University Student Mental Health

Version 2In these uncertain and anxiety-provoking times, our universities have an increased responsibility to support student mental health and wellbeing. This is not about the issues of “spoiled and coddled” Gen Xers, helicopter parents, and the endless debates over the use of trigger warnings in higher education. This is about having a positive impact on not only our future workforce, but also our future leaders and change agents.

William Pang, a second-year student at McGill University in Montreal, wrote a moving NYT op-ed piece “The Season to Be Stressful” (December 19, 2016). He discusses his experience of learning to deal more effectively with overwhelming anxiety exacerbated by the highly competitive atmosphere of his university. He states, “I don’t think we should demonize an entire generation as reliant and narcissistic. We should instead celebrate a generation that is coming to realize the importance of initiating conversations about our mental health.” It is dismaying to read through the NYT comments to Pang’s op-ed piece with so many people basically telling him to buck up and become an adult.

The photo above is of me with the amazing UK nurse and PhD student Josephine NwaAmaka Bardi  with her social media campaign, “Raise Awareness of Mental Health in Higher Education” (#RAMHHE)  I met NwaAmaka Bardi this past September in Seville at the 5th Annual International Health Humanities Conference: Arts and Humanities for Improving Social Inclusion, Education and Health. She also works in the area of mental health cafes as an effective alternative community mental health service. London’s Dragon Cafe is a good example of a creative, welcoming, and supportive community cafe with a focus on mental health and wellbeing. It would be great to have a similar community cafe open to university students.

Universities UK is developing a mental health framework for universities to embed mental health and wellbeing across all university activities with the goals to decrease stigma and increase access to a variety of mental health and wellbeing services. (See: “New Programme to Address Mental Health and Wellbeing in Universities” December 2, 2017.) They point to the need of “getting universities to think about mental health and wellbeing across all their activities, from students and teaching, through to academics and support staff.” It doesn’t end with the provision of mental health and support services for students but needs to permeate the entire campus.

Doris Iarovici, M.D., a psychiatrist at Duke University Counseling and Psychological Services has written a book titled Mental Health Issues and the University Student (Baltimore: Johns Hopkins University Press, 2014). Although geared towards college mental health professionals, it includes useful information on the variety of mental health issues that our students face in universities—from anxiety, drug and alcohol problems, sexual assault, eating disorders, and relationship problems, to depression, suicide, and schizophrenia. She concludes by stating, “If we provide a range of services, including individual, group, and community programs, we will be in step with the goals of health care reform to focus on both prevention and optimizing outcomes.” p. 219

Commit to Mental Wellbeing

 

As we begin a new year, my wish is that we commit to mental health and wellbeing. This should start with our own individual mental wellbeing, but we need to use that as a base for supporting the mental wellbeing of our families and our communities. In the midst of so much turmoil, anxiety, bigotry, misogyny, and xenophobia in our country and our world, nurturing mental wellbeing is not a luxury—it is a necessity.

An essential ingredient for mental (and physical) health and overall wellbeing is social inclusion and a sense of belonging to a caring community. The adverse health effects of increasing population-based levels of social isolation and loneliness are now being highlighted. Dhrav Khuller, M.D. writes in “How Social Isolation is Killing Us” ( NYT December 22, 2016) that social isolation and loneliness, is linked in recent studies to a 29% increased risk of heart disease and a 32% increase in stroke.

Objective measures of social isolation include quantity and quality of social network ties, as well as living situation (living alone, whether housed or homeless). Loneliness is a person’s perception of social isolation and is, therefore, a subjective measure. Researchers point out that loneliness and social isolation are often not significantly correlated even though we commonly think of them as such. A recent large meta-analysis (a study of research studies) that included 70 independent prospective (following people longitudinally) studies representing 3,407, 134 participants, revealed a significant effect of social isolation—whether measured objectively or subjectively— on mortality. The researchers for this study also found that the largest detrimental effects of social isolation were for middle-aged adults as opposed to older adults. They call for social isolation and loneliness to be added to lists of public health concerns. (See: “Loneliness and Social Isolation as Risk Factors for Mortality: A Meta-Analytic Review” by Julianne Holt-Lunstad, et al. in Perspectives on Psychological Science, Vol 10, issue 2, March 11, 2015.)

