Year: 2020

Do you, or someone you know, ever start to feel dips in your energy, become irritable, and feel down every fall?  Keep reading to see if you may need to talk to someone about how you feel.

What is Seasonal Affective Disorder?

Seasonal Affective Disorder (SAD), or Depression with Seasonal Pattern, is a condition that comes and goes based on seasonal changes, appearing in the fall and going away in the spring/summer. This diagnosis should only be considered when the feeling is beyond the “winter blues” due to the lack of engagement in typical hobbies and/or outdoor activities due to weather.  Seasonal Affective Disorder can also occur during spring and summer although it is not as common to experience SAD during the warmer seasons.

There is debate regarding the cause of SAD. There is some that believe SAD is influenced by exposure to sunlight. Our bodies react to how much sun we are exposed to through our circadian rhythm. Our circadian rhythm is our natural clock that regulates many things, including mood and sleep.   Exposure to sunlight may also affect chemicals in our brain (serotonin) and our body (melatonin), which also influences how we feel.  Other experts do not believe there is enough evidence to support this theory, and connect mood changes to being inside more and being unable to engage in the same outdoor activities/hobbies that you enjoy.  This influence to mood can still benefit from treatment with a psychologist.

Who is at risk of developing SAD?

It is estimated that SAD makes up 10% of all reported cases of depression. Approximately 15% of Canadians will report at least a mild case of SAD in their lifetime, while 2-3% will report serious cases. People with a family history of any form of depression may also be at risk of developing SAD.  Canadians are particularly at risk, as we have decreased sunlight during the winter months.

If you have a history of depression or bipolar disorder, your symptoms may become worse seasonally.

What are the symptoms of Seasonal Affective Disorder?

If you have SAD, you may find yourself feeling many symptoms of depression, especially irritability, and you may be more sensitive in interpersonal relationships. People often report that their energy levels are unusually low, causing them to feel tired, heavy, or lethargic. As a result, you may feel that your regular sleep schedule doesn’t provide adequate rest. Oversleeping is commonly reported in SAD.

You may find that your appetite has changed, and you may crave foods that are higher in carbohydrates, starch, and fat. Some people report weight gain, especially when you are frequently eating “comfort foods” (e.g., high calorie and fast foods). You may lose interest in activities that you once enjoyed, which may cause you to develop a more avoidant or sedentary lifestyle. Physical intimacy may appear uninteresting or too demanding. You are also likely to feel stressed, distracted, sad, guilty, or hopeless.

Can Psychology Help Seasonal Affective Disorder?

There are many ways to reduce symptoms of SAD or the winter blues. The most widely recommended psychotherapy for SAD is cognitive behavioural therapy (CBT).  CBT helps individuals focus on immediate thoughts, moods, and feelings, which allows problems to be broken down and made more manageable. Your psychologist may also recommend lifestyle changes in the winter, such as opening blinds, going outside, and exercising. You can undergo CBT either alone or in a group setting. Research suggests that CBT can help improve present symptoms while providing you with a healthy defense for future episodes.

Other forms of psychotherapy commonly used for the treatment of SAD are counselling and psychodynamic therapies. These therapies allow you to discuss concerns and worries with a therapist in an open and confident environment. You may discuss feelings about yourself and others, or past experiences that could be influencing your symptoms. One goal is to identify any memories or feelings that could be influencing your current state of mind. Once possible causes have been identified, you will work through them to resolve any negative influences presently affecting you.

Are there other treatments for Seasonal Affective Disorder?

Some studies have identified light therapy as an effective method for improving symptoms. In this therapy, the user sits in front of a special light box or lamp for approximately 30 minutes a day. Light therapy can be administered in a doctor’s office, or at home with your own equipment on a schedule recommended by a clinician. You should consult with your doctor before beginning light therapy. Light therapy is not suitable for everyone as there can be negative side-effects associated with this treatment including eye strain, agitation, headaches, and nausea. Light boxes should only be purchased after a discussion with your treating professional, as not all light boxes are effective, and you may want to review with your treating professional the research regarding the use of light boxes.

Exposure to natural light can be helpful. Research has found benefits from exposure to sunlight within one hour from waking up in the morning, particularly for people with SAD. You can sit beside a window, keep your blinds open when you are home, trim branches that block light on your property, or take frequent walks outside with proper UV protection.

Most importantly, it is also encouraged that you live a healthy and balanced lifestyle to improve symptoms and reduce the severity of future episodes. Try incorporating exercise into your daily routine. Exercise will help increase your physical and mental well-being, ease your stress, and reduce feelings of lethargy. Eat a healthy diet and be mindful not to overindulge cravings for high sugar/starch/fatty foods. Make sure to stick to regular sleeping habits to combat fatigue and avoid oversleeping.  Additionally, make sure that you have a healthy level of vitamin D in your diet with your physician and/or pharmacist.

Although your symptoms may initially make this difficult, keep in regular contact with family and friends, both in person and via electronic means. These networks can provide opportunities to socialize and refresh your mood. Reach out to people in your support network for comfort and understanding. This can help ease feelings of guilt, isolation or hopelessness. Make sure to spend some leisure time doing activities that you find rewarding and gratifying. Practice mindfulness and pacing inside the home if you cannot make it outside (in front of windows if possible). Finally, exercise stress management techniques such as meditation and mindful breathing.

Alternatively, your physician may decide that medication, such as an antidepressant, is an effective treatment for you. Pharmacotherapy likely will be recommended for symptoms that are severe and have a significant impact on daily functioning. There are side effects with medications, which should be discussed with your prescribing professional.

Where can I get more information?

• Canadian Mental Health Association (BC branch): http://www.heretohelp.bc.ca/sites/default/files/seasonal-affective-disorder_0.pdf
• American Psychological Association (APA): provides information on symptoms management and how psychologists can help: http://www.apa.org/helpcenter/seasonal-affective-disorder.aspx
• Center for Addiction and Mental Health (CAMH): provides general information, as well as a short video about symptoms and treatments for SAD: http://www.camh.ca/seasonal_affective_disorder
• Information regarding the debate of the diagnosis: http://journals.sagepub.com/doi/abs/10.1177/2167702615615867

You can consult with a registered psychologist to find out if psychological interventions might be of help to you. Provincial, territorial, and some municipal associations of psychology often maintain referral services. For the names and coordinates of provincial and territorial associations of psychology, please visit:  https://cpa.ca/public/whatisapsychologist/ptassociations/

This fact sheet has been prepared for the Canadian Psychological Association by Sarah Amirault, Carleton University.

Date: July 2018

Your opinion matters! Please contact us with any questions or comments about any of the Psychology Works Fact Sheets:  factsheets@cpa.ca

Canadian Psychological Association

Tel: 613-237-2144
Toll free (in Canada): 1-888-472-0657

What is Social Anxiety?

It is common to feel some anxiety in social situations from time to time.  Many of us feel anxious when we’re at a job interview, on a first date, or giving a speech.  We all want to make a good impression and be liked.  However, some people feel very nervous and uncomfortable in social situations.  Individuals with social anxiety worry a great deal about doing something embarrassing and others thinking badly of them.  They tend to be very self-conscious and constantly feel “on stage.”  While some people with social anxiety fear lots of different social situations (e.g., meeting new people, going to parties, starting conversations, being the centre of attention, ordering food in a restaurant, etc.), some people only get anxious in very specific situations (e.g., public speaking).  When faced with feared social situations, individuals with social anxiety tend to experience the following:

• Thoughts: negative thoughts about themselves (e.g. “I’ll say something stupid,” “I’ll look anxious,” “I’ll have nothing interesting to say”) and how other people will react to them (e.g. “People won’t like me,” “Classmates will think I’m boring,” “Colleagues will think I’m weird”)
• Feelings: anxiety, fear, nervousness, embarrassment, shame
• Body reactions: sweating, blushing, trembling, shaking, racing heart, upset stomach, nausea, dizziness, lightheadedness, choking sensations, dry mouth
• Behaviours: avoidance of social situations (e.g., skipping the party, not going to a meeting or class, saying “no” to social plans with friends) and the use of safety behaviours, which include any actions used to try and feel safer and less anxious in a social situation (e.g., saying very little, avoiding eye contact, rehearsing what you say before you say it, not expressing your opinion, using alcohol or drugs).

When does social anxiety become a problem?

Social anxiety becomes a problem or is considered a disorder when it feels intense, happens a lot, causes us distress, and affects different parts of our lives including:

• Work and school (e.g., missing work or school, trouble participating in meetings or classes, poor performance at work or school, not pursing certain school programs or jobs/careers, and difficulty talking to bosses and co-workers or teachers and other students)
• Relationships and friendships (e.g., difficulty making and keeping friends, trouble dating, and difficulties being assertive and opening up to people)
• Recreational activities and hobbies (e.g., avoiding trying new activities or joining things such as going to the gym, joining a running club, or taking an art class)
• Day-to-day activities (e.g., difficulty completing daily activities such as grocery shopping, ordering food at a restaurant, making phone calls, asking for help, and using public transit)

Who has problems with social anxiety?

Anyone can have problems with social anxiety. You might not know from the outside that someone is suffering on the inside. When social anxiety causes distress and gets in the way of functioning in life, we call it Social Anxiety Disorder. It is one of the most common anxiety disorders, 8-12% of people being diagnosed at some point in their lives.

Research suggests that both genetics and environment can play a role in the development of social anxiety problems.  Social anxiety tends to run in families, which means if someone in your family has an anxiety problem you may be more likely to develop one.  Various life events or experiences, such as being teased or bullied, can play a role.  Social anxiety problems can develop slowly over time, often starting in elementary school or early adolescence, or after a particularly embarrassing or stressful event.

What treatments help people with social anxiety?

Pharmacological interventions (medications) can help people with Social Anxiety Disorder. Ask your family doctor (General Practitioner) or Psychiatrist about options.

Cognitive Behaviour Therapy (CBT) is the gold standard nonpharmacological treatment for social anxiety disorder. Scientific research shows that CBT helps people with social anxiety. CBT involves learning new ways of thinking (cognition) and acting (behaviour), which can lead to reducuctions in anxiety.  A typical course of CBT is 12 to 20 one-hour sessions.

People with social anxiety tend to overestimate the threat of social situations and underestimate their ability to cope with them. CBT teaches cognitive techniques (e.g., identifying and challenging unhelpful thoughts or beliefs) to help people feel less anxious and engage in social situations more.

People with social anxiety also tend to avoid feared social situations or people. Avoidance works well in the short term (e.g., anxiety temporarily goes down by skipping the party) but causes more problems in the long run (e.g., missing out on meeting new friends, sending yourself the message that that situation is dangerous and you can’t cope). A CBT therapist will help you gradually face your excessive fears. The process of “exposure” helps reduce anxiety by teaching people (through experience) that situations are safer than they think and they can manage them.

Mindfulness-based therapy and Interpersonal therapy can also help people with social anxiety; however, they appear to be less effective than traditional CBT. Mindfulness-based therapy (MBT) involves learning to pay attention to your thoughts, feelings, sensations, and surroundings in the present moment, without judging. Interpersonal therapy (IPT) involves exploring issues in relationships with other people to help you understand and improve interpersonal situations.

The good news is that psychotherapy has been shown to be effective for most people with social anxiety disorder, which means most people get better with treatment. However, it can take several weeks to months, or even longer to notice changes.  In terms of medication, it can take some trial and error to find the right medication.  So stick with it, change takes time.

How can psychologists help people with social anxiety?

• Psychologists educate people about social anxiety so they understand what it is and how to handle it.
• Psychologists conduct assessments that help clarify diagnosis and develop a plan for tackling social anxiety.
• Psychologists provide effective treatments, such as Cognitive Behavioural therapy (CBT).
• Psychologists engage in research to help us better understanding social anxiety and improve treatments.
• Psychologists can advocate for people with social anxiety. Currently, not every Canadian can freely and easily access evidence based psychological treatments for social anxiety disorder.

For more information:

You can consult with a registered psychologist to find out if psychological interventions might be of help to you. Provincial, territorial and some municipal associations of psychology often maintain referral services. For the names and contact information of provincial and territorial associations of psychology, go to https://cpa.ca/public/whatisapsychologist/ptassociations/.

You can find additional information and free self-help resources on social anxiety at:

• http://www.anxietycanada.ca
• https://cmha.ca

This fact sheet has been prepared for the Canadian Psychological Association, in cooperation with AnxietyBC, by Dr. Melanie Badali and Dr. Kristin Buhr, Registered Psychologists at the North Shore Stress and Anxiety Clinic.

Date: June 29, 2018

Your opinion matters! Please contact us with any questions or comments about any of the Psychology Works Fact Sheets:   factsheets@cpa.ca

Canadian Psychological Association

Tel: 613-237-2144
Toll free (in Canada): 1-888-472-0657

What Are Enuresis and Encopresis?

Enuresis means urinating (peeing) where you shouldn’t (e.g., in bed or in clothing). Encopresis means defecating (pooping) where you shouldn’t (e.g., in clothes or on the floor). To have enuresis or encopresis:

• A child must be old enough to be toilet trained, meaning 5 years old or older for enuresis and 4 years old or older for encopresis. Children younger than this probably just need more time to learn. You can look at the resources below on toilet training for more ideas on helping these children.
• The wetting or soiling (pooping) must also happen regularly. That means at least twice a week for enuresis and once a month for encopresis.
• The wetting or soiling must also happen That means this problem must happen for at least 3 months.

