Is higher education taking adequate care of students with mental health challenges? Maybe that’s the wrong question.
A recent 6-minute story on a nationally-aired popular morning show addressed the “crisis” in college student mental health, something no one who works on a college campus would dispute exists. But the story was, like much of the media’s coverage of this topic, skewed and, as is typical, missing the vital perspective of college staff. My frustration has led me to try and tell the story from the other side, a side I lived on for much of my career as a dean of students.
NBC investigative correspondent Ronan Farrow aired his “six-month investigation” report on the Today Show on June 20. I’m sure it’s challenging to distill six months into six minutes, but Farrow did just that. While he said he interviewed 22 students at ten institutions, he focused on just three: two from the University of Chicago and one from Yale. In the interest of full disclosure, I want to be clear that I do not know any of these women, nor do I know anyone who works at the University of Chicago or Yale (which both declined to allow a staff member to be interviewed for this story). But their stories are familiar enough that I can reverse-engineer them, drawing on my experience with similar students and situations. I am well acquainted with reports of “forced leaves” and misleading information, unfeeling administrators and unfair expectations.
Here is the path I imagine a student and her institution each have taken to get to the point where she is sent in an ambulance to a hospital and admitted for psychiatric care. Again—this is not to cast aspersions on the women Farrow interviewed who appeared on camera. I don’t know them, and I do feel for them as young and vulnerable women with mental health challenges.
It often begins when a student approaches her resident assistant and reports that her roommate is “cutting” or otherwise engaging in self-injurious behavior. Or perhaps the student is, to an alarming degree, sharing her emotional distress with her roommate who also is, we must remember, a vulnerable and stressed student. The roommate likely has tried to help, perhaps enlisting some of the other women on the floor, and the troubled student has become the focal point of a swirling drama around her. Once they realize they are overmatched by the condition of the roommate, these students seek assistance from staff. The RA is often the first contact, and if she or he is well-trained, a report to a professional staff member follows quickly. Help is available. Most colleges have counseling centers staffed by professionally-trained and often licensed individuals—psychologists, social workers, mental health counselors—who are familiar with the symptoms of depression, anxiety or personality disorders often found in the college student population.
The student in need is referred to the counseling center, or perhaps re-referred, as it is very possible she has already connected with them. In either case, she is now being cared for by staff who will maintain her confidentiality and whose goals are two-fold: keep her from harm and help her be successful as a student which is, after all, why she is here.
In a perfect world, the help she receives alleviates the stress or depression or anxiety that has led her to be at risk. But the world is rarely perfect. She may continue to behave in ways that are disruptive to her floormates, her RA, perhaps others who have become involved. While self-injurious behavior such as cutting is understood by clinicians as a response to emotional distress, to others unfamiliar with it, it is just plain frightening. Typical college students do not know that cutting is not often a suicidal gesture. It looks to them like it could lead to that.
Of course, not all students cut. Some are indeed suicidal, or at least may be deeply depressed, and share that with a roommate, a friend, a professor. If there is one good thing that has come out of the media coverage of suicides on campus, it’s that students are usually very alert to warning signs, to comments and actions that might mean someone is going to attempt suicide. Again—these are young, inexperienced and often compassionate students. They may be drawn in by a very depressed friend and find their own academic efforts compromised by caretaking.
Perhaps the student in crisis is getting the help she needs from the counseling center, but it is very possible that this care is not enough, that she is in a state of chronic crisis that is affecting everyone around her. At that point, more college staff may become involved. As a former dean of students, I know this is where I would have been pulled into the situation to calculate the equation that is at the heart of many situations in which a dean must act: the best interests of an individual student versus the best interests of the community.
A dean of students, as Mr. Farrow would probably not know, spends a good portion of his or her time engaged in the fraught calculus of community—trying mightily to find a way to care for an individual student who might be at serious risk while also trying to maintain a semblance of safety and sanity among the larger group of students for whom the dean is equally responsible. I have, in the midst of these situations--cases where mentally ill students act in ways that put at risk not just their own safety but the ability of others to live peaceably and focus on their academic obligations-- supported the clinical decision of a counselor to send a student to a hospital for evaluation.
Why would we insist on hospitalizing a student against her will, as one of Mr. Farrow’s interviewees reported? Because a college counseling center staff is not usually equipped to manage a suicidal student. Rarely do campuses have locked and secure units with round-the-clock staff to watch a student who may be at risk of self-harm. Hospitals have those things. What would Mr. Farrow’s interviewee have had university personnel do? Allow her to return to her residence hall after sharing that she was thinking of harming herself? Return her to the care of her friends or RA? Of course not.
