How to improve dental care in psychiatry

Dental care is poor and a disregarded health issue among people with serious mental illness. They are on a higher risk than average for tooth decay,inflamed gums and denture problems. Medication combined with reduced self care is an important cause. 

Poor dental health can increase the risk for social stigmatization / isolation and serious physical health problems. 
There is a causal link between poor oral health and cardiovascular disease and even stroke.Considering that people with serious mental illness like schizophrenia die 15-20 years earlier on average than the general population we have have enough reasons to take dental health seriously.

According to Danish research only 31% of schizophrenia patients complied with a regular annual dental check-up visit , compared to 68% in the general adult Danish population.  http://www.ncbi.nlm.nih.gov/pubmed/20584518 

Huge risks for poor dental care are: substance abuse diagnosis ,living in an institution or admission to a psychiatric facility for a minimum of 30 days  and male sex.

However Clozapine treatment, at least monthly outpatient visits , and age 50+ were associated with a lower risk for inappropriate dental care.

 

 Psychotropic meds can cause shortage or too much saliva or a change in acidity. Combined with poor oral health  this can make tooth decay occur faster. 

Many patients smoke. This increases the risk for gum disease : one of the leading causes of tooth loss in adults.

Smoking also slows down healing after oral surgery. It can damage gum tissue and receding gums leaving the roots of the teeth exposed. This can increase the risk of tooth decay and cause hot/cold sensitivity.

To improve the level of dental health we can help patients to

- Use less sugar and acidic products like carbonated drinks

- brush 2x a day preferably with an electrical toothbrush , they are much more efficient than ordinary brushes

- use fluoride toothpaste

- use floss or interdental cleaning brushes twice a day

- visit a dentist and support the visit if needed. We may ask the dentist about screening for the rate of salivation to see if the amount and acidity of the saliva is within limits.

- decrease smoking 
- Use 4 - 7 xylitol chewing gums or lozenges devided over the day. It needs to be 100% xylitol, no other sugar substitutes.This reduces dental    plaque. It stimulates the production of anti-bacterial saliva and remineralization of the teeth. And it partially replaces sugars in the diet (satisfies the ‘sweet tooth’) Using Xylitol chewing gum or rinse can decrease tooth decay with 60 %. For those who cant use gum or lozenges xylitol mouth water may be an option.

 In high amounts xylitol can have a laxative effect and cause flatulence.
- Inform patients that they should avoid to consume acidic products one hour before brushing  teeth. The surface of teeth is softened by the acid and can be damaged.

Let's make dental care a priority in psychiatry. After all it is basic care, not luxury .

Ethics and Meaning in College Life

Recently USA Today College ran a nice little piece concerning ethics in college.  The author, Miriam Schulman, assistant director of the Markkula Center for Applied Ethics at Santa Clara University, posed five simple questions for students to consider:

1. What is college worth to me?
2. How can I live with someone I don’t like?
3. How far will I go to be accepted?
4. Should I tell on someone who is doing something I think is wrong?
5. Is casual sex going to be part of my life?

Wonderful questions.  College life offers so many rich academic and personal experiences.  So many, in fact, that it is very easy to lose sight of fundamental questions which we all must face in our lives: Why am I here, and what am I going to do with my life?  From where I sit, working closely with students, a great many issues and problems could be averted, and a great many lives enhanced, through an active search for answers to these questions.  I believe Socrates said so way back in the misty past.

Students and their families are today focused on the practicalities of college life.  They rightfully ponder over where their students will live, what they will study, how will they spend their time, how will they make friends, and of course how they are going to pay for it all.  These are questions that do in fact need responses.  But the inquiry should not stop there, and all too often it does.  Without the bigger responses to bigger questions, students often live incongruently to their genuine identities and values.  They associate with people they don't truly respect.  They engage in activities which are meaningless or even harmful to them, which may result in a resume' packed with awesomeness but reveals experiences with little or poor quality.  A competent employer will see this instantly.

Spend time, ideally well before college starts, mulling over the big questions.  Set a target, well ahead in time and space, about where you would like to land and explore your existence.  One doesn't travel to another part of the world without having some sense of how one will live after arrival.  Why in the world would we cheat our future selves by not doing the same thing before our college and career journey begins?

No Need to Panic: The Art of Chilling Out

In addition to academic studies, many college students are learning about their limits with respect to stress and frustration.  As noted in a previous post, college is a time of new demands on many levels, which means adopting new stress management skills if one hopes to do well in life.


