Constellations

I.

We had crash-landed on the planet. We were far from home. The spaceship could not be repaired, and the rescue beacon had failed. Besides me, only the astrogator, part of the captain, and the ship’s AI mind were left. 

Outside, the atmosphere registered as hostile to most organisms. We huddled in the lifeboat, which was inoperable but still held air. Vast storms buffeted our cockleshell shelter, although we knew from prior readings that other areas remained calm. All that remained to us was to explore, if we wanted to live. The captain gave me the sole weapon. She tasked the astrogator with carrying some tools that would not unduly weigh him down.

Little existed on the planet except deserts of snow. But alien artifacts lay in an area near us. We were an exploration team, so this discovery had oddly comforted us, even though we had been on our way elsewhere. The massive systems failure had no discernible source, and the planet had been our only choice for landfall.

The artifacts took the form of 13 domes, spread out over that hostile terrain. The domes had been linked by cables just below shoulder level, threaded through the tops of metal posts at irregular intervals. Whether intended or not, these cables and rods formed a series of paths between the domes. 

Before our instruments failed, the AI had reported that the domes appeared to have a heat signature. The cables pulsed under our grip in a way that teased promised warmth far ahead. It took some time to get used to the feeling.

The shortest path between domes was a thousand miles long. The longest path was 10 thousand miles long. Our suit technology was good: A suit could recycle water, generate food, create oxygen. It could push us into various states of near hibernation while motors in the legs drove us forward. For the captain, the suit would compensate for having lost her legs and ease her pain. We estimated we could reach the nearest path and follow it to the nearest dome … and that was it. If the dome had life support capabilities, or even just a way to replenish our suits, we would live. Otherwise, we would probably die.

We revised the estimate of our survival downward when we reached the path and soon encountered the skeletons of dead astronauts littering the way. In all shapes and sizes, cocooned within their suits. Their huddled forms under the snow displayed a serenity at odds with their fate. But when I wiped the frost from face plates, we saw the extremity of their suffering.

It is difficult to explain how we felt walking among so many fatalities. So many dead first contacts. 

We no longer had to puzzle over the systems failure. Spaceships came here to crash, and intelligent entities came here to die, for whatever reason. We could not presume our fate would be any different, and adjusted our expectations accordingly. The AI’s platitudes about courage did not raise morale. There were too many lost there in the frozen wastes. 

Here were the ghastly emissaries of hundreds of spacefaring species we had never before encountered.

The number of the bodies and their haphazard positioning hampered our ability to make progress to the dome. The AI estimated our chances of survival at below 50% for the first time. We would starve in our suits as the motors propelled us forward. We would become desiccated and exist in an elongation of our thoughts that made us weak and stupid until the light winked out. But still, we had no choice. So even in places where the dead in their suits were piled high, we would simply plunge forward, over and through them, headed for the dome. 

What we would find there, as I have said, we did not know. But we were in an area of the galaxy where ancient civilizations had died out millions of years ago. We had been on our way to a major site, an ancient city on a moon with no atmosphere in a wilderness of stars. 

Although our emotions fluctuated, a professional awe and curiosity about the dead eventually came over us. This created much debate over the comms. We had made a discovery for the ages, but our satisfaction was bittersweet. Even if we lived longer than expected, we would never return home, never see our friends or family again. The AI might continue on after we were dead, but I doubt it envied being the one to report on our discovery centuries hence. And to who?

Here were the ghastly emissaries of hundreds of spacefaring species we had never before encountered. Their suits displayed an extraordinary range, although our examination was cursory. Some even appeared to be made out of scales and other biological substances from their home worlds, giving us further clues as to their origins. 

The burial of the suits by snow and the lack of access to anything other than a screaming face or faces, often distorted by time and ice, worked against recording much usable data. This issue was compounded in those cases where the suit was part of the organism and they had not needed any “artificial skin,” as the AI put it, to survive harsh conditions. That many had died despite appearing well-­prepared for the planet’s environment sobered us up even before our own suits dispensed drugs to help our mental states. 

After a time, each face seemed to express some aspect of our own stress and terror at the seriousness of our situation. After a time, the sheer welter of detail defeated us and caused us extreme distress. The captain made the observation that even one instance of alien contact might cause physiological and mental conditions, including anxiety, stress, fatigue. Here, we were constantly encountering the alien dead of what seemed at times an infinite number of civilizations. 

We stopped recording. We recommitted ourselves to the slog toward the nearest dome. 

The captain’s drugs unit had failed, but the AI found a way to help her by turning off the heating element in select panels of her suit. Some parts of her would soon be lost to the cold, but the system would allow her to live on with some measure of comfort.

I must admit, we were just glad the screaming had stopped and welcomed her counsel.


II.

For a long time, as we labored in our spacesuits on that planet—following the path, beleaguered by snowstorms—we could not understand why we found so many dead astronauts, of so many unknown alien types, and yet no spaceships. During good visibility, our line of sight reached, unbroken, for 500 miles. Where were the crash sites? 

But one day we chanced upon an antenna sticking up out of the ground. Clumsy attempts at excavation soon revealed that below this antenna lay a vast dead spaceship of a kind we had never seen before. The gash that had opened it to the elements had laid bare its unique architecture, but also gave the illusion that the snow had spilled out of it to create the world around us rather than having infiltrated and accumulated inside over time.

Aspects of the spaceship’s texture gave the startling suggestion that it had been made of some ultra-hard wood or wood equivalent. Clambering partway up to stare at the inner compartments, we all felt the strangeness of the dimensions and proportions of the living quarters. There was no sign of the occupants. Perhaps, I suggested, they had headed for the domes. Perhaps they had even made it to the domes. I tried and failed to keep hope from my voice.

But the captain had ordered the AI to perform a materials analysis. The “snow” in this region had been contaminated by ash and tiny particles of bone. The AI estimated that more than 70% of the white surrounding us was made of the remains of vertebrate sentient life and the remnants of suits. Of invertebrates there was no telling. A thaw might bring not just the drip, drip of water but a shushing sound indicative of bone particulate in the mixture. I imagined there might even be the clink of small objects not rendered down by whatever intense heat had created the ash.

The astrogator had insisted on digging deeper into the ship, with the idea that some recognizable commonality between technologies might yield a part or parts with which he could fix our ship. The rest of us allowed this delusion for the obvious reasons. But upon his return, he held in his hands ovals of snow not much larger than the space formed by the circle between a thumb and finger. Many of them had soft indentations, as one might find in the afterbirth of reptiles from eggs. A kind of ghostly cilia-like tread appeared along the bottoms of these objects.

The astrogator did not find any technology of use to us. Instead, he discovered that the species piloting the spaceship had been so different from us as to be safely encapsuled in suits the size of eggs. Much of what had spilled into or spilled out of the gash constituted the bodies of the crew, in their hundreds of thousands. Their suits had been inadequate to the conditions. They had died en masse attempting to escape their own ship.

The AI speculated that it had been a generation ship, perhaps fleeing a planet with a dying star. If we wondered how the AI had reached this conclusion, it was because we did not want it to be true.

The captain became silent upon receiving this further news and did not speak to us for more than 100 miles of further progress. 

As we left that site, unsure exactly what we stepped upon, we also knew that since the spaceship was entirely covered by snow, it had been falling into the sediment for days or months or years. We knew then that our ship might not be visible against the horizon should we retrace our steps. The already bleak probability of rescue through visual identification of a crash site from above would be lost to us in time, even as the line of cables remained perpetually visible to the horizon. We now thought of the planet as a trap. But of what sort? 


III.

We could not be sure, but in the absence of the captain’s voice, it may have been the AI that put forward the idea of the planet’s being “duplicitous.” The phrasing concerned us, for there was a duplicity in using the planet as the subject of the spoken sentence. A sphere rotating around a sun in deep space could not exhibit forethought or premeditation or other qualities of sentience. 

The AI meant whoever or whatever had created the conditions on the planet that allowed spacecraft to be trapped and then the occupants placed in a perilous situation with no recourse. But I distinctly recall the AI using the words “the planet.” In addition to being inaccurate, this also let us know that the AI did not have any analysis available that might help us understand the agency and motivations acting upon us. 

