 I'd now like to introduce our second speaker this afternoon. Dr. Gary Dunn received his PhD in clinical and social psychology from Hofstra University and is a licensed psychologist who has been working in mental health, hospital and educational settings for more than 30 years. Since 2011 he has been the director of CAPS, which is a counselling and psychological services at UC Santa Cruz. Prior to coming to Santa Cruz he served as the director of a hospital-based community mental health centre in New York and oversaw psychological services at a large tertiary care hospital in North Carolina. Dr. Dunn's primary training is in cognitive behavioural therapy and strategic therapy. He's also interested in health psychology, healthcare administration and leadership development. Recent areas of interest include understanding anxiety amongst college students, addressing suicidal thoughts and behaviours of college students and developing a college counselling centre to meet diverse multi-cultural and intersectional needs. Please join me in welcoming Dr. Gary Dunn. Good afternoon and I do want to thank the organisers of this symposium. It's definitely a favourite of mine and I really see it as an opportunity for mental health professionals, other helping professionals throughout Santa Cruz County and neighborhood counties to get together and to learn and to mingle and to reconnect with old friends and colleagues. So thank you all for what you do. It's greatly appreciated. So these are the questions that I want to ponder for the next few minutes today. Is anxiety increasing in college students? I imagine you have a good guess on that. If so, why? I want to drill down to how are we doing in the University of California? How about UC Santa Cruz specifically? What's the impact of identities on this? How do we assess for this? How are we treating anxiety and what research is being conducted? So I'm going to be referencing a number of different data sources and trying to be empirical in this discussion and I want you to understand where some of this information is coming from. So one is the National College Health Assessment. Actually, this is something that happens throughout the country and all the UCs participate. It happens that this year, for the first time, we actually got our acts together and all did the assessment in the spring of 2019. So it gives us an opportunity to benchmark against each other and compare and contrast, which is always helpful. The Counseling Center Assessment of Psychological Symptoms is the C-CAPS and that's another national measure that actually comes out of the Center for Collegiate Mental Health that measures outcomes for the students who come into counseling programs. So this is something several years ago all the UCs got together and agreed we were going to give this to students every time they had a counseling session so that we could see. Not only how they're coming into us but how they're progressing. Also that C-C-M-H has another index called the Clinician Index of Clinical Concern. I'll be mentioning the Healthy Mind Survey. The Student Questionnaire is another local form. It's a form that students complete when starting services at CAPS throughout the UC system and again we were able to coordinate six or seven years ago and come up with a form that we would give to students that was consistent across the board so that we can get a sense of how we're doing compared to each other and as a group. And the GAD7 is a generalized anxiety measure that we'll use from time to time. Okay, so nationally the percentage of students who report being diagnosed or treated for anxiety disorders these are college students in the last 12 months doubled between 2008 and 2016. That's from NCHA. Scores for students who present to college counseling centers have increased steadily in generalized anxiety, social anxiety and depression and that's that C-CAPS that I mentioned that we give to the students who come into counseling. So the difference is the first number that NCHA data is from the general population, all students whereas the C-CAPS are students who are coming in and asking for help. And then the Healthy Mind Survey which is also more general found college and graduate students screened positively for anxiety rose from 17% to 26%. So that clinician index that I mentioned, so what are we seeing on that? Anxiety is reported as one of the top concerns for almost 63% of the students who were coming into counseling almost 44% were stressed and the top concern was also anxiety 23.5 and it broke down, that 23.5 broke down as you see with the majority being generalized anxiety and those represent other diagnosable anxiety conditions, social anxiety, panic, other test anxieties, not a diagnosis per se and specific phobias. So this is more general, the 12 month prevalence of an anxiety disorder, 18 to 29 year olds was 22% in 2007. Now we're trending closer to 40%. And it grew more than two times as fast as all other mental disorders and it holds to dubious distinction of expanding more quickly than other mental health disorders pointing to a singular and pressing issue on college campuses. And as a general fact, teenagers report higher levels of stress than adults and think that's something we've gotten an impression from all our previous speakers. Okay, so how about the University of California? The rate increased even higher, nearly two and a half times higher in 2016 than 2008 and