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. 

15 Best Picture winners about mental illness

The entertainment industry has a tremendous power in shaping the public view of mental health topics. With Silver Linings Playbook, a romantic comedy featuring a protagonist with bipolar disorder, up for eight awards at tonight's Academy Awards, attention is currently being focused on the challenges faced by those affected by mental health conditions. 

It is the first movie nominated for all of the "Big Five" awards (Best Picture, Best Director, Best Screenplay, Best Actor and Best Actress) and all four acting awards (add Supporting Actor and Actress). While it is highly unlikely that it will receive all of the awards, Jennifer Lawrence is considered a frontrunner for Best Actress for her portrayal of a young widow facing a her own set of complications following the traumatic death of her husband. After seeing how the film fares tonight, I intend to write a commentary on it in the coming days. It has a lot of interesting implications.

Looking back, however, mental health conditions have definitely had their place in creating award-winning movies. Starting with the early days of the Oscars, here are fifteen films that emphasize a variety of aspects mental health and illness.

All Quiet on the Western Front (1929/30)

Showing World War I from the perspective of the Germans, this film deals with the expectations and realities of war, including the psychological aspects. Well before PTSD was officially defined, elements of it can be gleaned from previous wars, as demonstrated in this production.

Gone with the Wind (1939)

In this epic, the effects of personality disorders on oneself and others can clearly be seen. Critics have noted that heroine Scarlett O'Hara displays characteristics of narcissistic, histrionic, anti-social and borderline personality disorders. In other words, she's the epitome of the cluster B subsection. In addition, leading lady Vivien Leigh, who played O'Hara, struggled with bipolar disorder.

Rebecca (1940)

Hichcock's psychological dramatic noir thriller (thank you, Wikipedia) features characters who certainly have some significant problems. Based on the novel by Daphne du Maurier by the same name, it also handles themes such as grief, manipulation and suicide.

The Lost Weekend (1945)

With its plot centering on a writer's struggle with alcoholism, The Lost Weekend is, according to the Library of Congress, "a landmark social-problem film" with "an uncompromising look at the devastating effects of alcoholism." While the premise might seem like a cliché nowadays, it received significant opposition when it was being produced.

The Best Years of Our Lives (1946)

In the wake of World War II, a new group of veterans had to learn to adjust to civilian life. This movie follows three of them as they struggle to find normalcy. One of them, Homer, lost both hands in the war (which actually hard happened to the actor, Harold Russell). His struggle to deal with a physical handicap that he believes makes him unfit for his fiancée is metaphoric for a lot of the psychological aspects of living through a prolonged trauma like combat. Part of this film's strength is in how it shows the role of social support, both between fellow veterans and those around them.

One Flew over the Cuckoo's Nest (1975)

Because the film takes place in a mental institution, there is a lot of psychological material to draw from. The characters struggle with different conditions, but they also develop a community. The tyrannical Nurse Ratched is a legendary villain and under her reign, the viewer is exposed to a lot of the treatments that have historically (and presently) been used to treat mental illnesses. It's also one of only three movies to win all of the "Big Five" Academy Awards.

Annie Hall (1977) 

Considered one of Woody Allen's greatest and most influential films, Annie Hall follows the anxious and neurotic Alvy Singer as he tries to find out why his relationship with the title character failed. This film is worth noting because while Alvy has what appears to be a clear case of generalized anxiety disorder, he has actually lived a relatively normal life. This helps show that mental illness is not just reserved for those with traumatic histories or psychotic symptoms.

Ordinary People (1980)

An upper-middle class family struggles with the accidental loss of one son and attempted suicide of another. It tackles family dynamics in a stressful environment where each individual handles grief in his own way. Since one person with mental health issues will impact the entire family, this film is important in its portrayal of the struggle for normalcy without clear direction.

