Yesterday I blogged about the issue of confidentiality in psychotherapy with adolescents. The issue of confidentiality becomes more problematic once patients turn 18 because laws and ethical guidelines seem to work in opposition to family involvement. Having completed most of my training in university counseling centers, I can safely say that whatever law designated 18 as the “age of majority” is clearly in need of revision. Teenagers don’t suddenly become more responsible, more mature, more mentally stable, more independent, or more capable on their 18th birthday. Our knowledge of neuroscience supports this: the brain’s frontal lobes, which govern higher-level cognitive functioning (e.g., planning, decision-making, and impulse control), are not fully developed until the early- to mid- twenties. Moreover, the financial and social realities of our generation have extended adolescence well beyond the tender age of 18.
Most normally developing college students without mental illnesses rely on their parents for financial, emotional, and practical support, not to mention a roof over their heads during holidays and summer vacations. Now add to that the immense strain of being at a new school in a new environment in a faraway city, without your friends or family or the professionals who have treated you for years, while dealing with a mental illness. In previous generations, most of these students with mental illnesses would not have made it to college, but with the advent of more effective medications and evidence-based psychological treatments, most of them can live independently and lead relatively normal lives as long as proactive steps are taken to manage their disorders. Their chances of succeeding are far greater when their families remain fully informed and actively involved in their treatment, at whatever level is clinically indicated given the nature of their illness and mental state, NOT THEIR CHRONOLOGICAL AGE.
University counseling centers have been slow to adapt to the changing realities of their student bodies. Just a generation ago, college counseling centers dealt primarily with breakups, homesickness, test anxiety, and roommate quarrels. Under these circumstances, there is usually no need to involve parents in treatment, and students are generally capable of reaching out to their parents for help if needed. Nowadays, the typical university counseling center client has already been diagnosed with and treated for at least one, if not two or three, mental illnesses prior to entering college, such as bipolar disorder, OCD, ADHD, major depression, or anorexia nervosa. Many more clients have no history of treatment prior to college, but are experiencing the first signs and symptoms mental illness. After all, the average age of onset for many mental disorders is late adolescence to early adulthood, which happens to coincide with the college years.
Here’s the problem: many university counseling centers operate AS IF their clients were dealing with typical adjustment problems or social concerns. They view their clients’ problems as manifestations of typical developmental issues or of difficulty adjustment to the college environment. They treat 18-year-old students with mental illnesses AS IF they are healthy, independent, insightful adults who can and should make appropriate decisions about their mental health care. OFTEN, THEY CANNOT.
Unless a college student signs a waiver, her parents are not even permitted to know whether she is in treatment at all. If parents are not informed about their child’s symptoms and progress, they cannot intervene when necessary. Unfortunately, many mental illnesses, in their acute stages, impair judgment and insight or render the patient incapable of accurately reporting her symptoms or seeking the necessary help. The administration rarely intervenes unless a student is in imminent danger of killing herself or others. The end result? Many college students struggle for months or years before entering appropriate treatment. This delay in getting adequate care wastes time, exacerbates the student’s misery and the parents’ worry, and prolongs the recovery process.
Universities have come so far over the past couple of decades in terms of welcoming and embracing students of color, students of non-traditional age, students from foreign countries, students from disadvantaged backgrounds, students of all religions and races and sexual orientations. Universities have also made tremendous strides in terms of understanding and accommodating students with learning disabilities, ADHD, sensory impairments, and physical disabilities. Universities offer testing accommodations, build wheelchair ramps, hire sign language interpreters, offer classes on line and on weekends, recruit students from poor minority neighborhoods, and organize GLBT alliances. These changes have benefitted the universities, their students, and the nation as a whole.
I would like to see universities institute similar changes to help students with mental illnesses. For starters, they could really start to examine what students with mental illnesses need in order to thrive in college and make the necessary changes to ensure that these students’ needs are met. They could expand their mental health services to include larger counseling center buildings, offer more intensive and comprehensive mental health services, hire more psychologists and psychiatrists, and attract better psychologists and psychiatrists by offering competitive salaries. When an incoming freshman has been previously diagnosed with a mental illness, the university counseling center staff could meet with the student and her parents during orientation to obtain her history, develop a treatment plan collaboratively, open the lines of communication between home and school, and plan ahead for any potential problems or relapses.