Expectations and Mental Health

Mental health issues are best viewed in their entire context. Claims of increasing mental illness among our youth are overwrought in large part because these fail consider context. One important aspect of context involves the expectations of students, as well as those around them.

As noted previously, learning and growth is supposed to be uncomfortable. Refining one's approach to thought and decision-making is difficult business, as we must separate bias from rationality and objectivity, the dross and gold of education. Costa (2016) sees this as a process of unlearning, to which recent cohorts of students are reacting poorly to as a result of their expectations for their college experience. In particular she sees this as a clash between the inherent stresses of learning and a mindset which over-values performance ratings, preconceived notions of success, discomfort with ambivalence and doubt, and a hyper-focus on outcome rather than process.

This is a view which deserves more consideration. It could help explain, for example, high rates of self-reported distress in the absence of true or moderate to severe mental illness. It is consistent with observations concerning modern parenting practices, the coping skills repertoire of adolescents and young adults, and data which support rapid positive changes in these dynamics with just a modicum of support or counseling.

In the popular press we often see polarizing comments about higher education, parents, and students, and this is not useful. It is the interaction of all three, mediated by the expectations of each, which deserves our attention and investigation.

College Students and the Severity of their Concerns

Much has been written concerning recent cohorts of college students and their reported difficulties. See a prior post concerning one debate on this issue. These students are called, by various authors, slackers, socially inept, narcissistic, poorly equipped to cope, entitled and demanding, and perhaps most frequently, more mentally ill than previous generations.

But none of this squares with my direct experience. Large-scale epidemiological studies in America and Canada refute the claim regarding mental illness. The most recent annual report of the Center for Collegiate Mental Health notes that various indices of mental health have remained "generally flat" for the last five years. The authors hypothesize that noted increases, such as demand for services, are best thought of as "expected outcomes", that is, the result of increased attention and dollars devoted to mental health in higher education. It is puzzling that many continue to make contrary statements, including mental health professionals in my own field. Puzzling until one considers who or what may benefit from such reports: the profession itself. More specifically, the part of the profession oriented to the medical paradigm and the swift "delivery" of interventions such as medication.

There is little doubt that the current generation of students have distinctive attributes and challenges. But so did mine, and so did the one before mine. Many generational distinctions also happen to be positive, but one does need read much about that. Like so many things in life at present, one is more likely to read spin or distortions of data.

So where and how does the mental illness distortion originate? This is probably something that is over-determined, but one way this starts is via survey data. Two oft-reported data points come to mind. ACHA's "40% of college students report having been so depressed that it is hard for them to function", and AUCCCD's "85% of counseling center directors believe student's issues are more severe". Both are misleading. What is not reported in the first example is the meaning behind "depressed" and "function". Do 40% of students not get out of bed? Not sleep? Not eat? Not go to class? Higher education would collapse overnight if this were true. Regarding the AUCCCD survey item, I can testify as one who completes and submits it every year. The response options we are provided on the severity item include "increased", "decreased", and "unsure". "Remained the same" is not provided as an option. This would be my choice if it was. I believe this forced-choice results in a distortion, in this case an inflation concerning severity.

The data does say something, however it is not possible to say exactly what. One hypothesis is that both data points reflect a subjective sense of discomfort, and are mirror images of each other. Students are in fact uncomfortable and they readily admit to high levels of distress. Some of this is due to the stress and strain of growth and development. Some is due to changes in parenting patterns (about which I wrote previously). Some is due to global issues in politics, conflict, and economics. Many students have little faith that the degree they are working hard to earn will translate to a secure livelihood. In short, they are supposed to feel uncomfortable. I would too if I was them.

As for college counseling center directors, our discomfort is about meeting the needs of these students who are knocking on our doors with rising frequency. This is occurring in the context of a nationwide and chronic problem with under-funding and inadequate resources in many centers. Our subjective emotional state often involves something like panic and fatigue as we attempt to address the needs of the masses coming to us. We are supposed to feel uncomfortable too.

It's all about context. And context is missing from key surveys and thus the national discussion. 

Finding Your Voice: Assertiveness

In nearly 25 years of practice, I have not met or known anyone who did not need to improve their communication skills, including yours truly. All people struggle in expressing themselves and in deciphering the meaning of others' expressions. A vast body of psychological research has repeatedly demonstrated how communication is hampered by limits in perception including biases. We can spend the rest of our lives working on this and still not achieve perfection.

