by Amanda J. Rockinson-Szapkiw, LPC, Ed.D.
Liberty University

Abstract

Many doctoral students, even those enrolled in programs that focus on mental health, are not cognizant of factors that predispose them to mental health issues. They are not aware of ways they need to care for themselves to protect their mental health, how mental health disorders can develop, and how to recognize that they are experiencing mental health problems. This puts doctoral students at risk for failing to seek mental health assistance when needed and dropping out of their program of study. Thus, through the case of Ed, this manuscript discusses these issues and highlights strategies that doctoral students can use to care for their mental health.

Introduction

The doctoral degree is a laborious journey, filled with numerous challenges. An average doctoral student balances personal, familial, professional, community, and academic roles and responsibilities, each demanding his or her time and attention (Spaulding & Rockinson-Szapkiw, 2012). Balancing these multiple roles and responsibilities for a prolonged amount of time can result is stress, and eventually, distress. Stress and distress can negatively affect the doctoral student’s functioning (Cole, Martin,& Dennis, 2004), and the stress experienced during the journey can trigger mental health issues that have lain dormant (Dolbier & Rush, 2012). Willyard (2012) suggests, based on a review of surveys completed by Berkley and the American Psychological Association, that up to a third of all graduate students have mental health problems. Approximately twenty percent of graduate students struggle with mental health disorders, with mood and anxiety disorders being most prominent (Willyard, 2012). Unfortunately, the mental health of doctoral students is a topic that is rarely focused upon in the literature and rarely discussed in doctoral courses or orientations. Many doctoral students, even those enrolled in social work programs that focus on mental health, are not cognizant of factors that predispose them to develop mental health issues during their course of study. They are not aware of ways they need to care for themselves to protect their mental health, how mental health disorders can develop, and how to recognize that they are experiencing mental health problems. Thus, they fail to seek mental health assistance when needed (Zivin, Eisenberg, Gollust, & Golberstein, 2009). A few doctoral students recognize their need for mental health assistance, but fail to seek it due to the “unknown” or fear of being labeled as “crazy” (Willyard, 2012). As such, this manuscript provides information on these topics by examining the case of Edgy Ed. Ed is a doctoral student enrolled in a social work program, who is diagnosed with Generalized Anxiety Disorder (GAD) during his doctoral journey. The manuscript illustrates features of his diagnosis and his recognition of needing to seek professional mental health services, the etiology of his GAD, and his experience in seeking professional assistance. The manuscript also highlights strategies that Ed needs to practice to maintain good mental health during the remainder of his program to avoid further distress. Doctoral students are the primary audience for this manuscript; however, it also provide helpful information and strategies that faculty can provide to the doctoral students they are mentoring.

The Diagnosis of Generalized Anxiety Disorder

Recognizing a mental health disorder or issue begins with understanding what it is and what it looks like. Edgy Ed exemplifies the classic features and symptoms of Generalized Anxiety Disorder. Ed, a 29-year-old Caucasian male, is at the end of the second year in his doctoral program. He has completed his course work and comprehensive exam. He is now entering the dissertation process. Although a struggle, he has balanced taking courses full time, maintaining a 3.9 grade average, working as a school social worker in the public school system, being a husband and father, serving as a leader on a local religious board, and being his son’s cub scout leader. However, in the past six months, Ed has felt “on edge.” He constantly worries that he is going to be fired from his job, fail out of school, and be a disappointment to his family; he constantly worries that his wife and kids will leave him. In an attempt to regulate his critical cogitations and feelings, he often withdraws to his home office, telling his wife and children that he must work on his dissertation proposal for his upcoming oral defense. Yet, while sitting in his office, Ed stares at his books and computer until the early hours of the morning (i.e. usually 4 a.m.). He cannot concentrate and has only written one page of his dissertation. He often reads and reads the one written page highlighting all of its errors. He knows that if he submits work like this to his dissertation chair, his chair will immediately kick him out of the program.

When his dissertation advisor or wife attempt to provide support or feedback to encourage him in his work, he contemptuously argues with them, telling them that they cannot understand the pressure he is under. He wants them to “stop nagging him.” Although his feelings vacillate between anger and sadness, he most perversely feels a sense of dread and worry. His friends have begun calling him the “cave man” as they rarely see him at church or community functions, and he refuses all invitations to hang out, claiming he has too many responsibilities. He has even begun missing days at work. He has no energy. Every time he thinks about his dissertation and even his life, Ed experiences dizziness, sweaty palms, and heart palpitations.

