Saturday, December 27, 2014

Organizational Fragmentation is Hurting Us

Mental health professionals are like cats. We are hard to herd. Perhaps this is due to our independent and autonomous nature, at which most of us seem to arrive after years of study and work as strong advocates of the individual. Perhaps this is an example of western philosophy taken to an extreme.

Whatever the source this has resulted in an unfortunate situation in which we have created a seemingly endless array of professional organizations with which we affiliate. These organizations appeal to narrow sensibilities or professional pursuits. Here are a few examples from the college mental health profession alone:
  • ACCA
  • APA's Division 17 and its Commission on College Counseling
  • NASPA and its programs on mental health
  • ACPA and its programs on mental health
  • And professional organizations representing several disciplines within college mental health, such as APA, ACA, NASW, AMFTA, and those for psychiatry.
This is just a partial list. Other professions may have multiple associations as well, but often rely on a single one to speak on their behalf, such as ACHA or AMA for those in medical fields.

This degree of fragmentation is a major obstacle to advancing our specialty, which I believe it is. Due to all the voices, all the principles and customs on which these organizations were founded, it is next to impossible to form meaningful and potent alliances, position statements, and agenda for advocacy at any level. Attempts have been made, such as through HEMHA, but these may be limited in scope due to funding and staffing realities. Without appropriate funds and executive staff to carry out its goals, such efforts will always be quite limited in spite of the very best intentions behind them.

It is past time for us to correct this situation. Due to forces in the economics and politics of health care in the United States, some organizations are pursuing an agenda which often does not incorporate respect for other professions or their core philosophies, especially regarding youth and young adults. Trends toward pathologizing normal life experiences, such as bereavement, so that intrusive interventions may be deployed are but one example. Take note of the buzzwords associated with these efforts: evidence-based care, best practices, integrated care, and so on. As I covered in a previous post, these buzzwords mask another reality, which is integration without true integration, and selective review of research to support whatever may be called a best practice.

The professional organizations representing college mental health need to be consolidated in order to form a more active and potent and focused association. It is an irony that in our appreciation for diversity, we may have neglected the greatest diversity of all: the full range of our professional philosophies and service models. Without such a consolidation and re-calibrating of our efforts, this diversity will continue to suffer and may disappear altogether.

Monday, November 24, 2014

Wants and Needs

As higher education institutions have adopted business models a customer service orientation toward students has taken root. This is not always a bad thing. It helps faculty and staff stay on their toes and work hard to address legitimate needs of our consumers. It can serve to market the school well and also to advance its image and brand.

As with most things, however, there is a pernicious shadow to these trends, one that is anathema to college mental health which is all about addressing the needs of students. But customer service many times becomes more about satisfying wants. This in turn has created a phenomenon in which those around a student, such as parents, faculty, staff, administrators, and other stakeholders, have taken on a positively entitled, demanding posture concerning something they think should be done for a student. Sometimes there may be a positive basis for the expressed want, sometimes not.

Counseling and psychotherapy is about an individual's need to change something about themselves, something that is contributing to their own unhappiness. The things which need changing are determined by a trained professional, working collaboratively, who evaluates the individual's needs. Many times, early in therapy, clients focus on their wants and not their needs, but this is what may have led to the cultivation of life problems in the first place. Wants are often about being comfortable, while counseling, at least in the beginning, will entail a degree of discomfort. Lasting change is rarely if ever a comfortable process.

So we may face scenarios in which insisting on wants may actually lead to harm for a student, and therefore represent an abuse of counseling services. This we are obligated to prevent or stop altogether. Just as no one can dictate how a physician treats your ailing kidney, no one can dictate how psychotherapy is to be conducted (though insurance companies try to do this all the time). It is unhealthy for anyone to attempt to control what ought to be a collaborative working relationship between client and therapist. Counselors are obligated to uphold standards around this issue, so don't be surprised when they say "No." Of course, folks can seek other opinions elsewhere, where it it will be less convenient and more costly, if they like. Or they could give it several sessions first, say five or six, and then make judgements about the effectiveness of therapy after the discomfort begins to wane.

Monday, October 20, 2014

Supporting the Role of Psychotherapy in Modern Life

Psychotherapy has proven over and over to be effective. In some cases its has proven superior to other interventions, including medication. And yet, over the last 20-30 years there has also been a variety of factors which has limited access to these services.  From the time of the rise of accountable care or health maintenance organizations, many of which have limited its approval and duration, psychotherapy has been struggling to stay alive much less to thrive.

