Emotional Health in the Transition to College Life

College mental health professionals want the beginning of your college experience to be healthy and rewarding.  Incoming students with concerns about emotional health, including a history of psychological or psychiatric conditions, need to take care to preserve the progress they have made in treating those conditions.  Following some rather simple guidelines before and right after you arrive on campus can help ensure that your early days on campus are productive and enjoyable.  What follows are generic considerations only.

Health Insurance

Check your health insurance policies and make sure they are up-to-date.  If you are in the position of making decisions concerning health insurance, choose plans that provide for mental health services on a par with medical coverage.  Ideally, your plan will provide adequate coverage for therapy or counseling services, psychiatric services, and medication.  Also, before you arrive, check your plan to see what providers in your new home are covered by your plan.  If you find that there are few or none on that list, contact your insurance representative and ask for local providers to be included.  If you are unsure about which providers could be included, contact your campus mental health service.

Health Records

If possible, bring copies of your important health records with you to campus.  This may include copies of medical, psychiatric and therapy records.  In most cases, summaries of these records will suffice.  You have the right to ask any health or mental health care provider you have seen to send your records.  You can and should ask your home providers to send these records to your new campus area providers, but if possible keeping copies for yourself is a good idea.  It is very important that your local providers have this information, as it improves the continuity of the care you have received.  This is especially true of any records relating to psychological testing, even if it occurred several years earlier.  Without such records it may feel like you are starting all over again, resulting in unnecessary delays in your treatment and progress.

Referral to Local Providers

Your current providers can and should offer to assist you with a local referral.  Your campus mental health service can also assist you with such referrals.  In general we believe that students who are taking any form of psychotropic medicines, such as anti-depressants and anti-anxiety medications, should also be in therapy or counseling due to research that suggests superior results when the two are combined.  Students with a history of any serious disorder, such as chronic addictions, Bipolar Disorder, Schizophrenia, and Personality Disorders, should arrange for long-term care well ahead of their arrival on campus.  Due to the long-term nature of such conditions, treatment by private mental health professionals off campus is sometimes indicated.  Finding and securing the appropriate providers will avoid the “ping-pong” effect that some students experience if they delay treatment or seek it in a random manner.

Use and Misuse of Medication

If you have been on medication prior to your arrival on campus, it is highly important that you remain on it during the transition to college.  Make sure that your prescriptions are current and that you have an adequate supply, at least enough to last two months.  Many students have the idea that college is a “new start” and that the stresses they experience will somehow disappear when they arrive.  Many underestimate the normal stresses and strains of college life, and by the time this is apparent to them it may be very late in the first semester.  When a student discontinues medication it sometimes takes weeks or even months to recover previous gains.  For example, it is not uncommon for a student who relapses in October to not be fully functional until December or January, too late to make up for any losses that may have occurred in the fall semester.

Avoid any misuse of your and others’ medication.  Take it as prescribed to you and don’t make changes in dosages without consulting your physician or psychiatrist.  Avoid taking medication prescribed for others, or giving your own medication to others.  This can lead to problematic or even disastrous consequences including side-effects, serious medical complications, and death.  It may also be against the law.

A Word about Attention-Deficit Conditions

If you have been diagnosed with an attention-deficit disorder before your arrival on campus, follow the same guidelines as noted above.  Remember to give your local providers all past and current information about your condition.  If you have never been diagnosed with such a disorder but notice problems with attention or concentration after beginning college courses and suspect an attention-deficit disorder, please keep a few things in mind:

• Almost all college students experience challenges to focus and concentration.
• Other conditions or disorders can mimic an attention-deficit disorder, including anxiety disorders, acute stress disorders, some mood disorders, substance abuse disorders, and even ordinary family or relationship conflict.
• Diagnosing an adult with an attention-deficit disorder is more complicated than diagnosing a child or early adolescent.  Ideally, a battery of psychological tests is used to confirm the diagnosis.  Simply relying on self-report or symptom checklists can result in a misdiagnosis.
• The criteria for an attention-deficit condition include impairment in two areas of functioning prior to age seven.  If you have a history of adequate or better academic performance it may be unlikely that you have an attention-deficit disorder. 