Late one evening, sitting in his office, Ed realizes that he is losing his grip on life and is not motivated to continue in his doctoral program. In fact, he wants to simply curl up in his bed and avoid the reality he calls life. He is incapacitated with worry, but he does not know what to do. He contemplates withdrawing from his doctoral program, but he does not see that as an option because it will disappoint his family and take away his opportunities for job advancement. He is not even sure if that would solve his “problems.” While Ed knows the doctoral journey is demanding, placing students at risk for stress and dropping out (Church, 2009), he recognizes that his “problem” appears to reach beyond “normal” stress. His regular tool box of self-care strategies, including exercise and eating right, do not appear to alleviate what he is feeling and have not assisted him meeting the demands of his life (Marinsuo & Turkulainen, 2011). His severe impairment in functioning makes him wonder if he is dealing with something bigger than he can handle and if he needs to seek professional help.

Since his worry and anxiety is persistent, excessive, intrusive, and debilitating, Ed’s worry and anxiety can be distinguished from what is considered a normal level of anxiety and is within the range that it would be wise for Ed to seek professional help. For example, after talking with a dissertation chair about the daunting process of the dissertation, the average doctoral student may feel a temporary sense of anxiety until he or she begins reading books about the dissertation process and charting out the steps to be successful. During times in which a doctoral student has multiple responsibilities to attend to, he or she may experience increased stress but still be able to complete tasks. Ed, on the other hand, stays up most of the night worrying about his dissertation and his dissertation chair’s response to his work. He is not able to engage in writing his dissertation and is unable to handle many of his familial and work responsibilities. Persistent, excessive, intrusive, and debilitating feelings, thoughts, or behaviors of any type may indicate the presence of a mental health issue that is bigger than a doctoral student can handle on his or her own.

Edgy Ed is experiencing something bigger than he can handle. He is experiencing what is known as Generalized Anxiety Disorder. GAD is an anxiety disorder characterized by chronic anxiety and excessive worry, which an individual experiences for a period of at least six months on more days than he or she does not (American Psychiatric Association, APA, 2013). He experiences worry and anxiety about a number of items and events (e.g. being dismissed from his doctoral program and his wife and children leaving him), with no single focus. Ed also experiences at least three symptoms related to anxiety: (a) sleep issues (e.g. not going to bed until 4 am), (b) tension in muscles, (c) irritability (e.g. contemptuously arguing with his wife and advisor), (d) inability to focus or concentrate (e.g. not able to write his dissertation), (e) fatigue (e.g. having no energy), and (f) restlessness (e.g. feeling edgy) (APA, 2013). Moreover, his anxiety significantly impairs his social and vocational functioning (e.g. missing work, not spending time with his friends, wife, and kids) (Borkovec, Newman, Pincus, & Lytle, 2002). As Ed is not taking drugs or medication and has a recent physical indicating he was in good physical health, his anxiety and worry are not related to organic causes. At the age of 29, Ed is at risk for GAD, as being 24 or older is a significant predictor of being diagnosed and the average age for onset is 30 (APA, 2013). The age of onset for GAD is later as compared to other disorders; this has been attributed to the fact that GAD may be linked to the accumulation of stressors that occur over a period of time (Kessler & Wittchen, 2002).

Like 40% of others diagnosed with GAD (Yonkers, et al., 1996, 2000), Ed is likely to experience GAD for a period of more than 5 years, with periods of agitation and remission. If he seeks treatment, his prognosis is good. Further, as he has a good relationship with his wife, his likelihood of remission and a good prognosis is higher (Yonkers, et al., 2000). If he does not seek treatment when he recognizes that his “problem” is bigger than he can handle, his prognosis is likely to be poor.

The Etiology of GAD Development

A variety of factors may be involved in the development and maintenance of any mental health disorder. This is illustrated as the etiology of GAD is discussed.Biology, personality, childhood and life experiences, cognitive distortions, and the current stress of the dissertation process put Ed at risk for developing GAD.

While Ed reports that he and his immediate family are in good health with no diagnosed mental health issues, he does have a paternal aunt and uncle who were diagnosed with “anxiety issues.” Further, Ed he describes his mother as a worrier. So, anxiety issues run in Ed’s family. This is consistent with research that suggests a moderate familial aggregation of GAD (Hudson & Rapee, 2004; Scherrer et al., 2000). Existence of parental disorders, including anxiety and mood disorders, place individuals at risk for developing GAD (Kessler et al., 2008). Ed’s relationship with his mother may have also influenced his emotionality, emotional- regulation, and interpersonal perceptions, all elements related to worry, a central characteristic of GAD (Cassidy & Mohr, 2001; Kobak, Cassidy, Lyons-Ruth, & Ziv, 2006). Ed’s parents have been married for 40 years and had Ed, an only child, after six years of being married. Ed’s mom had miscarried several times before conceiving Ed and after giving up hope of ever being a mother; thus, Ed remembers his mother being extremely overprotective and not letting him do a lot of “kid things” for fear Ed would get hurt. Ed’s father, on the other hand, was emotionally distant and dismissive. Ed’s father felt that his mother was too overprotective. His father saw Ed as weak and told Ed to “toughen up,” “be a man,” and “stop belly aching (i.e. showing emotion) like a sissy.” Childhood experiences with primary caregivers that fail to teach positive emotional regulation are central in understanding anxiety responses later in life (Grossmann, Grossmann, & Waters, 2006) .