In the U.S. we are good at doing yet more research documenting the adverse health effects of social isolation and loneliness; we are not so good at finding constructive and sustainable ways to intervene. Many industrialized countries, including the U.K., Australia, New Zealand, Spain, and Canada are way ahead of us in terms of implementing cost-effective, community-based interventions. (See: “Researchers Confront an Epidemic of Loneliness” by Katie Hafner, NYT September 5, 2016.) In the U.K. there is the Campaign to End Loneliness. In New Zealand there is the public mental health campaign that I love: the All Right? campaign implemented in the aftermath of the Christchurch earthquakes. And addressing gendered issues, there is the Men’s Sheds movement that began in Australia and has since spread to the U.K., Ireland, Canada, and New Zealand. Another lovely and creative community-based solution I learned about this past year is the Art Hive (La Ruche d’Art) in Montreal, as well as in many other communities, including in Spain. My other wish for 2017 is that we learn from these sorts of programs and find ways to implement them in our own communities.

** A note on my (intentional) spelling of wellbeing as one un-hyphenated word: I find it both fascinating and telling that all English-speaking countries except the U.S. have moved to the use of “wellbeing” instead of the Americanized “well-being.”

Spring Blue(s)

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Photo credit: Josephine Ensign, 2015

Why do spring and depression go together? The seasonality of illness is fascinating and is proof that our environment matters quite a lot to our individual and collective/public health. In temperate regions of the world, injuries and drownings go up in the warmer months, and deaths from influenza and carbon-monoxide poisoning go up in the colder months. These make sense. But when we think of depression and suicide risk, most of us would guess that these peak in the fall and winter months–what with decreased hours of sunlight and the stresses of some of the major holidays. In the U.S., September is National Suicide Prevention Month and October is National Depression Awareness Month, and many news reports continue to falsely link higher rates of depression and suicide with fall and early winter.

Yet studies worldwide find that depression and suicide rates peak in late spring and early summer. High pollen counts, increased hours of sunshine, higher temperatures, and even an increase in thunderstorms (ah–that Shakespearean pathetic fallacy!) have been linked to higher rates of depression and suicide. Within psychology and sociology circles, this seasonal link is theorized to be from the fact that people generally have increased social pressures and interactions in the spring, which can increase stress. (see “The Season of Renewal and Suicide” by Brian Palmer, Slate, 12-7-12).

The most current statistics from the CDC on the leading causes of death in the U.S. (for 2013), list suicide (intentional self-harm) as the tenth leading cause of death, with the total number of deaths by suicide as 41,149. (Suicide is the second leading cause of death for young people ages 15-24 years.) This continues the upward climb of suicide deaths in our country since the start of the Great Recession, with the largest increase being in people 45-64 years of age (peak wage-earning years.) With the possible exception of unintentional injuries, such as motor vehicle accidents, suicide is our most preventable form of mortality. And suicide deaths have serious impacts on the family members, friends, co-workers, and care providers who knew and loved the people who killed themselves. Note: they did not ‘commit’ suicide as is still too commonly used; suicide is not a crime or a sin–it is a preventable travesty. Using the term ‘commit suicide’ adds to the already debilitating stigma of mental illness.

So what are interventions that work to help prevent deaths by suicide?

1) Train healthcare providers to screen for depression, drug/alcohol use, bullying at school (for young people), history of adverse childhood events (especially sexual abuse), and suicidal ideation and attempts. In primary care screening for depression and suicide risk (as well as intimate-partner violence), a standard question is “Do you have access to a firearm?” This screening question seems so obvious, as access to a lethal weapon is an important part of the overall risk assessment. Over half of all deaths by suicide are by firearms. But now in Florida that healthcare screening question is illegal for physicians and nurses to ask their patients. (See James Hamblin’s 8-11-14 article in The Atlantic, “The Question Doctors Can’t Ask.” ) And other (mostly Southern, no surprise) states have similar legislative ‘healthcare gag orders’ pending.)