But in a sense, the AI only voiced something I had felt for several miles: that there existed an overlay to the planet’s surface, an area or space or different landscape unavailable to us. This overlay had also not been available to any of the prior astronauts who had died here. In this area or space or different landscape existed a wealth of the usual hoped-for things: a breathable atmosphere and abundant food and water. 

While we struggled with the line through the snow and through the storms that welled up, others could see us but chose to ignore us for reasons or perhaps just for their own well-being. For hundreds, possibly thousands of years, as explorers had died here in merciless and terrible ways, there raged a sumptuous feast for the senses, as excessive as it was ancient and unending.

I cannot tell you how powerfully the AI’s words struck us, so that our mouths watered at the thought of real food and of clean, unrecycled water, of a freedom unencumbered by suits and breathing apparatus. Even at our intended destination, we would have spent most of our days aboard a small space station. This tedium would have been broken only by the arduous process of reaching the unbreathable surface and its ancient ruins of jagged black stone. 

This vision that overtook us functioned not just as tantalizing delusion. It scared us so much that we could not compartmentalize it in our thoughts. It continued to overwhelm us like a wave.

We fought for the first time, with the astrogator expressing the wish to return to the ruined spacecraft and explore nearby areas for parts, while the captain broke silence to order us to continue to make progress toward the nearest dome. The AI, which had brought us to this point, stole the captain’s silence and said no more.

For each of us, those endless white plains with no real elevation, just the metal rope and the metal posts, had become a kind of repetition that hurt the brain, and the mind with it.

As I looked out across the white, I could not help seeing the impression of shapes in the wind, as if invisible entities fled by, carried there by gusts, unable to get purchase, swept up for hundreds and hundreds of miles before being dashed to the ground.

We did not give up, however.


IV.

About halfway to the nearest dome, amid a storm that reduced our progress incrementally and our line of sight to nothing, we came upon a peculiar tableau. 

Six astronaut suits had fallen across and around the metal rope. With the flurries of snow, it took us, even with our powerful headlamps, some minutes to determine the nature of the obstruction. The six suits had been created for a humanoid species that must have had torsos like nine-foot-long slabs, attached to six limbs, three for walking. Their heads had flared out like thick fans. All the helmets were cracked open, and curled inside were the skeletons of some other intelligent species no larger than 40 or 50 pounds, possibly warm-blooded. With no sign of the original occupants. 

After a brief analysis cut short by the conditions, we postulated that the warm-blooded species had worn breathable skin suits that, as they failed, required these intruders to seek shelter. All they could find were these six dead astronauts. Because we could discover no trace of the original occupants, the AI put forward the theory that this smaller species had eaten every scrap of the remains within the suits. 

Then they too had perished, and in time, the AI suggested, something smaller would take up residence inside those bodies, then smaller still within those, and smaller still—

At this point, the captain attempted a soft reboot of the AI using a coded question. We could hear the concern in her voice.

Yet the AI continued undeterred, suggesting that we might find this to be a common situation. It might be replicated across the planet, depending on a system’s ability to break down and process meat that had not evolved alongside the devourer for millions of years. In all likelihood, most who attempted to eat in this way died soon after, poisoned by alien flesh.

The astrogator had taken to muttering inside his suit, off comms, as if he no longer thought we functioned as a team. No amount of castigation from the captain served to change his mind.

In the terse harshness of the captain’s reprimand, I recognized that her pain levels had spiked once again.


V.

The AI began to talk to us in strange alien voices at mile 700, as we labored through the snowstorm to hold onto the cables and thus the path. The AI warbled and chirped and howled and hummed and clucked. The AI spoke in voices like fossilized choruses of beasts, vast and harmonious. And in voices like dry grass spun to fire by the sun. And in voices like the dissolution of all things, darkness in the blinding white that scared me. 

At first we thought the AI was deranged. Then that the AI channeled voices from the dome 300 miles ahead. But finally, the AI managed to make known to us that these were the voices of the dead astronauts we had come across from time to time. Huddled frozen. The suits in so many shapes and sizes. That the voices of the dead were channeled through the AI, and nothing could stop them.

We chose to believe that the AI had begun to malfunction. We did not waste time with a response. The captain asked the AI to perform self-shutdown and whispered the numbers in the correct sequence. We knew what we lost with this act, and yet we knew if we did not shut down the AI it might become harmful to us beyond the mental distress of what it had just conveyed to us.

Soon after, the AI gave up its own voice, and all that came from it were the sounds of the others. 

A little later, the AI no longer spoke at all.


VI.

The snow began to betray us, as the storms created different forms of ice. Often, our arms became weary, our legs cramping, and we had to rest with greater frequency. We came to accept the solid crunch that could support our weight. We came to reject the feather-light freshness that felt effortless underfoot but could give way just as easily as if it were air. In some places, slick purple-hued ice welled up in sluggish layers as if something half-alive. In others, we discovered strange islands of elevation, with brutal curls and curves that suggested two continental shelves had clashed in that space.

As we adapted to these conditions, and as conditions worsened and still we adapted, we came to feel an illusion of competency, one that made even the astrogator temporarily cheerful. The sounds through the comms of our efforts, the deeper breathing, the occasional muffled curse, seduced us in this regard. We felt that we were becoming adroit at handling the snow. We began to believe if we could only make it to the dome, we would be saved.

Yet this uptick in morale ran parallel to, rather than intersected with, the idea of our ultimate survival.


VII.

We lost track of the distance left to us without the AI to tell us. Or the captain, in her pain, no longer thought to issue updates. But across the distance left to us came sights beyond reckoning: three giant astronauts spaced 50 miles apart. Larger than most starships, each body lay sprawled across an area larger than several fields and in very different conditions.

The first had been badly burned and was thus unrecoverable, even in terms of salvage. The astronaut had crawled or pulled itself along for some distance. It had left a long smudge of black and red across that expanse. The alien species was, as ever, unknown to us, but the five arms were sunk in the ground as if in agony. The skull had once held three eyes, and the face plate had been cracked by force so strong it resembled a meteor strike. The body was bloated, the fabric of the suit gray with a shimmer of green that came and went, linked to photosensitive skin cells. The way the flesh took up space, and how it exhibited aspects more plant than animal, made it impossible to study further.

The second was a sprawl of limbs, with the suggestion of a defensive posture. The debris of conflict flared out to the side in an incomprehensible display. The suit had an intactness that surprised us, but a similar crack in the face plate without any trace of body within. The rest of the suit had become inhabited by a wealth of other dead astronauts of varying sizes and shapes, who had sought shelter or sustenance and then become trapped or simply … given up. As the AI had predicted, we had once again encountered bodies providing other bodies with temporary sustenance and shelter.

I felt like a parasite who beheld a god. Or was the scale even more ludicrous?

But this condition was not at first evident to us, becoming apparent only after we had clambered for an hour to reach the cracked face plate and the entry hole extended like a broken archway before us.

Despite the number of remains within, and the difficulty in moving through them to explore, the captain ordered an exhaustive recon. Her pulse in the readings had a thready quality. Sometimes I felt, and the astrogator too when we took private comms, that the captain had begun to say things similar to the AI’s delusions. Yet we obeyed the order, on the chance that some internal calculation on the captain’s part meant she believed this was the only way we would survive. 

What did we expect to find in the dead body of a once-­intelligent giant? Food? Oxygen? Some cause of death? To put off the thought of our own death by seeking shelter with a death so large we could not comprehend it?

I felt like a parasite who beheld a god. Or was the scale even more ludicrous? I had trouble envisioning the way the body must have twisted as it pitched forward into that icy ground. I had trouble holding onto my own thoughts.

More and more pressure moved through my skull as I contemplated that scene. We were in the midst of something none of my kind had ever known. We might be the only ones, ever. I better understood the unraveling of the AI and of the captain. My sharpness had dulled, taking my calm with it.

It was impossible to tell how long the astronaut had taken to die. Unless somewhere within that fallen figure some hint of life hid that we would never find.

The storms fell away, rose, then fell away again. 


VIII.

