Category: Health

Colleen Hoover fans—a passionate group of readers who call themselves the CoHort—are preparing to be emotionally walloped.

On Oct. 18, Hoover will publish It Starts With Us, the long-awaited sequel to 2016’s It Ends With Us. While her two dozen novels are mostly romances, Hoover specializes in the type of book that practically demands a reader have their therapist on standby. Consider recent reactions on TikTok, where the #ColleenHoover hashtag has been viewed more than 2.4 billion times: “I never cry while reading books but this ending just made me burst out in tears,” one person wrote. “I’m just about to go hit rock bottom, so I was wondering if anyone needs anything while I’m there,” another chimed in, clutching a copy of It Ends With Us.

Hoover’s novels probe dark themes: abusive relationships, toxic masculinity, sexual assault, miscarriage, infidelity. She’s been open about her personal connection to some of the things she writes about: Hoover has said that her father physically abused her mother, and that It Ends With Us was inspired by her mother. The novel introduces readers to Lily—a florist who grew up with an abusive father—and her neurosurgeon husband, Ryle, who turns a childhood incident into an excuse for assaulting her. He grows especially jealous and vengeful after Lily reconnects with her first love, Atlas. When Lily learns she’s expecting Ryle’s baby, she has to decide whether she’ll continue to tolerate the cycle of abuse she’s been trapped in her entire life. It Starts With Us picks up where the novel’s epilogue ends and centers on the relationship between Lily and Atlas. It promises to deliver more of Hoover’s signature heartache and ugly tears.

Some readers have noted online that books like It Ends With Us have shifted their perspective on domestic violence, helping them understand why a battered partner might struggle to leave an abuser they still love. Hoover recalls even more personal stories from fans. “I’ve heard from readers who left terrible situations that my books inspired them to do so—that’s the most amazing thing I could ever hope to happen,” she told TIME via email. “That just sharing stories could really help change another person’s life—the weight of that is immense, but if I’ve helped one person in any way, that’s something really special.”

Hoover isn’t the only creator to be inspired by the so-called trauma plot: other examples include Hanya Yanagihara’s A Little Life, the new Netflix movie Luckiest Girl Alive, and the HBO drama Barry. Some critics pan the approach, arguing that characters are flattened when defined only by their trauma, and that it could be exploitative.

That criticism is valid, says Naomi Torres-Mackie, a psychologist at Lenox Hill Hospital in New York City and head of research at the Mental Health Coalition. “When trauma is absolutely central to a character’s existence, it can be dehumanizing and parallel what happens in real life—when we learn about somebody’s traumatic past, and they have to fear that that’s all we’ll see now,” she says. “That’s very unfortunate because, of course, trauma survivors are full, multifaceted humans.”

However, Torres-Mackie adds, when executed well, trauma has an important place in literature and media. It’s key that such depictions exist “in a way that’s holistic and humanizing and balanced.” Darkness is an inevitable part of life, she stresses: “Reading content like this can feel like a relief within a culture where we’re all supposed to be happy-go-lucky.”

Making sense of Colleen Hoover’s appeal

Hoover self-published her first novel, Slammed, in 2012, and has since reliably churned out a couple new books a year. Much of her work has experienced a boom in popularity thanks to BookTok, the corner of the video-sharing platform TikTok dedicated to book recommendations. She authored the No. 1 and No. 2 books on the Oct. 9 New York Times best sellers list: Verity (43 weeks on the list) and It Ends With Us (68 weeks), both of which were published more than three years ago. In the past year alone, copies of her books have outsold the Bible.

It might seem counterintuitive that readers would be so eager to inhale uncomfortable books that leave them sobbing and heartbroken. But reading about trauma is appealing for a variety of reasons, one of which is that it helps us learn about the full spectrum of events that make up a life. “It gives you a lens into different experiences,” Torres-Mackie says. “As human beings, we’re inherently fascinated with each other.” In this case, that eagerness could stem from a desire to relate to people we know who have experienced trauma, or from good old-fashioned voyeurism.

There’s so much violence against women in the U.S. that it’s natural for readers to seek it out in fiction, some experts say. Forty-one percent of women have experienced sexual violence, physical violence, and/or stalking by a partner, according to the U.S. Centers for Disease Control and Prevention. “The themes in her books, while obviously dramatized and created for our entertainment, draw on a lot of what’s actually happening in this world,” says Willow Goldfarb, a Fort Lauderdale, Fla.,-based licensed mental health counselor with Thriveworks, a counseling practice with locations across the U.S. In It Ends With Us, she points out, there’s intense drama and jealousy between Lily and Ryle. Their relationship is also complex: even though Ryle’s violence is objectively unacceptable, he has a tormented but loving side that makes Lily, and some readers, wish they could rehabilitate him. “I think a lot of women can connect to that—of trying to save these men who we believe can be brought back from this brink of their own abuse and torture,” she says. Goldfarb has a point: in one TikTok video, a reader commented, “Am I the only one that wants to fix Ryle so bad?”

Readers who have experienced domestic abuse or other trauma often appreciate seeing themselves reflected back in a storyline, says Juli Fraga, a psychologist with a private practice in San Francisco. Such representation can help them feel less isolated and temper the feeling of being “other.” “They’re looking for themselves in the story,” Fraga says. “Hearing that somebody’s experiences were similar to yours, or even worse than yours, can help you feel less alone—even if it’s merely in a book of fiction.”