This learning is sometimes marked by peaks of anxiety and stress, of feeling overwhelmed, and of outright panic.  This can happen even in those for whom things are going well.  How a student manages these intense periods can make the difference between improving a situation or making it dramatically worse.  You can make things worse by impulsively acting on feelings of panic.  So let's talk about how to turn a stressful moment into an opportunity to make things better.

To manage peaks of stress one must learn to master physiological arousal, strong emotions and negative thoughts.  Most folks are aware of our body's built-in circuits of arousal, the fight-or-flight-or-freeze response in reaction to threat.  By the time someone reaches college, this system has been initiated countless times, and is so hard-wired as to be very rapid and even outside consciousness.  And therein lies the problem.  It has become a reflex for many, and their perception is they can't do anything about it.  But this is not true.  What many do not know is that our bodies also have built-in relaxation responses.  Just as our bodies and brains can mobilize against perceived threats, so too can they calm and slow down in order to access higher cortical processes or problem-solving.  This slowing down is essential for accessing our memory and use of judgment.  Panic is good for running, but horrible for higher thought.  If you've ever gone blank during an exam you know what I am talking about here.


So, here are some ways to calm down in a moment of intense stress:

• First, manage your breathing.  Sit down somewhere, and uncross your arms and legs.  Place one hand on your abdomen.  If you are breathing correctly that hand will rise and fall as your diaphragm muscle extends downward, allowing your lungs to fill with air.  Fix your gaze on a point in front of you, or close your eyes.  Slowly inhale through your nose, and slowly exhale through pursed lips.  Depending on body size, the breaths should be around three to five seconds apart.  In order to breathe well one must concentrate on these steps, and that is part of the secret because doing so is incompatible with worry or negative thoughts.  The other part of the secret is breathing of this type delivers a higher rate of oxygen to our brains than what occurs when we panic.  And oxygen makes our brains happy.  Keep breathing all the way through the wave of stress until you notice it is diminishing.  Practice your breathing at least daily, and every time you notice your earliest warning signals for stress and anxiety.  If you get good at it, you can abbreviate some of the steps and quickly enter a deeply relaxed state anywhere, at any time.  You can also learn more about helpful breathing.
• If you like imagery, close your eyes after your breathing and hold any image that you find peaceful, serene or relaxing in your mind's eye.  As you hold that image try to capture all the detail in the objects, sounds or smells of this place.  If you get distracted, don't worry about it, just keep going back to that image.  Another secret of stress management is taking yourself elsewhere, away from your troubles, in your own mind.  This acts like a reset button which clears the noise in our heads.
• Stress has physical components which increases tension in our muscles.  You can address this by tensing and relaxing, in alternating fashion, muscle groups from your toes all the way up to your head and face.  Create tension, for example, by clenching your fist as tightly as you can for a few seconds.  Then let it go, letting your hand fall as loose and limp as a wet noodle. And notice the contrast, the slightly warm or tingling sensation which comes from relaxing a muscle group.  The sensations are usually quite enjoyable.
• All of this is the easy part.  The harder part involves addressing our negative thoughts, our "stinking thinking".  Catch yourself engaging in typical thought patterns when under stress: magnification of problems, seeing problems as catastrophic, internalizing or personalizing problems, or hopelessness.  You can address these by saying to yourself "I am not thinking clearly.  I need to focus on one thing I can do today that will move me in the direction I want to go."
• Stress management is not complete until we examine what caused us to panic in the first place.  Such reactions occur for fairly specific reasons, such as over-extending ourselves,  poor preparation or coping skills, or perhaps failing to establish or uphold our personal boundaries in some way.  Once you are in a calmer state, and thinking more clearly as a result, spend some time problem solving about what needs to change.

Once these skills are developed a sense of confidence and resilience can be achieved.  Frustration tolerance will also increase such that future stressful moments are less likely to produce intense, reflexive reactions.  Like any skill, this takes practice, and there is no shortcut.  The skills are not a "cure" for what caused panic in the first place; that must be addressed through good judgment and decision-making.  But the skills are important management tools, the building blocks of which you already possess.  They simply await your time and attention.

College is a Trip

"We don't receive wisdom; we must discover it for ourselves after a journey that no one can take for us or spare us." -Proust

College is way cool, no doubt about it.  There are intellectual explorations and pursuits, exposures to a wide variety of people and cultures, sporting events, rich theatre and music opportunities, tons of ways to meet, socialize and party with folks from all over the world, and on and on.  The college years are a great time to learn and otherwise benefit from these experiences, and many students take full advantage of the possibilities.

