College Mental Health as a Specialty

I chose to focus my career on college mental health (CMH), or college counseling, in approximately 1987.  That was my first year in my doctoral program in counseling psychology.  Perhaps it was the time, perhaps the context, but I definitely perceived CMH to be a "field" of study and work.  I recall others being interested in pursuing this same career path then and especially during the early years of my professional life.

If I have learned anything from more than two decades of work in this field it is that CMH is in fact a specialty.  Explaining the nuances in this work could fill more than one volume, much more space than what is offered here.  Starting with an example of definition, the American Psychological Association (APA, 2011) defines a specialty as follows:

"A specialty is a defined area of professional psychology practice characterized by a 
distinctive configuration of competent services for specified problems and populations. 
Practice in a specialty requires advanced knowledge and skills acquired through an 
organized sequence of education and training in addition to the broad and general 
education and core scientific and professional foundations acquired through an APA or 
CPA accredited doctoral program. Specialty training may be acquired either at the doctoral or postdoctoral level as defined by the specialty."

There are professional organizations devoted to this specialty, about some of which I have posted previously.  A short list of American organizations is provided here:

• Association of University and College Counseling Center Directors
• International Association of Counseling Services, Inc.
• American College Counseling Association
• Section on College and University Counseling Centers, Division 17, American Psychological Association
• Commission for Counseling and Psychological Services, American College Personnel Association

But these are just formalities, and not included are the many college counseling centers which provide formal training opportunities including practica and internships.  The essence of the specialty lies in the nature of the work itself.  Some hallmarks of a competent approach to this field include:

• A thorough understanding of the holistic development of late adolescents and young adults as it relates to academic success and personal growth
• A broad range of skills in the area of psychotherapeutic approaches to common issues faced by college students
• An appreciation for the importance of outreach and prevention education programming on a college campus, including the skills of planning, delivery and evaluation of these activities
• A thorough and competent approach to delivering consultation services to members of a college campus community, including faculty, staff, parents, and others
• Where possible, a comprehensive mission of training graduate students in mental health professions in the CMH specialty

Much harder to articulate is what lies at the heart of this type of work.  The nuances mentioned above relate to the skills involved in managing very complex dynamics in multiple and sometimes conflicting work relationships, the urgency involved in responding to the needs of both the individual and the community, and the promotion of the full and genuine identities and life trajectories of students in this context.  If I was forced to explain one view in as few words as possible, which in fact I am in this space, I would offer the following statement:

"CMH is the training for, application, and on-going study of a range of psychologically-oriented human services focused on the academic success and personal growth of college students, with a full understanding of the complete context in which they function, including responsiveness to the needs of all who relate to, work with and serve them, and the successful management of professional boundaries with all involved such that the goals of the individual and community are promoted."

Diagnosis spotlight: seasonal affective disorder

Our environment has a strong influence on our mental health. In fact, an entire disorder is dependent on the time of year: seasonal affective disorder (SAD). Often referred to as the "winter blues," this disorder typically follows an increased depression that begins in the fall and increases as the winter moves on. In some cases, however, the disorder starts up in the spring and peaks in the summer.

Symptoms vary between winter and summer SAD. According to the Mayo Clinic, symptoms of fall and winter SAD include depression, hopelessness, anxiety, loss of energy, a heavy or "leaden" feeling in arms or legs, social withdrawal, oversleeping, loss of interest in activities you once enjoyed, appetite changes (especially a craving for carbohydrates), weight gain and difficulty concentrating. Spring and summer SAD, on the other hand, is demonstrated through anxiety, trouble sleeping, irritability, agitation, weight loss, poor appetite and an increased sex drive.

It's easier to dismiss a problem if it goes away on its own. It can take a long time for someone to be motivated to get help and since SAD dissipates after a few months, some people will never seek treatment. The problem is that this is a cyclical disorder that returns year after year, meaning that it isn't actually going away. 

SAD, though dependent on the seasons, is not any less severe than other forms of depression. It should be taken just as seriously as "regular" depression. This means actively seeking treatment is just as important. The most commonly used treatments are light therapy, medications and psychotherapy.

Light therapy (also known as phototherapy) involves sitting in front of a box that emits specific wavelengths of light. This treatment is based on the idea that a lack of sunlight is partially to blame for the illness, a theory that is supported by increased rates of winter SAD in the north. This is the least invasive treatment and a good first step. Make sure you buy a quality box and consult with your doctor. How long you expose yourself to the light and what time of day you do so is important and should be determined by a professional.

SSRI antidepressants are also used to treat SAD, especially in more severe cases. It can take several weeks for the medication to work, so if you know you know have a yearly problem with SAD, you might want to start a regimen before winter (or summer) hits. Make sure to not go off the medication before your doctor recommends it, even if you feel better. 

Psychotherapy can also be effective in treating SAD. While you can't control the coming and going of the sun, you can control other factors that might be influencing the SAD. A therapist can offer suggestions for managing and reducing your symptom. A therapist can also possibly get at other underlying causes of and contributions to the depression, seeing as it is rarely only one thing that is the root of the problem. 

It's unnecessary to suffer from seasonal depression year after year. If you or someone you know struggles at a particular time of year, don't dismiss it. The temporary nature of the disorder does not reduce its seriousness. Schedule an appointment with a doctor or therapist to further explore what your options are in treating SAD.

Do you get more symptomatic at certain times of the year? What has helped you? Share your thoughts in the comments.

My take on meds

Feel free to ignore this post if you don't want an opinion piece. I just feel that since I will be talking about medication, it's probably best that I explain my stance to provide some context. 

There's so much good that has come from modern medicine. This includes a wide assortment of medications that help treat and even prevent certain conditions. These include entire categories dedicated to mental health issues. Due to the fact that we don't know enough to not be experimental, new discoveries are made by chance. For instance, anti-seizure medication can be used in the treatment of personality disorders. It's a frontier we have yet to conquer.