But we should try anyway. One simple way to begin is to classify our speech patterns in one of four types, aiming for the most effective one of the four: assertiveness. Here are the four types:

1. Passive: failing to express one's needs or preferences, or expressing them in such an indirect manner, such that one's rights are easily overlooked or violated.
2. Aggressive: expressing one's needs or preferences in a hostile manner such that other's rights are easily overlooked or violated.
3. Passive-aggressive: Communicating in a passive manner in another's presence and an aggressive manner in their absence. (Most of what we call drama originates with this pattern.)
4. Assertive: expressing one's needs and preferences in a calm, direct, clear, and often brief manner such that others respect them and theirs are respected at the same time.

Here's the thing. All of us are capable of using all of four types of communication. That is part of what makes us human. Additionally, we tend to use each type in specific circumstances and also with specific people. Some of us are assertive at home, but not at work. Or vice versa. Some of us are assertive with a partner, but not our friends. Or with women but not men. And so on. These patterns usually derive from negative or stressful experiences and the emotional injuries or traumas that go with them, resulting in fears and anxieties arising when we are confronted by similar situations. But as with any fear or anxiety these can be overcome if you work hard enough..

We can begin this work by learning to reliably identify the patterns we use, and when and with whom we use them. This takes a lot of focus and time, so patience is needed. Once these patterns have been identified, the next task is to identify the history behind the preference; we once had good reasons for avoiding assertive communications in some scenarios, but now we have to realize that those reasons are probably no longer valid.

Now the real work begins...we must increasingly employ assertive language across all situations and all people. As you can imagine, this takes a lot of work and it progresses slowly at first. But it tends to pick up pace once you have even minor successes, and at times moves very rapidly once you get the hang of it. The quality of our lives, including the overwhelming majority of successful stress management, is then enhanced accordingly.

If you'd like a resource to accompany you on this path, try Your Perfect Right: Assertiveness and Equality in Your Life and Relationships (2001), by Michael L. Emmons and Robert E. Alberti, Impact Publishers.

Love and War in Cyberspace

Students are quite adept at the practice of cyber-relationships. Email, IM, texting, gaming, Facebook, Twitter and other media have become popular communication methods for students, even replacing face-to-face contact for some. While such methods are appealing due to ease of use and apparent anonymity, students are often not aware of the potential problems that can result. Some of the bad things that happen in actual relationships, such as harassment, stalking, and predation, can also occur online. There is even evidence that social media use can result in negative mental health outcomes.

Here are a few tips on how to protect yourself in cyberworld:

• Protect your identity. It is not a good idea to inform the whole world of your hometown, birthdate, high school, address, telephone number, credit card information, or Social Security number. Even just one or two of these items gives a predator all the means they need to find you. Also, be aware that some online services allow users access to programs that identify the physical location of other users.
• If you are planning on actually meeting someone, request a photograph or other identifying information, and cancel your plans if he or she refuses or makes excuses.
• Also, speak with the person by telephone before meeting with him or her. You can learn a lot about a person by paying attention to their social skills.
• If you decide to meet someone, do so in a public place, tell a friend where you're going and with whom, and drive yourself to and from the meeting.
• Look for warning signals of an unhealthy relationship, whether it be online or not.
• Listen to your discomfort. If something is occurring online that makes you feel uncertain, disconnect.
• Don't break the law or violate your code of student conduct. Threats and verbal abuse that occur online are still subject to these provisions, and you'll have written proof of it too!
• Keep an online time limit. It's harder to do well in class when you're online for more than a couple of hours per day.
• Finally, there's nothing like a real, live human being. Make time to relate to others in real space too!

To learn more about protecting yourself online, talk with someone at your IT department and counseling service.

Rule of Thumb: Getting Involved

In some ways college students are more connected than ever. Social media has provided multiple methods of staying in touch with friends and sharing information and content. Gaming has also provided a venue of being connected with others and having fun at the same time.

But in other ways many students are not connected at all, and they struggle with "face-time" that is real and not just virtual. Many living environments are both heavily wired and private; if one chooses one may isolate for huge chunks of time and "communicate" widely, yet not actually interact with anyone at all. This is a recipe for diminishing mental health.