2) Educate the general public about the warning signs of severe depression, problematic drug/alcohol use, and suicide–and give them the proper tools to be able to intervene effectively. Reinforce the fact that talking about suicide in a supportive way does not encourage suicide (just as talking about sex or drug use with adolescents does not encourage them to have sex and use drugs.) An excellent (free and 24/7) resource is the National Suicide Prevention Hotline at 1-800-273-TALK (8255). They can connect people with local crisis centers and assistance.

3) Implement a community-wide public mental health promotion (and depression/suicide prevention) program. One such model program that is cost-effective and that could be replicated in the U.S., is New Zealand’s All Right? Wellbeing Campaign, a Healthy Christchurch project that is being led by the Mental Health Foundation and the Canterbury District Health Board. As they state, “All Right is a social marketing campaign designed to help us think about our mental health and wellbeing. It’s about helping people realise that they’re not alone, encouraging them to connect with others, and supporting them to boost their wellbeing.” Although targeted at earthquake recovery efforts in the Christchurch area, this public mental health campaign could be most effective at building community resilience before major disasters occur.

My students and I stumbled across the work of the All Right? Wellbeing Campaign while we were in Christchurch last year studying community health. I wrote about it in a series of blog posts, including “New Zealand Postcards: The Allrighties” 2-3-14. Some of our health-focused students ‘brought this home’ to Seattle and started the student-led “What’s Up UW?” community for promoting social and emotional wellbeing.

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From the All Right? Wellbeing Campaign, Christchurch, New Zealand.

 

 

 

New Zealand Postcards: The Allrighties

DSC01176This morning we had a presentation on the All Right? population-based mental wellbeing campaign, a Healthy Christchurch project led by the Mental Health Foundation and the Canterbury District Health Board. Sue Turner, the All Right? Campaign Manager and her colleague Lucy D’Aeth gave our class an overview of the campaign, including their community-engagement strategies.
I mentioned the All Right? campaign in my previous blog post Disaster Tourism; All Right? (Jan 19, 2014). Their creative and engaging posters had been one of the bright spots in the midst of our (unplanned) tour of Christchurch’s Red Zone area a few weeks ago. I wanted to know more about their work, so I invited them to speak to us today. They are hoping to present on their innovative mental wellbeing social marketing campaign this coming November in New Orleans at the annual meeting of the American Association of Public Health.

It seems that theirs is the first population-based mental health and wellbeing campaign post-disaster anywhere in the world (they invite anyone who knows of another one to contact them so they can compare notes). They gave us a lot of information to process, so I’ll just mention some of the things that stood out for me.

  • Raising emotional literacy on a population level is important baseline work before any big ‘calls to action’ are implemented.
  • Pre-existing inequities in a community can be made worse by a disaster (as was highlighted in the U.S. in New Orleans post-Katrina); they are trying to pay attention to that here in Christchurch.
  • More targeted social marketing for mental well-being are being developed for ‘hard-to-reach’ groups, such as the Maori and men (‘blokes’ in the Kiwi vernacular–a poster geared towards men is included in this post. Don’t you just love ‘mate date’?) They are also currently targeting more efforts on mental wellbeing for children affected by the quakes.
  • People cannot truly start to process the trauma until they are in a safe, stable place, and many people in Christchurch are still displaced, awaiting repairs (or relocation) on their homes.
  • In surveys done in 2012, they found that 61% of Christchurch respondents did not use any relaxation techniques–but that they were interested in learning them.
  • The Giggles: (Hannah Airey, director) offers community groups and trainings in a laughter yoga technique. The ‘laughter therapy’ groups have become quite popular. Laughter is infectious. Check out the germ theory by watching this terrific short documentary on Christchurch area laughter yoga/therapy.
  • Their non-academic (yet based on extensive research/developed by the UK-based think tank The New Economics Foundation) framework for their campaign is five main categories or ingredients for well-being. These categories are: 1) be active, 2) connect, 3) give, 4) take notice (slow down/savor the moment), and 5) keep learning (enjoying a fresh challenge can boost confidence).

