Wednesday, December 28, 2016

Pouring from an Empty Glass

It is widely believed that the American healthcare system is broken, judging by the ratio of costs to outcomes in comparison with other nations. Perhaps one measure of this brokenness is the degree of burnout among those who work in the system. Though the work can still be rewarding, and one cannot yet assign a direction in causality, there is evidence that psychologists, physicians, and others are often emotionally depleted in their work, and that this state is related to reduced or poorer outcomes for those they serve. Some authors believe that industrialization of healthcare and the influence of the pharma-insurance conglomerate has and will continue to produce an environment driven by profits and not by any measure the healing relationship.

I was once the 76th patient to sign in to see a physician. I wondered how in the world he could muster the focus and energy it would take to see me. A sad state of affairs indeed. Many who practice the healing arts and science may be pouring from an empty cup.

There is nothing inherently wrong with the profit motive. But time with another human being is also an important motive, and these two motives must be in at least an effective balance for healthcare, and specifically psychotherapy, to work well for consumers. It is for these reasons that psychotherapy does not belong in medical environments as they are currently structured in broken healthcare systems. In such settings therapy is a square peg in a round hole, and it morphs into 15-minute consultation visits after the most cursory of screenings. I once learned of such an office which employed a three-item depression instrument. Friends, it is not possible to know someone with only three allotted questions.

There must be an effort to constrain the trend to subjugate time to profit in healthcare systems. This and other forms of contamination in healing are not resulting in better care. It is, I believe, wearing out the healers. It is also distorting the psychotherapy process which is inherently time intensive but the data have repeatedly shown it is well worth the investment. We need to fill the glass so that we can pour for others.

Saturday, November 19, 2016

Post Election Madness

In the aftermath of the Presidential election in America, college counseling services were besieged with calls for help for those in distress over the results. Students, faculty, staff, parents, and others who felt targeted by racist, sexist, and homophobic statements during the campaign were alarmed for their safety and that of their loved ones. When threatening messages were posted on some campuses it heightened and provided validity to the fear. Not that any was needed. For a few days, some students did not leave their living spaces for fear of being assaulted. At some schools, classes or exams were cancelled.
Post  Counseling centers advertised their availability in order to reach out to affected community members, which is a routine procedure for any service offered. Media reports then circulated about these events. Perpetrators of harassment and violence reacted harshly to the offering of help, decrying, in a nifty but irrational association, "favoritism" to one party over another, and chanting slogans like "Suck it up buttercup!" Some centers found themselves in the precarious position of managing safety concerns as their events became easy targets for miscreants in search of venues for their activities. A representative in Iowa went so far as launching an "investigation" into how schools spent taxpayer dollars on creating "cry baby zones". Some even suggested that students who were happy about the election results should also be served. Somehow, in the Twilight Zone atmosphere of the election, fairly ordinary outreach to verifiably threatened students was distorted and turned into both a political football and a means of further alienating or even harming them.

In this madness, one simple fact was overlooked, or rather trampled upon. College counseling centers exist to help students in distress, whatever the cause may be. Our job is, and always has been, to assist students and return them to ideal functioning so they may go about the business of learning. This we will keep doing, no matter how insane the world around us may be.

Saturday, October 15, 2016

A War Against Entropy

Definition of entropy (Mirriam-Webster)

plural: entropies

1:  a measure of the unavailable energy in a closed thermodynamic system that is also usually considered to be a measure of the system's disorder, that is a property of the system's state, and that varies directly with any reversible change in heat in the system and inversely with the temperature of the system; broadly :  the degree of disorder or uncertainty in a system

a :  the degradation of the matter and energy in the universe to an ultimate state of inert uniformity
b :  a process of degradation or running down or a trend to disorder

3:  chaos, disorganization, randomness

Developed in the context of thermodynamics, most psychologists feel entropy does not have an equivalent or synonym in that field. Yet it is appealing and many, including Carl Jung, have attempted to draw parallels in the area of psychology and mental health. This post focuses on one aspect of its definition: devolving into disorder.

Many human problems can be characterized as the result of negative energy being permitted to continue or even flourish, which then "trends to disorder". Take the well-known concept of passive-aggressiveness in relationships, or the failure to communicate assertively. Of all communication styles this one tends to be the most damaging, short of outright violence, because it does not allow for correction or adjustment in relationships. Rather, it facilitates further misunderstanding and conflict. One can see the parallels to entropy. A method of ending this trend to disorder is to "detriangulate" by simply removing oneself from the conflict, especially when it originates between, and therefore is owned by, other individuals. Doing so alters the outflow of negative energy.