So here is a rule of thumb to protect against that deterioration: at least twice a week, get involved in something that takes you out of your living environment, puts you in physical contact with others, and has nothing to do with class, work, or partying. This simple strategy incorporates crucial skill sets which, once learned, will benefit you for a lifetime. The skills also promote good mental health and are also related to retention and academic success.

So what kinds of things can you do? Most students had interests and hobbies in middle and high school, but they may have drifted from them in the excitement of starting college. Consider returning to them, or perhaps be more adventurous and take up new ones. Psychologists believe that learning new skills every five years or so is actually protective of brain health, so it will be good for you on that score as well. On most campuses there are dozens if not hundreds of student organizations, covering topics such as sport, politics or advocacy, environmental awareness, outdoor recreation, art, and so on. If you can't find one that suits you, start your own. You can also see some ideas on this list. There is really no excuse not to try something.

On the other hand, there is no need to get over-involved, as this can lead to meaningless activity and burnout. Trying new activities also does not have to lead to long-term commitment. Simply try some and if they don't feel like a good fit, move on and try another. Frankly, what you pick does not matter. What matters is that you pick something in the first place, and that you expand your skills and relationships. This is part of the recipe for feeling satisfied and in good emotional health, and generally your grades will improve too. That's hard to beat!

Healthy Relationships in College

On this Valentine's Day, let's take a brief look at the ingredients of a good, healthy relationship. While the focus of this blog is on college students, what follows can certainly apply to anyone, at any age. College students have many opportunities to meet new friends and develop enriching relationships on campus. Such relationships can make the difference between a positive and negative college experience. It is important to know the difference between healthy and unhealthy relationships, and to know how to make choices to preserve the former and improve the latter. Here are a few hallmarks of a healthy relationship:

• Mutual respect and civility
• A sense of reciprocity, or "give and take"
• Feeling supported and supporting the other
• A significant degree of trust and honesty
• Fairness and equality as adults
• Comfort with emotional intimacy or closeness
• Comfort with distance and "separateness", or being able to have your own life apart from the other
• Open, direct communication without fear of reprisal, hidden agendas, or manipulation
• Good "boundaries", or being able to set personal limits with self and others

While no relationship is perfect and we all have bad days, students should be able to evaluate their relationships and feel, on the whole, that they are positive and healthy. If they are less than healthy, steps should be taken to improve them. Such steps involve both assertiveness and listening. If you have concerns about the state of your relationships with family members, friends, roommates, faculty, co-workers or others, contact your campus counseling service for assistance.

Wants and Needs

As higher education institutions have adopted business models a customer service orientation toward students has taken root. This is not always a bad thing. It helps faculty and staff stay on their toes and work hard to address legitimate needs of our consumers. It can serve to market the school well and also to advance its image and brand.

As with most things, however, there is a pernicious shadow to these trends, one that is anathema to college mental health which is all about addressing the needs of students. But customer service many times becomes more about satisfying wants. This in turn has created a phenomenon in which those around a student, such as parents, faculty, staff, administrators, and other stakeholders, have taken on a positively entitled, demanding posture concerning something they think should be done for a student. Sometimes there may be a positive basis for the expressed want, sometimes not.

Counseling and psychotherapy is about an individual's need to change something about themselves, something that is contributing to their own unhappiness. The things which need changing are determined by a trained professional, working collaboratively, who evaluates the individual's needs. Many times, early in therapy, clients focus on their wants and not their needs, but this is what may have led to the cultivation of life problems in the first place. Wants are often about being comfortable, while counseling, at least in the beginning, will entail a degree of discomfort. Lasting change is rarely if ever a comfortable process.

So we may face scenarios in which insisting on wants may actually lead to harm for a student, and therefore represent an abuse of counseling services. This we are obligated to prevent or stop altogether. Just as no one can dictate how a physician treats your ailing kidney, no one can dictate how psychotherapy is to be conducted (though insurance companies try to do this all the time). It is unhealthy for anyone to attempt to control what ought to be a collaborative working relationship between client and therapist. Counselors are obligated to uphold standards around this issue, so don't be surprised when they say "No." Of course, folks can seek other opinions elsewhere, where it it will be less convenient and more costly, if they like. Or they could give it several sessions first, say five or six, and then make judgements about the effectiveness of therapy after the discomfort begins to wane.

Vignette 5: What Would You Do?

