Case for reform: College needs to reexamine mental health care

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GRAPHIC BY KAYLA PAYNE / THE FLAT HAT

The student mental health care system at the College of William and Mary is broken. Reform is long overdue. I am very familiar with the problems students face in getting adequate mental health care. In 2014-2015 there were four student suicides. I was president of the Faculty Assembly that year. I was devastated by those suicides, and I resolved to do something about them. I have a great deal of experience and training as a mental health activist, and I secured the support of psychiatrists in Richmond, where I live, in developing the Student-Faculty Mental Health Initiative, which I cleared with Vice President Ginger Ambler ‘88, Ph.D. ‘06 and announced to my classes in September 2015. The aim of the initiative was simply to start a conversation on campus. It was enthusiastically received by students. Unfortunately, I was removed from my teaching position in October 2015. I will not get into the details of the lawsuit I was eventually forced to file or the discussions that continue today about how to gain closure on that event.

Instead, to follow up on my student mental health care initiative, I would like to propose a full reform of the student mental health care system. I worked on this proposal for three months this summer and, once again, I had the advice of psychiatrists in Richmond. I will divide my proposal into two parts. In this essay I show that the current system is fundamentally flawed and needs to be replaced. In a second essay I will lay out an action plan for moving from the system we have to a system that works.

The College’s “health and wellness” approach is flawed in nearly every imaginable aspect of its structure:

– an unsupported and almost certainly false motivating assumption;

– an undefined and apparently meaningless overall goal;

– an antiquated model of health care delivery (relying on administrative units in a centralized system);

– an unscientific model of care to address what is a public health problem and must be treated as such if evidence is to be brought into decision-making in appropriate ways;

– subsidiary goals that are undefined and therefore useless as guideposts if we wish at some point to evaluate our progress;

– mutually inconsistent or collectively incoherent explanations of the disparate activities and services making up the full program;

– an inability to assess either the effectiveness or efficiency of the program’s component activities or overall structure;

– provided medical information that is false;

– provided program information that discourages help-seeking behavior;

– program activities that are needed but are not offered (suicide prevention) or are not offered in sufficient supply (counseling and therapist meetings); and

– unilateral and opaque decision-making by the administrative units charged with delivering health and wellness, coupled with their unwillingness to meaningfully engage different constituencies, in particular the students, in an open, respectful, honest discussion of mental health issues.

To summarize, the current system of student mental health care, centered on “health and wellness,” does not work. It is riddled with problems, starting with its core motivation and extending to multiple aspects of its programmatic structure.

The “health and wellness” program at the College is based on the claim that the primary obstacle to better mental health among students on campus is an academic “culture” that, according to Kelly Crace, associate vice president for health and wellness, “includes a kind of ‘stress glorification’ and the marginalization of people are who are intentional about healthy habits.” He adds, “The whole point we’re trying to make with integrative wellness is to try to show that wellness and excellence don’t have to be competitive.” Crace said, “that we can create a culture of resilience where wellness and excellence can be synonymous and that they actually help each other and that [students] can obtain a deeper level of excellence.”

The main problem with this rationale is that we have no evidence that such student attitudes regarding academic achievement exist at the College, and if they do, we have no reason to think they threaten student mental health. National data on student mental health care and the prevention of suicide, at least, would suggest as much. In studies of mental health disorders and suicides at universities, “poor grades” is considered a risk factor. But it is not, according to research, an important one. The College’s monocausal account, in any case, is simply not credible, even if students really do “glorify stress.”

However, the claim that poor mental health among students at the College, where it exists, can be blamed on a self-destructive academic culture sustained by the students themselves, should be considered a myth, not a foundation for policy.

A second problem with the College’s health and wellness framework is that its aims or goals are not defined. What outcome is the College aiming for? Crace says the goal is to create a “culture of resilience.” We are given no sense of what this means. How would student behavior be different in such a culture? What would it mean in terms of outcomes that might be measured?

The third difficulty with the College’s current mental health program follows from the second: without well-defined goals to aim for, we have no way of knowing how well the College is doing. Are the programs and activities in place and intended to improve the health and wellness of our students effective? If so, according to what measures? What assessment tools does the College use to determine whether the resources devoted to health and wellness are well invested? How does it track the mental health and wellness of the student population?

Fourth, the College’s literature on mental health and wellness, as well as the materials and information supplied on the websites of the Counseling Center, Health and Wellness Office and Dean of Students Office, all justify existing programs, services and activities in terms of a number of different and collectively inconsistent rationales and policy documents. These include the JED Campus Program, the Authentic Excellence Initiative, the Healthy Campus 2020 Coalition, the Life Values Inventory, the Kognito online At-Risk module and an emphasis on self-help literatures provided by disparate websites. No overall rationale glues these incommensurable activities together. No feature of the specified activities and no element of the logic of their implementation gives us reason to believe they make sense when combined. We have no basis for concluding that these activities and services will collectively promote either health or wellness. In short, given such a hodgepodge of services and lack of defined goals, we have no reason to think we will get anything from the current health and wellness program but a continuation of the status quo.

Fifth, in reviewing specifically the services for mental health disabilities, one finds inadequate, unclear or missing information; inadequate, poorly structured or missing services; or both. These problems appear where wanted or needed services apparently do not exist, should exist but are ruled out, or should and do exist but are made difficult to access or are clearly inadequate to the task. These problems are widespread in the Counseling Center specifically and the provision of mental health care at the College generally.