For Parents and Family Members

In addition to observing the practices listed above, families can play an important role in monitoring loved ones on campus.  Regularly ask your student whether they are receiving treatment or taking medications.  For serious conditions, get confirmation from the providers’ offices.  Watch for early signs of adequate adjustment to college and academic performance.  If you see indications of relapsing or slippage, follow-up promptly.  This can sometimes involve making a trip to campus to check on your student.  Consult with your student’s providers, while taking care to respect their right to privacy and some degree of control over their affairs.  If their providers give you suggestions or advice about how to manage a specific issue, follow it carefully.

Conclusion

Again, these are all simple principles in the management of emotional health care of students.  Professional experience is that the time devoted to following such guidelines is small compared to that spent on rectifying problems later on.  If you have other questions not addressed here, please contact your campus mental health service for assistance.

Time to Heal: Developmental and Medical Models of Service

Ty Cobb was once asked to describe baseball.  After a moment's pause he said "It's something like a war."  There is something like a war occurring in professional mental health communities, most recently rekindled through the debates on the development of the DSM-V, a diagnostic manual.  See a Scientific American blog series on this issue for more information.  This war has many facets, from economic if not downright mercenary (involving the coding of disorders and therefore billing of encounters), to treatment - given connections to the pharmaceutical industry, to, perhaps most broadly, a starkly contrasting view of human beings and their problems.  In this humble writer's view, nowhere is this contrast more palpable or consequential than in college mental health settings.

Late adolescents and early adults exist in the throes of a volatile period of human development.  As I have mentioned in previous posts, their psyches are roiling with energy, literally bubbling over as they experiment with identity in their search to find authenticity and manifest the real self in the world.  Anyone who remembers those years can resonate with this time marked by fear, various forms of aggression, behavioral instability, relationship turmoil, and academic or career missteps.  This volatility is quite simply inherent in, and in fact necessary to, their growth.  And as any parent knows, it takes a lot of patience for outsiders to see this process through, to support but also avoid negatively contaminating it in some way.  Contaminating development can send youth off onto an unintended and unneeded life trajectory, and this may be quite harmful indeed.  Forces which discourage or abort patience in work with youth stoke the flames of warfare between developmentally- and medically-oriented disciplines.


To address any temptation toward dichotomous thinking or polarization, which seems so rife in society today, let me be clear.  Medicine as a thoughtful profession and considered practice is a wonderful thing, capable of using its many massive powers to alleviate human suffering and facilitate human growth.  No one in their right mind can rationally argue otherwise.  But any thoughtless or unconsidered practice is capable of great harm, no matter the profession.


Recently, the former chair of the DSM-IV Task Force, Allen Francis, who is himself a physician, wrote a brief essay on the harm caused by misdiagnosing and mislabeling.  He counsels us to use caution and patience in this process, a very wise statement indeed.  Unfortunately, those individuals and entities who stand to make a great deal of money from the industry are working in the opposite direction.  Their apparent purpose is to transform medicine's grand promise into a ghastly and speedy intervention delivery system, which may result in incorrectly pathologizing, hospitalizing and/or medicating consumers.  Or worse.  In a rather breathtaking development, one vendor is advocating for the utilization of instruments to render diagnoses in three minutes, and reducing one's mental health status to a single number!


Given the complexities of college student life and development, I simply don't know how anyone, with any tool or level of experience, can accurately diagnose youth in three minutes.  Or in 10 to 15 minutes, the average duration of many medical encounters.  It takes time to understand the bubbling psyches of young and old alike.  Susie and Johnnie may meet "the criteria" others establish for disorder X, but that may not in any but the most cursory way capture the essence of what is happening with them.  This hypothesis does not compute in those who want fast and efficient delivery of products.  Susie may be caught in a cycle of fear and anger based in years of psychological torment in family dynamics, which she cannot even articulate in hours and hours of encounters.  Johnnie may have difficulty focusing due to years of exposure to video games and substance use, the latter of which he hides from others, and the anger he feels toward his father who abandoned him.


Susie and Johnnie deserve our time and attention, our best effort in creating environments which encourage them to tell their stories and be healed.  Let's support and fund those that provide such environments.

The Essential Magic of Confidentiality

It may not be well known to those outside of higher education, but there is a tremendous amount of energy behind the search for information concerning college students.  From vendors to credit card companies to judicial networks to administrators and parents, a great many individuals and entities want the skinny on students.  Sometimes the desire is based in altruistic and other well-intentioned motives; some times it is decidedly not.  Even when the motives are healthy, a very few understand the impact of this search on the campus mental health service and, more importantly, on the student seeking mental health services.