Some children with enuresis only have problems at night (bedwetting), referred to as nocturnal enuresis. Enuresis and encopresis are separate problems, but they can sometimes occur together.

Enuresis is fairly common in young children, affecting about 5-10% of 5-year-olds. Enuresis becomes less common as children get older, but about 1% of those over 15 years old have it. Encopresis is less common, with about 1% of 5-year-olds having it.

It is important to know that children almost never wet or soil their clothes to upset you! Most children would rather be able to use the toilet properly.

Why Does My Child Have Enuresis or Encopresis? What Are the Risk Factors?

There are many reasons children may develop enuresis or encopresis. Some common risk factors are:

• Lack of toilet training. Although some children seem to learn without being taught, many need someone to clearly teach them to use the toilet.
• Toilet training before the child was ready.
• Stress (e.g., birth of a younger sibling, moving, new childcare, etc.).
• Constipation (difficulty pooping) is a primary cause of encopresis and can be related to lifestyle choices like eating too much “junk food,” not eating enough fibre (e.g., fruit, whole grains), not drinking enough fluids, and not exercising regularly (e.g., walking, biking, running, swimming).
• Anxiety or worry about pooping following a difficult toileting experience (e.g., a painful poop, an illness, having an accident in public).
• Family history of enuresis (especially for bedwetting).
• Urinary tract infections.
• Distractibility (a distractible child may have difficulty listening to their body telling them they need to pee or poop).
• Anxiety about toilets, germs, bathrooms, or separation from a parent.

Sometimes the cause of a child’s enuresis or encopresis is unknown. All we can do is try to help them cope with it and treat it as best we can.

Why Are Enuresis and Encopresis a Problem?

Children with encopresis or enuresis may develop low self-esteem, feel anxious or sad, and struggle with behavioural problems. Some children with encopresis or enuresis may feel alone and embarrassed, and may be teased by other children. Children with encopresis or enuresis may also struggle with learning and school, and tend to miss more school than their peers.

Encopresis and enuresis can also have a negative impact on the family. Having a child with encopresis or enuresis can be stressful for parents. They often worry about their child being teased at school and about what other families may think. Parents of children with encopresis or enuresis may feel judged, alone, anxious, and helpless. Parents may also become frustrated with their child and other caregivers, which can be hard on their relationships.

How Can Psychologists Help Children With Enuresis and Encopresis?

Children with enuresis and encopresis often benefit from seeing a psychologist. Many children with enuresis and encopresis get better with time even without treatment. For these children, treatment simply helps it happen faster.

Psychologists can:

• Help children become aware of the signs their body uses to tell them they need to go to the bathroom.
• Explain enuresis and encopresis to families in a way that helps them see the accidents as the problem instead of placing the blame on the child.
• Provide behavioural treatment to encourage the child to use the toilet.
• Help parents guide their children in healthy eating, drinking, and exercise habits that are important for bowel and bladder control.
• Provide support with anxiety and challenging behaviours related to medical appointments and treatment (e.g., refusal to do enemas or take laxative or stool softener for constipation).

There are many treatment options available for enuresis and encopresis. Medical treatments can help and are sometimes necessary (e.g., the use of laxatives or enemas). Behavioural treatments have longer lasting results in treating enuresis and encopresis. Examples of common treatment approaches include:

• Dry bed training with a urine alarm for treating bedwetting. This approach involves having the child wake up in the night on a bathroom schedule and using an alarm to wake the child up if an accident happens. It is also important to praise the child when they stay dry!
• Enhanced Toilet Training for encopresis. This approach combines the use of a toileting schedule and rewards (to encourage regular toilet sits), making appropriate lifestyle changes (e.g., eating, drinking, and exercising habits), providing education on which body parts are involved with pooping, modeling how to properly poop to the child, and using medication.

Here are some ways parents and caregivers can help. See a psychologist for more support in using these:

• Reduce shame: When children poop and pee in inappropriate places such as their pants, they frequently feel shame and embarrassment. Parents may accidentally add to these feelings by showing their frustration, anger, or disappointment towards the child when accidents occur. This shame and embarrassment can lead children to have more difficulty with using the toilet. Talking about the issue in a way that externalizes the toileting difficulties (e.g., “That tricky poop is causing us some problems, isn’t it?”) helps to take the blame off of the child.
• Encourage and model healthy habits: Healthy, fibre-filled foods, frequent fluid intake, and regular exercise play a key role in helping children struggling with enuresis and/or encopresis. It is important to explain to children how physical activity and what we eat and drink are related to our bowel and bladder control. Knowing that children are constantly learning from watching others, we can be helpful by modelling healthy eating and having fun through regular exercise.
• Help your child identify their need to go: We know that our bodies give us clues when we need to pee or poop. Children with enuresis or encopresis may not notice these. We can help by pointing out these signs to children in a clear, non-judgmental way. For example, saying, “Your legs are crossed. That might mean you need to pee. Let’s go!”
• Reduce fear and anxiety: It is important to understand if there are any fears or worries that are getting in the way of a child using the toilet. We may be able to problem-solve with children to find solutions to reduce these fears. For example, a comfortable toilet seat and stool for a child to rest their feet on to address a fear of falling in the toilet. Some children may need more support with slowly facing their fear in small manageable steps to gradually reduce these fears over time. For example, if your child is afraid to sit on the toilet, we might start by having the child stand beside the toilet, and once they are comfortable with that they might move to sitting on the toilet for 10 seconds in their clothes, and slowly progress to sitting on the toilet without pants or underwear when they need to pee or poop.

Are There Other Professionals We Should See?

Medical doctors and nurse practitioners can help rule out other causes of your child’s wetting or soiling. They can also help your child with medically managing constipation and pain when pooping.

Dieticians can help with ideas for a healthy, fibre-filled diet to help maintain your child’s ability to poop regularly.

Physiotherapists can help your child strengthen the muscles needed to hold pee and poop in. They can also help children learn to pee and poop on command (learn to open and close their sphincters voluntarily) and can help your child figure out when they need to go.

Where Can I Go for More Information?

For more resources, see:

• American Academy of Family Physicians
  • Enuresis, https://www.aafp.org/afp/2014/1015/p560-s1.pdf
• Psychology Today
  • Encopresis, https://www.psychologytoday.com/ca/conditions/encopresis
  • Enuresis, https://www.psychologytoday.com/ca/conditions/enuresis
• Children’s Hospital of Eastern Ontario
  • Constipation, https://www.cheo.on.ca/en/resources-and-support/resources/P5593E.pdf
• UCanPoopToo, http://www.ucanpooptoo.com/
  • See especially Encopresis Tips for Parents, http://www.ucanpooptoo.com/parent-tips
• The Poo in You – Constipation and Encopresis Educational video (Children’s Hospital Colorado)
  • This helpful video explains why accidents happen and strategies for helping your child, https://www.youtube.com/watch?v=SgBj7Mc_4sc

You can consult with a registered psychologist to find out if psychological interventions might be of help to you. Provincial, territorial, and some municipal associations of psychology may make available a referral list of practicing psychologists that can be searched for appropriate services. For the names and coordinates of provincial and territorial associations of psychology, go to  https://cpa.ca/public/whatisapsychologist/PTassociations/.

This fact sheet has been prepared for the Canadian Psychological Association by Drs. Jennifer Theule¹, Kristene Cheung¹, Brenna Henrikson², Michelle Ward¹, and Kylee Clayton¹

¹ University of Manitoba

² Shared Health, Manitoba

Revised: July 2025

Your opinion matters! Please contact us with any questions or comments about any of the PSYCHOLOGY WORKS Fact Sheets:  factsheets@cpa.ca

What is health anxiety?

Most people have felt anxious about their health or the health of loved ones at some point in their lives. In fact, we are often faced with health situations in which it is entirely appropriate to feel some anxiety. For example, you may be waiting for the results of a biopsy or your friend may have just been diagnosed with a serious illness. It is natural to feel anxious and upset in these situations. Similarly, most of us worry about death and dying from time to time. Experiencing anxiety about illness and death is normal.

Worries about health and dying can become a problem if they get in the way of living and enjoying life. Health anxiety involves fears of having or developing a serious disease such as cancer, heart disease, or multiple sclerosis. Health anxiety is often associated with high levels of worry, substantial focus on bodily symptoms, repeated checking for signs and symptoms related to health concerns, focus on death and dying, and frequent efforts to obtain reassurance from family members, friends, or health care professionals. Some people with health anxiety avoid going to doctors because of fears of being diagnosed with a serious disease or because of dissatisfaction with previous health care experiences. Individuals with health anxiety may also avoid other situations related to illness and death, including activities such as spending time with loved ones who are ill, attending funerals, and writing a will.

Worries about health may be triggered by experiences such as everyday symptoms (a skipped heartbeat, a headache), a frightening experience such as finding a breast lump, or coping with illness or death of a loved one. Anxiety may also be triggered by stories about health issues in the community or media. Worries may be mild and transient or they may have a more severe and chronic course, waxing and waning over time. Some individuals may worry about one specific illness or body symptom, while others worry about many. Health anxiety can occur on its own and may then be termed illness anxiety disorder.  It may also be part of other problems such as panic disorder, generalized anxiety disorder, obsessive-compulsive disorder and depression. People who have diagnosed medical conditions may also experience high levels of anxiety as a reaction to their health problems. In some circumstances, the level of health anxiety may be excessive and may interfere with normal functioning and enjoyment of life.

How prevalent is health anxiety?

Estimates suggest that 3-10% of the general population suffer from significant health anxiety. Up to 30% of the population experience intermittent or milder fears about their health. This is a relatively common problem and one that can cause significant interference. It can also be costly to the health care system when it results in high levels of health service utilization.

What are the main causes of health anxiety?

There are a variety of factors that may contribute to the development and onset of problems with health anxiety. These include:

Genetics: Some people are born with a temperament that leads them to be more prone to experiencing anxiety than most people. In addition, most forms of anxiety run in families to some degree.

Family background and childhood experiences: Individuals who experience a stressful family life during their childhood (such as family conflict, high family stress, or abuse) are more likely to develop problems with anxiety and depression. People who have problems with anxiety in general may be more likely to also have worries and fears about health and illness.

Social Learning: We can learn many things from our parents, siblings, or other significant people in our lives. Sometimes these lessons can be positive but at times we can pick up negative things from those around us. Children often model what their parents or siblings do. For example, if an anxious parent avoids a range of situations, children watching this are likely to behave in similar ways (i.e., engaging in avoidance).

Parents or other important people can also pass on fears through verbal communication. For instance, fearful or anxious people may be overly concerned about potential dangers and often communicate these fears to their children by saying certain things, such as: “If you have a stomach ache you had better stay home and be in bed until you feel better” or “Did you hear about Sally – she was fine one day then she was diagnosed with brain cancer, and now she’s dead”.  In this case, viewing health as fragile and illness as painful and deadly may lead a child to become focused on health concerns, avoid certain situations, or worry excessively about illness and death.

Illness and death experience: Health anxiety may also be related to stressful experiences with illness and death in childhood or during the adult years.

What psychological treatments are used to treat health anxiety?

The primary psychological treatment that has been shown to be effective with this problem is cognitive-behavioural therapy (CBT). This treatment involves:

• understanding anxiety and how problems with anxiety can develop;
• decreasing specific behaviours such as checking one’s body for symptoms and asking for reassurance about one’s health;
• learning how to counter the excessive worries about health and illness;
• overcoming avoidance of situations related to illness and death using exposure strategies;
• learning to face worries about illness realistically and directly which can reduce the fear associated with these thoughts;
• coping with fear of death by emphasizing the importance of accepting the reality of death and enjoying life to the fullest; and
• general anxiety management strategies such as relaxation techniques and increasing exercise.

How effective are psychological methods of treating health anxiety?

Research demonstrates that cognitive-behavioural treatment is helpful in reducing fears about having and/or getting a serious illness. Studies show that individuals receiving from 6 to 20 treatment sessions generally report decreased illness fear and a reduction in accompanying depression. Both individual and group treatments are effective.

Where do I go for more information?

For the public:

• Overcoming Health Anxiety: Letting Go of Your Fear of Illness. By K. Owens & M. Antony (2011). Oakland, CA: New Harbinger.
• It’s Not All in Your Head: How Worrying About Your Health Could be Making You Sick – and What You Can Do About It. By G.J.G. Asmundson & S. Taylor (2004). New York: Guilford Press.
• Ten Simple Solutions to Worry. By Kevin Gyoerkoe & Pamela Wiegartz (2006). Oakland, CA: New Harbinger.
• https://www.anxietycanada.com/anxiety-disorder/health-anxiety/
• https://adaa.org/understanding-anxiety/related-illnesses/health-anxiety
• https://www.cci.health.wa.gov.au/Resources/Looking-After-Yourself/Health-Anxiety

For the professional:

• Treating Health Anxiety and Fear of Death: A Practitioner’s Guide. By P. Furer, J.R. Walker, & M.B. Stein (2007). New York: Springer.
• Treatment of Health Anxiety and Hypochondriasis: A Biopsychosocial Approach. By J. Abramowitz & A. Braddock (2008). Ashland, OH: Hogrefe & Huber.
• Treating Health Anxiety: A Cognitive-Behavioral Approach. By S. Taylor & G.J.G. Asmundson (2004). New York: Guilford Press.
• Tackling Health Anxiety: A CBT Handbook. By H. Tyrer (2013). London: RCPsych Publications.