Amadeus (1984)

While Amadeus is not very historically accurate, it does tackle the interesting issue of delusional obsession. As contemporary composers, Antonio Salieri cannot overcome his jealousy of Mozart's talent. The film shows how Salieri creates a worldview in which he feels justified in using a vengeful plot to gain some sort of "victory" over both Mozart and God Himself. Obsession is usually portrayed in a romantic context, making this film all the more fascinating.

Rain Man (1988)

After his father's death, the narcissistic Charlie finds out that he has a brother, Raymond, who is more or less inheriting everything from their father. An autistic savant, Raymond lives in a mental institution. The question of why Charlie was not told about his brother points directly at the issue of stigma against mental illness, even within families. 

The Silence of the Lambs (1991)

The only horror film to ever win an Oscar for Best Picture, The Silence of the Lambs is the most recent winner of the "Big Five" awards. It features Hannibal Lecter, who is both a psychiatrist and a cannibalistic serial killer. The epitome of genius and (criminal) insanity combined, this character has been deemed the greatest villain in movie history by the American Film Institute.

Forrest Gump (1994)

In this beloved movie, Tom Hanks plays Forrest Gump, a man with an intellectual developmental disability. The film displays a very positive attitude towards Forrest, giving him his own talents and showing how he contributed to a variety of historically significant events. It tackles both the challenges and joys experienced by the title character, offering a glimpse into how society treats those who are intellectually challenged.

A Beautiful Mind (2001)

Based on the Nobel-prize winning mathematician John Nash, this film tackles the role of schizophrenia in the protagonist's life. It follows the onset of the illness, which commonly manifests in early adulthood, its identification and how it affects Nash personally and professionally. It acknowledges the permanent nature of the condition, showing that he could achieve success while still experiencing symptoms.

The Hurt Locker (2009)

The effects of war are tackled again, this time with the Iraq War. The film, which made Kathryn Bigelow the first female to win Best Director, covers the acute stress experienced in a war zone and how it affects decision making. Instead of having the focus on the posttraumatic symptoms likely experience by the characters after the story's end, the movie gives insight into its development. This is a valuable perspective, considering the current public discussion surrounding PTSD.

The King's Speech (2010)

Not all mental illnesses are defined by mood or disconnect with reality. Stuttering is categorized as a mental health condition and can be comorbid with other disorders. In telling the story of King George VI, The King's Speech shows that not even royalty is immune to these challenges. With the help of a speech therapist, George admirably demonstrates the effort that goes into recovery.

Who do you think will win best picture this year? What awards do you think the cast and crew of Silver Linings Playbook might take home tonight?

Can you keep a secret?

One of the reasons that people seek out professional counseling instead of just talking to people already in their lives is that the conversations are confidential. While some people find talking to strangers uncomfortable, others find it liberating to be able to disclose details of their lives without the knowledge and involvement of other parties.

While an ethical mental health professional can be trusted with sensitive information, it's important to know the limits. The nature of their work means that they will encounter sensitive information that occasionally must be acted upon. Each therapist should provide information on when confidentiality must be broken before treatment begins. If this is not done (or if it's been a while and you've forgotten), ask your therapist to give you a copy of her policies. 

In general, the exceptions apply in these four situations:

1. Danger to self or others

If you threaten to hurt yourself or another person, your therapist will have to evaluate what actions are appropriate to keep all parties safe. Factors such as the the presence of an exact plan, directness of the threat, severity and the ability to follow through with it are all taken into consideration.

Don't hold me to these, as this is not an exact science, but here are some examples:

Should not report: 

"I'm so mad at my husband that I wish he'd get hit by a bus." 

"I wish I had a gun so I could shoot myself."

"If I catch my wife cheating again, I'll kill them both." (Contingent on followup questions suggesting it's a sentiment, not a plan.)

Should report:

"I bought a bunch of pills and alcohol so that when I go to bed tonight, I'll never wake up."

"I carry a knife so that when I see him, I can stab him repeatedly."

"After this, I'm gonna head over to my uncle's house and take care of him for good."