One could argue that, of all human problems, suicide may be the ultimate conclusion of the process of unchecked, or unreversed, entropy. The sufferer seeks release from unbearable pain, a very understandable motivation for any of us. One could characterize all attempts to help the sufferer as methods of checking or reversing a trend toward oblivion. Reversing the trend could be called, in such an example, the restoration of hope, of order, of positive energy. Most of the time this approach works, thankfully. Many times, the reversal of this entropy comes from outside the individual, through the acts of supportive individuals or systems.

Sometimes these attempts fail. The sufferer continues to wage the battle, or lose it, on their own. But even when we are totally on our own altering the conduit of negative energy is still possible.

In the final throes, we may still choose to take responsibility for arresting the entropy in our lives. Without that, the energy may pass unchecked, and survivors tell us this is exactly what happens. The sadness, the pain, the wound, opens up a hole in the universe for those left behind. Even for those who were not known by the lost loved one. This hole never closes fully. All of us, all of humanity, suffer from the loss of gifts that are not manifested in our world. A world which desperately needs all gifts.

If you or someone you know is suffering, please call or chat online with the National Suicide Prevention Lifeline at 1-800-273-8255, or

Thursday, September 29, 2016

How Disease Models Strangle Science

In some quarters substance abuse is rigidly defined as a "disease". Professionals trained from that perspective, as well as many addicts who recovered through 12-step groups, often hold onto this point of view very firmly. Explorations into other perspectives, and their resulting approaches to intervention, are often seen as heresy within those communities. I am personally aware of one facility which only allows medical protocols due to its fidelity to this paradigm. When one whispers "What about harm reduction?" this is met with gasps and even shaming, which is odd given the role of shame in substance abuse.

While disease models do allow sufferers to be unburdened by needless shame, and may help some on the higher end of the abuse spectrum, they cannot help the other 80-90% of those affected. Substance abuse is well-known as a stubborn, intractable problem for many people. For this reason alone we ought to creatively explore as many options as possible for investigating and helping.

Some are proposing that addiction is not a disease at all. They point to a consistent lack of supportive data (except for brain changes that may result from addiction), and argue for approaches focusing on skills like mindfulness and understanding the role of history in the development of abuse behaviours. Others believe that addiction is actually a method of disconnecting from relationships since, by definition, one is not functioning in reality when one escapes it. So, some people turn toward escape as a means of coping with problematic interpersonal patterns. This approach offers many possibilities in terms of program and service development. It is even easy to see how 12-step programs such as AA address addictions through the development of community.

Every field has its sacrosanct positions, sometimes borne of economic or political motives. That rigidity is dangerous in that it may stifle thought, investigation, and creativity. Of all fields one would think that mental health needs this degree of openness most of all.

Tuesday, August 30, 2016

Mental Health Movements

Slowly (sometimes not so slowly) and surely, a movement is taking hold which questions traditional views of mental health treatment, if not the concept of mental health itself. Many professionals and consumers alike are questioning systems which focus on disease models and the research, or lack thereof, which under-girds them. In the United Kingdom the movement is fairly advanced, as evidenced by publications in professional societies and various communications from humanistic psychology leaders.

While there has long existed serious criticism of psychiatry in particular, it has risen to higher levels since the advent of the DSM5 which many believe has significant conceptual problems and poor support in research. As noted elsewhere, the NIMH has abandoned it as a requirement in its research protocols. Questions are being posed about long-held notions of illness itself, an example being the addictions as some are viewing it as a social issue more than a brain issue. A recent review of 29 studies also posits that depression is much more than just a mental disorder. Perhaps most prevalent in recent years has been serious criticisms concerning the relationship between Big Pharma and medicine, with hundreds of articles available about this topic. But there's more; research is also demonstrating actual harms associated with psychiatric medications including antidepressants.

More importantly, the concepts of mental health and mental illness are getting another look. In particular some see these concepts as more complex than binary; that it is possible to have some measure of both in the same individual. Keyes (2002) proposes that each of us manifest aspects of both flourishing and languishing, both at once and at different times. In this view it is possible to view folks as a combination of both adjusted and impaired, which permits more sophisticated approaches to human problems as opposed to nailing down symptoms with a hammer.