New Zealand Postcards: Disaster Tourism; All Right?

DSC00965DSC01014DSC00994DSC00949Clearly I was an Ugly American Tourist/Professor stumbling (unprepared) into the Red Zone of Christchurch yesterday. After all, the New York Times lists Christchurch as #2 in its “52 Places to Go in 2014.” The article talks about things like seeing the “re-birth of a quake-ravaged city,” and shows a photograph of the inside of a transitional church made of cardboard tubes. What a good place to go on a Sunday afternoon stroll with a bunch of students, right?

I thought I had done my homework. I knew we would likely encounter some signs of the destructive earthquakes that hit Christchurch and surrounding areas in September 2010 and again in February 2011 (killing 185 people, including many international students.) But I wasn’t prepared for the magnitude of the still-raw destruction in the downtown core. It’s been almost three years and entire blocks of quaked-out buildings are propped up with shipping containers or just left in charred ruins.

Near the core of the central business district is this temporary memorial of ‘ghost chairs’ sitting out in a now-open field. The chairs are individualized to the people who died, so there are wheelchairs, armchairs, deck chairs, student desk chairs, toddler chairs, and infant seats. The plaque that describes the memorial encourages people to sit in a chair that speaks to them in some way and just spend a quite moment in reflection. This memorial reminded me of the shoe display room at the National Holocaust Museum in Washington, DC. It is truly haunting.

The second to the top photo I’ve included here is of a former Starbucks store near the downtown ReStart shipping container mall that has sprouted up since the quake. If you look at the window of Starbucks it has “OK, TFI Clear 26/2,” meaning it was checked and marked as not having bodies to remove four days after the earthquake. How long does it take to clean up a city after a major disaster? More than three years? That is what I thought–and still think–although I recognize I really know very little about the politics and psyche of this country I am visiting.

There are ‘Up With People/We Will Overcome’ signs posted everywhere amidst all the rubble. My favorites were on the outside of a temporary Christchurch Art Gallery space (in modular shipping container-like structures), and the mental health/PTSD prevention banners tied to chain-link fences, like the one in the first photo here. The banners are part of the All Right Wellbeing Campaign, Healthy Christchurch, a social media campaign supporting community mental health and wellbeing.

But I keep asking myself, “Why are we here?” Are we inadvertently participating in trauma tourism–also called disaster tourism, dark tourism, thanatourism? In downtown Christchurch they even have those very British double-Decker sightseeing buses for “Red Zone Tours.” At least we didn’t pay to ride on one of those, but is it even worse to have walked around taking photos of destruction, peering into windows of what people left behind when they fled?

Nurse Ratched’s Backstory

This week the assignment I gave students in my narrative medicine course was to apply the close reading drill they’re learning to a ‘read’ of a feature length movie. I gave students a choice of six movies around the theme of caregiving: The Diving Bell and the Butterfly, The Doctor, The English Patient, Midnight Cowboy, Rain Man, and One Flew Over the Cuckoo’s Nest. Besides doing a ‘close read’ of the movie of their choice, I asked them to reflect on the following questions: 1) What is the nature of caregiving as portrayed in the movie? 2) In the film, who is being cared for and who is doing the caring? (I should note that this narrative medicine course is a hybrid, with a mixture of in-class and online/distance learning. Last week and this week were both distance learning.) Not surprisingly, many students chose to watch and write about One Flew Over the Cuckoo’s Nest (1975) with the unforgettably villainous Nurse Ratched (Mildred) played to perfection by Louise Fletcher.

As I recently re-watched this movie, it struck me how good a nurse Mildred could have been. She is smart, sensitive, and perceptive, and could have used these attributes to be a strong therapeutic psychiatric nurse; instead, she used them to be a manipulative, destructive nurse. I kept asking myself: what went wrong with Nurse Ratched?

With all due respect to Ken Kesey who wrote the novel that the movie is based on, I offer my version of Nurse Ratched’s backstory. Perhaps it can be instructional on ways not to be a good nurse—or on good reasons for someone not to be allowed become (or continue to be) a nurse.