that's again general data. So on that general data, this was just from spring of 2019. So students reported in the last 30 days, 73% overwhelmed by all they had to do. 72% felt exhausted not from physical activity, 49% felt very lonely, 53% felt very sad, 46% felt overwhelming anxiety. So I've thrown a lot of numbers at you in a short period of time, but I want to pause on that and just have you reflect on that, what that's saying. So this is just an average student who chooses to participate in this survey, not somebody who's coming into counseling. What we're saying here is that 53% felt very sad and 49% very lonely and 46% overwhelming anxiety. So between 50 and 70% of students are having these experiences in the last 30 days. So that's just in my mind overwhelming and it really, you have to stop and think, well, how are you going, it's an epidemic, right? How are you going to respond to that sort of information? Because it's probably not going to be providing individual therapy for everyone, right? That's just not going to be a possibility. We have 19,000 students, for instance, on UC Santa Cruz. And this is throughout the UC system. Unfortunately, our campus, the numbers are actually more concerning. So some other pieces from that same study. These are the things that were very traumatic or difficult to handle. Career related issues, death of a family member, family problems, intimate relationships, other relationships, finances, personal appearance, personal health. Sleep came up earlier today from Gene. So almost 36% found their sleep situation to be traumatic or difficult to handle. And they found these things affected their academic performance. Again, sleep, stress, work, anxiety, concern for a troubled friend, depression, internet use, computer games, relationship difficulties. It's interesting, based on the talk, you would think that that number for internet use, computer games, would be higher. But like substance abuse, it's not what students come in and tell us about all the time. They're not like, hey, I'm here because I'm drinking too much or I'm worried about my internet use. That comes out. But it's not necessarily their presenting problem, per se. So yeah, under-reported on that one, to be sure. Okay, so I mentioned this CCAP. So this is this measure that we give to students every time we see them when they come into counseling services. And this is specifically now talks about our students at UC Santa Cruz. So we're higher than the national average on depression, generalized anxiety, and social anxiety. We also have another dubious distinction of being the highest in the UC system and way higher than national average on I have thoughts of ending my life. 49% scored greater than zero. So we see about 3,000 students a year, so do the math. Now just to break that down to be clear is that's anybody who scores greater than one on this Likert scale. So that 49% is made up of 20% of our students who scored a 1, 13% scored a 2, 10% scored a 3, and 6% scored a 4. So thankfully it's not the other way around. So Berkeley has been doing a study, a professor named Richard Schaeffler in the School of Public Policy, looking at anxiety and social anxiety. And by the way, I don't think it's been studied that much. Certainly not among college students. I think that the recognition that this is a mental health crisis has been slow to be picked up, and people are really first starting to look at it from what I can see. But they have been doing a study for the last couple of years, and it's not published yet, but I did get permission to share some of their information. And they found all of the following to be positively correlated with anxiety disorder in the UC system, the CSU system, and all campuses. So they found correlations with, and again, not causation, substance abuse, prescription drug abuse, alcohol use, negative consequences from alcohol use, attempted suicide, serious consideration of suicide, and sexual assault. UC students also, with anxiety disorder, were nearly nine times as likely to be diagnosed with a substance abuse or addiction, and CSU students were five times more likely. The national was over three times. So we see this interesting thing where UC students, in many ways, seem more acute in some of these areas. So I mentioned the student questionnaire data. So this is, every time we start with a student, it's like an intake form that students complete, and this is the one that we use throughout the UC system. So we see the top primary concerns. We give them a list and say, you know, check off as many of these as you want, and then which one is your top one secondary tertiary like that. So top primary concern is anxiety disorder, and the top secondary concern is also anxiety disorder, and stress is in there as well. So it's really most of what we're getting reported by this. This is what the students tell us when they come in. So I wanted to look at the impact of identities. So the rate of anxiety disorder for female identified students was over twice that of male identified students, 23% to 10%. The rate of increase from 2008 to 2016 was 65% for transgender students. So they went from 34 to 56% anxiety disorder. And there was a 67% increase for male students and a 92% increase for female students. The rate of increase was 150% for Asian or Pacific Islander students, 180% for Black students, 150% for Latinx students, 109% for White students. But you see the absolute