Sunday, May 20, 2012

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.

Sunday, May 13, 2012

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.