Ed is a perfectionist; he often has unrealistic expectations for himself. While taking course work, he would tell himself, “I am a failure if I earn a B.”, and he now tells himself that he is stupid since he has been unable to complete his dissertation proposal in less than a month. At work, he often becomes frustrated with the teachers under his administration because they are “not competent” and “do not implement strategies correctly.” He tells himself that if he wants things done correctly, he has to do them himself. Yet, he worries that he himself will do something wrong that will result in being fired. These unrealistic expectations and beliefs often result in negative affect, including irritability and anger. Ed’s wife explains Ed as “high-strung” husband; Ed has a high level of neuroticism, a personality trait leave Ed vulnerability to mental health issues (Kotov, Gamez, Schmidt, & Watson, 2010). The diathesis-stress model suggests the interaction between personality traits and life stressors is a predictor of anxiety and depressive related symptoms (Bulmash, Harkness, Stewart, & Bagby, 2009). Specifically, the personality trait of neuroticism, the tendency to experience negative feelings (e.g. tension, anger, anxiety) and the inability to cope effectively with the demands of life (McCrea & Costa, 1987), has been positively associated with the diagnosis of GAD (Kessler, et al., 2008; Kotov, et al., 2010). An individual who has a high level of neuroticism, a stable trait, views the world as a dangerous and threatening place (McCrea & Costa, 1987); thus, making him or her vulnerable to stress, chronic stress, and ultimately distress (Brown & Rosellini, 2011). When the demands of familial and vocational responsibilities are coupled with the demands of a doctoral program, Ed, who already has a high level of negative affect and perceives his world as a threatening or distressing place, is vulnerable to the development of GAD (Eberhart & Hammen, 2009). In fact, the combined stressors of the life of a doctoral student may have triggered the severe anxiety symptoms, and, ultimately the GAD (Brown & Rosellini, 2011).

Related, researchers suggest that cognitive factors place individuals at risk for developing GAD. Beck’s (1976, 1987) cognitive theory as well as the avoidance model of GAD (Borkovec, Alcaine, & Behar, 2004) and the emotional deregulation model (Mennin, Heimberg, Turk & Fresco, 2005) provide insight into the development and maintenance of GAD.

Beck (1976, 1987) suggests that cognitive distortions and irrational beliefs about self and the world predispose an individual to the development of anxiety and mood disorders, especially following a negative life event. Cognitive distortions, such as the ones Ed holds (e.g. “It would be horrible to make a B in my doctoral class; it would make me a failure”), leaves Ed vulnerable to the development of GAD, and maintenance of his negative schema perpetuate the anxiety symptoms over time (Beck, 1987). Using a negative cognitive framework to interpret events or process information in a distorted manner, Ed is likely to selectively attend to negative situational cues while ignoring the positive, thus reinforcing his irrational beliefs (Beck, 1987). For example, when Ed’s dissertation chair provides corrective, yet encouraging feedback with the purpose of guiding Ed toward the development of a solid proposal and encouraging Ed in writing his proposal, Ed only sees the corrections that his chair points out. This reinforces his belief that “I failed, and I am a failure.”

In addition to Beck’s theory for understanding the cognitive aspect of GAD, empirical evidence is growing to support the avoidance model of GAD (see Borkovec, et al. 2004 for a literature review). As explained in this model, worry is a distinguishing feature of GAD and has been identified as cognitive component of the disorder (Borkovec, Robinson, Pruzinsky, & DePree, 1983). Worry involves a preponderance of thought activity and is part of the verbal-linguistic system (Borkovec, et al. 2004). As individuals seek to avoid automatic arousal and distressing emotions in the short term (i.e. engage in an avoidant coping strategy), they engage in the more abstract, verbal-linguistic process, called worry (Borkovec, et al. 2004). In other words, Ed avoids processing his distress and attempts to distance himself from negative feelings and automatic arousal by using abstract, conceptual cognitions (i.e., worry).

