An Oxford researcher measured the effect of popular workplace mental health interventions, and discovered little to none.Employee mental health services have become a billion-dollar industry. New hires, once they have found the restrooms and enrolled in 401(k) plans, are presented with a panoply of digital wellness solutions, mindfulness seminars, massage classes, resilience workshops, coaching sessions and sleep apps.These programs are a point of pride for forward-thinking human resource departments, evidence that employers care about their workers. But a British researcher who analyzed survey responses from 46,336 workers at companies that offered such programs found that people who participated in them were no better off than colleagues who did not.The study, published this month in Industrial Relations Journal, considered the outcomes of 90 different interventions and found a single notable exception: Workers who were given the opportunity to do charity or volunteer work did seem to have improved well-being.Across the study’s large population, none of the other offerings — apps, coaching, relaxation classes, courses in time management or financial health — had any positive effect. Trainings on resilience and stress management actually appeared to have a negative effect.“It’s a fairly controversial finding, that these very popular programs were not effective,” said William J. Fleming, the author of the study and a fellow at Oxford University’s Wellbeing Research Center.Dr. Fleming’s analysis suggests that employers concerned about workers’ mental health would do better to focus on “core organizational practices” like schedules, pay and performance reviews.“If employees do want access to mindfulness apps and sleep programs and well-being apps, there is not anything wrong with that,” he said. “But if you’re seriously trying to drive employees well-being, then it has to be about working practices.”Dr. Fleming’s study is based on responses to the Britain’s Healthiest Workplace survey in 2017 and 2018 from workers at 233 organizations, with financial and insurance service workers, younger workers and women slightly overrepresented.The data captured workers at a single point in time, rather than tracking them before and after treatment. Using thousands of matched pairs from the same workplace, it compared well-being measures from workers who participated in wellness programs with those of their colleagues who did not.It is possible that there was selection bias, since workers who enroll in, say, a resilience training program may have lower well-being to begin with, Dr. Fleming said. To address that, he separately analyzed responses from workers with high pre-existing levels of work stress, comparing those who did and did not participate. But among this group, too, the survey answers suggested that the programs had no clear benefit.The findings call into question practices that have become commonplace across job sectors. But researchers said they came as no surprise.“Employers want to be seen as doing something, but they don’t want to look closely and change the way work is organized,” said Tony D. LaMontagne, a professor of work, health and well-being at Deakin University in Melbourne, Australia, who was not involved in the study.Workplace mental health interventions may send the message that “if you do these programs and you’re still feeling stressed, it must be you,” Mr. LaMontagne said. “People who don’t have a critical view might internalize that failure: ‘So I really am a loser.’”The corporate wellness services industry has ballooned in recent years, with thousands of vendors competing for billions of dollars in revenue. Companies invest in the interventions in hopes of saving money overall by improving worker health and productivity.Some research supports this expectation. A 2022 study tracking 1,132 workers in the United States who used Spring Health, a platform that connects employees with mental health services like therapy and medication management, found that 69.3 percent of participants showed improvement in their depression. Participants also missed fewer days of work and reported higher productivity.Adam Chekroud, a co-founder of Spring Health and an assistant professor of psychiatry at Yale, said Dr. Fleming’s study examined interventions that were “not highly credible” and measured well-being many months later. A blanket dismissal of workplace interventions, he said, risks “throwing the baby out with the bathwater.”“There is recent and highly credible data that things like mental health programs do improve all those metrics that he mentions,” Dr. Chekroud said. “That’s the baby you shouldn’t be throwing out.”There is also solid evidence that practices like mindfulness can have a positive effect. Controlled studies have consistently demonstrated lower stress and decreased anxiety and depression after mindfulness training.The lackluster benefits that Dr. Fleming found may reflect variations in offerings, said Larissa Bartlett, a researcher at the University of Tasmania who has designed and taught mindfulness programs. “Light-touch” interventions like apps, she added, are generally less effective than one-on-one or group trainings.Dr. Fleming’s study, she said, “misses most of these details, condensing intervention types into broad labels, engagement into yes/no, and dismissing the reports from intervention participants that they felt they benefited from the programs they did.”A key omission, she added, is longitudinal data showing whether participants experience improvement over time. The result is a “bird’s-eye view” of the well-being of participants that “skates over changes that may occur at the individual level,” she said.Dr. Fleming said that he was aware of the body of research supporting the treatments’ effectiveness, but that he had “never been as convinced by the very positive findings,” since the data comes from controlled trials in which the treatment is implemented very well, something that may not be the case in employer-provided programs.Dr. David Crepaz-Keay, the head of research and applied learning at the Mental Health Foundation in the United Kingdom, who has advised the World Health Organization and Public Health England on mental health initiatives, described Dr. Fleming’s data and analysis as “certainly more robust” than “most of the research that has created the consensus that employee assistance works.”

Traumatic memories had their own neural mechanism, brain scans showed, which may help explain their vivid and intrusive nature.At the root of post-traumatic stress disorder, or PTSD, is a memory that cannot be controlled. It may intrude on everyday activity, thrusting a person into the middle of a horrifying event, or surface as night terrors or flashbacks.Decades of treatment of military veterans and sexual assault survivors have left little doubt that traumatic memories function differently from other memories. A group of researchers at Yale University and the Icahn School of Medicine at Mount Sinai set out to find empirical evidence of those differences.The team conducted brain scans of 28 people with PTSD while they listened to recorded narrations of their own memories. Some of the recorded memories were neutral, some were simply “sad,” and some were traumatic.The brain scans found clear differences, the researchers reported in a paper published on Thursday in the journal Nature Neuroscience. The people listening to the sad memories, which often involved the death of a family member, showed consistently high engagement of the hippocampus, part of the brain that organizes and contextualizes memories.When the same people listened to their traumatic memories — of sexual assaults, fires, school shootings and terrorist attacks — the hippocampus was not involved.“What it tells us is that the brain is in a different state in the two memories,” said Daniela Schiller, a neuroscientist at the Icahn School of Medicine at Mount Sinai and one of the authors of the study. She noted that therapies for PTSD often sought to help people organize their memory so they can view it as distant from the present.“Now we find something that potentially can explain it in the brain,” she said. “The brain doesn’t look like it’s in a state of memory; it looks like it is a state of present experience.”Indeed, the authors conclude in the paper, “traumatic memories are not experienced as memories as such,” but as “fragments of prior events, subjugating the present moment.”The traumatic memories appeared to engage a different area of the brain — the posterior cingulate cortex, or P.C.C., which is usually involved in internally directed thought, like introspection or daydreaming. The more severe the person’s PTSD symptoms were, the more activity appeared in the P.C.C.What is striking about this finding is that the P.C.C. is not known as a memory region, but one that is engaged with “processing of internal experience,” Dr. Schiller said.The findings feed into a much debated question in the field of trauma: Should clinicians encourage people with PTSD to expose themselves to their most traumatic memories?In recent years, many Americans have embraced treatments such as prolonged exposure therapy and eye movement reprocessing and desensitization, or EMDR, which revisit traumatic memories in hopes of draining them of their destructive force. Ilan Harpaz-Rotem, an author of the paper, said the new findings suggested that revisiting the memory was a critical element of treatment.“You are helping the patient to construct a memory that can be organized and consolidated into the hippocampus,” said Dr. Harpaz-Rotem, a professor of psychiatry and psychology at Yale University.He described a case from his clinic: An Army medic was haunted by a fragmentary image from his past, of frantically bandaging a solder’s wound while under fire. In therapy, trying to “build a story, a coherent memory,” the clinician helped the medic fill in details around the edges of that scene, including a dead soldier who lay nearby, shooting in the background, and his own panicked use of too many bandages.Ideally, such treatments can help transform the traumatic memory into one that more closely resembles ordinary sad memories. “It’s like having a block in the right place,” he said. “If I can access a memory, I know it’s a memory. I know it’s not happening to me now.”Dr. Ruth Lanius, the director of PTSD research at the University of Western Ontario who was not involved in the study, described its findings as “seminal,” both because it establishes that traumatic memories have distinct pathways and because it indicates that key mechanisms for traumatic memory may involve less-examined areas of the brain. Much research into PTSD has focused on the amygdala, the stress detection center of the brain, and the hippocampus, she said. The posterior cingulate cortex is “really involved in the reliving of memories,” and in seeking self-relevance, which may explain why a sensory reminder may cause overwhelming fear or panic.“A soldier, if they hear fireworks, they may run and take cover,” Dr. Lanius said. “Traumatic memories are not remembered, they are relived and re-experienced.”Clinicians, she said, can use these findings to treat patients who “don’t feel that the trauma is over,” employing therapies that “bring on line context, so you know, ‘Oh, that happened in the past.’” She said researchers should explore therapies, like mindfulness, which are known to activate the parts of the brain known to provide context.If biological markers for PTSD can eventually be identified, it would be “a major scientific contribution,” settling differences within the field about what experiences constitute a trauma, said Brian Marx, deputy director of the Behavioral Science Division of the National Center for PTSD, who was not involved in the study.While most experts agree that motor vehicle accidents, sexual assaults or military combat are traumatic events, there is disagreement about whether experiences like racism or pandemic stress should be viewed as the basis for a PTSD diagnosis, he said.“It is one of the foundational questions of the field,” he said. “It is a debate we still wrestle with, because we don’t have an answer for it.”Dr. Marx called the new research “intriguing,” but not conclusive, noting that it did not include a comparison group of subjects without a PTSD diagnosis, specify how long ago the traumatic events took place, or specify whether the subjects had already received psychotherapy.And he said it was not likely to settle debates over whether PTSD treatments should include exposure to traumatic memories, since literature on treatment outcomes show that responses are highly individualized.“To say this is proof positive really ignores the reality that our treatments are imperfect,” he said. “They don’t work for everyone in the same way.”