I have a great level of respect for those who dedicate their lives to finding ways to improve and extend our lives. Unfortunately, the pharmaceutical industry as a whole is not run by philanthropists who throw money at it. It's a business. This means that they have to make money. The competition can be healthy in terms of innovation, but it has to be financed. This is how Prozac got renamed Sarafem and prescribed for PMS. Once the original use for a drug has been tapped into, it's time to find ways to keep making money off of the same formula. Do you have to take four pills a day? We just made a different one that does the same thing, but you only have to take it once! You think anti-psychotics are reserved for schizophrenia? No, they're also used for autism, dementia and even insomnia.

Honestly, it's a really complex system and I'm not here to preach about it. But since medication is a significant aspect of the mental health industry, I can't ignore it. In order to offer a respectful climate for discussion of something so attached to opinion, this is the perspective I am coming from:

• Medication has the potential to significantly improve and even save lives in the mental health field.

• Some people need medication. They have exhausted all their options and cannot find anything else that is sufficiently effective.

• It is not our job to judge whether or not someone needs medication. Don't think your sister needs lithium? It's the job of her and her doctor to figure that out. Think your friend needs some anti-anxiety pills? It's not your call.

• Side effects are a factor that should be taken into consideration when prescribing medication.

• When it comes to children, teenagers and young adults, special precautions need to be taken and other approaches should be more carefully considered. While the body and mind are still developing, a cost-benefit analysis is definitely warranted.

• Are we overprescribing? Probably. I refuse to believe all my classmates who take Ritalin or Aderall actually have attention deficit hyperactivity disorder (ADHD), a childhood disorder that doesn't spontaneously emerge in college.

• Never encourage or support someone in going off their medication without proper medical supervision. Not only may it be inappropriate in terms of treatment, but not regulating the tapering off of a substance can cause withdrawal symptoms and other serious – possibly permanent – complications.

• There are alternative approaches that can be taken, and that's okay, too.

• Ultimately, it's about getting better. Whatever works (and is relatively healthy) is great!

I understand completely if you disagree. I don't claim to be an expert. I'm just being honest about where I'm coming from so that any biases I have are pre-announced. 

I'm back

I apologize for my unannounced and unexpected hiatus from this blog. A lot of things came up very quickly and I had to prioritize other areas of my life for the last several months. I'm starting back up again, though, so look for more posts in the near future.

Thank you for your patience with this bump in the road.

Effective Campus Consultations

In the college counseling world, consultation refers to delivering mental health expertise to concerned third parties, such as faculty, staff, parents, and other community members.  On most campuses, the community sees the counseling service as a valuable resource which offers all some assistance in helping students effectively.

This aspect of services is rife with both potential conflict and opportunity (it's amazing how these two things often go together, eh?).  On the one hand, the student is always the focus of services and often also the client; on the other hand the institution is always the client, the corporate client in fact.  There are a few times when the needs of both are in conflict.  I submit, however, that such occasions are rare.  Mostly, there is enormous overlap among the needs of the two.  Indeed, each actually wants the same thing: to retain and graduate young adults.  My direct experience has been that when there is conflict it's often because one or both are nurturing needs which are unreasonable, though that is of course open to plenty of debate.

So, there are some tips on delivering effective consultations on campus.  In no particular order, here are a few.

• Establish the identification of the primary client, and do it early and often.  If the student about whom someone is concerned is a client of the center, they are the primary client, and the obligations to them are paramount.  In this scenario the institution becomes a secondary client, though in this context this does not mean its needs are inferior.  It's just that they must be addressed by someone who does not have a dual role with the student unless the student has authorized such activity.
• Respond promptly, every time.  The fortunes of college mental health rest on our showing up.  Always.  It is often expensive to do so, considering the labor involved.  But there is a huge return on investment.
• Don't just say no; find a way to help and tell them you will do so.  Successful businesses put the consumer first.  There is no reason why we should not do this as well.  Even when needs conflict or dual roles exist, there is always a way to be helpful.  It may take some time and creativity to pull this off, so one could always say "I'm not sure how to help you, but keep talking to me and I will find a way."
• Establish and maintain clear boundaries and expectations when needed.  At the same time, some requests are clearly inappropriate.  Such as when someone asks for privileged information and there is no authorization for same, nor is there any risk for harm to self or others.  You could be the FBI or a parent or an administrator.  It does not matter.  Abrogating the therapy relationship in this way can be fatal to therapy, now and perhaps well into the future for a student.  That's a really bad thing.  At the same time, there may be a need driving the request which can in fact be satisfied.  Figure out what that is.
• Keep your word and be consistent.  Whatever happens, do what you say you will do and do it each time.  Since we're all human here, we make mistakes and no one can rightly tell you that you can't.  But if you do, own up to it and set it right whenever possible.

Consultations are wonderful opportunities to get things back on a good path, for the student as well as the community.  Often the circumstances behind the consultation represent the logical though negative conclusion of unhealthy relating and expectations.  It is a kind of bubble which needs to burst, but all involved sometimes prevent or avoid that from happening.  An effective consultation facilitates the bursting in a controlled manner, so that maximum learning and change can occur.  Which is exactly what everyone needs, whether they want it or not.

