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New York University’s Applied Psychology Online Publication of Undergraduate Studies, also known as OPUS, was established in 2009. OPUS provides Applied Psychology undergraduate students with a forum for sharing their independent work. This publication is entirely written, edited, and designed by Applied Psychology undergraduates, and is one of the only undergraduate psychology journals in the United States.

We are thrilled to present our Fall 2020 issue this year. To reflect the developing landscape of the field of psychology, our Fall 2020 issue is centered around the themes of Gender and Sexuality. Specifically, the Fall 2020 issue reflects the clinical and research interests of our contributing writers and demonstrates a desire to understand the nuances of psychological phenomena in order to improve the lives of a range of groups, thus embodying the ethos of Applied Psychology.

Our issue this semester contains further explorations of psychological theories with real-world applications. In the first section, “Gender & Development,” Katie Mundt examines how gender stereotypes influence the career decisions of young women. Through an analysis of self-concept, Katie delves into the various factors that may subsequently encourage or discourage a traditional career path. Ancelma Vazquez’s piece addresses another aspect of gender and self-concept through exploring the positive and negative effects of social media network use on adolescent girls’ self-esteem. In the final piece in this section, Abby Rusnak investigates the factors that lead to adolescent females’ experiences of body dissatisfaction.

The following section, “Gender, Sexuality, & Inequality” includes Olivia Russo’s literature review exploring how different types of gender-based discrimiation affect the mental health of Transgender and Gender NonConforming (TGNC) individuals. Expanding on Olivia’s piece, Julia Leschi’s literature review examines how individuals with compounded marginalized identities experience minority stress. Julia highlights the protective and damaging factors of being a part of both Lesbian, Gay, Bisexual, Transgender, and Queer (LGBTQ) and Black, Indigenous, and People of Color (BIPOC) communities.

Thank you so much to our enthusiastic and talented writers for their scholarly contributions, as well as Sydney Liang, Grace Park, and Chloe Carlson, the OPUS administrative staff for their hard work and commitment to the journal. Additionally, we would like to acknowledge and thank Mel Pagliaro for contributing their artwork to be displayed on the cover of this issue. We are also grateful to Dr. Gigliana Melzi, the Director of Undergraduate Studies in Applied Psychology, and Erica Rodriguez, the OPUS advisor for their continuous support of OPUS. Finally, we would like to thank Dr. Adina Schick, our faculty mentor, for her guidance, wit, and dedication to OPUS, without which this issue would not be possible.

Best,

OPUS Editors

Olivia P. Russo (she/her) | Editor-in-Chief | op496@nyu.edu

Olivia is a senior in the Applied Psychology program, double majoring in Gender & Sexuality Studies. She is passionate about bridging psychology and gender & sexuality, evident by her research interests and experience. She is currently a research assistant on Dr. Yoshikawa’s Gender and Sexuality Alliance Research Consortium (GSARC), where she is involved on two smaller projects: the Principal Interview Study, exploring school principals’ experiences with the LGBTQIA+ community, and the Dissemination Efforts team, creating resources for high-school GSAs based on previous GSARC research. Upon graduation, Olivia is pursuing a Master of Arts at NYU Steinhardt in Counseling for Mental Health and Wellness, with an advanced certificate in LGBTQ Eduation, Health, and Social Services.

Maya Metser (she/her) | Editor-in-Chief | maya.metser@nyu.edu

Maya is a senior in the Applied Psychology program. She is currently pursuing an Honors thesis under the mentorship of Dr. Natalie H. Brito at the ISLAND Lab, where she is exploring the effects of mother-infant heart rate synchrony on infant attention outcomes. In the past, she was an advocate for the ROSES research team and a research assistant at the SCAN Lab, a fetal neuroimaging lab. Moving forward, she hopes to bridge her passion for neuroscience, education, and juvenile justice reform to make early environments better support positive development. Lastly, Maya hosts a podcast called Psych Mic that explores the lives and career paths of industry leaders who use psychology to make an impact in the world. Psych Mic highlights psychology’s versatile applications and provides practical advice about opportunities in the field.

Katie Mundt (she/her) | Editor-in-Chief | kvm256@nyu.edu

Katie is a fall graduate of the Global Public Health/Applied Psychology program. She is interested in improving community health through a psychological lens, applying the skills and theories from psychology to health research and policy reform. She worked at NYU Langone on the Smoke-Free Housing Project, which evaluated the effectiveness of a smoke-free policy in NYC public housing developments. Currently, she works as a research assistant for the RISE lab and has helped develop a grant-awarded research proposal for the Social Perception Action & Motivation (SPAM) lab, which examined how the media’s portrayal of the COVID-19 pandemic impacts perception and subsequent behavior. She recently accepted a Service Coordinator position with ComPsych, an employee assistance program headquartered in Chicago, IL.

Chloe Carlson (she/her) | Layout and Design Director | cec727@nyu.edu

Chloe is a sophomore in Applied Psychology with a strong interest in the effects of media on the mind. While pursuing a minor in Media, Culture, and Communication, she hopes to assist in the creation of more psychology related media in order to raise mental health awareness and educate others.

Sydney Liang (she/her) | Layout and Design Director | syl569@nyu.edu

Sydney is a junior in the Applied Psychology program with a minor in Media, Culture, and Communication. She is currently a research assistant at Play and Language Lab, which examines how children interact with their environment as well as how social and cultural factors influence children’s development. Previously, she has interned at various organizations ranging from nonprofits to multinational companies. She plans on continuing to explore various career paths which highlight the intersection between psychology, research, and communication before pursuing higher education.

Grace Park (she/her) | Layout and Design Director | hjp332@nyu.edu

Grace is a junior in Applied Psychology minoring in Nutrition and Dietetics. She is interested in raising awareness of mental health in minority communities and hopes to help such populations by providing culturally competent care. Grace will be working as a research assistant for The Listening Project which aims to train middle school students and teachers in a semi-structured method of interviewing with the goal of enhancing listening skills, empathy, trust, academic engagement and achievement. The Listening Project works to disrupt stereotypes and build relationships across differences. Grace ultimately hopes to complete her masters at NYU in Counseling for Mental Health and Wellness.

Janean Cuffee (she/her) | Contributing Writer

Janean is a senior in the Applied Psychology program double minoring in Sociology and History. She is also a member of the varsity women’s basketball team at NYU. She is interested in equal educational opportunities across socioeconomic backgrounds and the mental health impacts of childhood trauma. In the past, she has worked with under-resourced youth in her internship at Harlem Children’s Zone and fellowship at Uncommon Schools. Currently, she is an Assistant Lab Manager for the RISE Lab that works to advance and improve the lives of marginalized populations. Additionally, she is the founder of BLAC (Black Latinx Athlete Coalition), a space meant to provide comfort to minority athletes that may not always feel at home in a PWI. After graduation, Janean will be a middle school teacher at a charter school in Brooklyn in the Uncommon Schools Organization.

Anjali Mehta (she/her) | Contributing Writer

Anjali Mehta is a junior at NYU, getting a B.S. in Applied Psychology with a minor in Philosophy, and an M.A. in Mental Health Counseling. Anjali works at the Mindful Education Lab, where she is currently investigating the overlap between cognitive neuropsychology and meditation, specifically by researching attention and technology. Her research interests also include self-knowledge, violence, and PTSD, specifically from military trauma and sexual abuse. Outside of NYU, Anjali is a certified advanced yoga instructor, yoga therapist, and MBSR coach and has also delivered a TEDx talk on the “Power of Breath.” Though she has more than five years of experience as a yoga instructor, Anjali intends to earn a Ph.D. in Clinical Psychology and ultimately to become a practicing psychotherapist, in order to investigate the inner workings of the mind. Her career plans may include serving in the Singapore Military as a Clinical Psychologist.