The third huge astronaut was full of light and life and shone out across the wasteland of snow like a beacon. For a moment, I thought we had pierced the invisible layer and could see what lay beyond the veil. We would have comforts beyond anything found on our ruined spaceship even when it had been fit to cross galactic space. There would not be recycled urine for our water. There would not be the faint stink of sweat creeping into our suits as the ventilation system began to fail. Our liquid food would not taste stale and moldy. 

As we approached, the suit extended almost to the horizon in that foreshortened perspective created by the left foot. We noted through our remaining instrumentation that the suit remained intact. The pressure told us a kind of air circulated within its sealed surfaces. 

We climbed with a renewed energy, the promise of sanctuary so close making us giddy. We each exhorted the others on with such exuberance that it made me a little afraid. What lay on the other side of this state of mind but a fall?

When we reached the helmet plate, we could see inside not a face or a skull, but instead such a richness of healthy growth that we fell silent before it. None of us could, I believe, understand exactly what we saw, except that it equaled ecosystem—resplendent with vibrant greens and blues, stippled with other colors. There might be some parallel to a terrarium full of moss and exotic plants. There might be some sense of life moving amongst those plants, as of jewel-like amphibians or even tiny shy sapphire birds. We could not smell or taste or hear what lay behind the face plate. We could not experience it in that way, but somehow we each imagined enough to be calmed and comforted by it. 

The astrogator said he might be able to create a hole in the plate or elsewhere on the body to let us in, and then patch the surface such that not too much air or vitality would spill out. This workaround might take an hour or two, due to the delicate nature of what we saw within. But it was possible.

The captain considered the astrogator’s proposal and then agreed. The weather had begun to turn dangerous again. That we should begin immediately did not need to be said. With the proper pressure brought to bear, we would have some measure of sanctuary from which to recover for a final push to the dome. It could be the difference between life and death, the astrogator said. If the atmosphere was breathable, we might even be able to give the captain some better solution to her pain.

I unclipped the astrogator’s equipment from his waist and threw it off the mountain that was the astronaut and watched it sail through the air and into the snow. Then I used my weapon to fry it where it lay. Then I threw my weapon into the snow, too, in a place where the featheriness would cover it and hide it forever. 

We were a team and I had helped my team while showing them I posed no threat—although I knew the astrogator and the captain would not see it that way. I stood there on the face plate that we could no longer open with the diminished tools at our disposal as they both yelled at me through the comms. It’s unimportant what they said to me. They were admonishing me for something that had already happened and that they had no power to stop. I did not bother to explain, but began to make the descent to the ground so we could once again take up the metal rope and make for the dome.

Will you follow, I asked them from the ground, when I saw they still stood on the heights. There came no reply, but when they saw me take up the rope, they climbed down to take up the rope too.

I waited then, and let them catch up.


IX.

The captain died not long after. The pain was too great or the wounds she had suffered too damaging. I had known for some time she would never make it to the dome, but there was no point in emphasizing that to her. Nothing she had done until the end had required her to be removed from command. Her last words were the name of our ship and giving her love to someone who would be dead of old age even if we found a way to escape this place and return home. But the astrogator told her he would carry those words forward. 

Then we left her by the marker that meant we had 100 miles left to the dome. We knew the snow would cover her for burial. It had done so faithfully for all the rest.

That in that frozen hellscape, the persistence of life in that manner, an oasis in the midst of nothing, could be categorized as a miracle.

As the astrogator followed me down the rope line, he cried out for explanation. The captain’s death required it for some reason, in his mind. The captain had not deserved my betrayal. The captain would not rest easy until I told him why. 

You must believe in ghosts, I replied.

ROGAN BROWN

This reply incensed him and he castigated me in words not used among members of a team that respect each other. Once more, I ignored him, but told him if our oxygen got low, he could have mine if we calculated he could make it to the base. I meant this, as I knew the odds were low anyway. I had hurt my knee taking the equipment from the astrogator and then making my way so rapidly down from the dead astronaut.

The astrogator did not reply, by which I knew he did not accept my answer.

The reason I took the tools and destroyed them is because the wind had told me something it had not whispered to the captain or the astrogator. The wind had not spoken to me before, so I believed what it told me. That the astronaut within the suit lived on, if unable to move. That what we saw on the outside and registered as ecosystem, as separate “plants” and “animals,” instead formed a composite life-form and that to crack open the suit or cut through the suit at a leg would have been a violation.

That in that frozen hellscape, the persistence of life in that manner, an oasis in the midst of nothing, could be categorized as a miracle. 

I would not snuff that out. I could not allow that to be snuffed out. But I remembered too how I felt looking at that vast and alien country behind the face plate. So calm, so comforted, overcome by the depths of an emotion I could not place. Would I replace that feeling with the feeling of seeing all those explorers dead within the other vast suit? Even as I become one of them? 

Because the planet had already told us the rules, the consequences, and the ultimate outcome. There are no odds so terrible that they could not be experienced, and in dozens of ways, in this place. 

So I trudged on and the astrogator cursed me and cursed me and called out my childhood and how badly I must have been brought up and how I must have cheated to pass the psych exams, and yet I had thought the same of him at various points during our journey.

See how beautiful the snow is, falling now, I said to him over the comms. See how precise and geometric this line we follow across this expanse. 

He did not reply, but a little later he told me he no longer believed in the line at all, and by his calculations he would get to the dome faster if he abandoned it and struck out on his own.

I could not stop the astrogator and did not want to, so I watched him become a smaller and smaller figure against the white until the white ate him up and I was alone.


X.

I have been walking a long time, visiting with the dead. Here, against an arch of heaven that appears no different than what I see directly in front of me. 

Jeff VanderMeer is the author of the critically acclaimed, bestselling Southern Reach series, translated into 38 languages. His short fiction has appeared in Vulture, Slate, New York Magazine, Black Clock, Interzone, American Fantastic Tales (Library of America), and many others.

In Memoriam: Edna B. Foa, PhD

Dr. Edna Foa served for decades as a professor of clinical psychology in psychiatry at the University of Pennsylvania, where she also directed the Center for the Treatment and Study of Anxiety (CTSA), the internationally renowned program she founded in 1979. Through the CTSA, Edna created not only a hub for groundbreaking research, but also a training ground that would shape the future of evidence-based treatment for anxiety, obsessive compulsive disorder (OCD), and post-traumatic stress disorder (PTSD).

Foa_Edna

At a time when OCD was poorly understood and often ineffectively treated, Edna helped establish and rigorously validate exposure and response prevention (ERP) as a gold-standard intervention. Building on the early behavioral work of pioneers before her, she brought a level of empirical precision, clinical sophistication, and dissemination that transformed ERP from a promising approach into a cornerstone of modern treatment. In doing so, she fundamentally changed what recovery could look like for millions of people living with OCD.

Her influence extended well beyond OCD. Dr. Foa was also a central figure in the development of cognitive-behavioral models and treatments for PTSD, including prolonged exposure therapy, which has become one of the most widely used and effective interventions for trauma-related disorders. Across both domains, her work exemplified a rare integration of theory, research, and clinical application—always grounded in a singular goal: to reduce suffering and restore lives.

Her connection to the International OCD Foundation (IOCDF) was a natural extension of her commitment to bridging science and real-world impact. Edna was deeply engaged with the IOCDF community over many years, contributing to its mission of improving access to effective treatment and advancing understanding of OCD. The Foundation awarded her with the Outstanding Career Achievement Award in 2011. She was a frequent presence at conferences, where she not only shared her research but also helped elevate the standards of clinical care through teaching, mentorship, and collaboration.

The IOCDF’s growth into a global leader in OCD advocacy, education, and training reflects, in many ways, the scientific foundation that Edna helped build. Her work made it possible for organizations like the IOCDF to promote treatments that are not only evidence-based, but truly life-changing. And through her direct involvement, she helped ensure that the connection between research and practice remained strong, dynamic, and accessible.

Edna Foa showed us what it means to dedicate a life to advancing knowledge in the service of humanity. She illuminated a path forward for so many, and her influence will continue to guide the field for generations to come.

Below are several tributes to Dr. Foa from IOCDF community members.