Others might consider the books a way to buffer their own safety and prevention strategies. A reader might watch for warning signs before Ryle shoves Lily down the stairs, cataloging his behavior before and after. Torres-Mackie explains the thought process: “If by reading these kinds of narratives I can understand this traumatic experience, even though it’s fiction, maybe I’ll be able to prevent my own pain,” she says. “There can be a sense of self-protection and learning from other peoples’ traumatic experiences.”

Hoover’s popularity speaks to a cultural shift that’s transpired over the past couple decades, says Alexandra Cromer, a Virginia-based licensed professional counselor with Thriveworks. “You didn’t talk about trauma 50 years ago,” she says. “You sucked it up and moved on.” Now, with each new generation, that’s changing. “There’s been a lot more awareness and compassion toward trauma stories—so there’s more space for people to learn about this stuff.”

The mental-health implications

Reading about trauma could certainly lead to mental-health effects, experts agree. But—and here come a therapist’s two favorite words—it depends. An individual reader’s past experiences, emotional wellbeing, and other personal factors will determine the impact a book has on them.

It’s important to consider the reason why someone is consuming this content, Torres-Mackie says. It could be the pursuit of catharsis—the healthy release of previously repressed emotions associated with traumatic events. “It can be really hard to feel difficult emotions,” she says. “But if you can experience them through somebody else, like a character in one of these books, it allows you to feel your own dark feelings.”

Especially for trauma survivors who still have a lot of healing to do, however, the material could trigger flashbacks, unpredictable emotions, physical symptoms like headaches, or even post-traumatic stress disorder. Reading about difficult subject matter, such as physical abuse, activates our mirror neurons—brain cells that are likely the neurological basis of empathy and that influence the way we experience another person’s emotions or actions. “These neurons can get fired up, and that’s why these things give you that jolt of adrenaline or excitement,” Torres-Mackie says. “You feel as if you’re in the narrative yourself.”

Torres-Mackie advises closely monitoring your reaction to the reading material: you should be consuming it, rather than having it consume you. If you start feeling hyper-vigilant and unsafe in the world, or if you’re having nightmares about the book, it’s probably smart to stop reading. Torres-Mackie offers a guiding question: “Does it fill you up, or does it deplete you?”

Ideally, readers will experience novels like It Ends With Us and It Starts With Us as what they are: entertainment, Goldfarb says. She considers herself a Hoover fan and doesn’t feel like she’s been harmed by the material. “But I’m also a person who has worked through my own trauma, and done my own therapy,” she says.

The publishing industry could do a better job of sharing resources for readers who might be adversely affected by sensitive content, she adds. “In every book, there could be a little leaflet or disclaimer, like, ‘This isn’t healthy or normal. This is for entertainment purposes,’” she suggests—plus contact information for a mental-health organization like the Substance Abuse and Mental Health Services Administration or National Alliance on Mental Illness.

Readers can also look up trigger warnings for books, including on websites like doesthedogdie.com—and these ought to be included on the cover or in some other prominent place, Goldfarb says. That would provide readers with a clear sense of whether they would encounter themes it would be healthiest for them to avoid. “Take care of yourself and tune into your body when you’re reading these things,” she says. “If you’re upset by it in a way that doesn’t go away with a cup of tea and a hug, talk to somebody about it. And let’s push for more trigger warnings about these major themes in books, so we can protect each other and still have a great time reading.”

Contact us at [email protected].

Brandon Kapelow is a filmmaker and photographer from Wyoming. He is a suicide-loss survivor and a peer-support facilitator for SOLACE and the Greater Los Angeles chapter of the American Foundation for Suicide Prevention.

I was raised in the wilds of western Wyoming and spent my childhood exploring the foothills of the Rocky Mountains, camping in Idaho and Montana, and visiting family in Colorado and New Mexico. It was a beautiful but difficult place to grow up. Apart from Alaska, these are the states that continually rank highest for deaths by suicide, earning the Intermountain West the ominous designation “the Suicide Belt.”

My father made his first suicide attempt when I was 8 years old. He struggled for years with undiagnosed bipolar disorder and succumbed to his illness after four more attempts, in 2005 at age 64. After seeing friends and family members hospitalized or prescribed medication for suicidal ideation or attempts, I’ve come to realize how widespread this issue is for thousands of people living in small communities across the West, like the one where I grew up. Many of these Americans are struggling to process the complexities of grief that come with living through a generation or more of suicide loss, yearning for support and connection while surrounded by a culture that is rarely willing to offer or accept it.

I decided to travel to Catron County, a high-desert region in New Mexico along the Arizona border with the highest rate of suicide death of any county in the contiguous U.S. from 2010 to 2020, at 63.2 per 100,000 people. (The average national rate for the same time period was about 13.2.) I wanted to meet people who were living at the heart of this issue—to hear their stories and provide a window into their grief, as it mirrored my own. I’ve always found catharsis in talking about my experiences with suicide, and I hoped that this project might provide similar relief to those who chose to sit and speak with me. (Some asked that I omit their last names to help protect their families’ privacy.)

Catron County covers a vast area of 7,000 square miles and is home to nearly 3,600 people, according to the 2020 U.S. Census. Among them are more than twice as many veterans, seniors, and Native Americans than in the average county: three groups at highest risk for suicide death. The population has experienced a 4% decline from the decade prior that reflects a national trend of urbanization that has hollowed out communities across rural America. “I spent my whole life being a cowboy, working on ranches,” Ron, the eldest of a four-generation ranching family, told me. “I think that’s why you see these rural areas having such a high incidence [of suicide]—all of a sudden, we’ve become irrelevant.” Despite a life of continuous employment in ranching, Ron struggled to make ends meet after a heart issue caused medical bills to start piling up. His financial problems and feelings of low self-worth collided, and in the winter of 2019, Ron attempted suicide.