At the same time, however, many students seriously underestimate the stresses and strains that result from this time in their lives.  During college there are incredible demands placed upon a student’s intellect, physical well-being, social skills, spiritual or philosophical orientation, and sense of personal responsibility.  This is true whether that student is from Manhattan or Opp, Alabama.  Every student I have ever known (including yours truly!) has had to endure an adjustment period during the crucial first semesters of college, and often during the subsequent years as well.  Some have roommate problems.  Some party way too much.  Some are overwhelmed by their new-found autonomy or freedoms.  Some struggle with isolation.  Some have to manage the negative behaviors of others.  While many students negotiate through these stresses productively, albeit fitfully, others experience meltdowns of one kind or another, and truly have trouble functioning well as a student.  Grades may suffer.  Conflicts with friends or family may emerge.  Depression or anxiety may root and take up residence in the psyche.  Though students may not realize it, college is a microcosm of the world at large, but compressed in both space and time.  What happens here can establish precedents for the future.  College is a trip, indeed.  It is a funky but delightful journey during which learning can occur in every dimension imaginable.

Some students arrive on campus with plenty of tools in their survival kit.  Caring parents.  Good health.  Sufficient funding.  Supportive friends.  Others seem to have been given tools of little value, sort of like a duffle bag with a pearl necklace, a chocolate cake, and a catcher’s mitt, and all for an excursion into the Amazon!  A few unfortunate students appear to have no tools at all.  Just as I have never yet met a student who didn’t have to adjust, so I have also not met a student who could not overcome such limitations.  I have known courageous, admirable students who were nearly homeless, or who were afflicted with a nasty medical or mental condition, or who were abandoned or abused, but succeeded nonetheless.  My hat’s off to these folks; they had more than their fair share of troubles but in the end weren’t defeated.

So college is a trip, and there are some tricks students need to know about in order to reach their destinations with sanity intact.

1.    Prepare for the adjustment.  Think ahead about what you will need, then find out where you can get it.  Manhattanites will need variety.  Oppians will need familiarity.  If you didn’t have to study in high school, well, get ready to.  If your parents did everything for you, learn how to do it yourself.  And so on.

2.    Quickly figure out the nature and source of your stress.  Are you strung out because you’re not sleeping?  Because your roommate is messy?  Because you can’t concentrate?  Because you’ve never been good at math?  Stress has origins.  Find out how it started.

3.    Get the support you need.  Every problem, and I mean every problem, has a solution.  Granted, some solutions are difficult.  But don’t freak out!  Instead, calm down, define the problem, and then learn what person or resource or service you need.  Need tutoring?  Chances are your school has it.  Need time management skills?  There is someone who can help.  Need to choose a major?  It's covered.  Need someone to talk to?  Counselors are here for ya.  Just take a look at the web or campus directories.  I’m always a little amazed at how many students don’t look for or don’t know what resources await them, or worse, choose not to use them.

4.    Don’t wait!  Do the first three steps early.  Don’t wait until your homesickness turns into depression, your public speaking anxiety becomes panic attacks, or your stress leads to insomnia or substance abuse.  If you get what you need early, chances are good it won’t take long to overcome the problem.  If you wait, it can take much, much longer.  Don’t believe the lie that it isn’t “normal” to have problems.  I have yet to meet anyone who didn’t have a few.

To take the college journey well, students need to periodically examine their survival kits.  Make sure the needed tools are in there.  If unsure, ask someone who’s been around.  Wisdom and a good deal of fun are there for the taking, if students care enough to equip themselves for the ride.

A View Inside the Minds of College Students

Several years ago, a colleague provided a series of web postings written by college students.  The posts, if my memory is correct, were gathered in random fashion from a variety of public internet sources.  My memory definitely has failed in one important respect; I can't recall who provided these or exactly when I received them.  I apologize for that.


These snippets are simply too good, however, to not record them in some way.  They provide a glimpse, unsettling at times, into the minds of students.  The comments provide us with a sense of what their worlds are really like and therefore some guidance on how we, all of us, might assist them with their needs.  Spelling and grammatical errors are preserved as these too are a window into the state of the authors.  Here we go...


