December 19, 2010
STONY BROOK, N.Y. — Rushing a student to a psychiatric emergency room is never routine, but when Stony Brook University logged three trips in three days, it did not surprise Jenny Hwang, the director of counseling.
It was deep into the fall semester, a time of mounting stress with finals looming and the holiday break not far off, an anxiety all its own.
On a Thursday afternoon, a freshman who had been scraping bottom academically posted thoughts about suicide on Facebook. If I were gone, he wrote, would anybody notice? An alarmed student told staff members in the dorm, who called Dr. Hwang after hours, who contacted the campus police. Officers escorted the student to the county psychiatric hospital.
There were two more runs over that weekend, including one late Saturday night when a student grew concerned that a friend with a prescription for Xanax, the anti-anxiety drug, had swallowed a fistful.
On Sunday, a supervisor of residence halls, Gina Vanacore, sent a BlackBerry update to Dr. Hwang, who has championed programs to train students and staff members to intervene to prevent suicide.
“If you weren’t so good at getting this bystander stuff out there,” Ms. Vanacore wrote in mock exasperation, “we could sleep on the weekends.”
Stony Brook is typical of American colleges and universities these days, where national surveys show that nearly half of the students who visit counseling centers are coping with serious mental illness, more than double the rate a decade ago. More students take psychiatric medication, and there are more emergencies requiring immediate action.
“It’s so different from how people might stereotype the concept of college counseling, or back in the ’70s students coming in with existential crises: who am I?” said Dr. Hwang, whose staff of 29 includes psychiatrists, clinical psychologists and social workers. “Now they’re bringing in life stories involving extensive trauma, a history of serious mental illness, eating disorders, self-injury, alcohol and other drug use.”
Experts say the trend is partly linked to effective psychotropic drugs (Wellbutrin for depression, Adderall for attention disorder, Abilify for bipolar disorder) that have allowed students to attend college who otherwise might not have functioned in a campus setting.
There is also greater awareness of traumas scarcely recognized a generation ago and a willingness to seek help for those problems, including bulimia, self-cutting and childhood sexual abuse.
The need to help this troubled population has forced campus mental health centers — whose staffs, on average, have not grown in proportion to student enrollment in 15 years — to take extraordinary measures to make do. Some have hospital-style triage units to rank the acuity of students who cross their thresholds. Others have waiting lists for treatment — sometimes weeks long — and limit the number of therapy sessions.
Some centers have time only to “treat students for a crisis, bandaging them up and sending them out,” said Denise Hayes, the president of the Association for University and College Counseling Center Directors and the director of counseling at the Claremont Colleges in California.
“It’s very stressful for the counselors,” she said. “It doesn’t feel like why you got into college counseling.”
A recent survey by the American College Counseling Association found that a majority of students seek help for normal post-adolescent trouble like romantic heartbreak and identity crises. But 44 percent in counseling have severe psychological disorders, up from 16 percent in 2000, and 24 percent are on psychiatric medication, up from 17 percent a decade ago.
The most common disorders today: depression, anxiety, suicidal thoughts, alcohol abuse, attention disorders, self-injury and eating disorders.
Stony Brook, an academically demanding branch of the State University of New York (its admission rate is 40 percent), faces the mental health challenges typical of a big public university. It has 9,500 resident students and 15,000 who commute from off-campus. The highly diverse student body includes many who are the first in their families to attend college and carry intense pressure to succeed, often in engineering or the sciences. A Black Women and Trauma therapy group last semester included participants from Africa, suffering post-traumatic stress disorder from violence in their youth.
Stony Brook has seen a sharp increase in demand for counseling — 1,311 students began treatment during the past academic year, a rise of 21 percent from a year earlier. At the same time, budget pressures from New York State have forced a 15 percent cut in mental health services over three years.
Dr. Hwang, a clinical psychologist who became director in July 2009, has dealt with the squeeze by limiting counseling sessions to 10 per student and referring some, especially those needing long-term treatment for eating disorders or schizophrenia, to off-campus providers.
But she has resisted the pressure to offer only referrals. By managing counselors’ workloads, the center can accept as many as 60 new clients a week in peak demand between October and the winter break.
“By this point in the semester to not lose hope or get jaded about the work, it can be a challenge,” Dr. Hwang said. “By the end of the day, I go home so adrenalized that even though I’m exhausted it will take me hours to fall asleep.”
For relief, she plays with her 2-year-old daughter, and she has taken up the guitar again.
Shifting to Triage
Near the student union in the heart of campus, the Student Health Center building dates from the days when a serious undergraduate health problem was mononucleosis. But the hiring of Judy Esposito, a social worker with experience counseling Sept. 11 widows, to start a triage unit three years ago was a sign of the new reality in student mental health.
At 9 a.m. on the Tuesday after the campus’s very busy weekend, Ms. Esposito had just passed the Purell dispenser by the entrance when she noticed two colleagues hurrying toward her office. Before she had taken off her coat, they were updating her about a junior who had come in the previous week after cutting herself and expressing suicidal thoughts.
Ms. Esposito’s triage team fields 15 to 20 requests for help a day. After brief interviews, most students are scheduled for a longer appointment with a psychologist, which leads to individual treatment. The one in six who do not become patients are referred to other university departments like academic advising, or to off-campus therapists if long-term help is needed. There are no charges for on-campus counseling.
