Cannabis, Metabolic Syndrome, And Emotional Distress

Cannabinoids & Metabolism

Much attention has been paid to the emotional and cognitive effects of marijuana. However, we believe that these effects can only be understood in the context of the endocrine interactions which are initiated by marijuana’s ingestion. In this article we will examine the function of both endogenous and exogenous cannabinoids with an emphasis on metabolic functioning.

We will review evidence which points to endocannabinoids as critical components of the body’s energy balance apparatus, and implicates endocannabinoid dysregulation in the development of metabolic syndrome, type 2 diabetes, and mental illness. Finally, we will suggest that cannabis extracts may be useful in the treatment of metabolic dysregulation, and that illicit use of marijuana may in many cases constitute a form of self-medication for the emotional effects of metabolic disorder.

The Metabolic Disorder

The metabolic disorder is a constellation of prediabetes symptoms now recognized by the International Diabetes Federation. Its symptoms include central obesity, hypertension, fasting hyperglycemia, decreased HDL cholesterol, and elevated triglycerides. The metabolic syndrome is associated with the development of type 2 diabetes, gout, non-alcoholic fatty liver disease, polycystic ovarian syndrome, and an irregularity of skin pigmentation known as acanthosis negricans (IDF, 2006).

The etiology of the metabolic disorder is unclear and appears to be extremely complex. Some have argued that insulin resistance brought about by excessive dietary carbohydrate may be a primary cause of the metabolic syndrome, while others have pointed to obesity, chronic inflammation, or excessive uric acid levels caused by dietary fructose.

The Endocannabinoid System

Interest in the biological activity of cannabis sativa and its primary constituent, Delta(9) Tetrahydrocannabinol (THC), led to the discovery of an endogenous cannabinoid system. The endocannabinoids are natural phospholipids which bind to a pair of G-protein coupled cannabinoid receptors known as CB1 and CB2. THC primarily activates CB1 receptors, which are found in the hypothalamic nuclei, the mesolimbic system, and in peripheral tissues including fat cells and gastrointestinal organs (Pagotto, Vicennati, & Pasquali, 2005).

The hypothalamic nuclei is involved in regulating energy balance and body weight, and so it is believed that CB1 plays a role in up- and down-regulating the body’s metabolic rate in order to adjust to the amount of energy available. The mesolimbic system is believed to be involved in regulating the incentive value of food, and so is important for increasing and decreasing appetite as necessary. The peripheral tissues represent the final link in this chain of metabolic regulation, and are responsible for the absorption and release of nutrients. Because CB1 receptors are concentrated in these biological regions, and because THC administration is associated with increased appetite, the endocannabinoids have long been thought to be involved with regulating appetite (Pagotto, Vicennati, & Pasquali, 2005).

Biochemical Effects of Cannabinoids

The function of THC-activated CB1 receptors in adipose tissues has been clarified by laboratory experimentation. A recent study examined the biological effects of cannabis extract on both normal and insulin-resistant adipose tissue cultures. In cell cultures, THC increased insulin-induced glucose uptake, meaning that it essentially countered the effects of insulin resistance. These results support previous findings that smoking cannabis can reduce blood glucose in diabetics (Gallant, Odei-Addo, Frost, & Levendal, 2009). They also lend support to the hypothesis that cannabis and cannabis extracts may be useful in the treatment of type 2 diabetes and prediabetes metabolic disorders, which disorders are characterized by insulin resistance and consequent hyperinsulinemia.

The Metabolic Role of Cannabinoids

It appears that endocannabinoids play a central role in the metabolic process by mediating the effects of insulin and regulating the rate at which cells utilize insulin-induced nutrient uptake. For example, one study found that in healthy subjects who were not insulin-resistant, insulin reduced endocannabinoids levels. This effect was inversely proportional to the level of insulin resistance. (DiMarzo et al, 2009). The implication of this finding is that the popular understanding of type 2 diabetes as a disorder of insulin sensitivity may be incomplete.

It is well established that endocannabinoids plays a major role in the control of appetite and peripheral metabolism. CB1, which is activated by THC, is responsible for most of these effects. A natural hyperactivation of the endocannabinoid system results in a chronic positive energy balance and obesity. Drugs designed to block endocannabinoid reception reverse this effect, producing not only a decrease in appetite but also weight loss in excess of what could be explained by the reduction in caloric intake. In short, high levels of endocannabinoid activity induce energy storage while low levels induce energy expenditure (Despres, 2007). Further evidence for this relationship can be found in the characteristic accumulation of intra-abdominal fat that is seen in patients with type 2 diabetes and cardiovascular disease. CB1 reception appears to specifically mediate this effect (Cote, 2007).

Emotional Effects of Glucoregulatory Disorders & THC

Emotional distress has been identified as one of the two primary motives for marijuana use in young adults (Brodbeck, Matter, Page, & Moggi, 2007). However, the mechanisms by which marijuana alleviates emotional distress have remained mysterious. A study of high school students found that, among students with high rates of truancy, emotional distress was significantly associated with dysregulation of blood sugar levels. Students with hyperglycemia reported higher levels of distress (Iwatani et al, 1997). Since hyperglycemia is a result of insulin resistance, this study tells us that prediabetic conditions are significantly associated with subjective feelings of emotional distress.

Recent studies have demonstrated that metabolic syndrome is associated with the onset of depression (Takeuchi et al, 2009) and post-traumatic stress disorder (Jin et al, 2009). It is very possible that susceptibility to these disorders may be a result of endocannabinoid dysregulation, and could be treated by cannabis extracts. It is furthermore possible that chronic illicit marijuana use may represent a form of self-medication for metabolic dysregulation and its associated emotional effects.


As we have seen, the endocannabinoid system is intimately involved with the regulation of metabolic functioning. Cannabinoid receptors mediate insulin-stimulated glucose uptake, cellular lipogenesis, and energy balance. Type 2 diabetes and metabolic disorder are brought about by hyperinsulinemia, which in turn brings about insulin resistance and insensitivity to the effects of endocannabinoids.

Cannabis extracts, and specifically THC, exert a direct effect on insulin sensitivity and glucose uptake, resulting in lowered blood sugar. They also result in the alleviation of subjective feelings of emotional distress, although the mechanism for this effect remains unclear. Because the literature increasingly suggests a connection between metabolic dysregulation and emotional distress, we conclude that metabolic correction may be the means by which cannabis extracts provide relief from emotional distress.

Our conclusion is novel. Although others have suggested that cannabis may sometimes be used to self-medicate for symptoms of anxiety or ADHD, we are aware of no other researchers who have connected illicit cannabis use with self-medication for metabolic disorder. Nonetheless, we believe the evidence is compelling enough to warrant serious speculation and to prompt additional research. The evidence we have reviewed in this paper suggests that cannabis extracts may be effective treatments for metabolic syndrome, and may help to moderate the negative physiological, neurological, and psychological effects of glucoregulatory disorders.

The evidence furthermore suggests that treatment programs focusing on chronic marijuana use should give special attention to the medical and dietary implications that this drug use may have. It is possible that certain cases of marijuana dependence may be better conceptualized and treated if full metabolic assessments were performed concurrently with psychological assessments. This may be particularly true of those cases in which the reported reasons for marijuana use relate to emotional distress. The literature provides increasing evidence for mind-body interaction, and therefore suggests that quality of care will improve as medical and psychological treatment programs become more fully integrated.


  1. Brodbeck, J., Matter, M., Page, J., & Moggi, F. (2007). Motives for cannabis use as a moderator variable of distress among young adults. Addictive Behavior, 32(8), 1537-1545.
  2. Côté, M., Matias, I., Lemieux, I., Petrosino, S., Alméras, N., Després, J.P., & Di Marzo, V. (2007). Circulating endocannabinoid levels, abdominal adiposity and related cardiometabolic risk factors in obese men. International Journal of Obesity, 31(4), 692-699.
  3. Després, J.P. (2007). The endocannabinoid system: a new target for the regulation of energy balance and metabolism. Critical Pathways in Cardiology, 6(2), 46-50.
  4. Di Marzo, V., Verrijken, A., Hakkarainen, A., Petrosino, S., Mertens, I., Lundbom, N., Piscitelli, F., Westerbacka, J., Soro-Paavonen, A., Matias, I., Van Gaal, L., & Taskinen, M.R. (2009). Role of insulin as a negative regulator of plasma endocannabinoid levels in obese and nonobese subjects. European Journal of Endocrinology, 161(5), 715-722.
  5. Gallant, M., Odei-Addo, F., Frost, C.L., & Levendal, R.A. (2009). Biological effects of THC and a lipophilic cannabis extract on normal and insulin resistant 3T3-L1 adipocytes. Phytomedicine, 16(10), 942-949.
  6. International Diabetes Federation (2006). The IDF Consensus Worldwide Definition of Metabolic Syndrome. Retrieved from on November 24, 2009.
  7. Iwatani, N., Miike, T., Kai, Y., Kodama, M., Mabe, H., Tomoda, A., Fukuda, K., & Jyodoi, T. (1997). Glucoregulatory disorders in school refusal students. Clinical Endocrinology, 47(3), 273-278.
  8. Jin, H., Lanouette, N.M., Mudaliar, S., Henry, R., Folsom, D.P., Khandrika, S., Glorioso, D.K., & Jeste, D.V. (2009). Association of posttraumatic stress disorder with increased prevalence of metabolic syndrome. Journal of Clinical Psychopharmacology, 29(3), 210-215.
  9. Pagotto, U., Vicennati, V., & Pasquali, R. (2005). The endocannabinoid system and the treatment of obesity. Annals of Medicine, 37(4), 270-275.
  10. Takeuchi, T., Nakao, M., Nomura, K., Inoue, M., Tsurugano, S., Shinozaki, Y., & Yano, E. (2009). Association of the metabolic syndrome with depression and anxiety in Japanese men: a 1-year cohort study. Diabetes/Metabolism Research And Reviews, 25(8), 762-767.

Adlerian Career Assessment & Counseling

The Individual Psychology of Alfred Adler and his successors has always purported to have implications for career choice and satisfaction. The techniques of Adlerian lifestyle analysis, such as the assessment of psychological birth order and the interpretation of early recollections, provides a great deal of information about an individual’s motivations, preferences, and general orientation towards self, other, and the world at large. In this paper we will examine the ways that this information can be used to develop an expedient and comprehensive view of our clients’ career paths and to assist them in making choices that will satisfy their conscious needs as well as their unconscious private logic.

Overview of Adlerian Theory

The basic premise of Individual Psychology is that all individuals strive to transform their perceived inferiorities into perceived superiorities. The specific types of inferiority that an individual perceives originate in his or her relationship to the early environment. Elements of this environment include what is called the family constellation, or the arrangement of parents, siblings, and other family members in relation to the individual. For example, the order in which a child is born into his or her family will tend to exert a strong influence on the types of opportunities and expectations that he or she experiences while growing up, and so will influence the development of the individual’s personality and style of living across the lifespan (Watkins, 1993).

Another major premise of Adlerian assessment and counseling is that behaviors of all kinds, including emotional and cognitive behaviors, are teleological. In fact, Individual Psychology holds that the purposive nature of each behavior can be fit within the framework of an individual’s overarching final goal, of which he or she is unlikely to have any conscious knowledge. The pattern of behaviors which build up in support of this final goal, in turn, constitute the individual’s style of life (Watkins, 1993).

Finally, Individual Psychology holds that the individual is inseparable from his or her social environment. Because the individual’s perceptions and purposes are seen to emerge from the social situation in which the individual is positioned, all of the actual and perceived problems of life are seen as social problems, The well-adjusted individual, therefore, experiences a strong sense of connection with his or her social environment. Adlerians refer to this sense of connectedness as the community feeling or the sense of social interest (Watkins, 1993).

Overview of Adlerian Assessment & Counseling


Adlerian assessment is fundamentally an assessment of the individual’s manner of relating to the world around him or her. One way in which this relationship can be understood is through an examination of the early social environment in which the individual’s style of life originated and developed. Because the individual is seen as an active force in his or her world from the very beginning, the lifestyle assessment focuses on the ways in which the young individual began to make a place for himself or herself within the family unit.

A major component of this adaptive process can be surmised from the individual’s ordinal and psychological birth order. A first-born child, for example, is often cherished and expected to fulfill the wishes of his or her parents, and so is likely to tend toward conventionality and conscientiousness. The second-born enters the environment several years behind his or her older competitor and is therefore unable to match the elder sibling’s skill in fulfilling the parents’ wishes. This child will therefore often learn to demand attention and recognition through originality and rebellion, and by developing skill in areas where the elder sibling has not excelled. A key point in the consideration of birth order is that it is the child’s experience of his position within the family that is important, rather than the actual order in which the child was born. A second-born who is five or six years older than the elder sibling may feel and behave as though he or she were a second-born, an only child, an eldest child, a middle child, or any combination of the four, depending on the interactional dynamics of the family as a whole (Leong, Hartung, Goh, & Gaylor, 2001).

A key projective technique of Adlerian assessment is the interpretation of early recollections. Because the individual is seen as an active participant in the creation of his or her environment, the memory itself is seen not as a passive storage of past events but rather as an active recreation which serves to reinforce the individual’s private goals. Therefore, by scrutinizing an individual’s recollections of early life, the clinician can get a sense for the private logic that emerged from the early situation and the ways in which it may be maintained in the present day.

From these techniques the individual’s style of living can be deduced. This lifestyle consists of the individual’s attitudes toward him or herself, toward others, and toward the world at large. It is through the exploration and evaluation of these attitudes that Adlerian counseling and psychotherapy aim to assist the client in cultivating an increased sense of interconnectedness with his or her social environment. It is precisely this social interest which is, in Individual Psychology, seen as the essence of health and adaptation.

Implications of Lifestyle for Career Assessment

An individual’s choice of career can be seen as an extension and expression of his or her total style of life. As Watkins (1993) explains:

It is saying, “This is who I am,” “This is how I see myself vis-a-vis others,” “This is how I see myself vis-a-vis the world at large.” For example, the person whose life-style is oriented around helping and assisting others might gravitate toward such jobs as counseling, nursing, or some other helping profession. The person whose life-style is oriented around knowing (to know, find out) might gravitate toward such jobs as science or academics. Further still, the person whose life-style is oriented around getting and acquiring (to have and to hold) might gravitate toward jobs that emphasize collecting, buying, and investing (p. 357).

There is some limited research to support these notions and to connect them with other, better-studied models of career conceptualization. A 1978 study compared the predictive power of Holland’s Self-Directed Search (SDS) against Mosak’s lifestyle typology. This study found that life style type was “essentially as effective as SDS in such predictions.” A study published in 1980 also supported a relationship between vocational orientation and lifestyle type. This study compared Thorne’s Life Style Analysis measure against Holland’s Vocational Preference Inventory and found a number of significant correlations between indices on the two measures. In particular, the authors of that study noted strong correlations between Holland’s Enterprising scale and the Aggressive-Domineering and Domineering-Authoritarian lifestyle configurations. Mosak’s Conforming lifestyle type also correlated positively with Holland’s Conventional scale and negatively with his Artistic scale (Watkins, 1984).

As self-selected representations of the life-style, early recollections can therefore be used as an expedient tool for collecting information about individuals’ vocational motivations as well as their individual vocational needs. A series of early recollections provides the skilled Adlerian counselor with a wealth of information about the client’s way of learning, of motivating him or herself, of approaching work as a basic task of life, and of relating to others in both collegial and authoritative capacities.

Lifestyle and Career Counseling

According to Watkins (1984), “the more consistent the person’s life style is with the realities and demands of an occupation, the greater the likelihood that the person will be satisfied in the occupation.” He further explains that the compatibility of an individual’s own lifestyle with those of his or her coworkers will be a great importance, due to its effect on the individual’s ability to find a place for him or herself within the interpersonal dynamics of the workplace. These ideas are not at all dissimilar from other theories of career congruence, such as Super’s “life-span, life space” model (Anderson, 1995).

One Adlerian approach to career counseling, called the “Career Goals Counseling” process and developed by McKelvie & Friedland (1978, as cited in Watkins, 1993) focuses on assessing and modifying clients’ personal goals, assessing and intervening with the obstacles that impede those goals, and assessing or modifying the strategies that clients are using to meet their goals. When we speak of personal goals in this context, it should be noted that we are speaking not only of situational or intermediate goals, but also of Adlerian final goals, or the basic strivings which characterize the client’s lifestyle. Such goals might be along the lines of “being good” or “being superior” (Newlon & Mansager, 1986, as cited in Watkins, 1993).

Likewise, the obstacles that an individual faces may not only be objective in nature, such as discrimination, lack of education, lack of information, and so on. Individuals also carry with them their own set of personal, internalized limitations that impede their ability to select and succeed in career that they will ultimately find fulfilling. These include “irrational ‘shoulds,’ ‘oughts,’ and ‘musts’ that we maintain” (Watkins, 1993).

Strategies, then, are the patterns of behavior that individuals engage in in order to advance their goals. These strategies are reflective of the unique manner in which an individual attempts to implement his or her lifestyle. While two workers might share the goal of “advancing,” one might seek to do so through consistent and conscientious work while another seeks to accomplish the same goal by finding fault with and criticizing co-workers (Watkins, 1993).

In order to discover a client’s unique system of goals, obstacles, and strategies, the McKelvie-Friedland approach calls for a complete lifestyle assessment interview. This procedure is a standard practice in all types of Adlerian counseling and psychotherapy, and it involves taking a detailed psychosocial history, including information about the client’s family constellation and a set of early recollections. In this model of career counseling, the counselor concentrates on helping the client to gain insight into vocationally-relevant psychosocial dynamics in his or her own life. For example, the client might be led to consider the career ramifications of his or her life goal, and to consider more effective choices given his or her current life situation and direction (Watkins, 1993).

The main shortcoming of the McKelvie-Friedland approach, according to Watkins (1993), is that it is essentially a direct translation of the standard Adlerian counseling approach into the area of career counseling. As noted, it involves a complete lifestyle assessment interview, which is often quite lengthy and may include elements which, Watkins argues, the average career counseling client will have trouble relating to because of its abstract, “experience-distant” orientation.

Watkins finds a more creative reinterpretation of Adlerian clinical technique in the work of Savickas, who states “…much of the data gathered with the Life Style Inventory [or interview pertains to career-adjustment counseling, that is, helping clients cope with problems at work. Although enlightening, data about family constellation and early recollections are not needed for career-choice counseling” (1989, as cited in Watkin, 1993). Savickas refers, then, to a “career-style counseling” method that fits within the framework of Individual Psychology.

Savickas’ career-style counseling utilizes an abbreviated “career-style assessment” designed to gather lifestyle information that is directly applicable to vocational choice in an experience-near fashion. In this assessment process, clients are first asked to describe their role models in order that the counselor can begin to understand their values and potential ambitions. Next, clients are asked about their favorite books and magazines, thereby gathering further information about role models and valued characteristics as well as preferred environments and types of interactions.

Clients are next asked leisure activities they enjoy; this line of inquiry provides insight into the clients’ interests, ways of self-expression, and coping strategies. Questions about clients’ preferred school subjects next provides the counselor with information about “work habits, work attitudes, and preferred work environments” (Watkins, 1993). Savickas’ model directs counselors to next inquire about clients’ favorite mottoes or sayings. Personal mottoes are likely to directly reflect pertinent lifestyle information and so provide insight into the client’s basic heuristics for evaluating situations.

The next step in the career-style assessment is to ask clients to share their “occupational daydreams” as well as the ambitions that their parents had for them. These questions will provide insight into the internalized meanings that occupational roles hold for clients. Finally, clients are asked about an important decision that they made, and the process whereby they came to make the choice that they made. This final line of questioning allows the counselor to understand what steps will need to be taken to assist the client in reaching a decision.


While the ideas and methods of Individual Psychology certainly seem to have a lot to offer to the career counselor, there are two major problems with each of the Adlerian approaches that we have examined: lack of empirical support, and lack of a clear model for intervention. Although there is some very limited research indicated significant correlations between Adlerian constructs and more widely accepted career development and assessment models, this research derives from only a handful of relatively small studies which have been spread out over significant periods of time.

Likewise, Adlerian career counseling has not yet found a clear model for intervening in the career development of clients. The available literature speaks to the value of Adlerian projective techniques such as lifestyle analysis and early recollections, but makes no mention of specifically Adlerian methods for making use of this information. This lack may reflect Individual Psychology’s psychoanalytic roots, pointing to an underlying assumption that insight into the causes and dynamics of psychological and practical difficulties will ultimately provide the client with more and better behavioral choices. However, this assumption is far from explicit in the available literature and would be surprising given Adlerian counselors’ reliance on concrete tactics and strategies in psychotherapy sessions (Mosak & Maniacci, 2006).

