Alcohol and substance disorders. Life threatening eating disorders. Suicidal behaviors. Students’ mental-health needs continue to garner considerable attention at colleges and universities—as well as among the public and in the press when a high-profile tragedy occurs. Institutions and the boards of trustees that govern them are challenged with creating and supporting top-quality campus services and administrative structures that respond appropriately to those needs. However, many institutions do not have the resources in place or a comprehensive plan for dealing with the myriad of mental-health issues that their students grapple with today.
Although campus shootings historically have garnered the greatest public and newsmedia attention, the more frequent risks to students’ lives come from alcohol- and drug-related deaths and student suicides. Those deaths are often fueled by the desire to numb emotional discomfort in the case of substance use and the desire to escape psychological pain in the case of suicides. They are both rooted in the broader mental-health concerns of students.
In a recently released survey of 25,000 students by the National Association of Student Personnel Administrators (NASPA) and the Center for Collegiate Mental Health at The Pennsylvania State University, as many as a third of the respondents said they had sought counseling, usually for anxiety and stress. The same study reported that 5 percent said that they had attempted suicide. And according to the American College Health Association (ACHA) and the Suicide Prevention Resource Center, more than 1,100 students kill themselves each year, making suicide the second leading cause of death among college students after unintentional injuries. (In other research, students have reported that serious thoughts about suicide or attempts at suicide were the result of drinking.) The ACHA also found in a 2008 study that almost 15 percent of the students had in the past year “felt so depressed it was difficult to function.” Moreover, research shows that many students who need help the most don’t ask for it.
A fundamental role of any board of trustees is to be a good steward of institutional resources, and no resource is more important than the students themselves. Boards can promulgate and reinforce five key strategies that will help their institutions encourage student mental health and create a campus culture that sustains it. Those strategies are to: 1) adopt a public-health approach, 2) support adequate counseling and mental-health services, 3) develop outreach programs to get students to seek help, 4) create structures that coordinate support for students, and 5) attend to the physical environment of the campus and surrounding community. I will describe each strategy in more depth.
Adopt a Public-Health Approach
A public-health approach is best defined by “Rose’s Theorem,” named for British epidemiologist Geoffrey Rose, which states, “…a large number of people at small risk may give rise to more cases of disease than a small number who are at high risk.” That theorem is broadly applicable to issues related to student mental health. All of us as human beings struggle with various stressors and events that happen to us in our environment and can place us at greater or lesser risk of experiencing mental-health or substance-abuse challenges.
A public-health approach seeks to change those environmental factors in a way that decreases the overall likelihood of risk for an entire population. At a college or university, that is accomplished through prevention efforts focused on intervening before a student gets to a place of great risk. Murray Levine, a distinguished service professor of psychology and adjunct professor of law at the University at Buffalo, summarized this approach by saying, “Prevention goes beyond changing individuals—it changes cultural norms.”
A college or university and its board members can work to change institutional cultural norms in a number of ways. A place to start is within the key leadership positions, including the board itself. If there is political will at the leadership level to acknowledge mental-health issues as a priority, then presidents, provosts, and vice presidents will make statements about the importance of the health of students’ minds to the overall mission of the institution.
For the board, that can also involve endorsing polices that recognize mentalhealth issues as mediating factors when the institution establishes student codes of conduct. Mental-health concerns should in no way excuse problematic behavior; however, policies and codes can be modified to ensure students are encouraged to get help as part of a sanction if it is related to the conduct violation. That can play a larger role in establishing cultural norms that work hand in hand with other efforts to destigmatize mental-health issues on the campus.
Another tangible manifestation of that political will is to support the establishment of various councils charged by campus leaders and composed of faculty members, administrators, and students with the goal of having regular conversations about improving mental health and curbing substance abuse. Those conversations, which can occur when the institution is not in the middle of a crisis, can be the most effective way to raise the consciousness of people on the campus and shift the larger culture.
The institution can also encourage and create space for students to engage in grassroots efforts to address mental-health issues as a priority. Boards can accomplish that by encouraging the presence of student advocacy groups—like Active Minds, which develops and supports student chapters on campuses around the country that focus on mental-health awareness and education. Such groups help reduce stigma and provide healthy activities that can shape the conversation about mental health in a positive way.
It’s also important that boards understand the need for appropriate levels of financial resources for residence-life staff and programs. Such staff and programs play a crucial role in bolstering social connectedness among students and fostering the stress-management abilities of dormitory resident assistants.
Support Adequate Counseling and Mental- Health Services
It is not a simple task to discern the appropriate level of care and support for students’ mental health at a college or university. Yet board members often have expertise in areas like health insurance and employee benefits and can bring an important perspective to discussions around adequate care.