A threat of harm to self can be responded to as needed in the situation, ranging from calling a friend to come over for the night to forced hospitalization. As far as threats to others, law enforcement will usually be contacted, although the potential victim(s) may as well. Past crimes aren't held to the same standard as imminent threats, with a couple of exceptions.

2. Child or elder abuse

Because children and elders are considered vulnerable populations, reporting abuse and neglect of these groups is an obligation by law. Some states require everyone to be mandated reporters while others limit the duty to both therapists and some other groups, which may include teachers, health care professionals and law enforcement. 

The appropriate course of action is that when there is a reasonable suspicion of abuse, a report is made. The reporter gives relevant information to another agency, which then decides what the appropriate course of action is. Information leading to a report does not necessarily have to come from the victim or even be a verbal confession. A child with cuts and bruises of different ages with no compelling explanation, a mother who mentions her boyfriend's mistreatment of her son and a teenager mentioning that her underaged friend is a victim of incest are all cases that will most likely be reported. An adult discussing abuse from his childhood, however, will probably not require further action unless, for instance, he has a younger brother who is in the same environment and is likely to be abused as well. A therapist is also not forced to report situations between adults, such as domestic violence in the home of a childless couple. 

The same standards will often transfer to elders and possibly disabled individuals. 

If you have questions about reporting abuse, receiving support or available services, call 1-800-4-A-CHILD (1-800-422-4453). This will not create an official report, but the people on the line can help you find out the next steps. If you are unsure about a situation, please call. It's not a commitment and it's okay to just ask a question.

3. Court order

Occasionally, mental health professionals are asked by the courts to provide information about their clients. This does not mean that any time someone is arrested, the therapist is called to confirm the offense. The principle of confidentiality is so important to therapy that mental health professionals will only reveal the least amount of information required of them and only when presented with official orders. There are also limitations on what can be asked of them, as it has to be relevant. In a murder trial, your therapist can be asked to confirm that you confessed to being at the crime scene, but probably won't answer about whether or not you're having an affair (unless it's directly related to the case). 

This exception rarely comes into play, but it has to be mentioned. The point of therapy is to help you get better, so that should take precedence over the possibility that some day five years from now your therapist will be called upon to answer if you smoked some weed. (She won't.)

4. Medical records

A limited amount of information is given to your insurance company in order to qualify you for treatment. This usually is a diagnostic code showing what you are receiving treatment for. It's not comprehensive and it doesn't involve details; it's just a way of indicating what you are receiving treatment for so that they can cover you. This is a current issue, though, and if this is a concern, learn more about what is required in your area and by your insurance company.

Outside of this, your information may be disclosed to other health care providers with your permission. This will require you signing forms and you get to specify what, exactly can and can't be released and for how long. This applies to the medical field in general, so if you want your wife to be able to get your test results for you when you aren't at home next week, ask for the paperwork!

The topic of mandatory reporting is not without controversy, but these are general descriptions of the current standards. Please don't be afraid of opening up because the information may get out. Breaking confidentiality unless it's absolutely necessary would ruin the whole point of the entire field, so it's an ethical (and legal) obligation that is taken very seriously. 

If confidentiality is a concern, talk to your mental health professional. He'll be able to give you more information on local laws and his own stance on these issues. 

Preparing for the real s-word – stress

To state the obvious, stress is inevitable. I'm not going to be patronizing by trying to explain what it is because you know best what it is like for you. Besides, there's loads of information out there. But there is one aspect of this topic that I would like to discuss: stress management. While a therapist can be helpful in this pursuit, there is also a lot you can do for yourself.

It is very important to have a plan ahead of time to deal with stress. When you're in the middle of a crisis or a panic attack, it's not going to be easy to come up with good ideas for managing your symptoms. It's very basic but ultimately valuable to have a list of coping mechanisms. What helps you feel better? Write it down. Keep a copy at home and in your purse or wallet. Put it on your phone. Sometimes having a more tangible reminder that things will be okay is helpful.

(This technique also works well for depression and other challenges. Adapt this as needed.)