Backstory: Mildred Ratched grew up in rural Oregon, the first of seven children in a devout Catholic family. Her mother was a stay-at-home mom and her father was a logger. They all lived in a doublewide trailer. Her father was a heavy drinker and he regularly beat his wife. Mildred’s self-appointed (or assigned) role in the family quickly was established as caretaker and protector of her younger siblings. Her mother was timid, withdrawn, and depressed, to the point that she spent days and weeks in bed. Mildred’s father loved to shout out at the dinner table that women were only good for baby-making and housekeeping and were stupid. Mildred was a smart, precocious young girl who learned to read at age four, and then went on to excel in school. Her mother encouraged Mildred to get out of Oregon—to become either a stewardess or a nurse so she wouldn’t get stuck in a loveless marriage as she had. Her mother most strongly encouraged Mildred to become a nurse because that’s what she’d wanted to be, and nursing had the whole saintly, angelic, Catholic connotations. But Mildred dreamt of being the first in her family to finish college. What she really wanted was to become a lawyer (wouldn’t she have been an excellent lawyer with that poker face, intelligence, and ruthlessness? Perhaps she wouldn’t have been strangled by McMurphy—Jack Nicholson—and lost her voice if she’d become a lawyer).

Mildred was a freshman in high school when her father fell out of a tree at work and was paralyzed. He wasn’t eligible for L& I or other disability benefits because the hospital ED physicians established that he was legally intoxicated at the time of his fall. Mildred was forced to drop out of school to care for her father as well as all her siblings. She also started waitressing at a nearby diner. Her father died a year after his accident and then Mildred went to a nursing diploma program through the local Catholic hospital. In her last year of the nursing program she met her first boyfriend, a trucker, who found nurses sexy. Mildred got pregnant right away and immediately married. Her new husband openly cheated on her from the very beginning of their marriage. He also physically abused her. Her son was stillborn and her husband left her the following week.

Meanwhile her mother was showing signs of dementia, so Mildred moved back home to care for her mother and her siblings who were still at home. She had been working as a labor and delivery nurse, but after her own baby died she couldn’t face working in that setting, so she took a graveyard shift at the nearby state psychiatric hospital. Flash-forward twenty years and Mildred has worked her way up the ranks at the psych hospital and is now head nurse (“Big Nurse”). She still lives with her ailing mother, cares for her at night, and works days at the psych hospital. She never dated again after her husband left her. She goes to church by herself, has no hobbies, and has only a few female church friends (stuttering patient Billy Bibbit’s mother). Her only source of enjoyment in life comes from the thrill of being in charge, in power at the psych hospital.

Nurse Ratched would have rocked as a good nurse. My only hope is that the sweet young junior nurse shown shadowing Nurse Ratched in the movie (the one who goes into hysterics when she discovers Billy’s bloody body in the psychiatrist’s office) doesn’t become another Nurse Ratched.

On a related note, here are my all-time favorite movies with memorable nurses as major characters: 1) Magnolia (1999) with an amazingly good male hospice nurse, Phil Parma, played by Philip Seymour Hoffman; 2) One Flew Over the Cuckoo’s Nest (enough said about it above)…. and 3)????? I guess that’s it for movies with memorable nurses, at least for me. I do like the character of Abby in many of the ER TV series—as well as the Mississippi nurse practitioner in the “Middle of Nowhere” episode in season five (although it over emphasizes all the negative stereotypes of Southerners). Nurse Jackie is just too soap-operaish and silly for my taste. Come on Hollywood! Give us some more good and realistically portrayed nurses in movies! Maybe I need to start writing screenplays, but I envision myself as Barton Fink with writer’s block, stuck in a flaming hot hotel room somewhere…. Being stuck in the godforsaken Reno airport with a delayed flight home is nightmare enough (where this post was written). Especially since I got stopped by security and interrogated as to whether I’m any relation to naughty former Nevada Senator Ensign (the answer, thankfully, is no). Sometimes life is stranger than fiction—or movies.