December 4, 2002: Features

When college life overwhelms
On campuses, growing concern about mental health

By Kathryn Federici Greenwood

On an April night two years ago, a young woman named Elizabeth Shin set herself on fire and burned to death in her dorm room at M.I.T.

Shin, a sociable, overachieving 19-year-old, had teetered on the edge of emotional stability for two years. As a freshman, she tried to commit suicide by taking 15 Tylenol-with-codeine tablets. She drifted in and out of the mental health service. Friends and administrators knew that she had cut herself and purchased sleeping pills, and helped her get treatment. After her death, her parents – who had been notified about the suicide attempt in Shin’s first year – filed a wrongful death suit against M.I.T. for $27 million, claiming the university did not inform them of Elizabeth’s steep deterioration in the months leading to her death.

The tragedy and the questions it raised shook the M.I.T. campus and universities across the country, but college administrators already knew that mental health was a growing campus problem. Nationally, suicide is the second-leading cause of death among college-age students, after motor-vehicle accidents. (Shin’s death, believed to be one of about 1,000 suicides on campuses that year, has been in the spotlight largely because of the manner in which she killed herself and the issues raised by her parents’ lawsuit.) Mental health “is on everyone’s mind,” says Janet Smith Dickerson, Princeton’s vice president for campus life. Dickerson has been keeping a close eye on Princeton’s mental health programs, including medical care and parental notification policies, for the last two years, since it became clear that the need for mental health services had increased.

As it has on most campuses, especially elite campuses, the demand for services and care at Princeton is swelling – a result of the academic and social pressures on stressed-out students unaccustomed to failure, a growing student awareness of mental illness, and in some cases, new psychotropic medications that allow students with previously diagnosed mental illness to manage the disease and attend college when that would have been impossible in the past.

The number of students using Princeton’s counseling center has climbed 30 percent in the last two years, according to clinical psychologist Marvin H. Geller (pictured), the soft-spoken, gray-bearded man who has directed Princeton’s counseling services since 1968. Last year Geller’s staff met with 1,100 students with problems ranging from the situational, such as dealing with parents’ divorce or a death in the family, to serious mental illness including severe depression, anxiety disorder, and bipolar disorder. In the year ending June 30, 2001, the last year for which figures were available, 276 Princeton students were referred by the counseling center to psychiatrists, a 46 percent increase over the previous year, and two-thirds of those students were placed on medication. About 40 percent of all Princeton undergraduates use the counseling center at some point.

Andrew, a Princeton senior, was one of them. (The real names of students interviewed for this article are not used.) A self-confessed “golden boy” in high school who earned straight A’s, swam on the school team, and “was president of all the clubs,” Andrew says, “I had always gotten what I wanted. I had never really dealt with rejection.” That changed in his freshman year, when a coed fraternity turned him down. He stopped eating. A friend referred him to a local psychiatrist, who prescribed an antidepressant. Andrew improved, but the sophomore-year bicker process and room draw, in which he was excluded by friends, caused a mental breakdown. When he started coming up with suicide plans, friends took him to the dean of his college, who suggested he go to McCosh Health Center. He ultimately took a year off to receive intensive – and successful — therapy near his home.

Resident advisers – students themselves – trained by the counseling center to be alert for signs of depression and illness frequently serve as first-responders when their younger college mates run into trouble. Ted, a senior who is a resident adviser, recalls a late night last year when he received an e-mail message from one of his advisees, alerting him that another student in the college – someone Ted knew “was not adjusting very well” – was thinking of suicide. Ted immediately went to search for the student, only to find that he had left the dorm. The student returned that night, unharmed; the next day, Ted and the dean of the residential college convinced him to get help at the counseling center. For Ted, it was a scary experience but not wholly unanticipated, as he had already helped some freshman and sophomore advisees through emotional issues ranging from relationship troubles to severe depression.

“I think just about everyone is struggling through something,” says Martha, a former resident adviser who suffered from anorexia in high school and visited Princeton’s counseling center for depression. “We all feel this enormous pressure to succeed and be perfect.”

Although Shin’s death at M.I.T. brought it to the fore, the increase in students needing care “was sort of an insidious onset slowly over the last five to eight years,” says Morton Silverman, former director of student counseling at the University of Chicago and member of a panel that recently published a national report on suicide prevention on college campuses. For students with mild psychological problems, an eroding stigma attached to seeking help, heightened public awareness, and lower barriers to accessing care seem to have contributed to the heavier caseloads at counseling centers, he says. But for students with more serious problems, other factors may be at play.