Gunshots are the top cause of death for children and teenagers in the U.S. Fatal or not, the wounds reverberate through communities and the health care system.With each mass shooting, Americans look to one grim indicator — the number of dead — as a measure of the destructive impact. But damage left behind by gunshot wounds reverberates among survivors and families, sending mental health disorders soaring and shifting huge burdens onto the health care system, a new analysis of private health insurance claims shows.In 2020, gunshot wounds became the leading cause of death for children and adolescents in the United States. Though the government does not systematically track nonfatal gunshot wounds, existing evidence suggests that they are two to three times as common as fatal ones. These wounds can be especially catastrophic in children, whose bodies are so small that the amount of tissue destroyed is greater.“What comes after the gunshot is so often not talked about,” said Dr. Chana Sacks, co-director of the Gun Violence Prevention Center at Massachusetts General Hospital and an author of the new study, published on Monday in the journal Health Affairs. The study, which analyzed thousands of insurance claims, maps out lasting damage to families and communities.For families in which a child died of a gunshot wound, surviving family members experienced a sharp increase in psychiatric disorders, taking more psychiatric medications and making more visits to mental health professionals: Fathers had a 5.3-fold increase in treatment for psychiatric disorders in the year after the death; mothers had a 3.6-fold increase; and surviving siblings had a 2.3-fold increase.Children and teenagers who survive gunshot wounds become, as Dr. Sacks put it, “more like lifelong patients.” During the year after the injury, their medical costs rose by an average of $34,884, a 17-fold increase from baseline, driven by hospitalizations, emergency room visits and home health care, the study found.Children and adolescents who survived the most severe gunshot wounds, requiring treatment in an intensive care unit, struggled considerably. In that group, diagnoses of pain disorders increased 293 percent, and psychiatric disorders increased by 321 percent.The study examined medical records from 2,052 children who survived gunshots, 6,209 family members of children who survived, and 265 family members of children who died from gunshot wounds, comparing each with five controls. Because the study was based on private insurance claims, it did not reflect the experience of families who were uninsured or on public insurance.Rising costs linked to firearms injuries make it “increasingly an economic issue,” said Dr. Zirui Song, an associate professor at Harvard Medical School and co-author of the study. The prevalence of gunshot wounds has quadrupled over the last 12 years in the population covered by private insurance, he said.In a paper published last year in the Journal of the American Medical Association, Dr. Song calculated the annual cost of firearms injuries in lost wages and medical spending as $557 billion, or 2.6 percent of gross domestic product. The new study is the first to focus on the cost of nonfatal gunshot wounds, he said.“The cruel reality is that if one dies from a firearm injury, one is free to society — there’s no more health care spending, no more taxpayer dollars, no more resources used,” he said. “But actually surviving a firearm injury is quite expensive to society. The magnitude of that was previously not known.”National data on nonfatal gunshot wounds is “disturbingly unreliable,” but many survivors face long-term disability, said Dr. Megan Ranney, an emergency room physician and the dean of the Yale School of Public Health, who was not involved in the study.“It may be that they have been shot in the intestine, or through a major blood vessel, it could be a bullet has gone through their lung,” Dr. Ranney said. “It can also be that they’ve been shot through the head or the spine.”Trauma physicians have long observed the ripple effect of shootings on the health of family members and communities, she said, often because of repeated visits to the emergency room for nightmares, anxiety or depression, but “we’ve never been able to measure it.”Clementina Chery, a Boston woman whose 15-year-old son was fatally shot in crossfire in 1993, and who founded the Louis D. Brown Peace Institute, an organization to support families who have lost members to gun violence, said she had often seen survivors struggle with addictive behavior, job loss, suicidal or homicidal thoughts in the years after a young person dies.“In that immediate aftermath, I just felt that I was having an out-of-body experience,” Ms. Chery said. She turned to alcohol, she said — “a little wine here, a little wine there” — and found it difficult to leave her house. Her marriage ended. What finally woke her up, she said, was realizing that her younger children were starved of attention.“I literally was going through the motions,” she said. “I was not living. It was like, what do you call it, a mechanical robot.”The ripple effect of gunshot wounds is important because these injuries tend to be concentrated in specific communities, usually communities of color, where many young people know someone who has been shot, Dr. Sacks said.She traced her interest in the subject to the 2012 mass shooting at Sandy Hook Elementary School in Newtown, Conn., where the 7-year-old son of her cousin was one of 20 children killed. The child’s death “changed my life” and has continued to shape extended families and communities in the years that followed, she said.“We can’t think about this as a problem that starts and ends with the bullet going in and then the acute surgical care,” Dr. Sacks said. “Leaving the hospital is just the beginning of that family’s journey, and I think we need to treat it that way.”

