the global nature of the problems may not always align with your sphere of influence. In response to system change efforts, new professional roles can emerge, often grant-funded, but they might be temporary, coming and going as needed.

Bureaucracy, Hierarchy 

Bureaucracy and hierarchy within organizations can indeed create challenges for system-changers. Conflict between employees and administrators, as well as mismatches between programs or ideas and funding criteria, can add to the pressure. Dealing with bureaucratic red tape is a significant cause of burnout, leading to moral distress when top-level decision-makers may not be implementing positive changes for legitimate reasons.

Organizational Culture

The organizational culture can become a pressure cooker when infighting or tensions arise among different groups and individuals regarding how to approach a problem. This can often be a clash between the biomedical model, emphasizing over-medicalization, and a more holistic approach that includes social factors and policy changes to address disparities. Such conflicts go beyond day-to-day practice. The ethical climate within an organization can also be influenced by this, and many have experienced situations where they were proud to work somewhere with a clear mission and purpose, only to see changes in administration lead to a values mismatch or ethical concerns. When such discrepancies occur, it can be challenging to maintain positive momentum towards your goals, affecting your ability to perform at your best and having a psychological impact.

Self-Care

Self-care is not only important but protective, especially when dealing with the various stressors and risk factors that come with engaging in system change. It's essential to shift the stigma around self-care, viewing it as mission-critical rather than selfish. Focusing on basic needs and avoiding codependency – where you overly prioritize others' needs – is crucial. By taking responsibility for your self-care, you regain power and improve relationships and overall well-being.

Incorporating practices that enhance your overall wellness is key. Additionally, it's essential to separate your identity and self-worth from your career, as tying them too closely can lead to emotional highs and lows that affect your self-esteem and well-being. Decoupling your identity from your career allows you to offer better care by preventing emotional exhaustion. Cultivating emotional and interpersonal boundaries is also important for maintaining your well-being and preventing overwhelm from systemic and individual challenges.

Human Needs

Understanding and addressing human needs is a crucial aspect of self-care. These needs can be categorized into various levels, with physiological and connection with others being some of the top priorities when it comes to self-care. Ensuring your physiological well-being, which includes things like sleep, nutrition, and exercise, is fundamental for your overall health. Likewise, maintaining strong connections with others, such as friends and family, can provide emotional support and a sense of belonging, which is essential for your mental and emotional well-being. Building self-care routines around these needs can significantly contribute to your overall well-being and resilience, especially in the face of the challenges associated with system change work.

Figure 1. Maslow's hierarchy of needs.

Barriers to Self-Care

Engaging in self-care can be challenging due to various barriers. These obstacles include attachment to unhealthy behaviors or addiction, a lack of motivation, difficulty deciding when to adopt healthy behaviors, challenges in maintaining these behaviors without social support, dealing with multiple health conditions (multi-morbidity), experiencing significant life events such as relationship endings or loss, and having an inadequate response to the symptoms of burnout. Additionally, there may be a stigma associated with seeking help for self-care, particularly among health professionals who provide care to others but may hesitate to seek support for themselves. Recognizing and addressing these barriers is essential for promoting self-care and overall well-being, especially in high-stress roles like system-change work.

Self-Care in Practice

In self-care, you can start anywhere, but it's essential to cover various domains. Begin with physical well-being, which you may already be practicing. Next, set healthy boundaries, manage emotions effectively, and release negative feelings to think clearly and make sound decisions. Embracing your inner spirituality, regardless of religious beliefs, can offer a protective perspective that turns life's challenges into valuable learning experiences. This simplified paragraph maintains the core concepts while improving readability.

Physical Nurturing

Physical nurturing primarily revolves around the vital aspect of rest. It's crucial to remember the HALT concept: when you're hungry, angry, lonely, or tired, rest becomes your best ally. This is my catchphrase, "Rest is best." Additionally, your diet, exercise, and physical activity, which can encompass simple movements like standing up and down, dancing, or spending time outdoors in nature, play pivotal roles in regulating your overall well-being. Don't underestimate the significance of basic hygiene practices such as teeth brushing, hair care, and showering; they are integral to your physical nurturing. Lastly, engaging with healthcare professionals when needed and adopting other wellness practices further contribute to your holistic self-care routine.

Boundaries

Let's talk about boundaries, a key factor in your well-being and career sustainability. First, there's work-life balance, where setting clear time limits matters, even if it feels challenging in environments where work bleeds into personal time. Emotions come into play too; it's important to distinguish what's yours from what's others'. Plus, professional boundaries ensure you don't get overly involved with colleagues to the point where you lose your own identity. Remember, boundary-setting can be a lifelong process, especially if you've never learned it before; it often starts in adulthood and takes time to develop fully. So, be patient with yourself as you work on it.

Locus of Control

This also ties into the concept of your locus of control, which involves recognizing what you can and cannot control. This distinction becomes particularly crucial in effecting system-level change. Focusing excessively on things beyond your direct control can drain you emotionally. It's not that you can't contribute to changing the system, but it's important to differentiate between what falls outside your control, such as people, places, and external factors, and what you can control, which includes your responses and behaviors. While thoughts, emotions, and feelings can sometimes feel less controllable, they also fall within your influence and can change over time.

Emotional Regulation and Expression

It's crucial to recognize and identify your emotions. Sometimes, without clear boundaries or when you're overly focused on others, pinpointing your feelings can be challenging. Practicing mindfulness can help create a separation between strong emotions and your neutral inner self. Techniques like deep breathing, talking to a friend, journaling, engaging in art, participating in activities, singing, or even venting can serve as valuable outlets to express and process your emotions, which is essential for your well-being.

Spirituality & Your Inner-Self

To reiterate, spirituality involves connecting with your identity beyond your social and professional roles, potentially seeking support from a higher power when you're overwhelmed or uncertain about your path. This could involve practices like prayer and meditation, which offer valuable guidance. It also includes identifying your personal and professional values, finding solace in nature, and for some, spirituality is intimately tied to the natural world. How does all this help in your daily life? It provides you with a centered foundation, ensuring that the ups and downs of your professional life don't easily toss you about, helping you maintain a sense of inner calm and stability.

Social Support

Social support stands out as one of the most effective preventive measures for mental health issues, especially at a broader population level. This is even more crucial when you're involved in system change efforts. Seek out like-minded support groups, consider individual counseling or therapy, and if you're adopting new health behaviors, having a supportive buddy can be immensely beneficial. Building a strong support network can significantly bolster your well-being and your ability to navigate challenges effectively.

An Appropriate Outlet

In summary, my message, while not from a behavioral health professional, is grounded in real-world experiences involving programs, policies, initiatives, and organizational adjustments aimed at addressing pressing social issues. Undertaking such endeavors can indeed be daunting, but they can also be deeply inspiring and drive meaningful change. Our systems may have flaws, but they are amenable to improvement through ongoing innovations and initiatives, which you can explore through readily available resources.

Self-care plays a pivotal role in this journey because without prioritizing your well-being, progress becomes elusive. However, the key is to identify an appropriate outlet for your efforts. It involves discovering where you can make a difference, whether it's within your current role or beyond it, while understanding your limitations regarding time, workload, and emotional investment. The goal is to find the smallest difference you can make within your capacity, as this will fuel your energy for sustained work. Attempting to tackle something too vast can be overwhelming, akin to getting electrocuted, so the metaphor here is to find an appropriate outlet.

I've provided references for further reading, and I'm open to offering additional resources. Your time is greatly appreciated, and I welcome any comments or questions. I wish you the best of luck in your endeavors, whether they involve small or large changes. That concludes this course.

References

Belkin, G., Appleton, S., & Langlois, K. (2021). Reimagining mental health systems post COVID-19. The Lancet Planetary Health, 5(4), e181-e182.

Balch, C. M., Oreskovich, M. R., Dyrbye, L. N., Colaiano, J. M., Satele, D. V., Sloan, J. A., & Shanafelt, T. D. (2011). Personal consequences of malpractice lawsuits on American surgeons. Journal of the American College of Surgeons, 213, 657-667. doi:10.1016/j.jamcollsurg.2011.08.005

Bruce, C. R., Miller, S. M., & Zimmerman, J. L. (2015). A qualitative study exploring moral distress in the ICU team: the importance of unit functionality and intrateam dynamics. Critical Care Medicine, 43, 1–9.

Dzeng, E., & Curtis, J. R. (2018). Understanding ethical climate, moral distress, and burnout: a novel tool and a conceptual framework. BMJ Quality & Safety, 27(10), 766-770.

Maslach, C., & Jackson, S. E. (1981). The measurement of experienced burnout. Journal of Organizational Behavior, 2(2), 99-113.

O’Connor, K., Neff, D. M., & Pitman, S. (2018). Burnout in psychotherapists: A systematic review and meta-analysis of prevalence and determinants. European Psychiatry, 53, 74–99. doi:10.1016/jeurpsy.2018.06.003

Pawson, R., Greenhalgh, J., Brennan, C., & Glidewell, E. (2014). Do reviews of healthcare interventions teach us how to improve healthcare systems? Social Science & Medicine, 114, 129-137.

Reith, T. P. (2018). Burnout in United States healthcare professionals: a narrative review. Cureus, 10(12).

Riegel, B., Dunbar, S. B., Fitzsimons, D., Freedland, K. E., Lee, C. S., Middleton, S., ... & Jaarsma, T. (2021). Self-care research: Where are we now? Where are we going? International Journal of Nursing Studies, 116, 103402.

Welp, A., Meier, L. L., & Manser, T. (2015). Emotional exhaustion and workload predict clinician-rated and objective patient safety. Frontiers in Psychology, 5, 1573. doi:10.3389/fpsyg.2014.01573

Wilkinson, H., Whittington, R., Perry, L., & Eames, C. (2017). Examining the relationship between burnout and empathy in healthcare professionals: A systematic review. Burnout Research, 6, 18-29.

Yang, Y., & Hayes, J. A. (2020). Causes and consequences of burnout among mental health professionals: A practice-oriented review of recent empirical literature. Psychotherapy, 57(3), 426.

Editor's note: This text-based course is a transcript of the School Social Work Efforts to Support Students in Public Schools Post-Pandemic Podcast, presented by podcast host Benjamin T. Bencomo, DSW LISW, LCSW, and podcast guest Capella Hauer, MSW, NCSSW.

Learning Outcomes 

After this course, participants will be able to: 

• Describe the role of a school social worker.
• Explain the impact of the COVID-19 Pandemic on students.
• Identify effective strategies for supporting students post-pandemic.

Podcast Discussion 

Dr. Ben Bencomo: I am very excited about our podcast today. This is a topic that I know many of our listeners have probably been encountering in their work in different school systems, both public and private post-pandemic, and supporting students K-12. And I'm very excited to welcome our guest today, Capella Hauer. Capella Hauer graduated from New Mexico Highlands University in 2015 with her master's degree in clinical social work. Since then, she has worked as a school social worker, primarily in the elementary setting. She has provided trainings on both self-care, as well as trauma-informed work in schools. Capella recently achieved national certification through the School Social Work Association of America, the first to achieve this certification in her state. She is currently a practicing school social worker in Tucson, Arizona, working part-time in schools and part-time for the School Social Work Association of America as their membership coordinator. And I must say, I am doubly excited for today's podcast because it is always fun catching up with former students and seeing all the amazing things they are doing. And Capella, you really are doing some amazing things. And it's really fun for me because I get to flip the script and learn from you today. So thank you so much for joining us today.

Capella Hauer: Yes, thank you so much for having me. I want you to know and let our listeners know that I'm going to try to show up today just as my authentic self. School social work is really near and dear to my heart. This is the niche I've found myself in and have not left yet, so I'm sure I'll share some personal opinions today. And I want everyone to know I'm not an expert. I don't believe anyone can be an expert in anything. So my hope with this, and having this conversation with you, Dr. Bencomo, is to hope that our listeners become more interested in school social work, or at least what's kind of going on in our schools right now, and then really do some more research and advocacy afterward.

Dr. Ben Bencomo: Absolutely, yes. Thank you for that. Well, your experience and your practice wisdom is definitely something that we appreciate you sharing with us today. Now, if we can start from the beginning if we will. I'm always interested to know a little bit about guests' path to social work. I do remember some of this story from you in class when you were completing your master's, but would you mind sharing with our listeners a little bit about your path to social work and your social work education background? So how did social work find you, Capella?

Capella Hauer: Yes, of course. I think I've always been one of those helpers. I think a lot of social workers can identify with that. But even when I was younger, or I especially remember a little bit more vividly in high school, I tended to be that student that other kids would come and talk to if they had an issue at home or at school. And it just always felt very natural for me to kind of help problem solve, lend an ear, or just be someone that they could vent to.

And then, as my high school career was coming to an end, I didn't want to, at first, attend a university because I wasn't quite sure what I wanted to do. So I just ended up doing a lot of volunteer jobs. I was working at our animal shelter. I was volunteering at our local domestic violence shelter. And it just sort of became a little bit obvious to me that all the jobs and things I really liked to do were kind of in the direction of social work, or at least all these volunteer jobs. I was like, "Well, I can't just keep volunteering forever. I should probably start a career, and I need to be able to pay rent."

So I had kind of debated back and forth on whether I should do social work or psychology. And I just found, for me, for my personality, it felt like it fit more with social work because I could experience all sorts of work settings, working in prisons and hospitals, schools, all sorts of different niches. So I ended up choosing social work, obviously. And then, I got my undergraduate and master's degree from New Mexico Highlands. And ever since then, I've been working in public schools as a school social worker.

Dr. Ben Bencomo: That is great. Thank you, Capella. Well, we are definitely glad that you found your way to social work. I know that you've already been engaged in doing a lot of really good work, so we're happy that you found your way to our profession. Now, after graduation, how did you first become interested in school social work specifically?

Capella Hauer: Yes, so one of the things that, I guess, I should have said too, more specifically, that got me into social work was I really wanted to work in the field of adoption. For whatever reason, I think I really idealized and romanticized the whole work of adoption. I now realize it's much more complex and not as beautiful as I think I may have had it in my mind, that whole process and that work.

But really, actually, it was New Mexico Highlands that kind of led me to school social work. I know you know, Dr. Bencomo, but some of our listeners might not know that Highlands is in a really rural area, and that just translates to limited opportunities for internships. So I've always enjoyed working with children. I've always really connected with them.

And a really close friend of mine from high school ended up being a school counselor. And so, I always really admired that career that she was creating for herself. And that kind of had a connection with me. And so I had a wonderful opportunity actually to do internships at the elementary, middle school level, as well as an alternative high school for my practicum. And once I started that, it all kind of clicked, and I knew that that was a space that I really wanted to stay in. I also think back to when I was a six-year-old who was playing school with my cousins growing up. There's definitely that little girl in me who's so psyched that I grew up to be working in schools. So it's always just kind of been thrilling to me. I really love collaborating with the teachers and different professionals on campus. I really enjoy getting to really know families and kids and advocating for them, and then working with students one-on-one and in groups. It was just a blast. And obviously, I haven't left.

Dr. Ben Bencomo: Well, thank you for that. That's amazing. I'm glad that that internship sparked this interest for you and that you were able to find your niche within the social work profession because I know since that time, you've been able to do some pretty incredible things in the area of school social work. Now, many times, I think that social workers aren't sure about what is required to become a school social worker in particular. Is there a specific educational path? Are there licensure requirements? So if you could, could you clarify for our listeners whether a MSW is required for a school social work position? Or does the BSW suffice? And also, are there any specific licensure requirements that are needed for school social work practice?

Capella Hauer: Yes, so this is where the practice of school social work gets a bit tricky as far as requirements. So this is something that our profession is really trying to work towards. But right now, unfortunately, school social work doesn't have parody across the states. So each state, and even down to each district within states, can have their own requirements. A vast majority of school social work jobs do require at least a minimum of a master's degree. There are some that do work on a bachelor's level, but I've found that that's more in rural areas. And their work is primarily a broker or community liaison, and they might even have a specific focus or even a different title. So rather than school social worker, it might be a title like behavior interventionist or attendance clerk, or homeless liaison.

I think Alabama, and Louisiana, are some states that might have positions like that. And so, for another example, I'll talk a little bit about Missouri. So in Missouri, there isn't a master's degree required by the state. However, most of the school social workers in Missouri have a master's degree, and most positions require an LCSW, and that's becoming more and more common. There are some districts and agencies who contract to provide mental health in schools, and they might hire bachelor's level, but not often.

And, of course, school districts, when they're hiring, they prefer to see social workers who've had either school-based practicums or some type of experience with direct practice with youth. So yes, I would say overall, the vast majority of the positions require an MSW. And then, the second part of your question, it gets a little more complicated as far as certification. So again, it's different everywhere. Some states have their own certification requirements. So in California, in order to step foot in the school as a school social worker, you have to have the state certification. Here in Arizona, we have a certification through the Department of Education, but it's not required. It's up to each district if they want to list that as a requirement.

And I will say, too, part of the work we're doing as a profession to try to create more consistency across the board, SSWAA, the School Social Work Association of America, began offering a national certification. That's the one that you mentioned that I had recently gotten. And that's an advanced certification that shows that the practitioner has mastered the competencies within our national model. And we really hope that that's going to help create strong practitioners, more representation, as well as that parody in our practice.

Dr. Ben Bencomo: That's really interesting. And I think that brings up another question for me. I know that in the early days of what we considered school social work, a lot of times, many school social workers worked primarily in the area of special education, maybe working to help ensure IEPs were provided for students and that those IEPs were being followed to make sure that students had whatever resources they needed available. Would you say that this is still the case with many school social workers? Or are school social workers branching out into different areas of professional practice within the school setting?