These really could be exciting times as we rethink old or worn out professional chestnuts. We might be living in a time preceding major paradigmatic changes in mental health service delivery.

Keyes, CL (2002). The Mental Health Continuum: From Languishing to Flourishing in Life.
Journal of Health and Social Behavior, Vol. 43, No. 2, pp. 207-222

Saturday, July 30, 2016

Behind the Magnifying Glass: Categorizing Vast Human Experience

Current models of diagnostic systems are woefully imprecise. But their use continues and is embedded in the economics of mental health care. One is not paid or reimbursed for the cost of services by an insurance company without a DSM-5 diagnosis, even though there is wide acknowledgement of its shortcomings. The coin of the realm is depending on runes. Even the NIMH has changed its reliance on the DSM-5 in funded research projects, and has begun looking elsewhere for diagnostic constructs. Incidentally, as of this writing the United States is the only country not mainly relying on the ICD-10 for its diagnostic rubrics, though that may change soon. One wonders what this says about America.

This has thrust the discipline of psychiatry into some disarray; it is after all the author of the DSM-5. But it is not alone. All mental health professionals are flummoxed when they try to reconcile the height, width, and depth of human problems with rigid, confining, and just plain silly diagnostic tools. The situation results in working with folks who technically "meet criteria" for a disorder but don't have it, and vice versa. It also means that some folks have a disorder but do not resemble each other in the least, except for a handful of "criteria".

It is even the case that many who "have" common disorders such as depression, anxiety, and substance abuse, may need no "treatment" at all. A great many such persons have issues which remit on their own, and to a greater degree than those who were in treatment! This must partly be because we may not know what we're aiming at as we shoehorn complex human beings into simplistic pigeon holes. This phenomena comports with my own clinical experience. Most of those I work with might have intense periods of distress or crisis, but these are essentially transient as they are borne of developmentally- or contextually-based predicaments in their lives. And most of the time, a few sessions focused on understanding these predicaments plus some problem-solving results in demonstrably positive outcomes. This takes profound listening and respect on the part of the helper, not one who is guided by a manual.

Think about it. Remember how you felt on your worst days, and those parts of your past and present which were the ingredients for such times. Remember if you ever felt understood, and if you did, by whom. It might have been a therapist who did. I hope it was, because I know there are many of us who can. But it might have been a minister, a friend, a family member, or a stranger on the street. And chances are good they didn't follow a manual.  

Wednesday, June 15, 2016

A List of Demands

Recently I saw a list of demands put forth by a mental health advocacy group. Though I understand the need to advocate I was amused that anyone would think they could demand anything from anyone. After I looked further into the demands I learned that the authors did not do their homework; they did not work in the relevant field nor request information from those who do. Perhaps they were amateurs. I'd like to chalk this up to their being rookies as opposed to juvenile manipulators looking to make a splash.

At any rate it occurred to me that I could also generate a list of demands, one informed by years of practice in the field and the discernment of politics and agendas which interfere with our work and thus the healing of individuals. So here it is:

  1. Mental health and mental illness must not be solely reduced to brain functioning and physiology.
  2. Developmental processes and contextual factors are involved in a great many cases of diminished psychological functioning. These must be taken into account if we are to fully address human needs.
  3. Support for services which seek to establish a secure, confidential setting, in which people reveal their fears, shames, anger, and more, is essential if we are to create opportunities to work with development and context.
  4. The importance of maintaining rights to privacy cannot be overstated. This is the bedrock of effective psychotherapy; healing is impaired if records are not free of unnecessary intrusions and over-sharing.
  5. Therapy clients must also be treated with utmost respect and be afforded the right to significant autonomy and self-determination in their decision making concerning services. This is impaired when they are required, under the duress of psychological pain, to waive confidentiality and right to privilege at the outset of therapy and before they can know what is in their record.
  6. College students, due to their usual age and developmental stages, are uniquely susceptible to reductionism and threats to their emerging adulthood. Due to the intensity of life changes and identity formation, they tend to have volatile, but essentially transient, periods of distress. These can be misconstrued as severe illness and, if not received with skill, students may come to adopt an illness identity which disrupts normal development and may saddle them with lifelong harm. Instead, their primary need is for professionals who can create a holding environment, one that can absorb the intensity and help them pass through a volatile period unscathed while acquiring the learning and skills they need for independent adulthood.
  7. Due to the nuances described above, it is essential that college mental health professionals develop broad consultative relationships on campus for the purpose of delivering mental health expertise to consultees and implementing prevention-oriented outreach programming across campus.
  8. Professionals operating from other service paradigms must accept and respect these skill sets and philosophies. To fail to do so is to fail to serve the student.
  9. Administrators and funding sources must be courageous and carve out the needed resources to nurture the above orientation which seeks to incubate and produce healthy and contributing world citizens. This is an essential promise of higher education.
  10. Politicians and lobbyists must also be courageous and not bow to more base and dissolute motivations, in particular the profiteering of illness.