Numerous other societal influences have contributed to this problem.  These include:

  • The reduction of time in psychological services provided in medical settings, which have claimed to integrate such services but have only cursorily done so.
  • Shifting emphases away from psychotherapy in training programs.  It is now not uncommon to meet trainees with only a handful of therapy contacts under their belts. This is partly due to the sources of grant funding, an orientation toward other health care activities and settings, and the development of manualized treatment programs which place less value on the relationship dyad.
  • Burdensome issues relating to overhead costs and below market-pricing for those in private practice, a disincentive to engage in this work.
  • Clear valuing of medication delivery in the medico-pharma-insurance conglomerate, to the exclusion of other approaches.  (This may change as pharmaceutical development for mental health slows down due its reaching a ceiling in benefit to humans.)
  • A public which has been encouraged to seek quick, effortless relief from life's ordinary challenges.
  • A parallel trend in which the public has been convinced that ordinary challenges, such as bereavement, are mental illnesses requiring a biological intervention.
  • A reduction in mental health funding at the state level, which actually releases the hospitalized back into the community where they will face long waits just to talk to someone.
  • The erosion of privacy in healthcare settings.
  • The digital age, which has directed the attention of individuals to devices and away from the support of each other.
  • A lack of humanizing development in psychotherapy itself.  All recent "innovations" I can think of actually reduce human contact, as in the cases of online therapy and telemental health services.

In an era in which humans crave and need human contact and community, psychotherapy has a role which is more relevant than ever.  But on top of that, IT WORKS!  There is an ample base of evidence for this.  When you or yours need assistance with one of life's many challenges, seek out a competently trained therapist first.  Look for those trained in accredited, residential programs, who are fully licensed in their jurisdiction, and who will meet you face to face for no less than a full 50-minute session per week, just to start. Insist on a high degree of privacy such that only you and your therapist know your concerns, so that you may experience trust.  (As stated in a previous post, confidentiality is the magic behind therapy.)  When dozens have access to your record, this is lost.

Life-changing therapy relationships are possible.  Don't settle for inferior or illusory "interventions".  Seek out the best psychotherapy possible.  College counseling services are one of the last true preserves of psychotherapy; encourage your student to take advantage of this opportunity which may never be as cost-effective or convenient during their lifetimes.

Wednesday, September 17, 2014

Service Models in College Counseling Centers

An earlier post focused on one role and philosophy for campus counseling services based on my professional experiences.  But discussion on this subject would not be complete without an at least a brief overview of various service models already in use across the United States and perhaps other countries as well.

I have been surprised, 
even dismayed, to repeatedly observe how little literature or direction is available concerning these guiding philosophies or models.  Since very few mental health professionals receive any management training prior to becoming the manager of counseling services, this places new or emerging directors in a vulnerable position.  In the haste to develop services sorely needed by students, we can create a patchwork of disjointed programs and services which may not be rationally related nor focused on any particular values or orientations.  Further, we may also be vulnerable to other influences which are better schooled in business models but which have little to nothing to offer in the area of psychotherapy or relationship-based healing.

A comprehensive view of existing models is beyond the scope of a brief blog post.  Suffice it to say that what is offered here is a sample, a taste if you will, of the choices available to campus leaders.  It is my hope that this may whet appetities to examine this more deeply, and to investigate what models may best suit a particular campus, its culture, and its student body.  The reader will note that definitions are not presented here.  This is partly because the literature is so scanty I am not sure there are agreed upon definitions available, and partly because I do not want to constrain the imaginations of managers working to grow a center (more on that later).

The list below was developed by a convenience email sample of counseling service directors in August of 2014.  It is not to be construed as complete or exhaustive.  Each of the models listed have advantages and disadvantages, and none, in my opinion, is inherently superior to the others in all contexts, though some may claim otherwise.  And context is the key: understand yours first.  Then select the models or models which you think may best suit campus needs.  Then investigate and experiment and evaluate and refine.

