Prioritizing Mental Health in College

Students are struggling with mental health issues on college campuses. Dr. Stephanie Pinder-Amaker has over 25 years of experience in college mental health treatment, administration, and policy. As founding director of McLean Hospital's College Mental Health Program in Massachusetts, she conducts workshops for higher education institutions, as well as to parents and students, to help strengthen communication and increase  supports. In this episode of the Harvard EdCast, Pinder-Amaker discusses the factors leading to mental distress on campus, how colleges can create better responses, and how awareness of and supports for mental health issues should begin long before students get to college.

TRANSCRIPT

Stephanie Pinder-Amaker: There's certain things that we know for sure. We know in college student mental health that there's an increased demand for services. More students are seeking mental health treatment in this country on college campuses than at any time in our nation's history. A second related factor is that schools are really struggling to keep pace with the demand for services. And then a third factor is that the vast majority of students who self-identify as having significant symptoms that might indicate a mental disorder, depression, anxiety. Overwhelming majority of students, upwards of 80%, are not seeking treatment for those symptoms. So you put those three factors together and you have a significant piece of why so many people are talking about a crisis in college mental health.

Jill Anderson: Do you see specific times of year where some of these numbers might increase? Is it when you start school, is it midterms, finals?

Stephanie Pinder-Amaker: Yes. There are definitely times of year, you named some of them, like around midterms, exams. And schools do a really good job of tracking these things. So counseling centers on campus, they pay a lot of attention. They can sort of map out a chart. They know when these predictable peaks are going to happen. And that's great because then they can plan ahead and increase their staffing in order to keep up with the demand. It's essential that the wait times are kept low. Meaning that if I show up for a service on campus, I don't want to be told, "Oh, yeah, we can fit you in in two months from now." Two months is a lifetime in the experience of a college student. We generally want to keep the wait times under two weeks.

So, knowing those peaks and valleys are very helpful. But another driver that's unpredictable is when a crisis occurs on campus. So you might have a series of losses that are occurring on a college campus or you might have a tragedy, like maybe we think about things happen regionally. The Boston Marathon bombing is something that... So there are things happening not just on campus but also in the world that campus administrators and people who care about students and the mental health of students, we have to get better and more nimble at identifying those events and then asking ourselves, I call it scanning the ecosystem. It's taking a routine look at what's happening on your campus, controversial speakers coming to campus, campus specific incidents, but also looking beyond campus at other seminal events and getting really practiced at asking, "How might this event be impacting the sense of belonging of our students?" And if so, are there certain subgroups of students who might feel particularly targeted because of this particular incident. And schools are just learning how to get more adept at doing that and being able to respond in real time. Can I give you an example?

Jill Anderson: Sure.

Stephanie Pinder-Amaker: An effort that I learned about at a recent conference was in the aftermath of the Charlottesville incident, where the UVA faculty, they got together and supported each other in altering their core syllabi so that they gave students opportunities within the classroom to deal with some of these really distressing things that happened related to the Charlottesville incident. That's just one of many illustrations of being mindful of, "Oh, this is happening out there, but it's going to impact our students. What can we do now in addition to staffing up and being ready for more students to seek services? What are some of the other ways that we can reach students where they are and anticipate that they're going to be struggling?"

Jill Anderson: Do you see a lot of colleges and universities that maybe don't have the resources in place until after something happens?

Stephanie Pinder-Amaker: Before coming here to McLean and Harvard, I was an administrator at the University of Michigan. And part of my job was managing crises like critical incidents university-wide. And so, over time I think schools in the US, particularly since the Virginia Tech shootings, I think have gotten better at knowing how to respond to significant campus-based crises. But there will always be things that we don't yet know how to respond to most effectively.

Jill Anderson: I've heard this from students working in higher education, saying that students who have come to them with serious concerns and issues in their life and then there being a long wait to get a counselor. That to me seems like a serious issue.

Stephanie Pinder-Amaker: Yes. One of the things that schools are recognizing now is that we have to do more than provide direct mental health services, that we have to look upstream at ways that we can intervene. One way of thinking about it is that a lot of the really effective treatment and interventions that we have in behavioral health are designed to be most effective early on. So in a sense we have a mismatch with the kind of healthcare system that we have in place because we often discourage people from seeking treatment until they're really in distress. What we want to do then, and a college campus is a wonderful place to get really innovative and proactive and creative. We want to think about how do we connect with students early, get students more aware at the earlier stages of what some warning signs may be to look for, and then how do we direct resources that maybe aren't as expensive or as intensive as direct services psychotherapy. How do we get resources and skills to those students earlier in the process so that maybe they won't need to come in and seek mental health treatment a year from now?

And so, their resources, yes, they're dedicated to direct provision of services, mental health services, psychiatry is really important to have those resources available, but we also have to get dedicate resources to getting out into the campus community, meeting students where they are, increasing their awareness, their education about mental health, what to look for, and teaching them the skills that they can use early in the process that might prevent a mental disorder from really taking hold.

Jill Anderson: And you just mentioned, what are some of the things that we should be looking for on college campuses?