You can consult with a registered psychologist to find out if psychological interventions might be of help to you. Provincial, territorial and some municipal associations of psychology often maintain referral services. For the names and coordinates of provincial and territorial associations of psychology, click https://cpa.ca/public/unpsychologue/societesprovinciales/.

This fact sheet has been prepared for the Canadian Psychological Association by Patricia Furer, Ph.D., C.Psych., Dept. of Clinical Health Psychology, University of Manitoba.

Revised: June 2020

Your opinion matters! Please contact us with any questions or comments about any of the Psychology Works Fact Sheets:  factsheets@cpa.ca

Canadian Psychological Association

Tel: 613-237-2144
Toll free (in Canada): 1-888-472-0657

Most of us have experienced at least one traumatic event in our life. The events can have long lasting impact on our life, on our sense of self and identity, our belief system and on our overall functioning, whether personal, social, or occupational. We might have constant distressing memories of the upsetting or traumatic event, have bad dreams, feel that we are constantly on guard for any signs of threat or danger, fear of an impending doom or something bad happening, feel emotionally numb, feeling withdrawn, not having much tolerance for stress or public, feel angry, irritable, anxious, ashamed or guilty, or feel excessively jumpy.

Trauma has an individual impact. Each person might experience and feel the symptoms of trauma differently. For some PTSD is associated with emotional dysregulation such as flashbacks, distressing memories of the trauma, feeling excessively jumpy and being constantly on guard whereas for others, it is related to emotional numbness and self-isolation.

The majority of individuals exposed to potentially traumatic events experience posttraumatic symptoms, shortly after the traumatic event. Over time, in particular within the first month or so, the symptoms tend to gradually improve. In some cases, however, the symptoms can increase over time, create more emotional and psychological distress and interfere with overall functioning. In the latter case, the symptoms might be reflective of diagnosis of posttraumatic stress disorder.

There are as well risk factors that can increase vulnerability to PTSD (e.g., childhood adversity and abuse; high stress), risk factors during PTSD (e.g., accumulations of traumatic incidents; lack of social support), and risk factors following PTSD (e.g., financial or relationships strains; physical injuries); and the risk factors can contribute to severity and duration of posttraumatic stress reactions and impact functioning and recovery. Furthermore, the risk factors that contribute to the development of PTSD are not the same risk factors maintaining PTSD.

If the symptoms do not improve over time, and exacerbate over time, in particular over a month, cause more distress or you feel that you have more and more difficulty engaging in your daily activities or responsibilities and/or the symptoms are impacting your overall functioning then you might be suffering from PTSD. In such case, seeking professional from a mental health professional such as a qualified clinical psychologist can be helpful.

What are the symptoms of PTSD?

The Diagnostic and Statistical Manual of Mental Disorders, 5^th edition, DSM-5, (American Psychiatric Association, 2013)[1], defines PTSD and its four clusters of symptoms, including intrusive memories of the trauma, avoidance of trauma related stimuli, negative changes in mood or cognitions, and arousal symptoms.

PTSD symptoms^[2] for adults, adolescents, and children older than six; symptoms must persist for more than one month:

1. Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the followings:
   1. Directly experiencing the traumatic event(s).
   2. Witnessing the event occurring to others
   3. Learning that the traumatic event(s) occurred to a loved one such as family member or a close friend; and in such case, the event(s) must have been violent or accidental.
   4. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s). For instance, police officers conducting child abuse investigations. The exposure in this category is work related.
2. Intrusion symptoms:
   1. Recurrent, distressing and intrusive memories or images of the traumatic event(s).
   2. Distressing dreams or nightmares related to the traumatic event.
   3. Flashbacks, a sense of reliving the event or acting or feeling as if the event were recurring. Note: children may re-enact the event in their play.
   4. Experiencing psychological distress following any triggers related to the traumatic event or any cues that might resemble the event.
   5. Experiencing physiological reactions following triggers. For instance, heart pounding, sweating, and/or chest pain.
3. Persistent avoidance:
   1. Avoidance of distressing memories, thoughts, or feelings about the trauma.
   2. Avoidance of reminders of the trauma. For instance, location, going out alone, conversations, some people or objects, some materials on TV, and/or activities related to the event. It also not uncommon to engage in safety behaviours such as leaving the house always accompanied; when sitting in public, ensuring the back is against the wall.
4. Negative alterations in cognitions and mood:
   1. Inability to remember certain important aspect of the traumatic event(s).
   2. Exaggerated negative beliefs about self, others or the world. For instance, “I am a failure”, “I am weak”, “I cannot trust anyone”, “the world is completely dangerous no matter where you go or what you do”.
   3. Distorted cognitions about the cause or consequences of the traumatic event. In such case, it leads to either blaming self and/or blaming others. For instance, “it is my fault it happened”, “I should have done this, done that”.
   4. Persistent negative emotions such as feeling constant anxiety, guilt or shame.
   5. Diminished interest in activities or hobbies previously enjoyed
   6. Feeling emotionally numb or emotionally distant or cut off from others. For instance, you know you love your family but feel emotionally distant or numb and have difficulty feeling the love.
   7. Inability to experience positive emotions such as feeling happy or love.
5. Marked alterations in arousal:
   1. Irritable behavior and angry outbursts. It could be either verbal or physical
   2. Reckless or self-destructive behavior. For instance, if alcohol is consumed excessively to reduce distress then that can also be a type of self-destructive behaviour.
   3. For instance, feeling constantly on guard for signs of threat or danger.
   4. Exaggerated startle response. For instance, feeling excessively jumpy at any sound or noise.
   5. Difficulties with concentration, focusing or attention or memory.
   6. Sleep disturbance. For instance, difficulty falling or staying asleep; early morning awakening.

The American Psychological Association (APA)^[2] developed a guideline that provides recommendations on psychological and pharmacological treatments for posttraumatic stress disorder (PTSD) in adults. The guideline is based on recommendations of the Institute of Medicine report, Clinical Practice Guidelines We Can Trust (IOM, 2011).

Among many recommendations, strong recommendations are provided for the following interventions:  cognitive behavioral therapy (CBT), cognitive processing therapy (CPT), cognitive therapy (CT), and prolonged exposure therapy (PE). For pharmacological treatment, there are recommendations for fluoxetine, paroxetine, sertraline, and venlafaxine. There are significant individual differences as well as comorbidities among mental health conditions and comorbidities between mental and physical health conditions. Co-morbidities such as depression, anxiety disorders, substance use disorders, personality disorders, or and/psychosis are common. Thus, a comprehensive assessment to help with a comprehensive case conceptualization and whole person management approach can subsequently help towards optimizing treatment options for each person. It is recommended to always consult with your mental health professional and prescribing physician for any pharmacological treatment that might help concurrent with evidence-based psychological treatment.

Self-care, including for instance, balanced healthy diet, proper sleep hygiene, exercise, seeking quality support, managing thoughts and emotions, setting meaningful and realistic graduated goals, active problem solving, and remaining hopeful are among the many proactive strategies that help towards health, quality of life and well-being.

Where do I go for more information?

More information about PTSD/treatment of PTSD can be found at:

• American Psychiatric Association https://www.psychiatry.org/patients-families/ptsd/what-is-ptsd
• Australian Centre for Posttraumatic Mental Health https://www.phoenixaustralia.org/
• International Society for Traumatic Stress Studies (ISTSS) https://istss.org/home
• Institute of Medicine (IOM) of the National Academies of Sciences, Engineering, and Medicine https://www.nationalacademies.org/hmd/about
• United Kingdom’s National Institute for Health and Care Excellence (NICE) https://www.nice.org.uk/
• US Department of Veterans Affairs and Department of Defense (VA, DoD) https://www.healthquality.va.gov/
• World Health Organization (WHO) https://apps.who.int/iris/bitstream/handle/10665/85119/9789241505406_eng.pdf;jsessionid=F8FFF3C6CF9401DDCD81EEA15A16C564?sequence=1
• Global Collaboration on Traumatic Stress – https://www.global-psychotrauma.net/
• Canadian Mental Health Association: http://www.cmha.ca/
• Centre for Addiction and Mental Health (CAMH) https://www.camh.ca/en/health-info/mental-illness-and-addiction-index/posttraumatic-stress-disorder
• National Institute of Mental Health:  http://www.nimh.nih.gov
• Anxiety Disorders Association of Canada, http://www.anxietycanada.ca/
• Society of Clinical Psychology of the American Psychological Association, http://www.apa.org/divisions/div12

Where can I get more information about psychology/psychologists?

Provincial associations of psychology:  https://cpa.ca/public/whatisapsychologist/PTassociations/

Psychology Foundation of Canada: http://www.psychologyfoundation.org

American Psychological Association (APA): http://www.apa.org/helpcenter

You can consult with a registered psychologist to find out if psychological interventions might be of help to you. Provincial, territorial, and some municipal associations of psychology often maintain referral services. For the names and coordinates of provincial and territorial associations of psychology, please visit:  https://cpa.ca/public/whatisapsychologist/PTassociations/

This fact sheet has been prepared for the Canadian Psychological Association by Dr. Katy Kamkar, Ph.D., C. Psych, Clinical Psychologist & Chair, Canadian Psychological Association, Traumatic Stress Section.

Date: August 2020

Your opinion matters! Please contact us with any questions or comments about any of the Psychology Works Fact Sheets:  factsheets@cpa.ca

Canadian Psychological Association

Tel: 613-237-2144
Toll free (in Canada): 1-888-472-0657

Experiencing Anxiety Related to Climate Change

Climate change is a “long-term change in the average weather patterns that have come to define Earth’s local, regional, and global climates.”[1] Because of the uncertainty and severity of climate change, people are seeking treatment for negative feelings related to climate-related events and the future of our planet.  These negative feelings may include a sense of powerlessness and hopelessness about the current and future state of the natural environment, one’s own quality of life in relation to climate-related events, and about general human health and wellbeing.

What Contributes to Anxiety Related to Climate Change?

Feelings of anxiety about the state of the Earth’s climate can be experienced before, during, and after a climate-related event[2]:

Before a Climate-related Event

Warnings of climate-related events, such as hurricanes, storms, and wildfires, can cause acute worry about personal safety, the safety of loved ones, and/or the safety of homes and other property. Worry may also be experienced when people consider the possibility of impending and serious environmental problems—in the body of environmental psychology literature, this is known as habitual ecological worrying[3]. Individuals experiencing this type of worry may cope better by adopting pro-environmental attitudes and actions. Sometimes this form of worry can become less constructive if it is associated with feelings of loss, helplessness, frustration, and an inability to improve the situation. In the environmental psychology literature, this is known as eco-anxiety.[4]

During a Climate-related Event

Human mental health can be significantly affected during a rapid climate-related event. Victims of these events may quickly and unexpectedly lose property and belongings. Some may also lose family members and friends to disasters caused by climate change. Human mental health can also be impacted by climate-related events that occur gradually over time. For example, those who live in areas of the world where climate change has significantly affected landscapes and livelihoods tend to report a deep sadness, or solastalgia, about environmental change.

After a Climate-related Event

When a loss of friends and family, community, homes and belongings, employment, and economic certainty occurs because of a climate-related event, the results can be far-reaching and long-lasting. Outcomes may include depression, post-traumatic stress disorder (PTSD), grief, despair, aggression, interpersonal difficulties, substance abuse, and even suicide. In some cases, individuals may develop a condition called the climate change delusion,[5] characterized by a belief that one’s actions, no matter how insignificant, will have a serious negative effect on those suffering through climate-related events.

Who is Most Vulnerable?

Gifford and Gifford (2016) reference studies indicating that anxiety related to climate change tends to strongly affect children, older adults, individuals with pre-existing mental health conditions, and people with fewer economic resources. For example:

• Children with anxiety about climate change may experience symptoms such as low mood, anxiety, nightmares, flashbacks, social withdrawal, and difficulty being separated from caregivers. These symptoms have been shown to be more severe in children than adults and may persist later in life.
• Older adults can be more physically vulnerable to changes in the climate around them, and are sometimes less able to employ effective coping mechanisms, such as pro-environmental behaviours, during times of distress.
• People with fewer economic resources may also be more vulnerable to climate-related events as a result of their living conditions, employment conditions or status, a lack of access to resources, goods and services, and inability to engage in pro-active eco-conscious behaviours.
• Individuals living in countries with fewer resources available to protect people against the ramifications of climate-related events may become more severely affected by climate change.

How can Psychologists Help People who are Experiencing Anxiety about Climate Change?

