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.