From Jonathan Grayson, PhD

My mentor, Tom Borkovec, used to talk about our psychological lineage; that in 1979, you only had to go back a few generations of your “forefathers” to reach the founders of American psychology. In this respect, Tom is my psychology father – he taught me to discipline my thinking – he encouraged wild flights of speculation, but to always temper it in print with what could be researched and proved. With this in mind, Edna is my psychology mother. As I noted elsewhere, for all of us who work with OCD, we are her children, grandchildren and so on.

I first met Edna  in 1979 at Joseph Wolpe’s Behavior Therapy Unit at Temple University. She hired me as an adjunct research assistant professor. This was in the ancient days at the height of the first wave. There was no cognitive behavioral therapy. ABCT was AABT, American Association of Behavior Therapy. The disorder we were studying was OC, the DSM labeling it obsessive compulsive disorder doesn’t yet exist. Edna was on the first of her landmark OC grants.

She was the flashpoint for all that we do with OCD.  Don’t get me wrong, she didn’t invent ERP, but her work was/is the basis of all OCD treatment today. In the same way that cognitive therapy techniques existed before Aaron Beck, but his work was the flashpoint of that second wave; and the techniques of ACT pre-exist Stephen Hayes, but his work and thinking were the flashpoint of the third wave. There was no OC Foundation.

I joined Edna and Gail Steketee and to work with Edna was always a collaboration. So many hours of discussing, designing and analyzing research. Writing papers together often until midnight and beyond. You may have heard that Edna was demanding.  She was, but that had nothing to do with the hours we worked.  The same clinical skills she used with patients, she used in choosing those who worked with her. We were all driven. There are those who found her direct delivery difficult, but it wasn’t anger or belittling, it wasn’t intimidating (okay, maybe a little), she was simply direct without sugar coating. The truth about Edna was that she was caring and very generous.

As I said, our research was a collaboration and the order of authors on publications reflected our contributions. If you had a research idea that was tangential to her main projects, she would support you.  When I told her I thought we should have support groups to help sufferers maintain their gains, I was given a free hand to develop and run GOAL as I saw fit. When my son was nine months old and I told Edna that I was going to change my work hours to: one and a half daytime hours and the rest of my hours after 4 pm, she accepted this. She didn’t have to admonish me or warn me to do my job, Edna knew the kind of people she had chosen.  She wanted the people who worked with her to grow. When it came time for me to move on, she was like any parent, sorry for me to go, but happy for me to pursue my life.  She was like that with all of us.  So many of those who have shaped the OCD world worked with Edna.  While I was there, Michael Kozak joined the team and later Edna and Michael published their ground breaking paper on emotional processing. Alec Pollard, Charly Mansueto and Rich McNally also passed through our center. Marty Franklin and Jon Abramowitz came after me making up the many generations of her “children.”

For those whom I’ve neglected to mention, forgive me, but the list is too long. My OCD career began in 1979. Her loss is a hole in the fabric of reality, but her legacy and wisdom lives on through all of us whose OCD psychological lineage can be traced back to Edna Foa.

From Marty Franklin, PhD

I am writing this tribute while waiting at an airport gate for a flight to a national conference. Over the course of the next few days I will have the opportunity to present applied research data, participate in a clinical roundtable about OCD and its treatment, & engage with colleagues as we toss around ideas for how best to move the field forward. Edna’s profound influence on my career, my life, and even my thinking is most often accessible during relatively quiet moments like this, where opportunities for reflection make their way forward amidst the work I have committed to myself to doing.  Indeed, I learned of Edna’s passing a few weeks ago while right in the middle of presenting a clinical training about exposure-based treatments for OCD. I paused for a moment to take it all in, but before I could decide how best to proceed under the circumstances, I heard Edna’s voice, in her characteristic and unmistakable Israeli accent, telling me that these clinicians took time out of their busy schedules to receive this training, and therefore I must continue straight through to the end. My feelings?  You can process those later. Classic Edna.

My very first day of internship in 1991 at the Medical College of Pennsylvania was spent in Edna’s presence at her Center for the Treatment and Study of Anxiety, the unit she established in 1979 to develop, test, and disseminate cognitive-behavioral interventions for anxiety and related conditions. Edna’s work even by then was highly influential, and her legend was already well in the making.  At that initial meeting, Edna slid a formidable stack of old-school medical charts across the table to me and said, “Marty, is it?  These are your OCD cases for this rotation.” I thanked her, then asked the first of myriad naïve questions in the legendary Tuesday Meetings:  “When will I receive the training to treat these cases?” She pivoted back to look at Michael Kozak, her Clinical Director, as if to wax nostalgic about the process of indoctrinating yet another green intern. Edna then gestured at the pile, and said, “The training is in there.” Edna was a fine clinician too, and thus read well my horrified expression, then offered, “But don’t worry: we’ll help you.” True to her word, she did exactly that.

Edna’s influence on the field broadly speaking, on the development and expansion of cognitive-behavioral theory, on using clinical science to alleviate human suffering, and in pushing the proverbial envelope, has been chronicled elsewhere and cannot ever be overstated. Edna was one of the true pillars of clinical psychology, and the effects of her work will live on in perpetuity, of that I have little doubt. What was less well known except for those of us fortunate enough to have been mentored by Edna was the incredible amount of time and emotional investment she made in seeding the field with the next generation of theorists, scholars, and clinicians who would carry that work forward in the years to come. I count myself in that incredibly lucky group, all of whom were blessed by her personal investment in our training and careers. Edna had exacting standards for herself and for us, and fully expected that same level of investment and intensity on our part. Vigorous debate was just part of the process, where occasionally the fur would fly. But Edna also knew us well enough to understand what each of us needed in order to help us make the commitment needed to join her in the vanguard. In one of our many career development conversations back in the mid 1990s, likely in her East Falls office well after 8 pm, I was fretting about the “soft money” environment of academic psychiatry, and openly wondering if it was time to pivot to hard-line academic psychology or even to private practice. Edna stopped my rumination dead in its tracks, looked into the depths of my soul (which she did regularly), and said, “It’s only soft money if you can’t get it…and I know you can get it. Plus, academia is a really fun way to make a living, and a life.” Edna Foa believed in me:  it was about damn time to believe in myself as well, and to make the commitment required to honor that belief. And to always keep pushing to get better at the work, which is truly a never-ending process.

Sitting in this airport now, on my way to give another set of talks on topics I have come to know very well and continue to pursue with the passion that comes from also believing that this work is vital, I concur with Edna’s assessment of academia, and am truly grateful that I listened. Thank you, Edna, for illuminating a path forward for me, as I know you did for countless others. You were unforgettable, and your work will continue on in the hands of those you mentored and trained to carry on the legacy.

From Gail Steketee, PhD, MSW

I had the pleasure and helpful educational challenge of training under Dr. Edna Foa beginning in 1976 and continuing for a decade during which I worked closely with her studying OCD and co-authoring manuscripts and federal grant applications.  Edna generously provided me with excellent clinical supervision during my training at the Behavior Therapy Unit at Temple University where I learned how to treat phobias, agoraphobia and panic, and especially OCD.  Edna’s encouragement and specific feedback guided my understanding of patients and how to provide effective treatment.  Her supervision coincided with the end of her important early study of the impact of exposure and response prevention, following in the steps of Victor Meyer, Isaac Marks, and Jack Rachman. I treated the last few patients with OCD in her study and co-authored a case report stemming from that work – my first published paper in the field in 1977.

Edna opened many doors for me to join colleagues around the world who were studying OCD and behavioral treatment methods. Together we wrote and published 26 papers and 14 book chapters.  And I mean “together”.  We would schedule writing times during which Edna generated ideas and spoke aloud in her heavily accented Israeli English while I contributed my thoughts and sharpened the language as we went along. Grant applications were a special challenge as NIMH became strict about page limits.  More than once we stayed up all night writing grants to meet the deadline – we were both younger then – and once we actually drove to Bethesda to deliver a grant application just in time for the deadline.  I joined Edna at many conferences in the U.S. (especially AABT [now ABCT] and OCF [now IOCDF]) and in Europe at EABCT and WCBCT (the World Congress of CBT). We met many delightful OCD researchers and clinicians – it was an exhilarating time.  I traveled with Edna and friends to her home country of Israel where she treated us to delightful sights and experiences including the Dead Sea.

