October 26, 2004
The Dorms May Be Great, but How's the Counseling?
few weeks ago, the parents of a Harvard student told Dr. Richard Kadison, the chief of the university's mental health service, that they suspected their daughter had a serious drug problem.
"The student in question argued that, although she needed some help, her problem was not substance abuse," Dr. Kadison said. "From my standpoint, the problem was not who's right and who's wrong or what's the diagnosis, but whether she is getting the right help."
The college campus can be a stressful place. Surveys show that the number of college students with mental health problems of all types is steadily increasing. And some students find themselves emotionally at sea, struggling with problems from homesickness and relationship breakups to drug or alcohol abuse, severe depression or even thoughts of suicide.
Experts say that, given the prevalence of emotional difficulties on campus, it pays to find out, before choosing a college, what mental health services are available.
"Since each student has roughly a 50-50 chance of having some symptoms of depression or other problems, I think it has to be part of the consideration in choosing a college," said Dr. Kadison, who is also the author of "College of the Overwhelmed: The Campus Mental Health Crisis and What to Do About It."
Most universities offer counseling and other psychiatric care, but that care varies widely in range and quality. Some mental health services may be covered by a student's tuition, fees or health insurance. Others - visits to a psychotherapist or medication specialist in the community, for example - may not.
A good strategy, experts say, is to find out how large a staff of mental health professionals the campus health center retains, what kind of services are offered, and what the school's policies are in severe cases, when a student needs long-term treatment or hospitalization. Entering students who are already being treated for depression or another mental illness may want to make arrangements ahead of time to continue that care once they arrive on campus.
Nearly half of all students at some point find themselves feeling so depressed they have trouble functioning, and 15 percent meet the criteria for clinical depression, according to a 2004 survey by the American College Health Association. Among students seen at campus counseling centers, the number taking psychiatric medications rose to 24.5 percent in 2003-2004, from 17 percent in 2000 and just 9 percent in 1994, according to the National Survey of Counseling Center Directors, conducted annually by Dr. Robert P. Gallagher of the University of Pittsburgh.
Most college mental health counselors, surveys show, also have noticed a sharp rise in the number of students with severe crises, like major depression, bipolar disorder and eating disorders and drug and alcohol problems severe enough to require hospitalization.
The seven apparent suicides last year by students at New York University illustrated what a grave threat some students' psychological troubles can present.
"There's this illusion that the university is a safe haven in a stable setting," said Dr. Dennis Heitzmann, director of psychological services for Penn State. "But for many students, it's not a carefree environment at all."
Although competition for college admission is stiffer than ever and workloads have never been heavier, experts say the rise in mental health treatment among college students has many causes. New medications for depression, bipolar disorder and other problems are enabling many people to go to college who would not have been able to in the past.
Though some students resist getting treatment, the general awareness of mental disorders like depression has grown, and seeking help is more acceptable. And some college counselors say the wider world that today's students live in is more frightening and anxiety-provoking than it was a decade or two ago.
Dr. Mark M. Harris, assistant director of counseling services at the University of Iowa, said his service saw 20 percent more students last month than in September 2003. And his colleagues at other universities are reporting similar increases.
"What I'm picking up on the national list serve is that this has been the worst fall for emergencies in two decades," Dr. Harris said. "We're seeing a lot more anxiety disorders and panic attacks. With the global war on terrorism and terror alert codes, the world has become a pervasively more frightening place to live in."
Less severe problems, like homesickness or roommate squabbles, can also be troubling enough to need treatment.
Very large public universities and wealthy private colleges typically offer the most comprehensive mental health services. But campus counseling centers of all kinds are finding themselves stretched to capacity. The typical campus mental health center includes some number of psychologists, social workers and nurse practitioners and often at least one psychiatrist, who may be a part-time consultant.
"Some campuses are so small that the counseling center may be just one professional," said Dr. Jaquie Liss Resnick, director of counseling at the University of Florida and president of the Association for University and College Counseling Directors.
But large institutions not only employ several counselors but can also draw upon the services of postgraduate residents in psychiatry.
