Arcadio Morales, one of six residence deans at Stanford University, has lived in an apartment in the campus dorms for 15 years, often fielding late-night phone calls from students about everything from Frisbee injuries to mid-term anxiety to alcohol poisoning. He says some arriving freshmen have always packed emotional baggage along with their laptops and books. But the mix of problems he's called to weigh in on has become more serious in recent years.
"Early on," he says, "most of the issues that surfaced were roommate issues, compatibility issues." He still gets that sort of thing, along with the calls from "very involved" parents who want him, for example, to go down the hall and wake up their son or daughter. But these days, Morales is getting more calls about students in need of substantial psychiatric support.
"We're getting students that wouldn't have been here 10 years ago," Morales says, "because they're on antidepressants or antipsychotic medication, and they're functioning fairly well." But it can be a big challenge for colleges when these students have crises, he says.
National epidemiological studies confirm that what Morales is seeing is happening on campuses nationwide, irrespective of the type of college or its size.
"Institutions are faced with several concurrent issues," says Daphne C. Watkins, a researcher at the University of Michigan School of Social Work who has been studying mental health issues on campus. "First, there are increasing numbers of students with increasingly severe emotional problems. Second, students — and the families of these students — look primarily to colleges and universities to provide mental health and other supportive services for their students. And finally, budgetary cutbacks at these institutions make the growth and advancement of campus mental health services very difficult."
Who Do You Call?
Some of the sorts of crises that colleges are increasingly called to handle are hard on any school — and any student. Amanda Gelender, now a successful Stanford senior, with many academic and public service awards to her credit, also has bipolar disorder. Her symptoms are mostly evened out with medication. But two years ago, the drug she had been prescribed seemed to stop working for a time, and her depression came roaring back. She remembers the night in the dorm when the bottom fell out, and she called a family member.
"I was in hysterical tears," she says. "I was making remarks (like), 'What's the point?' You know, things a depressed person would say."
Gelender says she was very sad, but certainly not suicidal. She just needed to vent. And after that, she hung up the phone and went to sleep. She had no idea that her family was worried enough after talking with her to call 911.
"And about an hour later, there's banging on my door," Gelender remembers. "I go to the door, and there's two armed police who barge in, [saying] 'Where are your pills? Where are your pills?'" The officers ransacked her room, she says. They searched her shelves and combed through drawers, all the while yelling a steady stream of questions.
"I'm half-naked," she remembers. "I'm dressed for bed, and you know, they're like, 'Are you going to kill yourself? Are you going to kill yourself?' And I'm just like, 'No. I'm not going to kill myself.' And they're threatening to take me to the psych ward, and they've got their handcuffs in their hands. I don't know what you say to convince someone that you're not going to kill yourself besides, 'No. I'm not going to kill myself.'"
The police phoned the psychiatrist on-call, and after some back and forth, they left. But the whole experience left Gelender horribly shaken. She understands that the police were following protocol in dealing with what they thought might be a suicide threat. And she doesn't blame her family; they just wanted to keep her safe.
"But that's the option that loved ones have," Gelender says. "If they fear for someone, they have to call the police, and they have to induce this whole mess."
Of course figuring out who is a risk to themselves and who is not isn't easy for anyone. One of Aracadio Morales' duties is to help train student resident advisers in the dorm. He says he instructs them to always err on the side of safety. "It's better to have someone angry and alive," he says, "than dead and dead."
Everyone involved agrees that it would be much better to intervene long before that sort of crisis develops. All across the United States, concerned colleges students and parents are trying to do just that. Earlier this year. Amanda Gelender started a theater project to bring mental illness into the light.
And down the street from Stanford, a former Palo Alto mayor and his wife — Vic and Mary Ojakian — became mental health advocates after their youngest son Adam died by suicide during his senior year at the University of California, Davis in 2004.
"We determined that he became very anxious due to a certain situation — what's called a triggering event," says Mary Ojakian. "It was ultimately severe depression that caused his death."
In retrospect, there might have been a few subtle behavioral clues, but none of Adam Ojakian's friends, family or others close to him recognized the depression before he died, Mary Ojakian says. "He had not been diagnosed with mental illness," she says. "He did not take drugs. He was a good student. He wasn't aware he was sick. He wasn't saying anything."
