An Essay on Hypochondriasis

1.     Introduction 

Hypochondriasis is one of the most frequent seen somatoform patterns, with a prevalence in general medical practice of between 4 and 9 percent. The disorder is characterized by multiple and stubbornly held complaints about possible physical illness even though no evidence of such illness can be found. Hypochondriacal complains are usually not restricted to any physiologically coherent symptom pattern; rather, they express a preoccupation with health matters and unrealistic fears of disease. Although hypochondriacal people repeatedly seek medical advice, their concerns are not in the least lessened by their doctors’ reassurances- in fact they are frequently disappointed when no physical problem is found.  

In the past hypochondriasis was considered as mental illness but the later researches prove that it is rather an anxiety disorder. Because it is characterized by anxiety or fear that one has a serious disease. Therefore, the essential problem is anxiety, but its expression is different from that of the other anxiety disorders. In hypochondriasis, the individual is preoccupied with bodily symptoms, misinterpreting them as indicative of illness or disease. Almost any physical sensation may become the basis for concern for individuals with hypochondrioasis. Some may focus on normal bodily functions such as a cough. Some individuals complain of very vague symptoms, such as aches or fatigue.

2.     Clinical description

Like many terms in psychopathology, hypochondriasis has ancient roots. To the Greeks, the “hypochondria” was the region below the ribs, and the organs in this region affected mental state. For example, ulcers and abdominal disorders were once considered part of the hypochondriacal syndrome. As the actual causes of such disorders were discovered, physical complaints without a clear cause continued to be labeled hypochondreasis. In hypochondriasis, severe anxiety is focused on the possibility of having serious disease. The threat seems so real that no amount of reassurance, even from physicians, will help for long.

3.     Major characteristics

Individuals with hypochondriasis may complain of uncomfortable and peculiar sensations in the general area of the stomach, chest, head, genitals, or anywhere else in the body. Complete physical examination and investigations do not show presence of any significant abnormality. They usually have trouble giving a precise description of their symptoms, however. They may begin by mentioning pain in the stomach, which on further questioning is not really a pain but a gnawing sensation, or perhaps a feeling of heat, or of pressure. The mental orientation of these individuals keeps them constantly on the alert for new symptoms.

Hypochondriarcal patients are likely to be avid readers of popular magazines on medical topics and are apt to feel certain that they are suffering from every new disease they read or hear about. Tuberculosis, cancer, exotic infections, and numerous other diseases are readily self-diagnosed by these individuals. Their morbid preoccupation with bodily processes, coupled with their often limited knowledge of medical pathology leads to some interesting diagnoses. Such individuals are sure they are seriously ill and cannot recover. Yet- and this is revealing – despite their exaggerated concerns over their health, they do not usually show the intense fear or anxiety that might be expected of those suffering from such horrible ills. In fact they are usually in good physical condition. Nevertheless, they are sincere in their conviction that the symptoms they detect represent real illness. Hypochondriacal persons often show a notable preoccupation with digestive and excretory functions. Some keep charts of their bowel movements, and most are able to give detailed information concerning diet, constipation and related matters. Many as suggested earlier, use a wide range of self-medications of the type frequently advertised on television.  However, they do not show the losses or distortions of sensory, motor and visceral functioning that occur in conversion disorder; nor so their complaints have the bizarre delusional quality- such as “insides rotting away” or “lungs drying up”- that occurs in some psychotic disorders.

4.     Statistics

We know very little about the prevalence of hypochondriasis in the general population. Early estimates indicate that anywhere between 1% and 14% of medical patients are diagnosed with hypochondriasis. Later estimates cite a range of 4% to 9% of patients in general medical practice. Although historically considered one of the “hysterical” disorders unique to women, the sex ratio is actually 50-50. It was thought for a long time that hypochondriasis was more prevalent in elderly populations, but this does not seem to be true. In fact, hypochondriasis is spread fairly evenly across various phases of adulthood. Naturally more elderly people go to see physicians, making the absolute number of patients in this age group somewhat higher than in the younger population. Hypocondriasis may emerge at any time of life, with the peak age periods found in adolescence, middle age (40s and 50s), and age 60.

5.     Causes

Investigators with generally differing points of view agree or psychopathological processes ongoing in hypochondriasis faulty interpretation of physical signs and sensations as evidence of physical illness is central, so almost everyone agrees that hypochondriasis is basically a disorder of cognition or perception with strong emotional contributions.

Individuals with hypochondriasis experience physical sensations that are common to all of us, but they quickly focus their attention to these sensations. Remember that the very act of focusing on yourself increases arousal and makes the physical sensations seem more intensive than they actually are. If you also tend t misinterpret these as symptoms of illness, your anxiety well increase further. Increased anxiety produces additional physical symptoms, in a vicious cycle. Using procedures from cognitive science such as the Stoop test, Hithcock and Mathews confirmed that subjects with hypochondriasis show enhanced perceptual sensitivity to illness cues. They also tent to interpret ambiguous stimuli as threatening. Thus, they quickly become aware of any sign of possible illness or disease. A minor headache, for example, might be interpreted as a sure sign of a brain tumor. Once again, this cycle is similar to what happens in panic disorder.

What causes individuals to develop this pattern of somatic sensitivity and distorted believes? Although we are not sure, we can safely say the solution is unlikely to be found in isolated biological or psychological factors.  There is every reason to believe that the fundamental causes of hypochondriasis runs in families a possible genetic contribution may be nonspecific, such as a tendency to over respond to stress, and thus may be indistinguishable from the nonspecific genetic contribution to anxiety disorders. Hypperresponsivity might combine with a tendency to view negative life events as unpredictable and uncontrollable and therefore, to be guarded against at all times.                                                                                 

We know that children with hypochondriacal concerns often report the same kinds of symptoms that other family members may have reported at one time. It is therefore quite possible, as in panic disorder, that individuals who develop hypochondriasis have learned from family members to focus their anxiety on specific physical conditions and illness.

Three other factors may contribute to this etiological process. First, hypochondriasis seems to develop in the context of a stressful life event, as do many disorders, including anxiety disorders. Such events often involve death or illness. Second, people who develop hypochondriasis tend to have had a disproportionate incidence of disease in their family when they were children. Thus, even if they did not develop hypondriasis until adulthood, they carry strong memories of illness that could easily become the focus of anxiety. Third, an important social and interpersonal influence may be operating. Some people who come from families where illness is a major issue seem to have learned that an ill person is often paid increased attention. The “benefits” of being sick might contribute to the development of the disorder. A sick person who thus receives more attention and less responsibility is described as adopting a sick role. These issues may be even more significant in somatization disorder.