Capella Hauer: So, the history of school social work is interesting, and I want to dive into this. So the very first traditional brick-and-mortar school social workers actually began what was called visiting teachers, and I want to describe that a little bit, but I kind of want to go a little bit further back because I think it's really important to first bring attention and recognition of the role social workers have played in schools, that maybe don't immediately come to mind when we think of our schools, and that's the Indian boarding schools.

I'm learning this, so I actually want to take a little pause here and just share that I want to discuss some really difficult historical trauma of our Native peoples over the next few moments. So our listeners, if you need to pause or skip ahead, I encourage you to do that. I know this isn't always a topic that we expect to maybe hear when we've logged onto this podcast, but I think it's an important piece, and I just want to touch on it a little bit.

So in 1819, I believe, the Civilization Fund Act began, and that was the beginning of the Indian boarding schools and the systemic effort of the U.S. government to forcibly remove children from their homes, with the goal of assimilating them. I think some of our listeners have probably heard the quote, "Kill the Indian, save the child." These boarding schools only goal was to eradicate our First Nations' culture and identity through this guise or belief that First Nations did not or do not already have any cultural beliefs or family values. And this was cultural genocide.

These boarding schools were more often than not run by religious organizations, and children were forcibly brought to them from their homes, often states away. There are records of children being taken from southern New Mexico all the way up to Idaho, and children as young as three were taken from their families. And if families didn't comply and turn over their kids, they were criminalized. So some Native men were sentenced to up to 20 years in Alcatraz for refusing to allow the churches to seize their children.

 I bring this up, and it's important because social workers were some of those government employees who enforced the removal of Native children during that time. And the children were emotionally, physically, and sexually abused and neglected. They self-harmed. They ran away or even completed suicide. And there are thousands of these children who never returned home and are to this day unaccounted for. Their burial sites are unmarked, and the number of child deaths is unknown. And this wasn't just during this time, that social workers had a role in this. Our role in this cultural genocide continued even after the boarding schools became less common.

So in 1958, the Bureau of Indian Affairs started the Indian Adoption Project. And this project enlisted social workers to visit reservations and then convince Native parents to sign away their parental rights. So we, as social workers, have a really long, painful history with our First Nations peoples. And again, I share this because it's really critical that, as social workers, we recognize the historical harm that our profession has caused.

You better believe that those parents, those ancestors, and these children remember on a cellular level the harm that we've done. And so, I want to share that because we, as social workers, need to walk into our door at work and know what weight that title carries and what harm that title has carried in the past.

Dr. Ben Bencomo:  I want to thank you, Capella, for sharing that because we, within the social work profession, sometimes have this tendency to romanticize the profession and romanticize the history of the profession. And in order to authentically practice in some of these spaces, I think it's important that we understand contributions that the profession has made in the past as well to some of these atrocities and to the historical trauma that a lot of marginalized populations, Native American, indigenous communities, and others that we have contributed to. So I want to thank you for sharing that, absolutely.

Capella Hauer: Yes, of course. And then, back to your initial question. So more officially, as for the brick-and-mortar schools that we think of, down the road from where we are now or whatever, social workers really started being hired and paid through the schools themselves around the 1930s. And again, that's when they were referred to as visiting teachers. So the visiting teachers' primary role was to be the liaison between home and school. They would help encourage attendance, address any needs of the families, and things like that.

And then, at that time, it was kind of, well, interesting for me because I adore SSWAA, but at that time, there was the National Association of School Social Workers, and then 40 years later, around the '70s, they dissolved to become what's now NASW and SSWAA. So during that time, we saw a shift and an introduction of new models in school social work practice, from primarily a casework model to then start including group work and systems interventions.

Also, at that time, the Education for All Handicapped Children Act became law, and that's when working with students with special needs became a bigger, more significant role for school social workers. And then, of course, school social work positions really start growing during that time. And you saw more school social workers deal with IEPs and things like that.

Dr. Ben Bencomo: So, in what ways has the field of social work changed, do you think, in terms of areas where social workers are supporting students in those school settings currently or recently?

Capella Hauer: I think now, again, it can be so different from state to state, school to school, district to district. It really is different every day. For me, a lot of the work that I do is a lot of group work. I have a fairly high caseload and only work part-time, so a good amount of the work that I'm able to do with students is in groups. We can do some one-on-one with students. We do home visits for attendance or basic needs, anything like that, crisis intervention. A lot of school social workers do class lessons, go into classrooms every week every day, and do class-wide lessons,  student meetings, and consulting with other professionals both in and outside the school. And then connecting with those community resources. Schools are such a massive hub in our community, so it's so critical to have those community resources around you as well.

Dr. Ben Bencomo: Absolutely. I think that the skill set that we bring, that social workers bring to that school setting, is being tapped into in a wider way, I guess you could say. Now, many of our listeners may already have a good understanding of this, but can you walk those listeners who've never had any experience with school social work, can you walk them through the typical day for a school social worker? I know that you mentioned that currently, you're doing a lot of groups. Is that something that you see with a lot of your colleagues who are also school social workers? Or do their days look different?

Capella Hauer: I think for quite a few, the majority of school social work colleagues that I have, groups are a big part of it. And that's a great opportunity to really focus on the needs of the students. And it can be a bit of a game of Tetris, sort of, putting those groups together and making sure they're all having the same needs, and those same needs are going to be met in the group. So that's a very common one, especially with high caseloads.

Quite a few school social workers that I know also do class lessons on social-emotional learning, and that can be sort of a year-long experience where you're going into a classroom for half an hour or an hour every week. And that is the school's SEL curriculum, and you're sort of teaching that curriculum. Or it could be class lessons because this 12th-grade class is having an issue with X, Y, and Z. And so, you come in to lend that extra support. School social workers really are massive leaders on their campus. So there's a lot of systemic teams that you might be a part of. And just, again, that consultation with other professionals on campus is a big part of it too.

Dr. Ben Bencomo: Absolutely. It's refreshing to hear that social workers have a bit more say so in terms of having a place at that table and in those discussions. I know that recently my son came home and said, "I thought you taught social workers. I didn't know you taught teachers," because one of our graduates mentioned that he had me an as a professor, and he was teaching social-emotional learning. And that was just a regular class, just like PE and music, and some of the other specials that they have in school were a couple of times a week they go to social-emotional learning. And it was very refreshing to see that skillset was being utilized in that way to help support kids, even in my son's elementary school.

Capella Hauer: I love that.

Dr. Ben Bencomo: Capella, in your experience, what are some of the challenges that you see in your role as a school social worker?

Capella Hauer: Again, I want to emphasize that this is just my personal feelings about what's a challenge. For some other people, it might be completely different. When I reflect on this, a lot of the things that are challenging to me are systemic problems. The day-to-day stresses that come with the job that's all things I signed up for. That's why I became a social worker. And that's manageable because I've learned how to manage that stress. But the systemic stuff, that's what gets to me. So one of the things I personally really struggle with is the more recent increase in attacks on our youth and just their right to equitable education.

So last month, we're just a little bit into April as we're recording this, but as of last month, there were over 400 anti-LGBTQ bills, just three months into the 2023 year. And that breaks my heart. But then, there's also this glimmer of hope because we're actually seeing a bit of a shift in acceptance. So, for example, the Human Rights Campaign they have some data that shows that we're seeing a massive shift in our youth and how accepting and affirming they are of each other's identity expression. And youth today are much more accepting in general of their peers than in previous years.

So when we were growing up, there was a lot of this talk about being worried about going to school because the kids were going to be picking up on us. But now that's sort of switched. And it gives me a lot of hope and fills my heart. But at the same time, these children are growing up in a world where there are elected officials who are taking aim at them, at who they are at their core.

And school social workers have a lot of responsibility for this, to ensure that our students feel welcome and accepted no matter who they are. Because the bottom line is that all students learn best when they feel safe, and they all deserve to feel safe and cared for.

We just to touched on this a little bit, but I'm going to flip it a tiny bit. We see, in conjunction with this anti-LGBTQ+ rhetoric, there's also a fight against anti-racist teaching as well as social-emotional learning or SEL in schools. And we hear things like, "Parents should be the ones teaching their kids values, not schools." And I'm going to be my authentic self right now, but it kind of makes me laugh a little bit for two reasons. But the first is our Founding Fathers created public schools to provide moral instruction, build character, and really set the tone and virtues of our nation. That was the goal of public schools. And I also laugh because if you are an auntie, a parent, any adult with kids in your life, if you spend six hours with a kindergartner or any kid, it's really hard to go six hours and not have to have some sort of conversation on sharing or kindness or any of those values that they're saying SEL is so dangerous for.

But I want to talk about it a bit because I know some listeners might not completely know what the term SEL is. And I want to, if it's all right, read a little bit from CASEL's website. And CASEL is the Collaborative for Academic, Social, and Emotional Learning. So they're like the pioneers or the leaders in the field when it comes to social-emotional learning. So I'm going to just lean on them because I think they could say it better than me.

So they say, "SEL is an integral part of education and human development. It is the process through which all young people and adults acquire and apply the knowledge, skills, and attitudes to develop healthy identities, manage emotions and achieve personal and collective goals, feel and show empathy for others, establish and maintain supportive relationships and make responsible and caring decisions. SEL advances educational equality and excellence through authentic school, family, and community partnerships to establish learning environments and experiences that feature trusting and collaborative relationships and meaningful curriculum."

So this sounds really familiar to what we as social workers do. At our very core, this sounds like a social work job description, and it's very reflective of our ethical standards. We teach and advocate for positive relationships. We advocate for safe and healthy communities. And then, going back to that equity, there are so many, many studies and evidence-based research that show that schools who prioritize SEL have higher outcomes on test scores, they have a more positive school climate, and overall, much higher well-being of their students and staff.

And this is what makes it really difficult for me and other school social workers. We know that this is evidence-based, and we know it works, but it's in a very real way tied to our ethical standards, along with the rights of LGBTQ+ students. So when there's this push from state legislators, and we start seeing new laws that are forcing school personnel to no longer teach SEL or even to out a student to their guardians, this goes against the core of our ethics. So it's a very tough field to navigate right now, and especially in those states where a lot of this destructive legislation has been happening.

We've also seen, and this has been going on for about a decade or so, but we've also seen a shift and this push to privatize education in America. And I'll use my state, Arizona, as an example because they are an example of privatizing education and how it can go wrong. So since around 2014 in Arizona, our government officials have been opposing and shutting down legislation and budgets that would supplement public education. So for those who don't know, Arizona ranks 49th in the country for teacher salary, last in the nation for per-pupil spending, and does not fully fund kindergarten.

So instead of putting money towards those critical pieces, our elected officials have been approving private school vouchers year after year, which in its most basic sense steals money that's meant for public schools. So I'm going to try to explain it, but this is again where I hope people afterward will kind of do a little bit of research and dig in.

So schools and districts receive a certain amount of funding from the state and from the federal government, and that funding is determined by the local census on how many students would be attending that school or district. So with the voucher system or what some people call school choice, a guardian can choose to remove their student from a public school, which is totally their right, and put them in a private school or homeschool, and the funding that would've been allocated at that public school for that child follows the child and is instead given to that private school. So that sounds kind of fine, but then it gets a little tricky.

So if a student leaves their public school, the funding for that student goes to the private school or straight to the family if they're homeschooling, and the public school can't get that funding back. So simplest breakdown, let's say I have a school of 100 kids, and 25 of them go to a private school, so I just lost funding for 25 students. Say I get more kids to enroll back in my school, so now I have 100 students again, but I don't get the money to cover those 25 students. So I'm now operating at 75% funding even though I have 100% of the students that the budget was initially created for.

So let me take a pause real quick. The other kind of issue with this is that these vouchers aren't regulated. So if you've ever worked in a school, there's like this red tape nightmare of something as simple as having to get approval for purchasing school supplies or attend a webinar. But private schools and home schools just aren't regulated in the same way. They don't have to justify every line item, which results in really no accountability for how that money is spent. Or, at the very least, it's a very inequitable system of how our money is spent on children.

And additionally, private schools don't have to adhere to the same equity laws as public schools. And public schools have been seeing a lot of parents choose to send their students with disabilities to a private school to try to get more support, more one-on-one. And they just return, saying that the school either didn't accept them or they were kicked out. And it's creating this even larger chasm between socioeconomic groups and, really, people of color. And again, it's complicated, and I hope people kind of do some more research on it because it is really fascinating and interesting how all this works. But it is a very methodical way to drain public school funds and privatize education systems.

Dr. Ben Bencomo: It's very interesting and telling, I think, to me that when I ask about challenges you experience in your role, it's not those day-to-day micro-challenges, but it's more looking at these systemic changes and systemic inequities and how really there is that trickle-down effect that you're seeing in front of you with the students that you're working with. We and I'm using the collective we for society, but sometimes we lose sight of the fact that our children, our K-12 children, are also multidimensional human beings. And so, when we focus primarily only on, "Well, these are the test scores, and this is the education," to the exclusion of do they feel safe, do they feel a sense of belonging, can they see themselves excelling in this way, can we create emotional safety.

And then, is there equity, and is there funding? Is there support needed to really create a meaningful supportive experience where these children can grow? I think it's so important, everything that you say.

I have a colleague, and I probably have mentioned this in previous podcasts as well, but I have a colleague who uses the mantra, "Micro is macro, and macro is micro." And I think you, in a very eloquent way, are explaining how this is the reality for school social workers, trying to do more with less in many instances, and also seeing the effects of what these macro-level policy decisions are having on the students that you're seeing in school every day. 

Thank you for sharing that, Capella. There's a reason that you continue to be passionate about the area of school social work as well. So would you mind sharing with our listeners a bit about what you see as some of the benefits that you find, some of the positive areas that you've found being a school social worker?

 Capella Hauer: Oh, there's a lot. But like you just said, working in micro and macro and those meso levels, I really enjoy that, because I feel like I can flex so much of my brain in different ways. So there's the one-on-one work with students, but then I also was on a school team that our whole purpose was to create a positive culture at our school in a systemic way, so then working on those meso levels. And then also on the macro levels, you have to be aware of what's going on in your local legislation and really advocating for that and calling up your legislators and looking at what's happening at the district level. So I like having that kind of complexity.

It's not just one-on-one with a client, and that's all I do. I also really enjoy working with a diverse team of professionals. It's really helped me grow as a professional to work with a phenomenal school psychologist and an amazing speech pathologist. There's a teacher that I worked with for many years who was a self-contained classroom teacher. And just the amount of things that you learn from these different disciplines is just amazing. And having principals who you can learn these phenomenal leadership skills from, I really like that too, just working with a diverse group of professionals.

I think something that also drew me to school social work is that you can work with students, and you kind of have access to these clients, so to say, for a longer time. So there are some of my students who I've known literally my whole career who are now in middle school, going into high school, and I have this beautiful honor of also working with their siblings and having these really strong relationships with their parents, with their families. And that's something that's really hard in other settings, and I think that just fits my personality. For other people, they may not like that, but I think that's such a beautiful piece of my work.

There's kind of like this community enmeshment that you might not find in private practice, where you're really connected with the food bank, and you know the people there, that come by name, and you know this whole family's history, and now their aunt is coming. There's just so much more involvement. I really love that.

And really, it's the kids. I'll try not to get emotional, but I just love being inspired by them. They lead the way. They clear the path. I don't think it's the adults that do that. I think children do. Their voices show a glimpse of what our future is going to be like. And bearing witness to their growth and their family's growth, it's an amazing honor. It really is. And kids say hilarious things, so you always know you're going to get a really good laugh each day.

Dr. Ben Bencomo: That they do. That's amazing, Capella, and inspiring, I think, to think about the real impact you've had working with so many children and families and commune entire communities and having that lasting impact as they continue to grow and develop. So yes, thank you very much for sharing that and for the work that you're doing.

Now, I do want to shift focus just a little bit to talk about current realities. Now, as our listeners well know, the COVID-19 global pandemic has really rapidly changed the field of social work in so many ways and in so many different areas. And in a little while, I'd like to talk about how that reality has changed for the kids that you work with. But first, how has the pandemic affected the setting of school social work and school social work jobs? What have you seen in that area?

Capella Hauer: So I think it's going to be interesting, especially looking forward to the next few years. During the pandemic and then in the years after, there was this flush of funding. We had a massive increase in funding for public education through a lot of different federal programs and state programs. I wish I had the data on it. The School Social Work Association of America's currently working on a massive census so that we hopefully get some of this data. But I believe, just through connecting with and talking with school social workers from across the nation, that there was quite an increase in positions in school social work positions across the states because of that additional funding. And there was a huge emphasis on social-emotional learning and building stability and safety returning back to school.

And so, a lot of districts, a lot of states put an emphasis on hiring school social workers. I'm curious to see what that will look like in the next few years. I think, in some places, that funding is starting to go away, so it'll be interesting to see what remains. And in that respect, I think school social workers need to advocate really hard for their positions right now, especially if they're funded by some of this. And, of course, that puts a lot of pressure.

But another thing that I think really affected school social workers, and I'm sure a lot of our listeners just noticed this in general, was there were increased crises and mental health concerns across the board. And then, in conjunction, there were fewer mental health supports because we had a lot of practitioners leaving the field, whether they were social workers, counselors, or whoever. The mental health system was just overwhelmed. And so, of course, that's going to affect schools too because a lot of our families couldn't get those mental health supports. So then we become the mental health supports on top of a lot of other things that we're doing too, rather than having kind of that community wraparound type service.