Gizem Kurtbolat (she/her) | Contributing Writer

Gizem is a senior in the Applied Psychology program. She is interested in working with children and adolescents and raising mental health awareness among this population. In the past she has volunteered at school for children with Autism as a classroom volunteer. Currently she is an intern at Ramapo for Children, working on creating content on school climate and researching for reports and articles that can be useful resources for schools. In addition she volunteers as a tutor at Econnected, a non-profit organization that supports English Language Learners with their English and Math skills.  After graduation, she would like to gain more experience working with children and adolescents in clinical settings to work towards becoming a child and adolescent psychologist.

Samantha Ruggiero (she/her) | Contributing Writer

Samantha is a senior in the Applied Psychology program with a minor in Public Policy and Management. Her research interests include the ways in which social inequality impacts individuals in the workplace. In the past, Samantha has interned in a variety of professional settings, including in schools, research labs, non-profits, and start-ups. Currently, Samantha is working as a Research Assistant in Dr. Rezarta Bilali’s Social Inequality and Intergroup Conflict Lab. Specifically, she is working on projects that are centered on evaluating the ways in which social movement organizations and mainstream media outlets portray historical narratives and their various components. She is also working on a code-writing project to analyze data from a study that measured participant perceptions of the Women’s March. Upon graduation, Samantha will be continuing her post-baccalaureate education at New York University in the Master of Industrial-Organizational Psychology program.

Vion He (she/her) | Contributing Writer

Vion is a junior in the Applied Psychology program with a minor in BEMT (Business of Entertainment, Media and Technology). She is interested in improving mental health literacy and increasing access to psychological services for marginalized populations, particularly the LGBTQIA+ community. As a research assistant at Families and Children Experiencing Success (FACES) Lab, she focuses on examining the effectiveness of parent-targeted interventions for children with behavioral challenges (e.g., ADHD) and their families, as well as parental engagement in treatment. In addition, she volunteers at the College Prep Academy program at NYU Metro Center, where she delivers group coaching services to high school students on topics including college planning, careers, and mental health. While planning to explore career path possibilities, she hopes to dedicate herself to providing mental health care and treatment to minority populations in the future.

Julia Leschi (she/her) | Contributing Writer

Julia is a senior in the Applied Psychology program minoring in Public Health. She is interested in applying a psychological lens to public health and policy issues. In the past, she worked as a clinical assistant at a substance use clinic in Midtown Manhattan. She is currently working as the Associate Director of Research at the Empower Lab, a clinical research and advocacy lab working to further gender equity through scientific approaches to issues of gender-based violence. There, she is conducting a qualitative exploration of sugar dating practices on college campuses, and studying the health needs of human trafficking survivors and asylum seekers. In the future, she hopes to put her research skills in service of policy reform and community work before continuing her education. 

Macarena Kruger (she/her) | Contributing Writer

Macarena is a senior in the Applied Psychology undergraduate program. She is also a member of the varsity women’s tennis team at NYU and a research assistant at NYU-LFELD (Latino Family Engagement and Language Development). Specifically, she works for the MEAL project, which focuses on examining Latine children’s development and math skills learning in the United States. Throughout the Spring semester, Macarena has been coding data collected on mother-child semi-naturalistic interactions. She is currently writing “Math heroes biographies” in Spanish for third graders. The main purpose of the project is for low-income Latine children to learn about the lives of people of color who have been successful and to make an explicit connection between their professions and the use of math. Macarena is also working on her Honors thesis under the mentorship of Dr. Gigliana Melzi., exploring Mexican-heritage mothers’ relative importance given to children’s academic and socio-emotional skills and their book sharing practices.

Joy Shen (she/her) | Contributing Writer

Joy is a recent graduate of the Applied Psychology undergraduate program. During her time at NYU, Joy was involved in research in Dr. Brito’s ISLAND Lab, where she worked with families and explored infant development. Currently, Joy works as a research assistant at the Cognitive and Behavioral Consultants, a mental health facility, where she works on various program and treatment evaluations to manage and track patient’s progress. Her projects focus on implementing DBT in schools, overseeing intensive DBT and CBT programs, and conducting qualitative studies on program dropout. Ultimately, she hopes to work with a diverse population to help promote equity in mental health treatment and to focus on the incarceration system. Outside of school, Joy spends her free time skateboarding, painting, and baking. In the fall, Joy will begin her PsyD program at Yeshiva University’s Ferkauf Graduate School of Psychology, where she will train to practice psychotherapy and broaden her research.

Ana Warner (she/her) | Contributing Writer

Ana is a senior double majoring in the Applied Psychology and Global Public Health programs. She is interested in expanding healthcare access and education with LGBTQ+ and BIPOC populations, especially amongst students. She is currently exploring these interests as an HRTP Intern at the NYC Department of Health and Mental Hygiene and a research assistant in the Gender and Sexuality Alliance Research Consortium (GSARC) at NYU under the direction of Dr. Yoshikawa. In the future, she hopes to combine her passions for public health policy and psychology to expand mental health access, education, and autonomy for young people.

Callie Hilgendorf (she/her) | Contributing Writer

Callie is a senior double majoring in Global Public Health and Applied Psychology. She is interested in actively engaging within communities to combat oppressive systems and how mental health trauma is experienced and pathologized by stigma. She is currently working as a research assistant in the Project for the Advancement of our Common Humanity Listening Project (PACH): The Listening Project at NYU under the direction of Dr. Yoshikawa and Dr. Way. She also holds a leadership position with the NYU chapter of Peer Health Exchange (PHE), a non-profit organization focusing on improving health equity and advocacy outreach for adolescents. Upon graduation, Callie will be pursuing a Master of Public Health at Columbia University in the Sociomedical Sciences and a certificate in Population Mental Health.

Ana Warner & Callie Hilgendorf

With the onset of the COVID-19 pandemic, many public health officials expressed a serious concern regarding the ramifications for mental health (Hasan & Bao, 2020). In fact, preliminary findings on the lack of educational opportunities and the rise in social isolation and partner violence reveal troubling trends in the already burdening effects of the COVID-19 pandemic on both physical and mental health (Goodman & Epstein, 2020; Wang et al., 2020). The intensity of COVID-19 in the United States has had a profound effect on the mental health of various communities, including  lesbian, gay, bisexual, transgender, and queer (LGBTQ+) college students (Meyer, 2013). Prior to the pandemic, LGBTQ+ individuals were more vulnerable to experiencing negative mental health outcomes, specifically anxiety, in comparison to their heterosexual peers (Price-Feeney et al., 2020 & Russell & Fish, 2016). LGBTQ+ young adults have endured suffering, social isolation, job insecurity, and a tremendous amount of community loss during the COVID-19 pandemic (Gonzales et al., 2020; Konnoth, 2020). These experiences may be unique to people in the LGBTQ+ community, as compared to their heterosexual counterparts, because they may also face housing and job discrimination, live with people who are not supportive of their identities, and may generally rely on in-person, queer, community support systems (Jackson, 2017). To add to these already high-stress situations, many college students have had to make the difficult and abrupt transition to online learning with little support (Perz et al., 2020). Yet, there is limited research that addresses the ways in which LGBTQ+ college students have experienced anxiety from the pandemic.

