Friday, November 23, 2012

Down in a Hole

Depression.  Churchill aptly called it "The Black Dog", though the alcohol and tobacco he reportedly consumed may have made it blacker.  Depression is so prevalent that it has often been called the common cold of mental health problems.  As an example, in its most recent annual report, the Center for Collegiate Mental Health noted that 31.6% of some 74,000 students seeking counseling endorsed just a single symptom consistent with depression (thoughts of suicide) at any level.  Endorsement rates for other depressive symptoms are in similar ranges.  SAMHSA reports that 8.4% of college students have experienced a major depressive episode in the past year, but also notes that this rate is not statistically different from that for non-college peers.  Some claim that rates of mental illness among American college students have increased, and reports of increased severity and emotional states which are incompatible with college life abound.  These observations are not without dispute in the college mental health community itself, in large part because other data don't square with the hypothesis.  For example, in the Center where I work, adjustment issues, a category one can think of as reflecting normal stresses and strains of living, still are the most common presenting problem and diagnosis, as they have been for the more than 20 years I have worked there.  By the way, depression was formerly number two in this ranking.  It has recently been overtaken by anxiety, which as you will see below supports other possible theories of dynamics in student functioning.

That is not to say there are no recent dramatic changes in college student behavior.  There is no question that the number, frequency and intensity of crises, for example, have increased during my career.  This has also been a steadfast observation among my counterparts for many years now.  Some, myself included, suspect that the phenomena we are seeing may not be due to diseases as defined in the medical model but rather to impairment in coping skills, which is somehow being transmitted across society and culture.  What could possibly account for the apparent rise in severity of what looks like more serious mental health problems?


All things being equal, the student with impaired coping ability will look "sicker" than the student with better skills.  I recall a student who struggled when she realized she did not know anything about how to look for a job, including understanding the classified ads.  In her next breath she also told me she did not know the location of the book store.  My friends, these statements were made in late October.  I assure you, she "looked" depressed, and if I only used a checklist I could say she had "depressive symptoms".  But depression in the medical sense was not her problem, per se.  She had somehow missed out on some very basic life skills which created the breeding ground for her symptoms.  This is but one example of a great many crisis situations in which I have been involved.  The facts change, but the essential pattern remains the same: the stresses of an environment or situation, most often involving relationships, exceeds the ability to cope.  Symptoms of depression and anxiety are the result.  Taking this a step further, this is the way it is supposed to be.  It is a clarion call for change.


Therapists of the analytic or psychodynamic ilk understand that the number and quality of our defenses against life's slings and arrows are what protect us from negative mental health.  When these defenses are too few or of poor quality, depression and anxiety are the expected outcome.  College life is interesting partly because it represents a distinct moment in time in which a late adolescent or young adult leaves familiarity, to which they have adjusted most, and joins novelty, to which they often have adjusted the least.  Any lack of preparation is likely to be revealed in short order.  This is because the defenses on which they have relied will fail.  (What former college student can look back on that time and not see that some of their behavior was "disordered"?)  "Symptoms" are often the result of reliance on defenses which are no longer working well.  Faced with this scenario humans tend to keep doing what they have always done, thereby digging down into the hole even further.  Yes, one could call that depression and throw medicine at it.  And it may even help in the short term.  But only lasting change in defenses will get students out of that hole.

Seeing a problem in living as an external entity which inhabits us, and which requires an external intervention, is a facile act.  It relieves us, students and parents alike, of a more complex responsibility to self and others: changing our behavior.  It also happens to be supported by enormous economic forces in healthcare industries which can, intentionally or not, keep us in a hole.  Any person well into recovery from a wide range of mental health states will tell you that assuming responsibility and agency was the essential ingredient to success, even when external interventions are taken into account.  That is one sound way out of the hole.

Saturday, November 10, 2012

Heroic Students

Few things in my professional life have been more rewarding than to witness college students overcoming tremendous obstacles to their success and happiness.  For most of those around them, professors and administrators, friends and sometimes even family, their struggles were invisible and silent.  Working with them in the privacy and safety of therapy, college mental health professionals are privileged to nurture their strength, shore up battered psyches, and nudge them in the directions they need to travel.