At a time when teen suicide was seen as random and unpredictable, Dr. Shaffer, a psychiatrist, led investigations that proved that it was not.Dr. David Shaffer, a psychiatrist who spent decades studying children and teenagers who died by suicide, constructing a framework for screening and laying the groundwork for modern prevention efforts, died on Sunday in Mastic, N.Y., on Long Island. He was 87.His son, Dr. Charlie Shaffer, said the cause was respiratory failure from Alzheimer’s disease. For about six years, as the disease progressed, he had lived on the estate of the Vogue editor Anna Wintour, his former wife and the mother of two of his children.In the 1970s, when Dr. Shaffer was a young doctor, most people saw the suicide of a child or adolescent as a random and unpredictable act. Trained as an epidemiologist, he undertook an investigation known as a “psychological autopsy,” gathering detailed information from adult caregivers of 31 children who had died by suicide.The research yielded surprises. In more than a third of the cases, the suicide had occurred in the midst of what he called a “disciplinary crisis,” as the child awaited consequences. Many of the children were described, not as depressed, but as aggressive or impulsive.And there were clusters of suicides apparently driven by contagion. Dr. Shaffer realized this when he repeatedly spotted the name of one Welsh town in coroners’ reports, a light-bulb moment that he recalled with satisfaction many years later.“He liked the detective work,” Dr. Charlie Shaffer said. “That’s why he loved being an epidemiologist. He loved detective stories.”That investigation, and the others that Dr. Shaffer conducted in the years that followed, have helped identify clinical, neurological and behavioral characteristics linked to suicide.As the head of Columbia University’s vast and influential child psychiatry program, he developed clinical tools that are widely used today, such as the Diagnostic Interview Schedule for Children, or DISC-IV, an interview that assesses more than 30 common diagnoses.The prevention and screening programs that he championed decades ago are now commonplace. Looking back on his career in 2004, in Focus, the American Psychiatric Association’s clinical review journal, he recalled that, in his youth, society had regarded suicide as “a reasoned choice for those facing harsh circumstances” that “defied prediction and prevention.”The work of epidemiologists and social and cognitive psychologists had proved that mental illness is common. “Once the province of the author, poet, and philosopher, suicide is now squarely in clinical territory,” Dr. Shaffer added.Colleagues recalled him as an insatiable researcher, seeking out the families of young people who had died by suicide and trying to learn everything about them, in hopes of eventually finding ways to interrupt a chain of events that can lead to suicide.“He was fascinated by how people behaved, and why they behaved that way,” said Prudence Fisher, a research scientist at the New York State Psychiatric Institute in Manhattan who often accompanied him on these visits.The interviews often lasted four to six hours, she said, and the researchers were frequently the first people the families had spoken to about their child’s death; they “welcomed someone coming in to ask these questions,” Dr. Fisher added.Dr. Daniel Pine, who worked under Dr. Shaffer’s supervision at Columbia for 10 years, said Dr. Shaffer was “really drawn to the tragedy of it all.”“He was this really passionate guy, and tragedy wouldn’t make him necessarily turn away where other people might,” said Dr. Pine, the chief of the emotion and development branch at the National Institute of Mental Health. “They talk about people who run toward the danger — David was that kind of guy.”David Percy Shaffer was born in Johannesburg, South Africa, on April 20, 1936, to Joyce and Isaac Shaffer. His father, an immigrant from Lithuania, was a wealthy businessman who oversaw factories for multinational corporations.As a child, David was repelled by South Africa’s apartheid system, and when he left for boarding school in Switzerland as a teenager, he was drawn to left-wing causes, his son said. At one point, he was caught smuggling socialist pamphlets home to distribute to workers in his father’s factory.That rebellion was interrupted by the death of his father in a plane crash when David was 16.He felt at home in London, where he trained at the Great Ormond Street Hospital for Children and the Maudsley Hospital. He had an “English eccentricity and values to life,” Ms. Wintour said, hosting a revolving cast of houseguests and gathering large groups for elaborate meals, only to vanish as they sat down because he thought of something else he wanted to serve.“He was supremely eccentric,” Ms. Wintour said. “He didn’t follow the traditional rules of life in any way.”In England, he began working with Dr. Michael Rutter, who pioneered child psychiatry as a specialty. He viewed suicide as an untapped opportunity, an area where “people were not doing science, and he thought they should be and they could be,” his son said.When he relocated to the United States, in the 1970s, American psychiatry was dominated by the psychoanalytic model, in stark contrast to his own data-driven approach. Each new research finding on suicide “reinforced his desire to sort of push back against the psychoanalysts’ grip on psychiatry at the time,” his son said.Mr. Shaffer’s first marriage, to society caterer Serena Millington, ended in divorce in 1983. His marriage to Ms. Wintour ended in divorce in 1999.Dr. Shaffer with his second wife, Anna Wintour, the editor of Vogue magazine, at a party in 1990. They divorced in 1999, but he spent his last years living at her Long Island estate after he was diagnosed with Alzheimer’s disease.Ron Galella Collection, via Getty ImagesBoth marriages situated him at the edge of high-octane New York glamour not typical of academic psychiatrists. Colleagues recall that he and Ms. Wintour would buy multiple tables at galas supporting mental health causes, and that extra seats were filled with models.He traveled widely and unpredictably. “You know, he took us to Libya for Christmas,” said his daughter, Bee Carrozzini.In addition to her and his son Charlie, both from his marriage to Ms. Wintour, Dr. Shaffer is survived by two sons from his first marriage, Joe and Sam, and seven grandchildren.Dr. Shaffer was diagnosed with Alzheimer’s disease in 2015. In 2017, Ms. Wintour invited him to live full-time on her property in Mastic. “He was never good at arguing with me,” she said.At first, they played dominoes and read together, she said, but “toward the end, it was, you know, holding his hand and eating with him, and feeding him.”He had been living there for more than a year when his daughter was married at the house. Ms. Carrozzini recalled her friends’ wonder at the arrangement: “They turned to me and said, ‘That is the purest form of love, the way that your mom was taking care of your dad.’”If you are having thoughts of suicide, call or text 988 to reach the 988 Suicide and Crisis Lifeline or go to SpeakingOfSuicide.com/resources for a list of additional resources.

As young Americans turn to TikTok for information on mental health, the T.H. Chan School of Public Health at Harvard is building its own team of influencers.One day in February, an invitation from Harvard University arrived in the inbox of Rachel Havekost, a TikTok mental health influencer and part-time bartender in Seattle who likes to joke that her main qualification is 19 years of therapy.The same email arrived for Trey Tucker, a.k.a. @ruggedcounseling, a therapist from Chattanooga, Tenn., who discusses attachment styles on his TikTok account, sometimes while loading bales of hay onto the bed of a pickup truck.The invitations also made their way to Bryce Spencer-Jones, who talks his viewers through breakups while gazing tenderly into the camera, and to Kate Speer, who narrates her bouts of depression with wry humor, confiding that she has not brushed her teeth for days.Twenty-five recipients glanced over the emails, which invited them to collaborate with social scientists at the T.H. Chan School of Public Health at Harvard. They were not accustomed to being treated with respect by academia; several concluded that the letters were pranks or phishing attempts and deleted them.They did not know — how could they? — that a team of researchers had been observing them for weeks, winnowing down an army of mental health influencers into a few dozen heavyweights selected for their reach and quality.The surgeon general has described the mental health of young people in America as “the defining public health crisis of our time.” For this vulnerable, hard-to-reach population, social media serves as a primary source of information. And so, for a few months this spring, the influencers became part of a field experiment, in which social scientists attempted to inject evidence-based content into their feeds.

@kate__speer Calling all people pleasers! 🙃💁🏻♀️ #anxiety #peoplepleasingrecovery #peoplepleaser #peoplepleasing #peoplepleasingendsnow #recovery #mentalhealthhack #mentalhealthlifehack #ocd #exposuretherapy ♬ Good Vibes (Instrumental) – Ellen Once Again “People are looking for information, and the things that they are watching are TikTok and Instagram and YouTube,” said Amanda Yarnell, senior director of the Chan School’s Center for Health Communication. “Who are the media gatekeepers in those areas? Those are these creators. So we were looking at, how do we map onto that new reality?”The answer to that question became clear in August, when a van carrying a dozen influencers pulled up beside the campus of Harvard Medical School. Everything about the space, its Ionic columns and Latin mottos carved in granite, told the visitors that they had arrived at the high temple of the medical establishment.Each of the visitors resembled their audience: tattooed, in baseball caps or cowboy boots or chunky earrings that spelled the word LOVE. Some were psychologists or psychiatrists whose TikToks were a side gig. Others had built franchises by talking frankly about their own experiences with mental illness, describing eating disorders, selective mutism and suicide attempts.On the velvety Quad of the medical school, they looked like tourists or day-trippers. But together, across platforms, they commanded an audience of 10 million users.Step 1: The subjectsFrom left, screenshots of the TikTok feeds of Ms. Speer, Khalida Himes, Rachel Havekost and Dr. Patrice Berry.Samantha Chung, 30, who posts under the handle @simplifying.sam, could never explain to her mother what she did for a living.She is not a mental health clinician — until recently, she worked as a real estate agent. But two years ago, a TikTok video she made on “manifesting,” or using the mind to bring about desired change, attracted so much attention that she realized she could charge money for one-on-one coaching, and quit her day job.At first, Ms. Chung booked one-hour appointments for $90, but demand remained so high that she now offers counseling in three- and six-month “containers.” She sees no need to go to graduate school or get a license; her approach, as she puts it, “helps clients feel empowered rather than diagnosed.” She has a podcast, a book project and 813,000 followers on TikTok.This accomplishment, however, meant little to her parents, immigrants from Korea who had hoped she would become a doctor. “I really just thought of myself as someone who makes videos in their apartment,” Ms. Chung said.The work of an influencer can be isolating and draining, far from the sunlit glamour that many imagine. Ms. Havekost, 34, was struggling with whether she could even continue. After years of battling an eating disorder, she was feeling stable, which did not generate mental health content; that was one problem.