Psychologists have the knowledge and expertise to help people process the negative effects of climate change on mental health, as well as to encourage effective and positive behavior.[6]

Psychological Practice and Services

Although some people may cope with their concerns about climate change by engaging in some form of climate-related activism (e.g., avoiding the use of single-use plastics, recycling, using less water, and so on), others may cope by disengaging or worrying excessively. Psychological therapies can help individuals experiencing anxiety about the climate to gain control over their worries, decrease their anxiety, and improve their overall quality of life. Therapies that can be effective are:

• Cognitive re-evaluation therapy to help correct thinking patterns that cause and increase worry
• Problem-solving training to learn better ways to solve everyday problems
• Exposure therapy to help confront and control, rather than avoid and be controlled by, fear
• Progressive relaxation to help decrease some of the physical symptoms of anxiety.[7]

For children, youth and young adults who have experienced a climate-related event or are experiencing anxiety about the climate, psychologists working in schools, colleges, and universities are available for support in school and academic settings.

Psychological Science

Psychological research can provide answers to existing and emerging climate-related questions. Whether the focus is to change destructive behaviors, like minimizing the use of motor vehicles, or to embrace beneficial actions, like using public transit, psychological research is key to understanding how people think about the environment and economic issues.[8]

Advocacy

Individuals, organizations, and all levels of government have a critical role to play in both understanding and addressing the relationship between climate change, health, the economy, and the behaviour of individuals. Effective responses to climate change will require promoting behavioural change at the individual and collective levels. Environmental psychologists can assist organizations and government in the development of education programs and public policies that overcome the discrepancies between what people understand about climate change and their everyday behaviours related to the environment.[9] For those experiencing anxiety and other mental health issues, appropriate funding for mental health services at all levels of society is important.

Knowledge Mobilization

To increase awareness of climate change as well as promote more responsibility and behaviour change on the part of Canadians, understanding how people process information and make decisions is important. Accurate and consistent information about climate change should be provided to individuals by trusted and knowledgeable organizations in an encouraging manner. Messages should be motivating and focus on the positive outcomes of prevention strategies, rather than be discouraging or frightening.

For More Information:

More information on the intersections between psychology and climate change can be found in these references:

• Gifford, R. (2011). The dragons of inaction: Psychological barriers that limit climate change mitigation and adaptation. American Psychologist 66, 290–302.
• Steg, L., & Vlek, C. (2008). Encouraging pro-environmental behaviour: An integrative review and research agenda. Journal of Environmental Psychology, 29, 309-317.

You can consult a registered psychologist to find out whether psychological interventions might be helpful for you. For the names and locations of provincial and territorial psychological associations, please visit https://cpa.ca/public/whatisapsychologist/PTassociations/

This fact sheet has been prepared for the Canadian Psychological Association by Dr. Lindsay J. McCunn, Vancouver Island University, Mr. Alexander Bjornson, Vancouver Island University, and Dr. Robert Gifford, University of Victoria.

Date: December 1st, 2020

Please contact us with questions or comments about any of the Psychology Works Fact Sheets at factsheets@cpa.ca

Canadian Psychological Association

Tel: 613-237-2144
Toll free (in Canada): 1-888-472-0657

[1] https://climate.nasa.gov/resources/global-warming-vs-climate-change/

[2] Gifford, E., & Gifford, R. (2016). The largely unacknowledged impact of climate change on mental health. Bulletin of the Atomic Scientists, 72, 292-297.

[3] Verplanken, B., & D. Roy. (2013). ““My worries are rational, climate change is not”: Habitual ecological worrying is an adaptive response.” PLoS ONE, 8 (9), e74708.

[4] Rabinowitz, P. M., & A. Poljak. (2003). “Host-environment medicine: A primary care model for the age of genomics.” Journal of General Internal Medicine, 18 (3), 222–227.

[5] National Wildlife Federation. (2011). The psychological effects of global warming on the United States and why the U.S. mental health care system is not adequately prepared. National Forum and Research Report, February 2012. https://www.nwf.org/pdf/Reports/ Psych_Effects_Climate_Change_Full_3_23.pdf.

[6] https://www.theguardian.com/environment/2020/oct/08/anxiety-climate-crisis-trauma-paralysing-effect-psychologists

[7] https://cpa.ca/docs/File/Publications/FactSheets/PsychologyWorksFactSheet_GeneralizedAnxietyDisorder.pdf

[8] https://cpa.ca/docs/File/Government%20Relations/Canadian%20Psychological%20Association’s%202020%20Pre-Budget%20Submission.pdf

[9] https://cpa.ca/docs/File/Government%20Relations/Canadian%20Psychological%20Association’s%202020%20Pre-Budget%20Submission.pdf

What are the symptoms of depression in older adulthood?

The Canadian Psychological Association’s fact sheet on Depression lists the symptoms of depression. These symptoms also identify depression in older adults. Symptoms typically manifested by older adults suffering from depression include loss of energy, decreased interest and pleasure in usual activities, pain and somatic complaints, and complaints of memory problems.

Who is affected?

Depression should not be seen as the unavoidable fate of older age. Still a number of seniors experience depression. On the one hand, the rate of major depression in older adults is relatively low, touching 3-5% of older adults aged 65 and over living in the community. On the other hand, the prevalence of symptoms of depression in this population is significantly higher, with about 15% of older persons in the community reporting significant levels of depressive symptoms

Some subgroups of older adults present a higher risk for depression, in particular individuals afflicted by chronic disease, older adults living in long-term care and nursing homes, and those providing care for a family member (e.g., to a partner suffering from dementia).

What are the other problems associated with depression?

Depression increases the risk of death in older adults by 2 to 3 times. Depression constitutes the most important factor associated with risk of suicide in old age.

Depression amplifies the functional disabilities produced by physical illness, interferes with treatment and rehabilitation, and further contributes to decline in physical and cognitive functioning.

Why is depression often missed and/or under-treated among seniors?

Depression can be hard to detect in older adults for several reasons. Older adults are often reluctant to admit to psychological symptoms or difficulties and are more likely to communicate their psychological distress by complaining of physical symptoms. Several symptoms of depression (e.g. sleep problems, feeling fatigued, and lack of energy) also naturally occur in older adulthood; as such, in some cases these symptoms may be mis-attributed to normal aging rather than depression. Also, the myth that it is normal for older adults to feel some amount of depression may result in true cases of clinical depression being overlooked.

What are the causes of depression in later life?

A history of depression in earlier adult life is a risk factor for depression in later adulthood. Chronic health problems and the loss of spouse, especially for men, can be associated with depression. Major depression may also occur after experiencing a cerebrovascular accident (stroke).

Factors such as loss of control and independence as the result of illness and/or disability, loneliness, and lack of social support can also lead to depression in older age.

What psychological approaches are useful to treat depression among seniors?

Several psychological treatments for depression used with young and middle-aged adults are also effective with older adults. In particular, cognitive behaviour therapy, interpersonal therapy, problem- solving therapy and reminiscence therapy are treatments whose efficacy is supported by empirical research.

Cognitive-behaviour therapy helps individuals with depression become aware of how thoughts influence mood and behaviour and learn to correct negative ways of thinking in order to alleviate depression.

Interpersonal therapy helps the depressed person cope with current stresses and challenges in interpersonal relationships – in particular in the context of conflicts, grief and bereavement, changes in roles, and social support.

Problem-solving therapy helps individuals with depression develop effective problem-solving skills to cope with current difficulties, such as managing a health condition or adjusting to living in a nursing home.

Reminiscence therapy helps individuals with depression re-evaluate personal memories in order to rediscover a sense of worth and life coherence and meaning.

These psychological treatments are safe and effective alternatives to medications, with combined drug and psychological treatment often used for complex cases.

Psychological treatments can be particular useful for people who are unable to, or unwilling, to take antidepressant medications.

Where do I go for more information?

More information on depression in older adults, including more detailed descriptions of psychological treatments and other supports, can be found in the National Guidelines for Seniors’ Mental Health: The Assessment and Treatment of Depression, Canadian Coalition for Seniors’ Mental Health (2006).

You can consult with a registered psychologist to find out if psychological interventions might be of help to you. Provincial, territorial and some municipal associations of psychology often maintain referral services. For the names and coordinates of provincial and territorial associations of psychology, go to  https://cpa.ca/public/whatisapsychologist/PTassociations/.

This fact sheet has been prepared for the Canadian Psychological Association by Dr. Philippe Cappeliez, Emeritus Professor, School of Psychology, University of Ottawa.

Revised: March 2020

Your opinion matters! Please contact us with any questions or comments about any of the Psychology Works Fact Sheets:  factsheets@cpa.ca

What is acute pain?

Acute pain is typically described as a mild to intense sharp pain. It comes on quickly and lasts for a short period of time, usually providing a signal to the body that something is wrong. Experiencing acute pain is important because it is a part of our body’s built-in warning system. The experience of pain varies across individuals, which means that the same painful event can be felt very differently among children.

Pain is like a puzzle that is made up of different pieces. There is a biological piece (e.g., previous injuries can make a person more sensitive to pain), a psychological piece (e.g., memories of past pain experiences can impact future pain experiences) and a social experience piece (e.g., the people who are in the room with you can impact how much pain you feel and how much pain you actually express). Even within the same person, the impact each piece has can change from situation to situation or as someone matures over their life. So even the same painful event can be experienced by the same person differently at different points in time!

Common causes of acute pain in children include everyday bumps and bruises (e.g., when a child falls off a bike), routine medical procedures (e.g., getting a needle at the doctor’s office), and post-surgical pain (e.g., the pain following tonsil removal that often lasts days). A person’s report of pain must be respected and paid attention to, no matter how old the person is. Sometimes a child cannot tell us they are in pain because they are too young or have intellectual or developmental disabilities. However, a good rule of thumb is that anything that causes pain in adults will also cause pain in children. There are well-validated ways to help assess and understand the pain of infants, children, and teens.  

Assessment of acute pain in children

Scientists and clinicians know that pain is tricky to assess even in adults, so a lot of work has gone into trying to understand the best ways to measure pain in children. With infants, toddlers, and preschoolers, watching body language is often the best way. For example, the FLACC (Face, Legs, Activity, Cry, Consolability) scale instructs caregivers to focus on the infant/child’s grimacing face, flailing legs, arched body or squirming, if they are crying, and how easily they are consoled. If children are hospitalized, it’s possible to use physiological measures like heart rate or how much oxygen is circulating in the blood. The higher the heart rate or the lower the oxygen saturation in the blood, the more stress the child is in and the more pain we assume the child is experiencing. Some pain assessment tools used in the hospital, such as the PIPP-R (Premature Infant Pain Profile-Revised), incorporate both behaviours and physiology measures. Sometime around the age of 6 or 7 years, children are able to self-report their pain more reliably, so parents and health professionals should try to ask them about their pain. For example, the Faces Pain Scale – Revised[1] (see below) is a great way to ask early school-aged children about how much something hurts. For older children and teens, who may have a good understanding of how rating scales work, you can just use a numeric rating scale without any aids. For example, you could ask an older child or teen, “On a scale of 0 to 10, where 0 is no pain and 10 is the worst pain you can imagine, how much pain are you experiencing right now?”.

Why is acute pain a priority in children?

Acute pain occurs frequently in both healthy children and those with chronic illnesses. Although pain serves an adaptive role, it may have adverse effects on the body, mind and social wellbeing of children if left unmanaged. Through experience, children learn the concept of pain, and previous experiences of pain influence how they experience pain in the future. Without appropriate assessment and treatment, acute pain can change how a child processes pain. A fear of needle-related procedures and avoidance of medical appointments may also develop if pain is not properly managed. Sometimes, acute pain can even lead to longer-term pain (i.e., pain that lasts more than 3 months). For example, research has suggested that anaesthesia and analgesia during surgery is important as it may protect a child from longer term pain.

Psychological strategies for managing acute pain in infants, children, and teens

Whether you are the parent (or caregiver) of an infant, child, or teenager, research shows that you play a major role in helping your child prepare for and cope with acute pain experiences. The way your child depends on you for support might look different depending on how old your child is.

Managing pain in infants and toddlers

Since infants (< 2 years old) haven’t yet developed the abilities needed to understand why they are in pain or what they can do to feel better, they rely on their caregivers more than ever to help them make sense of and cope with the experience. Parents can help reduce acute pain in infants and toddlers. One strategy parents can use with their infants that does not require any preparation is as easy as ABCD! The ABCD approach requires parents to calm themselves to help them calm their child. The ABCD’s are:

1. Assess your own anxiety. Your infant looks for hints from you to help them make sense of what’s happening. When you are calm, your infant is more likely to feel calm, too. If you have your child in your arms, your slow heartbeat will help you keep your child calm.
2. Belly breathe if you are stressed. Take some slow deep breaths in through your nose and into your belly. Slowing your breathing will slow your heart rate which can help slow your infant’s breathing and heart rate.
3. Use a calm, close cuddle with your infant. Your cuddle is extremely comforting to your infant, especially when used before, during, and after painful experiences. Depending on how old and active your infant is, this might involve skin-to-skin contact (holding your infant, dressed only in a diaper, against your bare chest, breastfeeding your child) or hugging your child while they sit in your lap or stand between your legs or while in your arms.
4. Distract your infant at the right moment. Distracting your infant using a toy, book, bubbles, or song, or by talking to them about something unrelated to the pain can help him or her calm down, but you should wait 30-45 seconds for their crying to slow down and their eyes to open before you start the distraction. Infants might show you that they are not ready for distraction yet (by becoming more upset, pushing the toy away, or looking away in response to the distraction). If this happens, go back to cuddling.