Therefore it is more likely that Adlerian career counseling methodologies are simply under-researched and poorly developed at this time. This is not to say that standard techniques of Adlerian counseling and psychotherapy could not be effectively adapted to the career counseling situation, but simply that doing so would require experimentation on the part of the practitioner. Individual Psychology has been enjoying a minor resurgence in the United States over the last five or ten years, and so the problem of Adlerian career counseling may be one that will yet be adequately addressed.


  1. Anderson, K.J. (1995). The use of a structured career development group to increase career identity: An exploratory study. Journal of Career Development, 21(4), 279-291.
  2. Leong, F.T.L., Hartung, P.J., Goh, D., & Gaylor, M. (2001). Appraising birth order in career assessment: Linkages to Holland’s and Super’s models. Journal of Career Assessment, 9(1), 25-39.
  3. Mosak, H.H., & Maniacci, M.P. (2006) Tactics in counseling and psychotherapy. Mason, OH: Thomson Brooks/Cole.
  4. Watkins, C.E., Jr. (1993). Psychodynamic career assessment: An Adlerian perspective. Journal of Career Assessment, 1(4), 355-374.
  5. Watkins, C.E., Jr. (1984). The Individual Psychology of Alfred Adler: Toward an Adlerian vocational theory. Journal of Vocational Behavior, 24, 28-47.

A Review of Interventions for Reducing Mental Health Stigma

Stigmatizing attitudes toward mental illness, individuals suffering from mental illness, and psychological service utilization are widespread. They result in social isolation, reduced opportunities, and outright discrimination against affected individuals (Gaebel, Zäske, Baumann, Klosterkötter, Maier, & Decker et al., 2008). The negative effects of stigma also extend to the families of individuals with mental illness, their close relationships, and even the professionals who work with them (Goffman, 1963; Sadow & Ryder, 2008). This stigma is associated with treatment underutilization, treatment delay, and premature termination (Masuda et al., 2007; Gaebel et al., 2008; Gould, Greenberg, & Hetherton, 2007; Corrigan, 2004).

Definitions & Understandings of Stigma

In his classic text on stigma as “spoiled identity,” Goffman (1963) describes stigma as a visible or invisible ‘mark’ that disqualifies its bearer from full social acceptance. Mental illness marks affected individuals as having “blemishes of individual character,” the acquisition of which “spoils” their identities and removes them from their place within the social hierarchy. While some argue that stigma should be clearly distinguished from discrimination, others define stigma as a multilevel interaction between affective, cognitive, behavioral, and contextual aspects. Campbell & Deacon (2006) elaborate:

The failure of individual-level approaches to effect widespread stigma reduction has led to an alternative focus on the links between stigma and wider macro-social inequalities (e.g. gender, ethnicity). Such analyses suggest that stigma is not something that individuals impose on others, but a complex social process linked to competition for power, tied into existing mechanisms of dominance and exclusion (Parker and Aggleton, 2003). Macro-social analyses imply that interventions such as anti-discrimination legislation or poverty-reduction will assist in stigma reduction. But taking this view can mean that researchers pay little attention to the individual psychological dimensions of stigma (2006, p. 412).

Those individual psychological dimensions, it is argued, have their basis in a universal human need to project fears of uncertainty and danger onto stigmatized ‘out-groups.’ The universality of this need can be seen in the separation and stigmatization of out-groups across cultures—the targets of stigma vary widely based on local power differentials, but the process of stigmatization can be seen anywhere (Joffe, 1999). For example, the stigmatization of HIV/AIDS sufferers in late-twentieth century United States culture helped to reinforce “middle American” morality through its association with marginalized out-groups who failed to meet prevalent social expectations: intravenous drug users, homosexual men, and prostitutes (Crawford, 1994). While applications of this principle to the stigma currently associated with mental illness can certainly be surmised, no research on the moral bases of mental health stigma could be found.

Why Mental Health Stigma is a Problem

Regardless of its causes, mental illness stigma has been found to pose a major barrier to some of the most basic tasks of life, such as establishing and maintaining friendships, employment, and housing. Stigma has also been found to significantly interfere with access to and outcomes for both psychological treatment and general medical treatment (Sadow & Ryder, 2008). Through shame, humiliation, and damage to the affected individual’s sense of self, stigma negatively impacts the likelihood of service utilization and treatment compliance. Consequently, patients who score higher of measures of stigmatizing attitudes are at higher risk for negative outcomes (Gould, Greenberg, & Hetherton, 2007; Corrigan, 2004). Stigmatizing attitudes have also been observed among students and professionals from many segments of medical and psychological service. As a result, people diagnosed with mental illness receive fewer medical services and a reduced range of insurance benefits; (Sadow & Ryder, 2008).

Review of Interventions for Mental Health Stigma

Corrigan & O’Shaughnessy (2007) list three main avenues for addressing the stigma associated with mental illness: protest, education, and contact. While each of these avenues has some degree of validity on its face, the efficacy of interventions based on any of these principles leaves much to be desired. Of the three, only direct contact has shown any effectiveness in reducing stigmatizing attitudes toward mental illness over an extended period of time.

Protest Interventions

Protest tactics involve directly challenging negative or stigmatizing representations of mental illness in the popular media in order to undermine the cultural maintenance of those representations. The primary means of protesting stigmatization in popular media is by way of economic boycott. Organized boycotts and threats of boycott from advocacy groups targeting the producers, distributors, and advertisers responsible for entertainment commodities have been successful in removing stigmatizing materials from public view in at least two instances.

An ABC television series called Wonderland depicted a person with mental illness behaving in a violent and sadistic manner. After intense targeting from mental health advocacy groups directed both at the network and the show’s advertisers, the show was discontinued after just a few episodes. Another instance cited by Corrigan & O’Shaughnessy (2007) is the advertising campaign leading up to the release of the comedy film Crazy People. Advocacy groups threatening Paramount Pictures with potential economic consequences convinced the company to remove movie posters depicting a large cracked egg with arms and a caption reading “Warning: Crazy people are coming.”

Despite these apparent successes, no empirical research has demonstrated that such efforts have a positive impact on the general public’s prejudices toward individuals with mental illness. In fact, the opposite may be true; some research suggests that protest strategies may produce an “attitude rebound.” The negativistic nature of protest interventions, which fail to provide positive alternatives to the attitudes they seek to undermine, seems to inspire an overall worsening of the public’s stigmatizing attitudes (Corrigan et al., 2001).

Educational Interventions

The educational approach, on the other hand, seeks to cultivate accepting attitudes toward mental illness by disseminating accurate information and dispelling myths about mental illness, such as the popular beliefs that persons suffering from mental illness are more likely to commit violence, or that mentally ill individuals are unable to be productive in the work force (Corrigan & O’Shaughnessy, 2007; Corrigan et al. 2001). The basis for this approach rests on a number of studies that have found individuals who are more knowledgeable about mental illness to hold fewer stigmatizing attitudes. Additionally, educational strategies for reducing stigma tend to be attractive to both researchers and policy-makers because they are affordable and easily reproducible. Some educational instruments that have been used in this way in the past include public service announcements, flyers, books, and informative videos.

Educational approaches are also the most-studied form of intervention for reducing mental health stigma. Unfortunately, the research seldom supports their effectiveness. Many studies have found significant reductions on stigmatizing attitudes through exposure to college courses or informational sessions, but the magnitude and duration of the effects tends to be very limited. Furthermore, the effects of educational interventions correlate to participants’ knowledge of mental illness prior to participation in the educational programs, indicating that the effects of education-based interventions may primarily reflect the attitudes of participants who had already agreed with the programs’ messages (Corrigan & O’Shaughnessy, 2007).

One notable implementation of the educational approach to stigma reduction has been the UK Royal Navy’s trauma risk management (TRiM) program, which seeks to improve recognition of and response to PTSD by reducing the stigma associated with the diagnosis. The TRiM program trains nonmedical personal in basic assessment of trauma risk and the administration of psychological first aid. The training encompasses only traumatic stressors and seeks only to facilitate early referral to appropriate counseling services. According to Gould, Greenberg, & Hetherton (2007), “the aims for participants are to understand PTSD and stress reactions, so that negative representations of mental illness are modified, and the problems associated with other posttraumatic management strategies (e.g., PD) are addressed” (p.507).

While the TRiM program does encourage individuals to share their experiences of stress and stress-related problems in order to reduce stigma, the program’s primary intervention is to provide education about the effects of traumatic stress and ways of assessing for risk and symptoms of PTSD. A brief longitudinal study of personnel who volunteered to receive this training found both significantly improved attitudes toward stress-related ailments and increased help-seeking. However, in light of evidence that attitudinal effects are unlikely to be maintained over the long-term, the study was severely limited by lack of follow-up. Additionally, the authors note that highly stigmatizing individuals tend to be those least likely to volunteer to attend educational packages, further weakening the evidence for this intervention’s effectiveness. In spite of these shortcomings, the study’s authors argue that the tightly integrated structure of the military organization makes it more susceptible to real-world improvements as a result of this type of intervention than the population at large (Gould et al., 2007).

Direct Contact Interventions

Among the general population, the most effective methods of reducing stigma appear to be those which facilitate direct contact between individuals with mental illness and members of the general population. Researchers have consistently found that greater levels of personal familiarity with mentally ill individuals tend to equate with fewer prejudicial attitudes toward mental illness. Additionally, while some reduction of stigmatizing attitudes can result from the disclosure of popular figures such as celebrities who disclose their experiences with mental illness, greater effects result from the disclosures of individuals perceived to be more similar to the recipient of the message, people “just like me” (Corrigan & O’Shaughnessy, 2007).

One program that has sought to reduce stigma using this direct-contact approach is the National Alliance for Mental Illness (NAMI) In Our Own Voice program, in which mentally ill individuals share their history and experiences with treatment in a workshop format. Audience members are encouraged to asked questions and interact with the presenters. Preliminary research has shown good initial responses from program participants along with promising reductions in stigmatizing attitudes several weeks after their participation in the program (Corrigan & O’Shaughnessy, 2007).

There are several difficulties in implementing contact-based interventions, not least of which is that they require disclosure from individuals living with mental illness. This type of disclosure puts the mentally ill participants at risk to experience the exact stigma which the interventions would hope to circumvent. While much greater reductions result from programs which put mentally ill individuals in contact with members of the general population, the effect may be insufficient to warrant this added risk. Furthermore, there is some evidence that the segments of the population who hold the most stigmatizing attitudes are also the least likely to become involved in this type of program (Corrigan & O’Shaughnessy, 2007).

One area in which this risk may be both minimized and justified is in the training of future health professionals. Sadow & Ryder (2008) have performed a number of studies aimed at decreasing stigmatizing attitudes towards mental illness among this group, typically with poor results. Various educational efforts that did not include personal contact with mentally ill individuals, including training programs which utilized videos of presentations by such individuals were not effective in reducing stigma among nursing students. However, when personal presentations by individuals with mental illness were presented in the classroom and followed by an opportunity to process the experience with a psychologist, stigmatizing attitudes were significantly decreased among this group. This is an important finding given our previous discussion of the dangers of mental health stigma among healthcare providers.

In their review of contact-based interventions to reduce stigma among schoolchildren, Pettigrew & Tropp (2000) identify five factors which they see as necessary for optimal stigma-reducing contact: equal status between majority and minority groups; a shared goal between members of both groups; a cooperative, rather than competitive, framework for accomplishing the common goal; institutional support for the interactions between members of each group; and minority members who moderately disconfirm the prejudicial stereotypes about their group. However, the efficacy of these school-based programs has been disappointing, with most studies showing mixed results or no differences in stigmatizing attitudes among the exposed children. On top of this, the risk of amplifying stigmatization is increased when working with children, as Corrigan & O’Shaughnessy (2007) argue:

The threat of “coming out of the closet” once again becomes a key factor in realising this kind of contact. Decisions need to be made as to whether children with mental illness will disclose their group status in order to facilitate contact effects. This means that some parents of children with mental illness, who are rightfully concerned about their child’s socialisation and education, must risk their child being stigmatised to attempt this kind of friendship building. Moreover, the mother and father must risk experiencing family stigma that suggests, for example, that bad parenting produced their child’s mental illness (p. 94).

Another notable shortcoming of contact-based approaches to reducing stigma is that they may be limited in the scope of attitudinal change they can realistically effect. While contact with mentally ill individuals helps to undermine beliefs that such individuals pose an immediate physical danger, it is less likely to affect other types of stigmatizing thoughts and feelings, such as overall anxiety and thoughts about “us versus them” (Masuda et al., 2007).

A Large-Scale Combined Interventive Approach

The World Psychiatric Association (WPA) has been working to implement a combined program including all three of the discussed strategies for stigma reduction through their “Global Program Against Stigma and Discrimination Because of Schizophrenia — Open The Doors.” In cooperation with the German Research Network on Schizophrenia, this program has been implemented as a large-scale controlled trial throughout Germany since 2001. Anti-stigma intervention programs, schizophrenia awareness intervention programs, and a no-intervention control condition were each assigned to two German cities. Cities were relatively homogenous in terms of population, with each city being home to a university-affiliated department of psychiatry and offering free psychiatric services to the community (Gaebel et al., 2008).

Several strategies were employed in the anti-stigma intervention cities. Educational programs were targeted at influential groups such as health professionals and educators, and direct-contact programs were initiated. These consisted of “lectures at adult education centers, art exhibitions, cinema events, readings, theatre events, and charity concerts. Most events included panel discussions with mental health professionals as well as people who were affected by mental illness as participants. Prior to the events, press conferences were held and/or press mailings were distributed. Furthermore, press workshops about schizophrenia and its misconceptions in the public were conducted to improve the reporting in the mass media about schizophrenia and mental illness in general” (Gaebel et al., 2008, p.185) Protest actions were also orchestrated to discourage structural discrimination and stigmatizing messages.

The researchers hypothesized a reduction in total mental health stigma in anti-stigma intervention cities, with no comparable reduction in the cities receiving awareness programs or no intervention. Stigmatizing attitudes were measured using pre- and post-testing of representative samples of each cities population via telephone survey. The results showed small but significant reductions in stigmatizing attitudes in the anti-stigma intervention cities, with most of the change relating to measures of perceived social distance in transient situations. The average citizen in these cities reported significantly more comfort having incidental day-to-day interactions with persons with schizophrenia in 2004 than in 2001, but was no more likely to be involved in repeated social or professional contact with these individuals (Gaebel et al., 2008).

An Alternative Approach: Cognitive Restructuring

A fourth method for reducing mental health stigma is the use of cognitive restructuring. For example, Sadow & Ryder (2008) describe a method of “turning the tables” on stigma within healthcare training programs by using the technique of “inspirational recruitment,” in which poorly paid and unpleasant work is elevated to the status of a noble cause. They cite a previous study in which this technique increased the rate at which psychiatry students were able to be recruited into otherwise undesirable positions working with severe mental illnesses in public health clinics.

Few other studies have utilized this more psychologically informed approach to stigma reduction, and we are aware of no studies which attempt to reduce stigma among the general population using similar techniques. However, modern understandings of perception and belief certainly make cognitive restructuring an attractive option, particularly in light of the previously cited evidence for its potential. This is a direction that stigma researchers should definitely be turning toward in the coming years, in both community psychology settings and clinical training programs.

Acceptance and Commitment Therapy As a Stigma Intervention

A similarly oriented approach is the use of Acceptance and Commitment Therapy (ACT) to reduce stigma. This approach addresses stigma only indirectly; ACT “uses acceptance, mindfulness, and value-directed behavioral change strategies in order to increase psychological flexibility” (Masuda et al., 2007, p. 2765). According to Masuda et al., research has supported the idea that increased self-acceptance produces increased empathy. While contact-based education only undermines beliefs about danger, ACT addresses the overarching avoidance of discomfort by increasing acceptance.

For example, in a study on substance abuse counselors, multicultural training reduced stigmatizing attitudes toward racial and cultural groups immediately after the intervention, but not at three-month follow-up. On the other hand, an ACT intervention which encouraged counselors to reflect on the automatic nature of judgmental processes and the “paradoxical effect of deliberate attempts to eliminate both self-stigma and stigmatizing attitudes” (Masuda et al., 2007, p. 2766) showed much better results. The ACT intervention reduced both stigmatizing attitudes among the counselors as well as measures of workplace burnout at follow-up.

Refocusing on more general factors like mental flexibility as contributors to stigma can also help to clarify the mixed results typically seen when other tactics are used. One study subjected college students to a single 2 1/2 hour ACT workshop focused on stigmatizing attitudes toward mental illness. Prior to the intervention, it was found that students with a lower level of general mental flexibility were more stigmatizing than their more flexible counterparts. The ACT intervention reduced stigma in both flexible and inflexible individuals, and in fact showed a particularly high comparative effectiveness for psychologically inflexible study participants. The authors speculate:

This pattern of results suggests that some forms of stigma may reflect uninformed attitudes about legal, cultural, and institutional practices related to mental illness. In more experientially avoidant individuals, however, stigmatizing views may become entangled in psychologically avoidant processes linked to the perceived threats of the stigmatized condition (Goffman, 1963) and to the inability to deal with the thoughts and feelings that arise as a result. These differences might help explain the somewhat inconsistent results for education in the stigma literature (Masuda et al., 2007, p.2769).


There has been much research on the effects of mental health stigma, but quite a good deal less research has examined potential interventions for reducing its presence or impact. This area of study is also significantly less ideologically sophisticated at present. None of the primary avenues for reducing stigma have proven satisfactory, although direct-contact programs have shown some promise and education programs have been effective within controlled social contexts such as military organizations.

A greater level of psychological savvy is needed in developing interventions for this purpose. Along these lines, some preliminary research on cognitive restructuring efforts and ACT-based interventions have shown a great deal of promise. It is unlikely that these early efforts cannot be bested by additional consideration for individual, social, and community psychological understandings.

While stigmatizing attitudes among the general public have been fairly well-studied, self-stigma and mental health service users’ reactions to stigma are more poorly understood. Bagley & King (2005) argue that the success or failure of expensive public campaigns to reduce the stigmatization of mental illness should be measured by the resulting feelings and experiences of the individuals affected by the stigma. To this end, they argue that primary interventions for newly-diagnosed cases of mental illness should include counseling aimed at mediating the effects of and improving responses to stigmatizing interactions.

Alternatively, an argument could be made for a more general measurement of the efficacy of anti-stigma efforts. The success or failure of these programs should hinge on the increased utilization of services and increased effectiveness of services utilized. This latter goal is likely to be too heavily confounded to be adequately measured as an effect of anti-stigma interventions. Therefore, future anti-stigma research should use the likelihood of the general public to utilize services, along with actual service utilization, as measures of outcome for anti-stigma interventions.


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Transformational Leadership In Mental Health Administration

The transformational model of leadership has gained considerable traction among leadership theorists and researchers over the past few decades. It appears to be a fairly reliable and unitary construct referring to a set of leadership behaviors which are associated with a variety of positive organizational outcomes. In this paper we will briefly detail the behaviors included within the transformational leadership model. We will review some of their benefits for organizations in general and health care organizations in specific. Finally, we will argue that a transformational leadership model offers unique benefits in the field of mental health, and should therefore be considered best practices for mental health service administrators. Throughout our discussion, we will attempt to make the subject matter directly applicable to mental health administrators by suggesting similarities to existing psychological concepts and opportunities for implementation in a mental health setting.

Overview of Transformational Leadership

Under a transformational leadership model, the leader focuses on creating positive change in followers through behaviors which help them to “transform” into more motivated, satisfied, and harmonious members of the organization. Transformational leadership is generally characterized by four types of leadership behaviors, often referred to as the four ‘I’s: idealized influence, intellectual stimulation, individual consideration, and inspirational motivation (Fisher, 2009).

Idealized Influence


The concept of idealized influence is similar to what might generally be thought of as charisma. Although the vast majority of literature on charismatic leadership focuses on the potential for negative social consequences, there is also an argument to be made that charisma is a component of highly effective transformational leadership (Aaltio-Marjosola & Takala, 2000). In this sense, the exertion of idealized influence refers to a “leader’s ability to generate enthusiasm and draw people together around a vision through self-confidence and emotional appeal” (Fisher, 2009, p.362).

At a more tangible level, a leader can become a more idealized influence by modeling desirable role behaviors within the organization and culture. By positioning him or herself as a positive role model, a leader can thereby engender the trust, respect, and even admiration of subordinates. In mental health terms, this has similarity to what clinicians refer to as ‘fostering transference’ with their clients. By exhibiting the types of behaviors that one would expect from a leader in a given situation, one can generally assume that they will be automatically afforded greater deference within that situation.

Intellectual Stimulation

Transformational leaders help to provide intellectual stimulation for their subordinates. In practice this means that transformational leaders foster more democratic working environments than other types of leaders, because they are frequently engaging their team members in creative and innovative problem solving (Fisher, 2009). This may be a key reason for the significant association between transformational leadership and feelings of psychological empowerment among subordinates (Fuller, Morrison, Jones, Bridger, & Brown, 1999).