@rachelhavekost this is your sign🦋🥰. “dance it out” merch is now up on my website🌈💃🏼boogie over the 🔗in my bio or type rachelhavekost.com/merch in your browser🎯🍟! I love you all SO MUCH!!! #dancetoheal #danceitout #somatichealing #somaticshaking ♬ ILYAF (I love you always forever) – Donna Lewis & Digital Farm Animals The other problem was money. She is fastidious about endorsement deals, and still has to tend bar part time to make ends meet. “I’ve turned down an ice cream brand that wanted to pay me a lot of money to post a TikTok saying it was low sugar,” Ms. Havekost said. “That sucked, because I had to turn down my rent.”At Harvard, the influencers were treated like dignitaries, provided with branded merchandise and buffet lunches as they listened to lectures on air quality and health communication. From time to time, the lecturers broke into jargon, referring to multivariate regression models and the Bronfenbrenner model of behavior theory.During a break, Jaime Mahler, a licensed counselor from New York, remarked on this. In her videos, she prides herself on distilling complex clinical ideas into digestible nuggets. In this respect, she said, Harvard could learn a lot from TikTok.“She kept using the word ‘heuristics,’ and that was actually a genuine distraction for me,” Ms. Mahler said of one lecturer. “I remembered her telling me what it was in the beginning, and I didn’t want to Google it, and I kept getting distracted. I was like, Oh, she used it again.”But the main thing the guests wanted to express was gratitude. “I spent my 20s in a psychiatric ward trying to graduate from college,” said Ms. Speer, 36. “Walking into these rooms at Harvard and being held lovingly — honestly, it is nothing more than miraculous.”Ms. Chung was so inspired that she told the assembled crowd that she would now post as an activist. “I am walking out of this knowing the truth, which is that I am a public health leader,” she said. When Meng Meng Xu, one of the researchers on the Harvard team, heard that, she got goose bumps. This was exactly what she had been hoping for.Step 2: The field experimentAmanda Yarnell, senior director of the Chan School’s Center for Health Communication. “People are looking for information, and the things that they are watching are TikTok and Instagram and YouTube,” she said.Sarah Blesener for The New York TimesMany academics take a dim view of mental health TikTok, viewing it as a Wild West of unscientific advice and overgeneralization. Social media, researchers have found, often undermines established medical guidelines, warning viewers off evidence-based treatments like cognitive behavioral therapy or antidepressants, while boosting interest in risky, untested approaches like semen retention.TikTok, which has grappled with how to moderate such content, said recently that it would direct users searching for a range of conditions like depression or anxiety to information from the National Institute of Mental Health and the Cleveland Clinic.At their worst, researchers said, social media feeds can serve as a dark echo chamber, barraging vulnerable young people with messages about self-harm or eating disorders.“Your heart just sinks,” said Corey H. Basch, a professor of public health from William Paterson University who led a 2022 study analyzing 100 TikTok videos with the hashtag #mentalhealth.“If you’re feeling low and you have a dismal outlook, and for some reason that’s what you are drawn to, you will go down this rabbit hole,” she said. “And you could just sit there for hours watching videos of people who just want to die.”Ms. Basch doubted that content creators could prove to be useful partners for public health. “Influencers are in the business of making money for their content,” she said.Ms. Yarnell does not share this opinion. A chemist who pivoted to journalism, she found TikTok “a rich and exciting place” for scientists. She views influencers — she prefers the more respectful term “creators” — not as click-hungry amateurs but as independent media companies, making careful choices about partnerships and, at times, being motivated by altruism.In addition, she said, they are good at what they do. “They understand what their audience needs,” Ms. Yarnell said. “They’ve done a huge amount of storytelling that has allowed stigma to fall away. They have been a huge part of convincing people to talk about different mental health concerns. They are a perfect translation partner.”This is not the first time that Harvard’s public health experts have tried to hitch a ride with popular culture. In 1988, as part of a campaign to prevent traffic fatalities, researchers asked writers for prime-time television programs like “Cheers” and “L.A. Law” to write in references to “designated drivers,” a concept that was, at the time, entirely new to Americans. That effort was famously successful; by 1991, the phrase was so common that it appeared in Webster’s dictionary.

@latinxtherapy Insurances can be so unfair (at least in california) to #mentalhealth providers #latinxtherapy #directory ♬ original sound – shawty bae 🥥🫦 Inspired by this effort, Ms. Yarnell designed an experiment to determine whether influencers could be persuaded to disseminate more evidence-based information. First, her team developed a pool of 105 influencers who were both prominent and responsible: no diet-pill endorsements, no “five signs you have A.D.H.D.”The influencers would not be paid but, ideally, would be won over to the cause. Forty-two of them agreed to be part of the study and received digital tool kits organized into five “core themes”: difficulty accessing care, intergenerational trauma, mind-body links, the effect of racism on mental health and climate anxiety.A smaller group of 25 influencers also received lavish, in-person attention. They were invited to hourlong virtual forums, united on a group Slack channel and, finally, hosted at Harvard. But the core themes were what the researchers were watching. They would keep an eye on the influencers’ feeds and measure how much of Harvard’s material had ended up online.Step 3: This study is not without limitationsA month after the gathering, Ms. Havekost was once again feeling depleted. It wasn’t that she didn’t care about her duty as a public health leader — on the contrary, she said, “every time I post something now, I think about Harvard.”But she saw no simple way to integrate public health messages into her videos, which frequently feature her dancing uninhibitedly, or gazing at the viewer with an expression of unconditional love while text scrolls past. Her audience knows her communication style, she said; study citations wouldn’t feel any more authentic than cleavage enhancement.Mr. Tucker, back in Chattanooga, reached a similar conclusion. He has 1.1 million TikTok followers, so he knows which themes attract viewers. Trauma, anxiety, toxic relationships, narcissistic personalities, “those are the catnip, so to speak,” he said. “Basically, stuff that feeds the victim mentality.”He had tried a couple of videos based on Harvard research — for example, on the way the brain responds to the sound of water — but they had performed poorly with his audience, something he thought might be a function of the platform’s algorithm.“They are not really trying to help spread good research,” Mr. Tucker said. “They are trying to keep eyeballs engaged so they can keep watch times as long as possible and pass that onto advertisers.”It was different for Ms. Speer. After returning from Harvard, she received an email from S. Bryn Austin, a professor of social and behavioral sciences and a specialist in eating disorders, proposing that they collaborate on a campaign to prohibit the sale of weight-loss pills to minors in New York State.Ms. Speer was elated. She got to work putting together a sizzle reel and a grant proposal. As summer turned to fall, her life seemed to have turned a corner. “That’s what I want to do,” she said. “I want to do it for good, instead of, you know, for lip gloss.”Step 4: System-level effectsDr. Sasha Hamdani, a psychiatrist and TikTok creator, center, with Ifelola Ojuri, of YouTube Health, right, and Ms. Speer during a panel discussion in New York City.Sarah Blesener for The New York TimesLast week, in a conference room overlooking the Hudson River, Ms. Yarnell and one of her co-authors, Matt Motta, of Boston University, presented the results of the experiment.It had worked, they announced. The 42 influencers who received Harvard’s talking points were 3 percent more likely to post content on the core themes researchers had fed them. Although that may seem like a small effect, Dr. Motta said, each influencer had such a large audience that the additional content was viewed 800,000 times.These successes bore little resemblance to peer-reviewed studies. They looked like @drkojosarfo, a psychiatric nurse practitioner with 2.4 million followers, dancing in a galley kitchen alongside text on the mind-body link, or the user @latinxtherapy throwing shade on insurance companies while lip-syncing to the influencer Shawty Bae.The uptake seemed to be driven by the distribution of written materials, with no additional effect among subjects who had deep interactions with Harvard faculty. That was unexpected, Ms. Yarnell said, but it was good news, since digital tool kits are cheap and easy to scale.“It’s simpler than we thought,” she said. “These written materials are useful to creators.”But the biggest effect was something that did not show up in the data: the formation of new relationships. Seated beside Ms. Yarnell as she presented the experiment’s results were two of its subjects: Ms. Speer, with her service dog, Waffle, who is trained to paw at her when he smells elevated cortisol in her sweat, and Dr. Sasha Hamdani, a psychiatrist in Kansas who presents information on A.D.H.D. to the accompaniment of sea shanties.Contact had been made. In the audience, the Brooklyn-dad influencer Timm Chiusano was wondering about how to build his own partnership with Harvard’s School of Public Health. “I’m going to 1,000 percent download that tool kit as soon as I can,” he said.But who was boosting who? Ms. Mahler, who was promoting a new book on toxic relationships, sounded a little sad when she considered her partners in academia. “Harvard has this abundant knowledge base,” she said, “if they can just find a way of connecting to the people doing the digesting.”She had learned a great deal about scientists. In some cases, Ms. Mahler said, they spend 10 years on a research project, publish an article, “and maybe it gets picked up, but sometimes it never reaches the general public in a way that really changes the conversation.”“My heart kind of breaks for those people,” she said.

