The link between trauma and negative health outcomes among adults, including chronic physical and mental illness, is well-established. What is less known are studies like this oneby Harvard Health, and other research, suggesting there is a link between trauma and chronic pain. Modern pain professionals understand that pain is a function of the brain and our processing of many inputs: our pain receptors, our environment, our culture and beliefs about pain, and our past experiences. So naturally, symptoms of trauma will have an impact on our physical well-being and how we process pain. While it is easy for one to make this connection by looking at the co-occurrence of these trauma and pain, it is not always the easiest connection to make when you’re the one suffering.
Trauma and Chronic Pain
As touched on in our discussion about “Big T” and “Little T” trauma, the lasting effects of significant trauma that triggers intense and damaging physiological responses can become clear decades later. While some trauma survivors may identify the single moment that led to their issues, others may be unaware that seemingly insignificant occurrences have actually left permanent scars.
This is particularly true for people whose chronic pain surfaces years after the person thinks they’ve “moved on” from adverse childhood experiences. Considering that the pain often manifests itself in the back, neck, and/or shoulders — areas that can be just as easily affected by stress, posture, or just the grind of daily life — people are likely to blame that pain and discomfort on a number of other factors rather than connecting their symptoms to the trauma.
PTSD and Avoidance
Aside from the devastating physiological impact of traumatic experiences, people who have been involved in an accident or have been injured as a result of abuse may push dealing these issues to their peripheral — or ignore them altogether — in order to not have to suffer the psychological consequences of addressing trauma. As we know, one of the three symptom clusters of post traumatic stress disorder (PTSD) is avoidance and when someone has trauma around an injury, avoiding certain movements or behaviors to avoid re-experiencing the trauma is an expected outcome.
However, this results in restricting movements and a host of chronic pain issues, including reduced circulation, muscle atrophy, joint issues, and “smudging the brain map” – or confusing the brain about where the pain is actually experienced. And because pain is actually a function of brain, believing you are experiencing pain means you are experiencing pain, and it can consume you.
“Pain can take over different areas of the brain when it becomes chronic. It can take over our cognitive centers, it will fire the movement areas so it will make us rigid and freeze. Pain occupies a lot of our resources,” says Dr. Michael Aquino, PT, DPT. He adds, “This is why a lot of patients will tell me that they’re fatigued and unable to think about other things”.
In addition to these types of traumatic events, people who undergo surgery for health issues are subjected to another type of trauma: medical trauma. As the National Child Traumatic Stress Network says, medical trauma, like any adverse life event, is a result of one’s subjective experience rather than the actual severity of the medical event. So identifying trauma in these cases it isn’t as easy as looking at their medical history, as a person’s experience undergoing a simple procedure like having their appendix removed could be traumatic for one person and not another.
The symptoms of a medical trauma are the same as that of childhood abuse or combat – avoidance, fear, anxiety, withdraw – so someone suffering from this type of trauma may avoid seeking medical attention even if they know they are experiencing pain or injury.
Trauma-Informed Chronic Pain Care
Understanding how trauma can contribute to chronic pain is the first step in healing from it and finding recovery from chronic pain. Rather than potentially slipping into a pattern of substance misuse and abuse by turning to medication as a means to reduce the discomfort, identifying and treating the cause — rather than the symptoms — can lead to a significantly better long-term outcome.
Programs like Roots Chronic Pain Recovery understand that the key to a better quality of life is to remove the fear around pain and movement, and address these underlying issues by reframing our pain experience. Using modalities like Cognitive Behavioral Therapy, Mindfulness Based Stress Reduction and Acceptance and Commitment Therapy, a holistic chronic pain recovery program like Roots help people shift their beliefs and understanding of pain, and take back control of their body.
For those who are already suffering from chronic pain — and possibly also using medications and other substances to treat it — turning away from what has worked in the past in favor of an entirely different method of therapy can be a scary proposition. Wrap that in with years or decades of misdiagnoses and mistreatment, and it can seem like an impossible mountain to climb at this point, which is exactly why facilities like Roots Chronic Pain Recovery are changing the way we talk about chronic pain.
