When Virginia Tech senior Seung-Hui Cho threatened self-harm in his undergraduate residence hall in winter 2005, the police took him to the hospital for an overnight stay. Cho was released the next morning, the last day of the fall semester, and attended a follow-up appointment at the campus counseling center before heading home for winter break. He never returned to counseling.
Eighteen months later, Cho killed 32 people and wounded 17 more before killing himself. The massacre at Virginia Tech in 2007 was the deadliest shooting incident by a single gunman in United States history.
“Everyone at the university was devastated,” remembers Christopher Flynn, the Director of Virginia Tech’s Cook Counseling Center. “When [Cho] came in, the counseling center was relatively understaffed. There were nine counselors on the staff; there was one psychiatrist, and maybe a part-time nurse practitioner, but they were clearly under-resourced for the size of the university.”
It took a tragedy that reverberated across the nation to expedite the improvement of mental health resources at Virginia Tech. Grants from the Department of Education and the Department of Justice helped the university expand its counseling programs—the administration quickly added counselors, case managers, and a wide array of resources for students. “Over the past six years, we’ve effectively doubled the attendance of the counseling center,” says Flynn. “It’s hard to say that anything good or positive came out of the tragedy, except that we have much better resources in place for the students now.”
Virginia Tech is not the only university to have responded to its worst tragedies by proposing and implementing an overhaul of its mental health services. In 2003-2004, six students at NYU jumped to their deaths. Since then, the school has created a 24/7 hotline, a walk-in clinic, and a two-question mental health screening survey to be administered before any general health appointment, among other initiatives. Closer to home, MIT also expanded its mental health resources in response to a spiked suicide rate in the 1990s.
In recent years, Harvard has also had reason to reevaluate its mental health policies. Two undergraduate students have committed suicide in the past year. In 2011, an anonymous Crimson article entitled “I Am Fine,” written by a student with suicidal thoughts, sparked a debate on the stigma behind mental health as well as on mental health services offered by Harvard. Another anonymous article published in February, by a student suffering from schizophrenia reinvigorated the conversation. From mental health rallies and national coverage of Harvard’s services to student-initiated Tumblr and video projects amid campus-wide outrage, Harvard students seem to have reached a critical mass in wanting to talk about mental health support.
Colleges across the country are dealing with some of the same mental health issues that have prompted heated debate on Harvard’s campus. Yet many heads of mental health programs note that a deeper engagement with these issues is often missing from these kinds of discussions. “It’s often really easy for students to criticize a counseling service,” says Greg Eells, the Director of Counseling and Psychological Services at Cornell. “It’s harder to go back and say, ‘What kind of service do we want? What is the level of care we want to provide to students?’”
Responding effectively to such questions necessitates an in-depth, comparative approach. Programs and policies implemented at peer schools, in addition to input from mental health experts across the nation, can shed light on the status of Harvard’s own mental health practices. Indeed, while Harvard can certainly improve its services—particularly regarding wait times—the main obstacles to overcome are, rather, misinformation and lack of information concerning existing resources, along with ignorance regarding the rationale behind Harvard’s mental health treatment philosophy. Clarifying these matters is the first step to understanding where Harvard currently stands, and how it can continue to do better.
A University Issue?
Some question whether institutions of higher education should be responsible for providing mental health resources and care to students, given that their primary purpose is education. However, many others insist that campus-supported mental health programs are essential for maintaining student well-being.
Eells of Cornell argues that strong mental health underlies the mission of higher education—according to him, the growth and development of the mind. “One of our guiding principles is to focus on the foundational nature of the health of the mind,” says Eells. “Our institution is really dedicated to expanding the life of the mind, growth of the mind, growth of the intellect, and realizing that for that to happen, the foundation, the healthy mind, has to be there first.”
Promoting a “healthy mind” becomes increasingly challenging and relevant for the college age population. The percentage of 18-24 year olds who seriously considered committing suicide anytime in the past year varies from 7 percent to 11.4 percent, depending on the study—rates significantly higher than those listed for the over-25 age bracket.
According to national surveys, the pressures of college, both academic and social, place additional strains on an already vulnerable population. A poll by the American College Health Association reveals that almost half of college students have reported feeling “hopeless” anytime in the past 12 months. About a third reported feeling that they were “so depressed it was difficult to function.” Mental health issues are not limited to depression: The decade between ages 15 and 25 is the most common period for the onset of schizophrenia, while late adolescence and early adulthood are also peak years for the onset of bipolar disorder and anorexia nervosa.
Victor Schwartz, the medical director of the Jed Foundation, claims that if colleges want to see higher percentages of students reach graduation, adequate mental health support is necessary. “The U.S. has many students who start college but we’re pretty dismal at making sure they finish,” he says. “The biggest problem [they face in finishing] is probably financial—but the next largest challenge is probably social, emotional, psychological factors.”
Laurie Martinelli, Executive Director of the National Alliance on Mental Illness of Massachusetts believes there should be parity between the physical and mental health services that colleges offer. Martinelli considers it unjust that many schools require a higher co-pay for mental health issues than they do for physical health concerns.