Applicants have challenged the Peace Corps practice of rescinding invitations to applicants on the basis of mental health conditions.Lea Iodice was thrilled to hear that the Peace Corps had accepted her application and was sending her to Senegal as a community health care worker. She shared the good news with her roommates, her family and her favorite professor and daydreamed about her last day at her job, managing a gym called SnapFitness.She was crushed, about a month later, to receive a letter from the Peace Corps Office of Medical Services saying that her offer was being rescinded because she was in treatment for anxiety. Though she had been in therapy to manage occasional panic attacks, she had never taken any psychiatric medication, been hospitalized or engaged in any kind of self-harm.“The reason for medical nonclearance is that you are currently diagnosed with an unspecified anxiety disorder,” read the letter, which appeared in her online application portal. “You indicated that your anxiety symptoms of increased heart rate and queasiness recur during periods of stress, which is likely to occur during service.”Searching online, Ms. Iodice discovered that her experience was not uncommon. For years, comparing notes under anonymous screen names, Peace Corps applicants have shared stories about being disqualified because of mental health history, including common disorders like depression and anxiety.The practice is the subject of a lawsuit filed this week in federal court, accusing the Peace Corps of discriminating against applicants with disabilities in violation of the Rehabilitation Act, which prohibits discrimination in programs receiving federal funds.The lawsuit, which is seeking class-action status from the U.S. District Court for the District of Columbia, includes accounts from nine people whose Peace Corps invitations were rescinded for mental health reasons. The suit alleges that those decisions were made without considering reasonable accommodations or making individualized assessments based on current medical knowledge.In a statement, a Peace Corps official said he could not comment on pending litigation, but added that “the health, safety and security of Volunteers are the Peace Corps’s top priority.”“The agency has a statutory responsibility to provide necessary and appropriate medical care for Volunteers during service,” said Jim Golden, acting associate director of the Office of Health Services, in a statement. “Many health conditions — including mental health care — that are easily managed in the U.S. may not be able to be addressed in the areas where Peace Corps Volunteers are assigned.”He said each candidate’s medical history is assessed individually to determine whether the agency can support the individual’s needs. The three plaintiffs in the lawsuit are not identified by name in the court filings. But other Peace Corps applicants described rescinded offers as a major blow at a vulnerable time in their lives, throwing post-college plans into doubt and forcing them to explain to family, friends and supporters that they had been rejected because of a mental health condition.“It was really heartbreaking to be dismissed like that,” said Ms. Iodice, now 26, who is not a party to the lawsuit. “It took a lot of processing to get over the initial feeling of unworthiness.”The Peace Corps medically screens accepted applicants before sending them overseas to ensure that they do not face health crises when they are in locations where specialized care may not be available. Similar screenings are used in the State Department and the military.But those policies are coming under pressure from legal activists. Early this year, the State Department agreed to pay $37.5 million to settle a class-action lawsuit, filed 16 years ago, challenging a hiring requirement that an applicant should be able to work in any State Department overseas post without the need for ongoing medical treatment.In recent years, the Peace Corps has deployed around 7,000 volunteers to more than 60 nations, according to recent figures from the Congressional Research Service. A review of the medical clearance system found that, in 2006, around 450 applicants were medically disqualified from serving.Carol Spahn, director of the Peace Corps.Michael Brochstein/Sipa USA, via Alamy Live News“I was shocked, at first, at how broad and antiquated some of these policies seem,” said Megan Schuller, legal director of the Bazelon Center for Mental Health Law, which, along with Bryan Schwartz Law, is representing the plaintiffs.One party to the lawsuit filed on Tuesday, Teresa, 22, who asked to be identified by her middle name out of concern that stigma would damage her employment prospects, had been accepted this past January for a volunteer position in Mexico working on climate change awareness.In March, before her planned departure, she was told that she had failed her medical clearance because of her history of treatment for anxiety and depression. She appealed the decision but was denied.Like many undergraduates, she had struggled during the isolation of the pandemic and attended therapy and took an antidepressant medication in 2020, never considering that these treatments might disqualify her from serving in the Peace Corps, she said.“There was part of me that thought, This can’t happen,” she said. “I do not know a single person throughout my whole college experience who didn’t struggle with their mental health.”The letter informing her of her nonclearance cited “active symptoms of anxiety, increased heart rate, inability to sit still, inability to say no,” all symptoms noted down by her therapist in 2021, she said. She spent the weeks around college graduation explaining, again and again, that she wouldn’t be going to Mexico after all.“It’s really humiliating to tell people that you got in and were then rejected because of your mental health,” said Teresa, who is now training to be a paralegal.Another party to the case, Anne, 34, who also asked to be identified by her middle name out of concern for stigma, was offered a Peace Corps position in Mongolia teaching at the university level.On her medical clearance forms, she shared that she had made two suicide attempts at age 15 and was hospitalized at the time, she said in an interview. Since then, however, she had lived abroad as an exchange student and worked for more than a decade as a public school English teacher with no recurrence of suicidal behavior.Her rejection letter, which arrived in November, said that she was assessed as a high risk for a recurrence of suicidal behavior. She scrambled to appeal the decision but was denied. “When you get a denial based on something from half your life ago, it feels like a punishment for being honest, and it feels like part of your past that you can’t escape,” said Anne, who teaches at a high school. “I was very upset. I was confused and trying to figure out how to do it — to save this dream.”Complaints over the policy have simmered for years in online forums and were the subject of a Change.org petition in 2019 and coverage this year in Worldview magazine, a news site for the National Peace Corps Association.Applicants are increasingly forthcoming in discussing their experiences with medical clearance, said Jade Fletcher-Getzlaff, 33, who outlined her own denial and successful appeal in a YouTube video in 2019. With each wave of deployments, she said, she receives between five and 10 inquiries from applicants who have been disqualified because of mental health conditions.“As more people are seeking therapy, and more openly talking about these issues, I think it may be coming up more often,” she said in an interview from Japan, where she now teaches, after serving as a Peace Corps volunteer in Cambodia.Rates of anxiety and depression among young U.S. adults have risen sharply in recent years. In 2020, a Centers for Disease Control and Prevention study found that 63 percent of adults aged 18 to 24 years reported mental health symptoms, compared with 31 percent of all adults. Young adults also expressed greater need for mental health treatment, with 41 percent of adults aged 19 to 25 reporting unmet needs, compared with 26 percent of all adults.Kirstine Schatz, 24, who is currently serving as a Peace Corps volunteer in Morocco, said she was initially denied a medical clearance because she took sertraline, a common antidepressant, for six months on the recommendation of her primary care physician. She discontinued the medication seven months before applying and never received any mental health diagnosis, she said, but she was informed that she was denied medical clearance because the stressful environment of the Peace Corps might trigger a relapse. Ms. Schatz appealed the decision, emphasizing that she had been off the medication and stable for six months, and the decision was overturned. She urged the agency to change its screening policy. “They are missing out on so many amazing people because of this archaic mind-set they have on mental health,” she said. “It’s 2023. They need to figure it out.”As for Ms. Iodice, she never appealed her initial rejection and is still at SnapFitness, where she is the general manager. She said she had no regrets about receiving therapy, even though it might have kept her from serving with the Peace Corps in Senegal.“If I had applied before I went to therapy, I could have gotten there, but I would have been a way worse worker, in my opinion,” she said. “In my perspective, I am a stronger person. I know myself better. I know how to cope.”