Psychological empowerment is a state of increased intrinsic motivation. Empowered individuals have a sense of agency in their work roles; they feel as though they are doing their jobs in ways that they choose and for reasons that they choose (Fuller et al, 1999). It is easy to see how engagement in problem-solving tasks related to the work situation itself would help to instill this sense of agency and improve personal investment in the workplace, because individuals are being actively recruited as collaborators in shaping their own organizational culture.

Individual Consideration

This leads naturally into the next aspect of transformational leadership, which is individual consideration. This refers to the ability of the leader to ‘get to know’ team members and show them individual respect and concern. If team members are being recruited as intellectual collaborators in organizational problem solving, their personal needs and preferences will naturally emerge.

Leaders can further the sense that individual consideration is being by regularly assessing their followers’ personal goals and working to create new opportunities which match those goals (Fisher, 2009). Monitoring followers’ progress and providing mentoring along the way will help to enhance this effect while also bolstering the leader’s position as an idealized influence. The leader’s requests will be more likely to be perceived as in the followers’ best interests, and so should be more likely to be fulfilled with enthusiasm.

Inspirational Motivation

Finally, a transformational leader “moves team members toward action by building their confidence levels and generating belief in a cause” (Fisher, 2009, p.362). This is highly compatible with the previously discussed aspects of transformational leadership. Through individualized consideration and mentoring, individuals are led to work toward improving themselves and their status within the organization. By providing a positive role model, individuals are given direction and momentum for guiding their own role behaviors. And by providing intellectual stimulation and making individuals active participants in their workplace, they are led to see how their own growth and development corresponds to the growth and development of the organization as a whole.

This latter effect is the key ingredient in inspirational motivation. Transformational leaders put this into practice by drawing team members around a vision of what the organization can be in the future. By setting high expectations for the organization as a whole and behaving in ways that are congruent with those expectations, transformational leaders are able to inspire their subordinates to hold similar expectations and to work toward realizing those expectations.

Benefits of Transformational Leadership

Transformational leadership behaviors have been associated with a variety of positive organizational outcomes across industries and across cultures. They are positively associated with overall leader effectiveness (Jung, Yammarino, & Lee, 2009). Employee effectiveness is also positively affected, with extra perceived effort, organizational citizenship behaviors, and job satisfaction all being associated with transformational leadership (Fuller et al, 1999). In this section we will discuss three effects of transformational leadership that may be particularly important for mental health care administrators: group cohesiveness, psychological well-being, and creativity.

Group Cohesiveness

Group cohesiveness is a concept that is well-known to mental health workers providing group therapy services. When there is cohesiveness among group members, each individual member is propelled by the group to accomplish more than could be done alone. The same is true of work teams.

According to Wang & Huang (2009), group cohesiveness among work teams results in more and better group interaction, stronger group influence, and greater individual involvement in the group. Studies have shown that group cohesiveness is associated with emotional intelligence, and this is a quality that mental health workers should exhibit relatively high levels of due to the demands of their profession. However, the primary mediating factor between emotional intelligence and work team group cohesiveness is transformational leadership (Wang & Huang, 2009).

Particularly in service agencies where turnover rates are high because of provider burnout, higher levels of group cohesiveness may serve as a protective factor by increasing the level of support that workers receive from one another. The higher levels of group interaction that cohesiveness brings about should also increase consultation between colleagues, resulting in a higher quality of services.

It is also pertinent that group cohesiveness induces higher levels of personal involvement with the group. A study of health care organizations found that employees’ personal involvement in their organizations was negatively correlated with their stress levels (Skela Savic & Pagon, 2008). In that study, the single greatest predictor of successful individual involvement was transformational leadership.

Psychological Well-being

Psychological well-being is the subjective experience of being in a positive state of mental health. Several studies have found that a leader’s behavior can affect the mental health of his followers, but there has been little research examining the possible mechanisms for this interaction. Arnold, Turner, Barling, Kelloway, & McKee (2007) noted that there is an established connection between transformational leadership and the sense that one’s work is meaningful. Since deriving meaning from events has been called a “fundamental human motive,” they hypothesized that the positive effects of transformational leadership on psychological well-being could be accounted for by this enhancement of meaningfulness. In their two studies of Canadian health care workers, they found that after controlling for humanistic beliefs about their work, the relationship between transformational leadership and psychological well-being was fully mediated by workers’ perceptions that their work was meaningful.

It is notable that these studies were carried out among health care workers, as most people would agree that this work—like mental health—is intrinsically meaningful. Yet it is not uncommon to hear workers in mental health service organizations describe their work experience in terms of a progressive loss of meaning. High case loads, inadequate funding, and arduous paperwork all contribute to the type of personal crisis that leads to burnout. It is the sense that one is simply making no difference in the world by continuing on with his or her work.

By directly enhancing the sense that there is meaning in the work that mental health care providers are doing, transformational leadership has a potential to strongly affect worker satisfaction and reduce burnout. And because this effect improves psychological well-being, it may also help clinicians to exercise a higher level of clinical judgment than they would otherwise be capable of. This improves the quality of services that are provided and so circularly enhances the sense that meaningful work is being done.


We have discussed the possibility that transformational leadership could improve clinical judgment, but most mental health workers would agree that a high degree of creativity is also required for their clinical work. Interventions must frequently be designed on-the-fly, and should ideally be tailored for each individual on the basis of their present behavior considered alongside their full history. There is some evidence to suggest that transformational leadership may increase creativity at both the individual and organizational levels.

Gumusluoglu & Arzu (2009) performed a study on transformational leadership in another field requiring a high degree of creativity: software research and development. They studied Turkish personnel and managers from organizations of various sizes in order to determine whether transformational leadership had an effect on creative output. They found that the most creative workers were those whose managers exhibited the most transformational leadership behavior. In examining possible mechanisms for this association, they found that psychological empowerment was the strongest mediating factor.

Whether by creating a culture of psychological empowerment within the organization or through some other mechanism, this effect seems to also be true at the organizational level. In a study of 50 Taiwanese electronics and telecommunications companies, a positive relationship was found between overall organizational innovation and transformational leadership behaviors from the CEO (Jung, Wu, & Chow, 2008).

Although neither of these studies were performed within the mental health industry, it seems likely that similar effects could be found among mental health care providers and administrators. Higher levels of personal investment, psychological well-being, and support from other employees should reasonably be expected to enhance the individual creativity of clinicians and to foster a culture of creative clinical intervention.

Transformational Leadership is a Natural Fit for Mental Health Administrators

Fisher (2009) has pointed out that adherence to any leadership model tends to produce better results than leadership which is not guided by any model at all. Therapists have long held a similar view of theoretical orientation as it applies to the psychotherapy situation. When a therapist or leader operates in accord with a coherent theoretical model, it provides a consistency and predictability. This helps people to feel safe and affords them an understanding of their situation which they could not otherwise have. This may be why both transformational and transactional leadership styles are associated with providers having positive attitudes toward adopting evidence-based practices (Aarons, 2006).

Regardless, there is some reason to believe that the transformational leadership model may be a natural fit for the social service fields, including mental health. For example, a study of social service supervisors found that they generally tended to use transformational leadership techniques spontaneously, whether or not they consciously identified themselves as doing so (Arches, 1997).

Mary (2005) found similar results in a survey of members of the National Network for Social Work Managers and the Association of Community Organization and Social Administration. When asked to think of a leader they had worked with and to rate them on the Multifactor Leadership Questionnaire, she found that the leaders discussed generally operated in a manner consistent with the transformational leadership model. In addition, transformational leadership qualities were positively correlated with leader effectiveness, satisfaction with the leader, and extra effort on the part of workers. These results match those of Gellis (2001), who found that transformational leadership factors in social service administrators were positively correlated with similar positive organizational outcomes. Social workers were more likely to engage in requested activities and reported feeling more satisfied with their leader when more transformational leadership qualities were present.


There is substantial evidence that the transformational leadership model produces organizational outcomes which mental health administrators would generally find desirable. By providing a practical means for generating positive role identification, intrinsic motivation, personal investment in the workplace, motivation and resiliency, transformational leadership promises to enhance the quality of services provided while reducing negative effects on workers. Because provider burnout is such a widespread and troublesome phenomenon in social service agencies, the benefits of transformational leadership may prove particularly compelling in this industry.

As we have seen, transformational leadership is already prevalent among social service organizations. Furthermore, the degree to which it is practiced corresponds to leader effectiveness, among other positive organizational outcome variables within these types of agencies. It results in better group cohesiveness, which will help workers to feel better supported and to feel more personally involved in their agencies. It also results in lower stress and greater psychological well-being for health care workers.

Transformational leadership also increases individual creativity and organizational innovation among workers in some creative fields, and this benefit may also apply to mental health workers. More creative workers will be more capable of adapting their skills and techniques to the needs of individual patients, thereby resulting in a higher quality of services and better clinical outcomes. For all of these reasons, the transformational leadership model is a natural fit for the mental health field, and its implementation should be considered an integral part of best practices for mental health administrators.


  1. Aaltio-Marjosola, I. & Takala, T. (2000). Charismatic leadership, manipulation and the complexity of organizational life. Journal of Workplace Learning, 12(4), 146-164.
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Cultural Factors In Problem Gambling Among The Chinese

The most current Diagnostic and Statistical Manual of Mental Disorders (APA, 2000) provides only a single gambling-related diagnosis: Pathological Gambling. This diagnosis requires that an individual meet at least five out of ten criteria which are representative of problem gambling among Western samples. However, even in the West, many individuals suffer significant financial and interpersonal consequences from gambling without meeting full criteria for this mental disorder. The literature typically refers simply to “problem gamblers,” a category which is inclusive of these subclinical cases as well as those which would meet diagnostic criteria (Raylu & Oei, 2004). In this paper we will follow the same convention, referring to problematic gambling behavior as that which is subjectively “out of control” for the gambler, whether or not it meets the Western diagnostic criteria. We will also see that conceptions of normative and problematic gambling vary across cultures, such that culturally-appropriate practices of diagnosis and treatment are called for.

In this article we will examine the differences in the ways that problem gambling is conceived of and presented within Chinese culture versus Western culture. We will review literature on the role that culture plays in the etiology and progression of problematic gambling behavior in general, as well as the specific cultural factors affecting its development among the Chinese people. We will see how the cognitive and emotional factors that lead to problem gambling in the Chinese are similar to and different from the factors that drive these behaviors in Western samples. Finally, we will examine whether our understanding of problem gambling among the Chinese may also inform our understandings of problem gambling in other Asian cultures.

We will conclude that, given the similarities between presentations of problem gambling across cultures, a cross-cultural model of gambling treatment which takes cultural differences into account may be possible. Because of the increasing size of immigrant communities in the West and the increasing intermingling between Eastern and Western cultures, such a model would be of inestimable value to clinicians now more than ever before. Regardless of whether a true cross-cultural model of gambling treatment can or will be developed, however, it is critical that clinicians consider both cultural and individual differences when designing and administering treatments.

The Role Of Culture In Problematic Gambling Behavior

Citing a significant gap in the literature on the role of culture in problem gambling, Raylu & Oei (2004) prepared a systematic review of the cultural variables involved in problem gambling and the cultural variations in problematic gambling behavior. They assert that gambling is a nearly universal human activity, with both problematic and non-problematic variations occurring in nearly every culture. Although there are not many studies investigating the prevalence rates of problem gambling across cultures, there is evidence that certain cultural groups are more vulnerable than others. The Western literature on gambling points to a number of significant genetic, social, and individual factors which contribute to problematic gambling. However, in order to develop better and more culturally appropriate treatments, the authors argue that these factors must be reexamined across cultures.

Cultural Prevalence of Gambling

Although there have been many anecdotal media reports that gambling problems are more prevalent among certain cultural groups, few systematic reviews currently support this notion. In the scientific literature, there is disagreement between studies as to which demographic characteristics predispose individuals to problematic gambling. Furthermore, most studies which have examined the prevalence of problematic gambling have done so within Western samples, while evidence suggests that cultural variations in the forms and functions of gambling may play a role in the initiation and maintenance of gambling behaviors. Even those studies which have attempted cross-cultural research on the topic have failed to explore the specific cultural factors which might influence gambling behavior. Raylu & Oei (2004) hold that this is a major limitation of the current literature on problematic gambling.

Many studies examining the prevalence rates of problem gambling have compared minority cultural groups such as indigenous peoples to the majority groups in the countries under study. Indigenous groups in the United States, Canada, New Zealand, and Australia have all been found to exhibit substantially higher rates of gambling behavior than the general populations of those respective countries. However, these studies have failed to investigate the relationship of problematic gambling with specific cultural factors such as norms, beliefs and values. It is therefore unknown whether culture is a significant determinant. Other factors such as socioeconomic status, unemployment, minority stress, or even genetic differences may very well be more important in generating this discrepancy (Raylu & Oei, 2004).

Cultural Perspectives On Gambling

In light of these limitations of the available literature, Raylu & Oei (2004) look to the cultural factors which have been implicated in other mental health concerns, and especially in substance abuse. They cite three primary, interrelated cultural factors which recur throughout the literature: cultural values and beliefs, acculturation effects, and attitudes toward seeking professional help. The authors hypothesize that these factors should also be important in the development and maintenance of problematic gambling.

Reylu & Oei (2004) argue that culture provides a framework by which individuals assess the desirability and risk of a given situation or behavior. These valuations are passed on by family members, respected community members, and through the social history of the community. According to the authors, each of these means of value transmission have been found to be relevant in the development of substance abuse disorders. They state that substance abuse is more common among individuals whose parents engage in and/or demonstrate positive attitudes toward substance use, as well as individuals living in communities where substance use is encouraged and considered normal.

This latter aspect is especially pertinent in the case of the Chinese, whose social norms and cultural history have portrayed gambling as “a way of life” for many generations, particularly among males (Reylu & Oei, 2004, p. 1096). Reylu & Oei offer that when one contrasts this Chinese cultural depiction of gambling with the historical condemnation of gambling among Muslim cultures, or the reserved approval that gambling has historically received in Western cultures, it becomes easy to see how the increased level of exposure and identification with gambling as a lifestyle and tradition could lead to increased gambling behavior among the Chinese. They argue that the collectivist orientation of Eastern cultures may further promote the retention of socially-endorsed gambling behaviors.

Because culture provides a framework not only for the assessment of value but also the assessment of risk, Reylu & Oei (2004) posit that cultural factors should play a role in individuals’ determination of what types of gambling behaviors are problematic. They cite research indicating lower overall rates of help-seeking behavior among minority groups, as well as the specific reluctance of some particular groups to seek help for mental health problems. It appears to be those cultures where the shame associated with problematic gambling is greatest whose members are the least likely to present for treatment, even when facing greater material consequences. This includes Arabic cultures for whom gambling entails an inherent shamefulness, as well Asian cultures for whom the loss of internal balance that problematic gambling represents is seen as disgraceful.

Cultural Factors in the Treatment of Problematic Gambling

In turn, the problem of poor service utilization among these groups may be caused or exacerbated by a lack of cultural sensitivity in the available treatment models. Treatments for problem gambling tend to be based on Western treatment models and do not take cultural variables into account, according to Reylu & Oei (2004). Thus, the treatment approaches used for problem gambling may be incompatible with the nature and etiology of problem gambling as seen from within other cultures.

For example, Reylu & Oei (2004) cite one study of Hong Kong residents which found that the solutions to psychological disturbances tend to be attributed to internal actions on the part of the patient. This is quite different from the predominantly external attribution that psychological treatments are afforded in Western cultures. Perhaps as a result of this cultural difference, the Chinese have repeatedly been found to rely on self-help and support from primary social networks when attempting to overcome mental health problems, rather than seeking professional help.

Gambling And Problem Gambling Among Chinese People

In order to correct a lack of systematic reviews of gambling and problem gambling among Chinese people, Loo, Raylu, & Oei (2008) performed an analysis of 25 studies on gambling among the Chinese. The Chinese culture is uniquely steeped in gambling, with its history including the oldest recorded accounts of gambling worldwide more than 3000 years ago. In modern China, social gambling is a common and accepted form of entertainment and celebration. This is also the case for many Chinese immigrant communities. A recent New York Times article described what has become a Thanksgiving tradition for many American Chinese: spending the day and night at a casino (Buckley, 2009). Problem gambling is also commonly reported among the Chinese, yet there is an unmet need for prevention programs and interventions that are tailored to the unique needs of the Chinese culture.

For the Chinese, gambling is predominantly considered a social activity. Several studies have found social and entertaining forms of gambling to be much more popular among Chinese respondents than other forms, such as games of skill or betting on horse races. The rates of engagement in gambling activities are consistently higher among Chinese people “who consider gambling to be a form of entertainment rather than as ‘gambling’” (Loo et al., 2008, p.1154).

The reported prevalence of gambling among Chinese communities has varied widely between studies. This may be due to culturally-determined variations in self-report. Studies on Chinese-speaking populations in both China and Australia have shown that individuals in these groups tend to underreport their own gambling problems, compared to the third-party reports of their friends and relatives. Loo et al. (2008) conclude that this is an example of the characteristic reluctance of Chinese people to admit self-regulatory failures.

Loo et al.’s (2008) analysis suggests that acculturative, social learning, and gender differences may also play a significant role in the development of problematic gambling behaviors in the Chinese. For example, higher levels of gambling were associated with both greater age and less education. Additionally, the country of residence influenced the amount of gambling that took place within Chinese groups. Chinese individuals living in Taiwan, a country whose dominant culture and attitudes toward gambling are relatively similar to those of China, gamble significantly more than those living in Australia. Australian Chinese were also more likely to report feeling guilty about their gambling behavior and to conceal it from others. Finally, Chinese males tended to have a longer duration of problem gambling than their female counterparts, and were much less reluctant to acknowledge that gambling had become a problem.

These findings have clear clinical implications for Western clinicians working with Chinese individuals. The practitioner should remain mindful of the potential for under-reporting of gambling behavior, particularly with male clients and in communities where gambling is not as accepted as it might be in a predominantly Chinese community. Furthermore, the practitioner would do well to frame the issue in a way that is sensitive to the Chinese client’s need to maintain a sense of internal control.

Cognitive & Emotional Differences in Chinese Versus Caucasian Gamblers

Oei, Lin, & Raylu (2008) noted that a substantial literature has developed over the last decade implicating two primary variables in problematic gambling among Western populations: gambling cognitions and psychological states. Some common types of gambling-related cognitions override the rational controls that would otherwise help to maintain control over the behavior. The psychological states of anxiety and depression are also related to problem gambling, and may further depress the gambler’s capacity to evaluate and react to the gambling situation pragmatically. Several studies have shown that the reduction of these two factors through cognitive and behavioral interventions was “the most effective treatment for pathological gambling” (p. 148).

Gambling-related cognitive errors can be divided into three major categories: illusions of control, illusions of predictability, and inconsistent framing of gambling outcomes. The “illusion of control” refers to a gambler’s sense that he or she can exert an unrealistic level of control over the outcome. This often includes superstitious behavior such as carrying a rabbit’s foot or not associating with losing gamblers. By “illusions of predictability” we refer to an unrealistic sense that the outcomes of gambling events can be predicted based on factors such as the weather, hunches, or the sequence of past wins and losses. Finally, “inconsistent framing” refers to a gambler’s tendency to attribute wins to internal factors and losses to external ones (Oei et al., 2008).

However, Oei et al. (2008) note that knowledge of these gambling cognitions has resulted from the study of Western samples. Despite the frequent generalization of these findings to other ethnic groups, it is largely unknown whether these same cognitive and emotional factors apply to Chinese problem gamblers. Research has shown that individuals with a Chinese cultural background are exposed to different environmental and socialization pressures, maintain different values and beliefs, and exhibit psychobiological differences from Caucasian populations that are evidenced in early patterns of development. They may therefore also exhibit differences in cognitions and psychological states related to gambling.

One example suggested by Oei et al. (2008) is the greater prevalence of superstitious thinking within the Chinese culture. Superstitious evaluation of the potential outcomes of gambling events has frequently been implicated as a cognitive factor in the development and maintenance of problem gambling in Western studies. In Chinese gamblers, culture-specific beliefs about luck, fate, and spiritual influence on events may present an “insidious and profound” (p. 150) precursor to problematic gambling.

To fill this gap in the literature on cultural factors in problem gambling, Oei et al. (2008) conducted a study of 501 residents of Brisbane, Australia. Of those, 306 participants were identified as Caucasian and 195 were identified as Chinese. All participants were administered a problem gambling screening questionnaire, a measure of gambling-related cognitions, and a measure of depression, anxiety, and stress.

This study supported the hypothesis that the same cognitive and affective factors known to be related to problematic gambling behavior among Caucasians are also significantly related to problem gambling among Chinese Australians. Some differences of degree were found between the two study groups, however. Specifically, the Chinese participants had a significantly higher illusion of control over gambling events than their Caucasian counterparts, as well as a significantly lower perceived ability to stop gambling (Oei et al., 2008).