Students are like any consumers in that they want value for their time and dollar.  They are in my experience pretty savvy customers, and fairly merciless when they are not convinced or disappointed with the service they receive.  Outfits that deign to provide those services better darn well have some magic in their goods, or the student is out the door before they know what hit them.  And therein lies the problem for college counseling centers.


One could argue that there is an enormous amount of value in mental health services.  And one would be correct.  The opportunity to learn about the self, to manifest authentic and healthy adulthood, to remedy past trauma, to have a healing relationship, and to live free of terrible symptoms are wondrous gifts provided by skilled hands.  But the average college student does not, probably can not, see this at the outset and sometimes even for awhile after that.  It's difficult for anyone to fathom life in the absence of pain, or the beauty of what it is like to be a genuine self.

Oh but what they can see is the gift of privacy, of having at least one place in their lives where they can say what they want and try out various selves until they find the one that fits.  College students can see this even before they dial the center's number or visit the office itself.  It will be clear to them in advertisement and in the physical orientation of the office.  It will be clear to them within minutes of entering the facility and of talking with a therapist.  And it will be very obvious to them as the service negotiates through requests and demands for information concerning them.  This is the essential magic of mental health services, the magic that breeds all other magic the services can provide.  Without it no other benefits accrue; it is the oxygen of therapy and change.  Even the slightest ill-considered breach of this boundary can be fatal to healing, though students generally understand when good communication is necessary.


All others in the student's life simply must understand this.  Everyone, from a police officer to a dean, must respect this fundamental truth if they have interests in the developmental goals of students.  In the overwhelming majority of situations, the goals of society and institutions are not that different from the goals of students; there is a great deal of overlap.  If you tamper with or deprive this magic, a vacuum is created and positive growth is stunted or terminated.  A very simple but oft-overlooked principle is to ask the student for the information you want.  Allow them the autonomy and self-determination which is embedded in our federal constitution, for all of us in the United States of America, in these words: life, liberty, and the pursuit of happiness.

Test Mastery

All students have attitudes about and reflexes toward taking tests.  In the college student, these are acquired over many years' experiences with testing, leading to conditioning of thought, emotion and behavior.  If students are not aware of these factors they will influence their responses to exams and control them, sometimes unconsciously.  Fortunately, just as behavior can be conditioned so it can be unconditioned, if you will.  But it takes knowledge, practice and skill.  Anyone can learn these skills and that is the good news.


First, beware of negative attitudes such as pessimism, magnification, catastrophic thinking and fatalism.  These thought patterns will diminish performance before the test even begins.  So check yourself for "stinking thinking" well ahead of the exam, such as when you are in class and during study.

In order to manage thoughts, we must increase awareness of negative thinking and actively combat those patterns when they are detected.  Here are some examples:

• Pessimism: these are thoughts of doom and gloom about testing or performance.  Address these by countering with “I am qualified to be in this program and if I work hard enough I will do well enough.”
• Magnification: thoughts like this magnify the importance of an exam way beyond what is healthy.  Respond with “This is one exam among many and it is no more or less important than the others.”
• Catastrophic thinking: this form of thought leads one to believe life as we know it will be over if we don't do well on a test.  Counter with “One way or another everything is going to work out OK.”  (This is absolutely true, by the way).
• Fatalism: these are thoughts that we will get the same outcomes no matter what we do.  Address this with “My effort counts.  Good preparation will get good results.”

Say them aloud when you can, and to yourself when you can't.  Repeat them, over and over again, even if you question or doubt them.  Remember, you are working on reconditioning your thinking in ways that promote good performance, not dismantle your confidence.  Some find it helpful to place colored stickers in places which will remind you of positive thinking, such as a backpack, notepad, refrigerator, or mirror.  A colored bracelet can also serve the same purpose.

The second part of test mastery involves managing anxiety.  This step is highly important as anxiety interferes with higher cortical processing.  Students who "go blank" during exams often have so much anxiety that it blocks access to memory.  Negative experiences with exams sometimes condition people to have anxiety reactions before, during and after them.  But this too can be undone if you work on it.