The NewsA comparatively quick treatment for post-traumatic stress disorder, in which a patient writes about traumatic experiences in five supervised 30-minute sessions, is as effective as the therapies most recommended by federal agencies, according to a study published on Wednesday.The treatment, called written exposure therapy, involves asking clients to write down the thoughts and feelings that occurred during a traumatic event, and then speak with the therapist about the writing process. In later sessions, they are asked to write about how the event has affected their lives.In the new study published in JAMA Psychiatry, 178 veterans with PTSD received either written exposure therapy or prolonged exposure therapy, which consists of eight to 15 therapy sessions that are 90 minutes long in which the patient vividly imagines the terrifying situation, and then, between sessions, confronts real-life reminders of it.iStock/Getty ImagesThe two therapies were found to be equally effective, and only 12.5 percent of subjects dropped out of the written exposure group before completing a course of treatment, compared with 35.6 percent in the prolonged exposure group. In 2018, a study by the same team found that written exposure therapy was as effective as cognitive processing therapy, another first-line, or most highly recommended, PTSD treatment.Writing down traumatic memories may be easier for some people, if they feel shame or embarrassment about what happened to them, said Denise Sloan, a psychologist who helped develop the treatment and is an author of the study. She said patients were asked to write by hand, which takes longer and allows them to engage with the memory.“It’s a slower process, that allows them to better think through ‘what happened next, and who was there, and what did they say,’ because they’re writing about it,” said Dr. Sloan, associate director of the Behavioral Science Division of the National Center for PTSD. “It slows everything down, versus just saying it out loud.”The therapy was inspired by the work of James Pennebaker, a Texas psychologist who, in the 1980s, began experimenting with what he called “expressive writing,” and found that people who regularly wrote about negative life experiences had stronger immune systems and paid fewer visits to the doctor.The first study of written exposure therapy as a treatment for PTSD appeared in 2012. It works, Dr. Sloan said, much the way other trauma-focused treatments do: by allowing the client to confront the traumatic memory, lessening their fear and avoidance, and allowing them to identify misconceptions like self-blame.Why It MattersCognitive processing therapy and prolonged exposure therapy, the two treatments most highly recommended by the Departments of Veterans Affairs and Defense, have been in widespread use since the 1980s and are backed up by abundant research. A newer method, eye movement desensitization and reprocessing, is rapidly growing in popularity.But all three are time-intensive, requiring sessions of 60 to 90 minutes for three months or more. A large number of patients — an average of 20 percent, and sometimes as high as 50 percent, studies have shown — drop out before completing a course of treatment.Written exposure therapy, Dr. Sloan said, seems to achieve similar effects in fewer sessions.“We have a lot of people that need mental health treatment, and we can’t accommodate the demand,” she said. “We need to revisit what we’re doing and how much is necessary for a good outcome. Because most people can’t go to treatment for 12 to 16 sessions.”What’s NextData on the effectiveness of written exposure therapy is still emerging.The studies comparing it to cognitive processing therapy and prolonged exposure therapy are non-inferiority trials — devised to demonstrate that a newer treatment is not worse than an established one — and “not as scientifically stringent” as trials devised to determine superiority, said Dr. Barbara Rothbaum, one of the developers of prolonged exposure therapy. She added that dropout rates at her clinic, at Emory University, were around 10 percent.There is a reason, she said, that talk therapy has such a strong record of success in treating PTSD.“There is something inherently healing about saying out loud the worse, most scary, most embarrassing, most shameful moment of your life to another human who is trying to be helpful,” she said. “Does it have to be that? No.”Written exposure therapy was not endorsed as a first-line intervention by the Departments of Veterans Affairs and Defense in its most recent clinical practice guidelines, largely, Dr. Sloan said, because of the small number of published studies examining it.That is likely to change over the next two years, she said, as a number of larger trials are completed. Clinicians, too, are going to have to get used to the idea of using writing, in addition to speech, to engage with patients on painful topics.“Some people, they feel threatened by this, because it kind of challenges the crux of what they generally do,” she said. “It flies in the face of what they think is important in treatment.”

A study of adults who were mistreated in childhood found that those who did not recall it showed fewer psychological aftereffects.For generations, our society has vacillated about how best to heal people who experienced terrible things in childhood.Should these memories be unearthed, allowing their destructive power to dissipate? Should they be gently molded into something less painful? Or should they be left untouched?Researchers from King’s College London and the City University of New York examined this conundrum by conducting an unusual experiment.Researchers interviewed a group of 1,196 American adults repeatedly over 15 years about their levels of anxiety and depression. Unbeknown to the subjects, 665 of them had been selected because court records showed they had suffered mistreatment such as physical abuse, sexual abuse or neglect before age 12.Not all of them told researchers that they had been abused, though — and that was linked to a big difference.The 492 adults who reported having been mistreated and were in court records substantiating the abuse had significantly higher levels of depression and anxiety than a control group with no documented history of abuse, according to the study, which was published last week in JAMA Psychiatry. The 252 subjects who reported being abused without court records reflecting it also had higher levels.But the 173 subjects who did not report having been abused, despite court records that show that it occurred, had no more distress than the general population.The findings suggest how people frame and interpret events in their early childhood powerfully shapes their mental health as adults, said Dr. Andrea Danese, a professor of child and adolescent psychiatry at King’s College London and one of the study’s joint authors.“It goes back to almost the stoic message, that it’s what you make of the experience,” he said. “If you can change how you interpret the experience, if you feel more in control at present, then that is something that can improve mental health in the longer term.”In a meta-analysis of 16 studies of childhood maltreatment published in 2019, Dr. Danese and colleagues found that 52 percent of people with records of childhood abuse did not report it in interviews with researchers, and 56 percent of those who reported it had no documented history of abuse.This discrepancy could be partly because of problems in measurement — court records may not have all abuse history — and may also reflect that self-reporting of abuse is influenced by a person’s levels of anxiety and depression, Dr. Danese said.“There are many reasons why people may, in some ways, forget those experiences, and other reasons why others might misinterpret some of the experiences as being neglect or abuse,” he said.But even considering these caveats, he said, it was notable that adults who had a documented history of having been abused but did not report it — because they had no memory of the events, interpreted them differently or chose not to share those memories with interviewers — seemed healthier.“If the meaning you give to these experiences is not central to how you remember your childhood so you don’t feel like you need to report it, then you are more likely to have better mental health over time,” he said.Traumatic childhood experiences have been the subject of some of psychiatry’s most pitched battles. Sigmund Freud postulated early in his career that many of his patients’ behaviors indicated a history of childhood sexual abuse but later backtracked, attributing them to subconscious desires.In the 1980s and 1990s, therapists used techniques like hypnosis and age regression to help clients uncover memories of childhood abuse. Those methods receded under a barrage of criticism from mainstream psychiatry.Recently, many Americans have embraced therapies designed to manage traumatic memories, which have shown to be effective in the treatment of post-traumatic stress disorder. Experts increasingly advocate screening patients for adverse childhood experiences as an important step in providing physical and mental health treatment.The new findings in JAMA Psychiatry suggest therapy that seeks to alleviate depression and anxiety by trying to unearth repressed memories is ineffective, said Dr. Danese, who works at the Institute of Psychiatry, Psychology & Neuroscience at King’s College.But he cautioned that the results of the study should not be interpreted as endorsing the avoidance of distressing memories, which could make them “scarier” in the long term. Instead, they point to the promise of therapies that seek to “reorganize” and moderate memories.“It’s not about deleting the memory, but having the memory and being more in control of that so that the memory feels less scary,” he said.Memory has always posed a challenge in the field of child protection because many abuse cases involve children below the age of 3, when lasting memories begin to form, said David Finkelhor, the director of the Crimes Against Children Research Center at the University of New Hampshire, who was not involved in the study.In treating people with histories of having been abused, he said, clinicians must rely on sketchy, incomplete and changing accounts. “All we have is their memories, so it’s not like we have a choice,” he said.He warned against concluding that forgotten maltreatment has no lingering effect. Early abuse may emerge through what he described as “residues” — difficulty in modulating emotions, feelings of worthlessness or, in the case of sexual abuse victims, the urge to provide sexual gratification to others.Elizabeth Loftus, a psychologist at the University of California, Irvine, and a prominent skeptic of the reliability of memories of abuse, noted that the study stops short of another conclusion that could be supported by the data: Forgetting about abuse might be a healthy response.“They could have said, people who don’t remember in some ways are better off, and maybe you don’t want to tamper with them,” she said. “They don’t say that, and that, to me, is of great interest.”