Photographing Ron, I saw a version of my father staring back at me. He, like Ron, survived a suicide attempt that resulted in significant facial damage and spent months undergoing reconstructive surgeries and rehabilitative care before resuming a life forever altered. Meeting people like Ron often required leading with my own story, in an effort to pierce the dense clouds of stigma that still loom heavily over the West. What I didn’t expect was how often I’d find daylight.

Early in my trip I stopped at J&Y, a local auto-body shop in the town of Quemado, to get air for a leaky tire. Owner Jerry Armstrong, who also serves as the volunteer fire chief, an EMT, and a church deacon, asked what brought me to Catron; when I told him, he started to cry. One of his employees, a high school student named Thane Morgan, had taken his life just three weeks prior. Armstrong employs a number of local teens in his shop, and he worries about the ripple effects of Morgan’s suicide. “I see those kids and it’s like, How many of ’em are going to follow suit?” he told me. Morgan was not the first teen at J&Y to attempt suicide. “I feel guilty a lot of the time for even saying, ‘I’ve also been suicidal before,’ because he’s the one who actually went and did it,” says Hunter Gossett, one of Morgan’s friends at the shop. “I get the reason for wanting to do it. At the same time, I’m still here.”

Suicide contagion among teens is a real phenomenon. In the early 2010s, Reserve Independent School District in Catron County experienced a string of student suicides that prompted administrators to implement a peer-support program in which students were trained to look out for warning signs among classmates. The program was such a success that local administrators wonder if a similar program could be as effective among the county’s adult residents.

Tremendous progress in suicide prevention and mental health has been made in the U.S. in 2022. The 988 Suicide and Crisis Lifeline network was launched, and a landmark bipartisan gun safety bill passed, which strengthens red-flag laws and invests in community-based violence-prevention and behavioral-health initiatives. New federal policy changes also make telehealth services for mental-health care more accessible to people in rural areas through Medicare and Medicaid. And a recent survey published by Harris Poll found that 80% of U.S. adults report that they would tell someone if they were having thoughts of suicide—a 13% increase since 2015.

Read More: How 988 Will Transform America’s Approach to Mental Health

But it will be an uphill battle for people in Catron and similarly remote Western counties. Federal data published on Sept. 30 found that in 2021 the U.S. suicide rate rose by 4% after two years of declines. The region’s lack of resources is visible in almost every sector of public health and safety, including law enforcement, emergency medical services (EMS), and mental-health care. There isn’t a state-run hospital in the county—only a medical clinic in Reserve (the county seat) that is funded and operated by a private religious organization. The nearest Veterans Affairs (VA) clinics are several hours away. A single therapist services the region, and they don’t work with children. There’s a wellness center in Reserve, but according to staff there, locals don’t want to be seen walking in the front door.

For 911 emergencies, volunteer EMTs are often dispatched from their homes or workplaces to respond to the incident. If the issue is beyond the capabilities of the local clinic, patients are taken to hospitals in neighboring counties several hours away. The burden on first responders is particularly high due to the nature of living and working in small communities. “We know 80% to 90% of the people that we transport,” says Mike Shriver, an EMS driver and former state policeman. Mike’s wife Vicki Shriver, the Reserve district EMS medical chief, is often confronted with situations for which established protocol is insufficient. “The medical system for behavioral and psychiatric patients is broken,” she says. “There used to be a mandatory 72-hour hold for an attempted suicide … Now sometimes they’re released within 12 to 24 hours, which I don’t think gives the hospital a chance to do a complete evaluation. They’re home before I get the paperwork done.”

Absent a social safety net, the community must care for itself. This feeling of self-reliance is so ingrained that in 1994, Catron’s county commissioners voted unanimously to pass a nonbinding resolution that stipulated every household should have a gun. In 2019, the county commission again voted unanimously to become part of a national group of “Second Amendment Sanctuaries,” counties across the country that nullify certain gun-safety measures, such as red-flag laws, that were designed in part to help law-enforcement officers remove lethal means from people in suicidal crises.

For Larry Iams, a combat veteran and historic-gunfight reenactor, the issue of firearm safety is urgent. Iams was first attracted to Catron County because of its solitude and its support of the gun culture he cherishes. But following the death of his wife, solitude turned quickly into isolation, and a suicidal episode landed him in a VA hospital. He now locks up his guns at a friend’s home in neighboring Arizona to keep them out of reach. “People that are wanting to do this need somebody that they can trust and talk to,” he says. “That’s going to be hard sometimes because there’s not a lot of people around.”

The stark geography of Catron and other Western counties like it increases the likelihood of social isolation, another major risk factor for suicide. “There’s a lot of solitude in the West. Conditions are harsh,” says Dr. Gary Knouf, pastor at the Quemado Cowboy Church, where Morgan’s memorial service was held. “Maybe the greatest dysfunction in America is loneliness.” The experience of loneliness is not purely emotional; social isolation has harsh physical effects on the body, such as increasing stress-hormone levels, and is a risk factor for suicide.