Two examples are worth noting. They give a sense of the extent of disrepair in the College’s mental health care system. First, consider two of the claims in the Counseling Center’s discussion of medications and therapy under the heading, “Things to know when seeking medication management.” They are:

(1) “Medications can help manage symptoms but cannot cure mental health disorders. The best course of treatment is often a combination of talk therapy and medication management.”

(2) “Of the many physicians who graduate medical school only a few choose psychiatry as their pathway. As such there are often limited numbers of psychiatric providers… It is not uncommon for psychiatrists to have waiting periods of 4-6 months for first appointments. Psychiatrists will not offer walk-in crisis appointments.”

These claims are false, as any review of relevant research or call to a medical professional will confirm. And these errors matter. If students who need help consult the College website and believe these claims are true, they would conclude that medications won’t treat their conditions if used alone (when we cannot say this is generally true), and they may decide medications cannot be obtained in the short-term anyway (when such a conclusion is uncertain until one investigates it). We should not be surprised if such students give up on medication and decide to continue struggling with their conditions without getting treatment. If that happens, we cannot absolve the College of responsibility for a very unfortunate outcome. These two false claims about medications have been on the Counseling Center website for some time. They may have discouraged at least one College student, maybe more, from getting medication therapy already.

A second example of the profound need for reform of the College’s current mental health care system is the systematic way in which it discourages help-seeking behavior in the realm of mental health. For over two decades, mental health programs nationwide have stressed the need for colleges to encourage help-seeking behavior and remove the barriers to treatment. In many ways — most notably, (a) with the many conditions and limitations the Counseling Center places on the services it will provide, (b) the number of times it states on its website that students have the option to go off campus for treatment, which it encourages them to pursue on their own by providing a database of off-campus providers and (c) the extensive resources provided on the self-help page — the staff at the Counseling Center signal that they are not eager, willing or able to treat students. The Center’s self-help page, for example, provides 39 links to disparate organizations covering fundamental mental and emotional problems such as eating disorders, trauma, anxiety, depression, sexual assault and helping the survivors of suicide. Offering myriad self-help links (and another page dedicated to self-assessment materials) for these serious disorders and profoundly complex emotional issues can only have the effect of discouraging students from making a counseling appointment even when they need one and are willing to take the leap of requesting one.

Seeking mental health care is a daunting task for any student, even in the best of circumstances. A successful college mental health care program will not only send encouraging and welcoming messages to students, making clear its desire to offer necessary treatment, but will work long term to remove barriers students face, for example, by implementing anti-stigma programs.

What would reform look like? In a second essay I will outline an approach that fixes the problems identified above and also addresses longstanding student concerns. News coverage of mental health issues in both The Flat Hat and the College’s news reveals that students feel shut out of the processes and deliberations that determine their health care options. These processes and deliberations are not transparent, it might be added, and it must be admitted that the decisions taken have not been responsive to student concerns. At most times, no one at the College is speaking to the issue of mental health. Discussion of this matter on campus, which had been vigorous in the 2015-2016 academic year, evaporated over the next two years, despite the fact that the administration never responded to the profound concerns students clearly and forcefully articulated regarding their mental health care in 2015 and 2016.

Students at the College have long identified their inability to engage the administration in a meaningful dialogue as problematic. One complaint is that the school does not acknowledge the realities that students face. At a campus discussion in April 2015, former Student Assembly President Colin Danly ‘15 made just this point in regard to student mental health.

Danly said that the College has done such a good job at marketing “One Tribe, One Family,” that students come to the College expecting it to be “this perfect, wonderful community when the reality of life sets in and it’s just like, some things aren’t perfect, and it’s hard to necessarily reconcile that.”

“And I think that’s the same idea of looking at the Counseling Center,” Danly said. “If you paint the Counseling Center as you go in one time and you’re fixed and that’s it, you’re going to have people more dissatisfied because that’s not how life works. Sometimes it works, sometimes it takes two sessions, sometimes it takes 20, sometimes it’s never fixed, and so I think it’s about having an honest conversation about what are our expectations, and I think having an honest conversation saying, just because we say ‘One Tribe, One Family’ doesn’t mean one perfect, happy family. No one wants a perfect family because that’s boring.”

In the SA election the following year, the main issue was mental health care, and the campaign platforms of all the candidates stressed the need for fundamental change at the College. Each pair of candidates promised to make communication on mental health issues between the College and students their top priority. Each stressed the need for greater awareness of mental health issues across campus, and two of the presidential-vice presidential pairs stressed the need for more education. Finally, all the candidates identified the reduction of stigma as a necessary goal.

In pushing for such changes, the students made clear their view that what needs fixing is not individual policies but the encompassing mental health climate. In other words, they advocated for reform, or for a structural change that could not be realized by pursuing the limited adjustments the College said it might take. Danly had said a year earlier: for the undergraduates at the College, “it’s about having an honest conversation.” What the students want and deserve is a dialogue that treats them as adult stakeholders and responsible citizens who are ready and willing to accept their share of responsibility for their own mental health. The proposal I will make does just that.

Email David Dessler at dadessler@gmail.com