I think another thing that directly affected the school social workers is there's also this really high number of burnout among staff, especially teachers, for some of the reasons I've already discussed, the systemic reasons. And again, school social workers are really leaders on their campuses, at their schools. And so, we're not just working with the children. We're also providing a lot of support to teachers and consulting with them and trying to help make sure that their classrooms are a safe and welcoming environment for them as well. And that's always been in place, but after the pandemic, returning to school, I think that was definitely magnified, just because there's such a high burnout.

Dr. Ben Bencomo: Right. Definitely. So looking also at how the pandemic has affected kids in particular. Now, we know that the pandemic has affected school-aged children in so many different ways, but really, probably nowhere more so than in the school setting. And I've seen this even with my own kiddos. I have two in elementary, one who's going to be in middle school next year, and then one high schooler. But what did you see in terms of educational needs most affected during the pandemic? And how have kids that you work with been impacted as we've moved from the acute pandemic era into the later stages of the pandemic or post-pandemic?

Capella Hauer: It's only 2023. We don't have a lot of data on this yet. I think it's going to come in the years. It just takes time. But I'll share just from my experience and what I've heard from colleagues and other mental health professionals as well, and maybe make some inferences based on some data that we have from other traumatic events.

So we had this global event, this trauma, COVID-19, but I think at the core of so much of this event is just massive loss. Loss of jobs, homes, schools, loss of consistency, loss of safety, and security. And then, of course, our loss of loved ones. And this is what I feel like we've seen most in our students, is grief and loss. A large part of what we do as school social workers work with both trauma and grief support and treatment of those two things can be different.

So anyone who's experienced any sort of grief can understand how major of an impact it has on your world. And we, as adults, can relate to the struggle of being in a pandemic. But imagine if you were five years old again or when you were in fourth grade. So when I was in fourth grade, that was when the World Trade Centers were hit. And everyone in my generation, everyone alive and cognizant of that event at that time, can still remember exactly where they were during that attack. So they did research in the New York City public schools after that event, and they found that 87%, so almost nine out of 10 students in grades four through 12, reported at least having one type of reaction six months after the event.

So we're doing some inferring here. So this traumatizing, horrible event that took place over one morning had drastic effects on the children then. So we can insinuate and imagine how our students now have been even more so affected by nearly three years of COVID. And, of course, academics were affected. How could they have not been? The majority of students struggled to learn effectively at home. Some were really successful at it, but I think we're social creatures. And as educators, we needed to return to campus with reasonable expectations. So meaning we wouldn't be able to teach them everything they missed, and trying to do that would overwhelm and distress the students and their teachers. So we really needed to return to campus and start at the basics again. We needed to establish trust and safety for everybody, kids and adults. 

And then, from there, we reestablished expectations and just how to be in school again. This was such a struggle when the first year was constantly changing. So we were in person, now we're virtual, now we're in person again, and then virtual. And once we were finally back fully, really in person, the regulations for quarantining and the practice of reducing the spread changed so often. And I'm sure you saw that too since you were in the university.

So another piece of data that we can sort of use to apply this to and infer some information, but research on transient students or students who are in foster care have been studied and researched as far as their academics. And so studies show that for every move a child makes from one school to the next, so just one move, one school to the next, they lose six months of learning. So depending on where you live in the U.S., most schools are in session for nine and a quarter months out of the year. So each time you move schools, you're missing roughly two-thirds of your learning. That data in and of itself can tell us a lot.

And we also know that there was a massive disparity in students' educations during COVID, and there were a lot of reasons for this. Each one is unique, but some students had their adults stay home with them and monitor their learning. Others were maybe caring for their younger siblings or had to work. Other families were just trying to find housing or basic needs. And then, some families might have just been completely remote, and they all worked together. So those kiddos who didn't have an adult over their shoulder, helping to ensure that they logged into their classes, or the kids who can't focus on school because they're suddenly homeless. So just moving a school can cause six months of missed learning. So what about those three years from doing school at home, with no school, in person, back to home, and that constantly changing environment?

Dr. Ben Bencomo: Right. I think that is incredibly insightful to look at, "This is what we know, and this is what has been proven," because we are still so early in this post-pandemic phase that the research is going on currently. But I think that can help us understand some of this prolonged trauma and some of these disruptions to the educational experience that our kids experience so that we can then look to ways to support them currently. And so, I do want to ask you, how can school social workers best support children and adolescents currently, given the current reality? And also, how can school social workers best support teachers, administrators, counselors, and other colleagues that are in the school setting currently?

Capella Hauer: I think at the very basic, we need to go back to social work 101 and look at Maslow's hierarchy. And that needs to be something that's always placed in mind. And just having in the back of our heads, too, that our students are still experiencing grief, loss, and trauma. So really just taking into account their basic needs first, really taking into account the whole child, the whole family, and the whole community, really. And I think for both teachers and students, anyone on your campus, I think a big thing that we need to get back to and really put the highlight on is connection and relationships. We are social creatures. We learn, grow, and develop through being with others.

There are all these studies on incarcerated people who have been in solitary confinement and the damage it does to their brain system. So the amount of time that we were alone, there was so much loss and connection and so much isolation. And I'm sure the data and the research in a few years is going to show us that it had a massive effect on our brains. And so, we learn through relationships. Even as a baby, we learn from that initial connection with our mother or whoever was there when we were firstborn. And if you have been blessed to have beautiful friendships or marriage or whatever, you know how much those people in your life have such a massive impact on your motivation, on your mental health, and on your physical health.

We missed out on that for three years, for two years. And so, I think really focusing on those connections and those relationships and getting back to that is going to really help build that safe space, that support where students and adults feel more regulated, more calm, more up in their brain, in their forward part of their brain, to be able to learn and to really participate. But those relationships have to come first.

Dr. Ben Bencomo: Absolutely. It's so essential to everything that we are and everything that we do. And I think that bringing it back to those basics, bringing it back to Maslow and looking at our basic needs being met, and that social connection to others is that basic need being met as well is really important. Capella, now I know that you currently serve as the membership coordinator for the National School Social Work Association. Could you tell our listeners just a bit about this position and this organization on the whole? What is the National School Social Work Association and what is your role there?

Capella Hauer: Yeah, absolutely. So SSWAA is really the only professional organization for school social workers. It's similar to what NASW is for all social workers, but really it's just for the niche of school social work. We host webinars. We do an annual conference. We actually just wrapped up our annual conference a couple of weeks ago. We provide tools, practice resources, liability insurance, networking opportunities, and then we also have state chapters too, so we provide support for states. And, of course, we also advocate for all school social workers on that national level. It's a really wonderful organization. I absolutely love my work there. I love being able to practice on a macro level, and kind of have that mission, that sole mission of really just driving this particular niche of social work forward and growing the profession. I definitely encourage our listeners to check it out because they have a lot, a lot of resources and information on their website.

Dr. Ben Bencomo: Absolutely. You mentioned there were state chapters as well. Are those active in every state?

Capella Hauer: Almost every state. I think the last time I looked, we had 38 or 40 states that were affiliated with us. So there are some state chapters too.

Dr. Ben Bencomo: I think that often we don't realize the importance of having this connection to colleagues and these organized advocacy efforts on that wider stage. But it's important for us to understand, I think, the importance of joining some of these professional organizations. Capella, how can some of our listeners learn more about school social work if they're interested?

Capella Hauer: Again, checking out SSWAA's website is a really good place to start. So it's just sswaa.org. Again, they have a ton of resources and articles, and they also have a blog, which I think provides really good insight into the field. And then, of course, there are also social media groups. So there are a lot of school social work groups on Facebook that you can join, and there's a really rich dialogue on those as well. And that can kind of give you a good idea or feeling of what this particular role is like.

Dr. Ben Bencomo: That's great. You just finished talking a couple of minutes ago about the importance of connection and finding that support for students and also for teachers and administrators, and other staff in school settings. I think that this could be a great avenue for school social workers to find that connection and mutual support as well as other people who understand what it's like and who can share resources and can be there to provide support. I think is really important.

We are almost out of time here, Capella, but I did want to thank you for being here. Thank you for sharing your practice experience and all of your knowledge. I want to thank you for sharing with our listeners the history, the good, the bad, and the ugly of the history of social work and of school social work in particular, and also a bit of understanding that can help us move forward. Where do we go from here in this post-pandemic era, and how can school social workers help to lead the way really with supporting the next generation that's coming up. So Capella, thank you so much for your time and for sharing so much of your authentic self with us and with our listeners today. We definitely appreciate it. Continue to do the work that you do, and just rock on, Capella. Thank you so much.

Capella Hauer: Absolutely. Thank you so much for having me. I really appreciate it. It's a great way to spend an hour.

References 
 

Daftary, A.-M. H., Sugrue, E. P., Gustman, B. D., & Lechuga-Peña, S. (2021). Pivoting during a Pandemic: SchoolSocial Work during COVID-19. Children & Schools, 43(2), 71–78. https://doi.org/10.1093/cs/cdab005

Lara, L., Saracostti, M., & de-Toro, X. (2022). Adaptation and psychometric properties of the school engagement and contextual factors questionnaires for Covid-19 and post Covid-19 context. PLoS ONE, 17(9), 1–14. https://doi.org/10.1371/journal.pone.0272871

Marraccini, M. E., Griffard, M. K. R., Whitcomb, C. E., Wood, C., Griffin, D. C., Pittleman, C., & Sartain, L. (2023). School‐based mental health supports COVID‐19: School professional perspectives. Psychology in the Schools, 1. https://doi.org/10.1002/pits.22869

Matsopoulos, A., & Theron, L. (2023). Resilience to COVID-19 challenges: Lessons for school psychologists serving school-attending youth with experiences of marginalization. School Psychology International, 44(2), 123–134. https://doi.org/10.1177/01430343231151591

Owens, C. L., Johnson, A. H., & Thornton, A. (2022). Addressing Equity in Schools: Youth Participatory Action Research and Transformative Social and Emotional Learning during COVID-19. Children & Schools, 44(1), 48–54. https://doi.org/10.1093/cs/cdab029

Sugrue, E., Ball, A., Harrell, D. R., & Daftary, A. H. (2023). Family engagement during the COVID‐19 pandemic: Opportunities and challenges for school social work. Child & Family Social Work, 1. https://doi.org/10.1111/cfs.13011

Yadav, R., & Yadav, A. (2023). The 6 A’s model of social worker associations and COVID-19: A preliminary insight. Qualitative Social Work, 22(2), 357–380. https://doi.org/10.1177/14733250211068066

Editor's note: This text-based course is an edited transcript of the webinar Pediatric Abusive Head Trauma: Recognition, Prevention, and Long-term Impact, presented by Alison D. Peak, LCSW, IMH-E.

Learning Outcomes

After this course, participants will be able to:

• Examine the legislation requiring PAHT continuing education, its origins, and its intentions.
• Identify the prevalence of PAHT, warning signs, and long-term outcomes.
• Analyze effective prevention programs and their role in preventing and mitigating PAHT in communities.

Introduction

We will talk about some heavy stuff today, and I want to ensure you know I will share stories as I share content. I encourage you to slow down, recognize your thoughts and emotions, and take care of yourself as we walk through this together. My great passion is working on behalf of children from birth through age five and their caregivers, working clinically, programmatically, and systemically on behalf of little ones and those who care for them. I also want you to know that I'm a social worker. I identify deeply as a social worker and love my work. It is part of who I am and all the things that come with me. It'll be a big part of my perspective and the stories I tell today.

I also want you to know that in the process of becoming a social worker, I spent four years as a floater in an early childcare center, so I have also been in early childhood classrooms. I remember working with 15 two-year-olds simultaneously and all the pieces that come with that. I remember those kiddos who were the first ones in the door, the last ones to leave, and who often spent more time with us than they did with caregivers at home. Even in that place of having children in your physical presence for long periods, there are still questions about what happens when they leave and what the rest of their day looks like.

This course is for both social workers and early childhood educators. I'll do my best to wear both hats and keep in mind all the different stories and perspectives you bring. Before we jump in, I want you to take a moment. I'm going to guide you through a grounding activity. As I said, we're going to deal with some pretty heavy content today, so I always like to make sure that we're deeply connected to our space and place and are present as we dive into these things.

I invite you to find a comfortable space. Make sure as you sit that your bones are deeply connected to your chair and that your feet are firmly grounded. After you read the instructions, close your eyes or stare softly about six feet in front of you, whichever is best for you. You're going to take three deep breaths. As you breathe in, count to four, then hold the breath for a count of seven, then breathe out for a count of eight. Do this three times, then come back to the course.

Pediatric Abusive Head Trauma (PAHT) in Kentucky

In 2010, the Kentucky General Assembly passed a bipartisan bill requiring many disciplines to receive consistent training in pediatric abusive head trauma. That original piece of legislation is tagged as Kentucky House Bill 285. That legislation has now been morphed into state policy and can be found in various locations throughout the state code. The original legislation is tagged as Kentucky House Bill 285. At that time, the goal was to increase recognition of signs and symptoms of pediatric abusive head trauma, increase prevention efforts for pediatric abusive head trauma, and ensure that professionals who interact with young children are aware of the potential outcomes of pediatric abusive head trauma given its considerable relationship to child well-being and child abuse.

In the state of Kentucky, the following people must be trained in pediatric abusive head trauma.

• Law enforcement
• High school students
• Inmates in state penitentiaries
• Guardian ad litems (attorneys specifically for the child welfare sector)
• Prospective adoptive parents
• Childcare providers
• Pediatricians, radiologists, family practitioners, trauma physicians, and family medicine physicians
• Physician assistants and nurse practitioners
• Paramedics, medical technicians, and first responders
• Nurses
• Social workers

I think it's intriguing to think about how, as individuals get closer to years in which they are no longer children but are becoming parents, we are preparing them to know what it means to take care of littles and show up on behalf of them.

What is Pediatric Abusive Head Trauma (PAHT)?

First and foremost, what is it? Pediatric abusive head trauma describes a constellation of signs and symptoms resulting from violent shaking and impacting an infant's or small child's head. In mainstream media, this more often gets referred to as Shaken Baby Syndrome, but the medical terminology is pediatric abusive head trauma. This definition clearly states that this does not occur and is not caused by general play, falls from a couch, or other things of that nature. Pediatric abusive head trauma is one of the primary physical child abuse incidents that occur in early childhood.

PAHT in the News and Media

We first saw pediatric abusive head trauma come into the news and media in 1962. At that time, a physician named Dr. C. Henry Kempe was beginning to identify a connection between aggressive and neglectful parenting and long-term behavioral and mental health symptomology within children who were the recipients of that aggressive and neglectful parenting. Sometimes in the literature, it gets referred to as scary parenting, based on the idea that the caregiver is the source that the child is afraid of. We think about those consistent moments when caregivers are large and out of control. 

As I mentioned, we don't see this constellation of pediatric abusive head trauma with somebody who fell off the couch. Also, we know that all parents get upset sometimes, and kids get yelled at. However, at the other end of the spectrum, the parent may be the person children are afraid of and cannot seek comfort from. Think about really exaggerated, aggressive behavior, including physical abuse, intense emotional abuse, and neglect. Also, keep in mind the intense interpretations of a parent about a child's intentions.

Dr. Kempe's study in 1962 began to categorize these symptoms as battered child syndrome. It was revolutionary for the early '60s to think that child abuse occurred in all types of homes and all types of environments. This was not just seen in families experiencing extreme poverty or only in families with single-caregiver homes. They saw this show up in lots of places regardless of socioeconomic status or kind of caregiving dynamics. This laid the initial foundation for child abuse laws and mandated reporting. When this study came out, the recognition of battered child syndrome prompted legislation to realize that something had to be done. They couldn't just leave things where they were. There needed to be a response to this aggressive and neglectful parenting that deeply impacted these children.

A paper published in 1972 proposed the idea that the brain, as an organ, could sustain injury from being thrown about. They categorized it as whiplash-shaken infant syndrome. It also identified a triad of symptoms observable by X-ray that may or may not accompany other signs and symptoms of abuse, including cerebral swelling and hemorrhaging. Imagine being in a car accident, busting your head open, and needing stitches. There may not be an external manifestation of what is clearly an internal injury.

In 1997, a British nanny was charged with the murder of an eight-month-old baby in relation to a series of symptoms that physicians and police called shaken baby syndrome. This case sparked a series of concerns and awareness from the greater US public about shaken baby syndrome and its potential impacts on children and child well-being. We see this evolution of language from battered child syndrome to whiplash shaken infant syndrome, to the concept of shaken baby syndrome, and, currently, pediatric abusive head trauma.

I was a child when this occurred and remember it fairly clearly because I had an infant cousin at that time. I remember my family being really cautious, more so than they had been in prior years, about who got to hold the baby and where they were standing or sitting when holding the baby. There was an increased awareness that something terrible might happen because of the increased conversations around shaken baby syndrome.

Within broader news media, there is increasing conversation about the role of investigation in child abuse reports. People are slowing down to ask, what is happening, and what is it that occurs in families when there is the experience of pediatric abusive head trauma? Current media is also highlighting that in previous years, people were quick to identify a "victim" and a "culprit" without allowing for the due diligence of an investigation that holds multiple outcomes as a possibility. It is rare to have clear evidence without proof of pediatric head trauma. It's unlikely we're going to catch it on camera. One of the things we are increasingly aware of is that some of the symptoms we begin to see in early pediatric abusive head trauma may be related to an event that occurred weeks or days prior and may not be the thing that happened most recently. 