COVID-19 Effects on College Communities

The COVID-19 pandemic has led to dramatic and undeniable losses worldwide, particularly for college-aged students (World Health Organization, 2020). With the continuing rise of COVID-19 cases, many universities shut down or shifted to fully remote learning (Grether et al., 2020; Perz et al., 2020). Due to campus closings, many students abruptly moved off-campus, which, in turn, caused many to lose their jobs and endure significant financial loss (Hoyt et al., 2020; Perz et al., 2020). This is in addition to the challenges regarding food, housing, and financial insecurity that many college students experienced prior to the pandemic (Owens et al., 2020).

The logistical and mental strain on college-aged students brought on by the pandemic challenged many to adapt to social, physical, and mental isolation (Wang et al., 2020). Recent research has indicated that college students have been coping with high amounts of stress and anxiety related to academic performance, physical risk of themselves or a loved one contracting the virus, study habits, social habits, remote learning experiences, current labor market participation, and expectations about future employment or further degrees (Aucejo et al., 2020; Chen et al., 2020; Perz et al., 2020). Specifically, the pandemic led to many students to withdraw from classes and even delay graduation because of uncertainty surrounding future educational plans and the current unemployment climate in the United States (Aurcejo et al., 2020). Additionally, students indicated a decrease in hours committed to scholarly activities, resulting in an overall decrease in academic performance (Aurcejo et al., 2020).

Each of these factors contribute to a general concern that an already existing mental health crisis is likely to become exacerbated due to handling of the COVID-19 pandemic (Hasan & Bao, 2020; Perz et al., 2020). According to the 2019 Annual Report of the Center for Collegiate Mental Health, anxiety was the most reported issue amongst college-aged students and has increased since the beginning of the pandemic (Wang et al., 2020). Research has found that those who indicated an increase in stress frequently cited five main reasons: academics (i.e., grades, delayed graduation, and remote learning), general uncertainty, health related concerns, finances, and social isolation (Wang et al., 2020). As social distancing protocols and the closure of public spaces continue, researchers have presented evidence that individuals, particularly young adults, experienced significant levels of anxiety and stress while in quarantine (Salari et al., 2020), and students have felt  unable to adequately cope with their stress during this difficult time (Wang et al., 2020). Yet, there is a clear gap in the support these students have been receiving, and universities need to take action to better support the mental health of their students (Wang et al., 2020).

LGBTQ+ College Students and Anxiety

Academic interest in the wellbeing of LGBTQ+ students is relatively new (Leider, 2012). Until the early 2000s, the research published regarding LGBTQ+ college students was mostly concerned with anti-LGBTQ+ attitudes, as opposed to the experiences of LGBTQ+ students (Leider, 2012). Today there is a growing body of research working to address mental health concerns, such as anxiety, in the LGBTQ+ community (Leider, 2012; Ottenritter, 2012). One meta-analysis showed a pattern of lower rates of anxiety amongst heterosexual people as compared to their LGBTQ+ peers, even when controlling for other predictors of mental health complications (e.g., people who are HIV positive or experiencing housing insecurity), especially on college campuses (Meyer, 2013). Researchers have generally come to believe that this may be a result of LGBTQ+ identifying individuals experiencing microaggressions, overt aggressions, identity confusion, and internalized homophobia (Meyer, 2013; Ross et al., 2018).

College campuses also have the potential to improve mental health outcomes for LGBTQ+ students. When LGBTQ+ individuals have safe community-oriented queer spaces to process impactful events in their lives, they perceive less social isolation and are met with more wholly advantageous coping strategies (Jackson, 2017). Community building and consistent access to these different support networks are crucial for LGBTQ+ students to manage anxieties surrounding their identities and life experiences, so that they can fully commit themselves to flourishing during their time in school and beyond (Leider, 2012; Ottenritter, 2012). Given the nature of collegiate institutions, LGBTQ+ populations, compared to their heterosexual peers, are more likely to experience mental health disparities which may have been exacerbated since the COVID-19 pandemic (Salerno et al., 2020).

Current Study

There is currently very little research available that seeks to understand the connection between anxiety in LGBTQ+ college students and the COVID-19 pandemic (Meyer, 2013; Ross et al., 2018; Seelman et al., 2017). While it is understandable that this research is not widely available yet due to the recency of  the pandemic  and the number of subpopulations affected by it, it is especially important to look at LGBTQ+ college students, because they are already at a higher risk of anxiety than their peers (Meyer, 2013; Salerno et al., 2020). Additionally, by focusing on this community, research can strive to discover trends in LGBTQ+ college students’ experiences with anxiety and prevent them from becoming more prevalent in the future. Experience with anxiety, in this case, will focus on symptoms (e.g., panic attacks, increased heart rate, feelings of being out of control, etc.), access to support systems, and environmental factors. This qualitative study, thus, explored the following research question: How has the COVID-19 pandemic affected the experience of anxiety in LGBTQ+ college students?

Method

Participants

Fourteen LGBTQ+ identifying students from New York University (NYU), recruited via social media, class forums, and word of mouth, participated in the study. Participants were told they must identify as part of the LGBTQ+ community and be currently enrolled at NYU to be eligible for the study. Students were also given the opportunity to request a specific interviewer to reduce response biases and encourage more open responses. All respondents (N=14) identified as one or more of the following racial/ethnic identities: White (47.1%), Black (17.6%), Latine (23.5%), and Asian (11.8%), and one or more of the following LGBTQ+ identities: lesbian (24%), gay (16%), bisexual (12%), transgender (8%), pansexual (4%), queer (36%). The following gender identities were also represented: cisgender female (62.5%), transgender (12.5%), and nonbinary (25%) with differing combinations of she/her (62.5%), they/them (31.3%), and he/him pronouns (6.3%).

Procedure

This study was conducted via 20-minute semi-structured Zoom interviews where participants were asked to report demographic information such as pronouns, gender identity, LGBTQ+ identity, ethnicity, age, and year in college. For questions such as gender identity, LGBTQ+ identity, and ethnicity, participants were not given options to choose and were encouraged to list any and all terms that they identify with. Participants were also asked questions about their experiences since the beginning of the COVID-19 pandemic and anxiety. The questions about the participants’ experiences with anxiety and COVID-19 can be found in Appendix A.

Results

All interviews were recorded and then transcribed by the interviewers. Researchers used the principles of grounded theory to code the semi-structured interviews, by coding 21% of the  transcripts and discussing and defining common themes related to the research question (Chun Tie et al., 2019). The codes that were generated based on the emergent themes are: anxiety surrounding routine (anxiety linked to changes in everyday life and uncertainties as a result of COVID-19), anxiety surrounding uncertainty (anxiety linked to unforeseen changes in previously secure long-term environments such as employment, housing, and community), social isolation (a decrease in daily interpersonal interactions and ultimate feelings of detachment from their communities), lack of normality (reported feelings of continued distress and inability to adjust comfortability into the world as affected by COVID-19), and less mental capacity (a lack of self-reported cognitive capabilities to perform everyday responsibilities such as homework, attending class or work, and personal maintenance).

Analysis of the data highlighted that 34% percent of participants indicated they were experiencing “anxiety surrounding uncertainty” over the past month. This included anxiety about relocating, changes in employment, and financial instability. Additionally, 13 out of the 14 participants indicated they were struggling with changes in everyday life, as well as “anxiety surrounding changes in routine” as a result of COVID-19. These changes included a shift to online learning due to COVID-19, adjusting to different workloads in employment or unemployment, moving locations during the pandemic, and shifting daily activities to a more indoor environment. Eighty-six percent of the participants reported that they were lacking a sense of normality in their daily interpersonal interactions. This included participants feeling equipped to adjust to a reorganized change in normality, and professors failing to recognize student accommodations due to COVID-19 related issues.

