As medicine has adopted electronic records systems and pushed for integrated health care operations (the actual working definition of which varies widely), concerns about privacy and oversharing records have arisen. A recent Google search for this erosion of privacy resulted in 97,600,000 hits. In 2015 an estimated 100 million health care records were stolen, affecting approximately one out of every three Americans, an increase of 11,000 percent over the previous year. Clearly security has not kept pace with developments in the technology involved. This situation is ripe for lawsuits.
Some have warned that such records systems can lead to other types of damages, pointing to 147 such adverse events in 2013 alone, and have clearly advised for the separation of physical and mental health records. There has also been a successful movement in Minnesota which is using legislation to challenge forced shared records adoption by psychologists in health care settings. Its leaders cite two main motivations: potential for harm, and the right of psychologists to govern their own practices.
As if this was not of enough concern, some of these operational models, which may include mental health services, also build in compulsory "consent" to share records with unnamed "healthcare professionals". I say compulsory because this consent is required in order to receive services. This consent process occurs when one is under the duress of suffering, and before one can know what exactly is in the record, the purpose of the sharing, and who specifically will receive it. This means that such a process fails to secure informed consent, part of the ethical bedrock of the mental health professions, something we learn almost from the moment we set foot in training programs.
In all 50 states clients of a variety of mental health professionals are granted the right of privileged communication in therapy. Aside from exceptions having to do with harm to self or others this right is absolute; no third party has an entitlement to this information. Compulsory consent processes force therapy clients to waive the right of privilege in toto; once it is waived there is no longer any privilege. No other professional services for which persons may claim privilege (clergy, attorneys) engage in compulsory consent in order to receive their assistance.
This is so because it is ethically and morally wrong.
In addition to the violation of informed consent and right of privilege, these practices fail to respect the autonomy of persons, their right to self-determination and choice. They also fail to act with integrity, beneficence and non-maleficence in carrying out professional services. These duties are spelled out in the ethical codes of all mental health professions in one way or another.
Compulsory and total consent processes are sought after presumably for two reasons: perceived ease of communication, and the convenience of business procedures including billing (in all honesty I think the latter is the real motivation). It is claimed that such conveniences result in improved outcomes, but research support for that is mixed. Where support exists it regards those who cannot speak for themselves, such as the very young, the very old, and those who have been deemed incompetent. It is an injustice to treat all persons in this same manner. Further, an informed consent process at the point information is needed has always been available. In 25 years of practice I have never known this to not work well.
Combine lack of security with totally open mental health records and you have an enormous problem. Oversharing and failure to respect persons will lead to injury and therefore litigation. That is one way to resolve these predicaments. The media will also get involved, and that is another potential pathway to resolution. Or we could all just go ahead and do the right thing.
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.
Does mental health and politics mix? Yes and no. The type of politics represented by consensus-building grassroots efforts, informed by solid data, to advocate for better policy and services definitely has a role to play in improving mental health care. Barbara Mikulski's work to improve parity in mental health is a prime example of this.
There is another kind of politics which has no place in mental health communities or movements. This type of politics seeks to gain attention primarily for its sponsors, tends to rely on spin or distortions of data which capture attention and followers, and avoids building consensus or involving stakeholders in any genuine sense. Such attempts are often short-lived because its true motives are shallow, which means true advocates will not stay on long. In reality, these methods result in harm for mental health and those who are in the trenches fighting for its advocacy. If they do produce a policy or service these will be faulty since the data they are built on are faulty as well, likely causing conflict or confusion among stakeholders. The sponsors of these movements tend to move on to other projects rather quickly, and qualified others do not step in their place to sustain what they started. Sometimes a group of vendors will develop related products, but their main goal is financial and has little to do with improving mental health care. Various attempts in support of conversion therapy for homosexuality, which has resoundingly been condemned in nearly all professional circles, are perhaps good examples of this type of politics. But many other, smaller movements are more mundane and numerous than this.