Seniors especially feel the sting of loneliness. At the southern end of Catron County sits the Glenwood Senior Center, one of the few places left for older residents to gather. “They were going to shut down all the senior centers in Catron County, which, unfortunately, would have probably increased our suicide rate,” says Amy Whetham, the center’s supervisor. “These seniors, it’s the only thing they have.” Whetham has lost two family members to suicide and has struggled with several attempts through the years; she knows some of her colleagues have too, but nobody talks about it. “They’re older, and that’s how they were raised,” Whetham says. “You don’t talk about this stuff.”

Throughout the course of this project, residents kept telling me that it was easier to share their stories with a stranger than with members of their own community. I spoke with people of different ages and walks of life—from parents to police officers, teenage students to health care providers and county clerks—and despite every demographic being touched by suicide, most people hadn’t discussed it in a while. I was the one who kept having to end the conversation, as if they felt it might be a long time before they got the opportunity to talk about it again.

But there are signs of healing, too. Ron had always been private about his suicide attempt. But in December 2021, nearly two years after his life-altering crisis, he felt something inside him shift. He was ready to talk. He visited his neighbor Craig Lang, an EMT, to thank him for finding him, praying for him, and saving him that day. Ron also tried tracking down the deputy sheriff who was present, but Lang told him that the man had retired shortly after the incident because he kept having nightmares; he later moved out of the county.

Ron now spends his days working the ranch with his wife and children, wondering why he was spared. He says that despite lingering feelings of regret, he ends each day filled with gratitude for being alive, for getting to enjoy more moments with his grandkids. “It would have fragmented my family, so maybe that’s why God let me live,” he says. He leans back into the seat of his truck and looks out toward the rolling cattle pastures. “Maybe just me talking to you is some of what it is. Maybe somehow I have kept somebody else from doing this. Maybe that’s what this is all about.”

If you or someone you know may be experiencing a mental-health crisis or contemplating suicide, call or text 988. In emergencies, call 911, or seek care from a local hospital or mental-health provider.

Contact us at [email protected].

Five months after the Democratic nominee in one of the nation’s most competitive Senate races suffered a stroke, there’s still a lot to learn about his recovery.

In the final weeks of the Pennsylvania Senate campaign, a key Republican attack against the state’s lieutenant governor, John Fetterman, has centered on his use of closed-captioning technology, which translates audio into text on a screen in real-time. He relied on the technology during an interview conducted Friday with NBC News, his first in-person, on-camera sit-down since his stroke in May.

“I sometimes will hear things in a way that’s not perfectly clear,” Fetterman said. “So I use captioning so I’m able to see what you’re saying.”

Fetterman also plans to use closed captioning for his upcoming debate with opponent Dr. Mehmet Oz, which is raising questions about Fetterman’s recovery.

Here’s we know so far.

What do we know about Fetterman’s health?

Fetterman suffered a stroke in May, just before winning Pennsylvania’s Democratic primary for Senate. In June, his campaign released a letter from his cardiologist that said that “he should be able to campaign and serve in the U.S. Senate without a problem.” He has not released information from his medical team since then.

Fetterman said earlier this year that his stroke was caused by a clot. The type of stroke in which a blood clot blocks blood flow to the brain is called an ischemic stroke—the most common kind of stroke and one of the leading causes of disability in America, according to a February report from the American Heart Association. Ischemic strokes can cause a variety of long-term conditions depending on which part of the brain connects to the clogged artery. According to Johns Hopkins Medicine, a stroke in the left hemisphere of the cerebrum can cause aphasia: difficulty finding the right words or understanding what others are saying, or both.

Does Fetterman have aphasia?

Fetterman’s campaign said in June that he did not have aphasia, and his communications director Joe Calvello told TIME in October that’s still the case. Calvello did not respond to a follow-up question about the differences between that condition and Fetterman’s.

Fetterman’s need to use closed-captioning technology mirrors some of the challenges faced by the estimated one-third of stroke survivors dealing with aphasia. Some aphasia patients might struggle to speak in complete sentences, while others might use incorrect words. During the 32-minute NBC interview, Fetterman mispronounced and confused several words before correcting himself. He often paused to read questions before answering. He repeatedly dodged inquiries about why he will not release his complete medical records.

Maria Town, the president and CEO of the American Association of People with Disabilities, says Fetterman’s use of caption technology doesn’t mean he wouldn’t be able to do the job of being a Senator. “People use captions all the time,” Town says. “It doesn’t have anything to do with with competence.”

“Concepts like competency, or fitness—these are extremely flawed concepts for many marginalized communities, including people with disabilities,” she added.

Dr. Kevin Sheth, the founding chief of the Division of Neurocritical Care and Emergency Neurology at the Yale School of Medicine, also says that just because Fetterman is experiencing difficulties with speech, that doesn’t mean he is having other cognitive issues. “If you have a blockage in the blood vessels that supplies the part of the brain that plays an influential role in language, then you’re going to have trouble with language,” Sheth says. “If it’s the parts of your brain that control your strength and coordination in your limbs, then you’re going to have weakness or paralysis. The deficits that you have depend on the part of the brain that’s downstream from where the blockage in the blood supply was.”

How does closed-captioning technology help him?

In his NBC interview, Fetterman blamed his challenges on “auditory processing issues” and indicated that he struggled to understand what he was hearing shortly after his stroke, but that his ability to do so has improved since then. Captioning, Fetterman said, helps him be precise.

Oz’s campaign manager suggested Fetterman wouldn’t be able to use closed-captioning on the Senate floor. Asked by NBC if he would need similar accommodations in the Senate, Fetterman replied, “I don’t think it’s going to have an impact. I feel like I’m going to get better and better every day and by January, I’m going to be much better and Dr. Oz is still going to be a fraud.”

