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.

Experiences Shape the Brain

Much has been said and written on the subject of medication and its role in mental health care.  Perhaps too much.  Though it is growing, comparatively little has been said or noticed about other ways the brain is and can be shaped in order to improve emotional well being.  Let's take a brief look at how experiences, both positive and negative, influence brain development and functioning.

A recent study, for example, examined the transmission of anxiety from parents to children.  This research found that socially anxious parents imparted anxiety through specific parenting behaviors involving lack of warmth and affection, and criticism and doubt directed toward the child.  The role of these experiences is thought to contribute to the development of anxiety apart from genetic contributions, because the latter alone are not thought to be sufficient in the etiology of an anxiety disorder.  It does not require a tremendous leap to imagine that parental warmth and confidence provided to children reduces the likelihood of a future anxiety disorder.  The experience of warmth and confidence is more powerful, in my opinion, than any medication we would later give to the adult child to address their anxieties.  And more lasting too.

In another arena, a play-based method of teaching social interaction, called ESDM, to autistic children was shown to result in positive brain changes.  Researchers studied brain activity in both autistic and non-autistic children, after the former received the therapy for two years, and could not identity differences which are apparent otherwise.  Clearly, this behavioral intervention altered brain activity in a very desirable manner.  I'll wager that there are not many parents of children with autism who would not jump at the chance of this non-medical or intrusive intervention.  If only they were given the chance, or that such behavioral interventions were as aggressively marketed as medications are.

Currently, one has to dig deeply into the literature or perhaps be lucky enough to have an insightful and gifted care provider to access information about evidence-based psychological interventions.  The American Psychological Association does maintain resources on these interventions on their very good web site and Help Center (www.apa.org).  I encourage consumers to be educated concerning these alternatives to physiological interventions, which, in my experience are helpful at times and with some individuals, though the benefits come with cost and ultimately fade with time.

Experiences shape the brain.  Those who have experienced stress, trauma and deprivations have brains, and even appearances, which show this.  Those who have experienced positive relationships and satisfaction of needs also have brains which show that.  It would seem, given that we know this, that individuals, groups, communities and even countries would develop systems which promote the application of sound psychological principles to the advancement of human welfare.

A Gathering of Colleagues

This week I have been attending the annual conference of the Association of University and College Counseling Center Directors, or AUCCCD, in Newport, RI.  I have previously written about the importance of this organization to our field (see post of January 3, 2012).  It is not an overstatement to say this conference is among the professional highlights of my year.  It is a time for colleagues to understand and support each other in sometimes very difficult work, for us to learn best and innovative practices undertaken in other centers, and for us to advocate for this profession and the communities and students we serve.  It is absolutely essential for college mental health administrators to participate in this association and its main communication vehicle, its listserv.

I joined AUCCCD as a brand new and wet-behind-the-ears director in 1998, and my earliest interactions with my peers occurred on the listserv.  Though there are a few texts relating to college mental health, there are certainly no manuals, no compendium of wisdom regarding establishing, maintaining and growing a fully functional college mental health service.  Thankfully this wisdom is accessible from the board and membership of this organization.  In a relatively short time I was able to develop benchmarks for our Center, to learn about standards and accreditation processes for the field, and to understand the distance we had to travel to bring our work closer to that which we aspired.  This simply could not be found elsewhere.  Without its support many centers would not be where the are today: vibrant and essential partners in the campus community.

I can site examples of various meetings and keynotes which were helpful this year.  Learning about the developments and future of the Center for Collegiate Mental Health (also discussed previously), understanding generational differences among counseling center staff members, listening to directors of institutions the same size as my own, and hearing Patrick Kennedy address the civil rights issue of equal access to mental health care are all memorable.  But hallway and lunchtime conversations with colleagues were just as important, for one very simple reason.  These interactions help us address the hazard of professional isolation which can be endemic in the mental health professions.  Because so much of our work is private and cannot be shared with others we simply must have mechanisms which facilitate dialog in a safe and trusting environment, devoid of pettiness, posturing and politics, where everyone has the obligation of maintaining the same level of confidentiality. This ingredient or attitude, set in place by its sage founders many years ago, promotes the development of administrators and the centers they manage.  It is a priceless benefit of membership in AUCCCD.

If you are thinking of pursuing a career in college mental health, and perhaps rising through the ranks to leadership roles, you must remember and join AUCCCD when the time comes.

Perception and Automatic Thoughts

Understanding the limits of human perception is an essential ingredient to good mental health and good communication skills.  Take any decent Psych 101 course and you will see just how limited our perceptual skills can be.  Long ago, during a lecture, I held up a plain sheet of yellow paper.  The yellow color could be described, in objective fashion, by its emitted wavelength and that would probably be well beyond dispute.  But that did not interest me.  I asked the audience to write down what they saw and any thoughts or feelings which arose from the "stimulus", the yellow paper.  There were, quite literally, as many perceptions as there were people in the room, though of course everyone "saw" the exact same thing.

How much more complex, then, are the other things we all experience in the course of our lives?  Yet all of us, often beyond our awareness, form impressions and interpretations of very complex information, and this in turn often leads to choices and actions which impact our lives and the lives of others.  Some of these make us happy, and some definitely do not.  By the time we reach early adolescence this dynamic has become like a reflex; it is lightning quick and automatic.  It is also dangerous.  You know what "they" say about assumptions.  "They" are correct.