Throughout the pandemic, community engagement (e.g., through roommates, family, family-friends, or colleagues)  has been a source of both reduced anxiety (21.4%) and increased anxiety (57.1%) for participants. Some specific examples of reduced anxiety that participants noted included a decrease in social anxiety given that social interactions decreased, and connecting with friends and family has switched to virtual communication. Out of the total responses, 13% of participants expressed that they had been experiencing “social isolation” through separation from their respective communities due to COVID-19. Potential causes for increases in anxiety levels that stem from “social isolation” include: living alone in an apartment, abrupt separation, limited social interactions, partner separation, contraction anxiety between partners, and NYU community seperation. Of the 14 interviews conducted, nine participants indicated that they were experiencing feelings of social isolation.

All 14 participants indicated at least once that they were struggling with less mental capacity to perform everyday responsibilities including homework, attending class or work, and personal hygiene or self-care. These experiences of anxiety focus specifically on the symptoms our population of study encounters. There was a noticeable trend in the participants’ quantity and quality of sleep; out of the 11 participants who chose to disclose their symptoms, six identified insomnia, or restlessness, as a significant source of their anxiety. These sleep disruptions totaled to 55% of the symptoms reported by the participants.

Another heavily represented symptom included trouble eating and nausea; five out of fourteen, or 35.7%, of participants expressed this manifestation of anxiety. Among the three participants who disclosed a medical diagnosis of Obsessive Compulsive Disorder (OCD,) two indicated that their obsessive thoughts or repetitive compulsions have increased because of an increase in anxiety related to COVID-19. Other common symptoms of anxiety that were expressed by our participants include: headaches, fidgeting, anxiety attacks (i.e., tightness in the chest, feeling an inability to breathe, and trouble thinking clearly), and dissociation from the present moment. Participants commonly reported struggling with one or more combinations of dissociation, lack of motivation, trouble focusing, and fatigue as symptoms of their anxiety. These symptoms combined with feelings of uncertainty, dramatic changes in routine, and intrusive thoughts and behaviors make it difficult to perform everyday tasks such as attending work and school and maintaining physical and mental hygiene. Some participants specifically said that they must be more strategic with planning their days around their available mental capacities. They also stated that they have had to significantly adjust their daily routines by increasing alone time, minimizing time on the computer, and scheduling daily outings.

Another aspect that was highlighted during the semi-structured interviews is that having access to mental health services is important for LGBTQ+ college students during the pandemic. Although it was not part of the formal interview questions, access to medication and counseling services came up organically in many conversations with the participants. Only five participants mentioned that they were taking medication to help manage their feelings and symptoms of anxiety and/or regularly seeing a mental health professional during the pandemic. In each of those cases, students reported a decrease in symptoms of anxiety and general improvement in their day-to-day lives.

Discussion

This study aimed to address the gaps in the literature surrounding the experiences of anxiety that LGBTQ+ college students face throughout the COVID-19 pandemic. The findings support past research by highlighting the anxiety experienced by LGBTQ+ college students (Goodman & Epstein, 2020; Meyer, 2013). One of the most common shared experiences from the participants was related to new or heightened stressors that have been increasingly difficult to manage since the pandemic. Specifically, individuals are forced to resume their lives with academics and work, but with less perceived mental capacity. Participants commonly reported struggling with one or more combinations of dissociation, lack of motivation, trouble focusing, and fatigue as symptoms of their anxiety. These symptoms combined with feelings of uncertainty, dramatic changes in routine, and intrusive thoughts and behaviors make it difficult to perform everyday tasks such as attending work and school and maintaining physical and mental hygiene.

Another aspect which has appeared to contribute to how LGBTQ+ students are re-prioritizing their available time and energy is their individual engagement in their classes. The rise of COVID-19 has created or heightened anxiety surrounding uncertainty with employment, finances, and housing amongst students and thus impacts individuals’ motivation and ability to be engaged in their coursework which is consistent with previous literature (Aucejo et al., 2020; Chen et al., 2020; Perz et al., 2020;). One student specifically mentioned that, “online school is not fun or easy, especially with professors who are not trained to teach online and when everything else in the world is a mess.” When participants were asked about how they were able to adjust their priorities and maintain engagement in school and work, every response mentioned the impact of their professors’ attitudes and/or policies in some way. Based on the findings, it appears that the attitudes of professors are impactful to LGBTQ+ students’ experiences with anxiety during COVID-19, which could be beneficial to take into account when planning lessons, deadlines, and general class structure in the future to better support students during this time.

Identity also seemed to play a role in the reported experiences of anxiety in this study. One person went as far as to mention that “some of [their] anxiety is specifically because [they] are LGBTQ+ and exist during the COVID-19 pandemic.” This feeling seemed to resonate in a few respondents who mentioned having to move out of their own spaces on or around campus and moving in with family or friends for extended periods of time in early 2020. Experiences ranged from not being able to engage in meaningful discussions with like-minded individuals about their lives or identities to entirely having to act as though they were not part of the LGBTQ+ community, which correspond to increased feelings of anxiety surrounding routine, anxiety surrounding uncertainty, social isolation, lack of normality, and less mental capacity based on the study’s coding measures. When LGBTQ+ college students are living through these experiences, it impacts their ability to perform at work and school as well as their ability to adequately take care of themselves. In order to address the ramifications of these experiences, it is especially important for institutions such as businesses, universities, and community organizations to prioritize the accessibility of a variety of mental health services (e.g., counseling, medication, etc.), as well as creating community support to re-engage young people in dialogue and action that empowers them in their identities. Organizations should also seek to utilize avenues that allow the individual to maintain their security within their living environment such as having e-book clubs, pen pals, and virtual affinity groups. It is important that research is able to center LGBTQ+ people to address existing disparities in mental health outcomes and prevent these from becoming exacerbated as a result of COVID-19.

Limitations and Future Directions

The researchers chose to identify patterns in experiences with anxiety amongst LGBTQ+ students at New York University in order to get the most representative sample for this context. With the resources available, if the study had included other universities there may not have been enough representation from any one place to get an accurate depiction of students’ experiences. Future research might  explore how the experiences of LGBTQ+ identifying students at other universities are the same or different so that administrators and other stakeholders can adequately support their students.

Aside from universities, one aspect that was often touched on in this study was respondent’s experiences with finances and employment. No participants discussed the level of support and communication that they received from their employers during the pandemic. Given that many of the participants mentioned being employed at some point before or during the pandemic, it may also be beneficial for future research to explore how LGBTQ+ individuals’ employment has been affected by the pandemic to better address potential financial discrepancies and discern how employers can best support their employees during this time. Additionally, it is common for people with anxiety to experience other mental health complications at the same time, such as depression and phobias (Kaufman & Charney 2020; Last et al., 1987). This study did not examine comorbidities of anxiety, but in order to get a more holistic understanding of the needs and experiences of LGBTQ+ individuals during COVID-19 future qualitative research should investigate intersectional mental health concerns as well.

Shedding-light on the experience of anxiety that college students are currently facing has a positive impact on the amount of attention this topic receives in psychology research. Future studies can address some of the limitations of this study in order to develope a more well-rounded understanding of how to support different LGBTQ+ communities. By highlighting the need for more anxiety-related mental health support for the LGBTQ+ community, further research can also expand to other mental health conditions that are prevalent in adolescents’ lives. As the pandemic progressively becomes under control, it is important to continue to support vulnerable communities.