Stephanie Pinder-Amaker: So, some of the signs to look for include withdrawal, increased isolation, distancing from friends, withdrawing, being alone, losing interest in things that were once pleasurable. We can look for changes in both sleep and appetite. And what's important to know about those categories is that the changes can be increases or decreases. We want to think about increased irritability, outbursts. Often, we're looking for changes in mood and it's more commonly understood, okay, I'm going to notice if someone is feeling really despondent or hopeless or even anxious. But often we forget to think about increased irritability and outbursts, particularly in young people that can be a warning sign. Unexplained episodes of tearfulness.

And then there are two things that I think are big red flags that should always require intervention. And that is excessive drinking and use of substances. A big red flag should be particularly when those behaviors result in negative behavioral outcomes, meaning fights, the destruction of property, legal consequence, being transported to the hospital for drinking too much alcohol. Those are situations that I think automatically require, "Let's sit down and talk about what's going on." And then the second is any sign of suicidal ideation, thoughts of hurting oneself or an attempt, a suicide attempt. Those are definite times to sit down and let's figure out what's going on.

Another thing that can be easily observed is a decline in performance. And it doesn't have to just be academic. It might be athletic performance, something that the student has typically really excelled in or done consistently well, and suddenly for no explainable reason, they're really not performing as effectively. A helpful formula for non-mental health providers just to keep in mind is that when these signs cluster together, so we're seeing not one or two, but three and four hanging together, that should increase our sense of urgency. And I'd love to ask students when we go and have these discussions, "How long would you wait before seeking help if you were experiencing some of these signs?" The answer is, if these signs persist for longer than two weeks, you should probably get that checked out.

The beauty of what we're talking about right now is that, unlike heart disease or cancer, all of the things that I just mentioned are, for the most part, observable.

Jill Anderson:  Right.

Stephanie Pinder-Amaker: And that means that every single one of us is in a position to pick up on these things, to notice these things in our students, in our children, in our friends. And I think there's real power in that. And on college campuses there are growing efforts to ensure that not just the counseling center, not just the mental health providers, of course they're prepared and ready to do what they do, but we want to really think more broadly about the entire campus and help everyone who's a member of a campus community to think about, "What's my role in all of this? I'm not as psychologists, maybe I'm an engineering professor. But as an engineering professor, what can I do to be a responsible member of the campus community who's also aware of some of these signs?"

Jill Anderson:  It seems like we do live in a culture that's very look the other way. That could really impact some of these things. Maybe you see the student in class next to you, or it's your roommate, or maybe you're a faculty member and you don't know the student all that well, but there seems to be some signs, and maybe there's a reluctance to intervene.

Stephanie Pinder-Amaker: It can be. I think about, as a member of a campus community, how can I be a better ally or a better bystander or a gatekeeper? And there are trainings that exist to teach people how to do those things on college campus. You can teach students, you can teach faculty members, you can teach staff. You think about, as an entire campus, how do we elevate our competency around these issues? That's a way of promoting mental health and wellbeing campus-wide, so we're lifting everyone up in addition to addressing the needs of those who are most distressed.

Jill Anderson:  I know that, for students of color, some of these signs can differ. It seems like a lot of the mental health services cater to one population of students, which was predominantly white, and don't really represent the entire student body.

Stephanie Pinder-Amaker: So, it's a really important question. In our work at McLean, in addition to developing treatment for college students, we also engage colleges and universities. We consult with them, we partner with them, we do research projects together, we develop workshops. Overwhelmingly though, in the past six years, the number one request from colleges and universities has been related to the question you just asked, schools wanting to know how do we do a better job of supporting the mental health and wellbeing of increasingly diverse students? So I cannot overemphasize how important it is that campus efforts to promote mental health and to prevent suicide are multi-culturally informed across identities. Any place in which students might feel marginalized because of their identities, maybe if they're from a low social economic status or because of national origin, maybe because they identify as being a sexual and gender minority student. Wherever students are finding themselves being marginalized, it's important that colleges develop strategies for eliminating those stressors.

So for students of color encountering repeated to racism, discrimination, questions about belonging on campus microaggressions, it's not that these things are happening in isolation, it's the repeated exposure to these kinds of experiences that is highly correlated with an elevated level of psychological distress. And so schools have to get better at making sure that all of their efforts to promote mental health and wellness are really multi-culturally informed, that we're using the best of what we know from the research literature about how best to connect with communities who differ from us.

Jill Anderson:  I want to hear more about some of the education efforts that I know you work on, specifically educating high school age children to recognize symptoms of mental health issues.

Stephanie Pinder-Amaker: When we think about college student mental health more broadly, it's abundantly clear from the research that one of the most important things that we need to do and can do and schools are doing is to work with high school students, work with students long before they get to college to begin having these dialogues, to increase high school, middle school, grade school students even, increase their awareness of mental health issues, and also begin teaching them the skills and the strategies that they can use at the high school, secondary school level. They sometimes refer collectively to this category as social and emotional learning skills, and developing and cultivating these skills in our young people so that they get to practice these skills and hone them long before they step foot on a college campus.