6.     Treatment

Unfortunately, we know very little about treating hypochondriasis. Scientifically controlled studies have appeared only recently. Warwick, Clark, Cobb and Salkovskis randomly assigned 32 patients to either cognitive behavioral therapy or a no-treatment wait-list control group. Treatment focused on identifying and challenging illness related misinterpretation of physical sensations and on showing patients how to create “symptoms” by focusing attention on certain body areas. Bringing on their own symptoms persuaded many patients that such events were under their control. Patients were also coached to seek less reassurance regarding their concerns. Patients in the treatment group improved an average of 76% and those in the wait-list group only 5%; benefits were maintained for 3 months.

Although it is common clinical practice to uncover unconscious conflicts through psychodynamic psychotherapy, results on the effectiveness of this kind of treatment have seldom been reported. Surprisingly, clinical reports indicate that reassurance seems to be effective in some cases, because patients with hypochondriasis are not supposed to benefit from reassurance about their health. However, reassurance is usually given only very briefly by family doctors have little tome to provide the ongoing support and reassurance that might be necessary. Mental health professionals may well be able to offer reassurance in a more effective and sensitive manner, devote sufficient time to all the concerns the patient may have, and attend to the meaning of the symptoms. Participation in support groups may also give these people the reassurance they need. It is very likely we will see more research on the treatment of hypochondriasis in the future.

Conclusion

Most of us as children learn well the lesson that, when we are sick, special comforts and attention are provided and, furthermore, that we are excused from a number of responsibilities or at least are not expected to perform certain chores up to par. This lesson has been learned all too well by the hypochondriarchal adult. Such an adult is in effect saying I deserve more of your attention and concern and you may not legitimately expect me to perform as a well person would. Typically these messages are conveyed with more than a touch of angry rebuke, inconsolable demand.

Hypochondriasis may be viewed as a certain type of needful interpersonal communication as well as a disorder involving abnormal preoccupation with disease. Treatment of the latter in the absence of an appreciation of the former frequently produces clinical frustration, if not exasperation. In fact, it may be that the impatience with which many physicians react to these patients has the unintended effect of maintaining or increasing their fears of abandonment and an early demise from some terrible condition that remains undetected by an insufficiently caring physician.  

An Essay on Crowd

1.0 Introduction

A crowd is a temporary collection of people who gather around some person or event and who are conscious of and influenced by one another. Crowds differ from other social groups primarily in that they are short-lived, are only loosely structured, and use conventional spaces or buildings for unconventional purposes.

A crowd is quickly created and quickly dissolved. It is an unorganized manifestation occurring in a world of organization. Often the people collected in a garden for a picnic are called crowd but instead of calling them a crowd they may be termed aggregates. The crowd is a physical compact aggregation of human beings brought into direct, temporary and unorganized contact, reaching mostly to the same stimuli and in a similar way. A crowd is always a transitory and unstable organization.

2.0.Definitions

Maclver defines crowd as a “physical compact aggregation of human beings brought into direct, temporary and unorganized contact with one another.”

Kimball Young defines crowd as a “gathering of a considerable number of persons around a centre or point of common attraction.”

According to Contrill “crowd is a congregate group of individuals who have temporarily identified themselves with common values and who are expressing similar emotions.”

3.0.Characteristics of Crowd

The following are the characteristic features of a crowd:

1)     Physical presence

Without such physical presence there can be no crowd. The size of the crowd is limited by the distance, which the eye can see and the ear can hear. Since people cannot remain physically present for any great length of time, this means that the crowd is a temporary social group. The crowd is unorganized. It may have a leader but it has no division of labour. As members of the crowd all the individuals are alike because it has no organization which can utilize the individual differences.

2)     Anonymity

Crowds are anonymous, both because they are large and they are temporary. A crowd usually consists of a relatively large number of people. The members of a crowd do not know each other. They do not pay attention to other members as individuals. The individual in a crowd is free to indulge in behavior which he would ordinarily control. In a crowd moral responsibility is shifted from the individual to the group.

3)     Narrow attention

The crowd is devoid of a wide attention. It directs its attention only to one or two things at one time. It is incapable of rationality and is easily carried by intuition. The members of the crowd easily come under the magic influences of a skilful orator.

4)     The members of the crowd are not open to conviction.

They do not tolerate any opposition to their views, rather any opposition enrages them. They blindly accept the stories that suit their temper and openly reject any suggestion opposed to it.

5)     Credulity

With an increase in the capacity of suggestibility, the credulity of a crowd also increases. According to Ross, “Rational analysis and test are out of question. The faculties we deal with are asleep.”

6)     Low mental level

The ideas of a crowd are not wide or deep. They are charged with emotion. They do not see any reason in other’s arguments. One may make a crowd do anything. The individual’s power of volition is lost.  It is all due to low mental level of the crowd.

7)     Emotional

The members of a crowd are highly emotional, they respond not only to the emotional situation, but also the emotions to the emotions of other members of the crowd. Some members of the crowd get excited because the other members are excited. The members of the crowd do not know what they are doing. In the words of Bernhard, “it is usually some strong emotions or curiosity impulse which integrates the crowd.”

8)     Irresponsibility

From the viewpoint of responsibility the members of the crowd show very poor sense of it. When panic or hatred seizes them, they do the most shameful acts of which they themselves repent afterwards.  A crowd in action can be a terrifying thing. Lebon has written, “The sense of responsibility which always controls individuals disappears entirely in a crowd.”

4.0.Kinds of Crowds

Crowds are generally divided into two classes:

4.1.  Active crowd

4.2.  Inactive crowd

4.1. Active crowd

According to Kimball Young, “an active crowd is a mass of individuals who, with the common focus of attentions unleash certain deep lying attitudes, emotions and actions.” It is accidental and momentary. It is motivated by a common motive and behaves the same way to realize a common end.

The active crowd has been classified into five kinds:

4.1.1       Aggressive crowd

4.1.2       Panicky crowd

4.1.3       Acquisitive crowd

4.1.4       Expressive crowd

4.1.1. Aggressive crowd:

An aggressive crowd, as the name suggests, consists of people in an aggressive mood, capable of any destruction and inhumanity. It may commit arson and murder, rape and manhandling. The atmosphere is full of great excitement. The members of such a crowd are completely devoid of any reason or sense of poverty whatsoever.