References

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Joy Shen and Macarena Kruger

The COVID-19 pandemic has created significant shifts in people’s everyday lives (Brown et al., 2020; Prime et al., 2020). Social restrictions and business downfalls negatively impacted adults’ and children’s mental health (Centers for Disease Control and Prevention [CDC], 2020). Indeed, many adults lost their jobs (Karpman et al., 2020; Nicola et al., 2020), and almost all children globally transitioned to online learning (Golberstein et al., 2020). With athese transitions, many parents needed to take on a new role of teacher or school facilitator for their children at home (Prime et al., 2020). These added roles and responsibilities might have increased parental burnout levels. While parental stress is common and not usually detrimental to parents’ well-being (Griffith, 2020), burnout is indicated by extreme exhaustion, a feeling of distance from the family structure or child (e.g., being less responsive to their child or emotionally disengaged), and a sense of inadequacy or ineffectiveness in their parenting role (Griffith, 2020; Mikolajczak et al., 2018; Roskam et al., 2017). Extant research on parenting and burnout has examined emotional burnout in parents (e.g., Le Vigouroux et al., 2017; Mikolajczak et al., 2018), including in parents who homeschool their children (e.g., Lois, 2006). However, less is known about whether this burnout is different amongst caregivers who were forced to adopt teaching roles at home. Further, given the recency of COVID-19, research has not yet fully examined the effects of the pandemic on parenting. There are a few studies that have examined the pandemic in relation to higher parental stress levels and an increase in child maltreatment rates (e.g., Brown et al., 2020; Campbell, 2020). However, they fail to acknowledge other parental mental health aspects, such as burnout levels, as a result of the pandemic.

Parental Burnout in Parents With Young Children

Parental burnout is a significant problem, because it leads to sleep difficulties, marital conflict, and child rearing practices that could have a detrimental impact on children’s development (Mikolajczak et al., 2018). Specifically in the United States, parental burnout rates are alarming; approximately 3.5 million parents experience burnout (Mikolajczak et al., 2019). Children’s ages and the number of children in the household are key factors that play a role in parental burnout levels (Le Vigouroux & Scola, 2018). Indeed, young children (i.e., from birth to 6 years old) require more supervision and attention from their parents compared with their older counterparts (Le Vigouroux & Scola, 2018; Mikolajczak et al., 2018). For instance, parents play a key role in their young children’s development of healthy habits (e.g., limited time watching TV), as well as in the promotion of practices that foster childrens’ early skills (e.g., book reading; Olson et al., 2004).

In addition to factors at home, burnout levels may be impacted by external circumstances, such as unexpected events (Le Vigouroux et al. 2017) and social expectations for raising young children (Borelli et al., 2017; Meeussen & Van Laar, 2018; Roskam et al., 2017). For example, due to women’s increasing participation in the workplace, it may be harder for mothers to attend to their children’s demands, and these difficulties might be compounded by the social pressure that is placed on parents, specifically on mothers to be warm, present, and engaged (Meeussen & Van Laar, 2018; Roskam et al., 2017). Accordingly, mothers tend to experience greater parental burnout levels than fathers. Furthermore, parents’ socioeconomic status and their financial positions play a key role (Sorkkila & Aunola, 2020), especially when dealing with unexpected financial responsibilities (e.g., increase in rent and/or medical bills). If parents are not financially stable, finances become a constant stressor, and prolonged exposure to stressors leads to burnout (Lebert-Charron et al., 2018; Meeussen & Van Laar, 2018; Roskam & Mikolajczak, 2020).

Despite all the challenges that parents face, there are also protective factors which prevent parents from experiencing the negative effects of potential high stress (Sorkkila & Aunola, 2020). One of the most beneficial protective factors is to make time for self-care practices (e.g., practice self-compassion and self-acceptance; Sorkkila & Aunola, 2020). Another effective strategy is to perceive control over challenging situations, which consequently helps parents develop higher emotion regulation to cope with burnout (Brown et al., 2020; Dijkstra & Homan, 2016). In terms of family support, parental agreement when parenting children has also shown to help minimize the effects of burnout (Gérain & Zech, 2018; Mikolajczak et al., 2018).

Homeschooling, COVID-19, and Burnout

Parents who homeschool their children face unique challenges with balancing roles, and, thus, tend to experience greater burnout levels (Baker, 2019). Both their teaching and parenting roles are psychologically, physically, and cognitively demanding (Boyle et al., 1995; Friedman, 2003). Parents who take on the role of an educator at home may experience role strain, a common factor leading to burnout (Baker, 2019; Lois, 2006). Role strain may be exacerbated by role ambiguity (i.e., uncertainty about the expectations of a role) or role conflict (i.e., when there are multiple roles to fill, and they interfere with one another; Lois, 2006; Papastylianou et al., 2009). Juggling a career alongside parenting and teaching might contribute to even greater role strain (Green & Hoover-Dempsey, 2007). These role strains are often exacerbated if parents lack adequate resources and/or social support (Friedman, 2003; Lois, 2006). Many parents, even former school teachers who end up in a homeschooling role, feel a sense of inadequacy or insecurity surrounding their abilities to teach, causing more stress and exhaustion (Brissie et al., 1988; Friedman, 2003; Lois, 2006; Papastylianou et al., 2009). This sense of inadequacy is often exacerbated due to parents’ deep emotional commitment to the children, especially if their child lacks motivation or is failing to meet expectations (Baker, 2019; Lois, 2006).

Most research on homeschooling has focused on parents who made the decision to transition to homeschooling due to religious, moral or protective reasons; less is understood about parents who are forced to take on a similar role (Baker, 2019). The COVID-19 outbreak led many parents to take on homeschooling roles due to the closing of schools and transition to remote learning (“COVID-19 Educational Disruption,” 2020). While children continued to  follow curricula set by their teachers at school, young children needed their parents to aid them in the unfamiliar online learning format. This transition not only altered children’s everyday lives, but also family dynamics as a whole, and especially the role of parents at home (Brown et al., 2020). Research shows that parents in the U.S. reported to be more stressed during the COVID-19 pandemic compared with their non-parent counterparts and have attributed their main stressors to their parenting roles and transition to online learning (American Psychological Association [APA], 2020). Over the course of the pandemic, parents have reported having less emotional support and higher levels of stress due to financial struggles and health concerns leading to increased parental burnout (Center for Translational Neuroscience, 2020). Although, to date, there has been very little research surrounding the pandemic and its mental health implications, many parents have expressed this sense of stress and burnout through mediums like social media and popular journals. For example, Grose (2020) conducted an interview for The New York Times with Paige Posladek, a pregnant woman and mother of two children who are two and four years old. Posladek explained a sense of stagnancy and a failure to move forward because she feels overwhelmed and does not have time for herself. One of the few studies addressing parental burnout during COVID-19 (Mousavi, 2020) found that other parents are experiencing higher levels of parental burnout citing new stressors such as uncertainty, lack of control, and helplessness, confirming anecdotal evidence from parents with young children.

Current Study

Parental burnout is a feeling of extreme exhaustion due to high levels of stress and a mismatch between responsibilities and available resources, which includes a sense of disconnection with parents’ family and/or children (Griffith, 2020; Mikolajczak et al., 2018; Roskam et al., 2017). Past research has found that parenting young children can be very rewarding, yet challenging at times (Le Vigouroux et al. 2017; Mikolajczak et al., 2018), with additional difficulties on parents who homeschool their children (Baker, 2019). Research on the recent COVID-19 pandemic has begun to shed light on changing family routines and increased stress (“COVID-19 Educational Disruption”, 2020; Grose, 2020). However, little is known about the effect of a teaching role at home on burnout for parents who are forced to take on this role. Furthermore, minimal work has focused on the relation between COVID-19 and parental burnout levels. Thus, this study aimed to fill these gaps through the following research question: How has the COVID-19 pandemic impacted burnout in parents with young children?

