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.
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.