Managing pain in younger children (3-10 years)

Between the ages of about 3 and 10, children are gradually learning what they can do to get themselves through painful experiences, but still rely heavily on their parent or caregiver taking charge of the situation. During this broad age stage, successful coping with pain will usually involves a combination of child-led and parent-led strategies, with a greater emphasis on the parent the younger the child is.

While there are strategies that will work at any age from about 3 to adolescence (described later on), children in this stage have some unique psychological considerations. Children in this stage might experience some anticipatory worries when they know a painful procedure is coming. To help prepare their child for a painful experience, parents can take some extra steps in advance of a planned painful procedure:

• Decide when and how to share information with your child about an upcoming painful procedure. Younger children can be told the day of the procedure. Older children and teens should be told at least the day before, so that they can prepare coping strategies ahead of time and might benefit from learning about and practicing the steps involved in the procedure.
• Answer your child’s questions honestly. For example, if your child asks if a needle will hurt, you might say “It might hurt a small or medium amount, but it will be over soon”.
• Consider offering your child some choice in how their pain is managed, such as how they want to be distracted during the procedure, whether they want to hold your hand, and what they would like to do after the procedure. Offering choices to a young child is usually not helpful and might overwhelm the child. For older children, offering choices in advance (such as before you leave the house) helps them know what to expect and can help them feel more in control of the situation. They can also be motivated to get through the unpleasantness for a reward immediately after the painful procedure (e.g., lollipop) or in the near future (e.g., ice cream stop on the way home). In the below section are strategies that will work with children across childhood.

Managing pain in older children and teens (10+ years)

As children progress through the tween and teen years, they often take on an increasingly independent role in managing their pain. Although the preparatory strategies described above can help reduce the stress your child experiences before a procedure, they should always be used in combination with strategies for managing the pain while and/or after it occurs.

The following strategies can help reduce pain in children and teens during and after a painful experience:

• Effective strategies for distracting your child will vary depending on their age, abilities, and interests, and might include blowing bubbles or pinwheels, playing with a toy or video game, watching a movie, listening to music, or using virtual reality technology. Generally speaking, the more actively the child is involved in the distraction activity, the more powerful the distraction will be.
• Guided imagery. Through guided imagery, you can help your child use their imagination and senses to picture themselves in a different, more calming place. Guided imagery scripts for children of all ages are available online.
• Belly breathing. Breathing exercises that involve diaphragmatic (or “belly”) breathing can be used with children to help them feel calmer during and after painful experiences. Children can be instructed to breathe in through their nose and into their belly (keeping a hand on their belly to check that it rises with each breath) and breathe out through their mouth.
• Coping statements. Teaching children to use coping statements can help them think more positively and feel less negatively about the painful event. Having children repeat statements such as “I can get through this” or “I know the pain will go away”, aloud or in their head, can help them feel better. Reminding them after the painful experience about how well they did, how short the pain was, or how “worth it” the reward was will also help them build better pain memories for the future.

Parent behaviours to avoid

Sometimes despite the best intentions, parents overuse behaviours that have been linked to higher pain-related distress. Parents and caregivers should try to notice and limit their use of these behaviours:

• Reassuring your child by saying things like “it’s ok” or “you’re fine” when your child is visibly distressed or before they are distressed. It can cause them to feel confused, increasing their distress, or it can signal to them that something scary is coming, because parents don’t usually reassure their child when things are fine.
• Criticizing your child’s response to pain. Saying things like “your brother didn’t cry after his needle” or “big girls don’t cry” may teach a child that it is not okay to express pain when they are feeling it, increasing future distress and pain.
• Apologizing for your child’s pain. Apologizing for your child’s pain when you are not the one who caused it can confuse your child. It can also suggest to him or her that their pain has caused distress for you, which can further increase their distress.

Where can I get more information?

Learn more about assessing and treating acute pain at the AboutKidsHealth Pain Hub, a health education resource for children, youth, and caregivers approved by The Hospital for Sick Children (https://www.aboutkidshealth.ca/pain). In addition to describing psychological strategies we mention in this sheet, this resource provides parent- and patient-friendly information sheets that describe important physical (such as using smells and sounds or massage) and pharmacological strategies (such as acetaminophen, sugar water, or numbing cream) that often add to the success of psychological strategies.

You can also consult with a registered psychologist to find out if psychological interventions might be of help to you. Provincial, territorial, and some municipal associations of psychology often maintain referral services. For the names and websites of provincial and territorial associations of psychology, please visit:  https://cpa.ca/public/whatisapsychologist/PTassociations

This fact sheet has been prepared for the Canadian Psychological Association by Miranda Di Lorenzo, Shaylea Badovinac, and Dr. Rebecca Pillai Riddell, York University.

Date: November 24, 2020

Your opinion matters! Please contact us with any questions or comments about any of the Psychology Works Fact Sheets:  factsheets@cpa.ca.

Canadian Psychological Association

Tel: 613-237-2144
Toll free (in Canada): 1-888-472-0657

[1] Faces Pain Scale – Revised. Copyright ©2001, International Association for the Study of Pain.

What is schizophrenia?

Schizophrenia is a serious disorder that is related to a range of behavioural and thinking problems. Despite common myths, schizophrenia does not refer to ‘multiple personalities’, but rather a loss of contact with reality. The symptoms of schizophrenia are different from person to person, and symptoms, at least in a milder form, tend to last for a long time and long-term treatment is usually necessary. However, there is hope for improvement and a return to normal life for many people. With a combination of medication, psychological therapy, and family/social support, people with schizophrenia can function well in their community.

What are some of the problems faced by people with schizophrenia?

• Difficulties with perception of reality, such as hallucinations (for example, seeing or hearing things that are not real), delusions (for example, believing an organization is plotting to harm you; thinking that special messages are contained in advertisements), and bizarre behaviours (for example, peculiar speech). These are the kinds of symptoms that people often think of when they say someone is suffering from a “psychotic episode”. These symptoms are also sometimes called “positive” symptoms, referring to the presence of the unusual sensory experiences that are in excess of typical human experience.
• Difficulties with behaviours and emotions, such as reduced experience and expression of emotions, avoiding other people, lack of motivation, and a decrease in amount of speech. These symptoms are sometimes called “negative” symptoms, referring to the reduction or absence of usual social and emotional experiences.
• Difficulties with thought processes (called cognitive abilities), such as attention, memory, speed of processing information, planning, and problem solving. This means that many daily activities like grocery shopping, learning new skills at work, or following a conversation might be very difficult for people who have schizophrenia.
• Difficulties with social functioning, such as forming and maintaining relationships, or doing well at school or work.

Schizophrenia is not the only disorder associated with psychosis. For example, some people may have symptoms of both a mood disorder (like depression or bipolar disorder) and schizophrenia, or others may have just some psychotic symptoms (e.g., hallucinations). Those experiencing psychosis might be at risk for a more severe form of their disorder and should be encouraged to seek mental health treatment.

How common is schizophrenia?

• Approximately 1% of the world’s population meet the criteria for a diagnosis of schizophrenia
• Men are more likely to be diagnosed with schizophrenia – the ratio of men to women is 1.4 to 1
• Symptoms often start in late adolescence or young adulthood, and may occur for many years before diagnosis; on average, men are usually diagnosed at a younger age – 22 years old for men versus 27 years for women

What are the risk factors for schizophrenia?

There are several different causes of schizophrenia, which often act in combination:

• Heredity– Having a parent, sister, or brother with schizophrenia is a risk factor for developing the disorder. However, this does not mean that one is guaranteed to have schizophrenia, it just increases the likelihood  to a higher degree than people who do not have a family member with this diagnosis.
• Environment – Many factors unrelated to family history can affect brain development and the risk for schizophrenia. Examples include a mother having a serious illness or a long period of malnutrition while pregnant, low birth weight, oxygen deprivation during birth, and serious illness during early infancy. Additionally, there are experiences in a person’s environment that may increase their likelihood of developing psychotic symptoms (especially if they are already at a higher risk because of hereditary or developmental factors). Examples of this include childhood abuse, war zone exposure, and poverty.

What psychological treatments are available to help manage schizophrenia?

Historically, treatment took place in large hospitals where patients were completely removed from society. With the use of medications since the 1950’s, many people with schizophrenia are able to live in the community and do not need to be in hospital settings for long periods. While antipsychotic medications can be effective at targeting “positive” symptoms (i.e., hallucinations and delusions), they often have limited effects on “negative” symptoms (i.e., emotional experiences and motivation), and cognitive difficulties. As well, many people have trouble staying on their medication, due to multiple negative side effects. As a result, they are likely to start experiencing symptoms again if they stop their medication.

Research suggests that the most effective treatment plan is a combination of antipsychotic medication and psychological therapies that help people make changes in real-world behaviour. As we develop more effective treatments, people with schizophrenia are better able than ever before to function in society, even though some may continue to have symptoms.

• Cognitive Behavioural Therapy (CBT)– An active, collaborative type of therapy that focuses on a person’s thoughts and core beliefs, and the behaviours that are related to these thoughts. In CBT-P (a form of CBT for psychosis), a person learns to question and re-evaluate the source and meaning of their hallucinations and delusions.
• Cognitive Remediation – Focuses on training people to improve their thinking abilities such as attention, memory, reasoning, and information processing. New problem solving strategies are learned and there is a focus on helping the person be more engaged with cognitively challenging and stimulating tasks in daily life. Therapists play a large role in supporting the development of new skills and strategies as well as addressing negative core beliefs about cognitive abilities.
• Family Support– Provides information, support, and new interaction skills to people affected by schizophrenia and their family members, so that the whole family can learn to best manage the disorder.
• Social Skills Training– Focuses on teaching people more adaptive skills to use in interpersonal relationships, and allows practice of these skills in a group, and in one’s daily life.

An important note on stigma

Schizophrenia is often misunderstood by the public. The disorder often receives media attention, but, as with many news stories related to mental illness, many facts are taken out of context for entertainment or shock value. In particular, popular stories and media reports about people with schizophrenia sometimes make it seem like these individuals are dangerous or violent. In fact, people with schizophrenia are generally not dangerous, and usually pose a higher risk of harm to themselves (due to suicide) than to other people. As well, people with a psychotic disorder are more likely to be victims of violent crime than to be violent.

Where can I get more information?

• Surviving Schizophrenia: A Manual for Families, Patients, and Providers– by Torrey
• The Family Intervention Guide to Mental Illness: Recognizing Symptoms and Getting Treatment– by Mueser & Morey
• Schizophrenia Society of Canada:  schizophrenia.ca
• Canadian Mental Health Association: cmha.ca

You can consult with a registered psychologist to find out if psychological interventions might be of help to you. Provincial, territorial and some municipal associations of psychology often maintain referral services. For the names and coordinates of provincial and territorial associations of psychology, go to https://cpa.ca/public/whatisapsychologist/PTassociations/.

This fact sheet has been prepared for the Canadian Psychological Association by Dr.. Katherine Holshausen, St. Joseph’s Healthcare Hamilton, & Department of Psychiatry and Behavioural Neuroscience, McMaster University and Dr. Christopher R. Bowie, Head’s Up Early Psychosis Intervention Program – Kingston, & Department of Psychology, Queen’s University. 

Revised: May 2020

Your opinion matters! Please contact us with any questions or comments about any of the Psychology Works Fact Sheets:  factsheets@cpa.ca

Canadian Psychological Association

Tel: 613-237-2144
Toll free (in Canada): 1-888-472-0657

What Every Canadian Needs to Know about Suicide

Some Facts.  Although death by suicide is relatively uncommon, on average there are more than 10 deaths by suicide daily in Canada.  Thinking about suicide and engaging in self-harm and in suicidal behaviour are much more common.  When feeling overwhelmed or in psychological pain, people might contemplate suicide to varying degrees.  Sometimes people have passive suicidal thoughts such as wishing they wouldn’t wake up in the morning or wishing something fatal would happen.  Sometimes suicidal thoughts are more active, and people think about how to actively end their lives.  Although having suicidal thoughts does not necessarily mean that someone is on the verge of killing themselves, both active and passive thoughts need to be taken seriously because they suggest that something is not right at that moment in the person’s life.  Approximately 4,000 people die by suicide in Canada each year^[i].  This figure may be an underestimation since death by suicide may be misclassified^[ii] as an unintentional injury or as the result of a chronic health condition. In addition, this figure does not include the deaths of people who are terminally ill and obtain medical assistance in dying (MAiD).

Risk for death by suicide differs by as age (older), sex (male) and cultural group.  Three-quarters of those who die by suicide are men.  Most men and women who die by suicide are middle-aged.  Middle-aged and older men have Canada’s highest rates of suicide.  Suicide is the second leading cause of death for people between the ages of 15 and 34^[iii].     Suicide rates do not take into account non-fatal suicidal behaviour; statistics estimate that suicide attempts outnumber deaths by suicide by somewhere between 10 and 20:1^[iv].