Is Fetterman’s stroke recovery typical?

“As we’ve said over and over again, John is healthy and he also still has a lingering auditory processing issue that his doctors expect will go away,” Calvello wrote in a statement Thursday. “The whole point of the NBC News interview was to show how John is conducting this campaign and doing his interviews.”

Scientists and doctors are still working to understand stroke recovery, which varies considerably from patient to patient. Outcomes can range from full recovery to permanent disability, and many factors—such as physical therapy, rehabilitation, and lifestyle changes—can affect the process. But in general, recovery tends to follow a particular pattern. “If I draw a graph, I would draw one of those curves where you get steep recovery early, and then over time, the slope can still be there, but it starts to flatten out,” says Sheth. “The recovery between month 14 and 15 might be pretty small, whereas the recovery between two weeks and four weeks might be much bigger.”

When it comes to aphasia in particular, some research indicates that the bulk of improvement happens in the first three months, though survivors can continue to see slow improvement for years, just as they can with all symptoms after a stroke. “If a person at five months has a certain amount of deficits, it’s not like those deficits are going to disappear the next week,” Sheth says. “It’s gonna take some time.”

Write to Mini Racker at [email protected].

Public health data signals a genuine crisis in adolescent mental health: rising rates of anxiety, depression, and hopelessness. But as we worry about tweens and teens who are struggling, we can’t ignore another mounting toll—the burdens that are shouldered by their friends and peers in an “always on” world.

We have studied teens and tech for over a decade. Still, what we learned in our most recent study stopped us in our tracks. We collected perspectives from more than 3,500 teens on the best and trickiest parts of growing up in a networked world, and we co-interpreted these perspectives alongside other teens who helped us make sense of what we were hearing.

Here’s what they told us: Their networks are ever-expanding, in no small part because there’s a sense that being “nice” means by default accepting follow requests from acquaintances and friends-of-friends. We often tell teens not to connect with strangers, yet we overlook the complexities of staying connected to anyone and everyone they meet. Teens tell us, “I don’t want to hurt anybody’s feelings if I can’t stay in touch with them.” And it’s not just staying connected—it’s keeping up with what others post, too.

Evidence from both human beings and primates indicates that we have a natural capacity to limit our social networks. Today, apps like Instagram, Facebook, and Twitter make it easier to keep up more connections at a lower cost in terms of time investment. But it may be that the very architecture of our brains is the reason we have defaulted to the same average network size throughout history. Perhaps you’ve heard of “Dunbar’s number,” representing the number of individuals with whom humans can maintain stable relationships. Prepare yourself: it’s (only) 150! Social media platforms thus make it technically possible to “maintain” more relationships than we are historically actually wired to track and manage. The result is an overwhelming water hose of social information. It’s especially intense for adolescents whose developmental sensitivities drive them to care deeply about what their peers are doing and thinking.

How can parents and adults help? It’s tempting to criticize teens’ sensitivity to social pulls or to roll our eyes when they obsess over their friends’ locations on Snapchat’s Snap Map. But these reactions give teens a sense that we don’t “get it,” and they dead-end dialogue rather than opening up conversations teens need.

Read More: Instagram Is Doing Grave Harm to Our Generation. We Need Help to Stop It

We’ve seen firsthand that combining genuine curiosity with empathy and validation is a magic formula. Ask questions like, “What is it like to be able to see where your friends are all the time? Are there times when it’s helpful? Are there times when it’s hard?”, and then follow-up with validating statements such as, “I can see how that helps you stay connected, but also how it could make you feel left out.” When we take this tack, teens keep talking—and we keep learning. They’re also more inclined to actually listen to advice we have to share. What’s more, asking teens genuine questions creates space for them to reflect on their connected lives. This builds a kind of metacognitive awareness, which the fast-pace and clever design features of apps otherwise undermine at nearly every turn.

Teens tell us about significant stresses that come with trying to be a “good friend” in the age of social media, too. Friendship requires both public and behind-the-scenes support. Even before a social media post is made public, close friends can be pulled into photo selection, editing, and final vetting. Once posts appear, friends are expected to step up—and fast. Liking posts is the bare minimum. A seventeen-year-old recounted how liking a friend’s post immediately triggered a direct message asking her why she hadn’t commented yet. “Then I have to comment like three times…,” she explained, “And I get really nervous about it too, because I have to think of something quick, and it has to be something really good.”

Another pressure is responding the ‘right’ way and in the ‘right’ amount of time, which differs from one relationship to another. Read receipts are implicated here; they signal that a message has been “Read.” To many teens, the time between a message being Read and reciprocated matters a lot. Replying too quickly can be seen as over-eager, especially when the friendship is new or not close. But when it’s a close friend, too long a lag can be hurtful. One teen told us, “If I don’t stay connected, the friendship will fall apart.” Anxious second- and third-guessing of text wording and response times has become a routine part of teen courtship, too.

Teens also told us about the burden of bearing constant witness to peers’ mental health struggles on public display via Instagram stories, TikTok videos, disappearing Snaps, and more. Certainly, the “highlight reel” quality of social media posts—everyone is apparently living their best life—can be hard for some teens. But there’s a kind of emotional whiplash that comes as teens see peers’ cutest pics interspersed with cries for help.