The 10 year period with Edna was a heady time as my career unfolded. She supported my decision to get a PhD in social work at Bryn Mawr while working full time with her on our research. Eventually, I left Temple to take a full-time faculty position at Boston University, arriving with a strong publication record already in hand thanks to Edna’s masterful training and modeling of how to design and conduct research, how to write papers that accurately reflected the study and its findings, how to write strong grant applications, and how to connect with energizing colleagues around the world.  I am grateful for her mentoring that enabled me to establish my own career and become a mentor to others.  She was a brilliant theoretician who spawned impressive thinking and research on OCD, PTSD, behavior therapy, and related topics.  Hers was a long and full life.  She will be sorely missed.

The post In Memoriam: Edna B. Foa, PhD appeared first on International OCD Foundation.

Chasing the Zero That Matters

Mary Royal almost skipped her mammogram.

At 51, the mother of four from Wichita Falls, Texas, was busy,

Mary Royal,
Mary Royal, Patient

tired, and juggling the overlapping demands of work, family, and everyday life. The appointment felt routine—easy to reschedule and easy to dismiss. In a decision that would change everything, she went.

In 2023, Royal was diagnosed with stage 2B multicentric invasive lobular and ductal carcinoma. What followed was a cascade familiar to many cancer patients but deeply personal in its toll: a double bilateral mastectomy, months of chemotherapy and radiation, and the discovery of a nodule in her chest cavity. Another scan later revealed a mass on her ovary, prompting a preventative radical hysterectomy. By the end of the year, Royal had endured positron emission tomography (PET) scans, injections, fasting, and what she called “all that nuclear medicine.”

For many patients, completing treatment is supposed to signal relief. In reality, it often marks the beginning of a new phase—one defined by uncertainty. Surveillance imaging, blood tests, and follow-up visits can feel like checkpoints in an endless waiting game. Every scan carries both hope and fear.

Royal knows this phase well. Like many survivors, she lives with what patients and clinicians call scan anxiety. “I’ve never met a person diagnosed with cancer who did not live with scan anxiety,” she said.

That anxiety eventually led her to consider a different way of monitoring her disease—one that looks not for tumors large enough to be seen on a scan, but for microscopic traces of cancer that may remain in the body after treatment. These traces are known as measurable, or minimal, residual disease (MRD).

MRD basics

MRD refers to the small number of cancer cells that can persist after treatment, even when imaging and conventional tests show no evidence of disease. These cells are often invisible to computed tomography (CT), magnetic resonance imaging (MRI), or PET scans, yet they can drive relapse months or years later.

Historically, MRD testing has been best established in hematologic malignancies such as leukemia, lymphoma, and multiple myeloma. In these diseases, molecular and flow-based techniques can detect one malignant cell among tens of thousands, or even millions, of normal cells. In solid tumors, however, detecting MRD has been far more challenging. That is now changing.

Advances in liquid biopsy technologies allow researchers to analyze circulating tumor DNA (ctDNA): tiny fragments of DNA shed by cancer cells into the bloodstream. With increasingly sensitive assays, it is now possible to detect residual disease at levels far below what imaging can reveal.

MRD matters because cancer recurrence is often a race against time. The earlier residual disease is detected, the greater the opportunity to intervene—whether by intensifying therapy, switching treatments, or, in some cases, sparing patients from unnecessary additional therapy if no disease is detected.

Regulators are taking note. In January 2026, the U.S. Food and Drug Administration (FDA) issued draft guidance supporting the use of MRD negativity as an endpoint in clinical trials for multiple myeloma. The move signaled growing confidence in MRD as a meaningful surrogate for long-term outcomes, potentially accelerating clinical trials and access to new therapies.

Deciding to look closer

When Royal’s oncologist suggested the Personalis NeXT Personal® test, a blood-based MRD assay, her initial reaction was hesitation.

“I said, ‘Let me think about it,’” she recalled. As she researched the test online, her anxiety rose. “I thought, ‘No, thank you. I have had so much anxiety already.’”

Her husband disagreed. “You are insane,” he told her, “Why would you not want to do that?” Her oncologist offered a different perspective: “What is the point of science if we don’t use it?”

“That really resonated with me,” Royal said.

She agreed to the test and had her first ctDNA draw in early 2024. Since then, she has taken it 13 times.

“Seeing that zero in the results is a huge relief,” she said. “I really appreciate how much easier the test is on me, both mentally and physically. Now, I cannot believe anyone would say ‘no’ to this. It brings me so much comfort. And I want to know what to do next. I don’t want to just sit around waiting for something when I have the ability to see things early on.”

Her experience reflects a growing shift in survivorship—from episodic imaging to continuous molecular monitoring.

An ultrasensitive approach

For Richard Chen, MD, CMO at Personalis, the goal of ultrasensitive MRD testing has always been to address the uncertainty patients live with after treatment.

Richard Chen
Richard Chen, MD
Chief Medical Officer
Personalis

“Our NeXT Personal test pioneered ‘ultrasensitive MRD’ down to about one part per million of ctDNA, designed to be a leap forward in detecting very small traces of cancer from a blood sample earlier,” Chen said.

The test is tumor-informed, meaning that it begins with whole-genome sequencing of a patient’s tumor. From that data, up to approximately 1,800 tumor-specific mutations are identified to create a personalized molecular signature. Blood samples are then analyzed for that signature.

“The groundbreaking clinical data that we have published in lung and breast cancer shows that the ultrasensitive capabilities of NeXT Personal enable it to detect cancer many months to years ahead of imaging,” Chen said, “potentially allowing for earlier intervention and treatment of the patient.” Equally important, he added, is the reassurance that a highly sensitive negative result can provide.

Personalis is expanding MRD testing beyond simple detection. A new opt-in feature, the Real-Time Variant Tracker®, allows clinicians and patients to view potentially actionable mutations detected in ctDNA, including those associated with treatment resistance.

MRD testing is increasingly viewed not just as a prognostic tool, but as a way to actively guide care. Chen outlines three major applications: earlier detection of residual or recurrent disease; earlier de-escalation of therapy for patients who have cleared their cancer at a molecular level; and real-time monitoring of treatment response.

“Cancer is often a race against time,” he said. “If you can detect cancer that’s coming back much earlier than before, then you have the opportunity to intervene earlier with additional treatment for the patient.”

Adding biological precision

Sensitivity alone, however, is not the only challenge in MRD detection. Biological precision—understanding which cells persist and why—is equally important.

Zivjena Vucetic
Zivjena Vucetic, MD, PhD
Chief Medical Officer
Mission Bio

Zivjena Vucetic, MD, PhD, CMO at Mission Bio, points to the limitations of bulk sequencing approaches, which average signals across mixed-cell populations.

Mission Bio’s single-cell MRD assay simultaneously detects genetic mutations and surface protein expression across thousands of individual cells in acute myeloid leukemia. This approach reveals whether mutations coexist in the same cell and how they relate to cellular phenotypes.

“Our integrated single-cell approach provides a more biologically precise definition of measurable residual disease,” Vucetic said, which might improve risk stratification beyond conventional molecular or flow-based methods.

By identifying rare, therapy-resistant clones, single-cell MRD technologies offer insight into clonal evolution and emerging resistance. This information can guide treatment selection and drug development.

Decentralizing monitoring

Accessibility and turnaround time are also shaping the MRD landscape. For example, QIAGEN is advancing MRD monitoring by pairing tumor-informed assay design with decentralized digital polymerase chain reaction (dPCR), aiming to make longitudinal molecular monitoring faster, more accessible, and more informative for research and drug development.

In June 2025, QIAGEN announced a partnership with Tracer Biotechnologies to integrate Tracer’s tumor-informed assay design with QIAGEN’s QIAcuity dPCR platform. The approach begins with sequencing a patient’s tumor, often leveraging existing next-generation sequencing (NGS) data, to identify somatic mutations. Tracer then designs personalized multiplex dPCR assays to detect ctDNA carrying those mutations in blood samples.