These lists don't have to sound like a manual for Buddhist monks or a pitch from an overly optimistic presenter. The more individually relevant your list is, the better. Just as an example, my list of stress-reducing actions include the following:

• Cooking and baking
• Playing with my kitty
• Watching distracting movies
• Engaging in hobbies like amateur astronomy and painting
• Finding small steps to help overcome the problem I am facing
• Listening to music that mitigates my feelings
• Sleeping

Other common strategies include:

• Meditation, guided imagery, self-hypnosis and other relaxation techniques
• Quality time with loved ones
• Looking at the situation humorously
• Being productive (cleaning the house, completing homework, doing taxes, etc.)
• Prayer and other spiritual practices 
• Exercise (everything from running to yoga)
• Spending time in nature

It's important, of course, to not ignore or distract too much from legitimate concerns. Identify the cause of your stress and address it as well as you can when you have the chance. If you are anxious because of a work presentation the next day, not working on it can very well increase your stress. But if you are waiting for the results of a medical test, it is beyond your control and it's probably best to relax during the time of anticipation.  If you have no idea of why you are anxious, try to de-stress enough to where you can better assess potential causes.

For those who are interested in learning more about relaxation and meditation techniques, specifically mindfulness-based stress reduction, the work of Jon Kabat-Zinn is definitely worth looking at. He is a respected authority in the field by professionals and laypersons alike. His book Wherever You Go, There You Are is an accessible bestseller. He has also recorded an instructional CD that includes meditative guidance, Guided Mindfulness Meditation.

What helps you relax and reduce stress? Also, how do you identify your stressors? Please share your thoughts in the comments.

Failure to Launch

With the help of a film of the same name, the phrase "failure to launch" has entered the common lexicon.  Not that it needed that help.  Many a college parent has experience with the issue, whether it be direct or the source of chronic fretting.  Once, on a flight home from our nation's capital, I even overheard a very prominent legislator opining over his student's launching issues.  It was difficult to avoid thinking that we are beyond hope, if such a well-connected student was having a problem with developmental stagnation.  But of course no one is beyond hope of successful transition into adulthood.

There are a great many factors involved in the matter, many more than can be addressed in a brief blog post.  But I have noticed a few recurring themes among students struggling with emergence into independence.  In no particular order, these are:

• Lack of information and/or inadequate education.  Some students have just not been exposed, for whatever reason, to the world of employment and career-making.  This group does not know where or how to begin.  A solution: Get thee to the career center, and learn what is known about career success.
• Privilege and entitlement.  There are some students for whom the words "no", "limits", or "deference" are unfamiliar.  This group often demonstrates adaptation deficits in the areas of ambition, diligence, labor, and "paying one's dues".  They may also feel unchallenged and bored.  A solution: Get thee to the counseling center, and work on adjusting expectations.
• Lack of resources.  Many students have the knowledge and the willpower but not the financial or other necessities for taking the next steps in advancement.  This one is harder to address of course, but not impossible with enough persistent creativity.  A solution: Get thee to financial aid and the labyrinthine network of scholarship and grant funding.
• Aiming too low.  Students sometimes drift downward in their selection of friends, activities and goals.  It's tempting and easy to do the thing that's, well, easy.  A solution: Get thee to a mentor, and be mindful in your choice of heroes. 
• Too much partying.  It bears repeating that this can dull the senses and result in loss of motivation for enjoying the normal vicissitudes of living, like the rhythms of sleeping and waking, resting and working, pleasure and discomfort.  A solution: Get thee to the counseling center, and stop numbing out on life.

As already mentioned, there are other contributions to this problem, but these are some big ones.  Parents have role in monitoring these dynamics long before their children arrive at college.  It is ideal for rich dialog to occur beginning in elementary school, if not earlier.  Chances are that even small children have opportunities to address the themes at various developmental milestones, such as first attending school, first exposures to some form of labor and service to others, first responsibilities to others or pets, first earning of income, and so on.  Too often we parents let these pass by assuming the lessons will be learned and achievements earned.  Those early adults who remain frozen in stagnation will tell you this assumption is very faulty indeed.