A smoking ban for mental health workers at the workplace

To force a breakthrough in the smoking culture in psychiatry it should be prohibited for mental health staff to smoke in the work place. There I said it! (and yes I agree it should be like that everywhere in health care but in this blog I will focus on psychiatry).
Last time I said I would like to see a smoking ban for all mental health staff within hospital grounds and during home visits was when I arranged a meeting for mental health workers about psychiatry, health and sports. Many smokers weren’t pleased and that’s an understatement. Some were very annoyed and kind of hostile as if this was denying them a civil right. Many many health workers that smoke with patients say its good for bonding but its just an excuse to maintain the smoking culture.
It’s a challenge for patients to quit smoking in psychiatry where a lot of people smoke. They get discouraged. Mental health workers may often tell the patient that it’s too hard to quit with mental illness, that it stresses them out too much. And of course it’s quite an effort for them but I have seen enough to prove that it is not impossible. Sometimes I wonder if staff who smoke feel threatened by the brave attempts of patients who want to quit when they can’t manage to quit themselves.
Addiction to nicotine is the most common form of substance abuse in people with schizophrenia, who are more than three times more likely to be addicted to nicotine than the general population. The relationship between smoking and schizophrenia is complex. People with schizophrenia perceive certain benefits from smoking but at the same time it’s threatening their health and wellbeing in a serious way and can make antipsychotic drugs less effective. Heavy smokers often need higher doses of medication.
People with schizophrenia have a shorter life expectancy (up to 15-20 years shorter) than the average population and the main cause is smoking.
Over the years I have seen many people with mental illness die young because of smoking related diseases like heart failure, different forms of cancer, strokes, COPD. People in psychiatry can get help with quitting drinking, quitting street drugs, quitting benzo’s, quitting gambling… but there’s usually no specialised help for quitting or reducing smoking for people with mental health problems. Smoking doesn’t seem to have priority in the smoking culture of this specific field of health care with mental health staff having the highest percentage of smokers of all healthcare staff.
But with worrying statistics on physical health problems among people with mental illness we need clear measures. And mental health workers who are addicted to smoking should get over themselves and only practise their addiction outside the hospital gates and out of sight of patients, including in outpatients and in community settings. After all our goal is to improve and encourage health from a holistic point of view. Staff who smoke give the wrong message. Smoking should be banned and it should be the responsibility of managers in mental health care to enforce those bans.
I have been giving a “decrease-smoking-course” for people with mental illness for a few years now. The course is free. Most of the attendees have schizophrenia. There is always one chair for a mental health worker who wants to quit. They can attend the course during work hours. Thanks to the course we have a smoke free team now.
First it was called a “quit-smoking course” but we got very few subscribers. Quitting seemed a step too far for many. So we changed it to “decrease-smoking-course” which consisted of 10 sessions including a smoke break of 5 minutes. Soon we had a waiting list.
The first session was about smoking habits and keeping a smoking diary to get insight in smoking habits and coping. Many people started to smoke when they were admitted to a mental hospital for the first time. One of the patients started smoking when she was admitted with psychosis at age 27. She told us:
“Everyone, patients and nurses, seemed to smoke so I thought it might be helping and some nurses even promoted smoking by giving me a cigarette even though I didn’t smoke. And they took out the patients who smoked more often than the ones who didn’t smoke. So some started smoking to be with the others.”
Now at age 45 her GP told her she had to quit smoking because she had COPD. She joined the course and eventually managed to quit.
Most people who attend the course don’t quit but decrease a lot. That’s important improvement too. People who go from 60 to 10 cigarettes are not unusual. We involve psychiatrists, family, GP’s and mental health workers as supporters to make their resolution a success.
We notify and work closely with all people involved in their treatment and give information on how to offer support. The psychiatrist monitors blood levels especially when patients are taking Clozapine and sees the patient more frequently to adjust medication doses when needed. Smoking cessation can lead to higher plasma concentrations and potentially more side-effects. With Clozapine their levels can raise in a dangerous way.
Quitting smoking with this group should be monitored closely whether there is any exacerbation of symptoms or medication side effects, so possibly the dose of neuroleptic medication needs to be adjusted. Since quitting smoking is a challenge we make sure that the patients get extra support. Nicotine replacement methods may benefit their effort to quit.
Every mental health trust should offer specialised quit or reduce smoking support for patients and mental health workers.
I’m not promoting a smoking ban for patients. I’m very much against that. In the hardest times we shouldn’t force patients to quit. But I strongly believe that a healthier and more encouraging environment will help people to find the motivation to reduce or quit smoking and improve their wellbeing.
And that’s our job as mental health workers.

The Question of Marijuana

Nearly every day I read an item extolling the virtues of marijuana from a wide range of its apologists.  Even CNN's Sanjay Gupta has gotten in on the action, recently reversing his long-held opinion about its dangers.  It doesn't kill anyone, they say.  You cannot be addicted to it, they say.  Susan Sarandon says it's silly to send folks to jail over pot possession, for example, because no one has ever been harmed by weed.  It is now not only legal to have it in California and Colorado, but also to consume it.  And even distribute it.  There is even a date on which people on college campuses gather to smoke, in public, in areas in which it remains illegal to do so.  I for one won't help the cause by publishing that date.

The champions of pot like to claim that it doesn't harm anyone, that it is a natural substance "from the earth".  They report that they don't know anyone who has told them about having problems with it.  But if someone did have problems with it, would it be them that such individuals approach?  Not likely.

I know that smokers can and do see mental health professionals, and for a variety of reasons.  I know this because I am one, and I have worked with many over more than 20 years of practice.  They arrive in my office with motivational problems.  With broken relationships.  With chronic bronchial disorders.  Some have patterns of academic and career stagnation.  Some exhibit a kind of intellectual stunting, especially if they began smoking in their early teens.  About one or two of every ten present with an anxiety or psychotic disorder which was apparently unmasked by marijuana use.  It is felt that such disorders may never have been triggered were it not for the smoking.  The CDC, in its Surgeon General's Warning page on marijuana, lists many of these known issues related to use, and has done so since 1982.  Anything that has its own warning page by the CDC is worth a little scrutiny, in my opinion.

Recent studies reveal that 12% of young people have reported driving while intoxicated on pot.  It stands to reason that a portion of these drivers have been in accidents which harmed or killed themselves or others.  But I await real data about that.  Nevertheless, I think it is irresponsible to give others the impression that marijuana is always safe, no matter the full context or the individual human brain involved.  That is simply not true.  If I could I would introduce you to young people whose lives, and in some cases their bodies, were badly altered by their abuse of this substance.

This particular debate is independent of questions about legalization or incarceration.  I don't think the war on drugs has been useful or effective when it comes to pot.  Others who know me well will tell you I far from being a prude.  I believe, and have told my clients this many times, that it is possible to be safe, smart, and still have plenty of fun.  I stand by that 100%.

We speak of marijuana as though it were a single substance with uniform properties, which it is not.  It comes in many varieties and degrees of potency, and sometimes it is spiked with other substances which may or may not be known to the smoker.  The fact is that marijuana consists of chemicals which will impair some individuals.  The science has not evolved to the point where we can accurately predict exactly who will have problems resulting from consumption, at any amount and over any course of time.  Questions concerning addictive potential remain unanswered.  But I am here to tell you, if anyone can be addicted to shoes, so can some be addicted to pot.

No matter that it comes from nature.  Neither will kill or maim everyone who is exposed, but arsenic and snake venom come from nature too.