With personalized and meaningful therapy, increased movement and exercise, and integrated care, even the most severe trauma and chronic pain can be worked through with time. By identifying and addressing the roots causes of pain and overcoming the co-occurring mental health and substance use issues, Roots Chronic Pain Recovery helps with every step of the journey. Whether it’s stress-related, a work place injury, or stemming from an earlier trauma, getting help for your chronic pain can not only improve your quality of life, but save it in the long run.
Call us today at (562) 473-0827, or fill out the form below to have one of our specialists contact you.
In past articles and our most recent article on trauma, we have mentioned the impact that Adverse Childhood Experiences, or ACEs, can have on an individual. While it wasn’t long ago that we figured it out, there is a great deal of research supporting the notion that one of the key contributing factors to substance abuse, mental health and other behavioral disorders is childhood trauma. Adverse Childhood Experiences, known widely as ACEs, are common and seemingly passive experiences that one may have as a child, that, when occurring repeatedly or in combination, have a devastating impact on a person’s development and long-term health.
When an Adverse Life Event takes place during one’s life in later adolescence or as an adult, the connection for the survivor to make between the traumatic experience and their future issues can be clear. Whether it’s a singular “Big T” trauma or a series of less severe “Little T” traumatic events, the link between these experiences and a person’s behaviors can often be made easily. For example, a 58-year-old man who recently went through a divorce, was laid off and then lost his house, might make the connection between these experiences and his increased drinking and isolation.
However, the link between ACEs and mental health or substance abuse issues that develop later in life can be more difficult, for a couple of reasons. For one thing, the mental health or substance abuse issues often don’t surface until years, or even decades, after the Adverse Childhood Experience occurs. What starts as general family dysfunction, divorce, neglect, or abuse may seem relatively normal through childhood and even into adulthood. The early signs and symptoms of a greater issue often manifest themselves as isolation, lack of trust, avoidance and other social and emotional issues before they ever develop into substance abuse or severe mental illness.
What are ACEs?
The notion of Adverse Childhood Experiences, or ACEs, began with the research of the CDC-Kaiser Permanente Adverse Childhood Experiences (ACE) Study. The study was conducted between 1995 and 1997 and studied nearly 17,000 Kaiser patients in a San Diego Health Clinic. Patient health was studied through physical exams and surveys of current health and behaviors, while they also completed surveys about childhood experiences. What this groundbreaking study was looking at was the link – which was not understood at the time – between childhood trauma and physical, mental and emotional health later in life.
The ten childhood experiences they were looking at were:
1. Emotional Abuse
2. Physical Abuse
3. Sexual Abuse
4. Physical Neglect
5. Emotional Neglect
Growing up in a household were there was:
6. Substance abuse
7. Mental Illness
8. Violent Treatment of a mother or step-mother
9. Parental Separation/divorce
10. An incarcerated household member
Participants in the study were then given an ACE Score between 0 and 10, the total sum based on how many of the 10 types of adverse experiences they reported experiencing.
The Findings of the CDC-Kaiser ACE Study
The ACE Score, from 0 to 10, is used to assess cumulative childhood stress – now sometimes referred to as “Little T” trauma or by association with this study – a person’s “ACEs”. One of the clearest and most widely understood finding of the study was that Adverse Childhood Experiences (ACEs) are more common than one might think, or thought at the time. More than half (52%) of the participants from the original CDC-Kaiser study reported having at least one ACE, and more than 1 in 5 (20%) reported exposure to 3 or more ACEs, while another 6.2% reported 4 or more exposures.
The most prevalent of the categories of childhood exposure was substance abuse in the household (25.6%); the least prevalent exposure category was evidence of criminal behavior in the household (3.4%). Another finding was that the susceptibility of a person’s exposure to multiple ACE categories, as the relationship between single categories of exposure was significant. If someone reported any single category of exposure, the probability of exposure to any additional category ranged from 65%–93%; and then not surprisingly, the probability of more than two additional exposures ranged from 40%–74%.
The key finding of the study as it related to health outcomes, and which changed the way we understood childhood trauma, was that as one’s ACE Score increases, so does the risk for serious diseases and conditions, including:
Alcoholism and alcohol abuse
Illicit drug use
Depression and other mental health issues
Health-related quality of life
Heart and liver disease
Poor academic achievement
Poor work performance and financial stress
Risk for intimate partner violence
Multiple sexual partners
STDs and unintended pregnancies
Risk for sexual violence and intimate partner violence
The increased risk for these negative health outcomes and well-being are dramatic. Compared to someone with an ACE Score of 0, a person with an ACE Score of 4 or more is:
18 times as likely to have attempted suicide
Twice as likely to have had two or more weeks of depressed mood in the past year
Nearly 5 times as likely to have ever used illicit drugs
More than 11 times as likely to have ever inject drugs
More than 5 times as likely to be an alcoholic
How are ACEs Linked to Health Issues?