The special features of an aggressive crowd are as following:

a)     Intense emotionality

An aggressive crowd is marked is marked by intense emotionality. All individuals are in highly excited mood. In such a crowd we find one man shouting at the top of his voice, another waving his fists about, some running around, others manhandling.

b)     Suggestibility

The reason of the individual is dulled in an aggressive crowd. Every one imitates everyone else. A handful of people by their tactical methods succeed in blunting the reason of the hundreds of people who do not know what and why of their actions.

c)     Influence of rumour

Sometimes people collect in a crowd upon hearing some or the other rumour. A not unknown example is the rumour that a student has been beaten by a police constable at a cinema house. In no time many students gather together aroused to a high pitch of anger and having equipped themselves with haste rather than discrimination proceed towards the cinema house. They see a police constable on the crossroads and give him a beating who has nothing to do with the whole affair. They reach the cinema house and find there neither any student nor any constable.

d)     Tendency of imitation

In an aggressive crowd the members imitate each other and do not employ their reasoning power.

e)     Similar behavior

The behavior of the members of an aggressive crowd takes a single line. They are not prepared to listen to the arguments of the other side, neither are they interested in finding out the truth of the matter. Whatever has gone into their heads is difficult to be taken out by reason and arguments. They are bent up to the cause they have taken up to promote.

f)      Low educational level

The aggressive crowd is generally composed of people who are not highly educated or are uneducated. Even in an aggressive crowd of students the most active ones are those who are not interested in studies. Serious and intelligent students rarely are the members of an aggressive crowd.  

g)     Importance of leader

In an aggressive crowd the leader plays a very important role in rousing the emotions of the members. He excites them with his words and his gestures. He is the first to attack and exhorts the crowd to make an attack. He sets the example, which the crowd follows. He exercises a magnetic influence upon the members.

4.1.2. Panicky crowd

A panicky crowd is one, which is fear stricken and whose members are running hither and thither to save their lives. During war time a panicky crowd is a common phenomenon. In a panicky crowd every member is aware of the presence of the trouble. There is a feeling of fear, which spreads like contagion. All members think of things going out of their control. Their prime concern is to save their lives and they exhibit a lot of courage to save their life. The members exhibit fear because of crisis and this causes a tendency to escape.

4.1.3. Acquisitive crowd

The acquisitive crowd is one whose members have gathered together in order to acquire something. A crowd before the cinema booking window is such a crowd. Likewise, a crowd before a rationing shop to get sugar is an acquisitive crowd. Thus the acquisitive crowd is composed of individuals whose object is to gain something.

4.1.4.     Expressive crowd

In an expressive crowd the individuals gather together to give expression or to manifest their demands or sentiments. A not uncommon occurrence in the colleges is that the students come out of the examination hall whenever they find a question paper difficult or outside the prescribed course of study. They gather together before the principal’s office and put forth their demands that the examination be postponed and the question paper be reset. The members of an expressive crowd are interested more in voicing their grievances than in destruction. The expressive crowd may turn into an aggressive crowd if an effort is made to disperse it by violent means.

4.2.     Inactive Crowd

An inactive crowd is rather an audience, which collect for some peaceful purpose, for example, to seek some information or to hear a religious discourse. The action of inactive crowd does nto show any change even after an hour or two whereas in an aggressive crowd changes can be seen after a few minutes only. The difference between the active crowd and inactive crwd is only relative. The active crowd is somewhat more active while the inactive crowd is relatively inactive. An inactive crowd may be classified into:

4.2.1.     Information seeking crowd

4.2.2.     Recreation seeking crowd

4.2.3.     Conversation crowd

4.2.1. Information seeking crowd:

 This type of group gets together to gain knowledge or collect information. The aim is information. The members behave in an organized manner. A leader is heart of a large number of people.

4.2.3. Recreation seeking crowd:

The aim of recreation seeking crowd is to be entertained. A crowd gathers to witness a cinema. The object of such crowd is recreation. The conduct of the members is not controlled.

4.2.4.     Conversational crowd:

Such a crowd collects to exchange ideas and feelings for transformation. During election political parties try to convert the masses to their own way of thinking.

Lebon divided crowds into two categories:

1)     Homogeneous and

2)     Heterogeneneous.

The heterogeneous crowds may be anonymous like street crowds or non-anonymous like parliamentary assemblies. The homogeneous crowd may be sects, castes and classes.  

Blumer divides crowds into four categories

1.     the casual crowd

2.     the conventional crowd

3.     the expressive crowd and

4.     the active crowd

5.0. Theories of crowd   

Though it cannot be denied that the crowd also possesses a capacity for constructive work, yet its’ destructive character which has forced sociologists and psychologists to devote their attention to it. Many theories have been advanced to explain why the crowd behaves in a particular way.

5.1. Group mind theory:

According to the group mind theory the individual in the crowd loses his individuality and becomes a part of the crowd which comes to develop its own crowd consciousness. The crowd consciousness supplants the individual consciousness of the individuals. The members of the crowd participate in the crowd consciousness and act according to the stimulus provided by the crowd. The mentality of the individual members becomes de-individualized and he begins to act on an emotional level, which is common to all the participants. According to this theory, the crowd becomes so attuned that it responds only to the appeal, the slogans, and the ideas which are comfortable to the deindividualized mentality. The group- mind which is not the sum of the minds of the members of the group is a mind of its own distinct from minds working on different levels. Its working is based on emotions, appeals, suggestions and slogans. Its acts are less rational and more emotional. It is an irresponsible mind focusing its attention on some immediate object. Its mental level is very low. It becomes easily excited and acts in a hypnotic way. It is on this account that individuals behave most irrationally in a crowd than otherwise behave individually.

The Group- mind theory has been advocated by Lebon, Espinas, Trotter, Durkheim, McDougall Allport.

5.2. Lebon’s theory:

Lebon was the first writer to put forward the theory of group-mind in 1892. In his book crowds he has written, “the sentiments and ideas of all the persons in the gathering take one and the same direction and their conscious personality vanishes. A collective mind is formed, doubtless transitory but presenting very clearly defined characterstics.” Thus, according to Lebon, the different individuals in a group do not think individually but think experience and act through group mind. When individuals collect in a crowd, their individual minds become a part of the collective mind. The collective mind thinks in its own way and formulates its own ideas and thoughts which the individual minds do not formulate in their individuals capacities. In the crowd the mind of the individual acts in a manner in which it would not act if left alone.