Method

Participants

Ten parents of young children in New York City were interviewed (N = 10) via Zoom. Nine participants identified as cis-women, and one identified as cis-man. Most of them (N = 8) identified as White, whereas one participant identified as Hispanic or Latino and one participant identified as Black or African American. Parents’ ages ranged from 29 to 43 years old. All parents were married except for one who was divorced. All of them reported obtaining at least a Bachelor’s degree; four reported obtaining a professional or Master’s degree, and five parents reported obtaining a doctorate degree. The majority (N = 6) reported having one child and the remaining four parents reported having two children. Ten of the children were female and four were male; their ages ranged from 7 months to 10 years old (M = 3.26, SD = 2.62).

Procedure

In October and November of 2020, participants were interviewed by one of the authors via Zoom. The interview protocol was created based on findings in the extant literature; a trial interview was conducted to see which questions were relevant, and the interview questions were then revised accordingly. The interviews were semi-structured, including questions such as “In what ways did your child/children need more support or supervision for their schooling from home?” However, follow-up questions were also asked throughout the interviews for clarification. During the interviews, both the participants and the interviewers had their cameras on. All the interviews were conducted in English, and they were approximately 30-35 minutes long.

Transcription and Coding

All interviews were transcribed using Trint software. The coding scheme emerged from the data based on a grounded theory approach (Glaser & Strauss, 1967). To establish reliability, each researcher coded the same interview, compared codes, and clarified the discrepancies. Once reliability was achieved,  each transcript was read by one of the researchers twice and coded for main themes and specific codes that emerged from the data. The interviews were coded at the turn level, such that researchers coded each time the participant spoke (i.e., each turn speaking). Although the same code could not be assigned multiple times within a turn, codes were not mutually exclusive. Therefore, if a statement within one turn qualified for multiple codes, researchers double coded them. This decision was made in order to capture participants’ experiences in a nuanced way.

Final Codes

From the conducted interviews, two main themes emerged that gave insight into how the COVID-19 pandemic has affected burnout in parents. Although none of the parents in our sample experienced burnout in accordance with the definition, most of them experienced added stress. We will explore two themes that emerged: (a) contributors and (b) preventative factors to stress. Within those themes, specific codes (i.e., stressors, social support, roles, silver linings, self care, childcare) were developed and analyzed. See Table 1 for specific codes and definitions.

Results

Contributors

Results show variability among each participant’s experiences. Nevertheless, the “stressors” theme emerged in all ten interviews. All participants mentioned that the COVID-19 pandemic has brought additional stressors into their lives. Within this main theme, work/schooling, time management, and parenting were the most prevalent sources of stress.

Work and schooling. ‘Work/schooling’ came up 32 times across all the interviews. Four participants stated how they had more responsibilities and more things to do since COVID-19 hit. They were doing most of the household tasks “and then also school work, getting things done, making sure that I’m on top of everything, and I am on track, and everything… it’s hard sometimes.” In addition, two participants mentioned how they have always been overwhelmed due to workload, but how now it was even more stressful: “My work day is never sufficient, and that’s always the case. Now it’s worse…” and “so I felt like work became busier.”

Time management. Often co-occurring with work and school stress, “time management” stress came up 29 times. Most parents were very explicit when they talked about problems with time management, with statements such as “you know, it’s hard to manage time: home work, teaching and lots of meetings. It’s like this the whole week.” Along these lines, some parents reported being exhausted due to the great amount of energy they invest in their responsibilities. One mother referred to it as follows: “at the end of the week you’re like, wow, how did I actually survive that week?” In addition, two of them specifically talked about how their schedules were shaped based on their children’s needs. One of them said that her “workday was extended and sort of built around her [daughter’s] schedule.” Another mother explained what a typical day looks like for her: “I wake up at 7:00 and I prepare everything that [my daughter] needs to be able to do work at home. So that means creating a schedule, a reminder, so she has a little notepad that I put down to remind her when she has Zoom meetings…” which takes a lot of time.

Increase in parenting. Finally, “an increase in parenting stress” came up 22 times. All participants except one brought up this idea. They mentioned that spending most of the time with their children at home was challenging. Parenting sometimes interferes with their work and with their professional responsibilities because now “there’s lots of different disruptions.” For example, one of the mothers talked about how when she “was in meetings particularly, there was a push and pull. My daughter… doesn’t quite understand that when I’m working, I can’t be entertaining her.” Another parent mentioned how irritating it was to ask her child about her homework and getting a response such as “I don’t want to do it, I’m only doing it because I have to,” causing tension in their parent-child relationship.

Roles. The second most prevalent theme after stress was “roles.” Within this theme, the two most prevalent specific codes were “more roles” and “took on a teacher role.” For instance, eight out of the ten participants reported taking ‘more roles’ as a result of the pandemic. One of them mentioned that he was “working, making dinner and taking care of the three year old who needs attention.” The specific code called ‘took on a teacher role’ was also a trend among parents’ responses. Fifty percent of the participants reported taking on a teacher role, and it came up 11 times across those five interviews. The only father participating in this study said that he felt an additional burden because he now listens to his daughter’s Zoom classes, so that if her daughter did not understand something, he could help her based on what the teacher said. So he was “teaching now” and that “a lot of the teaching is falling on [him].” Most parents talked about how they struggled when their children needed to do homework, and how “that kind of negotiation adds stress.” Parents whose children had not yet entered the school system, also reported that their children’s education and development are main stressors. For instance, one mother who has a toddler was worried about the lack of social interactions her daughter had, and expressed the following: “I worry about her social isolation… not really knowing, you know, how to engage with other kids her age, so I do not know if I should have her in like half day programs.” Only three parents reported experiencing the specific code called ‘role ambiguity’.

Preventative factors

Financial stability. In addition to adjusting to the pandemic over time, many parents discussed several factors that helped them cope with and prevent burnout even during the early transition. For parents participating in the current study, one major factor that helped to prevent burnout was financial stability. Out of the ten participants, eight had obtained a graduate degree (either master’s or doctorate). During the interviews, no parent had reported stressors stemming from financial instability or loss of occupation, and some even explained that their incomes had not changed, allowing them to either move to a larger home, or continue to pay for childcare. In realizing the difficulties in living in a small apartment, one participant reported that her family “moved to New Jersey over the summer because [they] needed more space,” a larger home where her children would have space to do schoolwork while she worked from home. Moving to a larger space allowed for this family to have more privacy for work and combat some of the stressors of working from home. This ability to move reflected how good financial standing could prevent stressors for some families during COVID-19.

Silver linings. Changes in parents’ schedules and work was another helpful factor. Within the “silver lining” theme, one of the most commonly cited codes was the lack of commuting. In describing their routines pre-COVID, several parents noted that a main stressor during those months was due to their commute to and from work. One parent reported, “the most stressful part… was the commute… it takes me about two hours, one way to get to [work].” Fifty percent of the sample used the lack of a commute as an example for any decrease in stress levels. So while all of the participants discussed increased stress levels due to parenting and time management, this aspect of stress from pre-COVID was no longer there.

Social support. Lastly, one last preventative factor that helped parents cope with the increased stress due to COVID-19 was social support. Seven out of ten of our participants reported an increase in social support, despite the fact that they were not able to see people in person anymore, because frequent Zoom calling or FaceTiming friends and family led to more contact. One participant stated, “I feel like in a lot of ways, FaceTime has allowed for more intimate connections with supporters… [Before], we would not call that much. We would text a lot. And now we FaceTime. Much more than we ever called each other.” Another participant noted the increase of contact by stating, “So we’re able to talk to [family] more and face time with them more because everyone’s home, whereas before we never really were able to.” Through these reports, it was clear that many participants felt that they had support from family, friends and colleagues because everyone was experiencing the pandemic, leading to a “we’re all in this together” mentality.