There is a large and growing body of research about how childhood stress and trauma affect brain development, brain chemistry and, thus, the regulation of the body’s emotional, stress and fear response systems are impacted. Repeated stress and activation of these systems of the brain dramatically alter the formation of myelinated axons and the amygdala, the part of the brain that activates the autonomic nervous system (ANS) and releases hormones like adrenaline and cortisol into the body. If you’re walking through the woods and see a bear approaching, or you see a kid walking into oncoming traffic, the activation of this system is very effective in increasing your heart rate, opening your airways, and increasing blood flow to your organs and muscles, and away from certain parts of the brain.
However, if the stress response system is activated every night by the sound of your dad coming home, or the sight of your mom reaching for a bottle of alcohol, your body and brain are hit with the same fight-flight-freeze response. The repeated activation of this system take a toll on your vital organs as well as your brain’s ability to regulate emotions and responses to triggers. When the body produces too much of, or stops producing, the natural chemicals to sooth or excite you, it is very common for people to turn to external stimuli to compensate this: depressants like alcohol and benzodiazepines, stimulants like cocaine and methamphetamine, or even behaviors like gambling and sexual intercourse.
Exposure to abuse and neglect also impact the prefrontal cortex, the part of the brain responsible for high level cognition and controlling impulse, and the nucleus accumbens, the brain’s pleasure-reward center which releases the body’s natural dopamine. The nucleus accumbens was first discovered in 1954 by two scientists when rats became addicted to pressing a lever that activated this part of the brain. The role of the nucleus accumbens and its connection to the amygdala and hippocampus have great implications in the study of psychiatric disorders, substance abuse and addiction, obsessive compulsive disorder and Tourette’s Syndrome, and more studies are being conducted.
The CDC-Kaiser study also found a “dose-response” relationship between ACEs and negative health and well-being outcomes across a person’s lifetime. A dose-response relationship is one where as the dose or intensity of the trigger increases, so does the intensity of the maladaptive behavior or response. For example, the more a person is exposed to abuse or neglect, the more severe the negative health outcomes will be.
Dr. Nadine Burke-Harris
One of the most notable cases of these results in action was the work of Dr. Nadine Burke-Harris, a pediatrician in San Francisco who was originally unaware of the CDC-Kaiser ACE Study. She noticed when she began working in a hospital in Bayview-Hunter’s Point, a low-income area of the city riddled with addiction and violence, that there was an abnormal number of children being referred to her for Attention Deficit Hyperactivity Disorder (ADHD). One of her colleagues made her aware of the ACE Study, which led her down a path of studying her patients’ exposure to trauma and how the brain and body were impacting their health. She subsequently started the San Francisco Center for Youth Wellness, where Dr. Burke-Harris made it routine to screen children for their ACE Score to better understand the risk factors of these youth across their lifetime.
See her TED Talk on How Childhood Trauma Affects Health Across a Lifetime:
Behavioral Risk Factor Surveillance System (BRFSS)
In 2009, the CDC began collecting annual ACE data through the Behavioral Risk Factor Surveillance System (BFRSS) from voluntary respondents telephonically. It is now the longest-running phone survey in the world. The BFRSS asks questions modified from the original ACE Study, from people across 32 states, using randomly dialed numbers. The data collected from the BRFSS are:
All ACE questions refer to the respondent’s first 18 years of life.
Emotional abuse: A parent or other adult in your home ever swore at you, insulted you, or put you down.
Physical abuse: A parent or other adult in your home ever hit, beat, kicked or physically hurt you.
Sexual abuse: An adult or person at least 5 years older ever touched you in a sexual way, or tried to make you touch their body in a sexual way, or attempted to have sex with you.
Intimate partner violence:2 Parents or adults in home ever slapped, hit, kicked, punched or beat each other up.
Household substance abuse: A household member was a problem drinker or alcoholic or used street drugs or abused prescription medications.