Lebon has laid great emphasis on the unconscious motives. According to him, in a crowd these unconscious motives get more active. The individual is influenced by these unconscious motives and his own conscious motivation sinks into the background. In a group, the individual gets a sense of invincible power and hence, he tries to completely satisfy his instinctive passion in him. 

5.3. Durkheim’s theory:

Durkheim has sought to explain group behavior in terms of collective consciousness. According to him, when people collect in a group, a collective consciousness is created by the mutual exchange of ideas and notions. Mind is another name for the flow of consciousness. When several minds meet together there is a flow of consciousness is created which is not just a collection of consciousness of various individuals. Just as a chemical compound of several elements but its qualities are different from the qualities of the consciousness of the individual. According to Durkheim, the social consciousness is more superior and comprehensive than the individual consciousness.

6.0. The social psychology of Crowds

Until recently, mobs were seen as little more than unchained beasts, spurred by powerful, violent urges and with no sense of reason. What people did in crowd was seen not as the collective action of rational humans, but as collective behavior that was the result of regression to primitive levels of psychology. A chief proponent of this psychological perspective was the Frenchman Gustave lebon. As far as Lebon was concerned, the old social system, with its privileges and security for elites like himself, was being threatened by emotionally volatile mobs. Lebon regarded mobs as purely irrational and destructive, capable of treating apart the social order.

In his book the psychology of crowds Lebon argued that involvement in a crowd puts individuals “in a possession of a collective mind” that makes them think, feel, and act quite differently than they would if each person were alone. Crowds, Lebon maintained, gain control over people much as hypnotists do. Waves of emotions sweep through crowds, infecting one person after another. 

7.0.Conclusion

In our everyday life we use the word ‘crowd’ without any consideration for any group of people. If more than expected number of people gather at a place, we say that there is crowd or rush. If there are 10-15 customers at a shop, we generally say that it is a crowd there. But in psychology only more number of people cannot be called crowd. From psychology view point, the existence of crowd is not based on more number of people, but physical presence of people is needed for making it a crowd. People so gather in a crowd that they do not establish indirect or definite relations. The attention and feelings of people should be toward a common thing, person or incident to make it a crowd. The gathered persons are in such proximity to each other that they are alive to the presence to other. They are aware of their collective power. Their focal point too is one and their desires are directed to one point. If all these characteristics are found in a gathering, we would say that a crowd has been created according to psychological view point.

Using Exercise to Combat Depression

January/February 2012 Issue

Using Exercise to Combat Depression
By Joelle Ruben, MSW, LSW
Social Work Today
Vol. 12 No. 1 P. 22

A growing body of research shows that exercise can be an effective adjunct treatment for depression.

As a social work student, Amy Park (a pseudonym) often brought gym clothes to her field placement so she could get in a run before heading home. This tactic may sound familiar to many individuals seeking to fit exercise into their overscheduled lives. Park, however, had additional motivation for completing regular workouts: keeping her depression in check.

Diagnosed with severe depression in her late teens, Park remembers thinking that something as simple as running or lifting weights would not lessen her daily challenges with the condition. “In my mind, there was such a thing as being too depressed for exercise since very basic things at that time, like eating and bathing, were a real struggle,” she says. But after using a behavioral activation workbook to track the level of satisfaction she felt from daily activities, Park discovered she consistently felt better after working out.

Nearly a decade later, she continues to view exercise as an integral part of her treatment strategy. But Park cautions that people should not view physical activity as a panacea. “Personally, I find it most helpful as a temporary mood boost that gives me the short-term motivation to engage in productive activities that help me get unstuck and move toward things I value,” she says.

A Widespread Issue
Depression, in its multiple forms, affects millions of adults in the United States each year. According to the Substance Abuse and Mental Health Services Administration, 14.3 million adults reported at least one major depressive episode in 2008 that affected their ability to work, sleep, eat, or enjoy once-pleasurable activities.

In 2005, the Archives of General Psychiatry reported that in any given year, approximately 5.7 million adults experience bipolar disorder in which they fluctuate between mania and depression. Dysthymic disorder, a chronic, milder form of depression, affects around 3.3 million adults annually.

These numbers do not account for individuals experiencing symptoms related to postpartum depression, seasonal affective disorder, or more moderate forms of depression. Many people also experience the lethargy, lack of interest in daily activities, and sadness associated with depression without receiving a formal diagnosis.

Conversely, some practitioners report an increasing trend of self-diagnosis among clients before they can be formally evaluated. “Most people who come in to see me identify themselves as depressed even if they don’t meet all of the criteria of depression,” says Amy Chmielinski, LPC, of Jewish Family Service of Metropolitan Detroit. “It’s just a commonly known disorder, and most people have a layperson’s knowledge of it.”

While the statistics are imperfect, they begin to convey the scope of depression and its impact on society. They also set the stage for exercise as an accessible and cost-effective tool that social workers can leverage to help clients battle their symptoms.

The Exercise-Depression Connection
Since the early 1900s, researchers have published more than 100 studies examining the relationship between exercise and depression or anxiety. National attention increased in 1999 when the Centers for Disease Control and Prevention reviewed the literature examining the impact of exercise on mental health. The report concluded that physical activity appeared to relieve symptoms of depression and anxiety while boosting mood. It also called for further clinical research to examine the role of exercise in preventing depression.

Following this somewhat weak endorsement, Daniel Landers, PhD, a professor emeritus from the department of kinesiology at Arizona State University, compared five meta-analytic reviews of the exercise-depression research. His analysis showed a consistent relationship between exercise and moderate reductions in depression across subjects’ age, gender, and depression type. According to Landers (1999), symptoms subsided regardless of the frequency of physical activity, with antidepressant effects beginning as early as the first session.

The literature has also revealed similarities in symptom reduction for multiple types of exercise. Most research has focused on common physical activities such as running, walking, and strength training, but relaxation-focused activities such as yoga and breathing exercises are increasingly being studied.

Perhaps one of the more heated areas of debate is whether exercise should replace, rather than supplement, common approaches for treating depression. James Blumenthal, PhD, who teaches psychology and neuroscience at Duke University, has taken particular interest in studying whether physical activity can prove as effective as antidepressant medications in managing depression.