Ed’s worry centers primarily around his doctoral program and family; he feels troubled and uncertain about a set of thoughts which he continually plays through his mind (Brosschot, Gerin, & Thayer, 2006). He perceives that his dissertation chair sees him as a failure and will eventually kick him out of his doctoral program. If he gets kicked out of his doctoral program and does not earn a degree, his wife and children will then recognize that he is worthless and leave him. He simply could not tolerate it if he failed and everyone left him (Buhr & Dugas, 2006; Dugas, Marchand, & Ladouceur, 2005). Although his thoughts center on real life issues, they are excessive, often uncontrollable, and not realistic (Brosschot, et al., 2006). He focuses on the negative possibilities of his doctoral program rather than the positive one (Clark & Claybourn, 1997). This worry serves as a less than adaptive way for Ed to regulate his emotions (Mennin et al., 2005).

Complimentary to the avoidance model of GAD is the emotional dysregulation model (Mennin et al., 2005) as it provides a rational for why individuals with GAD seek to avoid their emotions; that is, why they worry. Mennin et al. (2005) explains that individuals with GAD, like Ed, experience emotions more intensely than the general population. However, like Ed, they do not have emotional regulation skills to first identify, and then, modulate these emotions. Consequently, they rely on the maladaptive strategy of worry to avoid the pain associated with distress. Maladaptive emotional regulation has been attributed to both the temperament style, behavioral inhibition, and family environment (Suveg, Morelen, Brewer & Thomassin, 2010). An individual who is reticent toward others and highly reactive to new situations has high inhibition (Garcia-Coll, Kagan, & Reznick, 1984); high reactivity is thought to impede the use of emotional regulation strategies (Suveg, Payne, Thomassin, & Jacob, 2009). For example, Ed has high behavioral inhibition; he has since he was a child. When his mother once left him with a baby sitter who he did not know well, he had a tantrum that lasted two hours. He was unable to calm himself down. Over time, prolonged arousal could have caused biochemical and neuronal changes that sensitized Ed to respond in maladaptive ways to regulate his emotions (Bremner & Vermetten, 2001). As an adult, sitting in his den thinking about his dissertation, Ed experiences a heightened level of arousal and then uses worry as a mechanism to regulate his emotions. Highly emotional or truncated emotional familial environments have also been positively associated with failure to identify and regulate emotions. Dunsmore and Halberstadt (1997) noted, “Overall frequency, intensity, and duration of positive and negative emotional expressiveness in the family is important in the child’s formation of schemas about emotionality, about expressiveness, and about the world” (p. 53). When focusing on anxiety disorders, researchers have demonstrated that individuals with anxiety disorders come from familial environments of low emotional expression and situations in which the display of negative emotion was discouraged as compared to a non-clinical control group (Hudson, Comer, & Kendall , 2008). If an individual grows up in a familial environment, like Ed’s environment, exposed to less than adaptive ways to handle anxiety (e.g. his mother worrying; father dismissive), then he never develops the skills necessary to successfully navigate stressful, emotional situations, such as the demanding doctoral journey. With GAD, worry is a central maladaptive emotional regulation strategy and has been shown to be reduced when individuals engage in cognitive–behavioral therapy (CBT; Dugus & Robichaud, 2006). Thus, in seeking professional help, Ed needs to choose a counselor who will use CBT as well as take into consideration his needs based on his current situation and past. As those pursuing doctoral education, they can search the American Psychological Associations’ website to identify empirically supported treatment for the diagnosis experienced and identify a counselor who specializes in the empirically supported treatment.

Assessment and Treatment

Ed recognized that he needed to seek professional mental health help, so he with much hesitation made an appointment with Dr. Jones, a counselor at a local mental health center. Being a social worker, Ed was familiar with the mental health process; however, he realized that he was not exactly sure what to expect. He had always been the provider of such services rather than the receiver. Upon scheduling the appointment, the secretary put him at ease by clearly explaining the process and what to expect. For the first appointment, she asked him to come early to complete paperwork. She informed him that the paperwork as well as his first meeting with Dr. Jones would require him to answer many questions; she explained that understanding his current situation and history helped identify the best treatment path.