Who is at risk for suicide?  There are many factors that contribute to suicide.  Commonly, people who think about or die by suicide may feel overwhelmed with psychological pain[v], which can be experienced as hopelessness, helplessness, loneliness sadness, anger, guilt or shame, or meaninglessness[vi].  Past behaviour tends to predict future behaviour; one of the strongest risk factors for death by suicide is having tried to end one’s life in the past. Studies show that suicide tends to be more common among people with one or more mental disorders, primarily mood disorders (like Major Depressive Disorder or Bipolar Disorder), psychotic disorders (like Schizophrenia), a substance use disorder, and personality disorders[vii]. Suicide risk may be elevated among people in pain and whose chronic illnesses restrict their daily functioning[viii], although this typically occurs when a mood or other mental disorder is also present.  It has been estimated that about 90% of those who die by suicide have a mental disorder, but most people with mental disorders do not die by suicide.[ix]  Additionally, although depression and suicide risk often go hand in hand, not everyone who dies by suicide is depressed, and not everyone who is depressed thinks about suicide. Nevertheless, when someone is depressed, it is important to find out if they are having suicidal thoughts. To find out more about mental disorders go to https://cpa.ca/psychologyfactsheets/.

What are some of the signs to look for if you are concerned that someone is considering suicide?  Specific signs of suicide risk include talking about suicide and death, talking about or collecting implements for self-harm or for suicide, preparing for death by writing a will or giving away prized personal possessions, previous suicide attempts, and recent experience or anticipation of serious personal losses. Some of the other signs that someone might be considering suicide are similar to signs of depression.  These include changes in eating or sleeping habits, withdrawal from others, extreme emotional changes, a blunting of emotional expression or loss of interest in usual activities particularly those usually enjoyed, and neglect of personal appearance.  There can also be increased use of alcohol or other drugs and increase in strange or risky behaviours.  As mentioned, although depression is a risk factor for suicide, the majority of people with depression do not die by suicide. Sometimes people are most at-risk for suicide when their depression lessens, and they appear to be doing better.  Suicide risk can be extremely high when someone is initially emerging from an episode of depression, especially if their energy returns but their thoughts of suicide remain strong. Some people are quite good at presenting themselves as being well put together even when they are not; support and the opportunity to explore their thoughts and feelings about life can be critical.

How do talk to someone about suicide?  Asking a person about suicide will not make them suicidal.  It is best to come right out and say that you have noticed some changes or signs that they may be hurting or in need of help, that you are worried or concerned and that you want to help.  If the person admits to feeling sad or hopeless, ask directly if they have thought about hurting or killing themselves.  Listen, don’t judge, and don’t try to solve their problems.  You may not understand how or why someone feels the way they do but accept that they are in pain and in need of help.  Don’t try to convince them that their way of seeing the world, or the actions they are considering, are bad or wrong.  If someone is thinking about suicide and discloses it to you, never promise to keep this information confidential.  A person feeling suicidal is a person who needs help and you may need to talk to others to help them get it[x].

How do I get help if I or a loved one is thinking about suicide?  There are supports and services that are effective in helping people deal with their psychological distress and recover from mental disorders.  Helping someone in need get help can be very important since less than half of people who have psychological problems actually get the help they need. Sometimes it is the stigma of mental disorders that gets in the way of people asking for and receiving help.  Mental healthcare services are not always funded by public health insurance, which can also make it harder for people to get the help that they need.  Keep in mind that helping loved ones doesn’t mean you can or should solve their problems, treat their illness or take away their pain.  Helping doesn’t mean that you should assume personal responsibility for someone else’s safety or for stopping their suicidal thoughts or actions.  It means listening, caring, supporting, and helping the person get the professional mental health help they need, when and where they need it.  It may also mean advocating for them. Navigating a complex health system can be daunting, especially when someone is in distress.  Helping to make calls and appointments, and acting as their advocate, can be very important to getting someone help in a timely manner.

Where do I turn if the situation is urgent? Thinking about suicide can be a health emergency and needs to be treated the same way as any other crisis.  Don’t assume that people who think about or talk about suicide are not serious, are being dramatic, or that their suicidal thoughts will simply go away on their own – they often don’t.  This is no time for “cautious waiting.” If you or someone you know is thinking about suicide, cannot make the thoughts go away, feels like acting on the thoughts, have a plan for how to die by suicide, or have access to the means with which to end life, you need to get help immediately!  Call 911, go to the nearest hospital emergency room or urgent care clinic, or call a crisis line or distress centre.  Crisis Services Canada can be reached at 1-833-456-4566.  The Canadian Association for Suicide Prevention has a directory of crisis lines across Canada http://suicideprevention.ca/thinking-about-suicide/find-a-crisis-centre.

Where can I get mental health help? If the situation isn’t urgent but you or the person you are concerned about is distressed, help is available.  Research shows that psychological treatments are effective for mental disorders and can reduce or resolve thoughts of suicide, or prevent suicide behaviour.  Provincial and territorial associations of psychology maintain referral services so that you can find a psychologist in your area https://cpa.ca/public/findingapsychologist/.   To find out what to expect when seeing a psychologist, see https://cpa.ca/public/.

Other avenues to get help include bringing your concerns to your family physician, primary health care team or community health centre. Some primary health providers like family physicians may be able to offer help directly or refer you to a health care provider or program that specializes in mental health treatment.  If the person in crisis is a student, the school or university may have mental health providers on staff.  The Canadian Mental Health Association can also be a helpful source of information and support. When choosing mental health help, it is always a good idea to seek the services of a regulated and specialized mental health care provider (like a psychologist or psychiatrist) to make sure that mental health problems are accurately assessed and diagnosed.  Not all mental health issues, disorders or treatments are the same.  Not all healthcare providers have expertise in assessing and treating mental disorders.  An accurate assessment and diagnosis is critical to making sure that you receive the right care.

Additional resources include:

CANADIAN RESOURCES:

Mental Health Commission of Canada
https://www.mentalhealthcommission.ca/English/what-we-do/suicide-prevention

Indigenous Services Canada
https://www.sac-isc.gc.ca/eng/1576089278958/1576089333975

Veterans Affairs Canada
https://www.veterans.gc.ca/eng/health-support/mental-health-and-wellness

Mood Disorders Society of Canada (MDSC)
http://www.mooddisorderscanada.ca/

The Canadian Association for Suicide Prevention (CASP) http://www.mentalhealthcommission.ca/English/issues/suicide-prevention
Video: Let’s Talk about Suicide — http://vimeo.com/98177990

The Canadian Coalition for Seniors’ Mental Health (CCSMH)
http://www.ccsmh.ca/en/projects/suicideAssessment.cfm
http://www.ccsmh.ca/en/booklet/index.cfm

The Canadian Mental Health Association (CMHA)
http://www.cmha.ca/mental-health/understanding-mental-illness/suicide/

The Centre for Suicide Prevention
http://suicideinfo.ca/

AMERICAN RESOURCES:

Suicide Prevention Resource Center
http://www.sprc.org/

The American Association of Suicidology (AAS)
http://www.suicidology.org/home

The American Foundation for Suicide Prevention (AFSP) http://afsp.org

The American Psychological Association (APA)
http://www.apa.org/topics/suicide/index.aspx

U.S. Substance Abuse and Mental Health Services Administration (SAMHSA)
http://www.samhsa.gov/prevention/suicide.aspx

INTERNATIONAL RESOURCES:

The International Association for Suicide Prevention (IASP)
http://www.iasp.info/

The World Health Organization (WHO)
http://www.who.int/mental_health/prevention/suicide/suicideprevent/en/

Where can I get more information?

Provincial associations of psychology:  https://cpa.ca/public/whatisapsychologist/PTassociations/

Psychology Foundation of Canada: http://www.psychologyfoundation.org

American Psychological Association (APA): http://www.apa.org/helpcenter

You can consult with a registered psychologist to find out if psychological interventions might be of help to you. Provincial, territorial, and some municipal associations of psychology often maintain referral services. For the names and coordinates of provincial and territorial associations of psychology, please visit:  https://cpa.ca/public/whatisapsychologist/PTassociations/

This fact sheet has been prepared for the Canadian Psychological Association by Dr. Karen R. Cohen (Canadian Psychological Association) and Dr. Marnin J. Heisel (Western University)

March 2020

Your opinion matters! Please contact us with any questions or comments about any of the Psychology Works Fact Sheets:  factsheets@cpa.ca

Canadian Psychological Association

Tel: 613-237-2144
Toll free (in Canada): 1-888-472-0657

[i] http://www.statcan.gc.ca/tables-tableaux/sum-som/l01/cst01/hlth66a-eng.htm

[ii] http://www.med.uottawa.ca/sim/data/Suicide_e.htm, http://www.apa.org/monitor/2012/12/suicide.aspx

[iii] http://www.phac-aspc.gc.ca/publicat/lcd-pcd97/table1-eng.php

[v] Shneidman, E.S. (1993).  Suicide as psychache (commentary). The Journal of Nervous and Mental Disease, 181 (3), 145-147.

[vi] http://suicideprevention.ca/understanding/why-do-people-suicide/

[vii] Bertolote JM, Fleischmann A, De Leo D, Wasserman D. Psychiatric diagnoses and suicide: revisiting the evidence. Crisis. 2004; (25(4): 147-155.

[viii] Kaplan, M.S., McFarland, B. H., Huguet, M.S., & Newsom, J.T. (2007).  Physical Illness, Functional Limitations, and Suicide Risk:  A Population-Based Study.  American Journal of Orthopsychiatry.  77(1), 56-60.

[ix] http://depts.washington.edu/mhreport/facts_suicide.php

[x] More information about suicide prevention and about talking about suicide can be found at https://www.helpguide.org/home-pages/suicide-prevention.htm

What is perfectionism?

Perfectionism is a multidimensional personality style that is associated with a large number of psychological, interpersonal, and achievement-related difficulties.

It is not a disorder but a vulnerability factor that produces problems for children, adolescents, and adults. People often confuse perfectionism with achievement striving or conscientiousness.

Perfectionism is distinct from these attitudes. It is a maladaptive pattern of behaviours that can result in a large number of problems. Achievement striving and conscientiousness involve appropriate and tangible expectations (often very difficult but attainable goals) and produce a sense of satisfaction and rewards.

Perfectionism, on the other hand, involves inappropriate levels of expectations and intangible goals (i.e. perfection) and a constant lack of satisfaction, irrespective of performance.

Perfectionism is a chronic source of stress, often leaving people feeling like failures even when other people see them as successful. Perfectionistic individuals require themselves to be perfect. This constant expectation is a source of stress and pressure and contributes to maladaptive ways of coping.

Dimensions of Perfectionism

Perfectionism involves three major components: perfectionism traits, perfectionistic interpersonal behaviours and perfectionistic thoughts concerning mistakes, expectations, failures, and self-criticism.

Perfectionism traits are enduring personality characteristics that reflect the need to be perfect:

• Self-oriented perfectionism is the requirement for the self to be perfect.
• Other-oriented perfectionism is the requirement that others (e.g., spouse, children, and other people in general) should be perfect.
• Socially prescribed perfectionism is the perception that others (e.g., parents, boss, and other people in general) require oneself to be perfect.

Perfectionistic behaviours involve the need to appear or seem perfect to others:

• Perfectionistic self-promotion involves the presentation of a perfect self-image to others.
• Nondisplay of imperfection involves the avoidance or concealment of any behaviour that could be judged by others as imperfect.
• Nondisclosure of imperfection involves the avoidance of verbally disclosing imperfections to others.

Finally, individuals with perfectionism will often engage in negative thoughts centered around the need to be or appear perfect and with harsh self-criticism, worry over errors, and self-blame.

Problems associated with Perfectionism

Individuals with these perfectionistic traits, behaviours and thoughts can experience a variety of negative outcomes. These problems can be found with perfectionistic children, adolescents, and adults. Here are some problems that have been found to be associated with perfectionism:

Psychological/Psychiatric Problems

• Anorexia nervosa, anxiety, binge eating and bulimic disorders, depression, suicide thoughts and attempts.

Relationship Problems

• Low self-compassion and the tendency to feel responsible for fulfilling others’ needs at the expense of one’s own, poor marital satisfaction, sexual dissatisfaction, and excessive anger towards others, social disconnection, difficulties with intimacy, loneliness, and social hopelessness (i.e. having negative expectations concerning future relationships).

Physical Health Problems

• Prolonged elevations in stress responses, sleep problems, chronic headaches, cardio-vascular responses, and early death.

Achievement Problems

• Workaholism, burnout, fear of failure, procrastination and self-handicapping (i.e. where individuals spend time finding excuses for poor performance rather than preparing for a performance).

Treatment Problems

• Negative attitudes toward seeking help with professionals, difficulties in self-disclosing personal information which negatively impacts treatment, not being able to engage in treatment.

How can psychology help?

Because perfectionism is an ingrained personality style, psychotherapy is very appropriate and often tends to be fairly intensive and longer term (often more than a year).

Recent research has demonstrated the effectiveness of both group and individual therapy for treating perfectionism and its associated complications. There has been promising evidence for dynamic-relational group therapy, psychodynamic/interpersonal group therapy and cognitive-behavioural group and individual therapy in reducing perfectionism and its attendant difficulties.

Several Canadian studies are currently underway that focus on both fine-tuning current treatment approaches and evaluating the effectiveness of these treatments in children, adolescents and adults.

Where do I go for more information on Perfectionism?