A Sample of Service Models

1. Bio-Psycho-Social Model

2. Brief Therapy Models

     a. Brief Intermittent Model

     b. Short Term Episodic Model

     c. Time Attendant Model

3. Building Resiliency and Supporting Personal Success and Goals Model

4. Campus Stakeholder Model

5. Client-Directed, Outcome Informed Model

6. Community Mental Health Model

    a. Brief Campus-wide Services Model

7. Consultation or Organizational and Community Development Model

8. Contextual/Environmental/Ecological/Systemic Models

9. Cube Model

10. Developmental Model

    a. Broad-based Comprehensive Student Development Model

11. Educational Services Model

12. Feminist Model

13. Human Service Model

14. Medical, Health Service or Clinical Model

15. Multicultural and Cross Cultural Models

16. Public Health Model

17. Strengths-based Model

18. Hybrid (of two or more)

Significant Areas of Emphasis in Centers

1. Training Emphasis

2. Evidence-based Therapy

Wednesday, August 20, 2014

Best Best Practices

Certain buzzwords appear and fade during the course of a long career in mental health.  Many times such words are reflective of economic trends rather than any scientific breakthrough.  They galvanize groups and can serve as momentum to pursue one avenue or other in the field, on the promise that the folks we serve will have better "outcomes".  The word outcomes itself has spent some time as a buzzword.  While having better blood pressure is a desirable outcome, a host of problematic side effects to blood pressure medicine are also outcomes, though apparently not the outcomes of interest for some.

One of the current buzzword phrases is "best practice", or its cousin "evidence-based practice".  Something may make a best practice list through rigorous research, which is great, or it may happen through a rather casual and cursory literature review.  Some times they are based on the opinion of a single individual, well known though he or she may be.  And there are times when it just so happens the list parallels a new product or the marketing of services.  It can be difficult for a trained practitioner to make sense of such lists, much less the ordinary consumer, which is to say all of us.

I have found that addressing the credibility of a "best practice" claim is a bit like being a party pooper.  This occurs even when the party goers are supposed to be trained professionals who are in theory versed in the scientific method.  In fact, I once heard someone say "well, that was a buzzkill" when a colleague disputed such a claim.  A buzzkill of a buzzword.  If it fits, so be it.

Maybe it's out there somewhere and I have missed it, but I don't recall ever seeing a method of evaluating best practice claims in the mental health field.  So here goes.  When you hear this claim being made, ask yourself the following questions.  Better yet, ask the one making the claim.

  • What disconfirming evidence was sought prior to the claim, and how was it sought?
  • What is the disconfirming evidence?  (Hint: there is always disconfirming evidence.)
  • What sources of evidence were examined, and were they as broadly distributed across disciplines as possible?
  • What other practices achieve comparable or better results?
  • Is the practice accompanied by any risks?
  • Can the claim be clearly separated from economic pressures, such as ties to pharmaceutical development, billing incentives, or lobbying from professional guilds?
  • Even if the claim stands up to scrutiny, is it possible to offer consumers alternatives better suited to their circumstances, and has this been done?
Many mental health professionals are trained in a scientist-practitioner model, so these questions should not be unfamiliar or treated with disdain.  If that happens, there is something horribly wrong.  Insist on the best of best practices.  Caveat emptor, my friends.

Monday, July 14, 2014

Vignette 5: What Would You Do?

Annie, a suicidal student

Background: Annie is a sophomore with a psychiatric history dating to age 12. She has had multiple depressive episodes and was hospitalized at 16 after a suicide attempt by overdose. She has been in some form of treatment off and on since she started high school. Annie engages in cutting but that is a coping measure and not suicidal in intent, though she frequently thinks about suicide.

Scene: Annie answers questions in class which alarm her instructor and classmates.

Dr. Hokumba: So, can you recall an experience in your life which is evoked by your reading this week? Yes, Annie?

Annie: (Raising her hand) Well, when I was sixteen I was sent to a hospital after I tried to kill myself. Let me tell ya, it was exactly like what Kafka said.

(Other students quickly turn around to look at Annie.)

Dr. Hokumba: I see. In what way?

Annie: (Holding up both wrists, which reveal very red marks on the wrists.) See? People freak out over this but I went because I overdosed. The hospital was like a maze just like Kafka spoke about. I never did figure out what was supposed to happen or what I was supposed to do. It just seemed like whatever I did was the wrong thing, but when I tried to do what they wanted it just made it worse, ya know?

(There is obvious discomfort among the students.)

Dr. Hokumba: (nervously) Anyone else?

Annie: But I’m used to it. I still think the way I used to. After all, suicide would have solved Kafka’s problem. My shrink says I am stubborn that way.

Dr. Hokumba: Annie, let’s talk more about that after class, OK?

(After class, Annie approaches Dr. Hokumba.)