During the first meeting Dr. Jones conducted a mental status exam and clinical intake interview, which consisted of questions about Ed’s current functioning, medical history, and relationships as well as his family history. There were a number of questions directly related to the anxiety he had been experiencing and aimed at determining whether he met the diagnostic criteria for the DSM-V(APA, 2013) diagnosis of GAD or other disorders. Ed also completed several self-report measures; each instrument was aimed at determining whether he met the diagnostic criteria a DSM-V(APA, 2013) disorder and aimed understanding the nature and severity of his worry. Dr. Jones, drawing from a CBT theoretical standpoint and based on her assessment of Ed’s current functioning and history, saw that Ed’s current thinking (“If I do something wrong, my wife will leave.” “It would be the worst thing in the world for my dissertation chair to think I am a failure”) contributes to his state of worry, feelings of anxiety, and his problematic behaviors (e.g. avoiding social interactions and inability to concentrate). Key developmental events and biological factors (i.e., genetics, undifferentiated family dynamics, insecure attachment, childhood loss and trauma) influenced his difficulty with emotional regulation and enduring thought patterns of interpreting current events; thus, having predisposed Ed to GAD. Dr. Jones diagnoses Ed with 300.02, Generalized Anxiety Disorder. Dr. Jones, recognizing Ed’s openness to counseling and background in mental health, discussed her conceptualization and diagnosis with Ed, and he agreed that it seemed like an accurate assessment.

Based on this case conceptualization and literature, Dr. Jones recognized that implementing cognitive behavioral therapy (CBT) for the treatment of Ed’s GAD as the best course of action (Borkovec & Whisman, 1996; Dugas, Marchand, & Ladouceur, 2005; Hoyer, Beesdo, & Gloster, 2009); twelve sessions were planned. Dr. Jones chose a therapeutic protocol that is based upon cognitive behavioral theory. As 87.5% of clients with GAD improved using the Mastery of Your Anxiety and Worry (MAW) protocol (Zinbarg, Lee, & Yoon, 2005), she specifically chose this protocol to address the concerns and goals she and Ed collaboratively identified in their first session together. However, Dr. Jones modified the protocol attending to current research as well as Ed’s unique history and current situation. As Ed has poor emotional regulation due to childhood attachment and history, Dr. Jones recognized the importance of assisting Ed in developing better emotional regulation skills, which will not only enhance his relational function but also his cognitive capacity for completing his dissertation. Mindfulness practices that focus upon teaching awareness and attention for the purpose of bringing mental processes under greater voluntary control have been shown to reduce rumination through disengagement from repetitive cognitive patterns, thus, enhancing attentional and cognitive flexibility, working memory capacities, and emotional regulation (Chambers, Lo, & Allen, 2008; Dekeyser , Raes, Leijssen, Leyson, & Dewulf, 2008; Hoffman, et al., 2010).Thus, Dr. Jones integrated mindfulness training into Ed’s treatment. Drawing from the protocol and the behavioral tradition, Dr. Jones and Ed practiced relaxation techniques and deep breathing exercises to help Ed decrease arousal and regulate his emotions. Cognitive techniques were used to help Ed minimize cognitive distortions by more realistically thinking about worry. The focus of CBT is on the relationship among thoughts, feelings, and behaviors, and provide Ed with short-term, present-focused techniques to apply in a variety of situations to manage his anxiety (Dugas & Robichaud, 2006). Dr. Jones also recommended that Ed see a doctor for medication management.

CBT with medication management assisted Ed in modifying his thoughts and belief to more realistic thinking, decreasing his worry about interpersonal and school related activities, and, ultimately, helping him function in his daily life within his family, at school, and at work (Alford & Beck, 1997; Dugas et al., 2005). At a follow up session, Ed reported that he was spending time with his family and has successfully written chapter 1 and 2 of his dissertation. He believes that he will successfully finish his doctoral program. Ed recognized that he probably would still not have begun his dissertation had he not sought mental health assistance. And, he wishes that he would have been more aware of mindfulness techniques and other stress reduction strategies prior to seeking counseling that he believes could be helpful for all doctoral students to practice to avoid stress turning into distress and burnout.

Strategies for Maintaining Good Mental Health

The following are the stress reduction strategies that Ed learned and practiced on a regular basis. While Ed knew about some and thought he regularly practiced them, he recognized, through self-monitoring during his therapy, that many of the strategies he neglected to practice regularly. Practicing these strategies regularly helps Ed to alleviate his anxiety and stress, and thus, function effectively.

Mindfulness is a reflective awareness of experiences and has been associated with perseverance toward long term goals (Duckworth, Peterson, Matthews, & Kelly, 2007). Mindfulness strategies that Ed found helpful included visualization, meditation and self-awareness as they helped him to maintain focus. He prepared written goals that that are reviewed daily and used them to evaluate his moment-to-moment behaviors. “To Do” lists created via his iPhone app helped him to heighten awareness of task timelines and enabled him to celebrate small task completion. He would take time to stop in the moment to mediate and observe, describe ,and accept his thoughts and feelings without judgment. Self-regulatory strategies, specifically positive self-talk, assisted Ed increasing his resilience toward meeting his goal of finishing the doctoral program (van Gelderen, 2012). Ed reminded himself, “A doable dissertation is one broken into tasks” and “I can complete this dissertation one task at a time.” He also began evaluating his self- talk and expectations of himself , for he had the tendency to expect too much of himself in a short period of time without considering all of life’s responsibilities. For Ed, he wanted to do it all. He had unrealistic academic expectations to get his dissertation done in a few short months and was simultaneously telling himself that he needed to eat dinner and play with his kids every night to be a good father. In working on his dissertation, he experienced feelings guilty for not spending time with his family. He had to modify his definition of what it meant to be a good father, “A good father schedules time to play with his kids weekly,” and academic expectations, “The dissertation is part of the doctoral journey, and a journey takes time.”