number. White students reported the highest rate of anxiety disorder at 23% while Asian and Pacific Islander students reported the lowest rate at 10%. And important to note that differences in cultural attitudes and access to mental health care and important considerations to consider. So according to a recent study, Black and Hispanic students had lower rates of psychiatric diagnoses than White students, but at similar rates of past year suicide attempts. Okay, so I want to shift to why this might be going on and some thoughts. So another study, the National Longitudinal Survey of Youth, found the following associations, not causations, but that young adults with mothers that had a mental disorder were more likely to have an anxiety disorder. Perhaps this supports a genetic link. This was kind of an odd artifact that young adults with mothers with at least an undergraduate degree were 45% more likely than those without a college degree. Yeah, interesting. Young adults in households that have difficulty paying bills, that makes sense, are 1.3 times more likely and it supports financial stress, increases anxiety. And young adults in the top quartile of computer use, leisure time, which includes cell phones, above 20 hours per week, were 54% more likely to have anxiety than the bottom quartile. And that supports a lot of what we've been talking about today and I do want to dive into that a little deeper and some of it is reinforcing what's already been talked about by our presenters and sometimes maybe looks at it from a slightly different perspective. So you might have seen some of this already today, this Common Sense Media Reports and Pew Research Reports, so I can skip over that in terms of use. This is interesting. So Nancy Sheever is a psychologist from CSU Dominguez Hills. Any Dominguez Hills folks out there? No? No cheers on that one? All right. So her theory is that phone-induced anxiety operates on a positive feedback loop. So it keeps us in a persistent state of anxiety with the only relief being looking at the phone. That relieves our anxiety, then the anxiety builds up and we reduce that anxiety by engaging with the phone. You saw that clip that Paul showed. She did an interesting study where the setup of the study was that she was looking at test anxiety. That's not really what she was looking at. She brought students in and hooked them up to EKG monitors to measure their heart rate and then said, you know, so that they don't interfere with the mechanisms here, we're just going to take your cell phones. And they took the cell phones and put them just kind of, you know, out of reach but not out of hearing. And then they started calling those cell phones, right? And they were literally measuring the autonomic response of the students as those cell phones were going off and they couldn't go to them. And they just, you know, found that the stress levels were off the charts on that. So I also found that some of our colleagues in other countries are doing a lot of important research in this area, maybe a little more than we're getting into. And so a study was done by a group in Serbia and Italy and it's interesting all in all, but one of the pieces was that supports what we've been hearing is that the strongest predictor of high stress levels was keeping the mobile phone less than one meter away during sleep. So they found that that was the cutoff. If it was further than that, maybe the stress level wasn't as high, if it was essentially within reaching distance. And I also found that 65% of us sleep with or next to our cell phones, right? So and among college students, it's even higher. So I had thought about that and we've also thought about why that might be the case. But I think that we can develop a psychological link with our phone and that if it's with us all the time and we're just connected to it and that that act of taking that phone and whether we're locking it away somewhere or putting it downstairs or at least the other side of the room, it allows us that separation and individuation if you will from our phones, right? And maybe that's what we need to do because again, from different perspectives I'm hearing the same thing and it's a fairly easy behavioral change that we can make for ourselves and for the people we're working with. So think about that. So this is a study out of Oxford in England and they came up with, they call it the digital Goldilocks hypothesis, right? I remember Goldilocks. So they found that a moderate use of digital technology is not intrinsically harmful and maybe advantageous in a connected world. But that overuse may displace alternative activities. Too little tech use might deprive young people of important social information. And in the study they found certain, what they call inflection points, the point at which it went from being helpful to being harmful. So on the weekends you could do more and it was still helpful because you were socializing and doing things like that. During the week when you were supposed to be in school and attending to other activities, that inflection point was lower. And they also broke it up by types of use whether it was gaming or texting and those kind of things. And they found smartphone use and video games had lower inflection points on weekends. So that was more quickly, if you were using your phone for those things, that point in the number of minutes that you could engage with a phone before it was tending