Sleep Quality Linked to Alzheimer's Disease

According to a new study published by Johns Hopkins Bloomberg School of Public Health, sleep quality may influence the onset and progression of Alzheimer's disease. Lead author, Adam Spira, PhD, and his team of researchers discovered a link between shorter and/or poor sleep quality and higher levels of Amyloid beta build-up in the brain.

“Amyloid beta is a peptide of 36–43 amino acids that is processed from the amyloid precursor protein (APP). While best known as a component of amyloid plaques in association with Alzheimer's disease, as Aβ is the main component of certain deposits found in the brains of patients with Alzheimer's disease, evidence has been found that Aβ is a highly multifunctional peptide with significant non-pathological activity.” 

Researchers observed self-reported sleep habits and β-Amyloid deposits of adults from the neuro-imaging sub-study of the Baltimore Longitudinal Study of Aging where the average participant age was 76 years. Subjects reported sleep that ranged from more than 7 hours to no more than 5 hours. Using the Pittsburgh compound B tracer and PET scans of the brain to determine the amount of β-Amyloid in the brain, researchers noted that shorter sleep duration and lower sleep quality were both associated with greater amounts of β-Amyloid deposits.

Even though no causal link has been established, if sleep habits do in fact have such an impact, researchers suggest that these findings could potentially slow the progression of Alzheimer’s simply by promoting and maintaining healthy sleep patterns. Furthermore, as this is not the first study to link sleep and Alzheimer’s disease, more research with objective sleep measures could determine whether poor sleep actually contributes to or accelerates Alzheimer's disease.

“Results could have significant public health implications as Alzheimer's disease is the most common cause of dementia, and approximately half of older adults have insomnia symptoms."

Alzheimer's disease is a type of dementia that causes problems with memory, thinking and behaviour. It is most common in people over 65 years of age; however up to 5% of people develop early-onset in their 40s or 50s. The most common early symptom of Alzheimer's is difficulty remembering newly learned information as changes in the part of the brain associated with learning is often the first to be affected. Eventually these individuals will experience symptoms, including disorientation, mood and behaviour changes; more serious confusion about events, time and place; unfounded suspicions about family, friends and professional caregivers; more severe memory loss and behaviour changes; followed by difficulty speaking, swallowing and walking.

Shorter Sleep Duration, Poorer Sleep Quality Linked to Alzheimer ’s Disease
Beta amyloid
Alz.org

 © www.mentalhealthblog.com

The Vitality of Youth

Much has been written about millennials and Gen Y students, a lot of it negative.  They have been variously characterized as lazy, self-absorbed, safely cocooned in electronics, and worse.  Some of this is based on real data.  But I am here to tell you, they may save us from the havoc we "adults" sometimes wreak.  We absolutely need them.

For one thing, they are apparently more optimistic than older adults.  They believe they will have more opportunity than their parents did, and that life is better today for them than it was "in the good old days."  It spite of the doom and gloom being written about the state of higher education in this country, they see it as a good investment in their future.  Who doesn't need freshness of opinion, and a hopeful view of the future?

I have written elsewhere in my blog about the energy and creativity of youth, so this item is really just another snapshot of the gifts they bring to the table.  As we older adults wrangle over chronic and confounding issues of our day, such as racism and military conflict, it is our youth who sometimes present brilliant and "never mind all your rules" approaches to problems.  Rule-breaking teens are even thought more likely to become successful entrepreneurs later in life.  I am reminded of a recent news item about a pre-teen who solved a centuries-old mathematical conundrum in just a few minutes, startling others in the room.  Their hopefulness and lack of constraint is very valuable indeed.  While adult members of faith argue over the "right" approach to inter-faith gathering and dialog, for example, younger folk go ahead and get together and talk.  This pattern has occurred among Christians, Muslims, Jews in the middle east, and among Protestants and Catholics in Northern Ireland.

If they can forge ahead there, what else can they do?  What will we encourage them to do?

Vignette 3: What Would You Do?

Juanita, a disoriented student

Background: Juanita has had her head on her desk throughout class.  She appears to be napping.  She is disoriented with slurred speech.  It is not clear if she is intoxicated or not.

Scene: Her professor approaches her desk after class.

Dr. Jones: Juanita class is over.  (No response)  Juanita?

Juanita: (Stirring around a little) Mmmmm?

Dr. Jones: Class is over, time to go.

Juanita: (Speech is slurred) Time to go where?

Dr. Jones: The class is over.  You can leave now.

Juanita: Books are at home.  Left them with my papers.  Be here tomorrow though.  (Giggles)

Dr. Jones: Look, it’s time to go.  What are you doing next?

Juanita: (Slurred) The big question.  No one really knows, do they?  Big planet, you know.  Time to go you say, so say you.

Dr. Jones: (More alarmed) Juanita, are you OK?  Where are you supposed to be?

Juanita: No worries, chief.  Doin’ okee dokee.  Gotta get to formica, need the ruzzle from there.

Dr. Jones: (Worriedly) What is your name?

Juanita: The one who shall not be named, in Madrid.

Dr. Jones: What is today?

Juanita: Today what?

Suggestions: Such behavior is generally an indication of a serious condition, which could be anything from intoxication, psychosis, or another medical crisis.  Consider a swift transport to the emergency department of a local hospital, or summoning paramedics.

Notes on the Matter of Suicide

Recent tragedies which have captivated national attention have raised both awareness and anxiety regarding college student suicide.  Though the reason for heightened awareness is of course unfortunate, the awareness is a positive development.  But the anxiety may or may not be, depending on what one does about it.

If the anxiety translates to knee-jerk reactions in policy and procedure, and in campus-wide interventions, we may not only be ineffective, we may actually unwittingly contribute to the problem.  Here's how.

Research shows that suicide prevalence rates in higher education settings is 4.3 per 100,000*.  This is in contrast to the same rates for same-age non-college peers, which fall between 11.0 and 14.0 per 100,000 according to the CDC and its data for states.  While any loss of life is a tragedy and deserving of prevention efforts, we can conclude that simply being in college offers some protection against suicide.