In a 2001 survey, directors of college counseling centers listed numerous explanations for the increase in sicker kids: students’ experience of divorce and other family dysfunctions; experience with sex, alcohol, and drugs at younger ages; and even too much pampering, which prevents young people from developing the skills needed to deal with difficult situations. In addition, better medications with fewer side effects have allowed high school students with serious psychological problems to move on to college – and when they arrive, mom and dad aren’t around to make sure they take those medications on schedule and the doctors who prescribed them often are far away.

In the survey, 85 percent of colleges reported an increase in the number of students they see with severe psychological problems, says psychologist Robert Gallagher, a former counseling center director at the University of Pittsburgh, who has conducted such studies for 21 years. Those students, he says, require “more time and more involvement” from counselors, leaving less time for the bulk of students with more typical developmental concerns. In October 2000, seeking increased funding for psychiatric consultations at Princeton, then-Health Services Director Pamela Bowen reported to the university’s Priorities Committee that the number of students referred for psychiatric consultation and prescribed medication had more than doubled within the previous decade. “We don’t believe this is only an indication in the rise of psychopathology, although we have seen such a rise, but rather the general acceptance and utility of antidepressant medication in particular,” the report noted. Funding was increased.

Certainly, anxiety and depression are nothing new at Princeton or at other universities, and Geller is not certain whether the counseling center’s growing caseload represents an increase in illness or heightened awareness of treatment. Karen Smith ’83 experienced a major depression in her senior year. “I went from a 3.7 GPA in my major (classics) to receiving a D on my thesis,” she recalls. “I used to cry all the time.” One evening, she lay down in the snow on Prospect Avenue, hoping to be run over. No cars came by, so she got up and walked home. She sought advice from her chaplain, but he told her to “buck up and get over it.” And when she went to the infirmary, the nurse asked her if she wanted to see a doctor or “to just forget about it.” Smith walked away. Now a rheumatologist in Arizona, Smith got help from the dean at her medical school and has managed her depression successfully since then. When should parents be called?

One of the thorniest issues raised by Shin’s death concerns whether — and when — to notify parents that their children are in distress if students don’t want their parents involved. The common-law doctrine of in loco parentis on university campuses began to die in the late 1960s and early 1970s. Suddenly viewed as adults, students got new rights to live their lives as they saw fit. Federal privacy regulations gave students more control over their educational records, and courts in several states found universities were not responsible for protecting students from themselves. “In loco parentis hasn’t been in effect for a couple of decades” in New Jersey, or anywhere, explains Barbara A. Lee, dean of the School of Management and Labor Relations at Rutgers University and coauthor of a textbook on higher education law.

But she and other experts note that the issue is not clear-cut. As states raised the legal drinking age from 18 to 21 in the 1980s, universities began to retake some of the control they had relinquished, as a means to protect against liability. The law governing the privacy of educational records was amended to permit – but not require – colleges to inform parents about violations of alcohol and drug policies. Today, the relationship between universities and parents continues to be defined.

The Shin lawsuit again turned a spotlight on this question, complicated further by issues of medical confidentiality. Like other universities, Princeton generally considers students to be adults with a legal right to privacy concerning their emotional and psychiatric problems. The university encourages students to contact parents themselves – but is likely to step in if doctors and therapists believe a student presents a risk to himself or others, according to Dickerson. “Princeton has taken the position that we will more likely err on the side of notifying the parents in a critical case,” she says.

Geller agrees. “I think we should strive never to go around students’ wishes,” he says. But if he believed a student were in danger, Geller says, “I would contact a parent and take whatever legal consequences came. And part of the reason why I do it is that I feel that students in trouble who can’t notify their parents are also letting us know that there is family trouble.”

More student services

The tragedy at M.I.T. also has contributed to a new focus on the level of services and staffing in university counseling centers. “Although Elizabeth Shin’s death brought painful scrutiny to M.I.T., it increased community awareness of mental health issues and catalyzed support to make improvements in a good way,” says M.I.T.’s Kristine Girard, cochairwoman of M.I.T.’s mental health task force. Since the death, M.I.T. has increased counseling hours, added staff members, and initiated new outreach programs to lower the stigma surrounding mental illness. Every new mental-health patient now receives a lengthy phone call from a counselor the day he or she first phones, Girard says.