Regulation of Ed’s time and schedule was also important to regulating his stress. Ed took time to schedule time for work, time for friends and family, personal time to relax, and study time. All of these important times were scheduled on his calendar so they would not be overlooked. He also set deadlines for certain tasks in order to optimize his stress and avoid unnecessary stress (Powers & Swick, 2012). He took time to evaluate life responsibilities and made a list of negotiable and non-negotiable responsibilities. For example, being a dad and being his son’s cub scout leader was non-negotiable. However, serving on the religious board was negotiable. He relinquished all of his negotiable commitments in order decrease his stress and maximize his performance in the important areas.

While Ed thought that he had a healthy diet, he realized that to optimize his brain functioning, especially concentration, he needed to have a diet rich in antioxidants and healthy fats as an efficiently functioning brain requires the synthesis of glucose and energy producing nutrients (Turner, 2011). After reading a chapter on brain health (Cadle & Rockinson-Szapkiw, 2014), he identified good foods and maintained a regular diet of foods such as (a) blueberries , which are in antioxidants and phytochemicals; (b) avocados, which are a good source of monounsaturated fats; and (c) hummus , a source for complex carbohydrates, protein, and fats.

Ed realized that prior to entering the doctoral journey, he exercised 5 times a week. In his doctoral journey, his exercise dwindled to once a week. As mood and anxiety disorders associated with lower levels of serotonin and norepinephrine; a good strategy for doctoral students is participate in 30 minute to 60 minutes of aerobic activity on a regular basis (at least 3 times a week) to enhance blood flow to the brain and increase neurotransmitter activity and decrease depressive and anxiety symptoms (Rethorst, Wipfli, & Landers, 2009). He also recognized that despite his busy schedule, he also needed to take time to relax and get good sleep in order to rejuvenate his body. Weekly, he scheduled a 24 hour break away from his work and academic responsibilities in order to rejuvenate.

Finally, Ed strengthened his support system as his counselor informed him that recovery happened more quickly for those with social support and doctoral students with strong social support systems are likely to complete their degrees (Eng & Heimberg, 2006; Spaulding & Rockinson-Szapkiw, 2012). Ed identified a friend in the doctoral program with whom he could share his struggles and accomplishments .

Conclusion

The demanding social work doctoral journey coupled with genetics, cognitive processes, and life experiences may place some individuals at risk for developing mental health issues and disorders, as was illustrated in the case of Edgy Ed. Understanding how mental health issues can manifest and the risk factors that predispose individuals to their development may assist doctoral students in recognizing if they develop mental health concerns. While stress, worry, sadness, and other emotions are a normal part of life and feelings that are regularly experienced throughout the doctoral journey, professional mental health services need to be sought when they become persistent, excessive, intrusive, and debilitating. The seeking of mental health services when needed may make the difference between a doctoral student becoming a drop out statistic or completing successfully.Understanding what takes place when treatment is sought can benefit the doctoral student in recognizing when it may be appropriate to seek professional mental health assistance and reduce their anxiety about seeking treatment. Further, understanding mindfulness and stress reduction strategies can assist doctoral students in maintaining their mental health or alleviating diagnosed mental health disorders.

References

Alford, B. A., & Beck, A. T. (1997). The integrative power of cognitive therapy. New York: Guilford.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). Washington, DC: Author.

Beck, A.T. (1976) Cognitive therapy and the emotional disorders. New York:International Universities Press.

Beck, A.T. (1987) Cognitive models of depression. Journal of Cognitive Psychotherapy:An International Quarterly,(1), 5-37.

Borkovec, T. D., Alcaine, O., & Behar, E. (2004). Avoidance theory of worry and generalized anxiety disorder. In R. G. Heimberg, C. L. Turk, & D. S. Mennin (Eds.), Generalized anxiety disorder: Advances in research and practice (pp. 77-108). New York: Guilford Press.

Borkovec, T. D., Newman, M. G., Pincus, A. L., & Lytle, R. (2002). A component analysis of cognitive– behavioral therapy for generalized anxiety disorder and the role of interpersonal problems. Journal of Consulting and Clinical Psychology, 70, 288–298.