For more information visit the following:

• The Perfectionism and Psychopathology Lab at Hewitt Lab FAQs – https://hewittlab.psych.ubc.ca/faq-2/.
• Hewitt, P. L., Flett, G. L., & Mikail, S. F. (2017) Perfectionism: A relational approach to conceptualization, assessment, and treatment. New York: Guilford
• Greenspon, T. (2002) Freeing our families from perfectionism. Minneapolis: Free Spirit.
• Egan, Sarah J., Tracey D. Wade, Roz Shafran, and Martin M. Antony. Cognitive-behavioral treatment of perfectionism. Guilford Publications, 2016.

You can consult with a registered psychologist to find out if psychological interventions might be of help to you. Provincial, territorial and some municipal associations of psychology often maintain referral services. For the names and coordinates of provincial and territorial associations of psychology, go to http://cpa.ca/public/whatisapsychologist/PTassociations/.

This fact sheet has been prepared for the Canadian Psychological Association by Dr. Paul L. Hewitt, Ms. Sabrina Ge from the University of British Columbia and Dr. Gordon L. Flett, York University.

Revised: March 2020

Your opinion matters! Please contact us with any questions or comments about any of the Psychology Works Fact Sheets:  factsheets@cpa.ca

Canadian Psychological Association

Tel: 613-237-2144
Toll free (in Canada): 1-888-472-0657

What is Racism? What Can We Do to Address it?

Racism is a combination of stereotypical thinking, negative and hateful emotions, and discriminatory acts targeting individuals or groups of individuals who are regarded as being inherently inferior, somewhat socially deviant, and deserving of inferior status in society. While all humans have the capacity to hold stereotypes and prejudices towards other groups, racism becomes a serious problem when one group or its individual members have the power to act on these views and evaluations of others.

• Racism is a complex of social categorization and a system of behaviours that are deeply rooted in histories of colonization and slavery. The construction of a racial hierarchy by colonial powers continues to create advantages for those with power in maintaining their social, economic, and political dominance.
• The groups which become the recipients of racism typically have distinct physical characteristics such as skin colour, facial features, and body types. Historically, these groups in North America and other Western countries tend to be people who have darker skin tone, are a minority, and are socio-economically disadvantaged (e.g., Black, Indigenous, and People of Colour (BIPOC) due to systemic racism. In this fact sheet we will focus on racism, but we recognize that racism exists in combination with sexism, homophobia and transphobia, classism, ableism, etc.   

Individual Racism refers to internalized racism that resides within the person. Examples include anti-Black, anti-Indigenous, and anti-Asian sentiments, words, and actions. Believing that some groups are inherently inferior to others is an example of individual racism. People may endorse racism overtly or in more subtle ways, also known as microaggressions.

Systemic Racism refers to the unfair practices and unequal treatment of the affected groups either as a result of institutional legitimization or by way of general consensus and long-standing informal practices among the majority and privileged groups. Systemic racism in North America provides a foundation for White Supremacy that allows oppression and exploitation of racialized minorities. A few of the many historical examples of systemic racism in Canada include:

• 200 years of slavery from the 17^th to the 19^th centuries where Black and Indigenous peoples were the primary enslaved peoples.
• Indian Act in 1876 essentially made Indigenous Peoples wards of the state. In 1894-1996 Canadian policy required Indigenous children to be taken away from their families and placed in residential schools run by Christian priests and nuns. These children were forced to abandon their cultural practices including their language.
• 1885 Chinese Immigration Act required Chinese immigrants to pay a very high tax for coming to Canada while European immigrants were not required to pay this tax.

There is a tendency to frame racism as an issue of “good” people versus “bad” people, which often leads White people to seek to position themselves as “good” since they believe themselves to have good intentions, and therefore cannot be racist. This creates a pattern of avoiding being able to look at one’s own racist attitudes and behaviours. As such, BIPOC individuals can be met with an intensely defensive, and at times aggressive response, denying the racist behaviour. This dynamic serves to maintain White supremacy by silencing BIPOC individuals’ expressions of their experiences of racism.

What is the Psychology of Racism?

Racism is comprised of i) Social stereotypes; generalized thoughts, ii) Prejudice; negative attitudes and negative emotions, and iii) Discrimination; unfair and unequal actions against individuals due to their group membership.

Social Stereotypes and Biases in Judgements

• It is a fundamental property of the human mind to divide the social world into the categories of similar-to-me (In-group) and not-similar-to- me (outgroup). This perception of similarity and dissimilarity with others may be based on clearly noticeable criteria such as the skin colour, gender, age, language, or they may be based on criteria not so clearly visible such as one’s belief systems, religion, culture, or ethnicity.
• Due to familiarity and frequency of interactions with one’s ingroup members, one can identify and distinguish one’s ingroup members with relative ease. In contrast, the relative low familiarity with outgroup members is associated with the tendency to perceive and judge the outgroup as a whole. The result is Social Stereotypes or generalized thoughts about outgroups such as “natives are alcoholics” or “blacks are criminals”.
• The tendency to perceive an outgroup as a whole is associated with the “They all look alike” effect. This may partially explain why police officers may make errors in identifying individuals from their unfamiliar “outgroups”. When this judgement error occurs within the context of systemic racism, more severe negative consequences can result, such as the police officer not only apprehending the wrong individual but also quickly meting out brutality against this individual if they happen to be from a BIPOC group.
• Implicit Bias refers to having a stereotypical view of a category of people without having a conscious awareness of it. However, some circumstances can trigger them without the individual’s conscious awareness, which in turn may trigger a biased behavioural response. This may include an unintended racial slur or unintended unfair treatment of the individuals from the BIPOC groups.

Prejudice and Feelings of Hate

• Negative stereotypes of a category of people are accompanied by negative attitudes and emotions such as anger, hate, irritability, and fear.
• Prejudice can also appear to be “positive,” but these attitudes are paternalistic, condescending, and prescriptive; e.g., “You should be caring and kind. You are a Filipino”, or “You should do well on math. You are Chinese”.
• Prejudice can be reflected in the feeling of discomfort, irritability, anger, pity, and disgust towards members of racialized, ethnic and cultural minority groups and avoiding associating with them. Yet there may be a denial of conscious awareness of this emotionally negative attitude.
• When minority individuals do well and follow rules, they are viewed without prejudice. However, when minority individuals deviate from the norm, violate a law, perform below expectations or give a negative feedback or assessment, the reaction from the privileged group member can be swifter and harsher. For example, if a Black professor gives good grades and favourable comments to students, they are viewed on par with a colleague from a White-European majority. However, if both professors give low grades and negative feedback to students, the Black professor is likely to receive far more harsh evaluation from their students compared to their White-European colleague.
• Prejudice impacts the receiver negatively and may lead to reciprocal feelings and actions. That is, if one person dislikes or discriminates against another person, these attitudes and behaviours are returned. Those who express prejudice and engage in discriminatory practices cannot expect to be liked or accepted by those who are excluded. Hence, those individuals who are routinely excluded by systemic or individual prejudice are likely to react against those who are the sources of such prejudice.

Discrimination: Unfair and Unequal Treatment

• Discrimination is the behaviour of treating individuals differently, and to their disadvantage, based on their group membership.
• Discriminatory acts can have serious impacts such as a physician who spends less time with a member of a racialized minority group or dismisses or misinterprets the seriousness of their symptoms and refuses due care. This act of discrimination may or may not be intentional, but the consequences can be serious.
• Discrimination may be subtle and often non-verbal. For example, a bank teller may greet their ingroup members with extra courtesy, an extra smile, and may offer extra help, but may remain very formal and task-focused without offering any informal or personal courtesy to the member of the racialized minority group. Other examples include half-hearted or neglected greetings, showing signs of lack of interest while interacting, or not offering help when clearly needed, being quick in pointing out minor violation of some norms in a loud voice (e.g., “Hey, you can’t sit there. It is for seniors only”).
• Discriminatory practices are commonly found in employment settings. It may start with the preference for selecting candidates from the privileged groups for jobs, so fewer members of racialized minorities are called in for interviews. During the interview, discrimination is evident in behaviours such as spending less time on the interview processes and showing signs of discomfort or a lack of interest. Also, the racialized minority candidate is likely to be offered a lower start-up salary, contributing to pay gap discrepancies which combines with accumulated wealth disparities to maintain White supremacy. Discrimination may continue in the form of biased performance evaluations and not offering promotion despite one’s credentials. This highlights the importance of power differentials between groups. In other words, negative evaluations of others happen when one group is able to act on their negative stereotypes and prejudice towards another group.
• The result is a “vertical mosaic” whereby at the top jobs in most organizations, we see individuals from the privileged group, notably from White-European background. At the bottom of the employment hierarchy; the low paying manual labor jobs such as cleaning and dish washing, we see an overrepresentation of racialized minority groups. This leads to economic disparity. For example, in 2016, more Black Canadians were unemployed compared to Canadians who were not visible minorities (12.5% vs. 7.3%). Also, the average income of Black Canadians was significantly lower than average income of Canadians who were not visible minorities ($35,310 vs. $50,225).
• Discrimination is also reflected in the judicial and foster care systems. While Indigenous peoples make up only 3.8% of the total population, 23.2% of all people incarcerated in prison and 52% of children in care are Indigenous.
• Experience of discrimination negatively impacts one’s physical and mental health. There is consistent and strong evidence that self-reported racism is associated with negative outcomes for physical health such as high blood pressure, heart disease, and obesity. It is also evident in increased mental illnesses such as depression, anxiety, distress, and substance abuse. The negative impact of racism on physical and mental health have been found amongst men and women of all ethnic groups including Blacks, Indigenous, Latinos, Asians, and Whites for all age groups (i.e., adolescents, university students, and adults).

How Do We Learn to Live Together Without Racism?

The approach to changing individual and systemic racism must be both at the individual level, and at the government, legal, and policy level.

• Racism, if not checked has the potential to escalate. Genocides for example, do not occur overnight. Hence it is important to confront racism at its slightest and subtlest expression, in person or in social media. Signs and symbols of racially motivated oppression and harassments on smaller scales such as pranks, vandalism, racial slurs, and racial jokes must be confronted and addressed right away. Individuals, for example, may confront their friends and relatives, and respond to negative social media posts by them.
• The burden of bringing awareness and preventing hateful acts of prejudice and discrimination should not be solely on the shoulders of the racialized minority groups. Rather, majority members who have inherited, and therefore benefit from the systems of racial power have the responsibility to repair harm and establish justice. They must step forward to becoming true partners in making change. This will also establish the basis for trust between majority and minority groups, which will nurture racialized minority groups’ willingness to work with majority partners. It is crucial for both majority and minority groups to work together to bring about social transformation.
• The psychological principle that familiarity and similarity lead to liking may be implemented by creating opportunities for people to increase interactions with the dissimilar “others”. This would allow them to find core similarities to enhance a sense of overall familiarity while understanding cultural differences. Education strategies including lesson plans for young children may include a focus on exploring similarities and understanding and appreciating differences among children.
• Community activities and events must be inclusive of ALL cultural groups at all levels (organization, representation, participation). They must include majority and privileged community members alongside racial minority groups. Community programs should target fostering meaningful interactions and cooperation between privileged majority groups and racialized minority groups to reach a common goal.
• Contact between individuals of different backgrounds has been shown to improve mutual acceptance. However, such contact is likely to be more effective when contact is voluntary; is among individuals of roughly equal status; and when it is supported by promoting inclusion and limiting discrimination. These conditions need to be put in place by enacting public policies and programs.
• All social institutions (government, healthcare, education, family, etc.) need to recognize and actively commit to dismantling racist policies and behaviours in combination with repairing past discrimination. Measures and actions need to be put into place which favour equity, diversity and inclusiveness. This is achieved through several processes: (1) continuous education, training, and discussion; (2) holding ourselves accountable to prevent racism from being committed, as well as addressing racism when it is committed; and (3) organizing our institutions in a way that inherently favours diversity and social justice.
• We must support policies and programs that promote the acceptance of people for who they are, and what matters most to them such as their cultural heritage, and religion.
• Holding ourselves accountable for the ways that society has been structured to advantage White people, and for the racist actions at both individual and institutional levels, will enable social change towards living together without racism.

Where do I go for more information?

• Building a Foundation for Change: Canada’s Anti-racism Strategy: 2019-2022
  https://www.canada.ca/en/canadian-heritage/campaigns/anti-racism-engagement/anti-racism-strategy
• Race Relations in Canada 2019 Survey
  https://www.environicsinstitute.org/projects/project-details/race-relations-in-canada-2019
• You can consult with a registered psychologist who is trained in anti-racism and cultural diversity to find out if psychological interventions might be of help to you. Individuals impacted by racism may benefit from working with a psychologist who identifies as Black, Indigenous or as a Person of Colour. Provincial, territorial, and some municipal associations of psychology often maintain referral services. For the names and coordinates of provincial and territorial associations of psychology, please visit:  https://cpa.ca/public/whatisapsychologist/PTassociations.

This fact sheet has been prepared for the Canadian Psychological Association by Gira Bhatt (Kwantlen Polytechnic University), Saba Safdar (University of Guelph), John Berry (Queen’s University), Maya Yampolsky (Université Laval), and Randal Tonks (Camosun College).

