Monday, March 13, 2017

Helping Patients with Schoolwork

In my clinic, I mainly see university students.  I believe it is important, and therapeutic, to invite students to bring their schoolwork to their psychiatry appointments, so that we can sometimes look at it together and discuss it.

Last year, I mentioned this practice to a reviewer, and I suspect it was considered an inappropriate use of time in a medical appointment, and a waste of resources -- a psychiatrist "helping with homework."

I would like to make a case for why "helping with homework" is useful, and part of a good therapy relationship:


In order to help with a mental health issue, it is good to understand what your client, patient, or friend is doing with their time.   University students often spend thousands of hours studying, writing, and thinking about academic subjects.  Sometimes this work is experienced as a joy of life, a passion, or as a source of meaning.  For others, the work can be experienced as a burden, a chore, or as meaningless "jumping through hoops."   In many cases, a student's academic work is a reflection of health status (both mental and physical),  For many students, academic performance affects self-esteem:  low grades can cause a person to feel like a failure.  Perfectionism in schoolwork can cause almost any grade to feel like a sign of failure or inadequacy.

In order to understand another person's emotional life, it is very important to learn about how he or she is spending time.   Is the schoolwork a meaningful life pleasure?  Is it only a chore, a burden, or a stress?

It deepens understanding of this issue to explore it in more than a superficial way.  I believe it is valuable for understanding and rapport to encourage patients to show their notebooks, textbooks, and assignments, to talk about them a little bit.  Often this leads to a much better understanding of a whole range of other issues, including mood, attention, motivation, anxiety symptoms, learning disabilities (often never previously recognized), relationship problems, and existential uncertainty about direction in life.

Shared Interest

Many students I have seen have been passionately engrossed in their studies for many years, including at a graduate level.  But sometimes, they have almost no social conversation about their studies, with a person who shows interest.  The academic study becomes an insular, lonely experience, rather than a source of potential social interest.  Sometimes this lack of social sharing is due to an entrenched habit...the therapy setting can be a place to change this.    Not only does such a conversation boost rapport, it is also a practice for the patient to be able to converse with other people about their work, for the benefit of their social life.

Also I believe it is psychologically beneficial for a patient or client to have an experience of sharing their own expertise, and learned scholarship, rather than only being on the "receiving end" of such expertise.  It is a humble and respectful position for the therapist to take, which can only improve a therapeutic alliance.


All mental health issues affect cognitive functioning and academic performance.  A direct discussion about academic matters is relevant to the assessment of overall mental health.  Sometimes cognitive and academic function is good, but a person's feelings about this functioning is very negative.  In this case, looking together at academic work leads to a very direct focus on an active set of symptoms.

What do Notes Look Like? 

The manner in which a person might keep notes, or organize essays, or surf the internet doing research, gives us better understanding of psychological health.    Are notes tidy, meticulous, or disorganized?  Do the notes fluctuate a lot from one week to the next?  Are the notes clear for someone else to read and understand?  Are there gaps where notes are missed entirely?  Is writing fluent once started, but just difficult to start?  Is there evidence of tremor or other neurological symptoms manifest in handwriting?

Cognitive Testing

If cognitive testing is to be done, it is most useful to refer to subject matter that the person is actually interested in, and experienced with.  A mathematician or engineer might not show any decrement on a simple arithmetic test (such as "serial sevens") despite having significant cognitive problems.  It would be more appropriate to ask them to solve a complicated mathematical problem having to do with their current work.    A literature student might not show any decrement on a simple verbal test (such as memorizing words, or reading a sentence) but might have difficulty describing the themes or dynamics of a current novel on the curriculum.    Another benefit to "testing" this way is that it can highlight unusual strengths and talents, which can then be a subject of positive feedback and encouragement.