more negative than positive was lower. So, yeah. And they did try to emphasize, and I think it's important that we not come off as too judgmental about this whole thing. I mean, this is the reality that we're living in and there are some that have been articulated already some really positives from our technology. And 83% of adolescents say that social media makes them feel more connected to friends. And 68% receive social support through digital technologies in tougher, challenging times. So, maybe something to consider this Goldilocks hypothesis that sort of abstinence or just total removal is not always the best solution, but finding some kind of moderate use would be a better way to go. So, Paul had gotten into this about addictions. Just to reinforce it a little bit that, you know, here are some other things that, you know, might be an indication that this is a problem for somebody texting and driving, causing family conflict, causing functional impairments, compulsive checking, causing sleep disturbance or anxiety or irritability, if not accessible. Any of you heard the term NOMO phobia? That's what we need is another phobia, right? So that's actually a term that's being used for no mobile phone phobia. And it's the irrational fear of being without your mobile phone or being unable to use your phone for some reason, such as the absence of a signal or running out of minutes or battery power. So, just to be clear, this is not a DSM-5 diagnosis. But it is a reality. And the numbers that they were hypothesizing of people who actually experienced some form of NOMO phobia is really quite high. And we also heard it. Do you remember what this is, FOMO? Fear of missing out, right? There's another study. Actually, I just saw this as a recent study out of China looking at undergraduate students. And they looked at the relationship between what they termed problematic smartphone use in depression and anxiety. So they defined problematic smartphone use as entails addictive use, prohibited use, and risky behaviors. Addictive use is linked to excessive reassurance via smartphone use. Internalized psychopathology did not predict smartphone addiction. But they did find that the fear of missing out may be an important variable accounting for why some types of psychopathology, like anxiety, are associated with problematic smartphone use. So, shorthand for that is, yeah, that fear of missing out does predict when smartphone use can cause anxiety. Other causes, and clearly it's not all about cell phone use, the anxiety we're seeing, gun violence, 75% of Gen Z, what we're supposed to call them now, iGens, so okay, report that mass shootings are a significant source of stress, 72% are worried about possible school shootings, something they found from the Berkeley study, academic pressures, finances, big cause of anxiety, environmental stressors. More than two-thirds of Americans are stressed about the direction of our country. I'd have to think that was more like four out of five. I don't know who that fifth person is either, but that's a whole other story. Yeah, and on college campuses where we have this, we have stress related to institutional racism, we have stress related to what our DACA students are going through, what our LGBT students go through, what our first-generation students deal with. So, and other demographic variables, a changing demographic that we're seeing in college campus across the board and certainly in the UC system, which is great and it's a much more diverse population than we've ever had, but it also brings other challenges. One of which is poverty and 20% of dependent undergraduates were from families in poverty and that is up from 12% in 1996, so the good news is higher percentage of students who are in poverty are getting to universities, but it's also again causing more challenges and we have other causes. I'm sure you've seen some of the issues that we're dealing with with our graduate students and you see Santa Cruz right now and that, yeah, it's a challenge and tough situation that graduate students are in with cost of living and then our undergraduates are impacted by not having graduate students around. I don't know how that's going to resolve and of course the coronavirus is starting to create more and more stress on campus or just some day-to-day problems that we're seeing. This was interesting and I think really supports what Gene was talking about and this is a guy named Jonathan Haid who wrote a book called Coddling of the American Mind and his theory is that children are, he uses the term antifragile and they need to have experiences to go strong and we've been treating them as if they're fragile, trying to protect them and help them avoid problems and failures and concerns and that by trying to eliminate risk from our kids we're doing a disservice. This next stat actually we all seem to pick up on and I thought it's interesting to look at the average life experience of Gen Z going to college is equivalent to that of a 15 year old 30 to 40 years ago. So think if you're of let's say a generation like mine think about what it would have been like for you to go to college at 15 instead of at 18 and how well you would have fared and that gives you an idea what the experience of our students is today. And this all coincides with the whole social media piece and children being exposed to an often harsh environment at a young age without any preparation for it. So check