Clearly additional research is needed to confirm and expand upon these results. However, these findings suggest that similar clinical approaches may be effective with both Caucasian and Chinese problem gamblers. We are also given clues about how to design more culturally appropriate treatments for gambling problems. Interventions for problem gambling should target those cognitive and affective elements that are most culturally and individually relevant.

Applicability to Other Asian Cultures

As we have previously noted, many cultural similarities can be found between Asian peoples. This raises the question of whether our understandings of problematic gambling behavior among the Chinese might also apply to other Asian cultures. The literature on this topic is extremely sparse.

Emotional and Acculturative Factors in Vietnamese Women

One qualitative study of Vietnamese women living in Australia suggests that acculturative factors may play a substantial role in the development of problem gambling for female Asian immigrants, particularly those whose ethnic communities are very small (Chui, 2008). Loneliness and boredom are cited as primary reasons for taking up regular gambling activities. Some Asian immigrants feel that gambling is the only entertainment available to them in areas where they do not speak the local language. Study participants also discussed their reluctance to seek outside assistance for their problematic gambling. They described the same sense of shame and personal failure that we have seen to be associated with mental illness and help-seeking among the Chinese.

This study was too small for us to infer much about the larger Asian immigrant population. Additionally, the study participants were all women, while most studies of problem gambling have focused on men. Males in all cultures yet studied tend to be impacted more by cognitive errors than by emotional factors (Oei et al., 2008). However, the interviews described by Chui (2008) do underscore the necessity for clinicians to evaluate acculturative stress and culture-related resistance to treatment on an individual basis.

Cognitive Factors in Thai Lottery Gamblers

With regard to cognitive errors, we find a related quantitative study of lottery gamblers in Thailand (Ariyabuddhiphongs & Phengphol, 2008). This study examined the effects of superstitious thinking  by comparing two groups of regular Thai lottery gamblers. The first used superstitious methods to select their lottery numbers, such as searching for numbers at temples or divining numbers by dripping candle wax into bowls of water. The comparison group did not engage in any superstitious procedures to select their numbers.

The study found that lottery gamblers who used superstitious methods to select their numbers were also more susceptible to two particular cognitive errors: the “gambler’s fallacy” and entrapment. The gambler’s fallacy refers to the irrational belief that a particular gambling outcome is less likely immediately after it has taken place, and more likely when it has not taken place for some time. In the case of a lottery, the gambler’s fallacy leads players to believe that a number which has recently been drawn is unlikely to be drawn again. “Entrapment” refers to the escalation of commitment that occurs when a gambler has lost a substantial sum and feels that he or she is “close to winning” or has “gone too far to give up” (Ariyabuddhiphongs & Phengphol, 2008, p.296).

These cognitive patterns fit into the categories of gambling-related cognitive errors outlined by Oei et al. (2008). The gambler’s fallacy is based on an illusion of predictability, while entrapment seems based on a combination of attribution error and an illusion of control. Because it has been successfully applied to both Western and Chinese populations, and is a good fit with these findings from Thailand, Oei et al.’s basic model of gambling-related cognitive error appears to have cross-cultural applicability. This provides clinicians with a good starting point for evaluating individual cognitive factors which may encourage problematic gambling.


There is a relatively small amount of research on the cultural factors that affect problem gambling. However, based on the research we have reviewed, we believe there is sufficient evidence to conclude that cultural factors are significant. In order to provide culturally sensitive treatment to individuals with gambling problems, it is therefore important to take inventory of their cultural values and beliefs, acculturative experiences, and attitudes toward help-seeking.

Cultural factors are particularly salient when working with individuals from Chinese cultural backgrounds. Gambling is a heavily entrenched and widely accepted social activity in this culture. Superstitious beliefs about gambling outcomes, which have been associated with the development of gambling problems, are also more congruent with normative thought patterns in China than they are in the West. Oei et al. (2008) have suggested that psychoeducation targeting culture-specific superstitions about gambling outcomes may be of great benefit to the Chinese.

Individuals from Chinese cultural backgrounds also experience problematic gambling differently than those from Western backgrounds. They are more likely to attribute the problem to personal failures, are more likely to feel shameful as a result, and are more hesitant to seek help from outside their immediate social networks. This is an extremely important consideration for those working within Chinese communities, and indicates that preventive programs and community psychoeducational efforts may be very useful in these communities.

There are significant gender differences among Chinese problem gamblers that clinicians should also be aware of. Chinese females tend to be more heavily impacted by psychological factors such as anxiety and depression than their male counterparts. Conversely, Chinese males tend to be more susceptible to gambling-related cognitive errors.

Finally, although much more research is needed, it seems that cultural understandings of problem gambling among the Chinese may be largely generalizable to other Asian cultures. The current literature shows a broad overlap between the components of problematic gambling in Western cultures and those in China. The primary differences appear to lie in the degree to which particular cognitive and affective factors are expressed, rather differences in the types of factors that are present. This bodes well for the development of cross-cultural treatment models.


How Changes in Chinese Culture May Affect Problem Gambling & Its Treatment

The articles which we have reviewed have not discussed the potential effects that changes in culture may have on the presentation and conceptualization of problematic gambling. However, neither mental illnesses nor their associated diagnoses are stagnant. They change based on new scientific understandings as well as cultural shifts which alter the range of what individuals consider to be possible within their cultural frameworks. The range of possibilities also varies widely from one individual to another even within an apparently unitary cultural framework.

It will therefore behoove the culturally-sensitive clinician to pay attention to the phenomenological differences in clinical problems both within and between cultures. Depending on an individual’s level of exposure to Eastern or Western thoughts, ideals, and role models, he or she may exhibit attitudes toward gambling which are more or less congruent with the “Eastern” or “Western” attitudes which we have described. In a complicated and changing world, we must always be mindful of individual differences, no matter how scientifically grounded our preconceptions of a given culture may be.

Personal & Professional Importance of this Topic

The Chinese people comprise the largest ethnic group in the world, representing 22% of the planet’s population (Loo, Raylu, & Oei, 2008). Many millions of those live outside of mainland China, making it likely that the average clinician in just about any geographical location will encounter patients from Chinese cultural backgrounds. Unless clinicians are apprised of the unique cultural factors affecting these individuals, they will have difficulty providing them with high-quality services.

One of my own clinical interests is the treatment of impulse-control disorders. These disorders include substance abuse, problematic gambling, eating disorders, and compulsive behaviors. Behaviors which are subjectively involuntary and yet apparently volitional represent a fascinating interaction between conscious and unconscious processes. These include not only neurological, cognitive, and emotional factors, but cultural influences as well. As Castillo (2001) has argued, culture is a determinant of possibility, and so shapes the way in which both pathology and its resolutions are able to manifest.

Problem gambling is a fascinating topic for cultural study, because it is a rather pure form of impulse dysregulation. Unlike substance abuse or eating disorders, the problematic behavior is not tied to any physiological dependency. However, the manifestations of problem gambling often resemble substance abuse in both their inward and outward aspects. I was very interested to find such good research on this problem within the Chinese culture, and to find out the ways that cultural differences play into its etiology.

A Treatment Scenario

Clinical Vignette

We will now adapt a clinical vignette presented in Chui (2008, p. 277), in order to see how our understandings of culturally-appropriate treatment for Chinese problem gamblers might play out in clinical practice:

Ms. Choi, aged 39, is a divorced mother of four who is receiving a government pension as a single mother. She came from China to Australia in 1995 when her ex-husband sponsored her and the children. She was introduced to gambling by her friends who would drive her to the casino. Her ex-husband also encouraged her to gamble as a social activity because she stayed home most of the time. With limited English skills, she lacked vocational skills and felt dependent on her ex-husband. At the casino she would play card games, in particular blackjack. She would also watch other people play and bet her money on them (or “back” them). She believed that these other people had the “skill.” She would spend AUS$500-$600 a week on gambling and often borrowed money from her friends. She also felt obligated to financially support her family back in China.

Treatment Planning

This case exemplifies some of the cultural differences we have examined. The Chinese, as we have seen, tend to consider gambling a much more social activity than do individuals from Western backgrounds. In this vignette we see a lot of social encouragement for Ms. Choi to engage in gambling as a way to augment her social life and seek entertainment. An effective treatment plan for Ms. Choi will therefore need to help her to improve her social connections and find recreational activities outside of gambling.

The gender differences that we have seen described in Chinese gambling patterns also come into play in the case of Ms. Choi. Compared to Chinese men, cognitive errors related to gambling processes and outcomes play a relatively small role in the etiology of problem gambling. This appears to be the case for Ms. Choi, who engages in gambling primarily to fulfill emotional needs. It will therefore behoove the clinician to assess Ms. Choi for symptoms of anxiety and depression and to address these symptoms as needed. Based on the literature we have reviewed and on Ms. Choi’s clinical presentation, we will be surprised if these emotional factors do not underlie her loss of control over gambling behaviors.

Finally, we see in Ms. Choi’s presentation a combination of dependency and obligation that are almost certainly damaging to her self-concept under the present circumstances. Each of these feelings is related to gender roles that would be and most likely were adaptive for Ms. Choi during her life on mainland China, but which now are failing to serve her emotional needs. It will therefore be a major task of the therapy to assist Ms. Choi in becoming acculturated to her new environment. The therapist will need to help her critically evaluate the differences in cultural and personal expectations that face her in her new life in Australia.


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  • Buckley, C. (2009, November 26) A tradition that cherishes poker, not pumpkin pie. The New York Times, p. A28.
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  • Castillo, R.J. (2001). Lessons from folk healing practices. In Seng, W.S. & Streltzer, J. (Eds.), Culture and psychotherapy: A guide to clinical practice (pp. 81-101). Arlington, VA: American Psychiatric Publishing.
  • Chui, W.H. (2008). True stories: Migrant Vietnamese women with problem gambling in Brisbane, Queensland. Journal of Social Work Practice in Addictions, 8(2), 276-280.
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Mental Health Parity: A Policy Analysis

Although psychological and addictive disorders have come to be recognized as common and treatable conditions within the medical profession and even among the general population, the United States health care system is still lagging behind. Insurance companies do not provide equal coverage for mental health services, and most Americans lack access to even basic mental health care. The goal of interest groups campaigning for better mental health coverage has been to achieve “mental health parity,” meaning that that mental health services would be covered at the same level as general medical services and surgical procedures.

The first major victory is this campaign came in 1996, when Congress passed a law mandating equal annual and lifetime dollar limits for mental health benefits. A more recent piece of legislation has extended this parity in benefits to co-payments, deductibles, out-of-pocket limits, and caps on the number of inpatient or outpatient visits. The passage of this law is being hailed as a tremendous success by advocacy groups. However, the law has problematic limitations that may actually serve to increase systemic barriers to mental health treatment, particularly among the working poor and the lower middle class.

In this analysis we will examine the consequences of the present mental health parity law, and the structural barriers that continue to limit access to mental health services. We will examine the consequences of these limitations, both for the affected individuals and for the society as a whole. Finally, we will propose changes to the current policies which could remedy the problems we outline.

Why Mental Health Parity Is Needed

The Substance Abuse and Mental Health Services Administration (SAMHSA) conducted a comprehensive National Survey on Drug Use and Health in 2002, and found that more than five million individuals meeting criteria for serious mental illness “perceived themselves as having an unmet need for treatment in the year prior to the survey” (Bender, 2003). Of these, nearly 2.5 million severely mentally ill individuals cited insufficient financial resources as the primary reason that they were unable to receive appropriate treatments.

This means that, as of 2002, nearly 1% of the entire population of the United States is comprised of severely mentally ill individuals who want treatment but are unable to afford it (U.S. Census Bureau, 2003). This figure does not include individuals whose mental illnesses are distressing but not debilitating, who likely number in the tens of millions, nor does it include individuals suffering from substance abuse disorders, of whom there may be more still. The magnitude of the problems we face in ensuring treatment of psychological and addictive disorders constitutes a public health crisis.

This crisis reaches beyond the mental health system by putting an undue strain on the nation’s medical infrastructure. According to O’Donohue & Cucciare (2005), “research consistently shows that patients with psychological problems use more [medical] services than those without diagnosable psychological problems.” For example, one recent study tracked a sample of individuals admitted for inpatient treatment of various medical conditions. At four years, patients who demonstrated psychological factors such as depressive or aggressive tendencies had been readmitted for further medical treatment at a rate twice that of their counterparts with no psychological comorbidity. The total number of days of inpatient care utilized for the treatment of physiological conditions also doubled for these patients (Saravay, Pollack, Steinberg, Weinschel, & Habert, 1996).

The good news is that psychotherapeutic treatment reliably reduces medical service utilization. Mumford, Schlesinger, Glass, Patrick, & Cuerdon (1998) describe a history of research demonstrating that the delivery of mental health services is strongly predictive of decreased utilization of medical services across the board. They conclude that the evidence for a general cost-offset effect following outpatient psychotherapy is “widespread and persistent” (p. 85), with the most substantial savings coming from a decrease in inpatient service utilization.

Steps Toward Mental Health Parity Implementation

As we have mentioned, the first step toward mental health parity in the United States came with the passage of the Mental Health Parity Act of 1996 (MHPA). The act required that insurance policies which included mental health coverage do so at the same annual and lifetime dollar value as their coverage for general medical and surgical services (NASW, 2002). However, disparities between co-payments, deductibles, and out-of-pocket expenses were not affected by the bill, nor were any of the millions of insurance policies which provided no mental health coverage at all.

The U.S. Congress expanded on this effort to improve mental health coverage for Americans in 2008, by passing the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA). The MHPAEA addressed a number our concerns regarding the MHPA. It required that employers whose insurance plans include mental health and/or substance abuse coverage eliminate any remaining disparity with medical coverage, including co-payment amounts, total out-of-pocket expense limits, deductibles, and annual limits on inpatient and outpatient visits (Bernstein, 2008).

However, the MHPAEA still placed no requirements on payees to provide mental health coverage to their beneficiaries. This means that, as before, only patients whose medical coverage includes optional mental health benefits will be able to benefit from the new law. Individuals’ whose insurance coverage does not include optional mental health coverage will remain without access, as will the millions of uninsured Americans (Jenkins, 2008).

Problematic Impacts of Mental Health Parity Legislation

Like the 1996 Act, The MHPAEA places a substantial financial burden on employers and other insurance payers without placing any additional regulation on insurance providers and managed care organizations. Opponents of comprehensive parity legislation have argued that any new regulations on the insurance industry would precipitate the loss of other, unprotected health care benefits in order to offset the cost (Carroll, 2004). However, placing the burden on employers will likely result in severe consequences for lower and middle class workers.

We can predict this because it is essentially what took place after the passage of the MHPA, which represented much less of an imposition on employers. According to the National Association of Social Workers, the “U.S. General Accounting Office reported in May 2001 that 86 percent of employers surveyed reported that they had complied with the requirements of the 1996 Act. Nevertheless, the vast majority of those employers substituted new restrictions on mental health benefits, thereby evading the spirit of the law” (NASW, 2002, Background and legislative history section, ¶ 10). With the new requirements being much more demanding, it is likely that many employers will simply see no benefit in continuing to provide mental health coverage, particularly for employees who are not considered valuable enough to warrant competitive benefits packages.

This means that by placing the burden of providing additional coverage on employers, the MHPAEA has essentially given employers an incentive to drop existing mental health coverage for low-wage employees. Workers who previously had inadequate access to mental health services are likely to see even their inadequate mental health benefits disappear. Such a change will disproportionately affect the working poor, a group whose high levels of external stress create a greater need for the very services they will be losing access to.

Meanwhile, advocacy groups such as the American Psychological Association are lauding this new law as a huge victory in the fight to end discrimination against sufferers of psychological illness (APA, 2008). What has actually taken place is the passage of federal legislation which effectively institutionalizes the medical discrimination which was already taking place within the insurance industry. Furthermore, the Act has freed the insurance industry from any responsibility for ending that discrimination, instead placing the burden on a group which has far less interest in the provision of those benefits to the individuals who need them most.

Solving The Problem Of Mental Health Parity

The laws that have been passed so far are out of line with the basic ideology underlying mental health parity, which is that mental illness is a medical condition. Based on this premise, it is reasonable that sufferers of mental illness be able to expect treatment comparable to that which they would receive for any other illness. Any medical service plan that excludes coverage for psychological conditions is therefore unfairly discriminating against sufferers of a particular set of conditions in a way that has been outlawed when it has occurred in the past.

There are two main counter-arguments that can be made against this premise. The first is that mental illnesses are not medical conditions (Kershaw, 2008). However, as executive director of the Suicide Prevention Action Network USA in Washington Jerry Reed (2007) points out, a growing body of research has solidly established distinct physiological correlates of individual mental illnesses. Furthermore, mental illness results in a far greater number of fatalities each year than HIV/AIDS. There are nearly 30,000 mental illness-related suicides in the United States each year (Reed, 2007).

The second major counter-argument against our premise of mental health parity is that insurers should have the right to exclude certain classes of conditions as they see fit. As we have already discussed, legislative precedent contradicts this idea. Congress has already specifically outlawed this type of exclusion both for the elderly and for patients diagnosed with HIV/AIDS (Wellstone, 2002). This precedent takes on added weight when we consider that the level of fatality resulting from mental illness is much higher than that of the very disease for which Congress previously intervened.

Given, then, that the premise of mental health parity is sound, it becomes the duty of insurance providers to include mental health coverage as a part of basic medical benefit packages. Placing the burden of improving mental health coverage onto the individuals and organizations purchasing the coverage is not in keeping with the philosophy that mental illness and its treatments are equivalent and of equal importance to all other medical conditions and services. The way to implement that philosophy would be to require that insurance providers simply include mental health services under the existing terms of their coverage for general medical services.

Aside from being philosophically sound, this method of implementing mental health parity is also highly pragmatic. Insurers stand to benefit financially from offering better coverage for mental health services. Full mental health parity would represent a total cost increase of about 1.5% for most managed care organizations (Carroll, 2002). That increase would be more than offset within just a few years by the resulting reduction in general medical service utilization (Mumford et al, 1998). Employers, on the other hand, may stand to realize some increases in worker productivity as a result of better access to mental health services (see, for example, Wang, et al, 2007; Hartmann & Zepf, 2004; Hafner, Haug, & Kachele, 2004; Jordan, Grissom, Alonzo, Dietzen, & Sangsland, 2008), but ultimately have far less demonstrable interest in the provision of these services.

We therefore conclude that the most logical, feasible, and enforceable method of implementing mental health parity is to require insurance providers to include mental health treatments in their definitions of general medical treatments. By prohibiting the segregation of mental illness from physiological illness, equitable coverage is ensured without the substantial loopholes seen in the 1996 Parity Act and again in the 2008 Act. Furthermore, this method of enactment provides an ultimate financial benefit to the very organizations it holds responsible for implementation.

The problem in implementing this strategy is, of course, a political one. The insurance lobby is both exceptionally powerful and highly resistant to legislation which would increase its obligations. They have, unsurprisingly, supported legislation which offloads responsibility for mental health coverage onto businesses. For this reason, the business lobby seems like a natural ally in our attempts to redefine medical coverage to include mental health services. However, it is arguable that they have enough to gain to make substantial involvement worth their while.

The primary stakeholders in this redesignation seem to be healthcare providers and patient groups. Providers stand to gain from the opportunity to expand their mental health services, while patient groups have an interest in ensuring that comprehensive services are available. It may be possible to enhance the support of both groups by forming grass-roots organizations for individuals and families whose medical status has been affected by inadequate mental health care. These groups could act as emissaries between other stakeholder groups.


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Hypno-Oncology: Hypnosis in the Treatment of Cancer


Clinical hypnotherapy has been soundly established as an effective treatment for the symptoms associated with cancer and its related therapies, including chronic and acute pain, nausea and vomiting, fatigue, insomnia, anxiety, and mood disturbances. Its use produces strong tendencies toward improvement of patients’ quality of life and of treatment cost. As the etiology and progression of various forms of cancer become better understood, the potential of hypnotherapy for increasing survival rates by improving medication response and even slowing or reversing the progression of the disease increases. Given the lack of risks to patients and the wide potential for benefit, additional research and clinical experimentation into this area are encouraged, and recommendations for this type of hypno-oncological exploration are discussed.


Cancer presents the patient with a wide variety of symptoms and challenges. Many types of cancer cause intractable and chronic pain or other organ-specific symptoms in the areas they affect. Patients frequently experience a variety of nonspecific symptoms as well, such as fatigue, malaise, and insomnia. Hypnosis and self-hypnosis are extremely flexible and highly effective treatments for all types of cancer-related symptoms (Sunnen, 2004), and also aid in the numerous psychological adjustments that are required of cancer patients: “adjustment to the condition itself, to its treatments, and to the poignant intrapsychic, family, and social changes it may induce” (Kubler-Ross, 1969, as cited in Sunnen, 2004, p.15).