Suggestions: First, if you plan on having class exercises which involve personal history, creative projections of fantasy, or stream of consciousness thinking, you need to be prepared to field and respond to disturbing material.  This means being familiar with sources of support, referral, and immediate crisis response.  In this vignette the student reveals her thinking is current and not just in the past, and the fact that she is in treatment already.  Make sure others in your area are aware of your meeting and consider having your campus police nearby for support if needed.  In your discussion encourage her to continue in treatment and make every effort to refer her for follow up that same day, either to the campus counseling service or her current therapist if she is being seen off campus.  Either way the situation warrants timely follow up in order to determine her current level of distress.  If in doubt, ask your campus counseling service to send a counselor to your office in order to make a literal handoff to those services.  There may be many other considerations involved which cannot be covered here, so follow the recommendations of the counselor as they are provided during your discussions.

Thursday, June 19, 2014

A Role and Philosophy of Counseling Services in Higher Education

College students have a great many needs across many dimensions of experience, including the academic, spiritual, relational, psychological and emotional, physical health, finance, occupational and avocational spheres of college life, and more. Each of these dimensions, were we able to graph them on paper, would appear very different in scale, orientation, and overlap for each individual student we attempt to describe. Yet each student needs access to various forms of support and learning in all of these areas, if we truly seek to fulfill our mission of retaining and producing ethical and contributing leaders of our society.

Developmental or Contextual Service Models

An individual’s life dimension profile places him or her in a specific context. No student lives and functions in a developmental or an environmental/contextual vacuum. It is true that each student brings with them their own internal or biochemical endowment, but one cannot fully understand the total student without placing the student in context.

Mental health service entities have choice to make concerning which service model they will follow. The most basic choice relates to the medical model, which is based in content-derived symptoms and diseases, and the developmental or contextual model, which is based in process-derived states of growth transitions and stressors in context. Each model begets related choices concerning funding priorities and goals which are rationally linked to different units of interest or focus. In the medical model the unit of interest is the student’s symptom or disorder, which must be treated and alleviated. In the developmental or contextual model, the unit of interest in the student’s growth pattern which is either enhanced or limited by their total context.

As an illustration, consider a student who has been diagnosed with ADHD or Bipolar Disorder. Each diagnosis requires meeting the criteria of a specific list of symptoms and symptom clusters. Suppose you meet such a student and you find he or she is also experiencing the following contextual factors:

• Stress related to global political and marketplace influences
• Extremely poor sleep routines and hygiene
• Arrhythmic lifestyles, or more simply put, chaos
• Too much screen time, not enough play and exercise
• A paucity of trusting, mutually satisfactory relationships, in any sphere
• Racism and discrimination
• Increased sense of threat and diminished opportunity for affiliation
• Poverty, or resources insufficient to being a good student
• Alcohol and drug abuse
• Poor nutrition
• The inherent transitional “volatility” of the late adolescent and young adult
• The seasonal and cyclical nature of stresses in the academic environment
• Violence, rape, sexual assault, harassment
• Environmental toxins in the food supply or living environment

It is not uncommon to meet a student managing half or more of these factors. If we were able to somehow bathe any person’s brain in these factors, what would that person look like? How are they likely to behave? Might they have problems with attention? Or disruptions of energy?

Benefits of the Thoughtful Orientation of Counseling Services

Orienting the focus and philosophy of a campus counseling service need not be, nor should it be, an unthinking activity, nor an activity of convenience, economics, or politics. It should ideally be purposeful and embedded in the deepest traditions of promoting the education and success of the greatest possible majority of young adults. Typically these traditions are most consistent with Student Affairs divisions.

After all, ALL students experience developmental and contextual challenges. Students experience homesickness, roommate or family conflict, stress from academic demands, communication difficulties, peer pressure, cultural biases, identity confusion or misdirection, etc., at very high rates. The prevalence of specific medical/psychiatric diagnoses range from, say, two to five percent of the general population. It makes sense, then, to orient campus counseling services accordingly. It is known that allocating resources toward the lower and middle quartiles of a distribution results in greater degrees of problem mitigation and prevention. Orienting counseling services toward a student’s overall development also provides for the greatest reach into the various cells of the classic cube model of counselor functioning (Morrill, Oetting & Hurst 1974), including each type of target, each purpose of intervention, and each method of intervention. In a purely medical model, the focus of interest tends to be on the remediation of the individual’s condition at the level of direct service alone. This results in allocating resources to the sickest who are much farther along in the development of chronic health problems, and there is a place in the world for this. The point is not whether one model should predominate; it is that there should be room for a wide range of approaches to the broadest segment of the campus population possible. We argue that higher education institutions obtain the greatest degree of cost effectiveness and problem mitigation when each point in the spectrum of human life problems may be addressed.