In 2007, Blumenthal and his research team published results from a study in which they randomly assigned participants to one of four treatment approaches: home-based exercise, group exercise, antidepressant medication, or a placebo. All 202 participants had been diagnosed with major depressive disorder and had completed their respective treatments for 16 weeks. While all three treatment options proved more effective than the placebo, remission rates among the home-based and group exercise cohorts were not statistically different from remission rates among the group taking antidepressants (Blumenthal et al., 2007). This study reaffirmed the results of earlier research involving 156 adults aged 50 or older with major depressive disorder (Blumenthal et al., 1999).

From a practitioner perspective, Chmielinski emphasizes the importance of consulting with a client’s physician or psychiatrist regarding a possible medication change, regardless of findings such as Blumenthal’s. ”I wouldn’t recommend a client start or stop a medication outside of the context of the physician’s direction,” she says.

Chmielinski adds that social workers have an ongoing responsibility to assess the impact of medication changes even after clients have been medically cleared to stop taking antidepressants. “What I would say to some clients is if they’re serious about incorporating exercise and other coping techniques rather than medicating, that’s something we can closely monitor for two or three months.”

Identifying the Cause
Despite growing clinical evidence suggesting that exercise can reduce symptoms of depression, scientists still struggle to determine what causes these changes in humans.

“One of the things I get asked most often is, ‘What is the mechanism by which exercise affects depression?’” says Lynette Craft, PhD, an assistant professor of preventive medicine at Northwestern University. “The short answer is that we don’t really know exactly how exercise works.”

Several hypotheses have emerged. One of the most common theories focuses on serotonin, a neurotransmitter responsible for sending impulses across the brain. Researchers have established that individuals experiencing depression tend to have lower levels of serotonin in their blood. The same is true for the neurotransmitter norepinephrine. Many antidepressant medications, such as Prozac, Zoloft, Effexor, and Cymbalta, seek to increase the amount of these neurotransmitters outside human cells with the aim of better regulating outcomes such as mood and sleep.

But Craft, a trained kinesiologist, cautions that the scientific research in humans is not far enough along to reveal the true effects of either neurotransmitter, let alone the impact that exercise can play on their levels in the human brain. “We don’t have good, noninvasive ways of measuring serotonin or norepinephrine in the brain,” she says. “With improved neuroimaging technology, we hope to get a better sense of what is occurring in the brain following exercise.”

The National Institute of Mental Health (NIMH) has also explored the neurological connection in animals between physical activity and psychosocial stress, which can lead to behavior mimicking depression. In 2010, NIMH research showed that laboratory mice living in environments that allowed for exercise and exploration responded better to bullying from other mice than rodents living in more basic settings (Schloesser, Lehmann, Martinowich, Manji, & Herkenham, 2010).

A later study re-creating this experiment found that mice living in enriched environments also contained signs of increased neuron activity in a portion of the brain known as the infralimbic cortex. According to the NIMH report, the inframlimbic cortex is responsible for activating nearby parts of the brain and may contribute to how animals, and potentially humans, respond to fear and stress (Lehmann & Herkenham, 2011).

Psychological Impact
While scientists continue examining the biological and chemical effects of exercise on depression, it is also important for social workers to consider its potential psychological effects.

Michael Otto, PhD, a psychology professor at Boston University, believes that more emphasis should be placed on the nearly immediate impact of exercise on mood. He claims that most mood benefits occur within five minutes of exercise, although they can be delayed for up to 30 minutes following more intense activity.

Reaping these mood benefits often involves overcoming serious obstacles to working out. “When you’re depressed or anxious, exercise is not the natural option. Both [disorders] encourage you to do less, whereas exercise encourages you to do more,” Otto says. “The most helpful thing we can teach people at the outset is that we don’t want you to dig deep for motivation. We want to you to use all the available elements to make exercise come naturally.”

Otto, who specializes in the cognitive-behavioral treatment of mood and anxiety disorders, advises social workers to suggest incremental changes to clients’ exercise habits to make them seem more manageable. Examples include placing a pair of tennis shoes by the front door or ending workouts on a positive note to instill a happy association with physical activity. More recommendations are included in Exercise for Mood and Anxiety: Proven Strategies for Overcoming Depression and Enhancing Well-Being, a book authored by Otto and colleague Jasper Smits, PhD.

In keeping with Otto’s emphasis on positivity, laughter yoga has emerged as a growing exercise practice promoting the physical and psychological benefits of laughter. While some laughter-based activities involve a lot of movement, programs can be adjusted to accommodate those with physical or cognitive limitations.

“You meet people where they are,” says Lainie Diamond, a certified laughter yoga instructor who teaches two free classes per week at the Houston Public Library. “It is absolutely for everybody.”

Diamond adds that individuals do not need to be in a good mood or even have a sense of humor to benefit from the practice. Indeed, one of the key laughter yoga mantras is to “fake it until you make it,” referring to the real laughter that often emerges from an initially forced response.

Meeting an exercise goal can also affect clients’ sense of accomplishment and fulfillment, potentially leading to an improved psychological state. This argument resonates strongly with Park, who claims that exercise helped shift her focus to a specific goal and its outcome rather than how she was feeling that day. “Exercise is one of those things that can very easily give you a sense of mastery of your environment, which can easily carry over into other aspects of your life,” she says.

The Social Work Role
With so many questions about exercise and depression unanswered, it may seem difficult for social workers to find their role in the equation. But according to Chmielinski, who sees many of her clients on a weekly basis, social workers and therapists are in an ideal position to promote change because of the continuity of their relationship and therapeutic rapport. “How often do you see your doctor every week?” she asks.

Common social work approaches, such as the person-in-environment theory, also come into play. Camielle Call, LCSW, who runs a private consultation practice in Sitka, AK, recalls working with a client who reported decreased enjoyment in daily activities. Although the symptoms appeared to be triggered by southeast Alaska’s continuous cloud cover, Call says the client ultimately benefited from living in a community where she saw people exercising outside. “Seeing people maintaining their physical health by walking with friends, being active with their children, or walking their dogs helped her mindset get to a place where she could say, ‘That’s what I can do to help myself get better.’ She wanted to be a part of that healthy environment,” Call says.