So one thing we could do to prevent suicide is make it easier for young adults to have dreams (thereby projecting into the future, a major protective factor as you will see below) and attend, stay in, and graduate from college.  Reflexively reacting to the fear of suicide may lead us to respond to less-than-honorable vendors who are hawking suicide reduction wares in higher education and other settings.  (Please note here that some of these may have merit, and some may not.)  In a setting in which the base rate is already considerably lower than that of the surrounding community, and depending on its features, such programs may unintentionally create an ecology of threat, making it appear that it is a larger problem than it truly is.  To the despairing, this may have the most unfortunate outcome of making it appear to be a viable option that others nearby are considering and acting upon.

Questions to ask such vendors are: What rate is your program designed to address?, and What rate will be the outcome of your program?

Surprising as it may seem, researchers are only now investigating motives for suicide among students, the "why" of suicide.  Research to date has focused largely on demographic factors, or the "who" of suicide.  A recent study tells us rather affirmatively where we might focus our attention.  The authors state it is time to move beyond "one size fits all approaches", and strongly indicate that hopelessness and overwhelming emotional pain are the two internal motivational risk factors most associated with suicide.

Campuses would do well, then, to focus on community interventions which promote hope and future orientation toward maximizing and manifesting student gifts, talents, and dreams.  It is important that students feel they belong, that their identity matters and is wanted and needed by others.  They would also do well to promote the adequate funding of mental health resources, so that those in unbearable pain have a place to go for help.  To date, most of the vendors described above appear to focus on identifying those in pain, not their ultimate assistance.  Most college counseling centers can already tell you how to identify those in distress, and their perspectives are based in local experience and not the marketing of a product.  Listen to what these professionals have to say, then make it possible for the suffering to be assisted by them.

*Schwartz, A. J. (2011). Rate, relative risk and method of suicide by students at four-year colleges and universities in the United States, 2004-05 through 2008-09. Suicide and Life-Threatening Behavior; 41(4), 353-371. 

The Incubator

Late adolescents and young adults need space and time to develop an authentic self.  While there are of course a great many contexts in which this can occur, perhaps few are better suited to the purpose than the higher education environment.  In my view, when carried out well, this is a major benefit of the college experience.

During such a time, youth are exposed to ideas, knowledge, experiences, social feedback, and a wide range of relationships which either enhance or detract from personal growth and fulfillment of latent promise.  A forming adult can benefit immensely from this environment, which represents an incubator of the emerging self.  In this way students experiment, explore and try on various selves to see for themselves which one fits and works the best.

It is both an exciting and trying time, for students as well as those around them, especially loved ones.  The experimentation brings highs and lows, successes and failures, flashes of brilliance and the pain of mistakes.  But these ups and downs are absolutely necessary, assuming we all want to produce healthy, competent and productive adults.  Older adults, be they professors, administrators, family members or friends, simply must respect the need for this period of incubation.  Sheltering young adults from all pains can harm them significantly, though we should of course protect them from the most serious ones if we are capable of doing so.  There were times in human history when there was no such thing as this kind of incubation, due to the hardship of living many faced.  But we are able to, and should, provide this now.

Respect requires allowing enough space and time for growth to occur.  For parents this means gritting one's teeth, teaching what one knows but allowing students to venture off, even when mistakes are a near certainty.  Doing this, a sense of faith and trust is communicated, which is the fuel on which the emerging self thrives.  It means patience in the face of a tattoo, purple hair, exploring a major which is a "bad choice", financial incompetence, or partnering which causes heartburn.  The incubation can take a very long time, but learning does in fact occur.  Students learn on their own what will and won't sustain them in life, because life itself teaches them.  We parents don't always have to do the teaching, as much as we want to.  Attempting to do that, we actually interfere with natural consequences and learning, slowing down and disrupting the entire process of development.

So give them space and time to incubate the self.  Trust that the self will unfold in the way it should, one way or another.  Students, take the opportunity to learn about and become who you are.  Just as you have the freedom to do so, so do you have the responsibility to accept the feedback you will receive, and to adjust accordingly.

Listening Always Comes First

So there's a great little video called It's Not About the Nail out in the electronic ether, all about the importance of listening.  Upon watching it one thinks about relationship contexts mainly, especially the oft-seen tendency of men to fix things instead of just empathizing and supporting their partners.

Ah but the video is a great object lesson for professional helpers.  There is a strong sense of urgency among many healthcare providers to quickly and efficiently apply the "intervention" to the "symptom", because that is what the diagnosing/insurance/billing industrial complex demands. The forces behind this complex are tremendous and so embedded in some helping systems that many don't stop and think for a moment about how this form of "helping" may be affecting the "helped".

Sometimes, it doesn't matter how "right" the helper is.  The one receiving the help must feel heard and understood first, as this facilitates acceptance and motivation to be helped in the first place.  I recall a story about a homeless woman, hungry and cold, who upbraided a good Samaritan for "throwing me a bone".  Before she received food and clothing, she wanted to be understood.  In particular she wanted her pain to be understood.  That was her primary need at the moment.  Her "helpers" assumed her physical needs were more fundamental than her emotional or spiritual needs.  This is where many of us go awry.

The video takes us back to the early days of our training.  We were first taught basic helping skills, such as empathy, genuineness, positive regard and active listening.  Somehow the systems we work in may distract us from these elemental approaches to human suffering.  Let's go back then, and learn this all over again.  If you are involved in training the next generation of helpers, consider showing them the video.  After the jokes subside, tell them to get serious about this one.

Vignette 2: What Would You Do?

Sarah, a depressed student

Imagine you are in the position of advising a college student about her classes.  She walks into your office unexpectedly, looking for help.

Background: Sarah is a junior and does well in class and is usually perky and energetic.  Lately though she appears fatigued, quiet, and withdrawn.  Instead of being her usual talkative self, her close friends notice she just keeps her head down and seems to mope around.  Others haven’t seen her in a while and don’t know what is going on.

Scene: Sarah meets with her advisor about next fall’s schedule of classes.

Mr. Hayes: Hey Sarah!  Haven’t seen you in a while.  (He notices her appearance, which is unkempt and tired) How are you?

Sarah: (Looks down, emotionally flat) OK.

Mr. Hayes: OK, well, what did you have in mind today?