Breadth and Depth of Developmental or Contextual Models

Professionals providing services in developmentally oriented counseling centers provide human services and not health services per se. This means that a college counselor is free to address any human or life issue a student may bring, even those that may fall outside the scope of traditional diagnostic tools. This model confers advantages to students in concrete, observable ways. One does not have to be “sick” to go to counseling in such centers, because no concern or issue is too small or too large to discuss with a counselor. This results in a better probability of seeing students much earlier in the cycle of problem development. It also allows for an entire course of counseling to be focused on acquiring skills which are needed for future success, such as assertive communication and healthy coping behavior. In this sense the college counselor is also an educator and may advocate for the student outside of the counseling hour, or engage in activities other than traditional “clinical interventions”. Further, such centers are firmly focused on learning that will last a lifetime. And, not insignificantly, the increased comfort in accessing such positively-oriented services also results in a greater likelihood that students will reach out to this service in a time of more intense crisis.

As noted above, traditional-aged college students are living through a psychologically volatile period. They pass through various stages of identity and skill development, some of which are painful. This results in rather intense reactions and behavior which can be unsettling for all involved, but are essentially transient, unless, perhaps, something occurs to arrest their development. One week a student may appear very ill; at another time they appear calm and coherent. It is easy to mistake transient but intense mood states as serious illness, thus the risk of pathologizing normal, albeit occasionally alarming, behavior in some settings. Developmentally oriented centers are primed to “tolerate” intensity, firm in the knowledge that the psychic stew will settle down for the large majority. Holding this intensity in a safe environment allows the student to pass through the intensity unscathed, without potentially life-long labels and, most worrisome, a damaging and limiting conception of self as “sick”, and yet also allow for the learning which needs to take place. Counseling provided from this point of view places a priority on having adequate time with the student, as this is required in order to accurately determine a student’s full context and needs. The amount of time required for this is typically not available in medical facilities.

Orientation of Current Counseling Centers

Over a long period many counseling centers have worked diligently to orient the center’s mission and services to serve the greatest number of students in need. This was done with much forethought, research, and exploration. All aspects of the missions of these centers (including counseling, outreach, consultation, and training) incorporate a developmental philosophy such that each seeks to meet students where they are, develop the strengths and genuine identities possessed by them, encourage them and give them hope and confidence, and address life problems at the same time. Without care and nurturing, these approaches can become disjointed and misaligned with the student’s growth needs. When such centers are acquired by a medically-oriented entity and folded into their operations with little thought and planning, some predictable losses or reductions of various functions occur. These include: both perceived and real privacy, outreach, prevention, consultation, mental health screening, groups, programming, well developed relationships with the administration, faculty, staff and community professionals, community and campus liaisons, functionally coordinated teams, strategic directions aligned with those of the university and student learning outcomes, services proven to positively influence retention, graduation, and academic performance in positive ways, networking and exchanging information with other higher education professionals, immediate phone consultation, training residence hall staff, assigned committee participation, consulting with students concerned about another student, staff trained in young adult development and strength-based counseling, and simply a more warm and supportive environment. In my work as President of the International Association of Counseling Services, Inc., an accrediting agency, I have seen first-hand that many such centers jeopardize their accreditation status due to thoughtless mergers. In reality, these mergers are more like acquisitions in which the counseling service is consumed whole by the host; there is little to no actual integration which occurs. Generally these losses occur when the counseling service is viewed primarily as a resource for those providing medical services, much as a pharmacy, a lab, or an X-ray department is seen. This posture results in what is best called a failure to thrive syndrome in the counseling service. My position is that this should be avoided, and that the many benefits of other current models are worthy of continuation and support.

Reference: Morrill, WH, Oetting, ER & Hurst, JC (1974). Dimensions of counselor functioning. The Personnel and Guidance Journal, 52(6), 354-359.