Wednesday, May 11, 2016

Privileged Communication, Respect of Persons, and Informed Consent

As medicine has adopted electronic records systems and pushed for integrated health care operations (the actual working definition of which varies widely), concerns about privacy and oversharing records have arisen. A recent Google search for this erosion of privacy resulted in 97,600,000 hits. In 2015 an estimated 100 million health care records were stolen, affecting approximately one out of every three Americans, an increase of 11,000 percent over the previous year. Clearly security has not kept pace with developments in the technology involved. This situation is ripe for lawsuits.

Some have warned that such records systems can lead to other types of damages, pointing to 147 such adverse events in 2013 alone, and have clearly advised for the separation of physical and mental health records. There has also been a successful movement in Minnesota which is using legislation to challenge forced shared records adoption by psychologists in health care settings. Its leaders cite two main motivations: potential for harm, and the right of psychologists to govern their own practices.

As if this was not of enough concern, some of these operational models, which may include mental health services, also build in compulsory "consent" to share records with unnamed "healthcare professionals". I say compulsory because this consent is required in order to receive services. This consent process occurs when one is under the duress of suffering, and before one can know what exactly is in the record, the purpose of the sharing, and who specifically will receive it. This means that such a process fails to secure informed consent, part of the ethical bedrock of the mental health professions, something we learn almost from the moment we set foot in training programs.

In all 50 states clients of a variety of mental health professionals are granted the right of privileged communication in therapy. Aside from exceptions having to do with harm to self or others this right is absolute; no third party has an entitlement to this information. Compulsory consent processes force therapy clients to waive the right of privilege in toto; once it is waived there is no longer any privilege. No other professional services for which persons may claim privilege (clergy, attorneys) engage in compulsory consent in order to receive their assistance.

This is so because it is ethically and morally wrong.

In addition to the violation of informed consent and right of privilege, these practices fail to respect the autonomy of persons, their right to self-determination and choice. They also fail to act with integrity, beneficence and non-maleficence in carrying out professional services. These duties are spelled out in the ethical codes of all mental health professions in one way or another.

Compulsory and total consent processes are sought after presumably for two reasons: perceived ease of communication, and the convenience of business procedures including billing (in all honesty I think the latter is the real motivation). It is claimed that such conveniences result in improved outcomes, but research support for that is mixed. Where support exists it regards those who cannot speak for themselves, such as the very young, the very old, and those who have been deemed incompetent. It is an injustice to treat all persons in this same manner. Further, an informed consent process at the point information is needed has always been available. In 25 years of practice I have never known this to not work well.

Combine lack of security with totally open mental health records and you have an enormous problem. Oversharing and failure to respect persons will lead to injury and therefore litigation. That is one way to resolve these predicaments. The media will also get involved, and that is another potential pathway to resolution. Or we could all just go ahead and do the right thing.

Saturday, April 23, 2016

A Lesson on Splitting

I am opposed to selective recall of history. Andrew Jackson’s treatment of Natives and Africans are well known and he is accountable for this conduct. He shares this responsibility with wealthy landowners who funded this treatment for their own economic interests. But Jackson is like all humans and was a combination of good and bad. Unlike all humans he was President, and unlike all Presidents he occupied the office during the late 1820s and through the 1830s, a difficult period in American history in which the seeds of the Civil War were nurtured, intentionally or not. The bad things he did were hugely bad and reverberate to this day.