Finding "the one," part 2 of 2

First of all, I feel the need to apologize for this post coming a lot later than it should have. I became seriously ill last week and that inhibited me from getting it done. I'm working to build up a backlog for future incidents of that sort, but haven't gotten there yet. Thanks for your patience. :)

When the practical issues of finding a therapist have been resolved, it's time to narrow your options down based on who you want to work with. Remember that whoever you choose will be an important figure in your life, even if only for a while, so don't close your eyes and point at a random name on a list. Following are some areas to pay attention to.

The first thing you'll probably notice is personality. Now, everyone deserves a fair chance, but not everyone is going to be your confidant. If there is a trait or quality that truly interferes with your ability to fully engage in the sessions, it's worth some consideration. On the other hand, for a while I saw a therapist that seemed – no, was – excessively eccentric. It turns out that he was also extremely empathetic (and entertaining). A complaint about personality should not always be an automatic elimination, but if it keeps being an issue and it's not
                                                                                                                   something that can be addressed and solved, it                                                                                                                            might be worth looking elsewhere.

While therapists purport to be specialists in certain issues or conditions, experience can be worth much more than certification. If you are an adult male with an eating disorder, you might be better off with a clinician who has dealt with a handful of clients in the same situation than with a specialist that has only worked with teen girls. During an initial consultation, ask what the concerns and conditions the therapist typically sees in her practice. Find out if she has experience with similar issues or populations. A child therapist might not be so great with end-of-life issues. Everything's case-by-case, but use good judgment.

Similarly, talk about what techniques are used. While hypnotherapy, thought modification and biofeedback can all successfully treat anxiety, you might have a preference for one. "Theoretical orientation," or the specific theory of personality and behavior a clinician subscribes to, might come up during this discussion. This deserves (and will get) its own post, but in short, be comfortable with how the therapist conceptualizes his field. A behaviorist believes that we become the way we are through our environment, punishment and reward, etc. while an existential therapist focuses more on the larger questions in human existence and how they impact the individual.

When it comes to choosing a therapist, however, the quality that trumps all others is trust. Treatment is more or less useless – maybe even harmful – if you don't trust your therapist. You might think you're coming in for something small and relatively unimportant ("I'm having a hard time sleeping"), but keep in mind that other unexpected issues might come up ("My spouse was killed in a car accident this weekend"). Would you feel comfortable with your therapist in more extreme circumstances? Alternately, are you confident that your therapist will take you seriously when you bring up something that might seem insignificant?

You are choosing someone that you can share every single aspect of your life with, as needed. Yes, trust does need to be earned, but if you just know it's not going to happen, trust that feeling. If not, you will be more likely to withhold important information or be less willing to follow any guidance you may receive.

Closely related to trust is rapport. You are entering a relationship of sorts and if you have a hard time communicating, it's the therapeutic equivalent of a highly inquisitive person dating someone that gives one-word answers. It's just not going to work. This doesn't mean that there has to be a constant conversation. Silence definitely has its place. I was told by one psychologist that he once had a client come in, cry on his couch for an hour without saying anything, then leave. He found out the next week that it actually helped. Find someone you feel comfortable around whether you're at your best or your worst. Trying to tailor yourself to your therapist (or trying to get him to be something he's not) defeats the whole purpose of why you are there.

It is essential that you feel comfortable with whatever practitioner you choose to work with. If you aren't, find someone else. You aren't getting married! It's okay to try someone else after one session or even ten years. If a therapeutic relationship fails and you still need help, don't be afraid to move on. If you are switching therapists on a monthly basis, however, the problem might be you. Be reasonable, but also go for what you need. You deserve respect as well as treatment that works for you, specifically.


Have you ever worked with a therapist where any of these issues were relevant? Share your story – good, bad or hilarious.