Child Well-Being

Kentucky

Kentucky ranks 37th overall in child well-being for the United States. It ranks 38th in economic well-being for children but 26th in educational well-being for children. It ranks 42nd for family and community well-being. This ranking highlights an above-average presence of alternative caregivers, such as grandparent or kinship placements, single-parent homes, and high poverty. This does not include children engaged in the state child welfare system.

Nationally

Nationally, three out of every thousand children are in foster care. On average, the US spends about $1.3 billion on foster care placements, care, and associated adoption costs every year. Child welfare is not cheap. For the nation to step in and take care of vulnerable children and families comes at a price. I live and work in Tennessee, and right now, there are nearly 30,000 children in foster care in the state of Tennessee. While it might only be three out of every thousand, that is still a significant number of kids.

Regarding the connection between child welfare and child well-being, we want to consider those placement disruptions associated with foster care or other similar arrangements are generally connected to a six-month regression in development for each placement disruption. Statistically speaking, if we have a three-year-old who's removed from their primary caregiver and placed in a foster home, that's one disruption. If that foster home says, "I cannot manage this child. They're going to have to go someplace else," and they are then placed with another foster home, that's a second disruption. Then let's say, heaven forbid, that foster home says, "Oh my goodness, I have had an elderly parent who now has an end-of-life need, and I'm going to no longer be able to foster," and that child moves again, that would be the third disruption. Some of our kiddos in child welfare can be disrupted fairly frequently. It is not uncommon that in most states, children in foster care have an average of three and a half placements in their first year in child welfare.

If a child has three placement disruptions, and we think about that from a mathematical standpoint, that would be an average regression of 18 months' worth of development. That means we are in a place in child welfare where the children in foster care often function as children much younger than their chronological age and present with some significant challenges. Some states have what can generally be referred to as privatized foster care. These states will have programs or nonprofits where parents are allowed to give temporary custody to an agency instead of their child being placed in child welfare for things like rehab stays, short-term incarceration, and homelessness that appears as though it will resolve at some terminal point. Those may not be technically foster care, but they would be very similar. Those kinds of placement disruptions become connected to that six-month regression.

Taking care of our kiddos who've already had experiences of trauma and potentially scary parenting becomes really important because the more there is disruption, the more compounded we see the impact on development and delays. When possible, children are best raised in the care of their families. When that is not possible, we look for permanency in other settings. One of the major goals of child welfare is to try to keep kids in homes and connected to families as much as possible. Awareness, prevention, and intervention opportunities around pediatric abusive head trauma reduce the likelihood of child welfare placements or duration of placements and reduce the cost of long-term out-of-home stays.

Child Welfare

Kentucky

In 2020, 66.9 per every thousand children in Kentucky were the identified minors in a child welfare investigation. Remember, I said about three out of every thousand children go into foster care, but about 67 out of every thousand have some related Child Protective Services (CPS) report. CPS is generally a division of the child welfare system. Of those roughly 67 per thousand kids who were part of a child welfare investigation, about 17 of them had a substantiated abuse finding.

A substantiated abuse finding can be defined in a couple of ways. When a child welfare report comes into the mandated reporting system, it becomes the responsibility of that part of the child welfare system to identify whether or not a report is "valid." There are lots of reasons why a report might not be valid. There are times that folks have told me that they filed a report because they saw a caregiver spank a child in a grocery store, but they didn't know the child, didn't know the caregiver and didn't have names or any information. While they called that in, at the end of the day, the child welfare system couldn't figure out who it was. There's no way to connect it to an individual or to an option to investigate further. All of those calls pretty much get screened out because there's not enough information there to do anything with them.

There are also calls that get made to child welfare that may not rise to the definition of what is considered dependent abuse or neglect. I can think of reports I have filed that did not meet that qualification. There have been times when I was very worried about a family's dynamics and very concerned that choices were unhealthy. That can be difficult to communicate. Unhealthy decision-making does not necessarily equate to unsafe and may not leave bruises or indicate that a child doesn't have a place to sleep and a roof over their head. Those can be screened out.

There are many other reasons a report may not be "substantiated." But a substantiated abuse finding means that the state agrees that there's an issue and that we need some support. Those supports can look like lots of different things, such as foster care or additional services in the home. Of those 17 per every thousand children in Kentucky with a substantiated abuse report, not all of them entered the foster care system. However, of those roughly 17 per thousand, about one per every hundred thousand was specifically a child abuse-related fatality, meaning that the abuse had been egregious enough that the child did not survive. For 2020, there were about 16,750 children in foster care across the Commonwealth. Of those, about 15% were under a year old, and about 47% of all foster care children were age five or younger.

Nationally

I also highlight that, nationally, about 16% of all children engaged in child welfare were one year or younger. Nationally, 42% of all the children in child welfare were age five or younger. Kentucky is not alone in this. Consistently across all the states, infants and young children have the highest rate of engagement with child protective services and the highest rate of removal.

It's a curious statistic to take a step back and reflect on because, most of the time, when folks think about foster care, they think about school-aged children and often think about teenagers. They may have a picture in their head of a 15-year-old who needs a place to go because things at home are so intense and difficult. While nationally, 58% of the kids in child welfare are not aged five or under, the single largest age bracket engaged in child welfare is birth to five. Most of our kids in foster care are young. Most of them are in developmental spaces where they cannot fully give words to their experience or have the kind of cognitive development to connect cause and effect. They cannot understand how they got here and where they are.

Why?

Children aged five and under are at the most risk for CPS investigation and removal because infants and young children are much more dependent on caregivers. When we think about allegations of neglect that are substantiated to removal, it may be the difference between healthy and safe. A 10-year-old can find their own Pop-Tarts. While that may not be great, and it may not be the nutritional density that we would hope for, the reality is that they're fed. Often it is because they feed themselves. A two-year-old won't do that.

They are also less verbal or nonverbal than older children, meaning they cannot be an active narrator about their experiences. I think that makes pediatricians, CPS workers, and others involved aware of what may be happening in the world of young children. Whereas, I think, for older kids, there's some expectation that they'll tell us when something is wrong.

Littles have big emotions in little bodies. As part of the developmental trajectory, even with typical developing, best-case-scenario kiddos, the number of meltdowns children have between birth and 18 continuously decreases. Even more emotional kids have emotional stability the older they get. But littles have a lot of big feelings. One of the statistics we use in ZERO TO THREE talks about how the average number of meltdowns for a two-year-old in a day is about one meltdown every 24 minutes. It is typical that about every half an hour, a two-year-old is completely melting down with all the tears and feelings. We know as kids get older, that tends to dissipate. They can better internalize their coping skills, self-regulate in those moments, and hang in there a little bit longer with all those big emotions.

Children under five are also more at risk for CPS investigation and removal because they've got first-time parents. Often, families will tend to stabilize with repeat children, and first-time parents are often overwhelmed. Babies may very well find themselves welcomed into overwhelmed caregiving systems, where there may be a parental mental illness and parental substance abuse, and grandparents who don't live close by or have their own mental health and substance abuse concerns.

Coming into those spaces, I frequently say, "All babies mean change." The most wanted and planned-for and hoped-for babies mean change and change is hard. I had a meeting this morning with a colleague, and I said, "How's your week been?" She said, "You know, four-month sleep progression plus a time change is not my favorite weekend." Even the most wanted and planned-for babies can be hard. When this may have been a baby who was not planned for or when we think about systems that are already overwhelmed with mental health concerns, low socioeconomic status, and substance abuse concerns (risk factors), welcoming a very needy, very dependent, nonverbal being into the space is often a tipping point.

Across all states, it doesn't really matter where you are; the single largest category age-wise for kids at risk of child abuse is under six weeks of life. The first six weeks of life is the most volatile time and the most likely time for an incident of physical child abuse, specifically for that physical child abuse to be pediatric abusive head trauma.

Babies

As I said before, babies mean change. Even wanted, adored, and loved babies mean change. Change can be really hard, and a new baby is a major adaptation. I think about others in my world who say, "I wanted this baby so much, and I never leave my house. I haven't seen anybody else in weeks. I wanted to apply for this promotion, but it would be more time, and I don't have it to give." Even in the place of intentionally thought-about children, there's change. When we have not had the privilege of slowing down to think about what a baby may mean, that change will be even harder. I use the word privilege intentionally because when we think about insight and reflection, there is truth about it being a privilege. Not all of us live in spaces without risk factors such as mental health concerns, substance abuse, low socioeconomic status, incarceration, legal charges, etc.

When working to survive, we don't often slow down to think and wonder what this might be like. How might it be for all of these things to be different? Because we're just trying to keep a roof over our heads and keep going. Hold in mind that babies mean change. Also, hold in mind that the process of becoming a parent is one of the most emotionally evocative life changes that occur. It's a real dynamic shift to suddenly have someone who needs you far more than you have needed other folks. In that process of being needed and needing help, becoming a parent calls back to the parent's own experience of being parented.

When we've got a parent who had their own history of early neglect, abuse, or emotional abandonment, then when there is a new baby, there is a deep remembering that, oh, I want to do all of these things for this kiddo that I did not get, and grief that they did not get those things. Or, we see parents who say, "Well, it was good enough for me. I don't know why it wasn't good enough for them." We hear that a lot, and so in the process of becoming a parent, we call back to what it was for us to be parented and make decisions from that information.

Early childhood has a certain aspect of universality that nothing else has. Out of everybody who completes this course, there will not be a piece that everybody's ever had. Not everybody will have experienced psychosis. Not everybody will have dealt with a substance abuse issue. Not everybody will have a learning disability. But every single person who accesses this material will have at one time been three. In that space of thinking about infants and young children, there is a universality that also calls us to think about what it was for us to be little and how people cared for us.

I made the caveat early on about leaning into how you are feeling and thinking. Take time to take care of yourself. Take a moment to get up and walk around the room. Find some water and come back. The reality of the parallel between our work, the children we see, and the experience of what it was to be children ourselves is closely connected. As we walk through the next part of our time together, I will tell some stories. I mentioned that I'm a social worker. What I don't know that I named quite prolifically is that my clinical specialization is in severe early childhood trauma, and a lot of that looks like physical abuse.

I always find it very important to name at this point that some of my stories can be quite intense to hear. For me, they are humans, and so I know all of their stories. I know the funny moments in addition to the sad moments. I know the things that make them great and wonderful human beings. You all will get a snapshot for the purposes of educational demonstration. Sometimes that's intense material, and I want to name that outright.

The First Six Weeks

When we think about the statistic that the first six weeks of life are the highest likelihood for an incident of physical child abuse, most often pediatric head trauma, there are a number of reasons. One is that birth can be very traumatic. Frequently, unexpected complications, surgeries, the sense of feeling out of control, or recovery can take longer than expected. All of those things can be frustrating for caregivers.

When I think specifically about labor and delivery complications, mama may be out of pocket, those complications may result in longer healing time, or it may mean that mom is sleeping or has her own physical limitations. I think about a friend of mine who ended up having an emergency C-section and, six weeks later, had to have her gallbladder removed. She didn't sit upright for about 2 1/2 months. Some limitations from unexpected complications can put increased stress on an alternate individual. Sometimes that might be whoever that second biological caregiver is. It may be support from extended family called in, a nanny, or some other type of interim childcare that was hired. That person then is going to be in the position of the primary caregiver for that tiny baby.

The other piece, when we think about the experience of the first six weeks of life, is that the body releases several hormones immediately upon giving birth. The first we'll talk about is oxytocin. Oxytocin is the hormone that tells us to love babies. I always make this joke, and I inevitably get somebody who says, that's not accurate. But brand-new newborn babies are generally not that cute. If you take a step back for a moment and think about it, they're red and slimy, and they're really squished and swollen. Babies get cute after a few weeks as they fill out and have their appropriate color. But, right after they are born, babies are not particularly cute. Again, someone will always argue with me that their newborn baby was very cute, but I will also say that I think that's the oxytocin talking.

The hormone oxytocin that's released at birth is the thing that tells us from an evolutionary, biological state that we're supposed to love for and care about babies. It is the hormone released when you see a picture of a baby, and everybody in the room goes aw. It's a collective shared experience because our brain says, "Oh, that's a thing you're supposed to take care of. That's a thing you're supposed to love." It also happens with dogs. I would say it happens with cats, but I'm not a cat person, so I don't register with that experience. So oxytocin gets released, and we have this kind of euphoria that happens with a deep biological sense to take care of this being.

The second thing that happens is that your hormones crash into a pre-pubertal state. Think about that. You go from age 30 to 13 in about 45 seconds. That can make people fairly moody. For most folks, there's a period of about two weeks of what gets referred to as the baby blues, but for some folks, it can trigger some significant mental health concerns. Both of those pieces together, the hormone release and the possibility of birth trauma and complications, can increase our risk factors and shift our stress.

The other piece is the baby themselves. Babies are not blank slates. Babies come into the world with their own personalities. With that personality, they also bring parents' perceptions of who that baby is. In the first six weeks of life, babies' primary goals are to try to get in a pattern around breathing, eating, and sleeping. That's the goal in the first six weeks, meaning we don't have a pattern in those first six weeks.

Sometimes they're sleeping a lot, not sleeping, or cluster feeding, where they eat about 20 minutes apart and then don't eat for six hours. They're just trying to figure out how to breathe and get into a pattern of being. In the first six weeks, babies often cry excessively without the ability to be soothed. In infant and early childhood mental health, we talk about the concept of being with. One of the examples we give is the process of being the caregiver to a young child, walking the floor, and having no solution. If you have been the caregiver to littles, you know what it is to be up at 2:00 AM, pacing up and down a hallway with a screaming baby, saying, "I don't know what you want. I'm still here, but I have no idea what you want." We've tried all the things we know to try. In the first six weeks, the periods of really intense crying without the ability to be soothed are much more common. Also, during that time, babies don't sleep regularly. They're not predictable and are not yet in a pattern.

That also means that caregivers don't sleep regularly. Think about caregivers who may have had a traumatic experience. Their hormones are off and may have triggered some mental health episodes. Now they have only slept for three hours in the last 24, and their baby is screaming at the top of their lungs. They don't have any paid maternity or paternity leave. They're also concerned about whether or not they're going to make rent because Mom can't go back to work because now she has all of these complications from surgery. All those factors together in the first six weeks can make for a really intense perfect storm.

It is not uncommon in early childhood that parents perceive babies as fussy. There's always the reality that parents perceive their children to be in specific ways that the rest of the world may not. I think about some of the kiddos that I work with clinically that parents will describe as difficult, and they're no more difficult than anybody else. This is not an early childhood example, but we recently had a family who was extremely frustrated and kept referring to their 14-year-old as distracted. The 14-year-old was on Snapchat and losing track of time. They weren't distracted. They were just 14-year-olds on electronics. The same is true with infants. Some families perceive their baby to be fussy and, internally, feel less successful at calming that baby or soothing the process.

We talked about the oxytocin release right after labor and delivery. Remember, this release starts the biological process of bonding that leads us to an attachment relationship. There are situations in which we know that caregivers will produce less oxytocin. These include a history of major depressive disorder, severe mood disorders, anxiety, and obsessive-compulsive spectrum disorders. By virtue of that, this immediate bonding hormone may not be as strong.

When we know that families have support in place and they've got good resources, many families navigate that and can overcome and find their way. But that's not the case for all of our families. While the body will produce oxytocin as a biochemical reward for taking care of something and loving a thing, there's also the reality that the body produces cortisol whenever we're super stressed. When we're stressed, that cortisol comes out, and it says, "Something is wrong. Something is wrong. You have to fix it." I often tell my little kids that it's our brain's fire alarm. It's the thing that beeps and tells us something might not be safe.

In that first six weeks, we're trying to find those cues, develop our patterns, and be in that place. As the baby is soothed and parents feel successful, oxytocin produces the biochemical reward that says, "You did it. See? We did it together." Babies also produce oxytocin that says, "This person can help me feel better. Everything will be okay." On the other side, when we don't feel successful in that place, our body produces cortisol because it is stressful. The crying is really intense, which overwhelms the caregiver, who often feels they aren't doing things right. This will also produce increased cortisol levels in infants, who say, something's not right, and I don't know why, but I can't get calm.

Thinking about our folks engaged in child welfare when there have been persistent incidents of physical abuse and neglect, the overproduction of cortisol long-term can have neurological implications that we can see. Children have an intense stressed time in infancy and early childhood. They are much less able to tolerate shifts and change and self-regulate. Even as they age, they become much more easily overwhelmed and stressed and much quicker to respond to lower-level stimuli. I refer to this process as the ABA of neurodevelopment. If you do a thing well and connect, you get the oxytocin reward. Your brain says, "Good job." That's the thing you should do. When we're unable to find each other and match, our brain produces cortisol, which often means we don't want to do this and want to fix this as quickly as possible. That back and forth begins to add to that place of rhythm and getting into a routine, finding our own way. The first six weeks of that kind of cue and response helps lay that foundation.

The Crying Curve

In 1991, Barr, Kenner, et al. conducted a study examining infant crying to determine what happens, what it means for babies to be fussy, and how bad it is. The study found that generally, crying peaks in intensity and frequency at about six weeks old and then decreases. That study is usually referred to as the crying curve. Now, while the study found that, generally, crying peaks at six weeks and then decreases, that crying curve looks different for all babies. Even in stable, sustainable, consistent, and predictable caregiving environments, some babies just cry more, and others don't cry as much. While they may also reach their peak at six weeks, they may not have cried as much to begin with, and then also cry even less after that six-week mark. But, pretty consistently, crying increases and peaks at about six weeks and then dissipates from there forward.