Female
I've dropped a lot of courses. I've also failed a lot of courses. I don't know my material. I feel like I haven't learned anything. I'm not competent. I've ruined my life. I don't know what I'm going to do. Maybe I will work in fast food for the rest of my life.
I feel like such a loser. I skip final exams. I waste thousands of dollars.
I'm not smart enough. I'm not hard working enough.
I have no future. I can't do anything. I may as well be dead. I'm useless.
My parents should kick me out and leave me homeless. I don't deserve all that they've given me.
I wish I could start over, from the very beginning. I've messed up big time. I've ruined my grades.
I'm getting old. I'm going nowhere. I don't want to face life, it's too scary.
I'll never graduate. Even if I graduate, I'll do nothing with my degree.
I should just die or something. :-(

Male
So, I failed my midterm. I huge 45%. The frustrating thing is I know what I'm doing. It's not like I just didn't study, or not go to class, I did all of that. My prof was even like "What happened?" I didn't do so well on my last quiz, and I'm pretty sure I didn't do well on the one we just had. For awhile now I've been feeling like school is impossible for me. Now, it feels like it is. I don't want to keep going, but I'm afraid of dropping out. I don't konw what to do...


Female
A couple students including me talked our professior into extending our test date! Heehee! Good for me! I need an extra week!


Female
i go to university and this is my last semester of classes, or at least, that's the plan, before i do my internship and then one math class in the spring. howveer, my past practice of doing the bare minimum of what's required of me as a student (even less than the bare minimum when it comes to studying for test or reading), has been doing me wrong this semester especially. i have met a guy who has been screwing with my emotions, whether on purpose or not, it doesn't matter i guess. but i am soooo scared that i won't pass some of these classes and then i'll have to stay another semester, here in this wretched town. but i have no energy again. it's like i wish i could be one of those students who can not study and get all a's, but i am not. but although i know my end goal, getting my degree, which as it turns out, again has to be put off till the end of next fall, for other reasons, i cannot seem to focus on that enough to complete my studying, or at least to put more effort into it. i have no job, so it's not time restraints. i don't have a car, so it does take convincing to get myself to walk to campus, if i need to, and i have been skipping more...and i don't know...does anyone here ever just feel like quitting school, just lie around and do nothing? but then again, that's exacly what i do anyways. i guess i am just here to conplain and ask if anyone else feels like they just do the minimum required of them as students.


Male
I'm done! My brain is full. It's really sad because the my presentation is less than 2 minutes. What do you do when you just can't stuff anymore in???


Female
I love school!  All the people, the energy, learning, the professors, and everything except the very few parking spaces. LOL I have my first exam in a week, gotta study this weekend. :-)


Female
I'm sooooooooooooooo nervous! My classes start tomorrow. What if I'm not good enough? What if I fail? What if....? (this coming with someone who has never gotten lower than an A-) uggh. I hate this feeling.


Male
Classes started up again yesterday. I only have the one class on campus, the other is online. The one class on campus is taught by the same lecturer as the summer math class I just finished. She said we could call her late last week for our grades. She told me I could come by her office and see my final exam, and get my grade.
I haven't done either of those things.
Today I finally emailed her, asking for my grade. She just emailed me back, but I'm too afraid to open it. I know it's going to be awfully close, and I can't stand to see it.
I know, and my T tells me that it's going to be OK to get a B. She says she thinks it would be very good for me to get a B.
I'm too afraid to open the damned email.
I guess it's better than finding out in person, and crying in front of her.


Male
I woke up yesterday with sore throat, nausea, aches, etc. Still feel yucky.
And I sat down in front of an exam that did not look at all familiar. Not much that looked like anything I had ever seen before. I get depressed when I'm sick anyway, but that just made it that much worse.
I'm pretty sure I won't have an A on the exam. I am currently hoping only that I did well enough to allow me to get an A in the class. I think I can miss 65 or so points, out of 200.
Of course, when I got home again, I could think of how to work out one of the problems. I did get the right answer to that problem, but I had no idea how to set up the equation. {sigh}
I really don't want this to be the time that I find out what happens if I don't get an A. I don't know that I can handle that right now.
Maybe school is too stressful for me.


Female
I was just diagnosed bipolar ultradian rapid cycling 6 weeks ago, with social phobia 1 week ago, and while I'm getting treatment, none of it is really working yet!! My psychiatrist is confident I'll be ready to go back to school in 5 weeks but I'm soooo scared!! It's like, I don't know if I can handle being in school but if I don't go what do I do? Be a college dropout? Ugh.


As you can see, most of the posts reveal a sense of being overwhelmed by academic demands, some to the point of hopelessness.  Another, perhaps more troubling, theme is that few of them wrote about seeking or asking for help.  For this and many other reasons college mental health services are an absolute necessity for students.  Ideally, these services will be well-resourced and thoroughly and repeatedly advertised across campus, in a variety of media.  Students tend to dismiss information when they perceive they will not need it, then suffer from a lack of information when troubles visit them.  Institutional support of the mission of college mental health is a vital ingredient to student success, as we see so clearly in the messages provided above.

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.