First, boards can ensure that the institution provides affordable student health insurance or requires students to sign an insurance waiver stating that their current insurance is adequate. Mandating some type of insurance is essential, especially when referrals are needed for specialized care outside the scope of the campus’s counseling or mental-health service.
Boards should also approve adequate financial support for the staffing of the counseling or mental-health services on their campuses. According to the Association for University and College Counseling Center Directors (AUCCCD), as few as one-fifth of counseling centers say they are about where they should be when it comes to the number of hours of psychiatric services they can offer. Indeed, growing numbers of students with increasing levels of need go to such counseling centers each year, but those centers average fewer than one counselor per 2,000 students. The International Association of Counseling Services (IACS), an accrediting body for many college and university counseling services, suggests one counselor for every 1,000 to 1,500 students.
That ratio is a good place to start, but it does not consider a number of relevant variables, such as whether the institution is located in a rural or an urban environment, the number of students seeking care, and other factors. Urban environments generally have more sources for referral, and students may be more likely to seek out those resources on their own. Urban areas also provide greater options for psychiatry services, an important factor to consider when deciding whether or not to make such services available on a campus. (Meanwhile, more centers are adding psychiatry resources if they did not have them previously or increasing those same services if they did—generally a positive development that allows for more-coordinated, holistic care.)
Other variables include the size of the institution and whether it is public or private. Small private colleges tend to have different expectations among students, alumni, parents, and faculty and staff members due to the increased likelihood of frequent interaction and a more family-like culture. They may need to have one counselor for every 500 to 700 students, whereas a larger state institution may be able to meet the demand with one counselor for every 2,000 or 2,500 students.
Benchmarking data at comparable institutions is the most effective way to determine the best counselor-to-student ratio for your college or university. You can obtain specific comparisons from AUCCCD’s annual survey. Board members can work to inform themselves and then advocate for adequate resources for such services based on some of the relevant factors that I’ve outlined.
Develop Outreach Programs to Get Students to Seek Help
Many of the students at greatest risk on college campuses are those who are the most ambivalent about getting the care they need. Higher-education institutions are distinct communities in that they provide a broad range of services to their students—housing, dining, health care, and many others. That creates the opportunity to develop programs that encourage students to seek help. Boards can take an active role by offering leadership or promulgating financial support for such efforts, which often fall into two general categories.
The first category includes programs for faculty members, administrators, and students to help them actively encourage students to seek care and convey a message of hope about that care. At our institution we have developed a series of videos, “Notice & Respond,” which depicts professors, staff members, and others on our campus in various situations reaching out to upset or troubled students—contacting them and offering resources while acknowledging the ambivalence that is often involved in the process. We show the videos in faculty and staff meetings as well as at training sessions for resident and teaching assistants. Their primary purpose is to start a conversation about student mental health and how each member of the campus community can support it.
Another excellent program is “Campus Connect,” developed at Syracuse University. The program is experientially based and directed to staff members and students. Other institutions have used different programs to accomplish similar goals, such as “Kognito” (www.kognito.com), which offers interactive games and simulations, and “Question, Persuade, Refer” (QPR) (www.qprinstitute.com), which trains people specifically in suicide prevention.
Faculty members can also become more involved in student mental-health issues by infusing lessons about them into the curriculum of relevant courses. Actually discussing mental-health issues in the classroom can be an exceptional way to reduce the stigma surrounding them and to provide important educational information about topics like self-care and stress management. It can also help broaden the conversation about how everyone at the college or university can play a role in the mental health of those around them.
The second category involves special programs that reach out to students unwilling or unable to seek help. Many counseling services or student-affairs divisions are adding care managers to respond to students who are ambivalent or unwilling to receive the needed care or who require a level of care that goes beyond outpatient counseling. Boards can support such efforts by encouraging the funding of positions with these responsibilities.
For example, at Cornell, we have developed a program, “Community Consultation and Intervention,” that views the entire university community as the client. The program’s staff members develop relationships with key campus partners—like academic advisors, faculty members, and residence-life staff members—and assist them through consultation, training, advocating for students, and case-management services. They also intervene in crisis situations.
Another program at Cornell that seeks to lower barriers and provide immediate support is “Let’s Talk.” Adapted by 17 other colleges and universities, it gives students immediate access to a counselor at various locations across the campus. The service, which is free, can be anonymous for a student’s initial visits.
The University of Michigan at Ann Arbor has also developed several effective outreach programs including the “Do Something” campaign—a large-scale mental-healthawareness campaign that focuses on students helping themselves and their peers. They have also developed “MiTalk,” an interactive multimedia Web site focused on mental-health issues and developed exclusively for Michigan students.