We have a short supply of the type of work Mikulski has carried out. But we have an abundance of the other. Those working in mental health professions are always looking, if not starving, for help. When approached by marketers or politicians there can be a real temptation to take the bait. The switch comes later of course, and by then there will disappointment that one's expertise or carefully maintained information drew no attention in the development of the product or cause. A far worse outcome may involve a cheap and immature denigration of your work in order to falsely contrast it with what is being sold.
So, here are some tips in managing these contacts:- Do thorough research on the individual or cause before you meet with them
- Involve other stakeholders and witnesses to the discussions and agreements
- Put any agreements in writing with signatures of all concerned
- Consider contacting the media with your perspectives on project development
- Push out content broadly on social media
- Maintain fidelity to your philosophy and work throughout the process
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.
Recently, the president of a college in Oklahoma penned a note on the school's web site in response to a student who apparently complained about feeling victimized by a sermon there. Dr. Piper pointed out rather adamantly that higher education is for learning which often involves, by definition, sometimes feeling uncomfortable. He expressed the same frustrations felt by many in the field who daily struggle with the unreasonable expectations of students and others. As higher education has adopted business models along with that came a customer service orientation, not that this is always a bad thing. It can be a very good thing to improve one's services and meet the needs of customers. Sometimes, however, this progresses into an orientation of entitlement such that the customer may demand the product (a degree) with as little discomfort (dissonance or struggling) as possible, much as one might do when one purchases, say, shoes. This obviously flies the face of time-worn traditions in education since the time of Socrates. Further, those of us in the mental health professions know that any growth worth achieving is difficult, while the rewards of the struggle are enormous and life-altering.
In another part of the blogosphere, a student countered with her own message that the notion of the coddled college student is a myth. Ms. Sampath rightly points out that a great many students have real struggles having to do with overcoming trauma, discrimination, and harassment. She notes that today's student may be more vocal in their search for recognition and equality in education. There is truth in this, though I believe more so for the individual; group activism on many campuses is at an all-time low.
The two authors are both right though they capture trends in education from different vantage points. This should not be surprising since one is an administrator and one is a student, populations that often do not see eye-to-eye. We should listen carefully to both. Incorporating and adjusting to the student experience is paramount if we hope to remain relevant and just in our work. At the same time we need to uphold reasonable boundaries with respect to expectations or else we diminish our product, an educated and balanced citizen, substantially. Should we understand who our students are and how they best succeed? Absolutely. Should we allow their parents to schedule appointments for them, or lobby for a better grade? Positively not.
As with most things in life, the devil of this debate is in the details, and the truth is somewhere in between. Let's find it.
We are living in a strange time in college mental health. One the one hand we are negotiating through thorny issues related to trigger warnings in higher education; faculty now are being counseled to take care to issue warnings to those who may be offended by course content, to soften their language, or to avoid upsetting topics altogether. Trigger warnings actually have a long history in mental health, starting with helping combat soldiers recover from trauma, then later survivors of sexual or physical trauma for the same reason. The concept now has expanded to virtually anyone with a sensitivity to something (is there anyone who does not have this?). Emotions are high on all sides of this issue. Those in recovery do not want to be overlooked or re-traumatized. Teachers and other leaders do want their speech infringed.
On the other hand, those of us working in higher education are increasingly alarmed about the press on "school shootings" (though many of these are actually targeted crimes and not random episodes of violence). Also unsettling are the debates about open and concealed carry of firearms on campus. Some have left the field altogether due to their anxiety over this. Campus police departments tend to align with the opposition to carry, and even these experts in campus safety are concerned. Others seem aloof, uninformed, or blindly supportive with no acknowledgement of the complexities involved.
So everyone has a right to their opinion, and there are good reasons for having several different views on these matters. But, seriously, are we to soften the hardships of life for everyone through our speech, but harden life for everyone through access to our weapons?
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:- 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.
- Aggressive: expressing one's needs or preferences in a hostile manner such that other's rights are easily overlooked or violated.
- 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.)
- 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.