Jackson did some good things too, and these were also huge in their own way.
  • Jackson, against all odds and the elitism of the times, rose from poverty and dire circumstances to the Presidency. He was the first President born to immigrant parents.
  • He participated in the Revolutionary War at age 13, and had scars to prove it.
  • At his inauguration Jackson invited farmers, merchants, “commoners” and their families, virtually off the street, into the White House. This was a signal about whose interests concerned him the most.
  • Jacksonian democracy is the political movement during the Second Party System toward greater democracy for the common man symbolized by Andrew Jackson and his supporters. Up until oligarchs began taking control of our country (again), this form of democracy was still predominant. Ironically, at key moments in our history, it would serve the groups that he himself had persecuted.
  • Jackson is credited with placing the Executive office on a par with the other branches of government.
  • Jackson believed that voting rights should be extended to all white men and not just property holders. By the end of the 1820s, attitudes and state laws had shifted in favor of universal white male suffrage. Of course this left out others who had to wait to win the same privilege, but this was an enormous shift for the time.
  • In Washington’s social circles, overwrought with elitism and favoritism, Jackson showed favor only to those who treated his friends justly and proved their loyalty to him in other ways. One example was known as the Eaton Affair and it turned Washington on its head. In its aftermath he terminated his entire cabinet except for one individual. He communicated that he was not going to bow to elitist ideals. 
  • To address corruption in politics, Jackson replaced about 10% of a variety of office holders. For this, he is credited with what he called “the principle of rotation in office”. 
  • As a result of aggressive controls on spending, Jackson is the only president in American history to pay off the national debt and leave office with the country in the black.
  • Jackson limited the powers of the Second Bank of the United States, which had previously benefitted mainly private stakeholders and the government itself. He saw the threat to individual liberty posed by government institutions when they became too powerful, and he actively battled to keep them in check.
  • Jackson prevented a break in the union when South Carolina threatened to secede due to a tariff issue. This set precedents that Abraham Lincoln would later use to oppose secession. 
  • Jackson was the first President to establish the use of the veto over a matter of policy.
  • “Jackson had many faults...but...With the exception of Washington and Lincoln, no man has left a deeper mark on American History. “ ~Theodore Roosevelt
I think it’s great to put Miss Harriet on the 20 dollar bill. She deserves it. I also think it’s fine to remove Jackson from it, though I understand now he will still be present on the reverse. It seems fitting to memorialize the complexities in our country’s history in this way. (Actually he could be removed from all bills; he did not believe in paper money.) But I stand against reducing people to their sins alone, and engaging in juvenile psychological splitting to deny the full range of their humanity to advance an agenda. No one I know would want that for themselves or those they care about. Besides, if we only look at things as all good or all bad we cannot understand our history or even ourselves.

So I am standing up for the good in Andrew Jackson, a son of Ulster. He did some big, good things for this country which remain with us even now, though they are perhaps a bit tattered. The current political season in which we find ourselves would benefit from a healthy dose of Jacksonian democracy, though we would need to put a thick layer of justice all around it.

Learn more at

Adapted from multiple sources.

Saturday, March 26, 2016

Expectations and Mental Health

Mental health issues are best viewed in their entire context. Claims of increasing mental illness among our youth are overwrought in large part because these fail consider context. One important aspect of context involves the expectations of students, as well as those around them.

As noted previously, learning and growth is supposed to be uncomfortable. Refining one's approach to thought and decision-making is difficult business, as we must separate bias from rationality and objectivity, the dross and gold of education. Costa (2016) sees this as a process of unlearning, to which recent cohorts of students are reacting poorly to as a result of their expectations for their college experience. In particular she sees this as a clash between the inherent stresses of learning and a mindset which over-values performance ratings, preconceived notions of success, discomfort with ambivalence and doubt, and a hyper-focus on outcome rather than process.

This is a view which deserves more consideration. It could help explain, for example, high rates of self-reported distress in the absence of true or moderate to severe mental illness. It is consistent with observations concerning modern parenting practices, the coping skills repertoire of adolescents and young adults, and data which support rapid positive changes in these dynamics with just a modicum of support or counseling.

In the popular press we often see polarizing comments about higher education, parents, and students, and this is not useful. It is the interaction of all three, mediated by the expectations of each, which deserves our attention and investigation.

Saturday, February 27, 2016

Mental Health and Politics

Does mental health and politics mix? Yes and no. The type of politics represented by consensus-building grassroots efforts, informed by solid data, to advocate for better policy and services definitely has a role to play in improving mental health care. Barbara Mikulski's work to improve parity in mental health is a prime example of this.