The counseling center at Penn State, for example, where there are 43,000 students, has 12 full-time senior staff members, plus eight full-time equivalent positions staffed by interns and graduate assistants.
Students who come in for help are usually interviewed so that counselors can assess the severity of their problems. A student with significant depression, for example, might be scheduled for counseling sessions weekly or every other week, and in some cases antidepressants might be prescribed. Someone whose problem is not so severe might be offered a spot in group therapy.
"For broader groups, we'll offer workshops or even Internet chat lines," Dr. Heitzmann said. Penn State offers a chat line on homesickness, for example.
Therapy at university health centers is often very brief, lasting only four to six sessions. This is partly because many students are resilient enough to bounce back after receiving a little help, and partly because students often do not come in until midsemester and receive counseling only until the end of the term, Dr. Resnick said.
The midpoint of the fall semester tends to bring peak use of counseling services because increasing academic pressure and decreasing daylight spur depression and anxiety in more students. As a result, many campus counseling centers end up with waiting lists for counseling.
"We try to get them in as fast as possible for an initial assessment and to take care of immediate issues," Dr. Harris said. "We sort people out, and get a sense of who can wait and who can't."
Students who need long-term therapy, may be referred to a mental health professional in the community, Dr. Heitzmann said. "It's actually bad practice to see a patient when you know that you're going to have to limit the sessions," he said.
But if students do not have health insurance, or the community lacks adequate psychiatric services, outside referrals can be a challenge. Universities with medical schools may be better equipped to steer students to outside professionals. But in some cases, parents may have to undertake their own research to find a qualified therapist - and pay for the treatment out of their pockets.
Dr. Gregory Snodgrass, director of the counseling center at Texas State University in San Marcos, said he had been unable to persuade state mental health service agencies to treat students. "They won't see students, because they figure that we're there," he said.
When students without insurance have needed medications, he said, university psychiatrists have distributed office samples.
At Harvard, students who arrive at college with problems that require continuing treatment are placed under the temporary care of campus or community doctors, Dr. Kadison said. He added that Harvard students are also required to carry the university's health insurance, which includes coverage for psychiatric medications.
Sometimes, students who suffered an episode of mental illness in high school or earlier will experience a recurrence in college. The college years are also a time when serious mental disorders like schizophrenia first make their appearance.
"Late adolescence and early 20's is the time when you'll see the onset of various mental health difficulties," Dr. Harris said. "We'll see a lot of first-episode schizophrenia. And that's often in the emergency-room category because thought disorders can make people vulnerable to self-harm."
Students' mental health problems can raise questions about how much parental involvement is appropriate.
Some students who seek counseling prefer to keep their parents out of the loop altogether, and normally campus counselors will oblige. Students who have turned 18 are legally independent of their parents. But most college mental health counselors consider it permissible to notify parents if students are hospitalized, as long as the students are still financially dependent on the parents, according to Dr. Gallagher's survey.
Counselors usually encourage students whom they believe are at risk for suicide to let their parents know, and most of the time, the students do so, the survey found. The issue has become especially sensitive since the widely publicized suicide of Elizabeth Shin, a student at the Massachusetts Institute of Technology, in 2000. Ms. Shin had visited the university's counseling center before her death. Her parents are now suing the university for not keeping them informed.
In other cases, however, parents face the opposite problem: they know, or suspect, that their children are suffering but are not sure how to persuade them to make use of the college's services. But counselors say that they do not, as a rule, urge students to seek treatment at the request of parents.
"One of the things we abide by is the belief that the students, having reached majority age, are independent operators, and they are free to choose treatment or not," Dr. Heitzmann said.
But counselors can coach parents on how to approach their children - by listening more carefully, by avoiding lecturing and by staying in close contact.
Parents who feel that their child is in trouble might suggest at least one visit to the counseling center. If the student complies but then refuses further treatment, as often happens, parents may have no choice but to let it go.
"One thing I have to accept as a clinician, which is painful, and it would be more painful for the parent," said Dr. Kadison, "is that you can lead a horse to water but you can't make it drink."