One recent study of 20 terminally ill cancer patients allowed each patient to choose the symptom they would most like to address using hypnotherapy. As a result, 19 of those 20 patients reported dramatically improved quality of life, anxiety status, and ability to cope, as well as better sleep and more energy. The symptoms they successfully addressed during the course of the study included pain, fatigue, malaise, irritability, insomnia, nausea and vomiting (NV), anticipatory NV (ANV), food aversions, anxiety, depression, guilt, anger, hostility, frustration, isolation, reduced self-esteem, and helplessness. Additionally, significant cost savings were realized in the form of reduced need for medication and nursing (Peynovska, Fisher, Oliver, & Mathew, 2005).

On top of being proven effective for symptom management (Liossi, 2006), the beauty of hypnosis is that it can be readily adapted to the needs of the patient, can be used to address physiological as well as psychosocial issues, and is extremely well-tolerated. Christina Liossi explains:

“It is safe and does not produce adverse effects or drug interactions. Patients enjoy the hypnotic experience. They obtain relief without destructive or unpleasant effects. There is no reduction of normal function or mental capacity and no development of tolerance to the hypnotic effect. It is a skill that individuals can easily learn, that provides a personal sense of mastery and control over their problems and that counters feelings of helplessness and powerlessness. An additional benefit is that hypnosis can be generalized to many circumstances. The person who learns hypnosis for management of pain or nausea and vomiting may apply their skills to lessen the distress of insomnia and anxiety, to address dysphagia for pills or to enhance their performance in their favourite sport. For a clinician, hypnosis is an opportunity to be inventive, spontaneous and playful and to build a stronger therapeutic relationship with a patient while providing symptom relief” (2006, p. 55).

This paper will briefly review the literature regarding the efficacy of hypnotherapeutic interventions for symptoms management, and will explore issues surrounding the psychotherapeutic treatment of cancer in general. A general understanding of the etiologies and biomechanics of cancer as they are relevant to hypnotherapeutic treatment will be attempted, and this treatment’s implications and potentials for improving survival rates and directly influencing
the course of the disease will be discussed.

Hypnotherapy for the Control of Pain

Hypnotherapy is particularly effective for the control of primary and treatment-related cancer pain, and has achieved the status of an evidence-based treatment for this purpose (Liossi, 2006). Multiple studies have found it to be superior to acupuncture, massage, or CBT in the treatment of pain and anxiety (Peynovska, Fisher, Oliver, & Mathew, 2005). One randomized, controlled study, for example, found hypnosis highly effective for the prevention of post-operative pain in patients receiving bone-marrow transplants, while an intensive cognitive-behavioral skills program was ineffective for this purpose (Liossi, 2006).

A randomized clinical trial to examine the effects of a single 15-minute hypnotherapy session administered to breast cancer patients immediately prior to lumpectomy surgery found that the treatment group experienced significantly less pain intensity, pain unpleasantness, nausea, fatigue, discomfort, and emotional upset. In addition these obvious benefits to the patients, the intervention was found to be extraordinarily cost-effective: patients in the treatment group costed the hospital 9% less (almost $775 less per patient) than those in the control group, owing to their significantly reduced surgery times and significantly reduced need for anesthesia and analgesics during the procedure.

There is evidence that hypnotherapy can be highly effective with pediatric patients, who experience much less pain from the primary effects of cancer than their adult counterparts—owing to the varieties of cancer to which they are most susceptible, such as leukemia—but are subjected to repeated, painful and invasive procedures and usually consider this to be “the most difficult part of their illness” (Liossi, 1999). Children appear to be far less capable of using self-hypnosis to manage procedure-related pain and distress than adult patients, and so it is necessary for the therapist to remain present with them during the procedures (Liossi & Hatira, 2003).

The hypnotic technique for pain relief typically begins with relaxation, which significantly assists in analgesia by reducing anxiety and thereby dampening the perception of unpleasant sensory experience. After a standard hypnotic induction is used, many patients will respond to direct suggestions that their pain will simply “diminish in intensity to the point of becoming unnoticeable” (Sunnen, 2004, p. 16). Another technique for eliminating pain involves first producing “glove anesthesia,” or a deadening of all sensations in one hand. As Sunnen explains, “the hand is ideally suited as a starting point for hypnotic anaesthesia because it is so richly endowed with sensory innervation and occupies such a prominent place in the cortical homunculus. Once the anaesthetic experience is established in the hand, it is a relatively small step to transfer it to other parts of the body.”

The patient’s mental representation of their pain can also be altered such that it occupies a smaller portion of their phenomenological experience, and the pain’s qualitative aspects may be modified so that they no longer correspond with the patient’s conceptions of what substantial pain is like. If the patient experiences the pain as hot and stabbing, for example, the therapist might suggest that it is becoming cool and soft. Some individuals achieve extremely good results from the use of hypnotic imagery, while others are able to dissociate from the experience by imagining that the pain is falling away from their bodies and out of sight (Sunnen, 2004). It is highly beneficial to assess the patient’s cognitive style and hypnotic ability prior to the intervention in order that the techniques used can be matched to the patient’s own inner experience.

Hypnotherapy for the Control of Nausea and Vomiting

Hypnosis has achieved status as an evidence-based treatment for chemotherapy-induced NV (CINV), with numerous controlled studies attesting to its efficacy (Liossi, 2006). A comprehensive meta-analysis of hypnotherapeutic treatment for CINV found it significantly more effective than the standard treatment, and at least as good or better than CBT (Richardson et al., 2007). The researchers also noted that none of the studies they examined had evaluated the hypnotic ability of their participants. For reasons that will be discussed in a later section, it is reasonable to expect that a clinician who assessed and utilized their patients’ individual hypnotic abilities would achieve even more impressive results.

About 30% of patients receiving chemotherapy experience NV not only following the administration of the chemotherapy, but in anticipation of its administration as well. The most widely accepted model for understanding ANV is a classical conditioning model, in which NV becomes a conditioned response to procedures surrounding the administration of the chemotherapy. Anxiety plays a role in this effect not only by increasing sensitivity to environmental stimuli but also by potentiating the learning of conditioned responses (Marchioroa et al., 2000).

Marchioroa et al. (2000) conducted a study of 16 consecutive adult cancer patients affected by chemotherapy-induced ANV, in which they examined common personality factors of participants in order to surmise traits that may predispose patients to ANV. Common factors identified included “a strong need for approval, a tendency to reveal emotions in an exaggerate or unsuitable way, superficiality, inconstancy and difficulty in giving a detailed description of situations or people.” Each patient was subjected to a two-hour progressive muscle relaxation training session preliminary to hypnotic treatment. The treatment itself consisted of a one-hour hypnotic session immediately prior to chemotherapy administration, using an eye-fixation induction followed by suggestions intended to induce organ anesthesia. The hypnotherapy treatment prevented ANV in all 16 patients, and actually produced significant reduction in post-chemotherapy NV as well for 14 of the 16 patients.

Hypnotherapy for the Improvement of Overall Quality of Life

A number of meta-analyses have demonstrated the profound efficacy of hypnosis in improving cancer patients’ quality of life (Walker, 1998). This improvement involves the alleviation of the intense anxiety and depression that are common among patients diagnosed with cancer, as well as control of the physical symptoms that cancer and its medical treatments produce.

In 1999, Walker and his Behavioral Oncology Unit team randomized 96 consecutive breast cancer patients into a control group receiving general support and a treatment group receiving the same type of support along with guided imagery and relaxation training. As chemotherapy progressed, the quality of life and mood of the control group declined significantly, as expected. The mood and quality of life of the treatment group, however, actually improved. By the end of chemotherapy, members of the treatment group were not only suffering lower levels of anxiety and depression that they had been at the time of diagnosis, they were actually less depressed and anxious than the general population in their community.

A 2001 study of 50 terminally ill cancer patients found that patients receiving hypnotherapy in addition to standard medical care and psychotherapy enjoyed significantly better quality of life, in addition to reduced anxiety and depression. Another study even found that just giving patients tapes teaching hypnotic muscle relaxation and light, slow breathing alleviated anxiety attacks in all 35 study participants (Liossi, 2006).

The flexibility of hypnotherapeutic treatments allow them to accommodate the very specific needs of various groups of cancer patients. For example, post-operative breast cancer patients frequently suffer from “hot flushes” that “cause discomfort, insomnia, anxiety, and decreased quality of life.” They can be treated fairly effectively with a hormone replacement therapy, but that treatment increases the risk of breast cancer recurrence. Compelling case evidence indicates that hypnotherapy may be the preferred treatment for this problem (Liossi, 2006).

Some general hypnotherapeutic techniques for improving psychological adjustment include: learning relaxation and self-hypnosis, which help to improve self-efficacy and self-empathy among patients who often feel that they have lost control and that their bodies have turned against them; hypnotic ego strengthening, in which the adaptive functions of the patient’s personality are brought to the foreground for them and utilized in novel ways; hypnotic imagery, which the patient can play an active role in developing so that it suits their unique style; and enhancement of spiritual practice through the connection to favored religious symbols and ideas and deepening of the feeling of spiritual connection (Sunnen, 2004).

Understanding Etiologies

Connections between temperament and cancer growth have been suspected since ancient times, and have been repeatedly reexamined as new medical paradigms have developed (Harris, 2006). British surgeon David Kissen studied the relationship between emotional repression, cigarette smoking, and the development of lung cancer in the early 1960s. He concluded that smokers who exhibited a repressive coping style were five times more likely to develop cancer, and that the level of cigarette smoking necessary to induce cancer in a smoker was furthermore conversely related to their level of emotional repression. (Kissen and Hysenk, 1962, as cited in Harris, 2006, p. 5). These findings were replicated “in a most spectacular way” in a ten-year Yugoslavian study in which smokers who endorsed fewer than 10 or 11 items on a “rationality and anti-emotionality(R/A)” survey demonstrated no incidence of cancer, “suggesting that smoking alone is not sufficient to cause cancer” (Gossarth-Maticek, 1985, as cited in Harris, 2006, p.5). Harris suggests that the requisite emotional factors are the imprints of childhood experiences, and as such are intertwined with physiological as well as personality development. Clinical success in the treatment of maladaptive personality factors over the last few decades (McWilliams, 1994; Sperry, 2003) may therefore have profound implications for the emerging field of primary care psychology.

Harris (2006, p. 6) goes on to cite research implicating the repression of anger (RA) as a major factor in the development of breast cancer, and demonstrating correlations between this type of cancer and childhood disturbances or feelings of emotional disconnection. Researchers are not in agreement about the existence of such connections. While acknowledging that the link between breast cancer and psychosocial factors has been popular among medical theorists since pre-Christian times, Bleiker and van der Ploeg (1999) found the current evidence insufficient to establish any significant relationship in their informal review. A meta-analysis published the same year (McKenna, Zevon, Corn, & Rounds) found moderate correlations between breast cancer and “denial/repression coping (g = .38), separation/loss experiences (g = .29), and stressful life events (g = .25),” (p. 520) but concluded that the associations were too modest to provide confirmation of “the conventional wisdom that personality and stress influence the development of breast cancer” (p. 520). Butow et al (2000) confirmed this assessment in their own meta-analysis, stating that “evidence for a relationship between psychosocial factors and breast cancer is weak,” with the strongest acknowledged predictors of breast cancer being “emotional repression and severe life events” (p. 169). More recent research, however, continues to implicate life stress in breast cancer incidence and recurrence (Palesh et al, 2007). Participants in one recent prospective study who went on to be diagnosed with breast cancer had suffered significantly more severe stress in the 10 years prior to the study, as well as significantly more moderate and severe personal losses. (Ollonen, Lehtonen, & Eskelinen, 2005). Recent studies also continue to find significant correlations between repressive coping styles and breast cancer incidence (Manna et al., 2007) and survival rates (Reynolds et al, 2000).

A 35-year longitudinal study of Harvard students found a dramatic correlation between perceived familial love and caring and the likelihood of diagnosis with serious diseases (including cancer, cardiovascular disease, and asthma) in mid-life (Harris, 2006, p.6). On the other hand, when Dr. Bert Garssen of the Helen Dowling Institute, a Dutch center for psycho-oncology, reviewed the longitudinal, prospective studies available in 2004, he completely discounted these and other findings, stating that “there is not any psychological factor for which an influence on cancer development has been convincingly demonstrated in a series of studies” (p. 315).

Regardless of these wide discrepancies in findings, it is certain that the basic mechanism for an underlying psychosocial involvement in the development of cancer—damage to DNA, resulting in mutated cells—is present (Gidron, Russ, Tissarchondou, & Warner.) In a critical review of 21 human and animal studies, Gidron et al. find direct causal relationships between acute stressors and DNA damage, as well as significant correlations between DNA damage and ongoing psychological factors such as depression and repressive coping. Ernest Lawrence Rossi (2002) has compiled extensive research on the relationships between psychological factors and gene expression, finding not only significant effects from measurable psychosocial conditions but also psychotherapeutic potential for modifying these responses.

As an example, Rossi cites Stanford University researchers (Zhao et al., 2000, as cited in Rossi, 2002, p. 199-201) in their studies of the changing molecular dynamics of prostate cancer as it transitions from the early, controllable stage to the later, terminal stage. Specifically, this transition involves two genetic mutations which modify the affected prostate cells’ aberrant androgen receptors, which had heretofore been the instigators of uncontrolled growth, into pseudo-androgen receptor sites which can be activated by glucocorticoid stress hormones. From the time this mutation occurs, the advancement of the cancer is very clearly susceptible to psychosocial stressors and to psychological mediation.

It is difficult, on one level, to make any inferences at all regarding the etiology of “cancer,” simply because there are as many different types of cancer as there are types of cells in the human body—more than 200—and at least as many methods of action by which cancer might come about. Finish researchers Vauhkonen et al. (2007) summarize the current genetic understanding as such:

Cancer results from multiple genomic changes that affect DNA and its gene expression. The DNA sequences may be gained, lost or amplified, or translocated into different parts of the genome to form a fusion gene with oncogenic properties. The occurrence of specific chromosomal aberrations may be restricted to only one cancer type and it may be considered a primary carcinogenic event. Furthermore, the aberration profiles may be used to cluster tumors with similar origins. A variety of techniques exist for the detection of specific chromosomal and gene expression changes. However, the etiology of these molecular alterations remains unclear (p. 277).

Vauhkonen et al. investigate the roles of certain bacteria and chemical substances which may play key roles in carcinogenesis. Other researchers have established reliable connections between certain viral infections and almost 15% of all human malignancies, with a substantial number of additional viral etiologies suspected (Butel, 2000; Boccardo & Villa, 2007). Furthermore, it is known that viruses “are usually not complete carcinogens, and the known human cancer viruses display different roles in transformation. Many years may pass between initial infection and tumor appearance and most infected individuals do not develop cancer, although immunocompromised individuals are at elevated risk of viral-associated cancers” (Butel, 2000, p. 405).

These causal linkages between infectious disease, immune functioning, and cancer formation provide a clear inroad for the influence of psychological factors; research in the field of psychoneuroimmunology has soundly demonstrated the profound interrelationship between psychosocial and immunological functioning (Coe & Laudenslager, 2007). To add to this, solid evidence of direct immunological involvement in the phenomena of spontaneous regression of human cancer has been reported (Saleh et al., 2005). This finding gains enormous significance when it is considered that spontaneous regressions have been observed in nearly every type of human malignancy (Chodorowski et al., 2007).

Hypnotherapeutic Treatment of Cancer and Improvement of Survival Rates

It is clear that hypnosis and visualization are capable of having a direct effect on human immune functioning, including differential expression of T-cell subsets and disease-specific immunological activation (Gruzelier, 2002; Wood et al, 2003). It is also clear that these types of immune system changes take place when hypnotherapy and guided imagery are used specifically with cancer patients: natural killer cell counts are improved (Hudacek, 2007);  lymphokine activated killer cell activity is increased, total T-cell count (CD2+) is increased as are mature (CD3+) and activated (CD25+) T-cell counts; circulating levels of tumor necrosis factor alpha (TNF-α) are even decreased. Furthermore, these changes reliably occur in direct proportion to the perceived vividness of the patient’s visualizations (Ogston, et al, 1997, as cited in Walker, 2004).

What is not clear is the reason that these hypnotically-induced immunological changes do not appear to have a significant effect on the course of the disease or on clinical outcome (Hudacek, 2007; Walker, 2004; Spiegel & Moore, 1997), despite a small but compelling set of well-documented cases in which this type of treatment has apparently initiated spontaneous remission (Rossi, 2002, p.216; Chong, Smith Chong, & Fraser, 2001). This is particularly confusing when it is taken into account that standard, supportive-expressive group psychotherapy—which seems to be a less targeted treatment—can sometimes significantly impact the survival of cancer patients (Spiegel, Bloom, Kraemer, & Gottheil, 1989; Walker, 2004; Küchler, Bestmann, Rappat, Henne-Bruns, Wood-Dauphinee, 2007). For those cases in which psychotherapy does improve survival, Walker (2004) suggests enhanced treatment compliance, health-promoting lifestyle changes, improved mood-mediated chemotherapy response, improved host defenses, and amelioration of chemotherapy-induced immunosuppression as possible mechanisms. Other times, however, this type of treatment also appears to have no significant affect (Spiegel et al., 2007; Kissane et al., 2007).

The results are simply too strange for the problem to have been well-understood: there has to be a key ingredient which mediates the clinical success or failure of direct psycho-oncological interventions. Researchers at the University of Colorado Cancer Center, noting the proliferation of conflicting results in this area of research, came to essentially the same conclusion. They demonstrated that a highly significant factor in the success or failure of psycho-oncological treatment is the maturity of the individual patients’ styles of ego defense—a factor which is predictive of psychotherapeutic success in general (Beresford, Alfers, Mangum, Clapp, & Martin, 2006).

It could be noted, furthermore, that these findings are indicative of a confounding trend in psycho-oncological research which is likely responsible for many of the inconsistencies in its findings: failure to account for and accommodate psychological variables which are known to impact clinical outcomes. For example, Spiegel et al. (2007) suggest that their failure to replicate their previous findings may be due to differences between subgroups of breast cancer patients that are distinguished by receptivity to estrogen-replacement therapy. However, they did not report on the measurements of widely accepted therapeutic factors related to general group therapy treatment outcomes, such as group cohesiveness (Yalom, 1995), nor on the psychological
makeup of their participants.

As different styles of psychotherapy are indicated for patients operating at different levels of personality organization (McWilliams, 1994), it should go without saying that psychotherapeutic interventions specifically aimed at cancer must also take these variables into account. The fact that they are not being accounted for in the bulk of relevant research could reflect a basic disconnect between the required specificity of the medical model as a treatment metaphor and the contextual requirements and implications of psychological treatment (Wampold, Ahn, & Coleman, 2001), or perhaps some manner of entrenched condescension or apprehension toward psychotherapy as a potential medical treatment. The complexity of patients’ psychotherapeutic requirements, after all, should not be surprising: as pharmacological treatments have grown more complex, they, too, have acquired a greater need to accommodate individual factors in treatment. Depending on the type of cancer, degree of advancement, and other diagnostic features, a cancer patient may be administered any combination of surgery, radiation therapy, and more than 50 chemotherapy medications, and yet we study just a single mode of treatment called “supportive-expressive group psychotherapy”?

Likewise for hypnotherapeutic treatments: although individual differences in hypnotic susceptibility and absorption are clearly predictive of the efficacy of the treatment in up-regulating immunological functioning (Liossi, 2006), studies of hypnotherapy for cancer patients have almost uniformly failed to measure the hypnotic ability of their subjects (Richardson, et al., 2007). This oversight is problematic for three reasons:

  1. Hypnotizability is a normally distributed, stable personality trait with at least some genetic basis, which is known to be predictive of clinical success in hypnotherapeutic interventions (Wickramasekera, 2003). Hypnotherapy may therefore not be expected to be an appropriate treatment for individuals who fall in the low-hypnotizable range. Research which fails to identify these individuals will both underestimate the efficacy of hypnotherapy for those who can benefit from it and fail to discern elements of the treatment which may be beneficial to those lacking this trait.
  2. Low hypnotic ability may be modified or overcome. A number of techniques, such as biofeedback, have been found to at least temporarily improve hypnotic ability in low-hypnotizable individuals (Wickramasekera, 2002). Additionally, the application of multiple successive hypnotic techniques may be effective in patients who have failed to respond to standard hypnotic techniques (Crasilneck, 1995).
  3. Hypnotic ability is not a unitary trait. If overall hypnotic ability is not measured, then the interventions studied cannot be tailored to utilize the specific hypnotic abilities of each patient. Patients who are unskilled at hypnotic visualization but excel at kinesthetic representations, for example, will receive far less benefit from guided imagery-based interventions than they would from hypnotherapy that utilized their individual, measurable hypnotic strengths (Pekala, 2002).


Hypno-oncological interventions intended to directly alter the progression of the disease have not been yet been studied in controlled trials. However, the theoretical and biological bases for hypnotherapy’s potential as an effective adjunctive cancer treatment appear to be sound. Such interventions should be tailored to the individual hypnotic abilities of the patient and should be designed to foster the development and use of more mature ego defenses.