Date: August 10, 2020
Updated: October 12, 2020

Your opinion matters! Please contact us with any questions or comments about any of the Psychology Works Fact Sheets:  factsheets@cpa.ca

Canadian Psychological Association

Tel: 613-237-2144
Toll free (in Canada): 1-888-472-0657

Pandemics are complex dynamic systems that shift and change over time due to the influence of a huge and interacting set of variables. Cultural contexts, although they tend to change more slowly, are similarly complex. Research on cultural processes unfolding under pandemic conditions is therefore fraught with uncertainty. Nonetheless, thanks to research conducted during and after previous disease outbreaks combined with the first studies rapidly assembled in the first months of the current pandemic, we are in a position to make some initial evidence-based claims as cultural and cross-cultural psychologists.

Contemporary cultural / cross-cultural psychology rejects the idea that biology and culture are opposed. The SARS-CoV-2 virus is straightforwardly biological, as is the associated disease, COVID-19. Nonetheless, the cultural context shapes the ways in which people engage with this threat, affecting everything from pre-existing health status (and hence, vulnerability) and living conditions to how people react to the threat of the virus and to the measures being taken to combat it.

During the COVID-19 pandemic, we have already observed cultural variations in:

• Pre-virus readiness for pandemics and other disasters
• Transmission rates
• Behavioural responses (e.g., mask-wearing, handwashing)
• Official policies (e.g., “social distancing”)
• Compliance with official policies

While our biological immune system is critical when we are infected with a virus, our behavioural immune system helps protect us from getting infected in the first place. It does so by helping us to detect pathogen cues and then to trigger relevant emotional and behavioural responses to these cues. Many aspects of this system are shaped by the local cultural context.

Indeed, some aspects of culture itself may have been shaped by variations in historical levels of infectious disease risk, leading to longstanding differences between cultural groups. For example, cultural groups with a high historical prevalence of pathogens tend to show lower levels of social gregariousness and greater concern about outgroup members.

We can understand the links between cultural context and COVID-19 at three levels: 1) macro-level of whole societies; 2) meso-level of families and communities; and 3) micro-level of individual people.

Macro-level of Whole Societies

Societies differ in numerous demographic ways relevant to COVID-19. For example, societies differ in terms of the strength of the economy, development of the healthcare system, urban population density, and degree of emergency preparedness.

These structural differences are shaped by longstanding cultural tendencies. For example, we would expect societies characterized by widespread valuation of a long-term time horizon to emphasize preparedness as compared with societies focused more on short-term concerns.

Political polarization can also lower trust, leading people to prefer advice from politically motivated sources and/or advice that fits with political preconceptions. Structural discrimination against certain ethnocultural groups can also compromise trust. There is an added concern that such polarization can lead different segments of society to act in conflict with each other rather than in pursuit of common goals.

Societies also differ in cultural patterns of values and behaviour. The extent to which people in a given society move between different locations, or geographical mobility, is associated with a set of skills that facilitate frequent shifts between different social networks, or relational mobility. Recent research has shown that the transmission rate during the 30 days after the first case of COVID-19 is correlated with societal levels of relational mobility. It appears that one problem with mobile societies is increased ease of transmission across geographical and social distances.

The extent to which people in a given society adhere closely to rules or look for opportunities to violate such rules can be understood as a distinction between tightness and looseness. Tighter societies are more likely to accept behavioural constraints. Particular advantages may accrue to societies able to maintain tight-loose ambidexterity: tight norms with sufficient looseness to promote ‘outside-the-box thinking’. This combination of self-restraint and creativity might be very helpful in pandemic situations, as both are needed.

Meso-Level of Families and Communities

Normative behavioural patterns in particular social networks can affect the transmission both of (a) an infectious disease and (b) ideas about the disease. Whereas the former requires study of how a virus propagates within and between bodies (e.g., increased contagion of a virus that survives for a long time on surfaces), the latter requires study of how ideas propagate within and between minds (e.g., increased believability of an idea frequently repeated by a source deemed credible).

Social networks accelerate transmission of harmful and helpful ideas about a given disease and what one ought to do about it. Such transmission can take place through conversation or observational learning, but also through traditional news sources or social media. Social capital, or the value that comes from our social networks and connections, varies across families and communities. Whereas a focus on strengthening intra-group connections (high bonding capital) would keep the virus in the local bubble, a focus on strengthening inter-group connections (high bridging capital) would allow the virus to be transmitted more widely.

The centrality of social connectedness in many communities is reflected through participation in communal events, which may feel obligatory (e.g., festivals, weddings, funerals). Emotional expressivity in certain communities may be associated with close talking, handshakes, kissing, loud exclamations, and so on. All of this is conducive to droplet projection, which further propagates the virus.

Measures taken to combat pandemic spread are also received differently depending on local characteristics. For example, families and communities differ in their acceptance of hierarchy—and hence, compliance with authority. One complicating question is who is a legitimate source of authority: do people look to public health officials, family members, religious leaders, or celebrities? Moreover, public health officials may require measures that directly contradict local imperatives; impeding appropriate burial of the dead, for example, can be emotionally charged.

Given that outbreaks of disease are associated with high levels of anxiety and uncertainty, the potential for increased intergroup tensions should not be underestimated. There is evidence that disease risk increases prejudice and discrimination against:

• Outgroups that are disfavoured in general (e.g., visible minorities, Indigenous people, the poor and especially the homeless);
• Outgroups that are specifically associated with the source of transmission of a given disease (e.g., East Asian Canadians, in the case of COVID-19);
• Outgroup and even ingroup members that by vocation or circumstance have a higher degree of exposure to the disease (e.g., grocery store workers, healthcare workers—although in the latter case, there are also positive views).

Stigma has consequences, including stress/distress, barriers to effective healthcare, mistrust, distortion of public risk perceptions, hate speech/crimes, and other forms of marginalization. These consequences can further disease spread (e.g., stress weakens the immune system while healthcare barriers delay treatment).

Disfavoured groups, moreover, are at additional risk due to social inequalities. For example, certain minority groups are more likely to be found in jobs that involve high contact but low compensation. Disfavored groups can show ‘cultural mistrust’, understandable but problematic apprehension around official social structures (e.g., government, media, law enforcement, formal healthcare). Economic disadvantage is associated with higher likelihood of pre-existing health conditions that in turn appear to increase COVID-19 risks. For example, this combination of health vulnerabilities and reduced healthcare access is endemic to indigenous communities.

Importantly, stigma goes beyond disfavoured groups and can include people who are also being celebrated for their important role in fighting pandemics (i.e., healthcare workers). Fear of healthcare workers and their potential to spread disease may interact with cultural beliefs about health and illness. If pre-existing negative views about healthcare workers or conspiratorial beliefs that incorporate them are widespread in a given community, the problem increases. At the same time, these kinds of incidents have been reported for many diseases, including COVID-19, across a range of cultural settings, suggesting a degree of universality.

Micro-Level of Individual Psychology

People’s behaviours are based in their beliefs, the behaviours they observe in others (and interpret in light of their beliefs), and the behaviours they believe others expect of them. What a person believes and how they behave is strongly shaped by their cultural context. Individual differences that may in part be rooted in temperament—for example, in attention to health, hygiene, comfort with isolation, tendency to stay home when sick, and so on—are further shaped by local norms.

The tendency towards optimism versus pessimism is a good and relevant example of a dispositional trait that is shaped by cultural context. There is now considerable evidence suggesting that people living in East-Asian cultural contexts tend to hold a cyclical view in which positive and negative experiences tend to oscillate and balance out over time. In other words, a run of good fortune means that one’s luck will soon run out, but also vice versa. People living in Euro-American cultural contexts, by contrast, have a more linear view in which recent past and present experiences predict future experiences.

We can understand a long period of time without a serious pandemic as a run of good fortune, in which case we might expect cultural variations in whether we would expect people to respond with increased or decreased preparation for a future pandemic. In research conducted after the 2002 SARS outbreak, defensive pessimism was associated with traditional Chinese values and predicted increased anxiety about infection but also more consistent health behaviours, such as hand-washing. Unrealistic optimism, in contrast, predicted perceived imperviousness to infection, leading to better mood but also to lower intention to wash hands.

Tendency towards optimism versus pessimism is part of a cluster of personality traits that all share commonality with negative affectivity. Other examples include anxiety sensitivity and intolerance of uncertainty. Although negative affectivity emerges as an independent personality domain across a wide range of different cultural contexts, there is marked cultural variation in the extent to which negative affectivity is tolerated or minimized. Negative affectivity is associated with risk perception, leading to more distress but also more willingness to take recommended precautions.

Negative affectivity is also associated directly with the likelihood of symptom-like experiences. Anxiety about one’s health leads to increases in self-monitoring for signs of illness; moreover, anxiety itself can generate physiological reactions that might be mistaken for such signs. For example, increased anxiety can be accompanied by increased heart-rate, sweaty palms, trembling, shortness of breath, and so on, all of which could look like signs of illness. Note that some migrants and minority group members might already have elevated anxiety and uncertainty.

Experiences that might be mistaken for disease can thus be produced by a combination of:

• Ideas about pandemic disease symptoms circulating in a given community;
• Culturally-shaped tendencies to monitor particular bodily sensations; and
• Individual differences in negative affectivity.

Moreover, the very fact of paying attention to certain sensations can make them more salient. In some cases, the concern that one might have caught a dangerous disease can generate further anxiety, thus worsening these sensations. These kinds of feedback loops could lead to intra- and inter-group differences in the symptoms that are discussed and expressed.

Conclusion: What Should We Do?

The struggle against COVID-19, will require the ingenuity of biological scientists across a variety of disciplines. Nonetheless, the potential contributions of the behavioural and social sciences should not be underestimated. The pandemic, along with the measures taken to combat it, is shaped in important ways by culture. What, then, are the implications?

An unprecedented number of people worldwide are concerned about the same disease and are experiencing broadly the same distancing measures. As such, there may be a temptation to focus on the similarities. At a minimum, policy-makers, healthcare workers, and the public at large should keep in mind that the pandemic experience may be very different for different people. These differences are shaped by the society in which one lives, the communities of which one is a part, and culturally-shaped individual variations. Complicating matters, appreciation for difference does not mean treating all responses equally when it comes to effectively mitigating a pandemic. Clearly, some cultural patterns are more effective than others.

Nonetheless, understanding that people have reasons for their beliefs and actions is important. Such understanding can help combat stigmatizing attitudes and better tailor strategies to work with different cultural communities. For example, public health officials and other policy-makers might work with religious leaders to spread information about the need to rethink traditional public celebrations. Debunking false information once it has taken hold is extremely difficult. Cultural understanding can help in developing strategies to ‘prebunk’ these ideas: combating this information in advance, in ways acceptable to the target population.

Clinicians, meanwhile, are now practicing in very different ways compared to earlier this year. There has been a major uptake of online service delivery methods, some of which may continue into the foreseeable future. Nonetheless, even when a client is alone on a screen, it is important to keep in mind the web of influences around them. Clients may hold very different culturally-shaped beliefs about the pandemic, different from each other and also different from the clinician.

At the same time, cultural traditions can be a source of resilience, as sources of wisdom about how to make sense of and prepare for uncertainty for example. We should remember, moreover, that interventions are not limited to majority-culture healthcare workers and minority patients. The people on the front-line represent many different cultural groups. As with clients, this can mean specific, underappreciated stressors for minority group healthcare workers—but also potential access to a wider range of cultural resources.

Regardless of whether one is focusing on the laypeople or officials, patients or healthcare workers, we believe it important to be wary of claims that people from a given cultural background will therefore act in a predictable way. Such an approach can inadvertently promote stereotypes, a notable danger during a time of heightened anxieties. The complexities of research in a rapidly changing pandemic context further bolster the argument for caution. Yet, a rapidly shifting landscape fraught with cultural anxieties demands an evidence-based, culturally-attuned approach, and one that can be communicated quickly and effectively.

For cultural and cross-cultural psychologists, the overall message is clear:

• Culture is integral to understanding societal, community, family, and individual responses to pandemics;
• Keeping culture in mind leads to much more nuanced and effective responses to individual circumstances.

We expect many more findings to flesh out this overall message over the next several years. Nonetheless, we have every reason for confidence that such findings will serve to confirm and reinforce these core ideas.

Where do I go for more information?

To obtain  important and up to date information about COVID-19, visit the Public Health Agency of Canada (PHAC) website at https://www.canada.ca/en/public-health/services/diseases/2019-novel-coronavirus-infection.html

Provincial, territorial, and some municipal associations of psychology often maintain referral services. For the names and coordinates of provincial and territorial associations of psychology, please visit:  https://cpa.ca/public/whatisapsychologist/PTassociations

This fact sheet has been prepared for the Canadian Psychological Association by Andrew G. Ryder, Associate Professor, Concordia University, Jewish General Hospital; John Berry, Professor Emeritus, Queen’s University; Saba Safdar, Professor, University of Guelph; and Maya Yampolsky, Assistant Professor, Université Laval.

Date: May 27, 2020

Your opinion matters! Please contact us with any questions or comments about any of the Psychology Works Fact Sheets:  factsheets@cpa.ca

Canadian Psychological Association

Tel: 613-237-2144
Toll free (in Canada): 1-888-472-0657