There is another kind of politics which has no place in mental health communities or movements. This type of politics seeks to gain attention primarily for its sponsors, tends to rely on spin or distortions of data which capture attention and followers, and avoids building consensus or involving stakeholders in any genuine sense. Such attempts are often short-lived because its true motives are shallow, which means true advocates will not stay on long. In reality, these methods result in harm for mental health and those who are in the trenches fighting for its advocacy. If they do produce a policy or service these will be faulty since the data they are built on are faulty as well, likely causing conflict or confusion among stakeholders. The sponsors of these movements tend to move on to other projects rather quickly, and qualified others do not step in their place to sustain what they started. Sometimes a group of vendors will develop related products, but their main goal is financial and has little to do with improving mental health care. Various attempts in support of conversion therapy for homosexuality, which has resoundingly been condemned in nearly all professional circles, are perhaps good examples of this type of politics. But many other, smaller movements are more mundane and numerous than this.

We have a short supply of the type of work Mikulski has carried out. But we have an abundance of the other. Those working in mental health professions are always looking, if not starving, for help. When approached by marketers or politicians there can be a real temptation to take the bait. The switch comes later of course, and by then there will disappointment that one's expertise or carefully maintained information drew no attention in the development of the product or cause. A far worse outcome may involve a cheap and immature denigration of your work in order to falsely contrast it with what is being sold.

So, here are some tips in managing these contacts:

  • Do thorough research on the individual or cause before you meet with them
  • Involve other stakeholders and witnesses to the discussions and agreements
  • Put any agreements in writing with signatures of all concerned
  • Consider contacting the media with your perspectives on project development
  • Push out content broadly on social media
  • Maintain fidelity to your philosophy and work throughout the process

Monday, January 25, 2016

College Students and the Severity of their Concerns

Much has been written concerning recent cohorts of college students and their reported difficulties. See a prior post concerning one debate on this issue. These students are called, by various authors, slackers, socially inept, narcissistic, poorly equipped to cope, entitled and demanding, and perhaps most frequently, more mentally ill than previous generations.

But none of this squares with my direct experience. Large-scale epidemiological studies in America and Canada refute the claim regarding mental illness. The most recent annual report of the Center for Collegiate Mental Health notes that various indices of mental health have remained "generally flat" for the last five years. The authors hypothesize that noted increases, such as demand for services, are best thought of as "expected outcomes", that is, the result of increased attention and dollars devoted to mental health in higher education. It is puzzling that many continue to make contrary statements, including mental health professionals in my own field. Puzzling until one considers who or what may benefit from such reports: the profession itself. More specifically, the part of the profession oriented to the medical paradigm and the swift "delivery" of interventions such as medication.

There is little doubt that the current generation of students have distinctive attributes and challenges. But so did mine, and so did the one before mine. Many generational distinctions also happen to be positive, but one does need read much about that. Like so many things in life at present, one is more likely to read spin or distortions of data.

So where and how does the mental illness distortion originate? This is probably something that is over-determined, but one way this starts is via survey data. Two oft-reported data points come to mind. ACHA's "40% of college students report having been so depressed that it is hard for them to function", and AUCCCD's "85% of counseling center directors believe student's issues are more severe". Both are misleading. What is not reported in the first example is the meaning behind "depressed" and "function". Do 40% of students not get out of bed? Not sleep? Not eat? Not go to class? Higher education would collapse overnight if this were true. Regarding the AUCCCD survey item, I can testify as one who completes and submits it every year. The response options we are provided on the severity item include "increased", "decreased", and "unsure". "Remained the same" is not provided as an option. This would be my choice if it was. I believe this forced-choice results in a distortion, in this case an inflation concerning severity.

The data does say something, however it is not possible to say exactly what. One hypothesis is that both data points reflect a subjective sense of discomfort, and are mirror images of each other. Students are in fact uncomfortable and they readily admit to high levels of distress. Some of this is due to the stress and strain of growth and development. Some is due to changes in parenting patterns (about which I wrote previously). Some is due to global issues in politics, conflict, and economics. Many students have little faith that the degree they are working hard to earn will translate to a secure livelihood. In short, they are supposed to feel uncomfortable. I would too if I was them.

As for college counseling center directors, our discomfort is about meeting the needs of these students who are knocking on our doors with rising frequency. This is occurring in the context of a nationwide and chronic problem with under-funding and inadequate resources in many centers. Our subjective emotional state often involves something like panic and fatigue as we attempt to address the needs of the masses coming to us. We are supposed to feel uncomfortable too.

It's all about context. And context is missing from key surveys and thus the national discussion.