The information gained from the crying curve established some containment that the experience of "fussy" crying was, to some extent, predictable and typical. We can say that the first six weeks will be rough, but it'll get better. We can't say how much better or exactly when, but we know it decreases after the first six weeks. That gives some normalcy to this process. The National Center on Shaken Baby Syndrome used this initial information from the crying curve to develop the awareness campaign called PURPLE Crying.

PURPLE Crying

PURPLE is an acronym that stands for:

• PEAK of Crying
• Unexpected
• Resists Soothing
• Pain-Like Face
• Long Lasting
• Evening

We know there will be a peak of crying in the first six weeks, which can often be unanticipated. For example, everything seemed fine, and now they're crying for the next 45 minutes, they're not easily soothed, they appear quite distressed, and it can last a while, more commonly in the evening hours. The Period of PURPLE Crying is a period of time, so the awareness campaign hopes to emphasize that this is a typical early childhood development phase, much like biting. No one loves that, and it's not a fun phase. If you've ever been the caregiver of a kiddo who was a biter, you know we want this phase to be over quickly. It is a typical early childhood development phase that we can name and talk about. We can normalize that this event occurs in early childhood and parenting. When we name a thing, we can contain a thing. It also emphasizes that there's an end. That end may not be today. Tomorrow may only be marginally better. But the reality is that there will be an end.

Pediatric abusive head trauma most often occurs during this intense six-week crying curve of the Period of PURPLE Crying. We discussed this already, but parents often report higher-than-average stress around crying when they perceive their baby to be fussy. Whether that baby's actually crying more or less than other babies does not matter. Parents will report increased stress because they perceive their children to be fussy. Some of this can also come from a parent's background or cultural expectations of whether children should be seen and not heard. Is there an expectation that babies obey even when they're very young? By this kind of excessive perceived crying, what does that say about this baby? Is this baby going to be a problem child? Is this baby going to disrupt life as I expected it?

I have heard parents say, "See, this baby already won't listen to me. How am I supposed to parent them when they get older?" That's pretty common. Perceptions of babies begin before birth and are often connected to parents' experiences as a child and to their thoughts about being a parent. One of the things we often wonder about in this space is, who is this baby, and who is this baby to me? Again, I feel like I should asterisk here before I launch into these stories. Know this is about to be intense content.

I think about families where I saw this play out. One of the families I think about most intensely was a family seeing me for their ninth child. The eight prior had all been removed from child welfare, placed, and adopted in various dynamics. The ninth child, who was seeing me, was currently placed in foster care. The 10th baby was born during that process of services. There were many stories about the 10th baby. One time, they got to the office, brought the baby in a stroller, and I dropped into what we generally refer to as mother ease, that vocal tone you use when talking to babies. I said, "Oh, sweet girl, what's the matter?" Her mom looked at me and said, "Nothin'. She just knows when she's around people she doesn't like." This was a four-month-old baby. The four-month-old baby, I promise, did not have an objection to my personality. Her mother, however, did. This is an example of the perception of how we understand babies and what we understand their cues to be.

Here's another story about that same family. There was one time they were with me when Mom asked for a bottle. Dad pulled the bottle out of the diaper bag, shook it up, looked at it, and said, "I'm pretty sure this has gone sour." Mom said, "Ah, she'll learn to live with it," took the cap off, and fed it to her anyway. This is a moment where there is that question of how we perceive who this baby is and who this baby is to me.

Pediatric abusive head trauma occurs most often in kids under six months old. It is generally connected to a caregiver's sense of being overwhelmed, feeling out of control, and having limited support or skills to navigate these intensive periods of crying. We know that higher risk factors in other situations increase risk factors for pediatric abusive head trauma and that frequently, afterward, parents will say, "I did not know how to make it stop. I did not know what to do." 

Facts and Figures

Pediatric abusive head trauma occurs in about 1,300 child abuse cases annually. It is the leading cause of child abuse-related deaths in the US. While on a case-by-case basis, it doesn't often happen, usually at the point that it is recognized, which is part of our conversation today, it is very often fatal. For those kids who survive those traumatic experiences, the associated care, rehabilitative supports, educational supports, and child welfare interventions cost the US about $13.5 billion annually.

Possible Signs and Symptoms of PAHT

Possible signs and symptoms of pediatric abusive head trauma include seizures, difficulty breathing, cerebral swelling, and an infant being unable to lift their head when previously they could. A lot of these symptoms are associated with swelling, both cerebrally and into the spinal cord. Other signs and symptoms include unequal pupils, subdural hematomas, lethargy, and decreased muscle tone. With hematomas, there are times that pediatric abusive head trauma could be associated with stroke.

PAHT and Spinal Injuries

A study from the Cleveland Clinic found that spinal injuries are an often undiagnosed component of pediatric abusive head trauma that likely occurs more often than PAHT itself. Since there's no humane way to test pediatric abusive head trauma, the study took car crash mannequins and looked at the force of impact on the spine and the brain. Of the 131 mannequins in the crash simulations, 96% met the criteria for a spinal injury, while only 22% met pediatric abusive head trauma criteria. 

As a clinician, I am now much more curious about my kiddos, who I know were involved in stressful early caregiving experiences. They may not have a diagnosis of pediatric abusive head trauma or even some symptoms, but what is the likelihood of some spinal damage that may result in low muscle tone, frustration, or increased pain response? Because of this study, we know that it's highly possible and likely that roughly cared-for babies may experience neck and spinal injuries before any neurological impact or PAHT.

PAHT and Cerebral Functioning

Animal simulations of pediatric abusive head trauma have highlighted a clear connection between subdural hematomas and oxygen loss that occur during shaking or other abusive interventions. The initial cerebral impact can stop oxygen during shaking or other abusive interactions. Loss of oxygen means long-term damage to cells within the brain, which can result in a lack of weight gain, growth restriction, and ongoing respiratory concerns. It can also cause issues with your frontal cortex, which is cause and effect, working memory, reading comprehension, and other things that come much later down the developmental trajectory.

Long-Term Outcomes

Thinking about the long term, pediatric abusive head trauma can cause learning disabilities, fine and gross motor delays, speech delays, cerebral palsy, seizures, and cognitive impairments. Cerebral palsy is a cluster of symptoms that can be diagnosed from a myriad of onsets. Still, it is possible that an event of pediatric abusive head trauma could result in a cerebral palsy diagnosis.

Cerebral Damage

Our brain has three primary regions that impact our social-emotional functioning: the frontal cortex, which sits at the front of your brain, your limbic system, and your brain stem. The frontal cortex supports cause-and-effect, impulse control, and higher levels of thinking. Damage in this area will result in increased impulsivity, difficulty with self-regulation, and learning difficulties. Our limbic system supports access to words and memory. Damage in this area may result in speech delays or speech loss and concerns with long-term, short-term, and working memory. Our brain stem is responsible for heart rate, blood pressure, and body temperature. Damage to the brain stem is generally life-threatening.

Risk Factors

We've talked a lot about risk factors, including the perception of the "fussy baby." Parental mental health concerns are a huge risk factor. When parents are more stressed, they are more likely to respond aggressively when they don't feel like they can problem-solve. In addition to mental health concerns, substance abuse concerns are a risk factor. Parents recently in recovery will fall into this category of being fairly stressed and unable to access all their coping skills.

Also, factors that contribute to low oxytocin include placement with alternative caregivers, single-parent homes, and fathers/boyfriends/stepfathers in the first six weeks of life. Previously I talked about the oxytocin release that happens at birth. That is a biologically triggered response, meaning if you didn't biologically give birth to this baby, you would not have an immediate oxytocin response. When we look at non-biological caregivers, we know that their oxytocin response comes on at about six weeks of life. Euphoric flooding will occur, but it's just not at the same time because there's not a biological process there. Fathers, boyfriends, and stepfathers often end up being the "aggressor" in the first six weeks of life. For example, we may have a mama out of commission for some complication. We've got a father, boyfriend, or stepfather with their own risk factors. We don't have that biological support online yet to say, "I know you're upset, and you've been crying for 45 minutes, but you're really cute." That will increase that difficulty in single-parent homes or with alternate caregivers.

Poverty, low socioeconomic status, and low education are also risk factors. Domestic violence, another risk factor, is part of a very stressed system in which some level of aggression has become typical for navigating big feelings. That then becomes a risk factor that we're going to use that same kind of dynamic with everybody around us, including the littles.

Another risk factor is prior CPS reports. Most infants and young children with pediatric abusive head trauma are found to have evidence of other forms of maltreatment, such as bruising or broken bones. I often think about young children and finger bruises. Thinking through what you might see, you should not have four oddly spaced bruises on the upper part of your bicep. Broken bones are commonly seen in shaking, and you may see a baby with bones in various healing stages. One of the other significant pieces we think about with that CPS report is story inconsistencies.

A Case Vignette

Here's a case vignette to think through. It is a real story and is a case that I worked on. All names and major indicating features have been changed for HIPAA compliance purposes.

Bella is a 10-month-old who was referred for therapy due to excessive crying, difficulty being consoled, and extreme physical responses when visiting with her biological caregivers. Bella was removed from biological caregivers at 3 1/2 months old after EMTs were notified that Bella had stopped breathing. EMTs found Bella unconscious upon arrival, with excessive bruising to her head and face. EMTs transported her to a large, Level 1 trauma hospital, who later identified several broken bones in various stages of healing, including a femur break, a collarbone break, and a broken arm. Bella is the first child of her parents, who live in an under-resourced rural area. Upon questioning, the biological caregivers reported that Bella had been at home with a younger cousin and that a game system controller had fallen off the coffee table and hit Bella in the head.

Holding that in mind, I invite you to pause for a few moments and consider what risk factors you see. What risk factors might not be named that we might be curious about?

Mandated Reporting

In the Commonwealth of Kentucky, any person who has reason to believe a child is dependent, neglected, or abused must report this to the Cabinet, the state or local police, or the local prosecutor's office. That results in making everyone in the Commonwealth of Kentucky a mandated reporter. It's not one's single burden, but everybody's job to do it. If there is suspicion that abuse or neglect may have occurred, individuals in Kentucky are to notify the Cabinet for Health and Family Services. While we are all mandated reporters, confronting the need to make a call can often be emotionally evocative, especially if it's not something you've done before. The first one is always really hard. After 15 years, I've made a lot of CPS calls. They don't bother me anymore. But, in the beginning, they do as you think about what will happen, if it's the right call, and what comes next.

Your role as a mandated reporter is to state facts. Authorities decide what happens next. Our role as mandated reporters is never to investigate, only to state what we know. Then it is up to the folks on the other end, trained in that, to decide where to go from here. Not all reports result in CPS involvement. An overwhelming majority of reports do not result in the child's removal. Even those reports that are substantiated, most get therapy, maybe rehab, and some supportive options. A child is rarely removed and placed in foster care. When that happens, there has to be substantial evidence that that was the choice to make, usually partly because of the legal burden.

PAHT as Public Health

Figure 1. Promotion, prevention, intervention, and treatment of pediatric abusive head trauma.

We've talked a lot about pediatric abusive head trauma and the idea of medical terminology or risk factors or those pieces, but there is also the reality that it is part of public health. When we think about public health models, we're looking for promotion efforts that reach about 100% of the population. Then we look at prevention efforts that reach about 40% of people with higher risk factors and need more intensive support. About 10% of the population will need some intervention and treatment services to address a problem, not just to prevent there from being a problem.

One example of a promotion effort is this course. Another example is that Kentucky must provide some level of education to all high school students. That's 100% of the population. You're getting this information if you go to high school in Kentucky. 

Protective Factors

While all families have risk factors, we also want to name that all families have protective factors. When we think about the promotion, prevention, intervention, and treatment levels, we want to leverage the places where families have protective factors and increase parenting capacities to promote positive parenting during challenges. Babies are going to cry, and it's going to be stressful. It will be 2:00 AM at a four-month sleep progression on the weekend of a time change, and those are hard days. Leaning into those protective factors and supporting that place of building positive parenting goes a long way. The protective factors include:

• Knowledge and attachment
• Knowledge of parenting through a developmental lens
• Parental resilience
• Social connections
• Concrete supports for parents
• Social and emotional competence for children

We want to build out nurturing and attachment, knowledge of parenting through a developmental lens, and parental resilience. Often mental health literature presents an expectation that people are born with an internal resilience that will unfold itself magically and that if people are "resilient," they'll figure it out on their own. We know from resilience as a broader topic that resilient people know how to navigate their resources and access what they need. Others may need help building this. Regarding parental resilience, we're talking about those parents who can step away and say, "I've been at this for 45 minutes. My time is up. It is someone else's turn." They can step out, take a deep breath, and come back in.

Social connections mean they're not alone, have somebody to call, and have concrete supports. An example is that the baby goes to Grandma's house every Tuesday. There are predictable, consistent options available to parents. We're building social and emotional competence for children. This begins by thinking through and giving even the smallest babies words like, "You are so upset. Everything feels so big right now. We're going to figure it out together." 

Nurturing and attachment include supporting routines, predictability, and shared affect. Shared affect means matching affect. I think about a child we did an observation with a couple of months ago. One of the things we do is ask a parent to leave a room for a brief time so that we can watch the separation and reunion. The caregiver left the room, the child burst into tears, and the caregiver started laughing on the other side of the door. There was a fundamental disconnect in that affect. The child is deeply sad and upset, and the caregiver's affect doesn't match what is expected when seeing the child so upset. 

To build the protective factor of parenting and child development knowledge, provide parenting classes and bite-sized, brief information regarding child development and developmentally appropriate behaviors. For example, you may say, "Have you ever heard of PURPLE Crying? Let's check out this website together." Remind parents of developmentally appropriate behaviors and that things like biting happen and are normal. Increase parental resilience, support stress management, frustration tolerance, and flexibility.

Social connections include things like parent cafes. Many states do parent cafes electronically through Zoom so they can be done late at night. Parents don't have to have transportation, and they don't have to leave their houses. There's flexibility, and it doesn't have to be 3:00 PM while getting somebody off the bus. Many churches host moms of preschoolers (MOPs) groups or other support groups. 

Concrete supports for parents include WIC offices, Early Head Start, rental assistance, and paid parental leave. I also think about our home visiting sector, including Healthy Families, Nurse-Family Partnership, and Parents as Teachers. There is a variety of home visiting programs. Building social and emotional competence for children includes giving words to feelings and emotions. Becky Bailey's "Conscious Discipline" and the Whole Brained Child can help do this.

Promotions That Work

Let's talk about some promotions, preventions, and interventions that work. A study in Texas conducted from 2017 to 2018 worked with 63 Hispanic mothers to provide education and consultation around infant crying and crying behaviors. The study identified these mothers as Hispanic. Generally, we think about that as Latinx, so I cannot define what they mean by Hispanic. The pre/post tests found that mothers' knowledge and beliefs around infant crying had shifted significantly. Once we talked about it, gave them some education, and normalized it, we saw a change. What is curious about this study is that the pre and post-tests still revealed continued concerns that the information might not apply to their baby. That goes back to the sense of perception of who they are. Am I doing this right? Am I good enough? Is there something wrong? That internal worry, what I often refer to clinically as the heart, can persist even when our head tells us, no, we know differently now.

In Egypt, there was a study of 150 mothers who were given an educational curriculum regarding pediatric abusive head trauma and infant crying. Pre/post-tests were utilized to assess mothers' knowledge, attitudes, and beliefs about infant crying. Post-tests revealed improved knowledge, attitudes, and beliefs and improved implementation of the coping skills gained through the curriculum.

In Turkey, a randomized control trial study administered an eight-week course on skills to calm crying babies and build awareness of pediatric abusive head trauma. Post-tests were administered for the intervention and control groups. Results were statistically significantly higher in the intervention group than in the control trial group, meaning that when they compared an intervention with doing nothing, those who got an education could shift their knowledge and awareness.

Synthesizing Findings

When we think about those promotion efforts, we know education matters. When we talk to caregivers about infant and early childhood crying, we normalize what can be a really difficult experience. When we're able to provide skills to families around self-regulation, they're often able to implement those skills and successfully navigate the trying times of parenting. They can recall that education and hold onto it at 2:00 AM when they walk the floor for 45 minutes.

Preventions That Work

In Kentucky, the statewide home visiting program is called Health Access Nurturing Development Services (HANDS). It is funded by the Maternal Infant Early Childhood Home Visiting program (MIECHV), which provides federal dollars to states to provide early prevention services to at-risk families. Those MIECHV-funded opportunities have federal oversight and specific requirements around implementation and fidelity. HANDS supports first-time parents from prenatal to age three for enrollment. They will stay with a family upon enrollment until that child's third birthday. However, there is a requirement that families must face multiple risk factors. There are places in the US that do what's referred to as universal home visiting, which means everybody's got access to it regardless of socioeconomic status or risk factors. But that's pretty rare and doesn't happen often. I encourage you to look up your state's MIECHV and find out what kind of programs they provide. There are 15 or more curriculums that the federal government approves. 

Other in-home nursing supports, such as Nurses for Newborns or Nurse-Family Partnerships, are prevention options that support families in prenatal to early infancy. These programs provide additional resources, in-home support, lactation consultants, and increased screening and referrals for post-partum depression or parental mental health needs. It's like having a pediatric medical home for the parents. All of them have really strong outcomes.