CAMBRIDGE, Mass. — In the fall of 1994, the psychiatrist Dr. Judith Herman was at the height of her influence. Her book “Trauma and Recovery,” published two years earlier, had been hailed in The New York Times as “one of the most important psychiatric works to be published since Freud.”Her research on sexual abuse in the white, working class city of Somerville, Mass., laid out a thesis that was, at the time, radical: that trauma can occur not only in the blind terror of combat, but quietly, within the four walls of a house, at the hands of a trusted person.More than most areas of science, psychology has been driven by individual thinkers and communicators. So what happened to Dr. Herman — as arbitrary as it was — had consequences for the field. She was in a hotel ballroom, preparing to present her latest findings, when she tripped on the edge of a rug and smashed her kneecap.“Just, wham,” she said. “Smack.”On and off for more than two decades, Dr. Herman groped her way through a fog of chronic pain, undergoing repeated surgeries and, finally, falling back on painkillers. The trauma researchers who surrounded her in the Boston area moved on with their work, and the field of trauma studies swung toward neurobiology.“She is a brilliant woman who lost 25 years of her career,” said her friend and colleague Dr. Bessel van der Kolk, whose 2014 book, “The Body Keeps the Score,” helped propel the field toward brain science. “If you talk about tragedy, that is a tragedy.”At the age of 81, Dr. Herman has rejoined the conversation, publishing “Truth and Repair,” a follow-up to her 1992 book “Trauma and Recovery: The Aftermath of Violence — From Domestic Abuse to Political Terror.” During that period, trauma has gained broad acceptance in popular culture as a way to understand mental health.But the dominant idea now comes from Dr. van der Kolk, who argues that traumatic experiences are stored in the body and can best be addressed through the unconscious mind. “The Body Keeps the Score” has appeared on the best-seller list for an astonishing 232 weeks. TikTok bulges with testimonials from members of Gen Z, identifying all manner of habits and health conditions as trauma responses.Dr. Herman does not want to use this flush of attention to debate her old friend. But in “Truth and Repair,” she picks up where she left off in 1992, arguing that trauma is, at its heart, a social problem rather than an individual one.Drawing on interviews with survivors, she lays out a theory of justice designed to help them heal, centering on collective acknowledgment of what they have suffered. Her approach is frankly political, rooted in the feminist movement and unlikely to go viral on TikTok.This does not seem to trouble her at all. “In my own life, I feel like I’m in a good place,” she said. “On the other hand, I think psychiatry will have to be dragged, kicking and screaming, into any kind of progressive future.”A pledgeDr. Bessel van der Kolk, Dr. Herman’s friend and colleague. “We noted that people in academia were often very cruel to each other,” he said, “and we made a pledge to have each other’s back.” Kayana Szymczak for The New York TimesWhen Dr. Herman and Dr. van der Kolk met in the 1980s, she was treating the daughters of working-class Irish and Italian families, who were coming forward with stories of sexual abuse. He had been treating veterans who seemed trapped in the past, exploding with extreme rage at minor frustrations.She was reserved; he was expansive. Dr. Herman likes to call herself “plain vanilla,” doggedly faithful to psychodynamic psychotherapy; Dr. van der Kolk is “flavor of the month,” always exploring new treatments, first Prozac, then body work and eye movement desensitization and reprocessing.They had this in common: The patients they treated had been routinely dismissed by the psychiatric establishment as malingerers or hysterics. “We were in explicit agreement,” Dr. van der Kolk said. “We noted that people in academia were often very cruel to each other, and we made a pledge to have each other’s back.”The diagnosis of PTSD was brand-new, having first appeared in the Diagnostic and Statistical Manual of Mental Disorders, or DSM, in 1980, and the Boston area, Dr. van der Kolk said, “was to trauma what Vienna was to music.” A trauma study group convened monthly in the elegant stretch of Cambridge mansions known as Professors’ Row.Passing around glasses of sherry and cups of coffee, they argued, Dr. Herman said, about “what counted” as trauma. “The guys who worked with the vets, we had some back and forth, shall we say,” she said. “We had some knockdown drag-outs, calling out the sexism of the men who thought combat trauma was trauma and everything else was just whining.”Dr. Herman is widely credited with putting this question to rest. “Trauma and Recovery” addressed a general audience in “measured, gripping, almost surgically precise” language, as the Times review put it, and with the authority of a Harvard psychiatrist.Her ideas also radiated into the communities where she practiced, said Rosie McMahan, whose family worked with Dr. Herman and her colleague Emily Schatzow to confront sexual abuse by her father.“She did this remarkable thing — ‘Wait a minute, the same things that were happening to those soldiers, in a sense, happened in families,’” said Ms. McMahan, whose book, “Fortunate Daughter,” describes her family’s reconciliation. “They recognized that it was trauma and called it such. They behaved as if it was.”Their ideas were gaining ground. In 1994, the editors of the DSM expanded the definition of PTSD, dropping the requirement that the traumatic event be “outside the range of usual human experience.” Dr. Herman and Dr. van der Kolk began lobbying for the inclusion of complex PTSD, the result of recurring or long-term traumatic events.Dr. Herman at the 130th meeting of the American Psychiatric Association in Toronto in 1977.via Judith HerhamThen came what’s known as the “memory wars” — a pushback from leading psychiatrists against therapy that encouraged patients to unearth memories of sexual abuse. The criticism often zeroed in on Dr. van der Kolk, who served as an expert witness in high-profile cases, and Dr. Herman, whose work on dissociation was regularly cited by defenders of repressed-memory therapy.Dr. Herman shrugged off this critique as “predictable,” the same resistance that Vietnam War veterans and rape victims had encountered when they came forward. “You know, history is a dialectical process,” she said. “When you have a movement that challenges the power structure, you’re going to have a backlash.”Some clinicians did go overboard, Dr. van der Kolk said. They “started talking about satanic ritual abuse, kids being sacrificed in altars,” he said. “It got a little bit weird. Judy and I never went with that crowd. But they were part of our crowd.”By the time the debate faded, his laboratory at Massachusetts General Hospital had been shut down, and he lost his affiliation with Harvard Medical School. “Almost all of us bit the dust in the memory wars,” he added.Since the mid-1990s, the editors of the DSM have consistently opposed further expanding the definition of PTSD. The original definition was “intentionally strict, meant to avoid the possibility that all mental disorders are simply caused by trauma,” said Dr. Allen Frances, who chaired the task force for the DSM’s fourth edition.While stress contributes to most psychiatric problems, he said, PTSD diagnoses can be made quickly and carelessly, without pursuing underlying mental disorders, such as anxiety and depression. Taking that leap, he added, means “all the rest of the knowledge ever accumulated about mental disorders goes out the window.”Dr. Frances was similarly skeptical of “trauma-informed therapy,” which he said provided “a misleadingly reassuring explanation” to complicated psychiatric problems. He added that proponents of the idea, like Dr. Herman and Dr. van der Kolk, had succeeded in winning over a large part of the general public.“You can write best-sellers on this because it’s an appealing model for people searching for an explanation for the distress in life,” Dr. Frances said. That avenue was closing. But that wasn’t the only thing that happened.Pain of unexplained originA page from Dr. Herman’s personal journal from 1976, around the time she started writing her first book.Kayana Szymczak for The New York TimesOn the day she broke her kneecap, Dr. Herman was preparing to deliver a workshop on her latest findings, and was carrying a carousel of slides to a projector. She was distracted and did not see that a binding had come loose from the rug.Dr. Herman has offered vague explanations for the 30-year gap between her books. “Life intervened, in the form of illnesses and a move to an assisted-living community,” she writes in a forward to “Truth and Repair.” In an interview, she flicked away the question, calling it “a very long, sad tale which I won’t bore you with.”But there is a story. Her kneecap healed, but nerve tumors had formed in her leg, and the pain grew steadily worse. For long stretches, daily life became a challenge. There were remissions, but there were also times she could not get out of bed, where even changing positions was “extremely, extremely painful.” At one point, she was so desperate that she asked a doctor if he could amputate her leg.“All you could think about was pain,” she said. “It wasn’t even thinking about pain. It was being pain. One’s existence was just pain. It’s like being in a tunnel.” Like “your whole existence is pain, and nothing exists outside of it,” she added.There was a subtext in her doctors’ response, early on, which she, as a fellow physician, was uniquely qualified to identify: They did not quite believe her. “I was a middle-aged woman with pain of unexplained origin,” she said. In the jargon of medical residents, she said, she was a “crock,” or a female hypochondriac.Eleven years and three surgeries later, her doctors said there was nothing more they could do. This was the worst of it, when there was no hope of reprieve. “It made me not want to live,” she said. “That is literally what happened.”