Sarah: I guess I need to set up classes for the fall.  I am not sure though…what I want or need.  Or even it it’s important.

Mr. Hayes: I have to tell you, that surprises me.  You’re usually right on top of everything.

Sarah: (Angrily) I wish everyone would stop saying that!  I am so tired of doing what everyone expects me to do!

Mr. Hayes: Whoa, Sarah.  I’m not really telling you what to do.  I’m just surprised, that’s all.  What is going on?  You seem different.

Sarah: I’m not who you think I am…

Mr. Hayes: What do you mean?

Sarah: I’m bored.  I don’t care about anything anymore.  All this school stuff is stupid.  I just want to sleep and be left alone.  I’m tired of people calling me, asking me stuff.  (Tears start to flow) My boyfriend doesn’t deserve this, so I avoid him too.  He’s getting frustrated, just like you.  Just like everyone else.  I guess I can’t blame them…all I’ve done for a couple months is sleep and watch TV and eat junk.  But I don’t care.  Goodbye Mr. Hayes, you won’t be seeing me anymore.

Suggestions: First, that last statement requires clarification.  Ask Sarah exactly what she means by that before she leaves your office.  If safety appears to be an issue, contact your campus counseling service for assistance right away.  If safety does not appear to be an issue make an attempt to understand her obvious distress.  Say "Please tell me more about what is bothering you, I'd like to help."  Asking questions about basic things like eating, sleeping, going to class, family and friendships will often reveal a lot about the type of issues Sarah struggles with.  Once you have an understanding of her concerns, focus on empathizing and not judging Sarah.  Then offer to help her see someone who can help her further.  Say "We have a great counseling center and I'd like to help you get an appointment there."  Offer to make the call for her right there in your office.  But then hand the telephone to Sarah when it is time to set the appointment.  Or you could offer to walk with her to the center yourself.  Later, follow up with her and ask her about her appointment, and encourage her to go if she has not done so.  Benign encouragement and persistence can go a long way in getting students the help they need.

Childhood Disability Rates Rising For The Past 10 Years

A recent study shows a rise among children with disabilities over the past 10 years. The same study also revealed that disabilities relating to physical health conditions have decreased, while disabilities relating to neurodevelopment and mental health have increased dramatically. In addition, the most significant increase has occurred among children from higher-income families.

Lead author Amy J. Houtrow, MD, PhD, MPH, chief, Division of Pediatric Rehabilitation Medicine at Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center and associate professor of physical medicine and rehabilitation and pediatrics at University of Pittsburgh School of Medicine admits that previous studies have already demonstrated that the prevalence of childhood disability is on the rise. "Nearly 6 million kids had a disability in 2009-2010 -- almost 1 million more than in 2001-2002" says Houtrow.

Results were derived from the analysis of data gathered from 102,468 parents of children ages 0-17 years of age that participated in the National Health Interview Survey conducted by the Centers for Disease Control and Prevention in 2001-2002 and survey data from 2009-2010.

The surveys questioned parents on whether their child…

• had any limitations in play or activity
• received special education services
• needed help with personal care
• had difficulty walking without equipment
• had difficulty with memory
• had any other limitation

If parents responded yes to any of the preceding questions, the surveys questioned whether their child's limitations were due to…

• a vision or hearing problem
• an asthma or breathing problem
• a joint, bone or muscle problem
• an intellectual deficit or mental retardation
• an emotional or behavioral problem
• epilepsy
• a learning disability
• a speech problem
• attention-deficit/hyperactivity disorder
• a birth defect
• an injury
• some other developmental problem

Meanwhile, researchers classified conditions into three groups:

1. Physical
2. neurodevelopmental/mental health
3. other

Their research uncovered that “the prevalence of disability increased by 16.3% from 2001-2002 to 2009-2010”. In particular, the neurodevelopmental and mental health-related disabilities increased while those disabilities resulting from physical conditions had decreased over the decade. Remarkably, the increase was most significant among children less than 6 years of age, as their rate of neurodevelopmental disabilities nearly doubled over the decade.

Furthermore, results demonstrated higher rates of disabilities among children living in poverty over the entire period of study without any real increase; however the highest rate of growth was identified among children living in higher income households (i.e. household incomes at or above 300% of the federal poverty level or $66,000 a year for a family of four).

Unfortunately, Dr. Houtrow states: "the survey did not break out autism, but we suspect that some of the increase in neurodevelopmental disabilities is due to the rising incidence or recognition of autism spectrum disorders".

Evidently this study has put a broader perspective on an area in desperate need of research. The study leaves the several unanswered questions. Why are rates of disabilities rising among children? What could these demographics really mean? Could it be that children living in poverty are simply being undiagnosed? Could it be that affluent families are more persistent in obtaining a diagnosis? Could there be other reasons or factors yet to be revealed?

Childhood Disability Rate Jumps 16 Percent Over Past Decade

© www.mentalhealthblog.com

Cyberbullying Continues To Rise

Research shows that about 5 out of every 30 high school students report being victims of cyberbullying within the past year. In addition, roughly 10 of those 30 students spend about three or more hours per day playing video games or using a computer for other purposes than school work.

These numbers arise from the analysis of data gathered from the 2011 Youth Risk Behavior Survey, conducted by the Centers for Disease Control and Prevention, where 81% of schools and 87% of students from the 15,425 public and private high schools responded. The survey represents a national sample of high school students and takes place every two years “to monitor six types of health-risk behaviors that contribute to the leading causes of death, disability and social problems among U.S. youths”.

"Electronic bullying of high school students threatens the self-esteem, emotional well-being and social standing of youth at a very vulnerable stage of their development," said study author Andrew Adesman, MD, FAAP, chief of Developmental and Behavioral Pediatrics at Cohen Children's Medical Center of New York. "Although teenagers generally embrace being connected to the Web and each other 24/7, we must recognize that these new technologies carry with them the potential to traumatize youth in new and different ways."

In 2011, the Centers for Disease Control and Prevention surveyed students about whether they had been bullied in the past 12 months either through email, chat rooms, instant messaging, websites and/or texting. In addition, students were questioned on the number of hours they spent playing video games or using a computer for any other purpose than school work.