Household mental illness: A household member was depressed or mentally ill or a household member attempted suicide.
Parental separation or divorce: Parents were ever separated or divorced.
Incarcerated household member: A household member went to prison.
The findings of the BFRSS are similar to that of the original CDC-Kaiser ACE Study:
More than two-thirds of the participants reported at least one adverse childhood experience
More than 1 in 5 reported exposure to 3 or more ACEs
Similarly, they also found a dose-response relationship with ACE Scores correlated to an increase in the following:
Lowered educational attainment
Coronary heart disease
Treatment of Childhood Trauma
Understanding the role that adverse childhood experiences (ACEs) play in brain development and prevalence of addiction, mental illness and life-threatening diseases is a pivotal precursor to addressing these issues. Identifying and acknowledging the root of the issues is an important step in the recovery process, and only once a person can work through the lasting effects of exposure to Adverse Childhood Experiences can they truly recover. Because of the way these experiences embed themselves in our brain and body, the process of resolving them can take months or even years, but even the most complex trauma can be resolved with enough time and commitment.
Despite the acceptance of this research in the medical field, behavioral health professionals have been slower to integrate the identification and treatment of trauma into practice. It is important for someone who has been exposed to these adverse childhood experiences to find help at trauma-focused treatment programs like Roots Through Recovery, who utilize evidence-based approaches like Eye Movement Desensitization and Reprocessing (EMDR), Somatic Experiencing (SE), Mindfulness-Based Stress Reduction (MBSR), Trauma-Focused Cognitive Behavioral Therapy (TF-CBT), and expressive approaches like music and sound therapy, trauma-focused yoga, and art therapy.
The word “trauma” is used widely today to refer to an experience that is damaging to a person’s psychological health, and as we’ve mentioned in previous articles, the magnitude of this experience is completely dependent on the individual. What most people outside of the behavioral health profession don’t know is that trauma can be categorized into two classifications: what are known as “Big T” and “Little T.”
BIG T TRAUMA
In general, the Big T variation of trauma refers to a single, traumatic event that can leave a survivor of the event with symptoms associated with Post Traumatic Stress Disorder, or PTSD. Experiences like sexual assault, serious injuries, violent attacks, and near-death experiences all fall under this category, and it’s now widely understood what kind of impact Big T trauma can have on a person’s life. People coping with the effects of a traumatic event, and may be suffering from PTSD, experience various symptoms including:
Staying away from places, events, or objects that are reminders of the experience
Avoiding thoughts or feelings related to the traumatic event
Arousal and reactivity
Being easily startled
Feeling tense or “on edge”
Having difficulty sleeping, and/or having angry outbursts
Cognition and mood
Trouble remembering key features of the traumatic event
Given the general public knowledge of trauma, you might find it surprising that it wasn’t until 1980 that the American Psychiatric Association recognized PTSD as a clinical diagnosis, when they added it to the Diagnostic and Statistical Manual of Mental Disorders (DSM-III). According to the U.S. Department of Veterans Affairs, the diagnosis was both controversial and groundbreaking as it suggested for the first time that the cause, “was outside the individual (i.e., a traumatic event) rather than an inherent individual weakness (i.e., a traumatic neurosis)”. The introduction, research and development of the PTSD diagnosis has paved the way for more trauma-informed and trauma-focused care. You can read the latest criteria for diagnosing PTSD in the DSM-V below.
LITTLE T TRAUMA
Little T trauma is a very different thing though, because it includes virtually every other adverse life experience — each hardship and struggle that people deal with throughout life — that doesn’t fall under the Big T umbrella. Whether it’s a case of bullying, loss of friends or family members, or an emotionally abusive relationship, Little T trauma tends to be the tough situations that many people deal with on a daily basis that don’t necessarily result in a clear diagnosis of a lasting effect. Because trauma is subjective and depends entirely on a person’s resilience and perception, adverse life experiences include anything that could potentially result in trauma; not only the presence of a negative experience, but also the absence of a positive one.
Trauma is anything short of love.
Everyone handles trauma (in either variety) in different ways, and there is now a fairly prevalent belief — and the scientific backing to prove — that dealing with repeated Little T trauma can be just as significant as a single occurrence of its Big T counterpart. Much like experiencing a traumatic life event such as a natural disaster or surviving a serious car crash, experiencing repeated events that engage the body’s stress response system can alter the neural network, especially when these experiences take place in early childhood.