Discussion

The present qualitative study examined the impact of COVID-19 on parental burnout levels. Existing literature indicates that the COVID-19 pandemic has brought unexpected changes (Prime et al., 2020) and significant stress in 2020 (Klaiber et al., 2020). In line with these findings, the current study showed that many parents experienced an increase in parenting stress caused by taking on more roles at home, increased work stress, and less time. Yet, although most research, to date, examining COVID-19 and family-related factors only report negative implications (e.g., Brown et al., 2020; Power, 2020; Russell et al., 2020), this study also found positive outcomes of the pandemic. These included a lack of commuting, which was a source of stress pre-COVID-19, as well as increased social support due to the immediacy of technology and video calls.

Based on the operationalization of parental burnout proposed in past research (e.g.,  Griffith, 2020; Mikolajczak & Roskam, 2020; Roskam et al.,2017), parents in this particular sample did not experience high parental burnout levels in the aftermath of the pandemic. Parents reported experiencing more stress compared to their pre-COVID-19 stress levels and having a general feeling of exhaustion in some cases, but none of them reported experiencing a feeling of distance from their family structure and/or children. Rather, one parent explicitly mentioned how he is trying to emotionally support his daughter as much as possible, while others even reported feeling closer to their children. Furthermore, none reported a sense of ineffectiveness in their parenting role or experiencing role ambiguity. Thus, although certain symptoms of parental burnout such as increased stress were experienced, no parent reported facing all aspects of parental burnout.

Past research suggests that protective factors such as financial stability (Sorkkila & Aunola, 2020) and social support (Gérain & Zech, 2018; Mikolajczak et al., 2018) might help prevent parents from experiencing high burnout levels. In the current study, all participants had at least a Bachelor’s degree, and all of them reported having a stable job or a spouse with a stable job. Financial stability and income typically also come with health insurance, and access to safe housing and transportation, all crucial elements to navigating a pandemic. During this time, many businesses closed down and many people were laid off from their jobs, creating financial instability and turmoil for many families (Karpman et al., 2020; Nicola et al., 2020). Anecdotal reports of extreme exhaustion and parental burnout in the media came from families who were struggling financially to support their families during the pandemic, on top of all of the stressors the participants in this study experienced (“COVID-19 Educational Disruption”, 2020; Gross, 2020). Indeed, participants in the current study did not report financial instability or marital conflict, and thus, they relied on those protective factors. 

Another discrepancy between past research and the current findings is that previous studies suggest that parents who have less time for themselves, as well as less time to meet their responsibilities, tend to experience higher parental burnout levels (e.g., Griffith, 2020; Mikolajczak et al., 2019). Nevertheless, participants did not report this to be the case. All of the participants expressed concerns regarding time management, as well as having less time to engage in self-care practices. However, they did not meet all the parental burnout criteria, according to the definition of parental burnout that was adopted for the purpose of this study.

Findings of the current study should be interpreted with caution, as this qualitative investigation was a limited exploration of ten participants. Future research should explore this area of study using a qualitative approach with a larger sample size or using quantitative measures to investigate levels of burnout over time in the aftermath of the pandemic. Moreover, incorporating quantitative measures, such as the MBI or the Parental Burnout Assessment, might be more objective ways of capturing this variable, and might allow for the inclusion of larger samples (Maslach & Jackson, 1981; Roskam et al., 2018). Furthermore, due to convenience sampling, the sample was rather homogenous, as it included mostly white, highly educated, financially stable mothers, and, therefore, was not able to provide information on a variety of parents living through the pandemic. Because there was only one father, researchers were unable to gain a comprehensive understanding of gender roles in parental burnout due to COVID-19. The sample was all relatively high SES, as well, which is not representative of the population at large. Although this information helped in understanding factors contributing to or protecting against stress, it did not describe the struggles middle class and low income families might be experiencing during this difficult time. Despite these limitations, however, the current study provides valuable insight into the impact of COVID-19 on parental mental health through a preliminary investigation of how parents are coping and managing with young kids in the house.

Findings show that protective factors have the ability to prevent parents of young children from experiencing high burnout levels (Le Vigouroux et al., 2017). Parents reported high stress and anxiety levels due to external and unexpected circumstances like COVID-19 (Le Vigouroux et al., 2017). However, results demonstrate the importance of social support and economic stability in preventing stress and inform policy to prevent disproportionate levels of burnout in parents based on family income and access to resources. Despite being able to afford childcare, some parents participating in this study still commented that it was expensive. Thus, this study provides evidence for policymakers to incorporate more accessible childcare policies in New York City. This study also lays the foundations for future research to investigate the negative long term repercussions of high parental stress not only on parents but also on their children. For instance, future longitudinal research should examine the relation between children who had parents with high levels of stress and future personality disorders during adolescence. Although more studies are required to further explore this field, qualitative research like the present study is a first step to inform researchers and practitioners of the issues that families face during unprecedented times.

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Julia E. Leschi

Substance abuse is a public health crisis, with around 20 million adults in the United States struggling with a substance use disorder in 2017 (Substance Abuse and Mental Health Services Administration [SAMHSA], 2018). One of the major issues hindering substance abuse recovery is that too few people enter treatment (Cunningham et al., 1993; Kessler et al., 2001; Wang et al., 2004). Of those who do, there is often a treatment delay of at least a decade after identification of the substance use problem, and many do not complete treatment (Cunningham et al., 1993; Kessler et al., 2001; Wang et al., 2004). Research has identified motivation to change as one of the most reliable indicators of treatment readiness and engagement (De Leon et al., 1999; Heather et al., 1993; Hiller et al., 2002). Motivation to change evolves in five stages: pre-contemplation, contemplation, preparation, action, and maintenance (Prochaska & Diclemente, 1984). Where a patient is situated on this continuum at treatment entry has been linked to treatment outcomes and dropout rates (DiClemente et al., 2004; Heather et al., 1993; Klag et al., 2010; Simpson et al., 2002; Simpson et al., 1993). Thus, learning more about the factors leading to an increase in motivation to change is an important step in trying to improve the success of substance abuse treatment.

Families can play an important role in helping loved ones pursue treatment. Research has found that family support plays a considerable role in preventing substance use and in supporting recovering users following treatment (Dishion et al., 2003; Kumpfer et al., 2003). Expressed concern from one’s social network has also been found to greatly increase the likelihood of someone committing to treatment, reinforcing the impact family and friends can have on someone’s desire and ability to change (Pollini et al., 2006; Rapp et al., 2007). These findings all point towards the importance of families in tackling substance use issues, yet few studies have directly explored the association between family support and treatment entry.

Community Reinforcement and Family Training (CRAFT; Meyers & Wolfe, 2004), an intervention program highlighting the use of positive reinforcement from family members (referred to as Concerned Significant Others [CSO]) to get loved ones (referred to as Individual Patients [IP]) into treatment, has shown great promise in recent years (Brigham et al., 2014; Meyers et al., 2002; Roozen et al., 2010). CRAFT is a behavioral intervention aiming to both improve the CSO’s wellbeing and promote the IP’s treatment entry by transforming the IP’s environment (Kirby et al., 2017; Meyers et al., 2011). This happens through changes in the CSO’s communication, the use of positive reinforcement for sober behaviors, and a reduction of the CSO interfering with the consequences of substance use, among others (Meyers et al., 2011). CRAFT has been shown to be significantly more effective at engaging treatment-resistant loved ones than traditional approaches taught in Al-Anon Family Groups, a popular 12-step program for family members and loved ones of substance abusers, which encourages family members to detach from their loved ones and accept their powerlessness in the face of the loved one’s illness (Brigham et al., 2014; Meyers et al., 2002; Roozen et al., 2010). The mechanisms through which CRAFT functions have scarcely been researched, but existing studies suggest that family support and motivation to change could play a significant mediating role (Dishion et al., 2003; Kumpfer et al., 2003; Meyers et al., 2011), since the CRAFT approach depends on the IP having a relationship with their family, and aims to push the IP to seek treatment of their own volition.