Borkovec, T. D., Robinson, E., Pruzinsky, T., & Dupree, J. A. (1983). Preliminary exploration of worry: Some characteristics and processes. Behaviour Research and Therapy, 21, 9-16.

Borkovec, T. D., & Whisman, M. A.(1996).Psychosocial treatment for generalized anxiety disorder. In M. R. Mavissakalian & R. F. Prien (Eds.), Long-term treatments of anxiety disorders. (pp.171–199). Washington: American Psychiatric Press.

Breemner, J. D., & Vermetten, E. (2001). Stress and development: Behavioral and biological consequences. Development and Psychopathology, 12, 473–489.

Brosschot, J. G., Gerin, W., & Thayer, J. F. (2006). The perseverative cognition hypothesis: A review of worry, prolonged stress-related physiological activation, and health. Journal of Psychosomatic Research, 60, 113-124.

Brown, T.A., & Rosellini, A.J. (2011).  The direct and interactive effects of neuroticism and life stress on the severity and longitudinal course of depressive symptoms.  Journal of Abnormal Psychology, 120, 844-856.

Buhr, K., & Dugas, M. J. (2006). Investigating the construct validity of intolerance of uncertainty and its unique relationship with worry. Journal of Anxiety Disorders, 20, 222-236.

Bulmash, E., Harkness, K.L., Stewart, J.G., Bagby, R.M. (2009). Personality, stressful life events, and treatment response in major depression. Journal of Consulting and Clinical Psychology, 77(6),1067-77.

Cadle, C. & Rockinson-Szapkiw, A.J. (2014). Using neuro-informed education as a self-Intervention for Doctoral Success. In Rockinson-Szapkiw, A.J. & Spaulding, L.S. (Eds.), Navigating the doctoral journey: A handbook of strategies for success. Lanham, Md: Rowman & Littlefield.

Cassidy, J., & Mohr, J. (2001). Solvable and unsolvable fear: Attachment, trauma, and psychopathology. Clinical Psychology: Science and Practice, 8, 275–298.

Clark, D. A., & Claybourn, M. (1997). Process characteristics of worry and obsessive intrusive thoughts. Behaviour Research and Therapy, 34, 163-173.

Chambers, R., Lo, B. C. Y., & Allen, N. B. (2008). The impact of intensive mindfulness training on attentional control, cognitive style, and affect. Cognitive Therapy and Research, 32, 303–322. doi:10.1007/s10608- 007–9119-0.

Church, S. E. (2009). Facing reality: What are doctoral students’ chances for success? Journal of Instructional Psychology, 36(4), 307-316.

Cole, P. M., Martin, S. E., & Dennis, T. A. (2004). Emotion regulation as a scientific construct: Methodological challenges and directions for child development research. Child Development, 75, 317–333.

Dekeyser, M., Raes, F., Leijssen, M. Leyson, S., & Dewulf, D. (2008).Mindfulness skills and interpersonal behavior. Personality and Individual Differences, 44, 1235–1245. doi:10.1016/j.paid.2007.11.018

Dolbier, C. L. & Rush, T. E. (2012). Efficacy of abbreviated progressive muscle relaxation in a high-stress college student sample. International Journal of Stress Management, 19(1), 48-68.

Duckworth, A. L., Peterson, C., Matthews, M. D., & Kelly, D. R. (2007). Grit: Perseverance and passion for long-term goals. Journal of Personality and Social Psychology, 92, 1087–1101.

Dugas, M. J., Marchand, A., & Ladouceur, R. (2005). Further validation of a cognitive- behavioural model of generalized anxiety disorder: Diagnostic and symptom specificity. Anxiety Disorders, 19, 329-343.

Dugas, M. J., & Robichaud, M. (2006). Cognitive-behavioral treatment for generalized anxiety disorder: From science to practice. New York: Routledge.

Eberhart, N., & Hammen, C. (2009). Interpersonal predictors of stress generation. Personality and Social Psychology Bulletin, 35, 544-556.

Eng, W., & Heimberg, R. G. (2006). Interpersonal correlates of generalized anxiety disorder: Self versus other perception. Journal of Anxiety Disorders, 20, 380–387.

Garcia-Coll, C., Kagan, J., & Reznick, J. S. (1984). Behavioral inhibition in young children. Child Development, 55, 1005–1019.

Hoffman, S. G., Sawyer, A. T., Witt, A. A., & Oh, D. (2010). The effect of mindfulness-based therapy on anxiety and depression: A metaanalytic review. Journal of Consulting and Clinical Psychology, 78,169–183. doi:10.1037/a0018555.