Friday, May 30, 2014

Leakage in Violent Intentions and Why Professionals May Not See It

Psychiatrist Richard A. Friedman recently wrote an opinion piece for the New York Times about why professionals may not be able to identify those with violent intentions.  In it he states that mental health professionals predict or identify at a level no better than chance.  He also states what many of us in this field already know but the public largely does not; that is, only a few mental illnesses carry with them an increased risk for violence, such as schizophrenia, bipolar disorder and major depression.  And most people with mental health issues are not violent.  He notes that the role of substance abuse, which is much more prevalent that the disorders listed above, is often overlooked or not cited in specific cases.  Due to the media's portrayal of "shooter" incidents the public is developing a distorted view of these events which leads to faulty conclusions.  These include: "fixing" the mental health system will reduce these events, and it should be easier to identify killers because it's so easy to see after the fact.  There's also a related notion that keeping firearms out of the hands of the potentially violent should be an easier thing to do.

These conclusions are faulty for several reasons, not the least of which is the assumption that science is or should be able to help us identify killers.  While we are not without some applicable knowledge and skill, it has not advanced to the point where predictive power is very strong or even anywhere near that.  We assume that being in psychological care can reduce or eliminate risk in all cases.  While I certainly believe that many negative situations are avoided or contained by competently applied therapy, it is also true that anyone can mislead us if they choose.  We are not magicians.  And no, we can't read minds either.

The concept of "leakage" of violent intent is relevant here.  Studies of those who have chosen to harm others indicate they communicate their intent many times, and often long before the violence is carried out.  But how often does this leakage occur in the therapy session?  I submit to you that it is very rare, especially in cases in which the client knows they are being monitored by others who are worried.  The therapy hour is one of 168 hours in the week.  How hard would it be for any of us to maintain a mask for one hour compared to 167?  If you are intelligent enough, not very hard at all.  For the most part, the leakage occurs outside of the therapy hour, while the violent are moving and posting on social media among us.  It may happen in bits and pieces, or it may happen all at once, but it is us, the general public, that will see the lion's share of the messages.  Even if it is leaked in the therapy hour, there is currently no magic bullet, as it were, to swiftly contain and manage the potentially violent person.  As has been noted elsewhere, a mental health hold or commitment may last only hours or days.  Then what?

There are no simple answers to this problem.  Any solutions are likely to come from many quarters, including mental health systems (I use that phrase loosely because there is no actual "system" in this country), law enforcement, firearms statutes, families, and the general public.  But one element we all need, which the concept of leakage reveals, is a commonly taught survival tool of recognizing and reporting leakage.  It ought to be taught just as CPR is taught, and just the signs of heart attack and stroke are taught.  (We could do better even with those better understood conditions).  You cannot manage a threat until you know how to recognize it, and until you have a sound way of mustering support.  We are a long way off from having either.


Saturday, April 26, 2014

Vignette 4: What Would You Do?

James, an angry student

Background: James is hostile and belligerent.  He frequently appears angry and disrespectful, addressing others with profanity and aggressive gestures.

Scene: James asks to meet with you about his grades.

Ms. Forney: So, James I understand you wanted to see me about your grades.  How can I help you?

James: (Loudly) You can help me by getting rid of all the jerks in my life!  These grades here (hands her some papers) are unfair.  Those damn idiots gave them to me because they don’t like what I have to say.

Ms. Forney: Calm down, James.  Start from the beginning so I know how to help you.

James: (Even louder) Don’t freakin’ tell me to calm down!  I am sick and tired of being treated this way!  And by people who don’t know anything!!  (Gestures with fists in the air) If they don’t stop, I swear I’ll…

Ms. Forney: (Anxious, exasperated) James, you seem angry at me too.  What have I done that upset…

James: You’ve been OK, I guess.  It’s the others that jack me up.  (Slams fist on table)  Talk to them and tell them to leave me alone!

Ms. Forney: I can’t do that James.  But maybe I can help you arrange a meeting with the people you need to talk to about this.

James: Yeah, right, another meeting.  You go ahead and do that.  But it won’t matter tomorrow… (gets up and leaves the office abruptly)

Ms. Forney gets a call from her secretary, Gail, who says:

Gail: Are you OK?  James just stormed out of here and threw a folder at me on his way out!!  I’ve never seen such anger in all my life!

Ms. Forney looks down at one of the papers James handed her.  In the margins James has written: Moron.  You will pay for this.  I will see to it.

Suggestions: Because there are strong indications of threat, as well as objective evidence of aggressiveness, a call to your campus police and behavior intervention or similar team is warranted.  Attorneys have said there is no FERPA impediment to this action, as the information involved represents observable behavior.  It is important to move swiftly so that James gets the help he needs.