out Jonathan Haid if you want to find out more about that. I wanted to touch briefly how we're doing on time here by the way. Five? Okay. So let me cruise quickly through this assessment piece so you know anxiety is a behaviorally driven disorder so it's not that hard to assess in that it's not hidden. It creates a lot of discomfort and if you ask people about it they'll tell you about their panic and their worry etc. So clinical interview is really the main tool. You can use a structured interview. There's various other measures that you can use if you want to track over time and that's a good idea to look at change. What I wanted to emphasize here in my last piece is that because of the prevalence of this we've really started to think about environmental interventions and it sounds like Valerie was talking about a similar thing which I'm thrilled to hear in lower schools. So this is a picture of UC Davis. Any Davis folks out there? Yeah, a couple. So these are nap pods that are indicated up there so they have places where students can just take a nap. So we talked about like sleeping the big thing well let's find a place for students to sleep. This is, we don't have time to watch this but this is from CSU Long Beach and they've developed an oasis center. It's like a wellness center. It's a cell phone free zone by the way. You leave your phone at the door and it has meditation space. It has a labyrinth. It's really quite a relaxing lovely space for the students and I think this is a direction we need to go in to create a better environment. So thank you. Also this idea of learning how to fail. So we have a resilience initiative on our campus following in the footsteps of other universities including Stanford that did a resilience project where they worked to normalize failure. Several other schools did that too and we're working on developing right now a resilience initiative on our campus. Some other things that we're doing again to get to the vast number of students who need help is focusing more on our online service. So we use an instrument called TAO which is Therapist's Assistance Online and this is actually evidence based and there's a lot of mental health ads out there that aren't necessarily scientifically studied. This one is and we use others as well. These are just some clinical interventions that are part of our services at CAPS and we've recently started this anxiety toolbox which is three sessions of group therapy that are really psycho-educational and they're really taking off on our campus. We can start them throughout the quarter and more and more students are coming in. We also work with peers to train them how to work with students and psychopharmacology, case management, mindfulness, social anxiety group, so all these things we have going. Just quickly here, that is problematic smartphone use is a PSPU and so what do you do about it? It really hasn't been extensively studied that I could see. Ironically there's been many apps developed to help limit use. I thought that was kind of cute. But here's some potentially useful ideas that you might offer to somebody who's struggling with this. Not always answering your phone by turning off some alerts and setting limits about not using a phone during certain situations or time, deleting old apps, unfollowing news feeds and friends that don't contribute usefully cleaning up email subscriptions, moving a cell phone away from bed while sleeping. Let's do that. Balancing screen time and in-person time and trying a technology faster. I've had this fantasy about if we could only get maybe everybody on campus to close off their phones for five minutes together. What an empowering moment that would be. I don't think I'll ever get there, but I can dream. One of the more distressing things is when I leave work every day and I see 50 students waiting for the bus and they're all just looking at their phones. Then we know that social anxiety is a major piece that we're dealing with. Maybe if we started talking to each other a little bit we might do a little better in that area. We are investigating a lot of this. I'm working with the research team now and trying to understand why our students seem more impacted by mental health concerns. We're starting to look at this UCY data, what we can learn from that. There's a professor in the psychology department who we're working with to better understand and utilize online options and how we can improve digital hygiene and what are the impacts of the resilience-based efforts that we're working on and what can faculty or academic departments do differently to help reduce student stress. That's a really big piece. Another environmental stressor is how we structure the classes, how we structure the exams. What our expectations are. Frankly, at UCSC we haven't done a great job of considering the impact on the mental health of our students in a lot of those decisions. Given the extent of the problems we're starting to look at that and think about new innovative ways to teach our students and incorporating this in. That's all from me. This is a picture of what I'm blessed to see every day as I drive off campus. I like to put it in presentations to remind me and to remind people I'm talking to what an amazing environment we live in and how beautiful it is here and that we take the time to appreciate that and enjoy it. That's going to help us as much as any other intervention. Thank you all very much.