Results showed that 1 in 6 high school students or 16.2% reported being a victim of electronic bullying within the past 12 months. More specifically, results revealed that 22.1% of girls reported being bullied electronically while only 10.8% of boys reported being victims of electronic bullying, making girls more than twice as likely to report being victims of cyberbullying. In addition, “whites reported being the victim of cyberbullying more than twice as frequently as blacks”.

Furthermore, thirty-one percent of high school students reported playing video games or using a computer for something other than school work for 3 or more hours each day. Interestingly, boys (35.3%) were more likely than girls (26.6%) to report playing video games for more than three hours per day.

"Electronic bullying is a very real yet silent danger that may be traumatizing children and teens without parental knowledge and has the potential to lead to devastating consequences," said principal investigator Karen Ginsburg, also at Cohen Children's Medical Center of New York. "By identifying groups at higher risk for electronic bullying, it is hoped that targeted awareness and prevention strategies can be put in place."

Unfortunately, cyberbullying will only become more and more common in society, especially teens, as technology continues to advance. More research should help to spread awareness and develop legislation that may succeed in decreasing the number of victims of cyberbullying, thereby reducing the rising number of extreme cases that often result in fatalities.

Cyberbullying Rampant Among High School Students: Nearly One-Third of Youths Also Report Playing Video/Computer Games for More Than 3 Hours a Day

© www.mentalhealthblog.com

A Brief Word on ADHD

Attention-Deficit/Hyperactivity Disorder, or ADHD, is a pattern of persistent inattention and/or hyperactivity, most often evident before age seven. The symptoms cause impairment in at least two settings, such as school and work, and it is more severe than what is usually seen with others of the same age and developmental status.

Many students experience periods of time when they are restless or have trouble concentrating. In fact, almost all students will go through some adjustment strains from the time they arrive at college, and may have very similar attention problems as a result. Also, there are other problems that can mimic ADHD, such as anxiety disorders, traumatic stress, alcohol or drug abuse, overuse of social media and gaming, and even ordinary family conflict.

If you have arrived on campus with a history of ADHD, it is important to continue with your treatment and to provide your local psychologist with documentation of your past diagnosis and treatment. This will improve continuity of care and perhaps prevent unnecessary problems in school.

It is unlikely that ADHD will suddenly appear in a student's adulthood. Yet sometimes students are convinced they have ADHD and take medications offered to them by friends. And some know they don't have ADHD but choose to take amphetamines as a performance enhancement drug.  Please know this may do you no good at all and, in some cases, can actually cause you harm. Diagnosing an adult with ADHD involves a sophisticated and comprehensive evaluation by psychologists, and should be undertaken with great care so that other possibilities are ruled out.  One should avoid evaluations based on checklists and self-report measures alone, as these are likely to lead to over-diagnosing.

If you suspect you have ADHD but you have never been formally diagnosed or treated, call your campus counseling service for assistance.

Ode to the Campus Police

There are many campus departments deserving of praise, and many that work silently toward enhancing the well-being of campus communities without receiving a shred of positive attention.  The campus police department is one of these.

College counseling centers often work very closely with the police, especially in the area of crisis intervention services and various teams whose purpose is to prevent and respond to disruption and violence on campus.  Collaborations such as these were once infrequent but soared after the Virginia Tech tragedy and statutes requiring them were developed in that state.  A great many institutions have adopted collaborative models and, as of this writing, at least two others states have either adopted similar legislation or are considering it.

And so it is that mental health and campus safety professionals work arm in arm, many times in the wee hours of the day, attending to critical student needs.  Many stakeholders are unaware of the fine-tuned responsiveness of campus police departments.  In this area of their work, they are not just certified law enforcement personnel with investigative and arrest authority, though they are certainly that as well; they are supportive educators providing students with valuable life lessons.  Beyond consequences for negative behavior, often delineated in institutional codes of student conduct, officers are a living example of institutional care for the student and community.  Through their actions one may experience powerful messages, such as: "we are paying attention to you", "we will respond to you", and "we will go to great lengths to see to your safety and the safety of others".  This level of responsiveness is many times not available in municipal police departments, simply because the missions are so decidedly different.

A campus police officer may, for example, conduct welfare checks on individuals suspected of being in acute distress.  He or she may knock on the doors of, say, 40 apartments, in a search for a student.  This could happen in the middle of the night, or even when the university is closed for a holiday.  On occasion they may transport a student to a counseling appointment, or to the hospital when situations warrant it.  They may accompany a counselor to the scene of a crisis event, without any expectation of being directly involved unless needed, just to raise feelings of security among all who are present.  All of this may happen without any further actions on the part of the officer and police department.

Much of this activity is invisible to the campus community.  But a great many adverse events are contained, and a great many students are assisted, in just this manner.  Well-trained campus police officers are not there just to get us into trouble, as some would have us believe.  They are a vital part of the overall welfare of the community, and they are deserving of our praise.

Facebook Assures Our Self-Worth

A Cornell University communication expert claims that Facebook can be used to reinforce our self-worth. Particularly, users that receive negative feedback in every day life, tend to be instinctively drawn toward their own profiles to enhance their self-esteem and reinforce their sense of self.  

According to co-author Jeff Hancock, "the extraordinary amount of time people spend on Facebook may be a reflection of its ability to satisfy ego needs that are fundamental to the human condition."  As opposed to the typical view that Facebook is merely an activity that wastes time and often leads to negative consequences.  

To test the hypothesis, 88 undergraduate students were asked to deliver a short speech.  Students were then offered to look over their own Facebook profiles or someone else’s for a few minutes while awaiting feedback on their speech.  Participants then received negative feedback regardless of their performance.  When asked to rate the accuracy of the feedback, those who had viewed their own profiles were less defensive than those who had viewed another person’s profile.

Participants were then given the option to browse Facebook or other online sites after receiving either negative or positive feedback about their speech. Results showed that those who received negative feedback were more likely to choose Facebook than those who received positive feedback.  

These results suggest that an ego boost from viewing their own profiles could lighten the blow from receiving negative feedback about one’s abilities.  Whereas viewing another profile may increase the need to feel self-assured.  Similarly, the need for reassurance of self-worth after receiving negative feedback may influence one’s need to browse Facebook. 