Wednesday, March 26, 2014

Challenging Orthodoxy in Mental Health

Every profession has its orthodoxies, opinions or philosophies which have been accepted as truth, either implicitly or explicitly.  The field of mental health is no different.  At times these are presented with an air of sanctimony and imperialism which are serious obstacles to further inquiry or maturation of the field.  Given that many of us are involved in improving human welfare, this ought to be viewed with suspicion, if not derision.  When it comes to the study and advancement of human beings, everything is open for further questioning.

Here I list a few of the orthodox assumptions in our field, along with comments from my point of view.

  1. Confidentiality is absolute.  Though it is without doubt the bedrock of good psychotherapy, a healthy degree of which is required for success, confidentiality has never been absolute.  There are exceptions both in law and ethics, such as risk for harm to self or others, which are commonly known.  Lesser known, perhaps, are exceptions which in the judgment of the therapist are necessary for the welfare of the individual.  Sometimes this orthodoxy is taken to extreme and ridiculous levels, such as when therapists block any communications with third parties, nor allow them physically near the facility "in order to protect privacy".  Many times good therapy involves working with a broader system of people, organizations, or policies which offer wider possibilities for the advancement of human causes.
  2. There is a superior paradigm for mental health.  Advocates for this orthodoxy, often from medical disciplines, proclaim their model as "best practice", and cite evidence for this position.  But rarely is disconfirming evidence cited even though it is easily found (as it is for any position).  Too often, other evidence is not considered or acknowledged, nor is the existence of other paradigms or models.  These include developmental, contextual, feminist, and culturally-bound models, all of which have profoundly important things to say about the human condition and its improvement.
  3. There is a hierarchy in the mental fields, and the topmost is the leader of the "team".  This orthodox view is closely related to number two above.  This is part of an imperialistic attitude which has no place in mental health.  It runs counter to basic concepts of respect and egalitarianism which are central to the therapeutic process.  Regardless of marketplace values, all fields have important things to contribute and their diversity is to be held in high esteem.  Also, the most important unit is the therapist-client dyad, and nothing can alter this fact.
  4. Suffering should not be a part of healing.  Even on the most basic level of our physical selves this is a falsehood.  All wounds hurt, and this hurting is a sign the body is doing what it is built to do.  The body and brain are capable of self-correcting if we give them a chance.  Many people, clients and therapists alike, appear to operate from a position that all symptoms, all pain, should eliminated from the start.  This posture, promoted by the pharmaceutical and insurance conglomerate, leads to premature diagnosing, premature intrusive interventions such as medications, and often, the premature conclusion of therapy.  Suffering is a part of life, and it is not always "diagnosable".  As we come out of our unconscious stupors, our avoidance and fetishes, we are bound to feel bad.  And probably for a while.  This is a part of healing and it is to be embraced and understood.  Then real and lasting progress may occur.
  5. A toolbox of "interventions" is what makes therapy work.  Though such a toolbox is important to possess, as is knowing when to use its contents, non-specific factors account for the lion's share of progress in therapy.  These include the personalities and styles of the therapist and client, and the quality of their relationship.  In spite of all our technological advances, adequate time, good listening, a deeply trusting and understanding relationship, and the ability to communicate from the client's experience are the most fundamental components of good therapy.  Without these your toolbox is useless.
Orthodox positions usually derive from economic, political, legal, and even religious points of view.  In reality these may have little to do with a heartfelt, caring and professional relationship between two human beings.  To the extent that such points of view are given space in the therapy room, we may impair the healing process which is before us.

Wednesday, February 19, 2014

Management 101

Most managers of mental health services get very little training in the business of management itself.  In our academic preparation we hear next to nothing about human resources, marketing, budgeting and funding models, project management and implementation, and paradigm conflict, among other sundry topics involved in this work.  We mostly learn on the job, which is to say through trial and error.  Or trial and success.  Some of us may pick up exposure through continuing education, informal training provided on our campuses, and more rarely through formal education.  Many of us benefit from networks provided for by organizations in the field, many of which I have listed elsewhere in this blog.  I know I have benefited immensely from the consultations provided by more seasoned directors than I, which continues to this day.  I am eternally grateful for these opportunities.  I believe there is an admirable expectation in our field that wisdom is passed down to new generations of leaders, and that this is done freely.

In this way we come to develop skills needed to manage services competently.  One can find a few texts which assist in this process, but there is no substitute for a sort of folk wisdom, if you will, which has been hard-won over time.  Below I make a humble attempt to present one version of this wisdom which I have gathered in over 22 years of labor.