Social workers can also use a strengths-based approach to help clients overcome resistance to physical activity. Call describes another client whose extended family made him feel uncomfortable seeking help for his chronic depressive episodes. Call focused on the client’s strengths as a father to create a treatment plan that included family-building activities based around exercise.

Otto encourages social workers to remember the “doing parts of therapy,” such as developing workout recommendations for clients medically cleared to exercise. Taking this step, however, does not have to include a trip to the gym. For example, practitioners can learn the rated perceived exertion scale (a simple scale used by coaches to rate athletes’ exercise) to help clients measure the intensity of their workouts. Pedometers are another simple way to make people more aware of their daily behaviors.

Additionally, social workers can identify and provide resources to help clients incorporate physical activity into their lives. Donna Ulteig, LCSW, of Psychiatric Services SC in Madison, WI, remembers a client who experienced pain as she exercised. Ulteig responded to this challenge by identifying a nearby exercise class held in a warm-water pool and helping her client find a swimsuit.

Ulteig notes the importance of alternative reward systems for clients who may need additional encouragement. Rewards can be self-induced, such as a person allowing himself or herself to make a small purchase after a workout. Alternatively, social workers can identify external motivators such as friends or family members who can craft customized ideas for positive reinforcement. Ideas include family or friends going to a movie the client wants to see or offering to cook dinner if he or she completes a workout.

As for Park, who recently received her master’s degree in social work, she wishes her own therapist had provided tips to keep her motivated. She sees the benefit in guiding clients through their feelings as they experience both the sense of improvement and plateau often associated with exercise.

Park adds that guiding clients through their emotional response to exercise helps the social worker ensure they are supporting but not forcing the treatment. Ultimately, the decision to incorporate physical activity into a broader treatment plan should remain in clients’ hands.

The Top 5 Social Justice Issues Facing Social Workers Today

The Top 5 Social Justice Issues Facing Social Workers Today
Social Work Today
Celebrating Diversity By Lorraine Gutiérrez, PhD, LMSW

Our commitment to social justice and antioppressive work brought me into social work and keeps me here. Growing up in the late 1960s and early 1970s, the power of the people to transform society and work toward greater gender, racial, and ethnic equality was clear. During my undergraduate years, I learned that social workers active in the progressive movement were at the forefront of policies that reduced working hours, restricted child labor, and created public health clinics to improve conditions for low-income families. These models for how we can change our society shaped my involvement in organizations to end violence against women and work toward the empowerment of diverse groups.

My path as a social worker is not unique. Regardless of our setting, all social workers are engaged in work related to oppression and social injustice. We are more aware than most people of the challenges faced by children and families living in poverty, the inadequacy of our “safety net” of human services, the disproportionate incarceration of men of color, and the challenges experienced by those living with disabilities. We do this work while living and working in a society where groups have mobilized to restrict or eliminate existing rights such as public education for immigrants and the children of immigrants, domestic partnerships for gay men and lesbians, and access to reproductive healthcare for adolescent women. Surviving and thriving as a social worker requires that we have a true appreciation for human diversity and understand how social identities affect access to resources.

Throughout our history, social workers have been agents of both liberation and oppression. During the same era that we founded social settlements, we were involved in the incarceration of Native American children in boarding schools. While we were actively involved in crafting the Social Security Act, we participated in the deportation of Mexican American families who were “public charges.” While we participated in civil rights movements in the 1950s and 1960s, we referred many women of color to doctors who sterilized them against their knowledge. Our approach to diversity within our communities will influence whether we work toward social exclusion or inclusion. Will we work toward the rejection, tolerance, acceptance, or celebration of the different groups that make up our communities?

If we are to work toward social justice, we need to engage in the work involved in celebrating difference and diversity. I use the word celebrate based on its original meanings, which refers to honor, respect, or recognize. We must move beyond tolerating or accepting those who are different from ourselves to a position of cultural humility that requires us to question our own background and experiences to work in partnership with others. When working from this perspective, we, as social workers, must be engaged in ongoing self-assessment and awareness of how power differences affect our ability to be genuinely helpful. This process is an essential element of social justice work.

Celebrating diversity means working as an ally and advocating for marginalized and oppressed groups. We are allies to others when we can recognize and use the sources of our privilege to advance the rights of those who do not share our own identities or backgrounds. We need to ask ourselves how we can use the knowledge we have of unjust practices toward individuals and groups in society to work toward changes to improve their situation. Our knowledge and experience can be used to join with others and create new movements to reduce poverty, improve access to healthcare, support families, and eliminate discrimination on the basis of our social identities.

The United States is becoming an increasingly multiracial, multicultural, and multiethnic society. At the same time, conditions of economic inequality by gender and race have not improved. These trends in the substance and structure of society challenge our profession to evaluate how we address these demographic shifts. It is our responsibility as social workers to strategically use our position and privilege to work toward greater equality. There is no other ethical choice.

Child Welfare
By Judith M. Schagrin, LCSW-C

Social justice means all citizens are entitled to the same rights and services. I am deeply concerned that we continue to fail the children who are abused, neglected, and just plain unwanted. Foster children, who depend on society’s largesse for their very existence, go largely unseen. Because these are children, they don’t fund any political campaigns, lobby any elected representatives for an opportunity to be heard, or organize any marches to advocate for better services. They have no voice if we don’t speak for them.

It’s not that we haven’t tried to organize a functional child welfare system. Since the start of our modern-day foster care system in the mid-1880s, when Charles Loring Brace started the Orphan Train Movement to resettle orphaned children from New York City to states in the Midwest and beyond, there have been numerous efforts to get it right. We have strategically planned, privatized, transformed systems, thought outside the box, been accountable, computerized, wrapped around, and done more with less. But as a national priority, the nation’s child welfare system is nearly an afterthought. Without the occasional sensationalized child death, I suspect these families would fall off the radar altogether. Unfortunately, the story they have to tell often isn’t pretty, revealing a troubling underbelly of our society. Some prefer to keep these images far away, finding comfort in denial.

While we are a country of people who profess to love their children, there were 3 million reports of child maltreatment in 2004. Experts believe this represents only one third of actual incidents. More than 800,000 reports were found indicating a rate of 2.9 per 1,000 children. That’s not surprising, considering how staunchly we defend our right to physically discipline our children. As long as no injuries result, parents may hit their children with impunity.