Additionally, it seems likely that a degree of biological specificity which has yet to be achieved in this type of hypnotic treatment could have the potential to significantly enhance its efficacy. The types of imagery used in the studies we’ve reviewed, when mentioned, have tended to be combative—as though the cancer cells were isolated intruders. Biologically, however, we know that the occurrence of cancer is far more complex. At least two genetic mutations are required to convert healthy cells into malignant ones, and viral, bacterial, or chemical interference is involved in some or all of these mutations a substantial percentage of the time. (Butel, 2000; Vauhkonen et al., 2007; Boccardo & Villa, 2007) Some cancers seem to result from ongoing viral infections and to reverse their course when the immune system is awakened to the presence of the intruder. Other types of cancers seem to occur systemically, with numerous precancerous lesions preceding the development of a site-specific, diagnosable cancer (Baker & Kramer, 2007). If hypnosis is able to directly influence biological events—which it does seem to be able to do (Rossi, 2002)—it would seem logical that more accurate therapeutic metaphors would yield more accurate treatment.

Hypnotic imagery involving the mobilization of cellular warriors does, in fact, increase the mobilization of natural killer and lymphokine activated killer cells (Gruzelier, 2002; Wood et al, 2003; Hudacek, 2007; Ogston, et al, 1997, as cited in Walker, 2004). That alone is essentially cause for celebration; the implications are staggering. Using hypnosis, we can tell our patient’s bodies what to do, and they will do it. Now all that is needed is to understand exactly what human bodies must do to be free of cancer. Increasing T-cell activity and focusing that activity on the site of the cancer is clearly not sufficient. If research in this area is conducted in such a way as to directly compare the efficacy of different pathogenic models for particular types of cancer, the results may very well have implications for the development of new biological treatments as well. Perhaps the body can tell us what it needs in order to heal.

There is presently no evidence of any downside to open experimentation in this area. Hypnotherapy is already conclusively established as a highly effective treatment for many primary and secondary symptoms of human malignancies—acute and chronic pain, chemotherapy-related nausea and vomiting, food aversions, fatigue, insomnia, anxiety and mood disturbances—and is currently under-utilized (Liossi, 2006). Furthermore, there is no evidence that the addition of far-fetched suggestions into existing empirically-based clinical hypnosis protocols would reduce the effectiveness of existing treatments, significantly increase treatment expense, or present additional risk to the patient.

Appendix I: “Hypnotherapy Script for Befriending a Cancer”

[Begin with your induction of choice]

And when you’re just about as deep, and as comfortable, as you know how to be, let me know you’re there…

Good, because now, we are going to learn something, that may at first seem foreign to you. Something that you already have, inside of you, as a skill, that you have not yet learned, to fully use. Learning can be very uncomfortable, at times, and I understand, that you have felt very uncomfortable, in the past. But you don’t have to feel that way. You don’t have, to feel anything, at all that you don’t want to.

And you can keep right on sitting there, just as you are, and you don’t even have to feel it. You don’t even have to feel, like it is even your own body. And you can notice your arms and legs, and you don’t even have to feel that they’re attached to you. And you can notice your breathing, the way it keeps right on breathing without you, automatically, all by itself, and it doesn’t matter where you go, or how far away you, wander off now, and everything back here will, just go on ahead, just the way it is, with no interruptions. And you can keep on hearing the sound of my voice, and you don’t even have to listen. And some part of you will continue listening to the words that I am saying, and you don’t even have to hear them. It’s really amazing, how wonderful it can feel, to let yourself wander off now, completely off the beaten path. And my voice will go with you, as I fade off into the gentle sounds of breezes, the quiet singing of birds nearby, the chirping, and whirring, and crackling of insects and tiny, natural, lively things all around you now.

And you can find yourself, almost as though you had been sleepwalking, wandering through a beautiful countryside now, without a care in the world. One little step at a time through the lush green grass you find here. And as you walk this way, you’ll begin to notice all the interesting scenery around you, And you can notice, if there aren’t too many clouds, how high up in the sky is the sun today? I wonder what time it might be. Take a look around you now, survey the landscape. If you listen carefully, you may be able to hear the sounds of water, bubbling and frothing. Is there a stream nearby? Maybe you’d like to take a closer look, to go and lean down over the warm, smooth, sun-baked stones, and run your fingers through the cool water there. This world is just full of wonderful feelings, that you can find, and you will find, that they all feel, wonderfully, familiar to you. And you can wander around like this for as long as you like. It may be a very long, and very lovely time, that you have here now, just wandering around, just discovering, all the sights, and sounds, sensations, smells, of your, own, private, countryside. Really feeling, right at home here by now. It’s lovely here.

And after, some time, has passed, two-more things, will come to your attention. There is someone else nearby, a stranger. And from a little ways away, this stranger can-sure make you feel, very apprehensive, because they look as though they may be—unusual? strange?—maybe even very, dangerous, to you. But you like most people, I know you’ve found, that you’ve gotten much farther, with people, when you find it in yourself, to be friendly and accepting. And so, knowing now that this place is your very own home, and knowing that you are very brave, you can decide to walk towards this stranger, in a friendly way, with the intention of learning, to understand them, and to befriend them, so that, they will listen to you, when you know the best things for them to do, and you can even, listen to them, when they know what might be best, for all of you. Because, you know, the more deep and meaningful friendships that you allow yourself to build, now, the healthier, and more fulfilling your whole, long and luscious life, will be.

And as you walk toward them and begin to come closer now, you’ll start to notice that the expression on this stranger’s face is not a malicious one at all. You’ll see instead, that they appear to be, simply, confused. And although something about them is very familiar to you, you’re going to find out, how your stranger is having trouble remembering just who they are, and just what their purpose started out to be. And so you can start by just, introducing yourself, and discovering, that the two of you have a great deal, to talk about together. And while you’re having that long, productive conversation with your stranger now, I’ll tell you the story of a stranger that I met.

My stranger was a person whom I happened to befriend, by a stroke of luck, actually, although at first it didn’t seem that way at all. Because, you see, in my college days I had rented a room in large house—it was much, much taller than it was wide. My room was at the very top of the stairs, it must have been at least six or seven stories, and during the summer it would become very very warm up there. But, I had a little window on either side of the room, and it was high enough that if I opened up the both of them then I could usually get a nice breeze in there. My neighbor downstairs was not so lucky, the window on their far wall was stuck closed, and the window on the wall by the bed was so close to the place where they would sleep or sit and study, that it couldn’t be opened either. You see, my friend downstairs was really very tremendously fat, sort of engorged really. I came to find out later that they had started out ordinarily enough, wanting ordinary things just like you, wanting to be a part of something larger than themselves, just like anyone, just like anything. But something had gone wrong for them along the way. You see, when they were small, they developed, like many kids, a real taste for sugar—just couldn’t get enough sugar. So, they started out begging their parents and friends for whatever cakes or candies could be found, and soon enough they had progressed to stealing candy bars in stores. It got to be, that they became so focused on getting and eating all the sugar they could find that, well pretty soon they had mostly forgotten all about their other, wishes, hopes, dreams. all the real purposes for living that they had had. So they floated through life, growing larger and larger, sucking up all the sugar they could get, starving out anyone unfortunate enough to get caught around them, but mostly they just didn’t get noticed much, until one day they were my little downstairs neighbor, and the building inspection committee came through, and was dismayed to find, that my little stranger had grown so large that they couldn’t even be removed from our little building. And what was worse, there was no way for me to even get down around them, so I was stuck with them, and I very upset and, even, actually frightened about what might happen to me being stuck there with this big fattened blob stuck down there beneath me. Would I be able to get out of there to eat, to finish school, to work, to see my family and friends again? What might become of me, I thought. It just got worse and worse for me. Well, a long time passed, with just me and the stranger up there in this tower. People managed to bring me food through my window, but the window wasn’t small enough for me to fit through and the building was too old for them to be able to make a hole in it and take me out, so I was stuck there with the stranger and nothing left to do now except learn to understand how they got to be the way they were so that I could help them get back to being something much more manageable. And you know what? I ended up talking with them for an awful long time, about all sorts of things; a great, long, productive conversation with this stranger, and we talked about life purposes, the way that every little part of everything has a part to play, a purpose of being, and how sometimes we each felt as thought we couldn’t quite remember who we were, or just what we had started out to be, or what task we were meant to be accomplishing. We each got caught in our respective ruts, you understand, and we would just get scared and start running away from our true selves—them eating their sugar all day and all night, stealing from all the folks around them, getting lodged into places they couldn’t fit out of and seeing no way out but to take in more sugar and become bigger and fatter and more malignant, and me, I found, that I was very much the same in my way, so focused on the tiny little aspects of my life that I thought were so important that I would do nothing but gorge myself on them all day long, throwing myself into my tiny personal interests and not being able to grasp the big picture of what my life was supposed to be, you know, my ultimate purpose, my, destiny. And so it was, for the stranger, they just hadn’t remembered, their destiny: and you know, of course, that their destiny was just, just like the rest of us, just to be a part of something larger than themselves, to find meaning, real meaning and worth, in functioning, in society, right there in the middle of the great body of people, making differences, building real deep meaningful relationships, enjoying the purpose of themselves and everyone around them, all the squirming, pumping, growing, healthy parts of a real live society. Of course, there was no way for them serve any kind of greater purpose while they were caged up there in their hot little room, stuck with no way out, caged in by their own appetites and loss of purpose. But as we talked, we both found that it was, irresistible, to follow our true purposes, to learn how we could truly interact with the great human body and live of life in which we were beloved and really integral parts of the systems we belonged to. And as we talked we found that our confusion abandoned us completely, and the stranger and I began to see things perfectly clearly, and found that it was just so easy now, to forget about, whatever it was that we had been distracted by. Day by day, the stranger started shrinking; I noticed all at once that they had stopped eating all their stores of sugary deliciousness, and were instead fully driven by a renewed desire to perform their original function. We became such good friends, as we both became increasingly excited about the potential that we could have and the impact that we could make with these beautiful lives that we had, that I barely noticed how small they were getting, even smaller than me! Shrinking down to just the right size and turning into something entirely different—turning into exactly what they always should have been, a working, thriving part of the system; something valuable and useful; completely and cleanly disappearing into the workings of a beautiful, and important system. When the building inspection committee came back later that term, they didn’t even recognize the stranger at all; my stranger-friend was just another student by then, just another healthy part of the student body, coming and going as they pleased, getting through all the work they had to get through, and better yet, they became so healthy and vital now and they started to impact the whole student body in a positive way—pretty soon I would come home from class and find them scurrying about the building, full of energy, actually cleaning that place up! Making sure that everything was in perfect, healthy, functioning order. The whole situation had a big impact on me, too, as I know you can imagine; I had learned what it was like to be isolated from everyone I knew and loved, locked away in scary place, and I had learned that the way out, the way to feel good again, even better than I had ever felt before, was by building stronger and better and deeper relationships than I had ever built before. I haven’t seen my stranger-friend for a long long time now; they shrank away into my past. But the things that I learned, from meeting them, from being stuck with them, and from surviving the ordeal in order to become a healthier and more active and integrated person, why I wouldn’t trade the experience for anything, no matter how scared I might have been.

And I don’t know whether you’re already starting to feel like your stranger has made that kind of impact on you and on your life, or whether you’re just beginning to feel that way as they shrink off into your memory for good now. But I do know, that it can be really amazing, how sometimes our greatest teachers, and the greatest promoters of our health, and vitality, can start out looking like insurmountable obstacles. And we often think, during those times, that someone is trying to harm us, and they might even think that too, but as you take a closer look, you can quickly discover, that in fact, they were only confused, and only needed a little bit of help, to get right back on track, and that as soon as that happens, then everything can come back together, all at once.

And you can-sur–reptitiously remind yourself… even the stranger, and more frightening parts of yourself, that they don’t have to be afraid and build themselves up into large, and, scary, things. You-, can-cer —, repetitiously, remind yourself… especially the stranger, parts, that there is enough warmth, and nourishment, for all of your parts, and that there is, enough friendliness, there inside, your little world, so that nothing has to grow, out, of proportion, to the rest. And you will be surprised, how quickly, balance will be restored, as you’re thinking this way, and feeling, finally, as though all of your parts, are finally working together, in perfect harmony now. And when you look, inside yourself, you’ll find a world full of friends for you, with no strangers left at all, and no parts left out of the loop, feeling needy, or greedy. You’ll find, instead, only your beautiful landscape running along, just perfectly, amazing everyone.

And when you return, from your wandering, you may find that you have been, filled with wonder, over all the new and delightful sensations, that have come, to replace those feelings of discomfort, that you had experienced, in the past.

[End with your re-emergence instructions of choice]


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Meth Use & AIDS in The Gay Community

Methamphetamine use is highly prevalent among men who have sex with men (MSM) and presents a serious public health issue (Shoptaw & Reback, 2006). Use of the drug is associated with increased engagement in high-risk sexual behaviors with a greater number of partners, and therefore with increased transmission of HIV, hepatitis, syphilis, and other sexually transmitted illnesses (STIs) (Shoptaw & Reback, 2007; Mansergh, et al., 2006). Methamphetamine use may also directly increase the risk of STI contraction by suppressing immunological functioning (In, Son, Rhee, & Pyo, 2005; Mahajan, 2006). In this vein, it is relevant to note that immunological functioning may already be reduced in members of this population as a result of the increased social stress and discrimination that they encounter (Meyer, 2003; Richman, Bennett, Pek, Siegler, & Williams, 2007). Increased risk of psychological disorders is also a reality for this population (King & Nazareth, 2006; Meyer, 2003; Cochran, Mays, & Sullivan, 2003), and methamphetamine use dramatically increases this risk by negatively impacting neurophysiological health through several mechanisms (Scott et al., 2007). Furthermore, methamphetamine use actually potentiates the adverse neurological consequences of HIV infection (Cadet & Krasnova, 2007). Throughout the western world, MSM comprise the singular group most affected by the HIV epidemic (Herbst et al., 2006). It is possible that the increasing rate of high-risk sexual behavior that is responsible for recent outbreaks of HIV, syphilis, and gonorrhea among this group may be at least partly accounted for by the equally epidemic spread of methamphetamine use through its communities.

The perspectives and techniques of community psychology are vital to addressing this issue. It is important, first, to understand the unique psychosocial factors affecting members of the gay community in order to surmise the psychodynamic and sociocultural reasons for the drug’s appeal to this group. We will need to develop an understanding of the contexts in which methamphetamine is being used, and the purposes that its use may serve. What cognitive styles or personality components might be most predictive of methamphetamine use, and are their etiologies relevant from an interventionist perspective?

Due to the powerful immediate effects of methamphetamine and the wide array of cumulative neuropsychological effects that it exerts on its users, it is difficult to assess the premorbid psychological state of an individual methamphetamine user, or to assert causality in either direction with regard to behaviors that they exhibit. There do seem to be two readily identifiable groups of methamphetamine users in general: chronic users and binge users. Chronic users seem to use the drug as a part of an avoidant coping strategy, in order to evade unpleasant emotions and mediate the experience of social discomfort (Halkitis & Shrem, 2006). Binge users, on the other hand, tend to score much higher on measures of impulsivity and, notably, depression. These users tend to consume larger quantities of methamphetamine in a sitting, to have a larger number of sexual partners, and to engage in a greater number of sexual risk behaviors than users of the chronic type (Semple, Zians, Grant, & Patterson, 2005). Essentially, methamphetamine users seem to be divided between those self-medicating for anxiety and those self-medicating for depression. Methamphetamine bridges this divide by offering its users increased self-esteem and confidence, decreased inhibition and sexual ability, and feelings of euphoria (Halkitis, Fischgrund, & Parsons, 2005).

The causes of the dramatically disproportionate prevalence of anxiety and depression among the gay community (Meyer, 2003) are likely the same as those which have created a subculture conducive to methamphetamine abuse. On the surface, long-standing social stigmas surrounding homosexuality and the ‘minority stress’ of belonging to a group that is increasingly the target of discriminatory violence (Bello, 2007) nurture individual expectations of rejection and discrimination. The social attitudes which cause these types of psychosocial difficulties, however, are also internalized in many MSM—possibly owing to the concealable nature of sexual orientation, the psychosocial complexity of the ‘coming out’ process, and personal ambivalence resulting from negative conceptions of homosexuality acquired through socialization. The resulting “internalized homophobia” is itself significantly correlated not only with the occurrence of anxiety and depression in this population, but of substance abuse as well (Meyer, 2003).

In addition to the self-medication aspect of methamphetamine use, the majority of meth-using MSM report using the drug for sexual enhancement (Halkitis, Fischgrund, & Parsons, 2005). For many users, methamphetamine induces a profound sexual disinhibition, relief from feelings of shame and isolation, increased physical and emotional pleasure and vitality, delayed and prolonged ejaculation, and the ability to take part in sexual marathons sometimes lasting a dozen hours or more. The intensity of these internal and external experiences in combination frequently produces a situation in which the drug becomes integrated into the individual’s sexual identity. Methamphetamine becomes idealized as a means to “reclaim a sense of pre-AIDS sexuality” (Reback & Grella, 1999, as cited in Halkitis, Fischgrund, & Parsons, 2005, p. 1332). Methamphetamine is therefore experienced as an agent of social connection and cohesion for many members of this embattled community, and so is deeply embedded in the social fabric of many gay bars, clubs, and commercial sex venues. As individuals become socialized into this subculture, they identify more strongly with the drug and find it more difficult to remove themselves from the pattern of high-risk behaviors it encourages.

Review of the Historical and Contemporary Scientific and Theoretical Literatures

The Centers for Disease Control (CDC) have recognized social marketing campaigns as an effective means of promoting health within a targeted population, but the use of this technique for minority groups is relatively new. The movement toward using social marketing campaigns as an intervention for methamphetamine use within the gay community began with a New York activist named Peter Staley who used his own money to fund the placement of a variety of cheeky yet ominous ads in gay areas and gay magazines. A follow-up study (Nanín et al., 2006) revealed that the results of Staley’s experiment were not ideal, but definitely promising: placement of the ads was highly effective in targeting groups at the highest risk, and most respondents reported feeling glad that “someone was doing something about crystal use in the gay community.” About half were inspired to “think about not starting to use crystal or cutting down on my use.” More than a third of respondents reported wanting to “talk to my friends/partner about their use of crystal” and to “get help to stop using crystal or avoid starting use” as a result of viewing the ads. However, 11% of all respondents, and 27% of those at the highest risk, reported that the ads actually increased their urges to partake of methamphetamine.

In exploring the potential weaknesses of early Meth/HIV social marketing campaigns, Nanín et al. (2006) cite a meta-analysis of HIV interventions by Albarracín et al. (2005) in support of their hypothesis that the campaigns’ emphasis on fear of HIV may have undermined their effectiveness. This meta-analysis and several other studies have demonstrated the general ineffectiveness of fear-based community interventions, possibly due to the avoidant nature of many self-destructive behaviors. The results of the meta-analysis should prove extremely useful, because it examines not only the effectiveness of attempted interventions, but the implications that those results have for acceptance of the interventions’ theoretical underpinnings. In addition to finding poor support for the idea that enhancing individuals’ perception of threat will result in behavioral change—even when effort is made to improve coping skills in conjunction with disseminating the threat-based messages—the researchers found little support for approaches which focus on the modification of behavioral norms within a target community. They found instead that models which aim to modify attitudes, motivations, and perceptions of self-efficacy, and to provide information and behavioral skills, can probably be expected to have more desirable effects. Furthermore, they found that the specific types of approaches which will tend to have the greatest effect on an individual are those which are congruent with the individual’s current stage of behavior change.

Dissemination of information, as a tactic for behavioral change, appears to have some efficacy for individuals at all stages of methamphetamine use, including those who have yet to make use of the drug (Albarracín et al., 2005). Campaigns which seek to modify attitudes also appear to possess this quality, while interventions focusing on behavioral and coping skills are likely to prove beneficial for only individuals who have already reached the stage of contemplating behavioral changes. This information complicates our efforts due to the finding that informational and attitudinal arguments for condom usage tended to be successful only for female recipients, whereas males were more responsive to behavioral skills-based arguments and training. MSM, in particular, responded very poorly to attitudinal arguments but tended to respond better than other males to all other types of interventions.

Alberracín et al. conclude that condom provision is, overall, a particularly effective method of preventing the spread of HIV due to the long-term attitudinal changes that can result from an individual’s reflection on their own convenience-based usage of the condoms they have been provided. That is, based on their own previous usage, individuals estimate their attitudes toward condom use much more positively than they otherwise would. These individuals are then likely to extend those attitudes forward into more active roles in obtaining and using condoms. These findings leave us with the task of discovering the types of arguments that will be effective for individuals who are male, gay or bisexual, and users of or at risk for using methamphetamine. Although the distribution of condoms to high-risk populations should still be considered a sound component of comprehensive community intervention, the overconfidence and impulsivity that methamphetamine use incites may negate the effectiveness of efforts to promote general condom use.