Richard Watts
Richard Watts
Vice President
QIAGEN

Running these assays on QIAcuity enables absolute quantification of rare tumor-derived molecules by partitioning samples into thousands of reactions. According to Richard Watts, vice president of partnering for precision diagnostics at QIAGEN, “The result is a decentralized, high-frequency monitoring solution,” with turnaround times measured in hours to days rather than weeks. He noted that this model significantly reduces cost and logistical complexity compared with centralized NGS-based MRD testing while enabling earlier detection of molecular recurrence, often before radiographic changes are visible.

While currently intended for exploratory research use, the platform has clear implications for oncology drug development. By allowing assays to be run on standard dPCR instruments at clinical trial sites, sponsors can avoid centralized sample shipping, simplify global study design, and more rapidly generate data. Frequent sampling also provides detailed insight into tumor kinetics and treatment response, potentially enabling earlier assessments of drug activity.

Looking ahead, QIAGEN anticipates MRD evolving beyond detection toward biological characterization. Emerging single-cell technologies, supported by QIAGEN’s recent acquisition of Parse Biosciences, could reveal why residual disease persists by distinguishing resistant cell populations and non-genetic resistance mechanisms. Watts emphasized that future clinicians will not only ask whether MRD is present, but “why it persists and which pathways sustain it,” signaling a shift toward more precise, biology-driven intervention strategies.

The expanding ecosystem

Beyond ultrasensitive and single-cell approaches, a growing number of companies are contributing complementary technologies that are broadening how MRD is detected, characterized, and monitored across cancer types.

Twist Bioscience, for example, has developed scalable target enrichment solutions for MRD monitoring that support highly personalized approaches to disease surveillance. Its MRD Rapid 500 Panel enables fast design and manufacture of customized capture panels using silicon-based DNA synthesis. By offering panels that range from dozens to hundreds of tumor-specific probes and fast turnaround times, this approach allows researchers to assess adjuvant treatment response at a genomic level while remaining compatible with established NGS library preparation and hybrid capture workflows.

Whole-genome sequencing-based plasma assays are also playing an expanding role in solid tumor MRD detection. Labcorp offers a plasma-based assay for colorectal cancer that uses whole genome sequencing to identify ctDNA associated with MRD. This approach enables the detection of recurrence at a molecular level before clinical symptoms, biological markers, or radiographic evidence emerge, creating an opportunity for earlier and more proactive intervention.

In hematologic malignancies, ultrasensitive liquid biopsy platforms are demonstrating the ability to dramatically shorten the time required to detect residual disease. For instance, Foresight Diagnostics has developed a ctDNA-based MRD platform that achieves exceptionally high sensitivity across multiple cancers. In patients with large B-cell lymphoma, this approach can detect ctDNA immediately after treatment, rather than waiting for months or even years for disease recurrence to become apparent through PET or CT imaging.

Comprehensive NGS-based MRD solutions are also advancing in myeloid malignancies. Thermo Fisher Scientific offers an integrated research-use testing solution that combines highly sensitive DNA and RNA assays on a single sequencing platform. This enables the simultaneous assessment of single-nucleotide variants, insertions and deletions, and gene fusions alongside streamlined informatics and reporting designed to simplify MRD data interpretation in research settings.

Meanwhile, dPCR continues to play a crucial role in MRD monitoring, where absolute quantification and extreme sensitivity are required. Bio-Rad Laboratories has long supported droplet dPCR technologies that are well suited for tracking low-abundance disease markers. These capabilities are particularly valuable in both hematologic malignancies and solid tumors, where MRD signals in blood can be vanishingly small yet clinically meaningful.

Pre-analytical precision

As MRD assays push detection limits ever lower, pre-analytical steps such as sample collection and cell-free DNA (cfDNA) extraction become increasingly important.

Anagha Kadam
Anagha Kadam, PhD
Scientist, NEB

As one example, Anagha Kadam, PhD, applications and product development scientist at New England Biolabs (NEB), highlights how the Monarch Mag Cell-free DNA Extraction Kit addresses crucial challenges in liquid-biopsy workflows and MRD research.

This kit is a magnetic bead-based solution designed for the reproducible isolation of circulating cfDNA from biofluids like plasma, urine, and cerebrospinal fluid. “The kit can be used to isolate cfDNA for discovery and detection workflows, including ctDNA profiling, cancer biomarker discovery, and oncology diagnostics research,” Kadam explained. This technology efficiently recovers cfDNA fragments in the typical sizes of 150–300 base pairs, and even as small as 50 base pairs, while remaining compatible with common anticoagulant and preservative collection tubes. According to Kadam, “The silica-coated magnetic beads, combined with optimized buffer chemistry, help ensure maximum binding and recovery of cfDNA in manual or automation formats.”

Sensitivity and reproducibility are especially crucial for MRD applications. “A cfDNA isolation method that is compatible with different sample types, and that faithfully isolates cfDNA, is a key consideration when establishing MRD workflows,” Kadam noted. She added that the kit delivers “reproducible, high-quality cfDNA yields from different biofluid samples, without additional post-extraction cleanups,” enabling consistent fragment profiles while saving time. When integrated with NEB’s sequencing and amplification tools, the kit supports streamlined, end-to-end workflows for generating high-quality data from challenging clinical samples.

From waiting to watching

For Mary Royal, MRD testing has not eliminated uncertainty, but has transformed it.

Instead of waiting passively for scans, she feels engaged in her care. Instead of fearing every appointment, she has access to information that helps her understand what is happening inside her body in near real time.

“I want to know what to do next,” she said. “I don’t want to just sit around waiting for something when I have the ability to see things early on.”

As MRD technologies continue to mature, the desire to replace waiting with knowledge is becoming central to modern oncology. MRD is no longer just a research endpoint or laboratory metric. It is becoming a bridge between science and survivorship, offering patients, clinicians, and researchers a clearer signal in the noise of uncertainty.

And sometimes, that signal is a simple zero—small, powerful, and profoundly reassuring.

 

Mike May, PhD, is a freelance writer and editor with more than 30 years of experience. He earned an MS in biological engineering from the University of Connecticut and a PhD in neurobiology and behavior from Cornell University. He worked as an associate editor at American Scientist, and he is the author of more than 1,000 articles for clients that include GEN, Nature, Science, Scientific American, and many others. In addition, he served as the editorial director of many publications, including several Nature Outlooks and Scientific American Worldview.

The post Chasing the Zero That Matters appeared first on Inside Precision Medicine.

Strength of Evidence to Support Decision-Making on the Use of Digital Mental Health Technologies in NICE Evaluations: Cross-Sectional Analysis of Studies

Background: Digital mental health technologies (DMHTs) are playing an increasing role in mental health services. The quality of evidence for DMHTs is variable, and there are concerns that evidence is not sufficient to support decision-making. Objective: This study used a cross-sectional analysis of evidence supporting DMHTs included in National Institute for Health and Care Excellence (NICE) evaluations to examine the strength of evidence available for decision-making. Methods: We identified all NICE evaluations relating to DMHTs by reviewing details of published NICE evaluations on the NICE website. From each of these evaluations, we identified included DMHTs and reviewed committee documentation to identify studies that provided supporting evidence for each of these technologies. We extracted information on a series of items relating to study quality and summarized the characteristics of evidence both at the level of individual studies and across the package of evidence from multiple studies supporting DMHTs. We also identified key evidence gaps in available evidence. Results: We included nine NICE evaluations relating to anxiety, depression, psychosis, insomnia, attention deficit hyperactivity disorder (ADHD), and tic disorders. These evaluations included 30 DMHTs and referenced 78 supporting studies. We identified common evidence gaps relating to effectiveness compared to relevant comparators, use of appropriate outcomes, including health-related quality of life, cost of delivery, and impact on resource use, and reporting of adverse events. Conclusions: Our study highlights that some DMHTs have been supported by high-quality studies and that evidence to support DMHTs is likely to be developed across a series of studies. However, there are often key evidence gaps that need to be addressed to provide a stronger case for adoption. Developers should ensure that they consider these gaps while planning evidence generation, and where possible, address them earlier in the product lifecycle.
<img src="https://jmir-production.s3.us-east-2.amazonaws.com/thumbs/825f13db8cbad54213afa5c433d7adde" />

A Gamified Pain Management Intervention for Adults With Chronic Pain in Mainland China: Single-Arm Pre-Post Pilot Study With Machine Learning Predictive Modeling