“Judy’s fall had a gigantic impact,” Dr. van der Kolk said. “When you talk about suffering, that was suffering. She was really suffering physically. A large part of the joy and triumph of publishing a great book she did not get to enjoy.”He also said the injury had created a distance in their relationship. He was on fire with the ideas that would later become “The Body Keeps the Score,” among them a view that chronic pain may be an expression of suppressed trauma. He thought he could help. But she was, he said, “too injured to be all that curious.” After that, he said, “Judy and I started to go in different directions.”“It really was the source of sadness on my part, as I was entering this body world, that Judy did not go in the same direction,” he said.Dr. Herman had little recollection of this exchange. But she did not see any larger meaning to her pain; it was just pain, a bunch of malfunctioning neurons, and it preoccupied her entirely. She was fitted with a brace and crutches, and managed to continue teaching and supervising trainees by taking a large doses of fentanyl, applied through a transdermal patch.Asked what the experience taught her, she paused and said, “I guess I just had more empathy for people who go through various forms of torture.”A remedy appeared in 2019, almost by chance. She had gone to see a surgeon about arthritis in her hand, and instead, he peered at her knee. After she left, he emailed her an article about a surgery that had been developed at Walter Reed National Military Medical Center to treat amputees, war veterans from Iraq and Afghanistan.Later that year, surgeons removed the damaged nerves, sutured them to a motor nerve harvested from her quadriceps and then implanted them into her muscle. She weaned herself off fentanyl, set aside the brace and the crutches. She compared the relief she felt to the sensation women have when childbirth ends.“I mean, it’s really heavenly,” she said. “I’m in a permanent state of gratitude.”And that, she said, was why she had the energy to finish another book.“It’s a totally crazy story,” she said. “I owe it all to the forever wars.”The queen of traumaDr. Herman’s new book, her first in 30 years.Kayana Szymczak for The New York TimesWhen Dr. Herman walked into a launch event at the Harvard Book Store last month, wearing orthopedic shoes and multiple shades of purple, there was an intake of breath from the audience, largely made up of older women in mental health professions.The store offered books on healing trauma through weight lifting, quitting one’s job or blocking the nerves known as the stellate ganglion; books on trauma in the music of Dolly Parton, polyamorous families and the Indian caste system; and, of course, “The Body Keeps the Score,” one of those books that, the store’s buying manager said, “even people who aren’t necessarily readers have heard about.”This did not escape Dr. Herman’s admirers, who waited in folding chairs, grumbling discreetly about the authors who rode on her coattails. “All the noise around trauma is all about white men,” remarked Mary Gorman, a psychiatric nurse specialist. “It’s like she’s the forgotten stepchild.”Dr. van der Kolk, who has been helping Dr. Herman to publicize her book, was acutely aware of this dynamic. “The Body Keeps the Score,” he said, benefited enormously from its focus on neurobiology. “In the culture right now, if it’s based on the brain, it’s real,” he added. “Everything else is woozy stuff.”As his book neared publication, he said, he worried that it would supplant Dr. Herman’s as the best-known title on trauma. “She must have known that, to some degree, I would bump her to second position,” he said. “I wondered how she would deal with it.”Considering the whole story, he sounded stricken. Were it not for her injury, he said, “Judy really would have been the queen of trauma.”Dr. Herman, in contrast, sounded cheerful as she looked back on it all. For a woman of her generation to become a full professor at Harvard was a big deal, she said. As for the years lost to pain, she said that the work she had done in her 40s and 50s had already helped to launch a generation of younger scholars.“It wasn’t so much of a cult of personality,” she said. “The field is haunted by all that. But in my case, once ‘Trauma and Recovery’ came out, I wasn’t the only messenger.”At 81, she has the aches and pains of old age, but cannot shake the feeling of having been reborn. In the Black Lives Matter and the #MeToo movements, and in the psychiatric residents she supervises, she sees a return to the politics that shaped her as a young doctor. “I’m back in that exploring kind of moment,” she said. “It’s quite exciting. I just wish I had a 40-year-old body instead of an 80-year-old body to be able to keep up with it.”

Hospitalizations for pediatric suicidal behavior increased by 163 percent over an 11-year period, an analysis of millions of hospital admissions in the United States found.The portion of American hospital beds occupied by children with suicidal or self-harming behavior has soared over the course of a decade, a large study of admissions to acute care hospitals shows.An analysis of 4,767,840 pediatric hospitalizations by researchers at Dartmouth, published on Tuesday in the medical journal JAMA, found that between 2009 and 2019, mental health hospitalizations increased by 25.8 percent and cost $1.37 billion.The study did not include psychiatric hospitals, or reflect the years of the coronavirus pandemic, suggesting that it is a considerable undercount.Especially striking was the rise in suicidal behavior as a cause: The portion of pediatric mental health hospitalizations involving suicidal or self-harming behavior rose to 64.2 percent in 2019, from 30.7 percent in 2009. As a proportion of overall pediatric hospitalizations, suicidal behavior rose to 12.7 percent in 2019 from 3.5 percent in 2009.Though the rise in suicidal behavior among American youths is well-established, the study underlines the gaping inadequacies in our health system, said Dr. Gabrielle A. Carlson, director of child and adolescent psychiatry at Stony Brook University medical school, who was not involved in the new study.“You have got a whole system failure here that is registering itself in suicidal kids,” Dr. Carlson said. Parents seeking care for children, she said, encounter a series of frustrations: Clinicians who don’t take insurance or aren’t taking new patients; crisis interventions staffed by low-paid, poorly trained workers; insurers that don’t reimburse well.“The hospital ends up being the place you go when all else fails,” Dr. Carlson said. “Could you have nipped it in the bud earlier? That is a systems-of-care problem.” She added, “This is playing itself out in an attention-grabbing way.”The study analyzed the Kids’ Inpatient Database, the largest nationally representative database of pediatric acute care discharges, which includes patients under the age of 21. Mental health hospitalizations rose significantly in children between the ages of 11 and 14, but they declined in younger and older age groups during the same 11-year period. Girls became a larger portion of mental health hospitalizations, rising to 61.1 percent in 2019 from 51.8 percent in 2009. Hospitalizations for suicidal behavior rose to 129,699 in 2019 from 49,285 in 2009.The study did not examine what caused the trends, but Dr. JoAnna Leyenaar, one of the paper’s co-authors, pointed to “a growing, growing use of social media among children and adolescents and in particular, growing use among younger adolescents,” which she said had been shown to increase symptoms of depression.Whatever the reason, she added, “we don’t have the magic formula to figure out how to dial this back and make things better.”Dr. Leyenaar said the research was informed by her personal experience as a hospital pediatrician: Though her training included no formal mental health experience beyond a six-week rotation in medical school, children hospitalized after a suicide attempt or self injury are now a central focus of her working life.“Five years ago, my care for these patients didn’t look very different from my care for children with respiratory illnesses,” said Dr. Leyenaar, an associate professor of pediatrics at Dartmouth’s Geisel School of Medicine. Her team has added trainings on safety planning and cognitive behavioral therapy, in the hope that younger doctors “leave residency better equipped to care for youth with mental health conditions than we did.”The findings should spur policymakers to place more mental health care services in school and community settings, which “may well result in decreased hospitalizations,” said Mary Arakelyan, a research project manager at Dartmouth Health Children’s and another co-author. Meanwhile, she said, hospitals should confront their increasingly central role as mental health providers.“For so long, the culture has been, in the hospital, that medical emergencies are the true emergencies,” said Dr. Christine M. Crawford, a child and adolescent psychiatrist at Boston Medical Center, who was not involved in the study.Mental health training, she said, should be given throughout the hospital, “kind of like how everyone in the medical staff is trained on how to do CPR.” And, she said, hospitals need to be incentivized to add inpatient psychiatric units, which, because of reimbursement rates, “hemorrhage money.”The study traced a major shift in the kinds of mental health problems being treated in hospitals, with depressive disorders rising to 56.8 percent in 2019 from 29.7 percent in 2009. Hospitalizations for bipolar disorders, conduct disorders and psychotic disorders like schizophrenia decreased, which could reflect better outcomes due to early intervention programs and more wraparound care.Rates of suicidal behavior are a “marker of distress” among children who lack coping skills to manage stress and “big emotions,” said Dr. Crawford, who is also an assistant professor at Boston University School of Medicine.“When you actually talk to kids who engage in self-harm, who impulsively ingest the Tylenol, they oftentimes talk about an argument that they had with a peer, or a disagreement that they had with an adult,” she said.In most cases, she said, these children have suffered from diagnosable depression for “many, many months” without being treated. “The kids we’re seeing in the emergency room are doing this rather impulsively in the context of some argument,” she said.