And transportation in an ambulance, which Mr. Farrow reports happened to several of the women he interviewed? It is a best practice to transport someone to a hospital in an approved, licensed vehicle staffed by trained medical professionals. Should the counselor or the dean or a campus police officer transport a distressed student to an emergency room? Of course not.
I was troubled too by the comments made by the usually fair-minded Dr. Victor Schwartz of the Jed Foundation as well as the mother of one of the students interviewed who both stated that colleges and universities insist on “forced medical leaves” and involuntary hospitalizations in part because they are concerned about the public relations problem a suicide, or several suicides, can cause. That simply is not true. The overarching concern in these cases is the safety of a student who may be at risk of self-harm. But a second concern is in play as well, and it’s this: a college campus is not a treatment facility.
While the Americans with Disabilities Act (ADA) has justifiably pushed colleges and universities to figure out how to serve the needs of students with disabilities ranging from mobility impairments to dyslexia to obsessive-compulsive disorder, campuses are simply not good places for people in the throes of significant depression, anxiety or other severe mental health disorders to get the care they need. College is stressful for all students, and those with known diagnoses need to place their health needs first—learn how to function safely and independently without supervision—before they take on the challenges of higher education.
Does this mean that serious mental illness is incompatible with a college education? Not at all. Each year, thousands of people walk across a stage and receive a diploma despite (or perhaps because of) a significant mental illness. They have, hopefully, found the right balance of care, whether it’s therapy, medication, support groups, loving family and friends, or some combination of these. But the process of learning how to do this? That often is incompatible with the college experience, at least temporarily. Overcoming, or coming to terms with, a mental illness is complex, overwhelming, exceedingly difficult work. Balancing that with a full course load and the general chaos of residence hall life is unwise, to say the least. It may even be dangerous.
The mother Mr. Farrow interviewed said she saw “no compassion” on the faces of the University of Chicago staff who interacted with her daughter. Again, I don’t know those professionals, but I am incredibly skeptical of this claim. Perhaps what she saw were the expressions of professionals who are trying to convince a student, and her mother, that a pressure-cooker campus is not a safe place for a young woman in great distress, and maybe her priority needs to be her own health care, under the watchful eye of her obviously-concerned mother. “No compassion”? Not at all. Probably just the weary expressions of people who have had these conversations too many times. The specter of lawsuits brought by families of students who committed suicide, blaming institutions for inadequate care, is not entirely absent, but it is definitely not at the front of a dean’s mind in these difficult discussions.
“Forced leaves” for mental illness are not permissible under the ADA, but voluntary leaves so a student can adequately address mental health concerns may be proffered with as much persuasion as a college official can muster, knowing that a student’s safety is difficult to monitor on a college campus. Suspensions for behavioral issues may be used, but the federal government has made clear that threats of self-harm are not an acceptable reason for a behavioral suspension, so it is unlikely a student would be suspended for an act of self-harm. Disruption to the community is a different story, even if that disruption is rooted in a student’s mental illness. And isn’t it reasonable for any institution to require some evidence that the reason a student left in the first place has been adequately addressed prior to a return? Colleges generally want to welcome back students who have taken leaves to deal with serious matters—medical, financial, and personal—and look forward to seeing a student succeed as much as the student’s family does.
Most families would never ask campus officials to treat their child’s broken leg, brain tumor, or ruptured appendix. Most students would never expect to receive physical therapy at their college health center after a skiing accident. Why should campuses be expected to take on the complex medical care or aftercare of a serious mental illness? I started by suggesting that we may be asking the wrong question when we ask if higher education is adequately caring for students with mental illness. Maybe the right question is, “Why are we expected to provide this care?”
If Mr. Farrow wants to be helpful in addressing the mental health crisis on our campuses, a crisis that is real and frightening and draining resources that should be used for students’ educational services, he should do a second report. This one would be about the students and families who see college not just as a place to get an education and grow into responsible adulthood, but also as a milieu therapy site for individuals with serious mental illness, most likely conditions that existed before matriculation. These are students who need to remain at home or enter an actual treatment center and get the help they need before attempting, or re-attempting, college. They will be safer and more likely to learn to do the hard work of managing a mental illness if they are given that opportunity. College can wait. Mental health shouldn’t have to.