Practical Therapy

Cognitive therapy is a type of "academic" process:  it requires note-taking, reflection, analysis, and homework.  Many students might not have time for diligent cognitive therapy.  But they do have time for their schoolwork!   Cognitive therapy can take place while doing schoolwork!  It could be rewarding in a therapy session for a patient to have a successful experience of completing an academic task, while having a chance to reflect on the emotional changes or barriers happening at the same time.   A creatively constructed regime of cognitive therapy could involve combining it with academic study.

Behaviour Therapy for performance anxiety

Many students have anxiety about sharing their work, being called on by a professor, speaking out loud in class, presenting in front of others, etc.  The therapy session is a chance to directly practice these things, in a supported setting.  It is a simple CBT exercise!

Therapy for Procrastination

Procrastination is one of the most common problems faced by almost all students.  This is often much worse when there are other mental health issues going on.  The increased stress, and decreased grades, caused by procrastination, often cause further worsening of mental health symptoms.  Procrastination is sometimes even a critical part of a deteriorating cascade of events, leading to leaving school unsuccessfully.    The core necessity in treating procrastination is to do the procrastinated thing as soon as possible!  In a therapy session, if this subject comes up, I believe it is optimally therapeutic for the patient to have an opportunity to do the procrastinated activity right in the session, immediately!   It is an incredibly simple way for a therapy hour to be directly helpful.  Otherwise, sometimes visiting a therapist can be yet another way to procrastinate work, and feel even worse!   If a patient of mine does agree to do some procrastinated schoolwork during a session, it is my goal to help the patient enjoy the activity, feel supported and encouraged, and to have an experience of success.

Study Techniques

Many students work or study inefficiently, which is an underlying cause of worse academic stress, then leading to worse mental health.  Discussion and practice of better studying techniques is directly relevant to mental health therapy.  I like to discuss various memory and time-management techniques with patients, and try them out right in the session.  These ideas are applicable to other life activities, including CBT exercises.

Reading and Oration

It has been remarkably common to find students who have trouble reading.  Often they have other cognitive strengths, which have allowed them to manage with this reading difficulty all their lives, while still doing well in school.  But in advanced academics, a reading difficulty can greatly slow down the rate at which a student can study.  Reading textbooks becomes a gruelling chore.   Reading out loud, or giving presentations, can become a source of dread.

The most effective therapies for reading difficulties are very similar to therapies for mental health issues:  it involves practice, in a safe setting, with tasks that are easy enough to be enjoyable and easily mastered, but challenging enough to foster growth.    Reading out loud is very literally an exercise to strengthen one's voice.  Such voice-strengthening is a metaphorical cornerstone of all progress in psychotherapy.  Practicing this literally, in a psychotherapy session, is simple, relevant, enjoyable, diagnostically informative, and therapeutically useful, often in a very immediate way.

Study as Mood Therapy

I believe that studying and other intellectual work can be intrinsically therapeutic for mood.  It can be a meditative and meaningful experience, and a healthy coping technique or psychological defense.  But some students have study practices which are far from meditative.  The therapy session can be a chance to help people regain a sense of meaning and meditative joy in study, to recapture "flow."

Oliver Sacks

I am reminded of the famous neurologist, Oliver Sacks.  He spent time really learning to know his patients well, and in doing so became not only a great therapist and physician, but also a wise and insightful scholar about the ways of the mind.   Part of his technique was to always engage deeply with his patient's work and study interests.   In doing so, often he would discover phenomena that would never have otherwise been noticed or attended to.   I would hope to be a clinician more like him.

Other Work (not just study)

I think it is important to discuss other areas of work, with patients, and to be willing to look together at the work very directly at times, if desired.  I like to see examples of some of the work my patients do, and I think this relates to health in a similar way.

Benefit for the therapist

If a therapist takes sincere interest in a patient's work, study,  and other activities, it is also beneficial for the therapist.  What a delight it is to vicariously be part of an educational journey!   The therapist's health will therefore also be better.  This, in turn, will improve care within the system as a whole.  And this goodness will "bounce back" to the clients or patients, and continue a cycle of interpersonal positivity.

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