I wish I had the memory banks to tell each of their stories.  Everyone can benefit from seeing how a young adult bravely confronts horrendous conditions and accomplish things that many of us never have or will.  Here are some examples, disguised and condensed for the sake of confidentiality.
  • Tyrell, 21, came from extreme poverty and at one point lived in his car on the edge of campus.  He was the first in his family to attend college, and he was determined to graduate and make something of himself.  It took unrelenting energy and conviction to rise each morning, stay awake in class, and disregard the doubts from within and without, but he got his diploma.
  • Janie, 19, saddled with a history of physical, sexual and emotional trauma at the hands of adults who were supposed to be her caretakers.  Her days were filled with intense fear and phobic anxiety; just sitting in class around other students, thinking they were judging her, took gargantuan effort.  She battled impulses to harm herself and exit her life altogether, but deep inside there was a constant, though sometimes faint, voice which told her there were other possibilities in her life.  Class attendance and grades were far from perfect, but she did not give up or quit.  She registered each semester, and worked on her goals persistently, not with great force, but like ocean waves on the shore.
  • Will, 23, lost and roaming in the grip of various addictions he brought to college with him.  He encountered many entanglements with friends, family, the legal system.  He had to face academic probation more than once.  Will sought treatment several times, each with the same outcome: relapse.  With enough support and encouragement he entered treatment one more time, and began a 12-step program.  There were ups and downs even then, but he did better in school and eventually graduated.
  • Beatrice, 18, in great distress over her gender and sexual identity.  She encountered frequent harassment and bullying from middle school forward.  Those who professed love for her rejected her emotionally, and also communicated not-so-vague threats of disowning her altogether.  The simple act of walking across campus took immense fortitude and exhausted her at times.  Through therapy, she found supportive others and got engaged in activism and justice for all students.  This empowered her and gave her confidence to be herself and interact with others respectfully and assertively.
There are so many more stories to tell.  In each case, the student clung tightly to something dim but abiding in their core: a genuine, healthier self which sought expression and release.  So many have lost this fight.  We have all known them in our lives, and we would all do well to use our powers to "see" the whole person in front of us, imagining a great struggle in which they are engaged, and facilitating their journey into being who they really are, which is always the path to emotional health.

Sunday, November 4, 2012

Experiences Shape the Brain

Much has been said and written on the subject of medication and its role in mental health care.  Perhaps too much.  Though it is growing, comparatively little has been said or noticed about other ways the brain is and can be shaped in order to improve emotional well being.  Let's take a brief look at how experiences, both positive and negative, influence brain development and functioning.

A recent study, for example, examined the transmission of anxiety from parents to children.  This research found that socially anxious parents imparted anxiety through specific parenting behaviors involving lack of warmth and affection, and criticism and doubt directed toward the child.  The role of these experiences is thought to contribute to the development of anxiety apart from genetic contributions, because the latter alone are not thought to be sufficient in the etiology of an anxiety disorder.  It does not require a tremendous leap to imagine that parental warmth and confidence provided to children reduces the likelihood of a future anxiety disorder.  The experience of warmth and confidence is more powerful, in my opinion, than any medication we would later give to the adult child to address their anxieties.  And more lasting too.

In another arena, a play-based method of teaching social interaction, called ESDM, to autistic children was shown to result in positive brain changes.  Researchers studied brain activity in both autistic and non-autistic children, after the former received the therapy for two years, and could not identity differences which are apparent otherwise.  Clearly, this behavioral intervention altered brain activity in a very desirable manner.  I'll wager that there are not many parents of children with autism who would not jump at the chance of this non-medical or intrusive intervention.  If only they were given the chance, or that such behavioral interventions were as aggressively marketed as medications are.

Currently, one has to dig deeply into the literature or perhaps be lucky enough to have an insightful and gifted care provider to access information about evidence-based psychological interventions.  The American Psychological Association does maintain resources on these interventions on their very good web site and Help Center (www.apa.org).  I encourage consumers to be educated concerning these alternatives to physiological interventions, which, in my experience are helpful at times and with some individuals, though the benefits come with cost and ultimately fade with time.

Experiences shape the brain.  Those who have experienced stress, trauma and deprivations have brains, and even appearances, which show this.  Those who have experienced positive relationships and satisfaction of needs also have brains which show that.  It would seem, given that we know this, that individuals, groups, communities and even countries would develop systems which promote the application of sound psychological principles to the advancement of human welfare.