Background: The widespread prevalence of chronic pain (CP) significantly impacts daily functioning worldwide. In mainland China, maintaining engagement in biopsychosocial interventions remains challenging. Gamification, designed based on self-determination theory, can enhance motivation, while machine learning (ML) algorithms can assist clinicians in dynamically optimizing pain management. Objective: This study aimed to (1) evaluate the preliminary effectiveness of a gamified pain management (GPM) program on CP and psychological outcomes and (2) identify key factors of significant pain improvements through the application of ML to guide intervention adjustments. Methods: A single-arm, pre-post study was conducted with 16 participants with CP in mainland China, recruited via social media using convenience sampling. Participants engaged in a 10-week web-based GPM intervention consisting of education, physical activities, and gamified elements, including points, avatars, and feedback. Primary outcomes were pain intensity and interference measured by the Brief Pain Inventory. Secondary outcomes included anxiety, depression, and quality of life. Analysis included paired tests, and ML models were trained to predict clinically meaningful pain reductions. Shapley additive explanations, least absolute shrinkage and selection operator regression, association rule mining, and Kaplan-Meier survival analysis were used to identify key predictors and optimal sessions and intervention durations across subgroups. Results: A total of 16 participants were engaged, with a mean age of 27.63 (SD 9.584) years. Results from paired tests reported significant improvements in pain intensity (decreased by 27.3%, 95% CI 1.061 to 3.064; =.001), pain interference (decreased by 27.3%, 95% CI 8.159-17.216; <.001), and psychological distress, including anxiety (=3.538, 95% CI 0.969 to 3.906; =.003) and depression (=4.559, 95% CI 2.230 to 6.145; <.001). The gradient boosting model demonstrated the highest predictive accuracy (area under the curve=0.89 and accuracy=0.82). Least absolute shrinkage and selection operator regression identified session 3 (β=−0.45, 95% CI −0.68 to −0.22; <.001) and session 5 (β=−0.32, 95% CI −0.59 to −0.05; =.02) as most predictive of clinical success, while association rule mining revealed effective session combinations for different patient subgroups. Time-to-event analyses indicated that individuals with low back pain and higher baseline severity required longer intervention durations for improvement (5 wk; =.03). Conclusions: This pilot study presents an innovative method that combines ML with dynamic engagement data from a GPM program during interventions, rather than relying on static baseline data in prior studies. The results show preliminary efficacy and identify specific optimal session combinations and personalized treatment durations for different pain subgroups. These exploratory findings contribute to the field by providing a data-driven method for adaptive, personalized digital health interventions that move beyond one-size-fits-all strategies, potentially enabling clinicians to modify content and dosage to improve engagement and outcomes if validated in larger sample trials. Trial Registration: Chinese Clinical Trial Registry ChiCTR2400094247; https://www.chictr.org.cn/showprojEN.html?proj=245138

The Unspoken Toll: Why Exam Pressure Must Be Part of the Youth Mental Health Discussion

A Conversation with Tatum Redmond and Amanda van der Vyver-Anderson from Community Keepers, South Africa


By Mai El Shoush, Partnerships Campaign Manager, Stavros Niarchos Foundation (SNF) Global Center for Child and Adolescent Mental Health at the Child Mind Institute


Community Keepers is an award-winning organization based in Stellenbosch, South Africa, which works to improve the social and emotional well-being of learners and their caregivers. The SNF Global Center at the Child Mind Institute works with the organization to further advance the comprehensive mission of transforming schools into safe spaces where student well-being is prioritized alongside academic achievement. This includes strengthening the workforce to expand evidence-based support and brief interventions through low-intensity psychological therapy approaches.

While addressing the workforce gaps, the partnership has yielded valuable insight into the essential competencies front line workers require to effectively support young people experiencing mental health challenges. Together with other NGOs, Community Keepers has also been instrumental in strengthening the process of developing context-sensitive and culturally appropriate training materials scheduled for pilot implementation in South Africa later this year – representing an important step towards strengthening mental health care systems for underserved communities. The partnership also extends beyond training development, as the SNF Global Center at the Child Mind Institute continues to collaborate closely with Community Keepers on an upcoming randomized control trial (RCT). The scientific evaluation will assess both the feasibility of establishing a virtual clinic for young people and the effectiveness of remotely delivered cognitive behavioral therapy (CBT) interventions via video consultations. The research is intended to expand access to equitable and quality mental health care for young people across South Africa. Tatum Redmond has been a care facilitator in one of the Community Keepers’ high school-based offices, while Amanda van der Vyver-Anderson is an educational psychologist and heads the training and development of Mental Health First Aiders for internal and external staff.

Amanda van der Vyver-Anderson

How important is it to approach issues such as academic pressure within the wider conversation around youth mental health in South Africa, and beyond?

It is critical to integrate discussions of exam stress into the broader dialogue surrounding youth mental health, both here in South Africa and internationally. We see countless students under immense pressure to not only pass, but also secure their future prospects and meet family expectations. This is unfortunately often dismissed as “just school” or a “normal” experience. However, it impacts a substantial number of young people, often more severely than we acknowledge. And the level of support available is not equitable across the board. Addressing this is crucial because of the detrimental effects on core cognitive functions — and ultimately, academic performance — as well as the significant toll on mental health. This can manifest as anxiety, burnout, and even depression.

In what ways can exam-related stress connect to broader mental health challenges?

While a certain level of stress can serve as a beneficial motivator, severe distress can lead to cognitive shutdown. This specifically impacts the executive functions — planning, organizing, prioritizing, working memory, focus, and concentration — that are fundamental to preparing for exams. This shutdown can then create a detrimental, ongoing cycle of heightened stress about exams or the future, coupled with a decline in the ability to take effective action.

It’s vital to recognize that exam stress does not merely stay in the exam room — it can be a gateway to larger mental health challenges. Constant stress regarding school performance, marks, or the fear of failure can escalate into conditions like anxiety, chronic overwhelm, or depression. Students may experience sleep disruption, poor nutrition, and feelings of inadequacy. And these symptoms often persist long after the test is over. Compounding this is the reluctance of most students to seek help because they believe their feelings are normal or fear appearing weak. Yet, if left unaddressed, sustained pressure along with these symptoms can profoundly affect their psychological well-being.

Tatum Redmond

What role do community-focused organizations such as Community Keepers play in linking academic stress to systematic youth mental health support and improvement?

Organizations like Community Keepers play a truly pivotal role — not merely as emergency responders but as an integrated support system within educational institutions as well. Crucially, they move beyond immediate crisis response by collaborating with schools to develop long-term support and to provide safe spaces to engage in dialogue. They offer genuine attention and care when learners are struggling with school demands, exams, and family pressures.

The approach is not just “addressing stress today” but asking, “How can we create an enduring environment where young people feel safe, supported, and connected?” Doing this requires collaboration with the learners themselves, educators and school staff, as well as parents, caregivers, and community leaders.

What factors make schools uniquely positioned to be safe and supportive spaces?
Schools are exceptionally well-positioned to serve as safe and supportive spaces for students for several key reasons:

  • Learners spend a substantial portion of their day at school, making it a primary setting where adults can observe signs of distress, anxiety, or coping difficulties.
  • Schools have the opportunity to house critical personnel — teachers, counselors, and external partners like Community Keepers — who are on hand to offer support or a listening ear.
  • The curriculum can extend beyond academic skills and learning. It can include mental health and emotional literacy, stress management, and peer support.
  • When a school actively fosters an environment of safety, respect, and validation, it fundamentally alters how learners navigate pressure, stress, or complex personal problems. Having a guaranteed safe space at school is deeply stabilizing for the mind.

How can the goal of securing mental health support as a pillar of education be reached?
Achieving the goal of establishing mental health support as a solid, non-negotiable pillar of education requires several strategic commitments:

  • Schools must actively allocate resources for it, ensuring adequate numbers of support staff, rather than relying on minimal provision. Teachers need training to recognize signs of distress and respond helpfully and appropriately.
  • Mental health literacy must be integrated into the curriculum. Instead of only focusing on academic subjects, topics like stress management, emotional intelligence, and maintaining healthy relationships should be covered.
  • The government must demonstrate a serious commitment, including mental health support in education budgets, developing clear policies, and ensuring rigorous follow-through.