High school and middle school, those are ideal opportunities to also integrate this information into the academic curricula. Because teachers spend so many hours with students, they're uniquely positioned to ensure that students have a increased knowledge base about how to take care of their mental health.

Jill Anderson:  Societally, we focus a lot on getting our kids into college. There's a lot of pressure to do that. And then we leave them and drive away. And are there things parents can be doing once they get their kid to school to ensure that they stay well?

Stephanie Pinder-Amaker: Absolutely. Yes. And I really want parents to feel increasingly empowered around these issues. It's so important for a number of reasons. When we survey parents and ask them, "How likely is it that a young person will encounter a mental health issue in college?" The vast majority of parents will say, "Oh, it's very likely." But when we asked those same parents, "How likely is it that your child will have a mental illness?" The number goes way down. So there's a disconnect there.

So there are tons of things that parents can do. One, they can work with students at the high school level, help students work with their children to help them think about fit for college in a more holistic way. So we want to think about campus fit about academics, yes. But we also want to support children in asking, "How will my emotional wellbeing or my sense of belonging be both fostered and challenged in this particular campus environment?" And parents can guide those discussions and support their children in thinking about those kinds of issues, to think in a real holistic way about what school is the best fit for my child based on these, or for me, if I'm that child, based on these factors?

The construct of emotional preparedness is a really helpful one. We use it often with parents. And it means working with your child to think about your child's ability to do four things. Number one, to take care of themselves and the campus environment. Number two, to control negative feelings and behaviors. Number three, to build healthy relationships. And number four, to adapt to new environments.

I love the emotional preparedness construct because these are terms that everyone can use and think about. And so, if you sit with your child and help them begin think about, "Well, how am I doing in these areas? How is my ability to take care of myself?" And I'm talking about basic things like, "Does my child know how to fill a prescription? Do they know how to get a healthy meal when no one's home to prepare dinner? Do they know how to manage their money properly?" These are emotional preparedness skills, and parents are ideally positioned to begin developing and assessing and cultivating these skills with their children while they're still at home.

It's important because when we survey first year students and we ask them, "What's going well in your college transition? Where are the challenges? Where are the bumps? Where are you succeeding?" We know that students who feel less emotionally prepared, so they're less prepared to do those four things I just talked about. They're more likely to rate their college experience as terrible or poor, and more likely to have a lower GPA. So these are skills that we want to work with children, but we can also help parents to feel skilled up so that they know how to better support and guide their children.

A third thing for parents, overwhelmingly I think it's important to begin a dialogue at home to make home a place to create an environment that says, "Yeah, we talk about our mental health in this family at the dinner table, while carpooling, we're texting about it." That these topics are not taboo in this family. Parents have the power to do that, to open up these dialogues and to give your child permission to use words like anxiety or depression or talk about thoughts of harming oneself and to make it safe and okay to name these things. It's great modeling that parents can do for their children and it also empowers their child who may not be grappling with these issues currently, but in the future when they're transitioning to college and potentially encounter one of these difficulties, if not personally, then certainly with their roommate, or a friend or a lab mate or a coworker. The child will think back and they'll remember where those basic skills come from because parents began developing them at home.

Jill Anderson:  It's interesting because I think, when your child is young, we spend a lot of effort and time transitioning them from one grade to the next, to the next. And then it just seems like it falls off when they get older.

Stephanie Pinder-Amaker: Yeah, it's true. Another thing I would say to parents is to think about being proactive in preparing for this transition. Certainly, in all of the ways that we just suggested, but also real specific things like if you know your child takes medication for an illness, then make sure that there's a local doctor available to prescribe that medication. Make sure those appointments are set up in advance. If your child needs to access accommodations at school, many of those kinds of things can be done before the student even arrives on campus. So being proactive is important.

Jill Anderson:  And then once they're there, you just mentioned being proactive, but is there a easy way to walk the fine line between being annoying and being supportive?

Stephanie Pinder-Amaker: It's good to talk with your child before they leave for school, to talk in advance about what's an appropriate level of contact to have, what are the expectations around checking in or texting, and to set some expectations that are reasonable, that can feel comfortable to the parent, but also fosters a sense of growing independence and separation. Essentially, that's the task of a young adult, is to get more comfortable being on one's own. And so, certainly, no parent wants to pull all the supports out from under a child, but think about what's going to empower your transitioning age youth to feel more a greater sense of self-efficacy.

And so, for a parent, all of the decisions around how much contact is too much, "Should I intervene in this situation or stand back?" Can be guided by thinking, "At the end of the day, what's going to help my child to feel more accomplished? If I call up the school and handle this roommate crisis for him or her or them, is that going to result in a growing sense of self-efficacy, or is that going to just perpetuate a cycle of them feeling more dependent on me?" That type of framework can be helpful for parents.

Jill Anderson: Dr. Stephanie Pinder-Amaker is the founding director at McLean Hospital's College Mental Health Program, an initiative serving students from over 200 institutions in higher education. She is also an assistant professor of psychology at Harvard Medical School. I'm Jill Anderson. This is the Harvard EdCast produced by the Harvard Graduate School of Education. Thanks for listening.