This day the walk-ins included a young man complaining of feeling friendless and depressed. Another student said he was struggling academically, feared that his parents would find out and was drinking and feeling hopeless.
Professionals in a mental health center are mindful of their own well-being. For this reason the staff had planned a potluck holiday lunch. While a turkey roasted in the kitchen that serves as the break room, Ms. Esposito helped warm up candied yams, stuffing and the store-bought quiche that was her own contribution.
Just then Regina Frontino, the triage assistant who greets walk-ins at the front desk, swept into the kitchen to say a student had been led in by a friend who feared that she was suicidal.
Ms. Esposito rushed to the lobby. From a brief conversation, she knew that the distraught student would have to go to the hospital. The counseling center does not have the ability to admit suicidal or psychotic students overnight for observation or to administer powerful drugs to calm them. It arranges for them to be taken to the Stony Brook University Medical Center, on the far side of the 1,000-acre campus. The hospital has a 24-hour psychiatric emergency room that serves all of Suffolk County.
“They’re not going to fix what’s going on,” Ms. Esposito said, “but in that moment we can ensure she’s safe.” She called Tracy Thomas, an on-call counselor, to calm the student, who was crying intermittently, while she phoned the emergency room and informed Dr. Hwang, who called the campus police to transport the young woman.
When Ms. Esposito heard the crackle of police radios in the hallway, she went to tell the student for the first time that she would have to go to the hospital.
“This is not something students love to do,” Ms. Esposito recounted. The young woman told her she did not want to go. Ms. Esposito replied that the staff was worried for her safety, and she repeated the conversation she had had earlier with the young woman:
Are you having thoughts about wanting to die?
Are you afraid you are actually going to kill yourself?
She invited a police officer into the counseling room, and the student teared up again at the sight of him. Ms. Esposito assured her that she was not in trouble. Meanwhile, an ambulance crew arrived with a rolling stretcher, but the young woman walked out on her own with the officers.
Because Ms. Thomas, a predoctoral intern in psychology, now needed to regain her own equilibrium before seeing other clients, Ms. Esposito debriefed her about what had just happened.
Finally she returned to her office, having missed the holiday lunch, and found that her team had prepared a plate for her.
“It’s kind of like firemen,” she said. “When the fire’s on, we are just at it. But once the fire’s out, we can go back to the house and eat together and laugh.”
Even though the appointment books of Stony Brook counselors are filled, all national evidence suggests that vastly more students need mental health services.
Forty-six percent of college students said they felt “things were hopeless” at least once in the previous 12 months, and nearly a third had been so depressed that it was difficult to function, according to a 2009 survey by the American College Health Association.
Then there is this: Of 133 student suicides reported in the American College Counseling Association’s survey of 320 institutions last year, fewer than 20 had sought help on campus.
Alexandria Imperato, 23, remembers that as a Stony Brook freshman all her high school friends were talking about how great a time they were having in college, while she felt miserable. She faced family issues and the pressure of adjusting to college. “You go home to Thanksgiving dinner, and the family asks your brother how is his gerbil, and they ask you, ‘What are doing with the rest of your life?’ ” Ms. Imperato said.
She learned she had clinical depression. She eventually conquered it with psychotherapy, Cymbalta and lithium. She went on to form a Stony Brook chapter of Active Minds, a national campus-based suicide-prevention group.
“I knew how much better it made me feel to find others,” said Ms. Imperato, who plans to be a nurse.
On recent day, she was one of two dozen volunteers in black T-shirts reading “Chill” who stopped passers-by in the Student Activities Center during lunch hour.
“Would you like to take a depression screening?” they asked, offering a clipboard with a one-page form to all who unplugged their ear buds. Students checked boxes if they had difficulty sleeping, felt hopeless or “had feelings of worthlessness.” They were offered a chance to speak privately with a psychologist in a nearby office. Sixteen said yes.
The depression screenings are part of a program to enlist students to monitor the mental health of peers, which is run by the four-year-old Center for Outreach and Prevention, a division of mental health services that Dr. Hwang oversaw before her promotion to director of all counseling services.
She is committed to outreach in its many forms, including educating dormitory staff members to recognize students in distress and encouraging professors to report disruptive behavior in class.
In previous years, more than 1,000 depression screenings were given to students, with 22 percent indicating signs of major depression. Dr. Hwang credits that and other outreach efforts to the swell of new cases for counseling. “For a lot of people it’s terrifying” to come to the counseling center, she said. “If there’s anything we can do to make it easier to walk in, I feel like we owe it to them.”
Stony Brook has not had a student suicide since spring 2009, unusual for a campus its size. But Dr. Hwang is haunted by the impact on the campus of several off-campus student deaths in accidents and a homicide in the past year. “With every vigil, with every conversation with someone in pain, there’s this overwhelming sense of we need to learn something,” she said. “I think about these parents who’ve invested so much into getting their kids alive to 18.”
One student who said yes to an impromptu interview with a counselor after filling out a depression screening was a psychology major, a senior from upstate New York. As it happened, Dr. Hwang had wandered over from the counseling center to check on the screenings, and the young woman spent a long time conferring with her, never removing her checked coat or backpack.
“I don’t have motivation for things anymore,” the student said afterward. “This place just depresses me the whole time.”
She had been unaware that students could walk in unannounced to the counseling center. “I thought you had to make an appointment,” she said. “Yes,” she said, “I’ll do that.”