How have your practices and initiatives in promoting and supporting schools as safe spaces made meaningful change?
We’ve observed tangible change in the learners’ attitudes; those who feel comfortable expressing their emotions are generally happier and more resilient because they have established a safe, non-judgmental space where trust is built.

What role can teachers and school leadership play as partners in creating an evidence-based supportive learning environment? Where are the gaps in building capacity and how can they be better supported?
Educators and school leadership are essential partners in establishing an environment that successfully supports learner mental health and cultivates a culture of well-being. They can do so by:

  • Prioritizing both the physical space and curriculum time necessary for learners to engage with support services.
  • Serving as role models who embody and encourage emotional regulation and actively normalize help-seeking behaviour.
  • Remaining deeply cognisant of factors that contribute to learner distress so as to not inadvertently exacerbate it.

Investing in staff wellness and support, capacity building, and policy reform is not merely beneficial, but a foundational requirement to capacitate educators effectively. This allows them to sustainably support the mental health of their entire school community.

The SNF Global Center’s work in South Africa is carried out through the Child and Adolescent Mental Health Initiative (CAMHI South Africa). We are proud to expand the partnership with Community Keepers and value their collaboration towards co-creating scalable, school-centered mental health approaches that authentically respond to the diverse lived-experiences of young people.

The post The Unspoken Toll: Why Exam Pressure Must Be Part of the Youth Mental Health Discussion appeared first on Child Mind Institute.

Facing the Monster: My Journey Living with OCD and Finding Hope

by David Kedeme

I remember the day my white high top Puma sneakers my parents gifted me for Christmas became the exact opposite of the color they came boxed in. It was a post rainy day in middle school, on a mulch covered, semi grassy area we considered our soccer field with two benches representing goals. After enjoying an intense match, what I did not enjoy but assumingly brushed off was the fact of how dirty my shoes were. Fast forward to later that day, I spent hours cleaning the shoes, trying to restore them to their original look.

Something felt different than other times I cleaned.

Every speck had to be clean. The more time I spent, the more visible other “not as clean” areas of the shoes became, requiring their own dedicated time of cleaning. Slowly, this cascaded into many other aspects of life such as my bedroom and closet needing to be organized a certain way, a tornado of relentless doubts concerning my relationships, with this dark monster in my head controlling what I can do, think, and feel. It felt like an eternity but at the same time as if no time passed from when I first touched to clean those shoes to when I could not sleep in my own bedroom and instead slept downstairs due to not wanting to mess the space up and not being able to enter and exit my closet as easily, so needing to rewear clothes days on end. I thought that doing what the monster or voice or whatever it was wanted would lead me to peace, as the relief from the sky high anxiety and gloom that came from performing what I know now as compulsions came only to have what I learned were obsessions come back, if not stronger, reinforcing this vicious cycle. My parents noticed my change in behavior, from avoiding my room at most costs to being late to dinner by up to an hour or two at times. I had only vaguely heard of obsessive compulsive disorder, OCD, and brought the idea up to my parents. The landscape we were dealing with was completely new and I felt even more alone due to this in addition to the isolation the condition induces you to be in. But we began to look for therapists, where I started talk therapy, with the therapist trying their best but the therapy modality was not the right one for me. Next up was a hypnotherapist, which also did not work for me. I needed some action to be okay with the high emotion filled state I was in when the bouts came on, in other words, exposure and response prevention therapy. After doing some research, I landed upon NOCD, an OCD teletherapy and advocacy organization.

I could not believe what I was hearing through the basement, not my room, laptop screen about actually going into my room, and that was not even the worst part. I just had to open my closet, take clothes out, move items in my room, and not do anything. “Maybe it is, maybe it is not” was a phrase that my therapist told me throughout therapy. With the significant support of my family, therapist, and friends, I was able to be okay with not being okay. Exposure and response prevention therapy makes you face the monster, making you enter the state in which you experience high anxiety. The therapy makes you look the monster in the face and realize it was not that big, not talking or engaging with you, making you sit in the discomfort and not do anything you so desperately want to do. With this methodology and rigor, I was able to coexist with the beast, and slowly it shrank, still existing though. But that is okay. That happens.

OCD belongs to a category of disorders called Obsessive Compulsive and Related Disorders within the Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition, a manual that influences not only how patients receive care but also research funding and medical training. Although not officially recognized in the manual, there are many discussed subtypes of OCD depending on the obsessions and or compulsions one experiences. Some people, like me, had symptoms that ebbed and flowed in terms of severity and percolated from subtype to subtype. My symptoms throughout my experience with the condition range from having to keep most of the items in my room a certain way, doubting whether I want to be with my partner, questioning my morals, wondering whether something happened in the past pertaining to people in my life even though it did not, and more. Throughout typing this, thoughts flood my head, similar to ones I experienced, say, six years ago.

I hope to be able to perform research in the condition as well as treat people who were and are in my shoes. With up to 242 million people worldwide meeting clinical diagnostic criteria for OCD, about 40 to 60 percent experiencing treatment resistant OCD, more than two thirds of the general public not being able to accurately identify OCD, and mental health still being stigmatized today, there is more needed to be done from all fronts. When one type of online treatment is sought, about two thirds of patients achieve a clinically significant outcome, but on average, it takes greater than seven years for someone to receive a diagnosis of OCD and it can take up to seventeen years for an individual diagnosed with OCD to receive treatment. This is a multifaceted problem that requires a multifaceted approach which requires a banding of people worldwide to come together to promote awareness of the condition and a safe space for people throughout who have OCD.

Today, as I am typing this, I still am experiencing many of the symptoms I have before. The condition does not just go away, but it does become more manageable. If you are struggling, there is hope, there is a way, no matter how impossible it feels. I felt as if there was none, no light at the end of the tunnel, spending many hours crying out asking why to a source I was not even aware of, answered only by my own repetitive thoughts. But as someone who has been there, you will be okay. Even if multiple therapeutic modalities do not work, you feel like you want to give up because a current exposure seems impossible to do, you feel more anxiety at times, you feel like you are letting people down if you do not improve, you feel like the monster you were once fighting off keeps going, keep going. Seek help in many ways, rely on your community, and for those who have a hard time finding one, we are here for you, the International OCD Foundation community, and I most certainly am as well. Thank you for reading this and I am sending you hope and luck wherever you are. You are never alone.

The post Facing the Monster: My Journey Living with OCD and Finding Hope appeared first on International OCD Foundation.

Epigenetic changes associated with multi-generational trauma: characterization, mechanisms, and therapeutics

Trauma can contribute to lasting psychological, behavioral, and physiological effects that extend across generations. Intergenerational trauma refers to trauma-related effects observed in children of exposed parents, while transgenerational trauma describes effects observed in later generations without direct exposure. Proposed mechanisms involve interacting biological and psychosocial processes, including stress-responsive regulatory systems, epigenetic variation, and caregiving environments. This review synthesizes evidence on epigenetic changes associated with acute, chronic, and complex traumatic exposures and their relevance to multi-generational outcomes. Studies published between 1990 and 2025 were identified through PubMed and Google Scholar and evaluated for reported epigenetic findings, caregiving patterns, and offspring health outcomes. Across trauma contexts, reported epigenetic variation most consistently involves pathways related to stress-response regulation, immune-inflammatory signaling, neurodevelopment, metabolic processes, and developmental programming. Patterns across exposure types suggest that acute events are most often associated with stress-related and inflammatory signaling that may influence developmental programming, whereas chronic and complex trauma reflect cumulative physiological adaptation involving broader alterations in stress-regulatory, metabolic, and neurodevelopmental systems. Offspring outcomes most consistently include increased vulnerability to anxiety, depressive symptoms, stress-related disorders, and certain chronic medical conditions, often described alongside shifts in caregiving behaviors and psychosocial environments that may shape developmental vulnerability. Interpretation of the current literature is limited by small sample sizes, varying definitions of trauma, and limited multi-generational cohorts. Overall, current evidence supports a model in which trauma-related outcomes across generations reflect interacting biological and caregiving processes, highlighting the importance of integrated molecular and psychosocial frameworks for prevention and intervention.