The association between family support, motivation to change, and treatment entry must be further researched so that families can further help the recovery of their loved ones. Hence, this study proposes to address the following research questions: What are the differential effects of CRAFT and Al-Anon on family support and motivation to change for individuals struggling with substance use disorders? To what extent is the effect of CRAFT (vs. Al-Anon) on SUD treatment entry mediated by levels of family support and motivation to change?

Proposed Method

Participants

The proposed study will include 300 substance-abusing individuals and their CSOs. All participants will be over 18 years old. CSOs should be a direct relative, spouse, or cohabitating romantic partner of the IP who is in regular contact with the IP. Participating substance users will fit the diagnostic criteria for a DSM-V Substance Use Disorder and not be in therapy or receiving pharmaceutical treatment for addiction. The sample will aim to be as representative of the general population as possible in terms of gender, education level, socioeconomic status, race and ethnicity.

Procedure

Participating CSOs and IPs will be recruited through flyers inviting family members of treatment-resistant substance abusers to participate in a six-month long treatment program, posted in community spaces of towns located in counties with high rates of drug use, as well as on Facebook groups for loved ones of substance abusers. In order to only include CSOs of treatment-resistant IPs, CSOs will be asked their IP’s hypothetical reaction to being asked to enter treatment. CSOs will be excluded if they answer that the IP would already be interested and open to treatment. Participating CSOs will be randomly assigned to either CRAFT, an approach that seeks to transform the IP’s behavior through the family, or Al-Anon therapy, focused on detaching the family from the IP. When their family members commit to the program, IPs will fill out demographics and baseline measures of family support (Multidimensional Scale of Perceived Social Support, or MSPSS), motivation to change (Stages of Change Readiness and Treatment Eagerness Scale, or SOCRATES-8), severity of substance use (Drug Abuse Screening Test, or DAST) and psychological wellbeing to account for variation in depression and anxiety at baseline (Depression and Anxiety Stress Scale, or DASS-21).

The CRAFT group will meet once a week for six months with a licensed therapist trained in CRAFT who will teach them the primary components of CRAFT: how to identify a loved one’s triggers to use substances, positive communication strategies and reinforcement strategies, identifying appropriate times and ways to suggest treatment, and self-care practices (Kirby et al., 2017). The Al-Anon group will meet at the same frequency with a licensed counselor with a 12-step orientation reflecting Al-Anon’s philosophy. For both groups, if at any point the IP expresses desire to enter treatment, researchers will schedule the IP’s intake session within the next 72 hours, at which point the IP will once again fill out the baseline measures. Entering treatment is operationalized as having completed the intake measures and attended at least three individual treatment sessions. If the IP never expresses interest in treatment, they will fill out the measures again at the end of the study. Referrals to local mental health providers will be shared with all participants so that they may continue or begin to receive therapy after termination of the study. Information about open support groups and psychoeducation materials on substance use disorders will also be available.

Measures

Drug Abuse Screening Test (DAST). The DAST is a 28-item self-report measure for drug use. Research has established the DAST’s high internal reliability (α = .92). Validity was assessed by correlating the DAST with documented frequency of drug use in the last year (p < .05; Skinner, 1982).

Depression and Anxiety Stress Scale – Short Form (DASS-21). The DASS-21 is a 21-item instrument comprised of three reliable subscales measuring depression (α = .88), anxiety (α = .82), and stress (α = .90). The composite score (i.e., combining each of the subscales scores) has also been found to have strong s reliability (α = .93; Lovibond & Lovibond, 1995). The DASS-21 dimensions are correlated (all ps < .01) to the appropriate Positive Negative Affect Schedule (PANAS; Watson et al., 1988) dimensions, demonstrating high construct validity.

Multidimensional Scale of Perceived Social Support (MSPSS). The MSPSS is a 12-item self-report instrument assessing perceived social support from family, friends, and significant others on a seven point Likert-type scale from “Very Strongly Disagree” to “Very Strongly Agree.” Research has found the MSPSS has good internal reliability (α = .88), and moderate construct validity, with the scale being significantly correlated to depression (r = -.25, p < .01; Zimet el al., 1988).

Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES-8). The SOCRATES-8 is a 19-item instrument used to assess change readiness and treatment eagerness in substance users (Miller & Tonigan, 1996). It is scored on a five point Likert scale from “Strongly Disagree” to “Strongly Agree”, and is composed of three dimensions of Recognition, Ambivalence, and Taking Steps. Miller and Tonnigan (1996) found the internal reliability of the SOCRATES-8 to range from 0.85–0.95 for Recognition; 0.60–0.88 for Ambivalence; and 0.83–0.96 for Taking Steps (as cited in Abiola et al., 2015).

Data Analytic Plan

Two regressions will be run to explore whether participation in CRAFT leads to greater changes in perceived family support and motivation to change than Al-Anon (IV: experimental condition; DVs: family support, motivation to change). Baron and Kenny’s (1986) approach will then be followed to test the mediation hypotheses. We will use a logistic regression to show whether CRAFT is correlated with treatment entry status (C pathway), and a linear regression to show whether CRAFT is correlated with family support/motivation to change (A pathway). Then, both CRAFT and family support/motivation to change will be entered as predictors in a last logistic regression to see if the total effect of CRAFT on treatment entry diminishes when controlling for family support/motivation to change (B and C’ pathways). Sobel’s tests will be run to establish if the mediation effects are significant. Covariates (i.e., demographics, depression and anxiety levels, baseline severity of substance use) will be controlled for throughout.

Discussion

Although there is a great deal of research assessing CRAFT’s rates of successful treatment engagement compared to other popular programs for families of substance abusers (Meyers et al., 2011), there are no published studies investigating the steps through which CRAFT is effective. Hence, the proposed study would help fill a gap in the literature. However, this study will be limited by certain selection factors. Indeed, IPs who volunteer to participate in this research study may already be more motivated to change, and therefore to enter treatment, than the general population of substance users. This threatens the study’s external reliability and the generalizability of the findings. Furthermore, the least motivated study participants are more likely to drop out before the end of the study, which could skew the results. Assessing motivation to change levels at baseline will enable partial control for this. Additionally, this study should be adapted to look specifically at group and family-oriented populations, such as Hispanic/Latinx or East-Asian individuals (Corrigan & Lee, 202; Sabogal et al., 1987; Villatoro et al., 2014). These different family dynamics could make CRAFT even more effective, or, on the contrary, more difficult to implement. It is important to investigate if interventions research has deemed successful in the past remain so across ethnic groups.

Understanding how family support and motivation for change influence the efficacy of CRAFT could help improve other interventions’s success rates for treatment entry, strengthening other programs aimed at getting substance abusers to commit to treatment. Demonstrating the importance of family support in relation to treatment entry has implications for research to explore how it could play a role in other treatment modalities, building upon the literature that has explored family support as a tool for addiction prevention or maintaining recovery (Dishion et al., 2003; Kumpfer et al., 2003; Pollini et al., 2006; Rapp et al., 2007). Identifying mediators can also make CRAFT more cost-effective and, therefore, more broadly accessible to the millions of individuals struggling with addiction and their families suffering by proxy, lightening the burden of care.

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