ADVERSE CHILDHOOD EXPERIENCES (ACE) STUDY
Thanks to a study conducted by the CDC and Kaiser Permanente Health in the late 90s, we now know the impact the Adverse Childhood Experiences, or ACEs, have on a person’s neurodevelopment and social-emotional-cognitive development, and as a result, their later in life health outcomes. In the ACE Study, seven categories of adverse childhood experiences were studied: psychological, physical, or sexual abuse; violence against mother; or living with household members who were substance abusers, mentally ill or suicidal, or ever imprisoned.
What the study found was that a person with a higher ACE score was at significantly higher risk for substance abuse, mental health issues, intimate partner violence, and a host of health issues. Before the study was conducted and accepted by the medical and behavioral health community, these experiences that know refer to as adverse life events, adverse childhood experiences or Little T trauma, had been considered a normal part of life. Much like combat veterans returning home from war and being shamed or dismissed as being weak are now being treated for PTSD, these seemingly common but potentially damaging experiences are starting to garner the attention, empathy, or treatment that a Big T survivor might receive.
WHY ARE THESE IMPORTANT?
As mentioned above and in previous articles, exposure to trauma — whether it be Little T or Big T — can cause psychological (and sometimes physical) pain that often leads to destructive coping mechanisms, behavioral adaptations and health-risk behaviors. As a means to escape or numb the pain endured during the trauma, and the recurring discomfort that follows, survivors often turn to self-medicating with controlled substances. As with many addictions, it then becomes a vicious cycle that is generally only broken through proper trauma-focused treatment.
In all likelihood, every person will deal with some type of Little T trauma in their lifetime, and many will be no worse for the wear. But now that it has become recognized as a legitimate cause of maladaptive behaviors that can lead to mental health and substance use disorders, it can finally be treated and viewed on an even playing field with its “bigger” sibling.
Every September, the Substance Abuse and Mental Health Services Administration (SAMHSA) sponsors National Recovery Month in an effort to increase awareness and understanding of substance use and mental health disorders, and to honor and celebrate the people who recover. The theme for 2017 is “Join the Voices for Recovery: Strengthen Families and Communities”.One of the most prevalent issues individuals and families face in their journey of recovery is trauma, or the way in which they perceive and experience major life events. As we’ve written in the past, trauma is completely subjective and, if untreated, can lead to the use of behaviors and substances to escape the effects of trauma.
This year, Roots Through Recovery is honored to celebrate Recovery Month with a special speaking event with Deborah Sweet, Psy.D.: “The Nuances of Trauma Treatment: What to use, how and when”. Treating trauma is it’s own specialized area of psychotherapy. Specific tools and modalities are needed to help people recover from the effects of trauma. Trauma is held in the subcortical region of the brain therefore traditional therapy, though wonderful, will not move traumatic incidents the way that EMDR, Brainspotting, Somatic or Havening therapies do. In this talk, Dr. Sweet will provide information on types of treatment and when and how to use them.
Title: “Nuances in Trauma Treatment: What to use, how and when” Date: Wednesday, September 27th Time: 11:00am to 1:00pm Location: 3939 Atlantic Avenue, Suite 102, Long Beach, CA 90807
Deborah Sweet, Psy.D. is a licensed psychologist, trauma expert and Founder of the Trauma Counseling Center of Los Angeles. Treatment at TCCLA focuses on helping people recover from the overwhelming effects of trauma using modalities that are specifically designed to help people recover from trauma. These cutting-edge modalities include the Somatic therapies of Somatic Experiencing, Sensorimotor Psychotherapy and the Trauma Resiliency Model; EMDR, Brainspotting and the Havening Technique. At the Trauma Counseling Center of Los Angeles, the team helps individuals clear traumas by engaging the subcortical regions of the brain to restore resiliency to the nervous system, enable clearer thinking and an ability to enjoy life more fully.
Lunch will be provided, thanks to our event sponsor WEconnect Recovery. The event is completely FREE, but you must RSVP, and seats are limited.
This is an officially-registered SAMHSA Recovery Month event. Find more Recovery Month events here.
EMDR has received some notable attention recently thanks to its effectiveness in treating trauma. There is a lot of information available online and in academic literature of the therapy, so we put together this article as an overview of EMDR to help you understand what it is and how it works.