Another large, systematic review of behavioral risk reduction interventions for MSM was conducted by an independent Task Force on Community Preventive Services with the support of the CDC and the U.S. Department of Health and Human Services (Herbst et al., 2006). This study focused on person-to-person interventions operating at the individual, group, and community levels. Individual interventions reduced the incidence of unprotected anal intercourse (UAI) by 43% overall, including a 59% reduction in UAI with non-primary partners. Overall HIV contraction rates for the treatment groups were 38% lower than for controls. Surprisingly, individual interventions produced no significant changes in the number of sex partners. Also, no data was available regarding the cost-effectiveness of this type of intervention.

Interventions at the group and community levels were both found to be not only cost-effective but cost-saving, and both were effective in decreasing UAI by significant margins (Herbst et al., 2006). Effective group interventions were comprised of more than one meeting, were led by MSM, and included a skill-building component such as condom use training. Unfortunately, the most difficult aspect of implementing the group interventions tended to be recruiting and retaining participants. Use of “club drugs” (including methamphetamine) tended to be predictive of attrition. Community-level person-to-person interventions, on the other hand, may show some promise for our purposes. They involve the recruitment of MSM from key demographics who will act as peer-leaders by initiating discussions about sexual safety with their own personal contacts, and by then recruiting their contacts to do the same in order to continue the spread of risk reduction messages from peer to peer. These interventions reduced overall UAI by a very respectable 35%, and reduced the average number of sexual partners by 20%. Particularly given the strong social component of methamphetamine use among MSM, a person-to-person intervention at the community-level seems a natural choice for attempting to curb the spread of methamphetamine use and its associated high-risk sexual practices.

These and other types of community-based interventions for reducing methamphetamine use among MSM must be informed by factors that are specific to the subcultures in which the behaviors typically arise. Citing an under-emphasis on the “symbolic and interactional spheres,” Green & Halkitis (2006) set about collecting and analyzing qualitative interviews with MSM living in Manhattan in order to understand the meanings that sexual “circuit parties” and similar sociosexual events hold for their participants, and the ways that interactional norms and pressures within the subculture may shape drug-taking motivations and behaviors. They found that individual motivations were largely inseparable from participation in “contexts of sexual sociality and their attendant interactional pressures” (p. 319), and that these pressures—“the need for sexual arousal on demand, sustained sexual endurance, and the ability to have sex with newly acquainted partners”—were in the direction of precisely those behaviors which are enabled and perhaps even instigated by methamphetamine use. Study participants reported a level of sexual arousal and activity that they sometimes characterized as ‘compulsive’ and which often resulted in UAI, but the researchers point out that methamphetamine alone does not always induce a sexual response. Rather, there is a socialization process involved in shaping the user’s response to the drug so as to fit the needs of the particular social environment.

A 2006 Gay and Lesbian Medical Association (GLMA) report points out that casual methamphetamine use becomes problematic for a majority of users, and that treatment for methamphetamine addiction is often a “difficult and long-term process” that requires ongoing methamphetamine-specific treatment (p. iii). The standard of care is CBT combined with some form of contingency-management program in which incentives are offered for demonstrated abstinence from the drug. Alternate treatment models have proven more effective in the short-term, but about the same in the longer term. As with any drug addiction treatment, it is helpful for the user to receive support for the exploration of specific issues and triggers that lead them to use and abuse the substance. The GLMA notes that the most common triggers for MSM tend to be sexual, and asserts that treatment should therefore be tailored to this group in order to prevent the post-treatment relapse that has been common in recovery programs that fail to address the unique needs of this population.

According to the GLMA (2006), there is disagreement about the usefulness of harm-reduction approaches which aim to reduce harmful behaviors resulting from and associated with methamphetamine use rather than directly attempting to promote abstinence from the drug. From the perspective of this examination, in which the potentiation of sexually transmitted disease is considered as the primary reason for elevating methamphetamine use among MSM to the status of public health crisis, harm reduction measures are clearly desirable. As we have already seen, members of this group—and particularly those at highest risk—are significantly less likely to visit their primary care physicians. The GLMA reports that they are also unlikely to report their methamphetamine use to their healthcare providers. However, the provision of methamphetamine use assessment training to healthcare professionals in high-risk areas may be a very effective way of intervening in both individual usage and community perceptions of methamphetamine usage.

Critical Discussion of the Literature Reviewed

Based on their interviews, Green & Halkitis (2006) concluded that the social characteristics of the Manhattan gay and bisexual subculture, due to their emphases on sexual disinhibition, arousal, and sustained performance, demonstrated an elective affinity for the specific psychophysiological effects of methamphetamine above all other drugs. While there is yet no empirical evidence that this holds true to for other gay communities, it makes intuitive sense that this should be a common feature of methamphetamine-rich gay subcultures.

Consider that we are examining a minority group whose entire identity, as separate from the majority, rests upon the performance of and desire to perform specific sexual acts. From this perspective, it seems natural that a significant proportion of these individuals would cohere into subcultures which relied upon enhancement of sexual performance and willingness as a means of establishing and maintaining a sense of belonging. Since methamphetamine readily provides these effects for many users, it becomes not only a natural choice for members of the subculture in question, but also a reinforcer and even accelerator of that subculture’s normative sexual behaviors.

Methamphetamine furthermore counteracts what must be an immense sense of fearfulness and alienation surrounding a sexuality that has been strongly associated with the spread of disease and which has been consistently subject to public perceptions of filth and moral ineptitude. We are examining a group that is widely discriminated against and frequently victimized, and which is at high risk for a range of psychological disorders that center around narcissistic deflation resulting in symptoms of anxiety and depression. Methamphetamine is a drug which temporarily alleviates these symptoms, and allows individuals who have been the subjects of unusually difficult and intolerant acculturative experiences—and who are therefore subject to feelings of isolation and awkwardness—to experience a sense of social belonging and efficacy. If not for the horrific psychophysiological effects of the drug, its high level of addictiveness, its tendency to induce high-risk sexual behaviors and to reduce both endogenous and exogenous forms of resistance to infectious disease, it would behoove us to recommend this drug. It is as though methamphetamine were created with the psychosocial plight of today’s gay community in mind.

These observations are not intended to promote the value of methamphetamine use, of course, but simply to illustrate the inherent sensibility of the current situation when the available data is understood holistically. The significance of this understanding is that any interventions which would curtail methamphetamine use within the gay community can probably be expected to succeed only to the degree that they are able to account for and counteract this basic sensibility underlying the drug’s use.

For example, the literature is clear that inducing fear of the harmfulness of methamphetamine or the behaviors that it supports is an unsuccessful strategy. Why should this be? It is because the social structure we are addressing has developed in reaction to a state of pervasive individual and collective fearfulness. Exacerbating that fear will, as the research bears out, actually reinforce the problem behaviors in those individuals for whom the risk is the greatest. Interventions must therefore focus on providing relief from fear, as well as from social and sexual alienation. Again, this is exactly what the research has shown: interventions which work to instill senses of efficacy, informedness, and community have reliably promoted behavioral change in this population.

It is interesting how difficult it has been for researchers to pin down the specific factors that enhance or detract from the effectiveness of interventions for MSM. It is currently unclear whether arguments targeting behavioral skills or those aimed at advancing coping skills may be more effective. More research that specifically targets this demographic may be helpful for optimal program design. It seems likely from other research, however, that the key ingredient has more to do with social and community factors than with either of those two studied elements. Researchers in this area would do well to examine methods for increasing the overall social interest of study participants—their feelings of community connectedness versus isolation—as a factor in the decisions to use methamphetamine and to engage in high-risk sexual practices.

Our basic task, given what is currently known and unknown, is to surmise what types of interventions are best suited to the purpose of discouraging methamphetamine use and its associated high-risk behaviors by undermining the psychological conditions from which they arise. A major problem in accomplishing this task, which we encounter throughout the literature, is that interventions aimed at reducing methamphetamine use among MSM are relatively new, and insufficiently studied. However, there is a good deal of useful information available in the existing research on HIV prevention, which has largely been targeted at this same population. For this reason, it has been possible to develop a reasonable understanding of the issues involved and the types of interventions best suited to addressing them by reviewing this body of existing literature in combination with the somewhat less robust fund of more specific research.

It is worth noting, for example, that the comprehensive meta-analysis we have discussed by Alberracín et al. (2006) found that the only community-based interventions that have ultimately been effective in reducing the spread of HIV were those offering HIV counseling and testing. It seems possible that the direct, visceral involvement that HIV testing facilitates could initiate and/or solidify attitudinal change. While it is difficult to see any way to directly apply this principle to the reduction of methamphetamine use, it may be possible to develop a system of cognitive conditioning within the context of HIV testing which implicitly links the two concepts. Such an intervention could be as simple as asking a few specific questions about methamphetamine-usage each time an HIV test is administered, as a way of impressing upon the individual being tested that their risk is much higher if they are using methamphetamine.

Much of the research focusing on interventions for methamphetamine use within the gay community has focused on social marketing. Targeted advertising campaigns of this type constitute a relatively cheap and effective form of intervention which can be implemented quickly. Unfortunately, it can be difficult to measure the effectiveness of any single ad campaign due to the unlimited range of confounding factors and the difficulty of designing followup studies. However, it is evident from examination of Peter Staley’s early and even fairly naive attempts at social marketing toward these ends that profound impacts are possible even when the ads being used succumb to the popular tendency to use fear as a motivating factor for behavioral change. With a higher level of psychological conceptualization, this type of intervention has the potential to be one of our greatest tools in advancing broad improvements within our target subculture.

The other extremely interesting intervention model that arose in the literature is the community-level, person-to-person intervention, which operates on a model much like viral or multilevel marketing by recruiting recipients of the intervention as its next level of administrators. In this way, the intervention has a far greater potential of eventually reaching those individuals with the least probability of actively becoming a part of any program—who, incidentally, are also at the greatest risk for methamphetamine addiction and for sexually transmitted infection. This model may also take advantage of the motivation that individuals who have recovered from addiction often find to help those who are currently under its sway, as well as the motivation of healthier members of the gay community to improve the overall health of their social support network. Recruitment practices that specifically aim to exploit these factors are definitely worthy of additional study.

Synopsis of Future Action

Given that a majority of current methamphetamine-using MSM have tried to quit or wish to try but have not sought professional assistance (GMLA, 2006), it is of central important that information regarding the availability of treatment services be made readily available. As the Gay and Lesbian Medical Association suggests, the family doctor’s office is an excellent place to start. The venue itself allows for the framing of methamphetamine use as a health issue at a time when members of affected subcultures likely consider it a primarily social one. Simply placing informative pamphlets in the physician’s office conveys, in a non-threatening way, that the doctor is knowledgeable about methamphetamine and can provide assistance in the case that the user should ever want or need it.

However, as we have seen, those most at risk are also the least likely to visit family physicians. While it is reasonable to expect that shifting community norms instigated by efforts to reach higher-functioning members of this group will exert some influence on the attitudes and behaviors of the lower-functioning members, it is important that informational campaigns also explicitly target those who are at the highest risk of methamphetamine-related sexual risk behaviors and sexually transmitted infections. This is the case not merely for altruistic reasons, but because the individuals who are most profoundly affected by the psychosocial factors which characteristically affect this group act as hubs for the transmission of sexually transmitted disease within the community. Any action which inhibits the self-destructive actions of this minority of individuals within the gay community—whose drug consumption is the greatest, who suffer the most exhaustive psychological disturbances, and who engage in UAI with the greatest number of often anonymous partners—has the potential to prevent an immense range of negative outcomes for the rest of the community.

Unfortunately, this group is most elusive—to the point of being nearly hypothetical. It is comprised of those individuals who are the least likely, as has been noted, to engage primary healthcare services. They are the least likely to participate in studies or focus groups, to seek out or utilize drug treatment or other psychological services, or to retain membership in education or support groups to which they have been recruited. This group is an essential bogeyman that lurks in the shadows of nearly all of the relevant literature. Identifying their characteristics, predisposing psychological traits, social tendencies, and responsiveness to various types of interventions is a vital task for researchers in this area to attend to. It seems likely that comparisons could be drawn to similar groups within other minority populations and/or within other groups of substance abusers, so there may already be a pool of literature to draw from in those areas.

Further evaluation of community reactions to the social marketing campaigns which have targeted MSM in major US cities over the last decade is also necessary, in order to understand the types of effects that they are having on different demographics within the highly heterogeneous gay community (Nanín et al, 2006). As several researchers have noted, the healthiest subgroups seem to reliably show the greatest response to all interventions. While primary prevention messages have dominated existing campaigns and may have some effectiveness, a majority of MSM methamphetamine users report no access to treatment services. Future campaigns should certainly provide information on the availability of these services for individuals who wish to stop using methamphetamine, as this can be included as a secondary function of any campaign. It is also possible that a review of existing literature in the field of consumer psychology might help to inform future marketing efforts to undermine methamphetamine use by helping to apply psychological understandings in ways that exert directed influence on key demographics. In this way it may be more feasible to manipulate the dynamics of this relatively delicate subculture toward the end of improving the personal security and social interest of involved individuals.

Proposal for an Innovative, Socially Responsible Action Plan

A certain ingenuity will be necessary in order to convey truthful messages about the horrific effects of methamphetamine without evoking additional fear in an already fearful population. After all, it is true that the drug causes anxiety, depression, psychosis, permanent damage to neurological and other soft tissues, erosion of the teeth and bones, failure of the immune system and resultant physiological susceptibility to the very sexually transmitted diseases which one is likely to become exposed to when participating in the behaviors that are conscious motivations for a large percentage of MSM to use the drug at all. Simply communicating these facts, however informative, is likely to heighten the anxiety and hopelessness of a group far too affected by those emotions already and to therefore undermine individuals’ abilities to rationally assess their social and behavioral choices.

To some extent, the problem may be bypassed through the selection of messages that focus on the reasons that MSM are using the drug, using consequences as merely supporting data. The core of any communication will have to convey the basic message that methamphetamine does not help MSM to feel well-adjusted, and that it does not help to overcome feelings of isolation or of alienation. People intuitively connect with the idea of something being ‘too good to be true,’ but may be unable to reconcile terrifying consequences with euphoric present realities, particularly when those realities are being sought for the purpose of drowning out a troubling social circumstance. Alternative means to that end are needed to soften the dissonance.

Social marketing campaigns seem to be an excellent tool, but it will be difficult to achieve the level of subtlety necessary to make an impact on the most troubled elements of our target population. Perhaps the best solution would be a combination of social marketing designed to deflate the perceived benefits of methamphetamine use coupled with community outreach efforts offering a safe alternative for achieving the sought-after benefits. Group psychotherapy, after all, is generally valued precisely because it addresses psychological issues which inhibit social relatedness. Even as cost-effective as group psychotherapy generally is, however, the condition of scarcity must be anticipated when thinking in terms of community psychological interventions. For this reason, long-term investment in individuals will be avoided in this plan in favor of broader community-level interventions. There is some evidence that methamphetamine-specific twelve step programs are effective in reducing meth use as well as sexual risk behaviors (Lyons, 2005), which could make such programs an ideal ‘landing pad’ for our community interventions if we chose to address those MSM who are already using methamphetamine. This has the benefit of affording our most direct attention to those individuals most in need of assistance, while influencing group norms by spreading messages which presuppose that methamphetamine use is undesirable.

Taking twelve-step program attendance as our intended destination for wayward MSM, then, it becomes much simpler to design interventions which target this outcome. From the literature we have reviewed, two excellent intervention methods for engaging the community have emerged: social marketing strategies, which we have already discussed; and community-level, person-to-person interventions. This latter type of intervention is the more difficult, but also provides a great deal more depth in terms of the messages that can be delivered and the level of community feeling which can be invoked and leveraged.

As with our social marketing strategy, negative and fear-inducing messages should be heavily downplayed in favor of positive and empowering messages. Individuals recruited into the program should receive thorough instruction in this manner of delivery and the reasons for it, as well as training in the manner of providing instruction to others who will extend the program. The experiences of the individuals involved, as members of the community, should be heavily utilized. It would be much less effective, for example, for an individual to simply list the benefits of attending Crystal Meth Anonymous to a peer, than to convey their own experience of being a member of the community who has felt oppressed and confused and troubled, and for whom an increased level of community involvement has provided a level of day-to-day relief that methamphetamine did not.

It is to our benefit in designing programs of this type that there are a large number of fairly autonomous gay communities scattered throughout the United States and throughout the world. With relatively small amounts of funding, we can institute pilot programs in smaller communities where benefits and shortcomings of the program can be easily assessed before enacting improved versions of the programs in larger cities.


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The Medical Model of Psychology

The “medical model” that currently guides the majority of psychological research, assessment, and treatment is a deeply entrenched historical, social, and political phenomenon (Maddux, Snyder, & Lopez, 2004; Laungani, 2002) which has no empirical support whatsoever (Wampold, 2001). This article will outline some of the problems that the widespread acceptance of the medical model poses for the field of psychology.

Wampold, Ahn, & Coleman (2001) list five components of the medical model of psychotherapy: to begin with, the patient presents with symptoms of a classifiable disorder or disease; from the existing research and accepted materials, a psychological explanation for the disorder is available; the knowledge of this specific disorder and the theoretical conceptualization of such are sufficient that a potential mechanism for psychological change can be identified; having identified these properties, the therapist logically derives  a set of specific psychotherapeutic ingredients and administers them to the patient; these specific ingredients are responsible for the benefits of the psychotherapy thus administered. “The last component,” Wampold, et al. (2001) explain, “which is often referred to as specificity, is critical to the medical model of psychotherapy and gives primacy to the specific ingredients rather than common or contextual factors.” This is particularly significant in that no research has yet to provide any empirical backing for this principle of specificity in psychotherapeutic interventions, whereas a growing body of research is being accumulated in support of alternative, contextual models of psychotherapy (Wampold, 2001).

It is important to clarify the nature and purpose of the disorders being identified and treated within this context, because the illnesses, categories of illnesses, and entire conceptions of illness, as Maddux, et al. (2004) explain,

are not psychological facts about people, nor are they testable scientific theories. Instead, they are heuristic social artifacts that serve the same sociocultural goals as do our constructions of race, gender, social class, and sexual orientation—maintaining and expanding the power of certain individuals and institutions, as well as maintaining the social order as defined by those in power (Beall, 1993; Becker, 1963; Parker, Georgaca, Harper, McLaughlin, & Stowell-Smith, 1995; Rosenblum & Travis, 1996).

These criticisms are not new, but have been gaining momentum as part of the humanistic movement within psychology. Both Rogers and Maslow were strong critics of the medical model of psychology on the grounds that it “might serve to help people in one sense but that it also served to alienate and damage people in another” (Joseph & Linley, 2006).

Furthermore, as Reznek (1987, as cited in Maddux, et al. 2004) demonstrated, even our definition of physical disease suffers this type of socially constructed evaluation “because to call a condition a disease ‘is to judge that the person with that condition is less able to lead a good or worthwhile life.’” The tendency in applying this principle to psychology is therefore the gradual pathologization of all behaviors and characteristics that are not consistent with the ideals of the most powerful individuals and institutions, at the expense of diversity and social evolution, as well as the cause of social justice. This can be seen as a socialized parallel to the accelerating loss of biodiversity that has accompanied the development of civilization along the lines prescribed by the same scientific and modernistic worldview that gave shape to the medical community itself.

On this basis, a very strong argument could be made that the reliance on the illness ideology is proving equally problematic, and perhaps even equally at issue, in the medical community at large. This is evidenced by the last decade’s surge of interest in the areas of preventative and holistic medicine, which each attempt to draw the available store of medical knowledge into broader and more contextually relevant applications. The growing acceptance of health psychology as a specialization applicable to and relevant within the field of medicine is further evidence that a paradigm shift is in progress.

There are, however, powerful forces also at work to maintain the status quo. Laungani (2002) lists four major reasons that the medical model of mental illness maintains its dominant status despite its problems: political influence exerted by multinational corporations whose drugs are more likely to be used in treatment where a disease model is prevalent; increased income potential for psychiatrists due to the decreased consultation time necessary for drug therapy over “non-medical, non-drug related therapeutic intervention”; social and psychological factors which make it desirable for psychiatrists to avoid further alienation from the “medical fraternity” by rejecting the dominant paradigm in the medical field overall; and natural resistance to paradigm shifts in research programmes as described by Kuhn (1962), Lakatos (1971), and Laungani (1999) (as cited in Laungani, 2002).