Four children die from maltreatment every day, a number largely undercounted. Neglect, often associated with poverty, leads to slightly more child deaths each year than abuse. According to the 2005 census, 17.6% of children under the age of 18 live in poverty; the federal poverty level is $20,000 per year for a family of four. Of children in female-headed households, an appalling 42% exist under the poverty line.

Three years ago, news that Maryland could no longer afford our zoo’s elephants generated far more outrage than our child welfare hiring freeze. The freeze lasted three long years, leaving children’s needs overlooked and ignored. We are a wealthy country not just in money but in talent and brains. Surely we can muster the will to develop and support a top-notch child welfare system? What will it take for our children’s needs to grab the public’s attention with the same fervor as our zoo’s elephants?

As for solutions, let’s create the public will to do it better. Let’s reinstate the White House Children’s Conference—derailed by President Reagan in 1980—and bring together national experts from around the country. Lobby hard for loan forgiveness for social workers willing to specialize in child welfare. Enlarge the sphere of influence for social workers by running for a local, state, or federal office—or electing a colleague.

Our children have only a handful of years to be children, only a brief period to build the foundation for a productive and satisfying adulthood. It’s time we got it right—the children can’t wait.

— Judith M. Schagrin, LCSW-C, is the assistant director for Children’s Services at the Baltimore County Department of Social Services. She was named the 2004 Social Worker of the Year by the National Association of Social Workers.

Healthcare Reform
By Libby Gordon, MSW

I live in the healthiest state in the nation. This is according to America’s Health Rankings, issued yearly by UnitedHealth Group. I must admit, I felt pretty good about this, as I traveled to and from the gym, ate my yogurt and veggies, and took the stairs at work. This blissful denial lasted all of one day. The next day, while attending a health disparity task force meeting, I was brought back to reality: You can live in the healthiest state in the country and still be surrounded by desperate need. No statement drove this home so effectively as the African American public health worker who stood up and proclaimed, “My zip code is dying. Why, in a nation of so much, is my zip code dying?”

Why are 46.6 million people without health insurance (383,000 right here in my healthy state)? Why is employee-sponsored health insurance disappearing? Why are the numbers of uninsured African Americans, Hispanics, and immigrants so disproportionate to that of Caucasians? Why is the number of uninsured children—8.3 million—again on the rise, when it had been dropping steadily since 1998? And why aren’t more people as outraged as the public health worker who burst my bubble of denial?

Although these are questions without simple answers, social workers have a tradition of striving for solutions. To begin, we must understand who are most affected by the disparity in health insurance coverage. The Kaiser Commission on Medicaid and the Uninsured (KCMU) reported that families with incomes 200% below the poverty level run the highest risk of being uninsured. Contrary to public perception, however, 81% of the uninsured are in families where at least one adult is working. Also at high risk of being uninsured are minorities and immigrants. According to the Center on Budget and Policy Priorities (CBPP), African Americans (19.6% uninsured) and Hispanics (32.7%) are much more likely to lack insurance than Caucasians (11.3%). Meanwhile, 43.6% of noncitizen immigrants are without insurance. Lastly, 8.3 million children (11.2%) are presently uninsured, and their future looks grim. In Fiscal Year 2007, which began October 1, 2006, the children’s health insurance programs—which are block grants, not entitlement programs—face federal funding shortfalls in 17 states. This amounts to an estimated $800 million and equals the cost of covering 530,000 low-income children.

The recent escalation in the number of uninsured individuals is largely attributed to a continuing decline in employee-sponsored insurance (ESI). Even when employers do offer insurance, employees frequently cannot afford the skyrocketing premiums. A recent report from KCMU found that between 2001 and 2005, ESI premiums increased by no less than 9% per year. Meanwhile, employees’ earning grew by only 2.2% to 4%, making it difficult to keep pace with insurance payments.

The consequences for those who cannot afford or are not offered health insurance are life-altering. KCMU has found that they are less likely to receive preventive care, such as mammograms, and are more likely to be hospitalized for avoidable conditions. These misguided attempts to contain costs by denying treatment of minor conditions often result in the development of problems that are both more expensive and more serious. Those without insurance are likely to have problems paying medical bills—nearly one quarter are contacted by collection agencies. Most importantly, the Institute of Medicine estimates that 18,000 Americans die prematurely each year because they lack health insurance. If the uninsured were to gain continuous health coverage, mortality rates could be reduced by 5% to 15%.

These inequalities are not inevitable. Solutions do exist and can be created with an eye to both effectiveness and cost containment. Policies can be implemented to locate and enroll individuals who are eligible for public programs, while eligibility for these programs can also be expanded to cast a wider net. ESI premiums can be lowered, and employers with a certain number of employees can be required to pay a set percentage of their payroll on health benefits. Affordable health insurance plans can also be made available to small employers. Children’s health insurance can become an entitlement program, providing coverage to any who are in need.

It was not hyperbole for the public health worker to say her zip code is dying. Chances are, some of those 18,000 people who died prematurely—the minorities, the poor, the children—were her neighbors. So long as some zip codes remain endangered, social workers have a mission: to see the whole picture, the one that rankings do not show, and to advocate for those in need. Perhaps, then someday the health rankings will be a cause for all zip codes to celebrate.

Poverty and Economic Injustice
By Mimi Abramovitz, MSW, DSW

“True compassion is more than flinging a coin to a beggar. It comes to see that an edifice which produces beggars needs restructuring.”
— Martin Luther King, April 4, 1967, New York City1

The Bible says the poor will always be with us, but it does not say why. Since then, some observers have blamed the victim, choosing to punish the “undeserving” and offer a meager safety net to the “deserving” poor. In contrast, social workers believe poverty has many complex causes, including low wages, a lack of jobs, racism, sexism, and other forces beyond individual control. We favor helping rather than punishing people and changing rather than protecting a problematic status quo.

However, for the past 30 years, the fight against poverty and injustice has been an uphill battle. Indeed, major economic dislocations and victim-blaming public policies have taken their toll on the capacity of the three traditional sources of income—marriage, markets, and the state—to protect people from poverty even when they work hard and play by the rules.2 Instead of cushioning the blows of the sagging economy as they once did, today’s leaders confront wage stagnation and slow job growth with tax cuts for the rich, spending cuts for the poor, and a war in Iraq. The results include mounting rates of poverty, hardship, and social problems—all of which fall into social work’s domain.