The scale of this pattern of human behavior is enormous.  In a recent article, psychologist Jonathan Haidt discussed the science behind political and religious polarization in America, which has led to and may well lead to a great many more social conflicts and problems.  This polarization is partly borne of reflexive assumptions and automatic thoughts.  We would all do well to slow down, understand that we may be making attribution errors, and actively seek disconfirming evidence for our interpretations.  This is admittedly a difficult thing to do, given our well-researched human nature in this area.

But try we must, if we hope to have sound emotional health and positive relationships.  The recipe is actually quite simple.  Question what you think you see and understand.  Take your time, as very few things in life require instantaneous responding.  If you experience strong emotion, wait until the immediate feelings subside a little before you do the cognitive work of analyzing information.  This gives our higher cortex a chance to do its magic instead of our being controlled by the more primitive, reptilian portions of the brain.  Check out your understanding by getting feedback from others.  The payoff is tremendous: often we learn that what we thought we understood was WAY off.  Have you ever fired off an email or text and immediately wished you could suck it back through the electronic ether?  Then you know what I am talking about.

So really, it comes down to humility.  Knowing that we have a limited range of perception means knowing that we are often capable of being wrong.  It helps us exercise caution in forming conclusions about ourselves and others and the world around us.  Benefits of this practice are improved mood and self-esteem, and improved relating with individuals, groups, and cultures.  That makes it very worthwhile.

Loss of Chewing Ability May Be Linked to Dementia

Researchers from the Department of Dental Medicine and the Aging Research Center (ARC) at Karolinska Institutet and from Karlstad University in Sweden suggest that the loss of chewing ability may be linked to cognitive decline and a higher risk of dementia.

Dementia is a serious loss of global cognitive ability in a previously unimpaired person, beyond what might be expected from normal aging. It is not considered a single disease, but rather a set of signs and symptoms, in which affected areas of cognition may be memory, attention, language, and problem solving.

The study randomly selected a nationwide sample of 577 participants aged 77 or older to investigate tooth loss, chewing ability and cognitive function. Results showed that individuals that experienced more difficulty chewing hard foods were more at risk of developing cognitive impairments, even when controlling other variables such as sex, age, education and mental health. In addition, chewing with dentures or real teeth had no impact on their results.

It could be that “few or no teeth makes chewing difficult, which leads to a reduction in the blood flow to the brain. However, to date there has been no direct investigation into the significance of chewing ability in a national representative sample of elderly people.”

Unfortunately, this study does not specify whether all participants consumed similarly nutritious meals. Those with a reduced ability to chew certain foods may have been malnourished, which could have played a major role in their cognitive decline.

Nevertheless, the preliminary results of such research certainly provide further support for the fact that oral health impacts overall health. Good oral health brings significant benefits to self-esteem, dignity, social integration and general nutrition.

According the World Health Organization, the proportion of people aged 60 years and older is growing faster than any other age group, as a result of both longer life expectancy and declining fertility rates. Therefore, as our society ages, this type of research becomes more and more relevant…

• As of 2010, more than 35.6 million people worldwide are living with dementia, or more than the total population of Canada.


• The global prevalence of dementia stands to double every 20 years, to 65.7 million in 2030, and 115.4 million in 2050.


• Total health-care costs for people with dementia amount to more than 1 per cent of the global gross domestic product (GDP), or US$604 billion in 2010.

Chewing Ability Linked to Reduced Dementia Risk
Dementia
Ageing
Facts about dementia

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Early Emotional Neglect May Predict Strokes

New research conducted by the Rush Alzheimer's Disease Center at Rush University Medical Center suggests that emotionally neglected children are at risk of stroke as adults. 

"Studies have shown that children who were neglected emotionally in childhood are at an increased risk of a slew of psychiatric disorders. However, our study is one of few that looked at an association between emotional neglect and stroke," said study author Robert S. Wilson, PhD, a neuropsychologist at Rush.

Researchers’ selected 1,040 participants aged 55+ without dementia from the Memory and Aging Project were surveyed on physical and emotional abuse before the age of 18. Participants were questioned on such areas as how much love they felt from their parents or caregivers as children, whether they felt afraid or intimidated by their caregivers, the method of physical punishment suffered and other questions relating to divorce and family finances.

The participants were followed over a period of 3.5 years. In that time, 257 participants had died. Of the deceased participants, only 192 had brain autopsies, which revealed that 89 of them had experienced strokes. Furthermore, forty of the participants were said to have had strokes based on medical history or an examination.

Furthermore, participants that expressed moderately high levels of emotional neglect in childhood were nearly 3 times more likely to experience a stroke than those reporting moderately low levels of emotional childhood neglect, even when other factors such as diabetes, physical activity, smoking, anxiety and heart problems were controlled.

"The results add to a growing body of evidence suggesting that early life factors such as traumatic childhood experiences influence the development of physical illness and common chronic conditions of old age" says Dr. David A. Bennett, director of the Rush Alzheimer's Disease Center and co-author of the study

Of course results may not be completely reliable since this study relies on a self-report of recalled events many years later, which may be even further clouded given the nature of the potentially traumatic memories.

Emotional Neglect in Children Linked to Increased Stroke Risk Later in Life

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