  • Counseling or psychotherapy is mostly invisible and under-valued, and if you don't tell its story, loudly, no one will know much about it.
  • Just because you believe that college mental health is an oasis of sanity does not mean that others do.
  • One would think that mental health professionals who are trained helpers bound to a code of ethics always have the best of intentions and motives.  This is not true.
  • You can't please everyone or, alternatively, if you don't make an enemy along the way you are doing something wrong.
  • Take nothing personally.
  • Admit what talents you do not have, and collaborate with those that do.
  • There are people, organizations, and systems that will interfere with your attempts to help students.  There are many reasons why this is so, and not all of them are malevolent.
  • Praise in public, correct in private.
  • Know when to step away from work for the sake of your sanity.
  • Keep your word.  If you don't it can take a long, long while to earn trust back.
  • We are always one irrational student/parent/colleague away from disaster.  Unfair as it may be, such individuals can obliterate all the credit and stock which your team has earned.
  • Take up a new hobby every other year or so.
  • Nurture your relationships even if that doesn't come naturally to you.
  • When you are tired or weak, frustrated or angry, fearful or anxious, delay your decision.  You will feel better later.
  • Don't get distracted by petty games, fears, and a culture of blame.  Stay focused on what you believe is right and best.
  • Assert your authority, but treat this prerogative as you would a very expensive spice.
  • Be accountable to those above, below, left and right, but most importantly, to your self.
  • Work really hard to remove your ego from all considerations.  This is not easy.
  • Ask for help, permission, resources, funding, time to think, limits, forgiveness.  When it is denied ask again anyway.
  • Delegate.
  • Let go of pet projects when they are not effective.
  • Remember your family and friends.
  • Stand up to bullies and go to bat for your beliefs.  Others are watching you.
  • Play to the assets of your staff and overlook their weaknesses, but only up to a point which does not diminish your mission.
  • Many will expect perfection of you but not of themselves.  Get used to that.
  • When things get convoluted and you are in doubt, focus on helping the student in the best way you know how.
  • Even when things are messy and ugly spend some time recalling the inherent beauty and goodness in nature and human beings.
In subsequent posts I will expand on some of these themes, so please stand by.

Monday, January 20, 2014

Judgment, Inhibition and the Emerging Self

In 1994 Steve Jobs was interviewed on PBS for its One Last Thing documentary.  Speaking about insights which resulted in his life's work, he said:

"When you grow up you tend to get told the world is the way it is and your life is just to live your life inside the world. Try not to bash into the walls too much. Try to have a nice family life, have fun, save a little money.

That’s a very limited life. Life can be much broader once you discover one simple fact, and that is - everything around you that you call life, was made up by people that were no smarter than you.  And you can change it, you can influence it, you can build your own things that other people can use."

These are profound words, and not just for building things.  They describe key aspects for identity development and processes which limit it.  In my work and personal life I am too often struck by how much judgment we humans seem to ourselves, to others, to ideas, to thought, to dreams.  I and those with whom I work encounter it daily, and many times a day.  In my middle age I have come to ignore most of it, but this defense was hard won and took too long for me to develop.

So I work to help mostly younger adults to spot judgment which inhibits the genuine trajectory of the self.  There is no growth without risk-taking, without "bashing into the walls" on occasion.  We must all learn to manage unnecessary and harmful inhibition in order to become who we have always been.

There is of course a place in life for social feedback, for learning from others what we are and are not doing well or effectively.  But we ought to critically examine all feedback and determine for ourselves what is "true" and healthy for us and the world around us.  This takes time and practice, and the earlier one starts the better.  It is not easy figuring out where the world's great institutions of family, ethics or faith, school and government have gone astray.  Certainly each has something to offer, to help us reduce chaos and create meaning.  Institutions are made of people so there will not be perfection in these pursuits.  It is up to us to sort that out.

Sooner or later, everything which comes to us in life will be categorized as "belonging to me" or "not belonging to me".  We simply cannot accept all reflections of us as though we are carrying a mirror around with us at all times.  Attempting this will overwhelm the self and lead to poor mental health outcomes.  We have to be able to turn the mirror around and perceive that judgment is often more about the other or a system which is in need of our gifts and talents.  We don't always have to "live inside the world", but we do have the responsibility of changing that world for ourselves, and possibly for others, if we are to be authentic selves.