Interventions That Work

Look back at figure one, and you'll see the top tier is intervention. This represents ten percent of the children who have had something happen, and now we have to figure out how to repair things that are not going well. This is infant and early childhood mental health in the early childhood sector. This broad-range clinical field takes a psychodynamic perspective. It states that behaviors are rooted in survival and are recognized to have subconscious depth beyond verbal value. Infant and early childhood mental health services are heavily play-based.

Earlier I told you about the family with the four-month-old baby. In that space of rooted-in-survival, it was deeply evocative to watch that mom feed the baby a potentially soured bottle. As a mandated reporter, I had to call that into their DCS worker, but the other piece was that mama had spent many years of her life without food. She had learned that if you've got something, you eat it regardless of whether it's what you want because you don't know where your next meal will come from. Part of her was rooted in thinking; this baby would take what she gets because we may not have another option someday. The infant and early childhood mental health lens will hold that parent's experience and recognize the motivator for behavior while also being able to say, like, "We can't do that."

Interventions in the early childhood sector include child-parent psychotherapy (CPP) and parent-child interaction therapy (PCIT). CPP is evidence-based for kids as young as six weeks old. Infant-parent psychotherapy is what they're calling the perinatal version. That would work even with moms who have yet to give birth. CPP is dyadic, meaning it is caregiver- and child-focused and frequent, meaning it should happen once a week or more. The assessment phase is lengthy, and it takes a long time to get to know everybody and put all the pieces together. CPP is really intentional about its process. It is what we refer to as trauma forward, meaning that we are intentionally addressing potentially traumatic events that may have occurred.

PCIT is an intervention generally used in children two-and-a-half years old through six years old. We may have a kiddo who has had a pediatric abusive head trauma and who's now getting PCIT. That intervention is behaviorally-based, typically focused on compliance, and parent-coaching focused. It is not technically a trauma treatment but should be fairly intensive with weekly sessions. The assessment period is less, and the duration and frequency of sessions vary. Clinicians are highly trained in parent-child work.

Parent-child interaction therapy (PCIT), child-parent psychotherapy (CPP), trauma-based relational intervention (TBRI), Theraplay, and infant-parent psychotherapy are all evidence-based for kids under six years. I want you to know about them. If you're a social worker and a clinician, I encourage you to find some training because there are never enough early childhood clinicians available in any state. As early childhood educators, I encourage you to know that vocabulary to advocate for the families and kiddos you work with. I want you to know that these interventions exist and should be considered. We should be asking about these things.

Regardless of your perspective, there should be caution around any modality with young children that don't heavily involve the caregiver. There should also be caution around heavily talk-based interventions such as CBT for children under five years or where there are language delays. I am always curious how someone can treat an 18-month-old when no caregiver is involved. 18-month-olds are horrible agents of change, so we must rely heavily on caregiver involvement. Play is the language of children. Play is how they tell us about their fears, how they tell us about the wonderful things, and all the space in between. We want to look at their play and consider it pretty intensely.

Summary

Regardless of our professional role, we can offer families the following tips and skills. Take a deep breath and count to 10. Call somebody for emotional support. Many states have fussy baby lines with somebody you can call to walk you through what it is to be in the moment with a really fussy infant. Call a pediatrician. There could be a medical concern. Sometimes babies cry excessively because things hurt, so check it out and make sure that there's not a problem going on. Advise caregivers to leave babies only with trusted caregivers or those who've had a background or reference check.

As we think about the research findings and our promotion, prevention, and intervention sectors, reflect on what caregivers are going through. Considering the study in Texas, is it that parents' concern that something is "wrong" with their baby persists despite education to the contrary? What causes them to think, maybe it is me, perhaps something is wrong with us, or maybe we are not figuring it out? Hold and name that anxiety, and think through some of the skills we talked about that we might be able to share in whatever setting we're in to support caregivers to care best for their fussy babies.

Our Role in PAHT

So what's our role in pediatric abusive head trauma? First of all, our role is to talk about it. A colleague of mine often says, "Lots of things are green, but that doesn't make them all grass." Grass is a thing. The same is true here. PURPLE Crying is a thing. Lots of things can elicit tears, but this really is its own thing. It's important to remember that caring for young babies is difficult and unique for every caregiver. It's a different journey for everybody involved. Know and remind caregivers that services, resources, and supports are available.

Our role is also to report it. If you've observed concerning behavior, interactions, or signs of abuse or neglect, then we are compelled by state mandate to report it. If you're not sure, but you're worried, or something feels off or just not quite right, consult a mentor, leader, or trusted colleague. 

Questions and Answers

How is pediatric head trauma diagnosed?

Generally, much like my vignette about Bella, an event occurs that then becomes presented to an ER. We generally see X-rays, CAT scans, and other types of MRIs or imaging. Within that imaging, we're going to see that subdural hematoma. We'll see cerebral swelling and an impact point that may not be obvious externally. We may not have a child who's got a laceration and stitches, but through that imaging, we will see those kinds of symptoms.

Are there any free assessment tools that social workers or early childhood providers can use to assess risk factors for head trauma?

A couple of parental stress indexes are good tools that will give you risk factors across a broad range. They look at everything from socioeconomic status to parents' caregiving dynamic. An inventory called a Life Stressor Checklist (LSC) is helpful for social workers in thinking about what are all the things that a parent comes to this parenting relationship with. It's a thorough history of parents' perception of their baby and what it means to bring it into the world.

Do you have any suggestions for resources for working with parents and families, especially those that are at risk of causing head trauma?

I spoke about the MIECHV program. I'm a huge fan of MIECHV and have had the great privilege of working with them in the Tennessee statewide MIECHV program. Different states disseminate that differently. The evidence-based home visiting sector does such an incredible job. WIC offices are generally fairly well-trained in connecting folks in early prenatal and infancy to local resources. If there's an Early Head Start in your area, I strongly suggest you connect with them. Most states demonstrate Early Head Start as home visiting, not as childcare. That means you'll have somebody going into houses, looking at things, being responsive to phone calls, and connecting with folks in those first three years.

I also am a huge proponent of Part C services under Early Intervention. Even if a child is not terribly developmentally delayed if you think there is any reason that the child might need a developmental assessment, make that Part C referral. Those folks are great to come out. Even when development is on track, they're always offering parenting support groups or options about community-based programs, and they know what's available locally.

References

A complete list of references is available in the course handout. 

Editor's Note: This text-based course is a transcript of the webinar, Balance Over Burnout for Mental Health Professionals, presented by Khara Croswaite Brindle, MA, LPC, ACS, CFT-I.

Learning Outcomes

• After this course, participants will be able to identify the symptoms of burnout.
• After this course, participants will be able to explain self-care strategies for successful restoration for professionals within the mental health field.
• After this course, participants will be able to create a wellness plan against burnout.

Introduction

We will talk about burnout, prevention, and signs of burnout. It will be wonderful, and I know it is very applicable to everyone watching this presentation. You will be able to create a wellness plan against burnout. You will have some tangible tools that will help you and the clients you serve. What I love about this presentation is not only are you getting tools for yourself, but for any professional you might be serving who is experiencing burnout, these tools are also applicable to them.

Limitations and Risks

• Limitations include a Western perspective of burnout, self-care, and burnout recovery that reflects access to resources and some privilege.
• Risks include 1) presented strategies impacting self of therapist where additional support could be helpful. 2) These strategies are not a one-size-fit all approach and do not substitute your own work.

Limitations include that this is a Western perspective of burnout, self-care, and burnout recovery that reflects access to resources and some privileges—recognizing that for a lot of people, burnout recovery is, in fact, about having resources and being able to do something, in particular, to get out of burnout. It does not happen. There has to be some intentionality there. Risks include presented strategies impacting the self of the therapist where additional support could be helpful. By no means, by taking this training, will you have yourself recover from burnout. That would be wonderful, that would be amazing, but for today, we want to make sure that you have the strategies to implement, knowing that you probably have some more work to do if you resonate and realize that you might be in your burnout journey.

These strategies are not a one-and-done, are not a one-size-fits-all approach, and do not substitute your work. Hopefully gives you a sense of direction for yourself, but if you do find yourself in burnout currently or somewhere in the future, these are not the one thing that is going to get you out of burnout. This is the start of the journey, not the end.

Flossing

Burnout recovery is like flossing. Why? How could that possibly be? is what you might be asking yourself. How is burnout recovery like flossing? Well, let's think about it. Flossing is something that we are told to do. We are told it is important. We are told that a long-term strategy is good for our health. Burnout, recovery, and self-care is the other part of this combination. Also, when you ask people honestly how often they floss, they are like, "Eh, maybe not very often. Maybe right before my dentist appointment. Maybe like the month before I am supposed to be seen. Maybe it is sporadically when I remember or have time."

Flossing itself feels like effort, which is for a lot of you. Burnout and burnout recovery, burnout prevention and recovery feel like effort. Maybe when you think about burnout and self-care, you feel like a cringing person. "Ew, I do not like to do this." Versus someone who is like, "I have got this down. This feels good to me." 

In the long run, it is good for our health. Obviously, most of us want to avoid burnout but recognize that it is possible in our mental health profession. Burnout recovery is like flossing. It takes effort. It requires some repetition and self-care practice, which we will cover in today's presentation. As you think through some of these things, you will continue to have a reflection, something to pause and think about.

Self-Reflection #1

• What puts mental health professionals at greater risk for burnout?

Self-reflection number one asks what puts mental health professionals at greater risk for burnout. Thinking to yourself, what shows up? What would your answer be? Is it the possibility of vicarious trauma for mental health professionals? Is it compassion fatigue? Is it directly related to the population that we serve? If we are working with people who have had significant trauma, are we more likely to put ourselves into burnout? These are questions that might be coming up for you. It might not surprise you that 75% of working Americans feel like they have already experienced signs or symptoms of burnout while in the workplace, 75%. That is not even mental health professionals. That is across the whole American workforce. Burnout is common and is on the rise as we come out of a pandemic and build a new life. What puts mental health professionals at much greater risk? For some of you, it is everything you give to your clients and the fact that you want them to be healthy and do well and that you want them to succeed. That comes at a cost, which might be our health and wellness as we look at this further. Notice what comes to mind as you see this question and how you might respond.

Overview

• Burnout
• Values
• Self-Care
• Wellness Plan

Today's presentation will cover four topics: burnout, values, self-care, and a wellness plan. As we started to talk about already, we are looking at burnout prevention, but all four of these exercises are going to hopefully help you in either burnout prevention or burnout recovery, depending on where you are in your professional journey.

The first exercise to introduce to all of you is values. If you have had a values exercise, you might have had it in undergrad and grad school as part of a psychology course, or as a mental health professional, you might have introduced a values exercise to your clients because it can be a very powerful tool. For some of you, this might look familiar. For others, it might be completely new. All of the exercises from today's presentation have handouts attached to them. You will have access to those.

Exercise #1 Values

For right now, let's look at them here. There are about 40 values here in Figure 1.

Figure 1. Forty values from https://www.leadingfromwithin.net.

If you were to complete this exercise, the first thing I would have you ask yourself is, what value describes you as an individual? Looking back at this list, most people must start by narrowing down all these values. Your first task might be to narrow down your top 10 values because this is quite a list. From there, maybe you have a strategy to get down to your top five, then your top three, and then your top one.

Values and Burnout

• Think about what value describes you as an individual.
• What value describes you in your career?
• What value would you like to strengthen or improve?

What is a value that describes you as an individual? In my experience administering values exercises for the last decade, I will say that most people's values do not change significantly as they age. Maybe you have done a values exercise before and recall what those values showed up for you.

They tend not to change very often as you get through your lifespan. Thinking again, what value describes you as an individual? Is that value different from than one that describes you in your career? For example, as an individual, your top value is personal growth, but then in the workplace or in your career, it is maybe education is important to you. Recognizing how those differ in your individual life and your professional life. The third one to think about is what value you would like to strengthen or improve. Is it one of the two you have already named, as our example, personal growth versus education, or is there a different value that you would like to strengthen or improve?

Self-Reflection #2

• What are your top three values?

As you think about your top values and identify those top two or three, there is an overlap for many people. Even when you look at this full list, there are things that you might say, "Oh, I can say that both are important," but pick one to narrow it down. That is one strategy. For today's example, let's say personal growth versus education. Maybe for that third question, I say, "I want to strengthen leadership." As you start to notice those, how does that contribute to your burnout? If personal growth is important to you as an individual and education is important to you in your career, is it possible that they contribute to your burnout somehow?

Are you pushing yourself in an educational space to take on more than you can hold? Are you trying to pursue multiple degrees at once? Are you taking on a dozen pieces of training as a mental health professional? Notice how that might show up as part of your top value of education. Do you feel you always have to learn something and push for personal growth? Are you doing your therapeutic work as you support other clients in their mental health work? How does that contribute to burnout for you? Remain curious as you do this exercise to see how that might contribute to your burnout or burnout recovery. As we started to think about it, name what your top three values are now.

The examples I gave today personal growth, education, and leadership. If leadership is the one I want to strengthen, what does that imply when it comes to my burnout journey? Are your top three values showing up in your life right now? If we take this to the next level, what happens or what does it mean to you if your values are absent or neglected? If my top value is personal growth, but I have not done anything to feel like I am growing in the last year, how could that impact me? If I think leadership is important, but I have not done anything in the leadership arena or taken on a leadership role, how could that impact me?

Next Level With Values

• What does it mean if your values are absent or neglected?
• What can you do about it?

As part of this values exercise and how it ties back to burnout if you have these values and you are telling yourself they are important, but they are not present, that could be a warning sign for you. Something is amiss if we say they are important and not there. Something is off. This is part of why we want to start with values because values are part of who we are as professionals, mental health professionals, and people. If our values are not present, that could be a contributing factor. What you can do about it is another question to ask ourselves. Some of you might start to say from this exercise I remember my three values, and now I feel motivated to keep them present. I am going to do something in personal growth next quarter. I am going to figure out something in education. I am going to step up and go out of my comfort zone into a leadership role. Those might be examples that you might do to say, "This is how I am showing up and embodying my values." Then add goals specific to those values in the next three, six months, and next year to see how that might shift how you feel as a person and as a professional. Jot down a few things about what you think you can do if your values feel neglected or absent. How can you bring those back to the forefront for yourself?

What is Burnout?

Figure 2. Images showing burnout.

As we move into the second part of the equation, we have started talking about burnout. Burnout is a buzzword showing up everywhere. I said that burnout's on the rise. We have talked about 75% of the American workforce has experienced burnout symptoms. What is it? Maybe if you look at these first three images in Figure 2. You will start to get a sense of what you think burnout is. What could it be? Maybe you are writing down some of those things that are coming to mind. Is burnout a loss of focus? Are burnout, stress, and anxiety-like this middle image? Is burnout isolation being withdrawn? Is burnout about feeling overwhelmed? Many things go into the burnout experience. What if I told you there are more than 40 symptoms to keep track of for yourself and clients experiencing burnout? We are going to look at those.

Exercise #2 Burnout Symptoms

Exercise number two is about identifying the symptoms of burnout for yourself or, if you were to work with a client on this, having them identify them for themselves. Here on this list in Figure 3 are 40 symptoms of burnout.

Figure 3. Forty symptoms of burnout from www.Vitalhearts.org.

I can tell you, as a professional that has gone through burnout one and a half times in my career far, I knew about quite a handful of these, but there were still some that caught me by surprise. Let's talk about the ones that we kind of know and that have been normalized in our community. Number two, "I feel more irritable than I would like?" Short-fused might be how a client describes this to you. Maybe it is about feeling like you have no energy.

Number eight, "I have no energy to listen to my family when I get home." Maybe it is about number 21. "I do not share my work with my friends. They do not get it." Especially as mental health professionals, it is hard to feel we have to hold for confidentiality, but also that some of the things we hear are super heavy and traumatizing. We cannot open up to our friends or family about what we have done daily as mental health professionals.

Maybe you resonate with number 25. "I feel pessimistic as the result of my job." Well, there is that vicarious trauma, compassion fatigue combination that, if you are working with intense trauma or abuse, or neglect, can impact your worldview and how you see the world outside of the work you do as a professional. Some of us avoid violent movies, dramas, or TV shows that feel like work. I can tell you, as a professional myself, I do not like watching heavy content because it feels like work. I would rather have light and fluffy, funny movies, comedies, rom-com, something that feels lighter than the reality of what we do for a living.

Maybe it is number 31. "My health has declined." In my first professional burnout experience, I can admit that it took about two years to recognize I was in burnout and about a year to recover. That is disheartening for some of you to hear because a year feels like a long time to recover from burnout. Yet I went two years as a mental health professional ignoring my symptoms, being able to talk to clients about their health and wellness, but ignoring my own. I kept chalking it up to, "Oh, I am stressed. I am stressed. It is fine." I was working with a difficult population at the time. I had justified all the things.

It took my declining health to wake me up. For some of you, it might be a medical crisis or your health declining in some way for you to say, "Oh, this is not chronic stress. This is something more, and I want this to feel differently." My personal favorite on the list is number 35. "My road rage has gotten worse." Some of you might be like me and say, "Oh my gosh, I did not even realize that was connected to burnout," and yet it is. As part of that short fuse, irritability, number two can manifest as "I am angry on the road. I have a short fuse while driving or a low tolerance for other drivers." 