The stakes in overcoming these obstacles are nothing less than the potential for developing an entire new framework for understanding and working with psychological issues on the individual and social levels. A critical junction in this new development will likely involve the psychological community’s long-delayed empowerment to prescribe medications, a privilege currently reserved for the field of psychiatry, which is settled firmly into the ideologies and traditions of western physical medicine. As such, there is an artificial division between psychotherapeutic treatments and psychopharmacological ones. As Nussbaum (2001) explains,

We psychologists cannot be bound by existing models that we know are not suited to behaviour. However, we need the freedom and expertise to develop integrative biopsychological models to inform our thinking and practice, even our psychotherapy. When psychotherapy is effective, let no one delude themselves into thinking that significant neurobiological alterations have not occurred to allow the beneficial behavioural or subjective experiential effect…..

However, we must also realize that for some individuals suffering from some conditions at some points in time, the regular mechanisms allowing intrinsic production of transmitters or receptor molecules necessary for learning and memory are not functional. At these times, psychotropic medications will be effective where psychotherapy will not, as there is no endogenous currency with which to allow information processing to proceed. Psychologists should be willing to pioneer these new ways of thinking and developing truly integrative psychobiological treatments to capitalize on the drug-behaviour interactions…

While the development and adoption of more appropriate and accurate models of psychology, psychological research, and psychotherapy are vital to the development of an effective and coherent field of clinical psychology, a number of barriers stand in the way of mainstream adoption of those models in exchange for the flawed and potentially damaging medical model. There are, however, many indications that the field is progressing in this direction, and we can remain hopeful that the coming decade will see an increasing empowerment of the psychological community to assert its authority in applying its increasingly well developed theories and methods toward more effective and consistent psychotherapies that are free from the outmoded frameworks of twentieth-century medicine.


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Repressed Memory Phenomena

The issue of repressed memory is surprisingly heated, and comes loaded with the weight of several fundamentally different conceptions of the human mind. The real issue, hidden away in the word “repressed,” is whether a memory once repressed can be unleashed, or “recovered.” Thus we find ourselves in the awkward scientific predicament of having, for each paper published presenting evidence of repressed and recovered memories, at least a few papers published expressly to disclaim it. This article will attempt to make some sense of the available literature, drawing in alternative paradigms in addition to empirical studies.

Examples & Evidence

The issue of anecdotal versus experimental evidence becomes extraordinarily important in discussions of recovered memories, as we shall see, primarily because experimentalists have not managed to invent a way to replicate the phenomenon under controlled conditions. This creates a kind of paradigmatic crisis for experimental psychologists, for whom the temptation to discount uncontrollable phenomenon is a normal hazard of the workplace, so to speak. However, we may do well to consider, as Terence McKenna pointed out in an unrelated discussion, the etymology of “anecdote”, which stems from the Greek “anekdota”, meaning “unpublished items.” An anecdote then, can be thought of as a casually observed phenomenon; once that phenomenon is subjected to scrutiny, corroborated, and–specifically–distributed in a peer-reviewed publication, it ceases to be anecdotal evidence by definition and can instead be considered “medical history” (McKenna, 1998)

Probably the best source of this type of medical history of repressed-and-then-recovered memories is Dr. Ross E. Cheit’s Recovered Memory Project, which maintains an internet database of individual cases of recovered memory. “The cases are annotated and all have corroboration, including medical evidence, confessions, multiple victims, or even eyewitness testimony” (Cheit, in press). The database includes cases in three categories: those extracted from legal proceedings, in which the facts surrounding the repressed memories were subjected to extreme scrutiny and were in most cases corroborated; clinical accounts printed in scientific and academic journals; and other cases, drawn from sources such as legal proceedings that were not allowed to continue for various reasons, or from meticulous journalistic investigations.

One excellent example to be found in the Recovered Memory Project’s archive of clinical accounts is the case of “Claudia”, published in the highly respected journal Science News. Claudia had enrolled herself in an intensive inpatient weight-loss program to battle the severe obesity she was suffering from at that time. After losing more than one hundred pounds in the program, she began to experience flashbacks of sexual abuse at the hands of her older brother. While still an inpatient in the weight loss program, Claudia joined a therapy group for incest survivors at the hospital. During meetings, she remembered and revealed to the group that “from the time she was 4 years old to her brother’s enlistment in the Army three years later, he had regularly handcuffed her, burned her with cigarettes, and forced her to submit to a variety of sexual acts” (Bower, 1993). Upon returning home from the hospital, Claudia was able to examine her brother’s old room and belongings, which had remained untouched in the fifteen years since he had died in Vietnam. “Inside a closet she found a large pornography collection, handcuffs, and a diary in which her brother had extensively planned and recorded what he called sexual ‘experiments’ with his sister.” (again, Bower, 1993). Dozens of powerfully corroborated cases like this exist and are referenced within the archive.

There is a great deal of additional published work in which the recovered memory phenomenon is found to be not only very real, but also relatively common. Psychologists conducting a broad survey of British Psychological Society practitioners, for example, found that “memory recovery appears to be a robust and frequent phenomenon” in cases of total amnesia related to childhood sexual abuse as well as cases relating to other types of traumatic events (Andrews et al, 1995). A 1993 survey of 450 adult clinical subjects reporting histories of sexual abuse found that more than half of the subjects could identify a period of life before the age of eighteen when they had possessed no recall of the event (Briere & Conte, 1993). Another study (Feldman-Summers & Pope, 1994) interviewed a national sample of psychologists; of the psychologists from this sample who reported childhood abuse of any kind, about 40% reported a period during which they had forgotten some or all of the abuse. Of these, nearly half reported some form of corroboration for the occurrence of the abuse. Also significant was the finding that age and gender were not related to the occurrence of amnesia, but the severity of abuse was a strongly correlated factor. Finally, a particularly interesting study interviewed women with previously documented histories of sexual abuse, asking detailed questions about each of their abuse histories. “A large proportion of the women (38%) did not recall the abuse that had been reported 17 years earlier” (Williams, 1994).

Objections & Rebuttals

The major objection to reports of recovered memories is the difficulty in distinguishing them from false memories (Reisner, 1996). While this objection is certainly valid, and the potential for inducing false memories is a serious one for the therapist (Ofshe & Watters, 1996; Loftus, 1994), the preponderance of evidence in support of the existence of legitimate instances of repressed-and-then-recovered memory precludes any serious debate as to the general existence of recovered memories as a phenomenon. The recovered memory phenomenon has been sufficiently observed in a naturalistic environment that it is now fair to assume that any shortcomings in the way of controlled modeling or reliable detection of repressed information can be seen as problems of experimental science and therapeutic technique, rather than as invalidations of the existence of the phenomenon itself.

Furthermore, claims that individuals who report recovered memories are more likely to present symptoms of false memory syndrome (FMS) have been found by some studies to be grossly inaccurate. Hovdestat and Kristiansen (1996) found that FMS indicators were much less common in their sample than the hype surrounding FMS would suggest–no more common, in fact, for subjects reporting recovered memory than for those reporting that their memories of traumatic events had been continuous. In “the first direct investigation of suggestibility among patients who report recovered memory,” Rush Medical College’s Frank Leavitt used the Gudjonsson Suggestibility Scale to compare the overall suggestibility of subjects reporting recovered memories of childhood sexual abuse with that of subjects reporting no history of sexual trauma. “Results indicate that patients who recover memories were remarkably less suggestible than the clinical field has been led to believe by advocates of false memory…. Paradoxically, patients without a history of sex abuse were more at risk for altering memory to suggestive prompts” (Leavitt, 1997).

Models & Theories

Neuroscience, unfortunately, has little to offer us in the way of explaining this phenomenon thus far. While it is able to tell us that extraordinarily stressful conditions can lead to malfunctions of the hippocampus which prevent explicit memories of the surrounding events from being stored, and that implicit memory systems remain functional under these conditions, it is unable to explain how an explicit, conscious memory could be derived from an implicit, unconscious-emotional one. It would seem, in fact, that the implicit memories stored under such circumstances lack sufficient detail to reasonably allow for such a reconstruction to take place with any degree of accuracy at a later time (LeDoux, 1996). Therefore, the current research in this area leads us to assume–for the time being–that proper explicit memories are, in fact, being formed during the traumatic episodes in question and then repressed by way of an unknown mechanism. However, the research is incomplete. It is entirely possible that there is indeed enough information stored by emotional systems to reconstruct traumatic events in detail, and that neuroscientists have simply not yet discovered a way to reliably elicit such reconstruction. It is also possible that there are entire yet-unexplored memory systems at work.

The available research and case studies do, however, offer us significant clues as to the structure and function of memory repression. For example, the Feldman-Summers & Pope finding (1994) that personal indicators and demographics are generally unrelated to the occurrence of amnesia for traumatic events, and that this occurrence is instead reliant only on the severity of abuse, seems to support the hippocampal-interference model of memory formation under severe stress, suggesting that perhaps retrieval of and inference from implicit memory–or the storage of such memories in general–may be underestimated. Another study, however, indicates that the duration of the abuse is also a factor in the extent to which memory repression occurs in victims of childhood sexual abuse (Herman & Schatzow, 1987), which would seem to support the opposite hypothesis that explicit memories are in fact being stored (in the early stages of abuse at minimum), and then actively repressed at the psychological level.

Surprisingly, the most widely accepted model for this phenomenon may still be the Freudian one. It does appear that memory repression is a system of self-defense “by which an individual defends himself or herself against the conscious recollection of a traumatic memory and its associated consequences” (Golding, Sanchez, & Sego, 1996). Jennifer Freyd (1994) builds on this model by speculating that “victims may need to remain unaware of the trauma not to reduce suffering but rather to promote survival. Amnesia enables the child to maintain an attachment with a figure vital to survival, development, and thriving.” Individual cases like that of “Claudia”, in which memories were recovered during the course of extreme weight-loss (Bower, 1993), seem to point us in the direction of exploring externalized methods that individuals might use to assist them in this repression, such as abnormal weight gain. These could serve as a kind of emotional red herring, a reason for the emotions to exist without the necessity of remembering the events that actually created them.

Competing theories include the dissociative model, in which the memories are passively excluded from conscious awareness (Smith, 2000), and Philip T. Smith’s jigsaw-puzzle model: He provides a fairly eloquent description in a paper published in Memory in 2000:

According to the jigsaw model, unwanted memories can be rendered inaccessible in two different ways: by assigning a low importance value to their constituent fragments, or if the importance value is not sufficiently within a person’s control, by trying to ensure that few fragments are simultaneously encoded with the fragment to be forgotten. The former process shares features with repression, the latter process shares features with dissociation. What is novel about the jigsaw approach is that repression-like and dissociation-like phenomena could be seen to derive from initial encoding processes: there is no need to invoke active coping strategies in later storage and retrieval (Smith, 2000).

While this theory is compelling, it is clear that a great deal more research–particularly neuropsychological research–will be required to validate any model of memory recovery.

Practical Recovery

Finally, and perhaps most controversially, is the issue of inducing the recovery of lost memories. One study found that short-term group therapy “proved to be a powerful stimulus for recovery of previously repressed traumatic memories” (Herman & Schatzow, 1987), while another found that, in reality, “psychotherapy was the least commonly reported trigger” for such recall (Elliott, 1997). This study reported that most repressed events are actually recalled while watching television. In cases where recovered memories do arise during the course of psychotherapy, it would appear they do so “more typically during periods of positive rather than negative feeling toward the therapist, and they were more likely to be held with confidence by the abuse victim” (Dalenberg, 1996). At the present time, there simply does not appear to be a reliable way to elicit memory recovery, nor does there appear to be a reliable way to discern whether a “recovered” memory has any basis in truth, short of establishing external corroboration (LeDoux, 1996).


While it is clear that memories of traumatic events are in some cases lost or inaccessible for indefinite periods of time and then recovered, it is unclear what underlying neurological or psychological mechanisms might be responsible. A biological basis has been found for traumatic amnesia on its own, but this explanation is unable to account for–and would seem to preclude the possibility of–the potential of recovery. The major psychological models used to account for the phenomenon are repression and dissociation, although neither has much more experimental support than the other. What’s more, psychotherapy seems to be hit-or-miss at best when it comes to recovering lost traumatic memories, and the potential for the creation of false memories is profound. A great deal more research will be necessary, but a great deal more theoretical clarity will be necessary before research in this area is likely to be beneficial.


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Jonestown and The Social Psychology of Accepted Truth

Everybody “knows” what happened in Jonestown, Guyana in 1978. At the behest of their charismatic leader, all the members of the Peoples Temple religious cult—the residents of Jonestown—“lined up in a pavilion in front of a vat containing a mixture of Kool-Aid and cyanide” and  “drank willingly of the deadly solution” (Aronson, Wilson, & Akert, 2005, pp.4-5). That citation is taken from a popular Social Psychology textbook, and is a resounding demonstration of the phenomenon that this paper will attempt to explore: you see, the authors of that textbook feel so secure in their knowledge of the events surrounding the deaths in Jonestown that they feel no need to provide a reference for it. It is entered into the student consciousness as common knowledge. The fact that the popularly-accepted truth that Aronson, et al are parroting in this example is plainly false is almost beside the point, although this paper will provide a brief examination of some of the evidence which contradicts that accepted truth. The problem is much broader than the debunking of a single myth, and demands that some very important and difficult questions receive systematic evaluation: how is it that entire populations “know” things that contradict all available evidence, and what can be done to mediate this effect?

In considering the events of Jonestown, we might do well to start out by questioning our own credulity. What do we actually know about Jim Jones and The Peoples Temple, and from what sources? Does our understanding of the events stand up to logical scrutiny? Furthermore, as social psychologists, let us ask ourselves this very important question: In light of our current understanding of the power of social influence, do we believe it is plausible that 900 people took their own lives, simply because they were asked to? If so, are we willing to believe that we would behave in the same manner if subjected to similar social influences? As Aronson, et al (p.14) point out in their discussion of The Peoples Temple, “it is tempting and, in a strange way, comforting to write off the victims as flawed human beings. Doing so gives the rest of us the feeling that it could never happen to us.” The problem is that they use this rationale to imply that people would behave in a way that no empirical evidence has verified. Theirs is an argument from paranoia, having arisen out of its conclusion and stating as truism that which is both counterintuitive and unsupported. The idea here is not merely to pick on the authors of a textbook, but to pinpoint a mindset that is pervasive enough that it remains largely invisible in our society.

As Eileen Barker, the President of the Society for Scientific Study of Religions, has noted, “the belief in irresistible and irreversible mind-control techniques is so widespread that the democratic societies of Western Europe and North America appear to give ‘permission’ to citizens to carry out criminal attacks on someone merely on the grounds that he or she is a member of an unpopular religious group” (1996). Her research, however, does not support this belief. Furthermore, although there is very little research into the matter aside from her own, a small number of academics have taken up careers as “expert witnesses,” providing fervent yet unsubstantiated support to the idea. In the case of Jonestown, that man’s name was Dr. Hardat Sukhdeo. Jim Hougan writes:

Dr. Sukhdeo is, or was then, “an anti-cult activist” whose principal interests (as per an autobiographical note) are “homicide, suicide, and the behavior of animals in electro-magnetic fields.” His arrival in Jonestown on November 27, 1978 came only three weeks after he had been named as a defendant in a controversial “deprogramming” case. It is not entirely surprising, then, that within hours of his arrival in the capital, Dr. Sukhdeo began giving interviews to the press, including the New York Times, “explaining” what had happened.

Jim Jones, he said, “was a genius of mind control, a master.  He knew exactly what he was doing.  I have never seen anything like this…but the jungle, the isolation, gave him absolute control.”  Just what Dr. Sukhdeo had been able to see in his few minutes in Jonestown is unclear.  But his importance in shaping the story is undoubted: he was one of the few civilian professionals at the scene, and his task was, quite simply, to help the press make sense of what had happened and to console those who had survived.  He was widely quoted, and what he had to say was immediately echoed by colleagues back in the States. (1999)

The idea that a charismatic individual can completely overtake the decision-making power of random victims and use their mindless bodies to do his bidding even to the point of inciting a uniform mass suicide, with 600 adult individuals willfully—even joyously—killing themselves and their children is startling, anxiety-provoking, ambiguous, and enticing. It is, in short, good material for conversation. It is precisely the stuff of which rumors, gossip, and urban legends are made (Guerin & Miyazaki, 2006). It is not a realistic causal evaluation of plausible events, but is rather a good example of what is called “magical thinking,” the type of credulity typically associated with the pre-rational thought processes of young children. However, research indicates that as they mature, people tend to abandon magical beliefs in word only. “Indeed, in their general patterns of judgments, actions and justifications, adult participants seem to be prepared to respect both scientific and non-scientific causal explanations to an equal extent” (Subbotsky, 2001). By sharing rumors with amongst ourselves in the course of conversation and by receiving fantastical official versions through the media, this tendency toward fascination becomes manifest. Wherever mass media is the source of the information, we must also take into account the social component of individual judgement, which is a considerable influence (Joslyn, 1997). For, as McLuhan noted, sociality of mass media is profoundly experienced—when we watch television, we are influenced not only by the content of the programming but also by the knowledge that a large number of our peers are watching as well (1964).

This may help to explain why so many of us have accepted a version of the Jonestown events that are implausible. In addition to the psychological discrepancies we have already noted, let us observe that death by cyanide poisoning is a painful and grotesque affair. Central nervous system signals become scrambled, causing both voluntary and involuntary muscular systems to spasm violently. Twisted, contorted limbs and a terrible grimace known as cyanide rictus are typical of this cause of death (Jaffe, 1983 as cited in Judge, 1985). However, none of the more than 150 available photographs of the victims reveal these symptoms. Furthermore, the victims were laid out in neat rows, and some of the closer range photos reveal drag marks on the ground, indicating that the corpses were arranged in this way after their death. Based on an investigation that included the testimony of Dr. Leslie Mootoo, the top Guyanese pathologist who served as Chief Medical Examiner for the case and who personally examined many of the Jonestown bodies, a Guyanese grand jury concluded that only two of the 913 dead had committed suicide. Dr. Mootoo found fresh needle marks near the left shoulder blades of the vast majority of the victims he inspected, with some others exhibiting gunshot wounds or strangulation as the likely cause of death. The gun with which Jones himself is purported to have shot himself in the head was found lying nearly 60 feet from his body (Judge, 1985; Hougan, 1999; Schnepper, 1999). It is evident, then, that the supposed “mass suicide” was actually a massacre—but who would slaughter nearly a thousand U.S.citizens, nearly all of whom were African Americans, women, and underprivileged children?

There is a substantial body of evidence connecting Jim Jones and his Peoples Temple to the covert operations of the United States government intelligence community, not least of which are his longstanding ties with CIA operative Dan Mitrione, his adeptness at infiltrating and exploiting local governments, the suspicious circumstances surrounding the assassination of Congressman Leo Ryan in Guyana the evening before the massacre (whose escort was a high-ranking CIA officer), and the enormous cache of psychiatric drugs found on the premises of the Peoples Temple colony—all of the type being experimented with at that time under the CIA’s MKULTRA mind-control project (Judge, 1985; Hougan, 1999). Additional evidence of U.S.government involvement in the affair involves the self-proclaimed “anti-cult activist” psychiatrist Dr. Sukhdeo, whose own attorney has stated that his trip to Guyana was funded by the U.S. State Department.

The possibility exists that Jonestown, Guyana was indeed one of the many government experiments in mind-control of the 1970s. If it is, however, it would seem that the experimental subjects included not only the members of the Peoples Temple, but also the public at large. Regardless of intention, we have here a clear case of a governmental bureaucracy producing and disseminating misinformation for one reason or another, and the public—including the scientific community—accepting it without question, repeating it with authority, and even using it as a basis for social theory. The danger that this presents to free society is enormous, and the need for a concerted scientific effort to understand its limits and to develop safeguards is equally enormous.


  1. Aronson, Elliot, Wilson, Timothy D., & Akert, Robin M. (2005). Social Psychology, 5th Edition.New Jersey: Pearson Education, Inc.
  2. Barker, Eileen (1996). “The Freedom of the Cage.” Society, Vol. 33 Issue 3, pp53-59.
  3. Guerin, Bernard & Miiyazaki, Yoshihiko (2006). The Psychological Record, Vol. 56, pp.23-24.
  4. Hougan, Jim (1999). ‘‘Jonestown. The Secret Life of Jim Jones: A Parapolitical Fugue.’’ Lobster, Vol. 37, pp.2-20.
  5. Joslyn, Mark R. (1997). Political Behavior, Vol. 19 No. 4, pp.337-343.
  6. Judge, John (1985). ‘‘The Black Hole of Guyana: The Untold Story of the Jonestown Massacre.’’ In Keith, Jim (Ed.), Secret and Suppressed: Banned Ideas and Hidden History.Portland,OR: Feral House.
  7. McLuhan, Marshall(1964). Understanding Media: The Extensions of Man. Massachusetts: MIT Press.
  8. Schnepper, Jeff A. (1999). “Jonestown Massacre: The unrevealed story.” USA Today Magazine, Vol. 127 Issue 2644, p26.
  9. Subbotsky, Eugene(2001). British Journal of Developmental Psychology, Vol. 19, pp.23-46.