Hoyer J., Beesdo K., & Gloster AT, et al. (2009). Worry exposure versus applied relaxation in the treatment of generalized anxiety disorder. Psychotherapy Psychosomatic, 78,106–115.

Hudson, J. L., Comer, J. S., & Kendall, P. C. (2008). Parental responses to positive and negative emotions in anxious and nonanxious children. Journal of Clinical Child and Adolescent Psychology, 37, 303–313.

Hudson, J. L., & Rapee, R. M. (2004). From Anxious Temperament to Disorder: An etiological model of Generalized Anxiety Disorder. In R.G. Heimberg, C.L. Turk, & D.S. Mennin (Eds.), Generalized Anxiety Disorder: Advances in Research and Practice New York: Guilford Press.

Kessler, R.C., Gruber, M., Hettema, J. M., Hwang, I., Sampson, N., & Yonkers, K.A. (2008). Co-morbid major depression and generalized anxiety disorders in the National Comorbidity Survey follow-up. Psychological Medicine,38(3), 365-374.

Kobak R. , Cassidy, J, Lyons-Ruth, K. & Zir, Y. (2006).  Attachment, stress and psychopathology: A developmental pathways model. In Cicchetti, and Cohen, (Eds.) Handbook of Developmental Psychopathology, Vol. 1, (pp. 333-369). Cambridge: University Press.

Marinsuo, M., & Turkulainen, V. (2011). Personal commitment, support, and progress in doctoral studies. Studies in Higher Education, 36(1), 103-120. doi: 10.1.1080/03075070903469598

McCrae, R. R., & Costa, P. T., Jr. (1987). Validation of the five-factor model of personality across instruments and observers. Journal of Personality and Social Psychology, 52, 81-90.

Mennin, D. S., Heimberg, R. G., Turk, C. L., & Fresco, D. M. (2005). Preliminary evidence for an emotion dysregulation model of generalized anxiety disorder. Behaviour Research and Therapy, 43, 1281–1310.

Powers, J., & Swick, D. (2012). Research note: Straight talk from recent grads: Tips for successfully surviving your doctoral program. Journal of Social Work Education,48 (2), 389-394. doi: 10.5175/JSWE.2012.201000073

Rethorst, C. D., Wipfli, B.M., & Landers, D. M. (2009). The antidepressive effects of exercise: A meta-analysis of randomized trials. Sports Medicine, 39(6), 491-511.

Scherrer, J. F., True, W. R., Xian, H., Lyons, M. J., Eisen, S. A., Goldberg, J., Lin, N., & Tsuang, M. T. (2000). Evidence for genetic influences common and specific to symptoms of generalized anxiety and panic. Journal of Affective Disorders, 57, 25–35.

Siegel, D. J. (2007). The mindful brain: Reflection and attunement in the cultivation of well-being. New York: Norton.

Spaulding, L.S. & Rockinson-Szapkiw, A.J. (2012). Hearing their voices: Factors doctoral candidates attribute to their persistence. International Journal of Doctoral Studies, 7, 199-219. Retrieved from http://ijds.org/Volume7/IJDSv7p199-219Spaulding334.pdf

Suveg, C., Morelen, D., Brewer, G. A., & Thomassin, K. (2010). The emotion dysregulation model of anxiety: A preliminary path analytic examination. Journal of Anxiety Disorders, 24, 924 -930. doi:10.1016/j.janxdis.2010.06.018

Suveg, C., Payne, M., Thomassin, K., & Jacob, M.L. (2010). Electronic diaries: A feasible method of assessing emotional experiences in youth? Journal of Psychopathology and Behavioral Assessment, 32, 57-67.

van Gelderen, M. (2012). Perseverance strategies of enterprising individuals. International Journal of Entrepreneurial Behaviour & Research, 18(6), 630-648.

Willyard, C. (2012). Need to heal thyself? gradPSYCHMagizinge, 10(1). Retrieved from http://www.apa.org/gradpsych/2012/01/heal.aspx

Wittchen, H-U , Zhao, S., Kessler, R.C., & et al. (1994). DSM-III-R generalized anxiety disorder in the   National Comorbidity Survey. Archives of General Psychiatry, 51, 355–364

Yonkers, K. A., Dyck, I. R., Warshaw, M., & Keller, M. B. (2000). Factors predicting the clinical course of generalized anxiety disorder. The British Journal of Psychiatry, 176, 544– 549.

Zivin, K., Eisenberg, D., Gollust, S. E., & Golberstein, E. (2009). Persistence of mental health problems and needs in a college student population. Journal of Affective Disorders, 117(3), 180-185. doi: 10.1016/j.jad.2009.01.001.