Appropriately, the stakes feel high. A fourteen year old told us, “My biggest worry is that I don’t have enough contact with friends who are struggling…I don’t want my friends to do something bad just because I didn’t respond in time to stop them from harming themselves or worse.” This is a big weight on young shoulders, and a sentiment we’ve heard on repeat.

Vivid stories clarified how these dynamics can play out. When fifteen-year-old Aly saw her classmate Jaylen’s Snapchat posts hint at suicidal thinking, she started to worry. But she struggled to interpret the messages and figure out what to do. Then, Jaylen’s posts got more explicit and Aly’s worry shifted to panic. She grappled with a question we heard other teens voice: What should you do (and who should you tell) if a peer’s social media posts seem alarming?

The challenge of interpreting social media posts—and speaking up—feels all the more relevant in a time when mass shootings are recurring events and digital evidence of threats is unearthed after the fact. In some cases, the poster’s message is clear and so too are their intentions to cause violence. But much of what teens see in their everyday lives falls into a kind of grey area: They don’t always know what is a joke versus a real threat.

How can adults help teens manage this particular burden? We need to first teach teens to pay attention to red flag feelings—and even yellow flag feelings: the gut sense that something is (or might be) off. We then need to talk to teens about what they should do when they see such posts, which starts with looping in others. Have teens identify a few trusted adults who they can turn to for help. In Aly’s case, she told her mom, and her mom contacted Jaylen’s parent. They were already at the emergency room, but Jaylen’s mom had no idea that Jaylen was posting about his distress.

Above all, encourage teens not to just scroll on or struggle in silence. Especially for kind and sensitive kids, the burden can be heavy. They shouldn’t bear this load alone. Nor should they put aside their own needs for sleep, joy, and other essentials. So teens who are supporting fragile friends may need guidance in setting boundaries that respect their friendships and themselves. How do you tell someone that you care and that you’re not available around the clock? Adults can help teens find kind but self-protective language that communicates when they need to disconnect. Encouraging teens to help their friends access other sources of support (like school counselors) is also key.

The qualities that make or break friendships are actually the same as they’ve always been: mutual sharing of joys and sorrows, a give and take of validation and support, and an ability to weather and resolve conflicts. But technologies have transformed how friendships play out. Social media intensifies the burdens that come along with being a good friend. Too often, these dynamics hit teens hard in ways that are lost on adults. We need that to change.

Contact us at [email protected].

If you have unexplained episodes of diarrhea, constipation or gastrointestinal distress you could be one of the more than 25 million people in the U.S. with irritable bowel syndrome.

For relief, your doctor may steer you toward a new kind of treatment that integrates diet change with tools to work through the stress that often triggers symptoms.

Rather than relying only on medications that mask symptoms, doctors are prescribing a combination of diet counseling with therapies, such as cognitive behavioral therapy, mindfulness and even hypnotherapy. (They will first run tests to rule out conditions such as colitis, Crohn’s or celiac disease.)

“There has been a real sea change in terms of managing patients,” says William Chey, a gastroenterologist at the University of Michigan who has documented the benefits of integrative care. “The doctor has become an educator, somebody to help the patient to understand how he or she can help themselves.”

But most gastroenterology practices don’t have a registered dietician, psychologist or stress-management professional on staff, so finding this integrative treatment isn’t easy.

To fill in the gaps, doctors have started to recommend virtual support – apps – that let people access stress management and dietary strategies, on their own at home. Some apps are FDA authorized and require a doctor’s prescription; others can be downloaded on your own.

Here’s what to know about the science behind the integrative approach and how the new apps work.

A miswiring of the brain-gut connection

Let’s start with the basic re-set in thinking about IBS. It’s not just a problem of the gut. Scientists now know that disturbances in the way the nervous system, brain and gut interact can cause changes that trigger or worsen IBS symptoms, including stomach pain, bloating, diarrhea and constipation.

“There’s a continuous feedback loop between the brain and the gut,” explains Suzanne Smith, a nurse practitioner at UCLA’s Integrative Digestive Health and Wellness program. Information flows along the vagus nerve, which connects brain to gut, so what’s happening in the mind affects the gastrointestinal system.

Smith says stress and anxiety can increase sensations of pain in the body and disrupt the GI system. When you feel an unpleasant sensation in the body, “it’s registered as a threat, and the stress response is mounted,” she says. “That gets that negative feedback loop going.”

In a crisis – if your arm is broken – this amped up pain response is useful. It signals you should get help. But if there’s nothing structural to be treated, which can be the case with IBS, the heightened stress response is a problem, and can keep us stuck in the nervous system’s fight-or-flight mode. Every cramp or stomach sensation can register as a threat. The brain and the gut are talking, but it’s almost as if the brain is misinterpreting the signal.

Quiet the nervous system with mindfulness and relaxation techniques

A pillar of the integrative approach and many of the apps is to help patients limit anticipatory anxiety, and halt the feedback loop that can amplify the unpleasant feelings and sensations associated with IBS symptoms.

Mindfulness techniques can help patients tamp down the anxiety linked to their symptoms by learning to foster awareness of the present moment. In 2020, a study of patients who participated in an 8-week Mindfulness Based Stress Reduction course found that 71% of the patients had robust improvements in their GI symptoms.

“There was a significant improvement in quality of life and overall well-being,” Smith says.

The program includes various tools to help get patients to cultivate awareness and calm, including body scans, breathing exercises, or walking meditation.

It may raise eyebrows but hypnosis is another technique shown to help quiet the nervous system. New apps deliver specifically gut-directed hypnotherapy, including Meta Me (which requires a prescription) and Nerva, which people can purchase and download without a prescription. One small study found that about 70% of patients using Nerva had significant improvement in symptoms.