After Adam died, his parents interviewed his friends, people in the counseling center, police, professors — even the chancellor. And that's when they first learned about the shortage of therapists on college campuses. and about how little training most faculty and even first-responders get in how to recognize and handle mentally ill students.
"We realized — and they realized — that there was a lot that could be done to change the situation on campus," says Mary Ojakian.
The situation at colleges all across the country makes Vic Ojakian angry. "What's going on right now isn't acceptable," he says. "We took a look at our situation and we said to ourselves, "We don't want another good human being dying. We decided to do something about that — not to sit back, not to do another study. We decided we were going to go out and save lives." Mary Ojakian is emphatic, too. "Someone's got to draw the line," she says. The two have been lobbying colleges up and down the state of California to invest in more and better mental health services for students.
Strengthening Safety Nets
Someone else has drawn the line — or at least tried to. The International Association of Counseling Services (ICACS) sets the standards for mental health services, and it recommends that in order to keep students safe and healthy, a college campus should have a minimum of one therapist for every 1,000 to 1,500 students. When a school falls significantly short of that — and many colleges do — the wait-lists for students seeking help can stretch to a month or more.
In one recent study, students who got stuck on a long wait list were 14 percent more likely to drop out than those who got timely counseling.
When there aren't enough therapists, students with less severe problems suffer, too, the experts say.
"Students in crisis tend to get the greater share of limited resources, resulting in less assistance to other students who are not so acute but who are dealing with more 'traditional' adjustment and developmental disorders," according to an ICACS position paper. "These students may fall through the cracks."
By hiring six new therapists last year, Stanford brought its ratio closer to one therapist per thousand students. It also introduced a new system to triage phone calls so that the students who are most needy get in to see a counselor right away. And all callers at least talk by phone with a therapist within a day. Dr. Ron Albucher, a psychiatrist, was hired to head the counseling center, partly in recognition of the increasing number of students in therapy who are also on medication that may need adjustments or monitoring.
"Even with that many counselors, we're still incredibly busy," Albucher says. "And one of the consequences of having students with more severe illness on campus is that we recognize we're not a psychiatric facility. We can't provide 24-hour coverage for students in the dorms." Most of those who want or need long-term counseling — beyond a few sessions — are referred to therapists off-campus.
A Critical Time
When Stanford's endowment took a big hit last year and the school had to cut its budget, it largely spared the counseling center. Stanford did add a new health fee for all students — about $500 a year — with much of that money going to support mental health services.
But not every college has the same resources. Daniel Eisenberg, a mental health researcher at the University of Michigan, says that in these very tight financial times, many universities and colleges — large and small — are feeling forced to make tough choices.
"Part of the tension is that campuses see their central mission as education," Eisenberg says. "So I think there is sometimes a question about whether mental health really fits into that central mission."
Vic and Mary Ojakian, whose son died in the midst of a deep depression, think society doesn't have a choice given the statistics: Half of all cases of mental illness first show up in the early teen years; and 75 percent are present by age 24. College is a prime time to intervene and get these kids on a healthy path, they say.
Some big fixes will indeed cost big money, Vic Ojakian says. But others — such as peer support groups and a basic Web site that at least points students to other telephone and online mental health resources — are cheap enough that even the most financially strapped colleges should have them in place.
"Parents [of high school seniors] need to look at a college not just in terms of its academic credentials," he says. "Ask what sort of mental health services they have." The Ojakians were particularly dismayed as they began their work to learn that some schools have no counseling center and no mental health services at all. Ask schools about their therapist-to-student ratio, he says, and about what the institution does for students who have mental health problems after-hours. And although many people think about freshmen as the most vulnerable group on campus, studies show that college seniors and graduate students are at least as much in need of psychological support.
Amanda Gelender, who was so depressed two years ago, says strong support from friends, family and her doctor, along with a change in her medication, were all crucial to helping her get back on track.
"Every day's a struggle," she says. "But I have more hope. I'm applying to a lot of post-graduate programs, and I'm actually excited about my future."