“If [the college] pays 100 percent of hospital coverage for someone with diabetes it should pay for 100 percent of hospital coverage with someone with bipolar,” she explains. “If it pays for unlimited physical therapy appointments for someone with a broken arm, it should pay for unlimited appointments with one therapist.”
For the most part, the mental health offerings at Harvard University Health Services seem to match its physical health offerings. Student Mental Health Services at Harvard does not require a co-pay for internal treatment, and if patients request outside treatment they must contribute $35 per appointment, with Harvard subsidizing the additional cost. Harvard students are not restricted to a certain number of counseling appointments as students at Brown and other colleges are, but the frequency of their appointments is at the discretion of Harvard clinicians. If a student wants to have psychotherapy appointments every week, for example, but a clinician thinks that monthly appointments will suffice for treatment, the student will have to find an outside doctor and pay him or her out of pocket.
Though they are limited in what they can achieve, experts say that college counseling and psychological services groups are uniquely qualified to assist students in several concrete ways. Beyond providing therapy, college counseling centers can work with administrations to increase the physical safety of campus, as well as to educate, counteract stigma, and minimize accessibility barriers.
Campuses should manage their built environments, according to these professionals, so as to minimize opportunities for self-harm. This can involve securing dangerous bridges and windows, and keeping poisonous lab chemicals under lock and key. For example, features like gorges at Cornell or NYU’s high-rise library pose a safety concern within a mental health framework. Such features can often be modified: After a Harvard student attempted to commit suicide by jumping from Leverett Towers in the 1940s, Harvard sealed shut certain large windows in the building and instead designed a smaller, less-hazardous window that could be cranked open for air.
Counseling and mental health centers can also work to increase accessibility for their own mental health resources by ensuring that their centers have multiple points of entry, from drop-in offices to hotlines to confidential email addresses. Such mental health support should be fully integrated into the campus structure so that students can be quickly and seamlessly directed to the resources they need, no matter where they begin asking. At Harvard, the Bureau of Study Counsel, the Wellness Center, Office of Alcohol and Other Drug Services, and the Office of Sexual Assault Prevention and Response are all trained to identify signs of mental illness and help collaborate with Student Mental Health Services to direct students to appropriate resources.
Another part of improving mental health accessibility is financial: making care affordable for students and ensuring that counseling centers themselves are receiving appropriate funding. Harvard offers both mandatory health insurance coverage and an optional Blue Cross/Blue Shield plan, though the majority of students at the College do not take advantage of the Blue Cross/Blue Shield option. Those who opt-out, then, may not be aware that this choice restricts their access to mental health care. The optional plan includes additional mental health coverage: visits to therapists outside the UHS system, inpatient admission to a general or psychiatric hospital, and access to emergency medical funding on a case-by-case basis.
A major complaint posed by many Harvard students, including those who attended a mental health rally in February, is that wait times for SMHS appointments are unreasonably long. According to the Student Mental Health Service Patient Satisfaction Survey of 2013, 41.2 percent of students surveyed said they had to wait between 1 and 2 weeks between calling the clinic and having an appointment with a clinician, while 16.4 percent said they had to wait between 2 and 3 weeks for care and 5 percent listed waiting over 3 weeks for an appointment. 42 percent of students responded that clinician availability was the main barrier they encountered to scheduling an appointment and therefore seeking help.
Paul J. Barreira, Director of Harvard University Health Services, and Katherine A. Lapierre, Chief of Student Mental Health Services, say they consider seeing 75 percent of students within two weeks of their calling the clinic to be an adequate standard of care. However, other schools make their services immediately accessible to students. Virginia Tech, for example, aims to give every student who calls the counseling center an appointment with a counselor within 48 hours.
Virginia Tech achieves a two-day wait objective even though its counselor to student ratio is 1:1500— right on the national accreditation rate. Harvard’s wait times are longer despite its much more accommodating counselor to student ratio of 1:750. Flynn of Virginia Tech offers one hypothesis for Harvard’s longer wait times. “I think the health centers at the smaller schools are used by a greater percentage of the population,” Flynn says. “A smaller school is more likely to be private, and more likely that a greater percentage of the student body will be trying to get services.”
Barreira and Lapierre say they recognize that sometimes Harvard students want more appointments than SMHS counselors can offer them, but they do not consider wait times to be among the most pressing problems that the clinic faces. “Most of the time most students feel like what’s being offered meets the needs,” says Barreira.
“We try very hard to not make people into chronic patients,” says Lapierre. “We want people to come in and get well and get back to life.” Lapierre says that some people who started in long-term weekly psychotherapy before college are used to that regularity of care. “But then you’ve got to ask: are they improving? Are they actually getting better?” says Lapierre. “There can be a patient request which may not be what anyone would consider best practice.”