• The single best antidote to test anxiety is good preparation.  There are no shortcuts here!  See my earlier post on study habits and skills for more information on this topic.
• Don’t defeat yourself through negative habits related to eating, sleeping, and partying.  You must get enough of each, but not too much!  We perform at our best when our bodies are appropriately nurtured.
• Avoid “anxious talk” and anxiety-provoking situations.  There is no point in asking classmates last-minute questions, or in participating in hallway comparisons before the exam.  There's always someone who will say things like "I studied for 48 hours straight!", or "I'm going to ace this one just like I did the last one."  Statements like these can make us feel bad, even if there's no truth to them at all.
• Learn to manipulate your physiological anxiety response through focused attention and controlled breathing, both before and during exams.  A psychologist can help you learn these skills.
• Follow the principles of exposure and desensitization.  This means placing yourself in situations similar to testing, repeatedly and long enough to experience a reduction in anxiety.
• Practice testing, engage in testing rehearsal, and engage in actual test-taking in the same or similar environments.  Many benefit from taking a practice test in the same room where the actual test will occur.  Obviously, one must have the instructor's approval for this.
• Understand your degree of reactivity.  If it is very high, medication may be needed, but NEVER by itself.  A little therapy will maximize the benefits of the medication, and help you address issues on your own once you stop taking it.

With some effort and practice you can condition yourself to think positively and remain calm and focused during exams.  This gives your brain a good shot at accessing memory and performing well when it counts.  So go get 'em!

The importance of family support

Fourteen years ago, after working  11 years at mental hospital wards  I started working as a community psychiatric nurse. A month later I had to take my partner to a psychiatrist because he was psychotic. An unexpected  experience.

It started on a Saturday. We decided to wait till tuesday  so we could see the GP we knew. Monday was a bank holiday.Things got worse over the  weekend  and I had no idea where it would end. Although I was familiar with psychosis it was like getting hit by an avalanche in mid summer. We only just met a year and a half earlier.

On tuesday the GP referred us to an office for mental health that same day. We were welcomed very friendly by a  CPN who knew I was a colleague from another hospital. He took us to an office. A few minutes later he introduced us to the psychiatrist who seemed  unpleasantly surprised . His words: “ It is not usual that family comes along unannounced” . Then he shook my hand reluctantly.

That is not the best way to introduce yourself  to a highly stressed person with an adrenaline level way beyond that of the average marathon runner. I can’t imagine a doctor of an emergency room would have said the same if my partner would have had a heart problem or an accident. This was an emergency  as well. A psychiatric one. 

During the visit my partner only told about 40 %  of what had happened - being distracted and paranoid. After some time I added a few things to the conversation but I was being ignored  by the psychiatrist.  And when he finally asked me: “Do you have any idea what psychosis is?“ I was so mad that I answered very calm : “ I have read some about it a while ago”   

He wrote a prescription for an anti-psychotic  and handed us the piece of paper. I asked him to add Biperiden in case of side effects.  I guess he had not expected that because he looked a bit confused. He wrote it down and wanted to say something but I felt too reared for further conversations. I felt like yelling  , throwing things around or burst into tears and I didn’t want to do either one of them. If you come for help the last thing  you need is people who make you feel  worse. A few minutes after we got home the phone rang: the  psychiatrist. He asked me if I could come long next time.  I asked him if he would  have called if I had not been a CPN. Later on we talked and things went better. He learned from the experience. 

And so did I. Although I always had a focus on family support : really knowing the despair, fear and frustration helps to keep it on top of the “to do”- list and encourage others to do so. This was just a bad experience, educational though. Many psychiatrists do an excellent job.

Family support is an important thing in mental health care. Ifcourse there are very dysfunctional families  and some people have caused problems our clients are facing now. No need to deny that and very important to take that into account. But most of them have good intentions and are willing to learn and help.And they usually know their ill family member better than we health professionals do. We shouldn't consider ourselves too important but see family members as team members. 

Psycho-educational family interventions and family support can reduce relapses, readmissions and suicide risk. An important part of our work because it benefits to the welbeing of our patients and a better future for them.

Many family members have felt left alone by mental health care in the past on more than one occasion.Imagine yourself in their shoes and do the best you can to make their next experience a better one.

If family  is visiting a hospital ward make them feel welcome and comfortable. That will make it easier for them to visit more often. For mental health workers a mental hospital ward might be an everyday thing but for visitors it’s often a very  unusual scary place to go , especially the inpredictable crisis wards. If possible give them a quiet place to talk and relax. Encourage family and friends to stay in touch. 