So what exactly is EMDR and how does it work?
EMDR stands for Eye Movement Desensitization and Reprocessing, and it involves 8 phases including the use of eye movement, or bilateral stimulation, which appears to be similar to what occurs naturally during dreaming or REM (rapid eye movement) sleep. As we wrote about in past blogs, when a person experiences a traumatic event, their brain goes into defense mode and changes its function.
One of these functions includes the hippocampus, which usually works to store memories in a neat filing system that allows us to easily and accurately recall these memories. When faced with a threat, the hippocampus takes on the role of pumping cortisol throughout the body so that we don’t feel pain, and puts the memory storage on the back burner. So it’s no wonder it’s incredibly difficult to recall a traumatic event, or we recall it inaccurately by filling in the blanks later on.
EMDR allows us to go deep into the brain and file these memories with the appropriate meanings and emotions attached to them. According to the EMDR International Association, the goal of EMDR is to:
“Process completely the experiences that are causing problems, and to include new ones that are needed for full health… That means that what is useful to you from an experience will be learned, and stored with appropriate emotions in your brain, and be able to guide you in positive ways in the future. The inappropriate emotions, beliefs, and body sensations will be discarded… The goal of EMDR therapy is to leave you with the emotions, understanding, and perspectives that will lead to healthy and useful behaviors and interactions.”
One of the leading experts on developmental trauma and author of The Body Keeps the Score, Dr. Bessel van der Kolk recalls the experience he had using EMDR on a patient when he realized the power of the therapy. Watch below:
What are the 8 phases of EMDR?
Phase 1: The first phase is a history-taking session(s). The therapist assesses the client’s readiness and develops a treatment plan. Client and therapist identify possible targets for EMDR processing.
Phase 2: During the second phase of treatment, the therapist ensures that the client has several different ways of handling emotional distress. The therapist may teach the client a variety of imagery and stress reduction techniques the client can use during and between sessions. A goal of EMDR therapy is to produce rapid and effective change while the client maintains equilibrium during and between sessions.
Phases 3-6: In phases three to six, a target is identified and processed using EMDR therapy procedures. These involve the client identifying three things:
1. The vivid visual image related to the memory
2. A negative belief about self
3. Related emotions and body sensations.
In addition, the client identifies a positive belief. The therapist helps the client rate the positive belief as well as the intensity of the negative emotions. After this, the client is instructed to focus on the image, negative thought, and body sensations while simultaneously engaging in EMDR processing using sets of bilateral stimulation. These sets may include eye movements, taps, or tones.
Phase 7: In phase seven, closure, the therapist asks the client to keep a log during the week. The log should document any related material that may arise. It serves to remind the client of the self-calming activities that were mastered in phase two.
Phase 8: The next session begins with phase eight. Phase eight consists of examining the progress made thus far. The EMDR treatment processes all related historical events, current incidents that elicit distress, and future events that will require different responses.
Does it actually work?
At least 20 positive controlled outcome studies have been done on EMDR therapy. According to the EMDR Institute, which hosts a comprehensive list of EMDR-related research, some of the studies show that 84%-90% of single-trauma victims no longer have post-traumatic stress disorder after only three 90-minute sessions. Another study, funded by the HMO Kaiser Permanente, found that 100% of the single-trauma victims and 77% of multiple trauma victims no longer were diagnosed with PTSD after only six, 50-minute sessions.
EMDR International Association reports on the same topic, “Clients often report improvement in other associated symptoms such as anxiety. The current treatment guidelines of the American Psychiatric Association and the International Society for Traumatic Stress Studies designate EMDR as an effective treatment for post traumatic stress. EMDR was also found effective by the U.S. Department of Veterans Affairs and Department of Defense, the United Kingdom Department of Health, the Israeli National Council for Mental Health, and many other international health and governmental agencies. Research has also shown that EMDR can be an efficient and rapid treatment” (www.emdria.org).
Who does EMDR?
Only Masters-level or Doctoral-level professionals–therapists, nurses and doctors–who have gone through approved EMDR training can provide EMDR to people. Roots Through Recovery is proud to have two clinicians on our team that are trained and certified to provide EMDR. Clients who have undergone EMDR therapy for trauma have seen great improvement in their management of traumatic experiences, and how that plays a role in their addictions and mental health.