It’s not at all like what you’d see in the movies. There’s no pendulum swinging in front of your face. Gut-directed hypnotherapy combines relaxation techniques with suggestions and guided imagery to help reset communication between the gut and the brain.

When John Mastro, 38, of Melbourne, Australia, first heard about gut-directed hypnotherapy he was experiencing frequent bouts of GI distress that made him hesitant to join in normal day-to-day activities. “There was this sort of anxiety around the idea of leaving home, you know, the symptoms would just suddenly appear,” Mastro recalls.

Doctors had ruled out serious conditions and suggested stress could be a factor, but Mastro wasn’t convinced.

“I just sort of refused to believe that, hey, this could be some form of anxiety that’s triggering,” he recalls, though he was under a lot of stress running a business. He says using the Nerva app helped him understand the connection.

How hypnosis can calm IBS symptoms

Hypnosis can address “the hypervigilance and hypersensitivity that happens in patients that have irritable bowel syndrome,” explains Megan Riehl, a GI clinical psychologist at the University of Michigan who has been offering patients gut-directed hypnotherapy for several years.

“Our brain and our gut are communicating all the time. And if you’re somebody that has a digestive problem, it’s like the communication is turned up way too high,” she says. Hypnosis “helps calm that conversation down.”

The technique usually starts with taking some long, slow breaths, to activate the parasympathetic nervous system, followed by a type of body scan.

“You visualize, say, your chest relaxing or your stomach relaxing, your intestines relaxing,” says Ron Berli, 75, one of Riehl’s patients who lives in Grosse Pointe Park, Michigan. “You’re not into a deep sleep. I would call it just a deep relaxation. It’s almost like sitting in a hot tub.”

What distinguishes hypnotherapy from meditation alone is that after you’ve started to relax, a psychologist will talk you through a script. On the Nerva app, it’s a calming, mellifluous voice actor reading the script.

“Powerful changes are happening inside your body. Imagine the sensations of abdominal pain are becoming a thing of the past,” the soothing voice intones.

The voice tells you to imagine that you’ve been welcomed into an apothecary, where smells of herbs and concoctions fill the air. A pharmacist has made an imaginary special medicine just for you. You’re told it will create comfort and that it will soothe the line of communication between your mind and your gut.

“You’re put into a very calm state,” Mastro says. And the changes or “suggestions” articulated in the 15-minute sessions start to feel real, he says.

The app also includes short readings that distill the science of the gut-brain connection into easy-to-understand bits. Mastro says he came to understand how he was changing his physiology, activating the parasympathetic nervous system, which slows down the heart rate, lowers blood pressure and improves the digestive process.

“It’s been nothing but transformative,” Mastro says. He rarely has symptoms now, and when he does, he says he feels equipped to dial them back using the techniques he’s learned.

Cognitive tools to redirect anxious thoughts

There’s a lot of overlap between hypnosis, meditation, mindfulness based stress reduction and CBT, or cognitive behavioral therapy, which has a deep body of scientific research behind it. The basic gist of CBT is that it helps people identify the connection between their patterns of thinking, their emotions and their actions. And the goal is to recognize and alter their patterns of negative thinking.

CBT has been shown to help people overcome insomnia and poor sleep, and researchers are studying its effect on IBS too.

The idea is to help patients learn to “re-train” their thought processes to develop a more positive way of thinking, less likely to trigger stress.

For instance, if you’re hesitant to go out to eat because you’re worried about having a bathroom emergency, CBT can help break the cycle of catastrophic, negative thoughts. A more realistic assessment of the situation is to realize that if you did sense an urgent need to have a bowel movement, you could excuse yourself to the restroom.

There are now apps to deliver IBS-tailored CBT. Mahana is authorized by the FDA for the condition and requires a doctor’s prescription. Depending where you live, you can get a consult and prescription from within the app for a fee. Zemedy from Bold Health is another CBT-based digital app that has been shown to be effective in a small trial.

The benefit of the technique goes well beyond controlling symptoms of CBT. By developing more positive thoughts, CBT has been shown to improve overall mental health.

Foods to avoid to manage IBS symptoms

Changing what’s on the menu is another key tool for people to manage IBS.

The University of Michigan has had a dedicated GI nutrition program since 2007. “When I started to talk about diet as an important part of treating patients with IBS at that time, people literally laughed at me,” Chey says. “But now almost every gastroenterologist accepts that diet is an important part of the solution.”

The FODMAP diet has gained the most attention from researchers. FODMAP stands for fermentable oligosaccharides, disaccharides, monosaccharides and polyols — and the diet requires elimination or reduction of certain foods known to commonly cause gut distress, including gluten, lactose, excess fructose (found in some fruits and corn syrup) as well as certain nuts, beans and starchy vegetables.

Studies show somewhere between 52% to 86% of participants report significant improvement in their symptoms after following the diet, including reduced gas and bloating.

Researchers at Monash University in Australia explain that the FODMAP diet is based on the understanding that certain compounds in our diet can’t be completely digested or absorbed, so they can end up in the large intestine where they’re fermented by gut bacteria. This leads to gas and bloating.

“I saw the benefits almost within the first week,” says Karen Beningo of Northville, Mich., who was treated at the University of Michigan. After she started the FODMAP diet she found her energy level improved significantly. “The distension and the bloating went away very quick,” she says.