When I went through my first burnout recovery and started processing this number 35 with colleagues, I said, "Wow, that is eye-opening." For some of you, you might feel called out, and it is like a more playful way. As you look at this list of 40, notice what shows up for you. Which ones would you endorse? Which ones would you say, "Yep, I have experienced that"? Are there any that are missing from this list for you as you think about what it would be like to create your list of symptoms for burnout? If you have experienced it, maybe you have experienced and have healed from it, maybe you are in the midst of it right now, or even as part of burnout prevention, are these the things you are going to be looking for to make sure that you are paying attention to the warning signs?

I would love for people not to go through two years of ignoring it, like I did, to get the support and wellness they need. You are all here because you want to avoid that burnout.

Self-Reflection #3

• What’s one symptom of burnout for you?

As you reflect on this, what is one symptom you related to? What was one symptom from that list of 40 that you are like, "Yep, that is me." Even if it is not here and now, is there something in the past that would have shown up? If you find yourself stuck and not recognizing a symptom, you can always ask someone who knows you well. A loved one, a spouse, or a child. Hopefully, an adult child, we do not want to add stress to them.

Somebody who knows you, "What did I look like at that time in my life?" Sometimes they are the ones to say, "Oh, you were irritable. Oh, you ate a lot of sweets. You did not want to talk about work. You slept a lot more." Whatever it is. Sometimes our loved ones can be the ones to hold up the mirror, saying, "This is what you looked like." Burnout is not about having one symptom. If so, we would be done. As you saw, there are 40 symptoms because they all interplay with each other.

Next Level Burnout

• What does burnout look like for me?

If we were to take this to the next level, the next worksheet that I would want you to consider is the one that says, "What does burnout look like for me?" What does this look like, customized for you? Or, if you were to engage a client, how would you walk them through this worksheet together in Figure 4?

Figure 4.  Burnout worksheet (Croswaite, K., 2017). 

There is something very powerful about the visual of seeing all of your symptoms organized this way. Starting with physical, what would be some burnout symptoms for you or a client that would show up in the Physical box? What are some examples? Physically is it that they gain weight, have no energy, break out with eczema, or are losing their hair? Maybe they feel like they have a puffy face, are pale, or are moving slowly. Their limbs are very heavy. Recognizing that those are some quick examples of what might show up physically, what would you put in your box?

As we move to Emotionally, what does burnout look like for you? Is it that short fuse or irritability? Is it a loss of focus? Is it you cry much easier? I hear a lot from clients and colleagues that it shows up under the surface. Maybe you feel numb. In contrast, maybe you are not crying. Maybe you are dumb. Do not feel anything at all. Recognizing the Emotional box can also be eye-opening if you have already completed this for yourself or a client.

Intellectually, what shows up for you when you are in burnout? Are you having trouble with deadlines, again, unable to focus? Do you feel you are distracted easily and cannot retain information? Maybe you are trying to learn something new, and it is not sticking. Intellectually, noticing how you function in the workplace. Is it about having that tip-of-the-tongue phenomenon where you are like, "I can remember the thing, but I cannot articulate it"? Are you tripping over your words? Are you noticing that your brain is moving faster than your mouth, and you are feeling discombobulated? Those are some examples of what might show up in the Intellectual box.

Spiritually, now for this box, I always put the disclaimer that spirituality is not specific to religion. It might be spiritual. How you show up in the world: mindfulness, beauty, being present. Spiritually, when you are in burnout, what happens? What do you look like? Are you going through the motions? I had one client who described they were stuck on their phones. They were not noticing their environment. They did not notice the colors of the leaves changing, it was getting dark outside, or there was snow. They were focused on the phone. Spiritually, not being able to appreciate the things around you. Beauty, seeing different things, and smelling different things. How would burnout show up for you spiritually if you identify with religious practice? Are you questioning your beliefs? Are you feeling dejected? Are you feeling, you know, a different way about your religion than you normally would?

Additionally, the Work box is specific because most people, when we think about burnout, think about work. That 75% of the American workforce is thinking about work, yet burnout shows up in all different parts of our lives. That is what we saw with those 40 symptoms: they do not apply to work. They ripple out into our relationships, personal lives, and4 interests or lack thereof. I wanted to separate our work from the physical, emotional, intellectual, and spiritual because work might look very different. Your burnout shows up differently at work than at home, or at least that is my experience as someone who is through professional burnout.

At work, how do you show up? Are you now a workaholic because you are compensating? There is a running joke for mental health professionals that we would rather focus on other people's problems than our own. I say that with love and a smile because sometimes that is what keeps us going is focusing on someone else. As we are crashing and burning at home, maybe we are feeling solid at work because we are focused, and this is where our energy is going. At work, maybe your burnout is showing up as workaholism. Or are you checked out? Are you a disengaged employee or contractor? Are you fantasizing about selling your own business? Are you fantasizing about starting over or doing something completely different outside of mental health?

Those are all things I can normalize in the work that I have done with fellow clinicians. In your relationships, how does burnout show up? If we have that short fuse or are quick to cry, how does that show up in relationships? That is an example of some of the symptoms. Are we checked out? Is our tank empty because we give it all to our clients? We have nothing to give our family, loved ones, and pets when we come home. Is it about avoidance? "I do not want to talk about anything deep. I do not want to fight with you. I am exhausted." Is it about conflict because we feel that short fuse? However this relates, the hope is if you were to take this exercise to heart, you would fill it out so it is completely representative of your experience, not anyone else's.

If you decide to apply this with a client, what impact would it have to see all of those things listed in each box for them to say, "Wow, I did not realize my burnout showed up quite like this," or, "Now it feels more real." Is there motivation to do something about it? This exercise is about putting it on paper and seeing a whole picture of how burnout shows up in all the different spheres of your life.

Self-Care Strategies

Figure 5. Self-care strategies.

Now that we are aware of our burnout and have reflected on our values, self-care is the third category. For any of you who decide to see my TEDx talk, you will know that I hate the word self-care because of the pictures you see in Figure 5. Self-care has been commercialized. And for mental health professionals, many of us would say we do not do it well. We stuck at it. I say that with love and zero judgment because that is me, or it was me in my burnout journey. If you are thinking about this with clients or want to give yourself some self-compassion, identify that self-care has shifted but, for a while, looked like these things. These pictures represent some of the commercialized self-care we expect to d? Everything from meditation or yoga practice to travel, massages, manicures, and pedicures, bubble baths. Like, we have got all these stereotypes of what self-care could be.

Now, if you were a mental health professional at the beginning of the pandemic, you saw all these things go out the window quickly. It was like, "Nope, cannot do any of them. Cannot leave. Have to stay home." All of a sudden, self-care, by this definition, was not accessible. That is a problem. That is a problem for you and me. That is a problem for our clients. Self-care should not be these things. Self-care should be specific to what works for each person. Many clients we serve do not have the mental or financial resources to go on vacations, take time off of work, or have a massage. We need to get more crafty with our self-care strategies that are not the stereotypes you see here.

Exercise #3 Self-Care Wheel

Before we do that, we should probably start with the foundations of what self-care could be. Figure 4 shows the Self-Care Wheel that I love from Rachel Lane.

Figure 6. Self-Care Wheel (Lane, R., 2017).

I have used it for years and years because I think it is a powerful representation of our self-care when it comes to the traditional categories of functioning. Not massages and vacations, but here is how you show up in everyday existence. If you were to engage in this exercise, I would first encourage you to define each category for what it means to you, or if you were to do this with a client, what it means for them.

For example, in the top-right box, getting restful and enough sleep. One person's answer could be, "I get enough sleep if I get eight hours." Another person's answer could be, "If I fall asleep before 2:00 AM, that is a victory for me." Keywords "restful" and "enough" and having them measure and quantify those. What is restful and enough? Is it about not waking up five times? Is it about going to sleep quickly? Is it about a certain number of hours of sleep? have the person define that first before they jump into the exercise fully. as we work our way around the wheel, another personal favorite is what about exercise? What do clients think we are asking when we say, "Tell me about your exercise?" 

Well, for the most part, in my experience, it has been, "Oh, I must be failing that exercising because I do not go to a gym." Now, I work with clients of all different financial backgrounds. A gym is not a high priority, financially or otherwise. We want clients to challenge themselves to think about exercise from a different lens. Is it about how often they are moving around? Is it that they work a job on their feet, for example? Are they walking to the bus stop and back? Do they have a pet that they walk after work? Those are all forms of exercise that have nothing to do with the gym. That could be another way to define this category before they make assumptions about, "I am doing it well" or "I am doing it horribly." 

As we move around the circle, socializing with friends is a category. Pretty self-explanatory. What do they like to do with their friends? Do they like to play video games? Do they like to go out? Do they like to eat? Do they like to watch movies? What do they enjoy with their friends? Now, even introverts can socialize with friends. It might be less time. It is not a big part of their self-care, but it is still a part. What do they enjoy with their friends, even for a couple of hours versus a whole day? The bottom two are personal favorites for me as a mental health professional because you can have your client define this any way you want and for yourself.

Keeping a positive mindset and perspective might be all about boundaries, right? As mental health professionals, we love boundaries. What does keeping a positive mindset and perspective look like? Is it having healthy boundaries with other people? Is it about doing a gratitude practice? Is it about journaling? Is it about sharing your victories and your goals with others? Like, how do we keep that positive mindset? For many people, it will be unique to each of them, but maybe it is about gratitude and saying out loud what they have accomplished as two possibilities. In contrast, protecting your energy from negative influences still has that boundary component about who we share our energy with and our time. Especially if we are in a burnout place, we do not have a lot of energy, to begin with, let alone how are we going to give it to others or spend it on others?

Protecting your energy might be, "I am going to limit how much time I spend at that family function," or "I am going to bookend this heavier conversation with a colleague with something positive after, taking a walk or taking a nap to reset." Those kinds of things. For those that usually say, "Well, I have some pretty heavy interactions with family." We cannot necessarily restrict all of that, nor should we. Maybe it is about being intentional with what you do before and after and even how long you spend with that person so you do not feel completely zapped after the fact—using music or movies to soothe your stress. I would also add reading to this category.

If you have people who love to read, that could also be in this category. It could be read as music, reading, or movies to soothe your stress. And what does that look like? Is that something they enjoy? Is there one particular thing they like over another? Having people define that category for themselves. Moving up to eating well, another favorite 'cause what the heck is eating well? Each person's going to define this differently. One client will say eating well is remembering to eat at all during the day. Another client will be like, "I feel victorious if I have eaten breakfast." Another person might be, "I like to snack all day, and that feels good to me," versus someone who says, "I want three meals a day." 

Eating well can be defined completely uniquely to the person before they even go into how they are showing up in this arena. We want to make sure it is very clear to them how they define it before they jump in. And last but not least, engaging in humorous and fun activities feels like a repetition of socializing with friends, but as you will notice, this could be independent and separate. These could be things you do by yourself. To me, it is about, you know, watching a funny show, listening to comedy, doing something playful like dancing around your house. Does not require others. For the introverts in the room, this category might be yours. "I enjoy doing things by myself," and that is why I think Rachel Lane separated this into a different category.

We have defined all of the categories. The next step is to identify the number and numerical value we would put on each. On the worksheet you have access to, the directions say 1- completely dissatisfied and  7 -completely satisfied. Recognizing this is a snapshot in time, this wheel will look different from moment to moment, day to day, week to week, and month to month. If you were to use this with a client, it is a visual snapshot of where they are in the moment that you are talking to them or as their homework, depending on if you like homework. For yourself, if you were to do this with me at this moment, it is a visual snapshot of where you are right now.

Having a person circle the numerical value they feel fits where they are in this moment. 1, completely dissatisfied. 7, completely satisfied. Going around the wheel, circling off the numbers, with the last instruction to connect the dots. What is powerful, why I like this visual much, is the question asks us, what kind of shape did you make when you connect the dots around the wheel? It is very rare for me to see a circular shape. I usually see a starfish or some geometric shape where there are some solid numbers, like 5, 6s, and 7s, and then a couple of 2s and 3s. It looks a little more jagged. The question to ask ourselves is, if this was a wheel, how well would it roll?

For most of you, if you are a visual learner like me, that is a powerful question to ask. If I have a zig-zagged, jagged shape, and we are asking how well it would roll, it would kind of start-stop, clunk along, where there is maybe a rounded edge and then a big old chunk missing. In terms of self-care, we are not looking for perfect 7s. In 12 years of doing this, I have only seen one where it was perfect 7s, and I did not even believe them because they did not put a lot of thought into it. I could tell that this was not an exercise they had a lot of value in. For everyone else, because we see that weird shape, we can say it is about having balance.

Keyword balance. We are not looking for perfect 7s. We are looking for a well-rounded, well-balanced shape. If we have a lot of 6s and 7s on humorous activity and enough sleep but 2s and 3s on protecting negative energy and keeping a positive mindset, how do we balance that out? Those are questions to ask ourselves.

Self-Reflection #4

• Pick a category you feel you can focus on this week. What category did you pick?

As you think about your wheel, if you went ahead and decided to try this exercise and put your numbers out there, what is one category you feel you can focus on this week? What category did you pick? Coming back to our wheel, let's say you say, "Okay, I wanted to focus on socializing with friends. I was at a 3 or 4.

I would like to see that higher. My friends are important to me. I have not had a lot of time lately. I am going to pick that as my homework, my self-care homework." Maybe it changes your whole outlook on spending some time with your friends. Does it hold you accountable to say, "I need to reach out and schedule a lunch or a dinner, a walk with a friend," and see how that improves your mood and self-care? By no means are we taking all of the categories and saying, "Fix all of them right now," but you might have some intentional homework for yourself around, "I am going to pick one or two categories to improve upon and see if that changes my whole self-care strategy." 

That can be the powerful element of watching your wheel get a little bit more well-rounded from your efforts. If we were truly to take self-care to that next level, this is where I would redefine it when I said I hate the word self-care. If I could scrap the word self-care, I would. I redefine it as rest versus restoration. If people are saying, "Self-care, do self-care," we have been hearing this since grad school, "Do self-care, do self-care," but none of us knew exactly what it looked like. If we can redefine it this way, I think we can be more effective in doing and implementing it.

Next Level With Self-Care

• How do you define rest?
• How do you define restoration?

(Croswaite, K., 2021)

What do I mean when I say rest? What comes to mind for you? Rest could be everything from having nothing on your calendar to having a day off of work to unplugging from your technology and turning off your phone. For many Americans, it might be, "I am going to sit on my couch and watch a show or binge-watch a show and order takeout and relax." If that is your definition of rest, that does have value in our self-care plan. However, it is common for clients and colleagues to come back to me after a weekend of rest and still not feel great. Maybe they are saying, "I feel worse now than ever because I went from 60 miles an hour work-week to zero, and now I feel like I have been hit by a truck." 

Rest is a part of the equation, but we are missing a component: that restoration that has helped many of us through the pandemic and beyond. Yes, we want some rest in that recipe, but we also need restoration. What is restoration? When I introduce this to clients and colleagues, restoration energizes you, reinvigorates, boosts you up, and makes you feel alive again if you are feeling depleted. With that very quick definition, what would you put in your restoration for yourself? What restores you? What kinds of activities would show up here? If the rest is, "I am going to hang out and not have anything on my calendar after feeling scheduled or overscheduled all week," that is a part of it, but what will restore you to having that free space in your calendar?

Is it taking a nap? Is it dancing around your house? Is it doing something playful? Is it in nature? For some of you, it is baking. Others might be jigsaw puzzles, art, gardening, or dog walking. Each person's unique in what they will answer as restoration. For many of you, it is about starting to craft your list of things that do restore you. That is what I invite you to do with this slide define your rest and what that could look like, but then also define restoration and have some examples at the ready. When you have that next intention of, "I need to do some self-care," you have got some ideas right there that make it that much easier to do the self-care we are all told to do.

Wellness Plan

Figure 7. Wellness Plan.

Our wellness plan is our last exercise to cement all these things together. We have talked about values and how those show up and put us at either greater risk of burnout or prevent burnout if we are living in our values. We have talked about burnout symptoms. Now we have talked about self-care and what that can look like now, more than ever. The last piece is to put it all together with a wellness plan. Now, some of you have heard of wellness plans before because there is something called a Wellness Recovery Action Plan, a WRAP plan, and that is what we are modeling in this next portion of the presentation. The images in Figure 7 show a big contrast to the self-care images when we think about wellness.

Self-care, we saw meditation or yoga, vacation, and massages. What is being embodied in these pictures? Is wellness about connection? Is wellness about nature and movement? Is wellness about laughter and joy? Hopefully, it is all those things for you because that would be a nice balancing act for the self-care strategies we are discussing.

Exercise #4: WRAP

Let's look in real-time at what a WRAP plan would be. I call it a Personal Wellness Plan. It is a Wellness Recovery Action Plan, and this is one of your handouts from today's presentation in Figure 8.

Figure 8. WRAP Plan (https://brss-tacs-decision-tool.samhsa.gov/DA_files/LearnMore_Wellness_Toolbox.html).

It is similar to our burnout worksheet: boxes, nice white space for you to jot down a few things. Starting in the top-left, what does it look like when I am well? Pull in some of that information from the burnout conversation, pulling it from your awareness of yourself. Physically, what does it look like when I am well? How do I know when I am doing well emotionally, intellectually, and spiritually? Super powerful when working with clients for them to have self-awareness on this question. Do they know what it looks like when they are doing well? Maybe it is easier to start on the right-hand side with what it looks like when I am not well. Sometimes they are opposites of each other. If they start with a, "I am not well, physically I am lethargic, I am feeling heavy, my body hurts," maybe on the well side, "I feel energized, I feel like my posture is better, I am not in pain," might be the contrast.