Funding for mental health has increased at Princeton over the last two years (administrators would not say by how much), particularly for additional staff hours for psychological counseling and psychiatric services. Students and counselors suggest that Princeton has been spared some of the heartbreak of other elite universities, some of which have had a suicide each of the last few years, because of its small size and multilayered approach to mental health in which numerous people – residential advisers, deans, counselors, chaplains, faculty members, and fellow students – are encouraged and trained to look for developing problems. (Geller believes suicide attempts are relatively rare and says there has not been a suicide on the Princeton campus for about eight years.) But administrators acknowledge that the support system drops off during the junior and senior years, when students no longer live in residential colleges – a situation they hope will improve under Princeton’s recently announced four-year residential college plan.

With a student body that appears more troubled, Geller has increased the counseling center’s outreach programs, initiated relationships with more offices and departments across campus, and hired added two psychologists and one social worker in the last five years, for a total of 10 full-time employees. Princeton’s counseling center, located in McCosh, offers a range of services, including group therapy; short-term individual counseling; and peer education groups that focus on eating disorders, sexual harassment and assault, and alcohol and substance abuse. Because students are limited to 10 free sessions per year with a counselor and Princeton employs only two consulting psychiatrists, students who need long-term care are referred to a local therapist or psychiatrist. “One of the things that I have always tried to do is operate with no waiting list,” says Geller. Urgent cases are seen immediately; others may wait up to one week.

Princeton’s new chief medical officer and executive director of health services, Daniel Silverman, came to the campus from the Washington University School of Medicine in St. Louis, where he was associate professor of clinical psychiatry. While he believes the university is doing an “excellent job” supporting students with psychological concerns, he thinks more could be done. The university simply could use “more time, more help, more people to carry it out,” he says, and he has requested permanent support for positions currently funded only on a short-term basis. He also would like the counseling center to offer more extensive psychotherapy, services. Today, he says, “we do have to refer students out who need more intensive or more ongoing psychotherapy and they have to bear the expense. For many students that’s really a huge burden.”

Geller, on the front line, realizes that no system is foolproof, and he worries about that. “We have to face that,” he says. “I try to set it up so we minimize someone slipping through the cracks, but part of what we’re concerned about is that as it gets busier and we have more and more activities, people are more likely to miss something.

“It’s stressful.”

Kathryn Federici Greenwood is an associate editor at PAW.

Mental health at Princeton

This information was collected from Princeton students for the National College Health Assessment Survey in the spring of 2000. About 350 Princeton students completed the survey.

58.9% reported they felt hopeless at least once during the last school year.

45.6% reported they felt so depressed that it was difficult to function at least once during the last school year.

8.2% seriously considered suicide one or more times during the last school year.

1.2% attempted suicide during the last school year.

7.9% were diagnosed with depression at some point in their lives.

22.7% reported stress has affected their academic performance in the last year.

How parents can help

Parents can help students receive appropriate mental-health care when they leave home for college, says Morton Silverman, former director of student counseling at the University of Chicago and a member of a panel that recently published a national report on suicide prevention.

When selecting a college for students who already have experienced mental-health concerns, families should examine the level of care available through the university counseling center, including typical waiting times and the number of psychologists and psychiatrists on staff, Silverman says. They also should consider the resources available in the community should a student need ongoing psychiatric care that many colleges cannot provide.

Once a student has been admitted to college, parents can contact the counseling center even before the school year begins to arrange for a treatment program and consultations with outside specialists, if necessary, says Daniel Silverman, Princeton’s chief medical officer. Parents should contact the residential college staff to make advisers aware of special needs of the freshmen living in their halls, experts say.

Parents should watch for signs of emotional trouble, including a sudden drop in grades, a dramatic change in mood or behavior, withdrawal and self-isolation, according to Allan J. Schwartz, associate professor of psychiatry at the University of Rochester. And keep the lines of communication open, suggests Janet Smith Dickerson, Princeton’s vice president for campus life. “Parents can listen,” she says, and “find ways not to add to students’ sense of expectations and guilt by expecting too much.”