Mounting Poverty
In 2005, 12.6% of the population (or 37 million people) were poor—up from its all-time low of 11.3% in 2000 and higher than in 1979.3 Even the higher African American (24.9%) and Latino (21.8%) rates and the lower Caucasian (8.3%) rates rose above their all-time 2000 lows.4 Meanwhile, the American Dream—the promise that work pays—faded for the working and middle class. In 2004, 7.8 million people aged 16 or older spent at least 27 weeks either working or looking for a job but earned below–poverty-level wages in companies that provided few basic benefits such as healthcare or parental leave. More than 58% of these “working poor” women and men were on the job full-time and 90% worked at some time during the year—twice as many African Americans and Latinos as Caucasians.5 Thanks to tax cuts and corporate welfare, inequality also reached new highs. In 2005, the top 20% of households accounted for a record 50.4% of the national income, up from 49.8% in 2000 and 43.2% in 1970. In contrast, the bottom fifth’s share fell from 4.4% in 1970 to 3.6% in 2000 to 3.4% in 2005.6

Mounting Hardship
Poverty, in turn, takes its toll on people’s lives. In 2004, 40% of poor and 14% of nonpoor families faced food, health, or housing insecurity, considerably more families of color than Caucasian families.7 The situation has worsened over time. From 1987 to 2005, the number of people lacking food security rose from 31 to 35 million; those without health insured soared from 31 to 46.5 million while the number of households paying more that 30% of their income for rent jumped from 31% (1978) to 49% (2005).8-10 These losses were further compounded by a lack of social investment in low-income communities exposing people to: crumbling neighborhood infrastructures (e.g., abandoned housing, poor schools, lack of services, unemployment); interpersonal violence (e.g., battering, rape, child abuse); and community violence (e.g., gang fights, drive-by shootings, surveillance, police brutality, sexism, and racism).

Mounting Social Problems
Social workers know firsthand that people confronted with chronic deprivation and/or harsh living conditions often feel unsafe, insecure, and powerless. We also know that people cope with the desperate condition by harming themselves (e.g., self-medication, dropping out of school, unsafe sex, ineffective parenting, inability to hold a job, lack of self-care, and suicide) and/or others (e.g., crime, assault, battering, rape, homicide). Social workers have the know-how and the professional obligation to help people undo negative coping and promote positive coping—both self-advocacy (e.g., seeking needed social, health, and financial assistance) or social advocacy (e.g., community activism).

Given social work’s location between the client and society, we can either leave solving poverty to the economists or join the fight for economic justice. A growing consensus holds that exposure to economic hardship and adverse conditions often precedes the rise of individual and social problems rather than the other way around, as previously presumed.11 This conclusion translates into a mandate for prevention and social change. Some fear that making individual and social change a fundamental part of our work politicizes a previously objective and unpolitical profession. Yet, to argue for neutrality itself becomes a political stance—one that tolerates government neglect, compromises our profession’s ethics, and otherwise favors the status quo by letting it stand unchallenged. Since social work cannot avoid the political, it is far better to address these issues explicitly than to pretend they do not exist. The middle ground, if one ever existed, has fast receded. We must decide which side we are on. In the words of Martin Luther King, Jr., “Our lives begin to end the day we become silent about things that matter.”

Affordable Housing
By Frederic G. Reamer, PhD

Recently, I attended a meeting at the National Association of Social Workers’ (NASW) headquarters in Washington, D.C. NASW’s offices are located a stone’s throw from the U.S. Capitol, one of the most architecturally impressive and symbolically important buildings in the world. During my walk, I was overwhelmed by the majesty of the scenery but sadly, and ironically, I was also overwhelmed by the number of (apparently) homeless people I passed during my walk from the Capitol to NASW, men and women sleeping in broad daylight on concrete slabs and park benches. The juxtaposition—the contrast between the stately halls of Congress and the stark evidence of America’s poverty and affordable housing crisis—was one of the most stunning I have ever encountered.

Understandably, social workers concerned about affordable housing have focused primarily on the nagging problem of homelessness, particularly among people struggling with mental illness, addictions, and persistent poverty. However, the troubling problem of homelessness is merely symptomatic of a broader crisis of affordable housing, one that has profound implications for social workers’ clients.

Housing costs are staggering in many American communities. The National Coalition for the Homeless reports that approximately 3.5 million people—1.35 million of them children—are likely to experience homelessness in a given year. According to Harvard University’s Joint Center for Housing Studies, nearly one in three American households currently spend more than 30% of income on housing, and more than one in eight spend upwards of 50%. Approximately 2.5 million households live in crowded or structurally inadequate housing units.

It is essential for social workers to understand the magnitude and nature of this country’s affordable housing crisis and its implications for practice. The principal causes of the contemporary affordable housing crisis are complex. The demand for affordable housing is affected by increases in poverty and growth in the number of U.S. households. In addition to ordinary population increases, growth in the number of people needing housing also results from declining marriage rates and an increase in the average age at which people first marry, which postpone the combining of households.

Coinciding with increasing demands for affordable housing are threats to the nation’s supply. Declining and expiring federal housing subsidies, disappearing tax incentives to invest in and build low-income housing, restrictive and exclusionary zoning practices, demolition and abandonment of older housing stock, and gentrification join to reduce the number of affordable housing units in many communities. Consistent with one of the most basic laws of economics, increasing demand combined with diminishing supply can lead to skyrocketing costs.

To be effective advocates for clients and informed participants in the public policy arena, social workers must have a firm grasp of possible solutions. Social workers should seek to preserve the existing stock of affordable housing by pushing for programs that rehabilitate low- and moderate-income housing and advocating for preservation of existing subsidies for low- and moderate-income housing.

Also, social workers should seek to expand the supply of affordable housing through tax incentives that underwrite subsidized mortgages for builders, progressive and enlightened zoning practices that promote the “fair share” development of affordable housing across communities, and creation of housing trust funds fed by a renewable stream of income (for example, via real estate transfer taxes, interest on real estate escrow accounts, interest from government loans, and developer fees).

Social workers have an enduring tradition of concern about individuals’ most basic needs, including housing. One of the profession’s principal trademarks is its simultaneous concern with individual well-being and related public policy issues. Certainly, social workers must be concerned about the basic housing and shelter needs of individual clients. At the same time, however, social workers must be engaged actively in the advocacy, public debate, and policy formation that are so essential to the provision of safe and affordable housing. To do otherwise would be to stray from social work’s time-honored mission.