Emotionally, what does it look like when I am not well? Again, tearfulness, short fuse, irritability, numbness, checked-out verses, in contrast, "I am present, I am engaged, I am animated." Sometimes clients are aware of their facial expressions changing from flat affect to being present again. That could be powerful to see on paper. Intellectually, that loss of focus, taking in new information, remembering deadlines, remembering important things, having someone repeat themselves versus a lost train of thought. All those kinds of examples there versus that spiritual component. Yet again, not about religion, but about spiritual showing up in the world, presence in the world. Can I notice beauty? Can I notice changes in my environment versus being stuck looking at my feet and phone? Going through the motions?

Internal warning signs are similar to some of the safety planning you have done in other training. Warning signs, internally, what shows up for you or for a client if you are doing this with a client? What shows up on the inside that tells 'em that they are not doing well? Things like restlessness, irritability, feeling like they are on pins and needles, and feeling physically off. One client described it as their muscles jumping, and they had all these muscle ticks and twitches happening, which was very distracting. Other warning signs like negative thoughts, suicidal thoughts, catastrophizing, and black-and-white thinking might be warning signs on the internal side for you or a client.

In contrast, triggers are external things. What is happening outside of you or a client that would be adding to them not feeling very well? Maybe it is a fight with a partner, a trauma anniversary, a recent event, a political component, or something that stresses them out. Maybe they are having financial hardship, or they are having a hard time at work. Maybe their relationship is rocky. Maybe their dog is sick. You know, different things would contribute to them not feeling very well at this point in their life. Again, a snapshot in time.

The next would be My Supports as we move further down the list. My Supports has a primary, secondary, and then a relationship that I want to improve or, like, have more contact with. Who are your primary supports? Would this be a spouse or partner? Would this be a nuclear family member versus extended family, or a mentor or godparent versus friends, colleagues, or coaches? Having people think about who their supporters are. This one can be a mixed bag of emotions for folks, especially if they feel they have avoided or withdrawn from people as part of their burnout. Be very careful about how you tread on this topic because some people will get a little bit heavier, realizing that they have let some of their relationships go or have ghosted as part of their burnout, holding some compassion for that.

When Things Are Breaking Down is my favorite box. When things are breaking down as in, how do they know when things are spiraling out of control? We can have "I am not looking well" warning signs and triggers, but when does it get to that next level where it is, "Ew, I need some support, or I need something to change, or this is going to spiral out, and it is not going to be good." Maybe now they are picking fights, maybe they are self-sabotaging, maybe they are using substances or other negative coping skills. Maybe they are trying to attend to their grief through compulsive shopping or things of that nature. Noticing self-awareness, what would they put in this box for that reason?

As people are crafting these boxes, there are two more below this: What Do I Need from Others, a very powerful box to ask or to fill out, I should say. I am asking it of you. Hopefully, you are filling it out. What do I need from others? Do I need them to leave me alone? Do I need a hug? Do I need support? Do I need a distraction? Do I want someone to, you know, help me tackle laundry? What will help the person feel like they are returning to a place of wellness? And that is a vulnerable question of, "What do I need from others?" I recognize that can change from moment to moment, "I need a distraction" versus "I want to be left alone" are the two contrasts I hear—holding space for all of that if you do this with a client or for yourself.

Self-Reflection #5

• What’s one idea in your plan of action for when things are breaking down?

As you have crafted your wellness plan, what is one idea in your plan of action for when things are breaking down? You know, is there something you want to do to stop the spiral? Is it reaching out for support? Is it talking to a friend? Is it talking to a colleague? Even someone who has been through this. Who has been through their burnout? Can you understand how tricky it can be? Because it is hard to recover from something when you are still living in it. Is there a step you want to take? Taking some time off, if you have that ability?

Does that cause you stress and anxiety to think about taking time off? is it more about being intentional with the time off on your weekends or your scheduled days off from work? Thinking about what is that one idea in your plan of action for when things are breaking down and how we implement that would be that next step. Recognizing that this wellness plan can be as much, it can be as helpful or as unhelpful depending on how much you put into it. How much energy do you put into it? To take that to the next level, I have some suggestions. It does not become another piece of paper that you have written some stuff on and forget about, because, I say, again, that with no judgment because that happens.

Next Level With Wellness Plan

• Accountability Buddy
• Feedback from Others
• Month Check-in
• Compassion Satisfaction and Fatigue Test

https://www.isu.edu/bhstamm

Here are some ideas to have the wellness plans serve you the best possible. First of which is an accountability buddy. When I first learned how to do a wellness plan, they had to sit alongside someone and had to share all of those components in each of those boxes, not from a place of vulnerability but that someone could, like, ask clarifying questions, recognize, "Okay, is there an action step that we have forgotten?" "You said this is important, but it is not in this box." That can be empowering to have somebody sit alongside you but also check-in and ensure the things are represented. In those action steps, the accountability buddy can say, "Hey, did you take that time off?

Did you do some rest? Did you do a restoration activity? How did that go for you?" Many of you are familiar with accountability for lots of different therapeutic exercises. This is another area where that could apply. it is about getting feedback from others. If you find yourself trying to fill out your wellness plan and you have a mental block or writer's block in trying to put something on the sheet, who can you ask that can help you fill out and flush out what you look like when you are well, unwell, what the triggers and warning signs are? Who knows you the best? Who can help you with this? Now, the biggest task of vulnerability is asking someone who knows you well to help fill in the blanks if you feel like you cannot.

Sometimes what they have to say is somewhat painful, "Oh yeah, that is true." "Ouch." Feedback from others matters. Sometimes it is about flushing out the areas you cannot think of or addressing that writer's block if you have it, but it can be a very powerful tool in connecting with people around how you are doing. I use them in therapy a lot, the mirror image. Holding up a mirror and showing us how we are showing up to others and having a trusted person do that is powerful. I encourage .you to identify someone in your life who can hold up that mirror and say, "Hey, here is how you are showing up."

Here is how you are looking right now," and give you a chance to adjust and reflect. The monthly check-in is like the accountability buddy, but more, it could be a monthly check-in with yourself. What would it be like if you crafted it, handwrote your wellness plan, or typed it up? Putting a reminder in your phone to revisit it in a month and see how it is applying? Is it a gentle reminder to keep doing a couple of things? Is it, "Oh my gosh, I did none of those things?" Is it, "Oh, I forgot about this completely, let's try some goals for next month." By doing a monthly check-in, it stays fresh.

It does not be a one-and-done. You can revisit it, revamp it, rewrite it, whatever it takes to feel like the wellness plan is serving you or your client if that is the person you are doing this with. Last but not least is the Compassion Satisfaction and Fatigue Test. Now, this is a public document, that is. I believe 63 questions long. It is quite robust that way, but it is a document that people can administer to check in on satisfaction versus fatigue when it comes to compassion. A powerful weighing out of both compassion satisfaction and fatigue. I enjoy doing this with teams to ensure that my team is healthy. It gives them a chance to give me, you know, kind of an almost anonymous way of saying, "I am not doing well," or, "Here is where I am feeling good about my client work," "Here is where I am struggling," but also gives them that visual.

It can be a mile marker of, you know, here we are, and then six months from now, how is that looking? Did your satisfaction come down? Did your fatigue go up? Is there vicarious trauma we need to adjust and navigate in that way? Great for teams, but it also can be another touchpoint for you as a clinician to gauge your functioning. Where are you in satisfaction versus fatigue? Of course, it has a category of burnout as well. That document is also part of your handouts for this presentation to grab and utilize how you see fit. Again, 63-plus questions give us a sense of some powerful things we can ask ourselves but also measure that satisfaction-fatigue and burnout combination.

Other questions that come up before we do our wrap-up. The big one I started to talk about is how long it takes to recover from burnout. In most people, at minimum, it is going to take a year because it is one of those things that requires intentionality, like flossing, right? You gotta create a habit out of it. They say any good habit takes at least 30 days to cement. And if we are talking about that and then having to build off of different habits to get to a place where you do not feel like you are in burnout any longer, it is pretty easy to see how that could take a year or longer for us to do.

It does not mean you have to do it on your own. For that reason, you can have the support of colleagues, friends, supervisors, coworkers, consultants, and coaches to have someone hold you accountable and help you keep slowly chipping away at that burnout and getting back to a place of wellness. That is one of the biggest questions. Another question that I get a lot is, is there anyone who is not at risk of burnout? I do not think that happens. I do not think burnout discriminates. I think burnout is a human experience of being overworked and out of balance when it comes to work and life. I know work-life balance is another buzzword, and I want to introduce you to another concept: flow.

Instead of work-life balance, now we are talking about work-life flow. And some of you might like that terminology better because balancing implies that they have to be equal, right, that work has to be an equal amount of time to home life. For many of us who identify as entrepreneurs and mental health professionals, that might not be possible. Maybe it is more about permission, "I am going to work hard for six weeks and then take a week off," or "I am going to be in the flow because I am going to have this strong flow of working with clients for a couple of weeks and then have a flow of taking some more downtime." "Or going into the holiday season where I have fewer clients, or summer where I have less to do," and giving yourself permission to go with the ebb and flow.

Some of you might like that terminology better: work-life flow instead of balance. Other questions that come up. What is another one? What prevents burnout from happening? That is a huge one. Probably not a one-and-done situation, but a couple of things help prevent burnout from being such a high risk for folks, including us as mental health professionals. The boundary is a big part of it, but in any workplace, there are a couple of other things to name, one of which is feeling like you have autonomy. Some of the research that is come out is saying if you feel like you have a say, if you feel like you are being appreciated, if you feel like you are valued in the workplace. These three things would prevent burnout because now we feel emotionally invested in our work and appreciated for our work.

As a mental health professional, I do not think that it is a foreign concept to be like, "Hey, everyone wants to be appreciated. Everyone wants to feel valued."  We are providing a safe space for clients to echo that, and now we are looking at it for ourselves in our burnout recovery and prevention. If you are desperately trying to prevent burnout as part of your professional journey, you know, making sure that you are in a workplace that respects you, values you, provides autonomy and allows you to grow. These are the points of contact that people are noticing that prevent burnout from happening. Hopefully, that resonates, and it does not make completely nonsensical sense because we all want those things as humans.

Those things come up. Let's see, what else can I tell you that people have asked a lot about? Oh, here is a good one. in addition to those 40 symptoms of burnout, there was one significant thing that happened in 2020 that was another sign of burnout that we had not seen before: cracked teeth. According to US American dentists, we saw more cracked teeth in 2020 than we would see six years prior. Wow, more cracked teeth in 2020 than we would see in all six years prior. Well, that tells you we are under immense stress. It was the beginning of the pandemic. That was a factor. It was people working from home. Another factor was a lot of the stress and the poor work-life balance or poor work-life flow.

That all got tossed up in the air and disrupted as part of that pandemic. Not only are we looking at road rage and comfort in sweets and irritability and avoidance and all these things we have named, but we are also now looking at cracked teeth as a sign or symptom of burnout. That is pretty wild, too. With all this being said, if you are looking for additional strategies for your burnout recovery, we have looked at five today, right, four in real time, plus that Compassion Satisfaction and Fatigue Test. There are also some other great trainings out there. One I like to reference today would be the VitalHearts training. It is compassion fatigue training, also called secondary trauma training.

That is a two-day intensive where people get a look at their burnout symptoms but also start to recover from those symptoms. That was part of my burnout recovery journey. I did mention I have been in burnout 1.5 times. I playfully say one and a half because I started to see some of those same warning signs we talked about today, and I had to change to not go back into burnout a second time. I want to normalize that for everyone.

Wrap Up

Burnout is a challenge. It is an ongoing thing we must monitor, like self-care. As we look at the next steps, do not forget to floss is the analogy again. Creating habits. Habits take 30 days. Implement some of these strategies for clients, if not for yourself, because burnout does not discriminate. Anyone who is in the workplace or going through any amount of significant stress has the risk of burnout. That is something to think about. Noticing how we can make a difference and make burnout not part of the mental health experience as much as possible.

Question and Answer

That is interesting that you talked about cracked teeth. About 2021, when we were still having COVID issues, I started having a lot of teeth problems. I had to have wisdom teeth removed, and they said I was grinding my teeth. I did not have any issues with my teeth before that.

I appreciate you sharing that. I think people were more likely to say they were grinding teeth or would have tension headaches because they were clenching their jaw much with the stress of everything we were going through. If it was not cracked teeth, it was one of those other two, of tension headaches or grinding their teeth down to nubs. Mouthguards became popular again, and we were all trying to navigate it in a way that the dentists were saying, "What is happening?"

My dentist said, "You are grinding your teeth." I said, "Well, I have never grinded my teeth. I have never done that before, but now I notice it." If I have any stress or tension, I will feel it is very tense back here. That is a very interesting thing that they found in that study. It reminds me of one of my favorite activities, which is very simple, in the mental health sphere that I am sure participants here would appreciate if they are not already doing it, which is a lot of times when we are trying to drop into a space, whether it is work or being with a partner, getting ready for sleep, or winding down. It is doing a quick body scan, putting our feet flat on the floor, noticing our feet, and slowly coming up the body. Every time I get people to their chest, they recognize, "Oh, I am not breathing very deeply," and then they will start to breathe better. We get to the jaw, and I say, "Soften our jaw." They say, "Oh my gosh, I was clenching my teeth, and I had no idea I was clenching my teeth until you said, soften it." That can be something that can be a gentle reminder for each of us at night or whenever to let's do a quick body scan. Let it all loosen up and soften the jaw because most of us do not even recognize that we are carrying our jaw that way. I want to normalize that.

One of the first things they say when you are in a yoga session is, "Everyone, open your mouth and let your mouth hang open," releasing that tension. I always thought that was strange until I realized why they were doing that. Another thing I have been doing to help me sleep is I love lavender. It relaxes me. I put that on as hand lotion when I go to bed. I am a side sleeper and have my hands up by my face. I think it helps me to sleep.

Are there other tips or tools that you have similar to that engage the senses?

I think the sleep piece was a huge disruption and continues to be a disruption in burnout, where people are either sleeping too much, getting poor sleep, or not sleeping enough. I love lavender, essential oils, and things like that. It is all part of what we call sleep hygiene. What is your routine to get ready for bed to tell your body it is time to wind down? Everything from 20 minutes off your electronics, which is hard to do, to lavender or brushing your teeth or any of the things that would be a routine. To your question, one of my favorite activities is activating all five senses and figuring out a coping kit with all five senses accounted for.

I usually start with what you like to look at that brings you joy or comfort or calms you down. It might be pictures of family, pets, or nature that you could pull up on your phone when you are stressed. What are smells? That could be lavender or a familiar cooking smell, grass. Sometimes people like nature smells, like, fresh rain. Having them walk through all five senses can create a coping kit where they can start compiling those things to have them handy. If it is nature, it might be, "I need to get outside and take a walk in green grass." "I need to pull up a picture of my mom." Make it accessible.

My favorites are the sense of taste because those are the most intentional. Do you like mint and have that on your desk? Can you have like something spicy if you like spicy? Do you chew gum? Any of the things that people are not thinking about can have a significant impact on them feeling more relaxed quickly.

Did you find once you incorporated some of the sleeping and things in your journey, you felt better later on? For example, going back to work, did that help relieve some of that pressure?

For me, it was the boundary of not working 24/7. I had to set a regular bedtime and get up even though I did not feel like getting up. I know it is hard for many of us when we are feeling depleted, but I learned very quickly that I needed a certain number of hours of sleep to feel functional. I would not even say happy but functional. I had to start there. Then getting up every day, even on weekends, I had to get up at the same time. I would not do that whole, "I want to catch up on all my sleep and sleep until noon," but that did not work for me, and for most of my clients, it does not either because it is disruptive.

If you get up at 6:00 on a weekday, you are getting up at 6:00 on the weekend. That does not mean you do not get a chance to have a nap. By all means, have a nap. Letting the body have that rhythm, "Oh, this is when we wake up, this when we go to bed," has been helpful for mood and burnout.

References

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Northwood, K., Siskind, D., Suetani, S., & McArdle, P. (2021). An assessment of psychological distress and professional burnout in mental health professionals in Australia during the COVID-19 pandemic. Australasian Psychiatry, 29(6), 628-634. doi:10.1177/10398562211038906

O’Connor, K., Neff, D.M., & Pitman, S. (2018). Burnout in mental health professionals: A systematic review and meta-analysis of prevalence and determinants. European Psychiatry, 53. 

Posluns, K., & Gall, T.L. (2020). Dear mental health practitioners, take care of yourselves: A literature review on self-care. Int J Adv Couns, 42(1), 1-20. doi: 10.1007/s10447-019-09382-w. Epub 2019 May 23. PMID: 32435076; PMCID: PMC7223989.

Rivera-Kloeppel, B., & Mendenhall, T. (2021). Examining the relationship between self-care and compassion fatigue in mental health professionals: A critical review. Traumatology. Advance online publication. https://doi.org/10.1037/trm0000362

Seward, M.W., Marso, C.C., Soled, D.R., & Briggs, L.G.. (2020). Medicine in motion: Addressing physician burnout through fitness, philanthropy, and interdisciplinary community building. Am J Lifestyle Med., 16(4), 462-468. doi: 10.1177/1559827620983782. PMID: 35860365; PMCID: PMC9290178.

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