Create Structures that Coordinate Student Support
Often different offices on a campus work with students with mental-health issues without communicating with each other. To overcome that situation, colleges and universities have established different types of administrative structures or ad hoc teams. Such teams operate under a variety of names: student-of-concern teams, behavioral-intervention teams, threat-assessment teams, and so on. In fact, today more than 85 percent of counseling-center directors report having some type of team that examines threats, provides behavioral interventions, or offers students support, according to AUCCCD’s 2010 survey. Some states, like Illinois and Virginia, require colleges and universities to have such teams in response to tragedies that have occurred there.
Board members should realize that these types of teams are becoming more of a standard of practice and be aware of any state legislation requiring them. Boards should also support their institution’s administrators financially and politically as those administrators develop and modify such teams. And if an institution does not have a team to coordinate student support and response, the board should call for the development of one.
Attend to the Physical Environment of the Campus and Surrounding Community
This final strategy is often overlooked and difficult to carry out, but it is also essential. A major component of preventing suicide is to decrease student access to a lethal means of completing it. On most campuses, that means restricting access to high places (such as rooftops, windows, and balconies); prohibiting firearms or offering lockers for gun owners to store their firearms; and closely tracking, monitoring, and controlling access to toxic substances found in laboratories, pharmacies, and other departments.
At Cornell, we have focused on erecting barriers on many of the bridges and gorge edges that surround our campus. We decided it was crucial to do so after three students jumped to their deaths within a month of each other from one of those areas. It was a necessary step as part of a comprehensive response to suicide prevention, and it required the understanding and support of our trustees. At other campuses, such efforts have focused on limiting roof access to tall buildings or constructing barriers in places where multiple suicides have occurred. New York University is one example, where plexiglass barriers were erected in the tower of Bobst Library after several suicides.
It’s also important to assess the physical environment of the campus and that of the surrounding community when it comes to student access to alcohol. I’ve noted before how alcohol abuse can result from emotional discomfort and lead to thoughts of and attempts at suicide. What’s more, accidents where alcohol is involved account for a significant number of accidental student deaths across the country. For example, United Educators reported in 2010 that, of 16 student deaths related to slips and falls, 11 involved alcohol consumption.
One way a college or university can increase safety is by examining the density of alcohol outlets on the campus or surrounding it, such as clusters of Greek housing or bars, that may elevate risk. It’s also important to ensure that the institution has established guidelines for transporting an intoxicated student or a student who may have overdosed to a close hospital.
Many of these steps—such as limiting access to firearms or changing especially popular aspects of the campus’s physical landscape—can be controversial. They require the broad-based support of the board of trustees.
The five strategies that I’ve outlined provide a foundation for college and university boards to continue the discussion about mental-health issues on their campuses and the relationship of student mental health to the academic mission of their institutions. Our students will continue to confront these issues—and probably in growing numbers. Boards should understand the relevant concerns and how they apply to their particular college or university.
How Penn State and Its Board Work to Advance Student Mental Health
The health and wellness needs of students are front and center at The Pennsylvania State University. It is home to the Center for Collegiate Mental Health, which brings together 140 college counseling centers and key partners in business and health care to study student mentalhealth issues. In addition, the university’s Counseling and Psychological Services (CAPS) has created a number of initiatives to serve students and deal with the challenges of finding and reaching out to those who may experience pathology and distress. It has established:
• Workshops for faculty and staff members to help them identify and refer students of concern to CAPS. It has also created an interactive Web site designed to educate people at the university about how to cope with students who exhibit potentially disruptive behavior.
• A university response team, consisting of representatives from student affairs, campus police, the university health service, judicial affairs, and undergraduate education. The aim of the team is to identify as early as possible students who might be experiencing mental or psychological stress.
• Various programs that encourage positive mental health among students, eliminate stigma and misunderstandings about mental health, and alert them to warning signs of mental-health concerns. For example, CAPS offers online videos, resources, and educational programs designed to help faculty and staff members recognize and respond to students in distress, as well as outreach workshops to deal with issues like eating disorders and stress management.
• Enhanced services in a new Student Health Center. Every student who seeks help joins one of four multidisciplinary teams, each operating like a small group practice, to better support that student on his or her first visit and any return visits.Campus administrators keep the board of trustees abreast of emerging issues and activities regarding student mental health through regular reports to the Committee on Campus Environment and the full board. As Steve A. Garban, chair of the board notes, “Penn State’s board of trustees has had a long and productive relationship with the entire division of student affairs. We enjoy regular formal presentations at the board meetings on health issues, which include updates on initiatives for improved mental-health services.”
“Today’s students face a myriad of pressures—financial, socioeconomic, academic and family-related—and we are committed to providing students with the services they need to succeed at Penn State and beyond,” Garban adds. “As a student-centered university, student health is a top priority and therefore a focal point for the board.”
For more on this topic, listen to the podcast with Gregory T. Eells.
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