Loneliness is a huge problem for people with mental illness. And it is important to prevent that as much as we can.Giving good information and support to friends and family can make an important difference here.

-           

The Hidden Faces of Abused Children

Most folks with even cursory access to the news are familiar with more obvious variations of child abuse.  These include breathtaking accounts of physical abuse, horrific tales of sexual abuse and trafficking, kidnapping and torture, and unlawful restraint in confined spaces by parents and caretakers.  Even glaring cases of extreme neglect, such as declined medical care and abandonment in vehicles, often resulting in death, make it to the news and the consciousness of readers.  It is a good thing that the worst of these stories are given appropriate attention.

In recognition of April’s Child Abuse Prevention Month, let’s turn our attention to less obvious forms of abuse and neglect, as these also take an enormous and in some ways even more pernicious, toll on humanity.  In over 20 years of work as a psychologist I have known a great many who have suffered all manner of abuse and neglect.  Some succumbed to the trauma.  Some survived and later thrived.  All were heroic in one way or another.  Their voices and expressions resound in my memory; they tell me that physical wounds heal, that sexual victimization can be overcome, and that the neglected can find nurturance and love.  Of all these, the ones that stand out in their pain are those who have been rejected and abandoned by their families and caretakers.

This type of wound, more than any other in my experience, leads more consistently to lasting damage, to serious alterations in psychic architecture which can take a lifetime to modify.  To be told, in word or deed, “I don’t love you” or “I don’t want you” or “Go away” is tantamount to murder of the soul, as others have described it before me.  And this form of abuse has a thousand manifestations at every stage of development all the way through late adolescence and early adulthood.  Obvious abandonments are, well, obvious, as in the literal abandonment of a child to the streets or to the state.  But there are many, many variants which occur even while the child is still technically in the home and care of family.

Space prevents me from detailing every manifestation.  Suffice it to say that refusal or avoidance of the provision of support to the reasonable physical and emotional needs of children can be heard by them as “I don’t want you.”  This is especially true when the caretaker fails to come to the aid of a child, teen or young adult in a moment of crisis.  I have witnessed this many times over, and the psychic pain it causes is legion.  Some learn to abandon hope as a result, which of course is a literal dead end.  The more fortunate learn to find support elsewhere, because somehow they know they are worth it.

In our endeavors then, let’s work to prevent and react to abandonments, large and small, when we see them.  In so doing let us also demonstrate in word and deed the inherent value of all humans.

20 Commandments for Mental Health workers

1. Thou shalt respect your patient and not judge
2. Thou shalt increase the well-being, opportunities and happiness of your patient
3. Thou shalt be in time for appointments and phone calls. It will show your patients that they matter
4. Thou shalt have a well-chosen and well-timed sense of humour
5. Thou shalt reconsider your ‘professional distance’ if it makes your patient feel he stands alone; show that you are a person too
6. Thou shalt not let your bad mood or personal issues influence your professional attitude
7. Thou shalt have an open conversation if your patient is suicidal and give good support and protection if necessary
8. Thou shalt not hide behind a newspaper or smartphone on the ward or make any other unapproachable impression otherwise
9. Thou shalt not hide and chat in the nurses’ offices but be with your patients as much as possible to create a safe and friendly environment
10. Thou shalt consider family and good friends of your patient as team players (unless it’s impossible) and support them well in the interests of your patient
11. Thou shalt inspire and support your colleagues to make mental healthcare as good and friendly as possible and ask and give feedback on a regular basis to become a ‘winning team’
12. Thou shalt inform your patient well about side effects of medication, observe well and help to find solutions if needed
13. Thou shalt not avoid the subject ‘sexual side effects of medication’
14. Thou shalt help your patient to get good dental and physical care and support them on doctor and dentist visits if needed
15. Thou shalt help and support your patient to exercise on a regular basis to increase their health and give support to decrease smoking.
16. Thou shalt support your patient to overcome financial or housing problems and fight bureaucracy
17. Thou shalt listen well to the patients' aspirations for their life and give support to achieve them
18. Thou shalt stand up for the rights of your patient
19. Thou shalt fight the stigma of mental illness at every opportunity
20. Thou shalt help your patient to keep up hope

 © Nursewithglasses 2012-2013