Annie, a suicidal student

Background: Annie is a sophomore with a psychiatric history dating to age 12. She has had multiple depressive episodes and was hospitalized at 16 after a suicide attempt by overdose. She has been in some form of treatment off and on since she started high school. Annie engages in cutting but that is a coping measure and not suicidal in intent, though she frequently thinks about suicide.

Scene: Annie answers questions in class which alarm her instructor and classmates.

Dr. Hokumba: So, can you recall an experience in your life which is evoked by your reading this week? Yes, Annie?

Annie: (Raising her hand) Well, when I was sixteen I was sent to a hospital after I tried to kill myself. Let me tell ya, it was exactly like what Kafka said.

(Other students quickly turn around to look at Annie.)

Dr. Hokumba: I see. In what way?

Annie: (Holding up both wrists, which reveal very red marks on the wrists.) See? People freak out over this but I went because I overdosed. The hospital was like a maze just like Kafka spoke about. I never did figure out what was supposed to happen or what I was supposed to do. It just seemed like whatever I did was the wrong thing, but when I tried to do what they wanted it just made it worse, ya know?

(There is obvious discomfort among the students.)

Dr. Hokumba: (nervously) Anyone else?

Annie: But I’m used to it. I still think the way I used to. After all, suicide would have solved Kafka’s problem. My shrink says I am stubborn that way.

Dr. Hokumba: Annie, let’s talk more about that after class, OK?

(After class, Annie approaches Dr. Hokumba.)

Suggestions: First, if you plan on having class exercises which involve personal history, creative projections of fantasy, or stream of consciousness thinking, you need to be prepared to field and respond to disturbing material.  This means being familiar with sources of support, referral, and immediate crisis response.  In this vignette the student reveals her thinking is current and not just in the past, and the fact that she is in treatment already.  Make sure others in your area are aware of your meeting and consider having your campus police nearby for support if needed.  In your discussion encourage her to continue in treatment and make every effort to refer her for follow up that same day, either to the campus counseling service or her current therapist if she is being seen off campus.  Either way the situation warrants timely follow up in order to determine her current level of distress.  If in doubt, ask your campus counseling service to send a counselor to your office in order to make a literal handoff to those services.  There may be many other considerations involved which cannot be covered here, so follow the recommendations of the counselor as they are provided during your discussions.

Vignette 4: What Would You Do?

James, an angry student

Background: James is hostile and belligerent.  He frequently appears angry and disrespectful, addressing others with profanity and aggressive gestures.

Scene: James asks to meet with you about his grades.

Ms. Forney: So, James I understand you wanted to see me about your grades.  How can I help you?

James: (Loudly) You can help me by getting rid of all the jerks in my life!  These grades here (hands her some papers) are unfair.  Those damn idiots gave them to me because they don’t like what I have to say.

Ms. Forney: Calm down, James.  Start from the beginning so I know how to help you.

James: (Even louder) Don’t freakin’ tell me to calm down!  I am sick and tired of being treated this way!  And by people who don’t know anything!!  (Gestures with fists in the air) If they don’t stop, I swear I’ll…

Ms. Forney: (Anxious, exasperated) James, you seem angry at me too.  What have I done that upset…

James: You’ve been OK, I guess.  It’s the others that jack me up.  (Slams fist on table)  Talk to them and tell them to leave me alone!

Ms. Forney: I can’t do that James.  But maybe I can help you arrange a meeting with the people you need to talk to about this.

James: Yeah, right, another meeting.  You go ahead and do that.  But it won’t matter tomorrow… (gets up and leaves the office abruptly)

Ms. Forney gets a call from her secretary, Gail, who says:

Gail: Are you OK?  James just stormed out of here and threw a folder at me on his way out!!  I’ve never seen such anger in all my life!

Ms. Forney looks down at one of the papers James handed her.  In the margins James has written: Moron.  You will pay for this.  I will see to it.

Suggestions: Because there are strong indications of threat, as well as objective evidence of aggressiveness, a call to your campus police and behavior intervention or similar team is warranted.  Attorneys have said there is no FERPA impediment to this action, as the information involved represents observable behavior.  It is important to move swiftly so that James gets the help he needs.

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.

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.

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. 

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.