Students frequently complain about the wait times and counselor availability at SMHS, but when asked what SMHS would do with unlimited funding and resources, Lapierre says she would want the clinic to put more focus on prevention work. “I would not suggest that we would ever want to do weekly ongoing therapy. There’s a very very small percentage of people for whom that’s really indicated,” she says. Lapierre’s claim is backed by several recent studies, including a 2008 article published in the Chronicle of Higher Education, which confirm that simply adding more therapists is not always the best way to ensure that students are getting the mental health resources they need.
Indeed, experts note, the number of therapists on call does little to address an underlying obstacle for those considering seeking help: the stigma surrounding mental health care. Drew Walther is the National Chapter Director of Active Minds, a mental health advocacy group with chapters on college campuses nationwide. Walther emphasises that eliminating stigma is key to increasing the accessibility of counseling services.“If stigma is preventing someone from seeking services,” says Walther, “then if there are any other barriers—if there are fees, for example—it’s so easy to put off mental health concerns.”
Campus officials can minimize stigma, he says, by educating all students about mental health and modeling how discussions on the topic can be productive and respectful. Harvard’s SMHS starts this process early by hosting mandatory mental health resource orientation sessions during Opening Days for undergraduates, and during orientation for graduate school students. Harvard SMHS also trains proctors and tutors to detect mental health issues. Nevertheless, as a Crimson series published last fall noted, stigma surrounding mental health continues to plague Harvard’s campus, along with many others.
Mental Health as Public Health
The implementation of significant changes to mental health policy requires a shift in attitudes concerning mental health. For many this implies treating mental health as a broader issue of public health.
According to a mental health action planning publication put out by the Jed Foundation, a national organization working to reduce emotional distress and prevent suicide among college students, a public health approach involves expanding from simply providing treatment services to working to prevent mental health issues from surfacing—ultimately promoting the mental health of all students on campus. This two-pronged approach—prevention and treatment—should operate on a continuum that encompasses the enhancement of students’ general health, early recognition and intervention, treatment, maintenance, and “postvention,” or follow up.
Walther of Active Minds points to recent studies demonstrating that students’ relationships with their peers are crucial to preventing mental health crises. “When someone is depressed,” Walther adds, “two-thirds of those people go to a friend before they go to a professional, a parent.” It is students, then, who need to know how to respond. “The friend needs to be able to talk about those issues, and know what to do, and know how to help,” Walther explains.
Survey results demonstrate that Harvard students who have friends they can confide in tend to have better mental health overall. Barreira says that an anonymous survey administered to Harvard freshmen at the beginning of school asks students to list how many people they have in their lives with whom they can share their most private thoughts, fears, desires, and ambitions. The average response is between 5 and 7, but every year some students say they have no one they can share with. Further analysis of the results confirmed that students who have nobody to talk to account for more than half of those who have depression, anxiety, or suicidal thoughts.
“If you have no one in your life, you have the highest risk of suicidal thoughts,” says Barreira of Harvard. “If you have even just one person in your life the risk goes down.” Barreira goes on to explain that response data from this one survey question really helps raise awareness of who is at risk for mental health concerns and how these people can be helped.
“We need to help people to not keep things to themselves,” Barreira asserts, since those who can share their thoughts with others generally have better mental health according to the survey. Harvard’s numerous peer response groups—Room 13, Response, ECHO, and Contact—and its peer education groups like DAPA, Student Mental Health Liaisons, Consent, Assault Awareness & Relationship Education, and Harvard Men Against Rape all provide safe spaces where Harvard students can confide in their peers in hopes that students will feel empowered to tell somebody about what’s troubling them.
Barreira believes that the common focus on health promotion, education, and early identification that each of the five Harvard behavior health services departments share epitomizes a public health approach to mental health. He lists the depression screenings, which occur in all of the house dining halls and Annenberg each fall, as another example of how Harvard SMHS is trying to prioritize a public health-type strategy.
“You’re raising people’s awareness about what depression anxiety looks like, you’re asking people to look out for themselves and everyone else, you’re telling them where the resources are, and you’re doing early identification, or identification of people who haven’t been treated yet,” he says of the depression screenings. “That’s all public health kinds of work.”
Barreira spotlights the anonymous survey released to all new Harvard freshmen as a public health approach to mental health because of how much it helps with awareness and early identification. The survey asks students about their medical history, particularly as it pertains to mental health, so that the University can determine the types of clinical conditions that people struggle with right from the start college.
Given the large percentage of students who enter Harvard with existing mental health conditions, Lapierre asks, “How do we help [these students] recognize that and come in?” The depression screening is one way, she and Barreira argue. They also list required freshman study breaks that educate students about identifying mental health issues as well as training tutors and proctors in early identification as resources that help with recognition.
Ultimately, as Schwartz notes, even the best resources do not guarantee that tragedies will not take place. “You have to think about it in the context of medicine,” he says. “You can have a cardiologist on every street corner, and there will still be people who die of heart attacks.” But the attacks can be reduced—and their effects eased—through the close collaboration of students, professionals, and campus administrators, grounding their efforts in concrete data and national comparisons, in pursuit of progress in mental health services among the country’s most vulnerable population.