Effective Campus Consultations

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

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

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

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

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

A smoking ban for mental health workers at the workplace

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

The Question of Marijuana

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

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

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

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

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

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

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

Sleep Quality Linked to Alzheimer's Disease

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

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

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

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

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

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

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

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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.