Sleep: Protecting An Essential Life Rhythm

Many college students do not sleep well.  In fact, the typical student pattern can best be described as chaotic.  In many cases these patterns exacerbate and even trigger poor mental health outcomes.  Bipolar and other mood disorders, for example, are known to be sensitive to inadequate or unhealthy sleep rhythms.  Sometimes sleep problems are caused by factors outside their direct control, such as loud roommates, a medical condition, or living near a train track.  In these circumstances vulnerable students should consider working toward changes in their health and living situations, admittedly not always an easy thing to do.  More often than not, however, a student's sleeping problem is caused by poor "sleep hygiene", or poor choices about sleep that are within their ability to alter.

Due to their youth and general level of energy and vitality, traditional-aged students may grossly underestimate their ability to cope with chaotic life rhythms.  The average 20-year old can in fact rebound from sleep deprivation better than, say, the average 40-year old.  But this subjective feeling may mask an underlying deterioration which may be occurring, even at the cellular level.  So, students can pull off all-nighters for a time, but that habit is soon to catch up with them in the form of worsening mood, impaired ability to focus and concentrate, and diminished academic or athletic performance.

One simple set of guidelines to follow: pick and stick to a regular, reasonable rise time, avoid daytime naps, and use the bed only for sleep and other relaxing activity.  Seven to nine hours of nighttime sleep may be ideal.  But there are other tips which may be helpful.

Here is a list of practices conducive to good sleep, adapted from the American Academy of Sleep Medicine (2002):

• Try to sleep only when you are drowsy.
• If you are unable to fall asleep or stay asleep, leave your bedroom and engage in a quiet activity elsewhere.  Do not permit yourself to fall asleep outside the bedroom.  Return to bed when - and only when - you are sleepy.  Repeat this process of often as necessary throughout the night.
• Maintain a regular arise time, even on days off work and on weekends.
• Use your bedroom only for sleep and relaxing activity.
• Avoid napping during the daytime.  If daytime sleepiness becomes overwhelming, limit nap time to a single nap of less than one hour, no later than 3 pm.
• Distract your mind.  Lying in bed unable to sleep and frustrated needs to be avoided.  Try reading or watching a videotape or listening to books on tape.  It may be necessary to go into another room to do these.
• Avoid caffeine within four to six hours of bedtime.
• Avoid the use of nicotine close to bedtime or during the night.
• Do not drink alcoholic beverages within four to six hours of bedtime.
• While a light snack before bedtime can help promote sound sleep, avoid large meals.
• Avoid strenuous exercise within six hours of bedtime.
• Minimize light, noise, and extremes in temperature in the bedroom.

Down in a Hole

Depression.  Churchill aptly called it "The Black Dog", though the alcohol and tobacco he reportedly consumed may have made it blacker.  Depression is so prevalent that it has often been called the common cold of mental health problems.  As an example, in its most recent annual report, the Center for Collegiate Mental Health noted that 31.6% of some 74,000 students seeking counseling endorsed just a single symptom consistent with depression (thoughts of suicide) at any level.  Endorsement rates for other depressive symptoms are in similar ranges.  SAMHSA reports that 8.4% of college students have experienced a major depressive episode in the past year, but also notes that this rate is not statistically different from that for non-college peers.  Some claim that rates of mental illness among American college students have increased, and reports of increased severity and emotional states which are incompatible with college life abound.  These observations are not without dispute in the college mental health community itself, in large part because other data don't square with the hypothesis.  For example, in the Center where I work, adjustment issues, a category one can think of as reflecting normal stresses and strains of living, still are the most common presenting problem and diagnosis, as they have been for the more than 20 years I have worked there.  By the way, depression was formerly number two in this ranking.  It has recently been overtaken by anxiety, which as you will see below supports other possible theories of dynamics in student functioning.

That is not to say there are no recent dramatic changes in college student behavior.  There is no question that the number, frequency and intensity of crises, for example, have increased during my career.  This has also been a steadfast observation among my counterparts for many years now.  Some, myself included, suspect that the phenomena we are seeing may not be due to diseases as defined in the medical model but rather to impairment in coping skills, which is somehow being transmitted across society and culture.  What could possibly account for the apparent rise in severity of what looks like more serious mental health problems?