In essence, setbacks experienced in every day life may have less impact on self-esteem and self-worth if Facebook can be used to repair the damage caused by such threats to the ego.  "Perhaps online daters who are anxious about being single or recently divorced may find comfort in the process of composing or reviewing their online profiles, as it allows them to reflect on their core values and identity," Hancock says. 

Also, not only could Facebook supply the emotional benefits needed to repair deep-seated notions of self-worth, but “the research suggests that Facebook profiles could be used strategically in applied self-affirmation interventions”.  For example, campaigns aimed at reducing resistance to anti-smoking messages may be more effective in conjunction with Facebook as young adults may be more compelled to maintain their self-integrity.  

Unfortunately, this study suggests that a person’s Facebook profile offers assurance that they are valuable, worthy and good without touching upon the impacts on those who may receive constant threats to self-worth on Facebook, such as bullied teens.

Like It? We Love It! FacebookAssures Us We're Good Enough

© www.mentalhealthblog.com

How to Refer a Student for Counseling

There are both more and less effective ways to refer a student for counseling. Following the guidelines suggested below should help concerned others initiate and complete a successful referral.

1. Express your concern directly to the student. Be respectful, honest and straightforward in your language about the emotional health issues that you are noticing. Avoid belittling them or communicating pity. Remember that they are just not feeling well; otherwise they're just like you.

2. Check your own attitude about mental health services. If you see it as a negative thing chances are good the student will perceive that as well. Encourage them in this positive undertaking and ask them to call the counseling service to set an appointment. They can call from your location, or you can offer to call for them. If you call please be aware that centers generally don't allow third parties to set an appointment, but you can get the process started and then hand the phone to the student. You can also offer to walk the student to the center to set the first appointment.

3. You may call a psychologist first yourself if you have questions about services or about communicating with the student. If you wish to report your concerns to mental health professionals, please take great care to stay close to the facts as you know them. Steer clear of rumors, hearsay, or gossip, or at least identify it as such. A factual report leads to the best interventions and outcomes. False reports can lead to negative events for both the student and for you, including civil court proceedings and campus judicial sanctions.

4. In some cases mental health professionals will recommend that you meet with the student and give you suggestions about what and how to communicate with him or her. From the student's point of view, such an encounter is logical because you are known to them and they can understand why you might be concerned. Due to normal anxieties it is natural for you to feel an urge to disengage from the situation, but doing so is less than ideal. Try to stay engaged for the short period that is needed. After that, others will take over and assume responsibility for further assessment, counseling, or referral. Some feel they either don't have the right to "intrude" into students' personal lives, or feel they should avoid any responsibility for information they obtain about them. In our view, neither perspective is reasonable. Expressing concern for others based on observable behavior is not a violation of privacy, and once you inform others who are in a position to help, you have discharged responsibility you have for the information you obtained. This does not mean, however, that you should not remain involved to some degree, as noted above. Faculty and Staff members may also refer to FERPA guidance for other information on this topic.

5. In cases in which there is not an emergency or a life-threatening issue, one cannot "force" a student into counseling. One can only encourage it and keep monitoring the situation. Attempting to coerce or "trick" such students into counseling can backfire horribly; they may come to see counseling as negative and you as manipulative, thereby losing trust and faith in both. If they do pursue counseling on their own, it is highly important they feel a sense of privacy and a good measure of control over their affairs.

6. This does not mean, however, that you should never give a student an ultimatum about changing their behavior. Some parents or authority figures should consider doing so if the behavior in question is self-destructive or disruptive for others. The key in this scenario is "behavior change", and this can occur both in and out of the context of counseling. Counseling can be a useful mechanism of behavior change, but it isn't the only one. Sometimes parents, for example, may tell their student that they will withhold funding for school if they do not change failing grades, repeated alcohol violations, etc, and add that counseling is one way they can work on this. This can be quite effective when done well.

7. In emergency situations be mindful of your and others' safety. If safety appears to be an imminent concern, call 911 or your campus police department.  If safety is not an issue but the student is in an acute crisis with obvious signs of distress, a counselor may come to the scene to assist. Be aware that some have a policy to have a police officer with them in these circumstances, in the event that there is an escalation of disruptive or aggressive behavior.

Vignette 1: What Would You Do?

Jane, a homesick student

Let's imagine you are a member of a college's faculty and a student presents in some distress. Consider the following scenario, and think about how you might respond.

Background: Jane is a first-year student from a rural area.  She is overwhelmed with living in a larger city, learning about everything on campus, making friends, and keeping up with her studies.  She is not yet fully depressed but has bouts of crying, anxiety and stress.                                             

Scene: Jane approaches her professor after class to ask for more information about an assignment.

Jane: Dr. Roberts, I know we are supposed to write this essay for next week but I’m not sure what to do.

Dr. Roberts: It’s in the syllabus, you just write a first-person account of your experiences last summer, paying attention to sentence structure like we discussed this morning.

Jane: I know, but…

Dr. Roberts: Just let your thoughts and memories come out on paper first, then polish them up like we talked about.

Jane: Yes, but (tears start to flow) summer was a great time, and…I don’t like thinking about it.

Dr. Roberts: Well, pick something that…ummm, is everything OK?

Jane: (More tears, voice raised) No!  I think about home all the time, it brings me down and I can’t stop worrying about it.  But I know I want to be here but I hate it too.  I have all this stuff to do but it gets all jumbled up in my head, then I don’t know where to go or anything so I end up just crying and doing nothing.  Then my Mom keeps asking me how I’m doing and I want to tell her but then I don’t because she keeps bugging me about it.  I miss her…sometimes I just want everything to stop…

Suggestions: Because safety always comes first, that last statement needs clarification.  One might ask "Please tell me what you mean by wanting everything to stop."  Assuming Jane is not referring to suicide (that is not the intention of this vignette), one might encourage Jane to elaborate on her feelings, perhaps asking questions to further identify the source of distress.  Jane is likely to say more about her problems adjusting to college life, something a great many students experience.  But its prevalence ought not dissuade us from offering further assistance, because a deeper depression could result from doing nothing.  Jane would benefit from a referral to the campus counseling service.  Information about making a good referral will appear in a future post, so please stand by.