After following the diet strictly, she’s now added some foods back to her diet. She knows gluten is a trigger, so she remains gluten-free and avoids onions, broccoli and Brussels sprouts, as well as some nuts. The diet helped her learn what her triggers were.

“It was only through calming down my system and then reintroducing [them] that I pretty much confirmed, yeah, I’ve got a problem with those things,” she explains.

Following a rigorous diet takes a lot of awareness – luckily there’s an app for this one. Monash University has this FODMAP app that can help people follow the diet, detailing which foods, in which amounts, are ok, and which ones should be avoided.

Editor’s Note: Portions of this story were originally published in April 2022.

NPR’s Carmel Wroth contributed to this report.

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DES MOINES, Iowa — The U.S. Department of Agriculture on Friday proposed sweeping changes in the way chicken and turkey meat is processed that are intended to reduce illnesses from food contamination but could require meat companies to make extensive changes to their operations.

Despite decades of efforts to try and reduce illnesses caused by salmonella in food, more than 1 million people are sickened every year and nearly a fourth of those cases come from turkey and chicken meat.

As it stands, consumers bear much of the responsibility for avoiding illness from raw poultry by handling it carefully in the kitchen—following the usual advice to not wash raw chicken or turkey (it spreads the bacteria), using separate utensils when preparing meat and cooking to 165 degrees. The USDA’s Food Safety and Inspection Service wants to do something about it by starting with the farmers that raise the birds and following through the processing plant where the meat is made.

Their food poisoning target: Of the more than 2,500 salmonella serotypes, the Centers for Disease Control and Prevention has identified three that cause a third of all human illnesses from chicken and turkey products. The agency proposes limiting the presence of these on poultry products.

The USDA estimates the total yearly cost for foodborne salmonella infections in the U.S. at $4.1 billion, which includes the cost of doctor and hospital visits, recovery and premature deaths.

In 1994, the USDA’s Food Safety and Inspection Service took a similar step by declaring some strains of E. coli a contaminant in ground beef and launched a testing program for the pathogen which has significantly reduced illnesses from the meat.

In an effort to curtail salmonella outbreaks in poultry, the agency is proposing a regulatory framework that would include testing incoming flocks of chickens and turkeys for the bacterial disease that commonly affects the intestinal tract and affects 1.3 million people annually with symptoms that may include diarrhea, nausea and vomiting which could last for several days. Officials hope testing chickens and turkeys before they enter the slaughterhouse will encourage farmers to adopt practices that reduce the bacterial infection on the bird before they reach the point of meat processing.

A second measure would require enhanced monitoring for salmonella during processing by adopting sampling for the bacteria at multiple stages inside the processing facility. The third major change would be to establish a maximum level of bacterial contamination allowed and possibly limiting the three specific types of salmonella that can make people sick. Meat that would exceed the limits or that would contain the types of salmonella prohibited could be withheld from the market.

The USDA says there are about 3,000 federally inspected plants that slaughter poultry but about 220 produce the vast majority of poultry products. The agency said it is difficult to say at this point how many would be affected by the future rulemaking.

The FSIS will begin a lengthy process of proposing new rules by holding a public hearing on Nov. 3 to get input from the poultry industry and others. The government’s goal is to come up with new rules and regulations that could be rolled out beginning next year and completed within two years.

The agency said it is taking its time to roll out these ideas and get input before establishing firm regulations. The agency hopes to begin rulemaking in mid-2023 and complete it in two years, said USDA Deputy Under Secretary for Food Safety Sandra Eskin.

“We know this is quite a pivot from where the agency has been historically and for that reason we’re trying to be as transparent and deliberative and collaborative as possible,” Eskin said.

Consumer advocates have pushed for such action on poultry products for years. Eskin said the administration of President Joe Biden is pushing to make the changes.

Seattle-based lawyer Bill Marler, one of the nation’s leading lawyers to represent consumers sickened by food sources applauded the agency’s action which recognizes that controlling salmonella on animals before they reach processing plants is crucial to reducing meat contamination. He said FSIS should be bold and deem salmonella is an adulterant—a contaminant that can cause food-borne illness—in all meat as a starting point.

“What they’ve outlined is something that’s really unique that they have not ever done before but it doesn’t have a time line and doesn’t have regulations attached that would show it’s actually going to be accomplished. That’s my criticism,” he said.

The industry has been unable to meet government targets for reducing food-borne salmonella infections for a couple of decades. Meeting the new target set for 2030 of 11.5 infections per 100,000 people a year would require a 25% reduction, Eskin said.

Eskin said the industry has managed to reduce the number of chicken samples contaminated with salmonella by 50% from 2017 to 2021, but the rate of salmonella illnesses over the last two decades has not significantly declined. More than 23% of foodborne salmonella illnesses are attributable to poultry consumption with nearly 17% coming from chicken meat and more than 6% from turkey meat.

The North American Meat Institute, the trade association representing U.S. packers and processors of beef, pork, lamb, veal and turkey said efforts to combat salmonella are a high priority.

“We are encouraged to see FSIS is going through the regular rulemaking process. We look forward to reviewing the proposal and providing comment from the industry,” said Julie Anna Potts, the group’s president and CEO.

A spokeswoman for the National Chicken Council, which represents the companies that raise and process chickens for meat said they support efforts to reduce salmonella on chicken products.

“We are concerned that the proposed framework currently lacks industry input, research and data to support it,” said Ashley Peterson, senior vice president of scientific and regulatory affairs for the group.

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