All things being equal, the student with impaired coping ability will look "sicker" than the student with better skills.  I recall a student who struggled when she realized she did not know anything about how to look for a job, including understanding the classified ads.  In her next breath she also told me she did not know the location of the book store.  My friends, these statements were made in late October.  I assure you, she "looked" depressed, and if I only used a checklist I could say she had "depressive symptoms".  But depression in the medical sense was not her problem, per se.  She had somehow missed out on some very basic life skills which created the breeding ground for her symptoms.  This is but one example of a great many crisis situations in which I have been involved.  The facts change, but the essential pattern remains the same: the stresses of an environment or situation, most often involving relationships, exceeds the ability to cope.  Symptoms of depression and anxiety are the result.  Taking this a step further, this is the way it is supposed to be.  It is a clarion call for change.

Therapists of the analytic or psychodynamic ilk understand that the number and quality of our defenses against life's slings and arrows are what protect us from negative mental health.  When these defenses are too few or of poor quality, depression and anxiety are the expected outcome.  College life is interesting partly because it represents a distinct moment in time in which a late adolescent or young adult leaves familiarity, to which they have adjusted most, and joins novelty, to which they often have adjusted the least.  Any lack of preparation is likely to be revealed in short order.  This is because the defenses on which they have relied will fail.  (What former college student can look back on that time and not see that some of their behavior was "disordered"?)  "Symptoms" are often the result of reliance on defenses which are no longer working well.  Faced with this scenario humans tend to keep doing what they have always done, thereby digging down into the hole even further.  Yes, one could call that depression and throw medicine at it.  And it may even help in the short term.  But only lasting change in defenses will get students out of that hole.

Seeing a problem in living as an external entity which inhabits us, and which requires an external intervention, is a facile act.  It relieves us, students and parents alike, of a more complex responsibility to self and others: changing our behavior.  It also happens to be supported by enormous economic forces in healthcare industries which can, intentionally or not, keep us in a hole.  Any person well into recovery from a wide range of mental health states will tell you that assuming responsibility and agency was the essential ingredient to success, even when external interventions are taken into account.  That is one sound way out of the hole.

Heroic Students

Few things in my professional life have been more rewarding than to witness college students overcoming tremendous obstacles to their success and happiness.  For most of those around them, professors and administrators, friends and sometimes even family, their struggles were invisible and silent.  Working with them in the privacy and safety of therapy, college mental health professionals are privileged to nurture their strength, shore up battered psyches, and nudge them in the directions they need to travel.

I wish I had the memory banks to tell each of their stories.  Everyone can benefit from seeing how a young adult bravely confronts horrendous conditions and accomplish things that many of us never have or will.  Here are some examples, disguised and condensed for the sake of confidentiality.

• Tyrell, 21, came from extreme poverty and at one point lived in his car on the edge of campus.  He was the first in his family to attend college, and he was determined to graduate and make something of himself.  It took unrelenting energy and conviction to rise each morning, stay awake in class, and disregard the doubts from within and without, but he got his diploma.
• Janie, 19, saddled with a history of physical, sexual and emotional trauma at the hands of adults who were supposed to be her caretakers.  Her days were filled with intense fear and phobic anxiety; just sitting in class around other students, thinking they were judging her, took gargantuan effort.  She battled impulses to harm herself and exit her life altogether, but deep inside there was a constant, though sometimes faint, voice which told her there were other possibilities in her life.  Class attendance and grades were far from perfect, but she did not give up or quit.  She registered each semester, and worked on her goals persistently, not with great force, but like ocean waves on the shore.
• Will, 23, lost and roaming in the grip of various addictions he brought to college with him.  He encountered many entanglements with friends, family, the legal system.  He had to face academic probation more than once.  Will sought treatment several times, each with the same outcome: relapse.  With enough support and encouragement he entered treatment one more time, and began a 12-step program.  There were ups and downs even then, but he did better in school and eventually graduated.
• Beatrice, 18, in great distress over her gender and sexual identity.  She encountered frequent harassment and bullying from middle school forward.  Those who professed love for her rejected her emotionally, and also communicated not-so-vague threats of disowning her altogether.  The simple act of walking across campus took immense fortitude and exhausted her at times.  Through therapy, she found supportive others and got engaged in activism and justice for all students.  This empowered her and gave her confidence to be herself and interact with others respectfully and assertively.

There are so many more stories to tell.  In each case, the student clung tightly to something dim but abiding in their core: a genuine, healthier self which sought expression and release.  So many have lost this fight.  We have all known them in our lives, and we would all do well to use our powers to "see" the whole person in front of us, imagining a great struggle in which they are engaged, and facilitating their journey into being who they really are, which is always the path to emotional health.