Good Mental Health Care Requires Student Initiative

The game of chance was supposed to end with Harvard's letter of admission. But for students coping with personal problems--from dealing with a breakup to suffering from serious mental illness--the University's resources benefit only the "aggressive" or those who are lucky enough to find a tutor who cares, a teaching fellow who notices or a therapist who is available.

Each year, one or two students commit suicide at the College, and although that matches the national average, friends and classmates are left wondering how no one noticed.

But while the 1995 Dunster House murder-suicide may have prompted some reforms of an unwieldy counseling system, some tutors and health professionals say the House advising system remains deeply flawed, relying on a premise the College knows is unreliable: that students in trouble generally route themselves toward help.

Harvard may tout itself as a breeding ground for independence, but coping with mental health is not effective as an exercise in self-reliance.

Please Hold

It may take weeks to get an appointment at University Health Services (UHS), and when students do, they may find themselves alienated by UHS's version of managed care.

Dean of Students Archie C. Epps III, while not officially a resource in the University's mental health care network, says students and parents sometimes turn to him when they are not making progress within the system.

"They need an advocate because the system is not working well," says Epps, who likens himself to a shepherd. Student in tow, Epps often bypasses "the complicated bureaucracy" that impedes access to UHS therapists. With Epps' help, students can often see "the best care in Boston" without waiting up to three weeks for an appointment.

"Ideally, I shouldn't have to do that," he says.

Dr. David S. Rosenthal '59, director of UHS, says Epps' intervention is not necessary.

"When students call, they get right in," emphasizes Rosenthal, adding that "aggressive" students can secure "same day emergency visits."

But such a system assumes students can conduct a self-diagnosis, and that students-- many of whom have already taken great stridesin simply calling for help--will be willing tocharacterize their situations as requiring"urgent" care.

Dr. Randolph Catlin Jr., outgoing chief ofmental health services at UHS, says his departmenttries to train receptionists to ask studentswhether they need help immediately, or whether thehelp can wait. Catlin admits that this is not afoolproof plan, as the system relies on thestudents to take the initiative.

Even if a student does take that next step andsolicits urgent attention, Nadja B. Gould, aclinical social worker at UHS, says appointmentscan be limited.

Mental health services offers urgent care foran hour at 9:30 a.m., 12:30 p.m. and 3:30 p.m.While students can see a therapist on a walk-inbasis at these times, they are not assured a fullhour appointment, Gould says, because otherstudents might be waiting.

Patients can schedule a follow-up appointmentfor further treatment, but that sets them on theroller-coaster ride of UHS managed care: busytherapists and an emphasis on diagnosis.

UHS qua HMO

Recognized by peer counselors, administratorsand fellow counselors as one of the most effectivetherapists at UHS, Gould is also one of thebusiest.

In addition to her regular duties as a clinicalsocial worker and therapist, Gould supervises fiveof the College's peer counseling groups, is thefirst person on call for rape crisis situations,supervises pregnancy counseling and the AIDSsupport group as well as teaches medical studentsand oversees psychiatry students.

"It's difficult when students call or e-mailme," Gould says. "Right now, I'm booking for theend of June."

UHS mental services saw 12 percent of theUniversity's students--at 26,000appointments--last academic year.

Dr. Richard D. Kadison, the new chief of mentalhealth services at UHS, says every student whowants an appointment gets one. To accomplishthis--and manage costs--UHS has established agradient of care.

Students with less pressing needs get shorterappointments, and UHS recommends that manystudents who cope with similar long-term problemspursue group therapy, instead of individual visitswith UHS doctors.

Though he describes group therapy as "verypowerful," Kadison says managed care and studentservices mix "like oil and water."

"The more accessibility, the more flexibility,the better your mental health services," Catlinsays. "[But] there are limitations because of theneed to maintain a managed structure--there has tobe cost containment."

Limited accessibility is not the only problemstudents face when dealing with the UHSmanaged-care behemoth; because they are a medicalservice, many health professionals say UHS has todiagnose students, stamping their file with someclassification.

"We try to work around that problem," saysCatlin, who works to find the "least troublesome"label--"adjustment reaction" rather than "neuroticcondition."

Catlin acknowledges that his office oftendiagnoses a problem "when all they're doing isgrowing up."

Holes in the House

The problem of mental health care at Harvardbegins long before the first appointment, however.Most students visit UHS on referrals, not entirelyon their own, making House tutors and teachingfellows (TFs) the first line of defense.

But it is a line with cracks.

Resident tutors, the foot soldiers of the Houseadvising system, must juggle their classes, jobsand lives with knowing 20 to 40 students wellenough to detect early warning signs ofdepression, eating disorders or substance abuse.

Julia S. Rubin '84, a resident tutor in QuincyHouse for the past six and a half years, saystutors are often too consumed by their ownambitions to concentrate on advising.

"The Houses select graduate students who are inthe midst of high powered careers or in the midstof establishing high-powered careers," Rubin says.

Moreover, she says the University seemsindifferent to tutors who fail to do their jobs.

"You practically have to slap the House in theface with not doing your job [before they let yougo]," Rubin says.

Matters are made worse, tutors say, by thequality of training tutors receive during atwo-day orientation in September and monthlyCollege-wide tutor meetings during theyear--mandatory meetings which arepoorly-attended.

The plan for next year: those meetings willlikely only be held two or three times a yearstarting in the fall, according to Thomas A.Dingman '67, associate dean of the House system.

Administrators are wary of giving tutors themisimpression that training--be it a week or aday--makes them qualified mental healthcounselors.

But Rubin says if administrators want tutors toact as the first line of defense, they shouldsponsor a more extensive orientation, similar tothe Freshman Dean's Office week-long proctortraining program.

"You need people who can deal with a variety ofindividuals in a pressure-filled situation" sheadds. "I don't think a 24-year-old graduatestudent is necessarily equipped to do thatalways."

Added to this are conflicting messages from theadministration, which maintains there aresituations where tutors should intervene but isnot particularly clear when that time is.

Dean of the College Harry R. Lewis '68 saystutors should not be "diagnosticians."

"The standards of normalcy at Harvard are verybroad," Lewis says. "To what extent do studentswant the College to be negligent or to what extentdo we end up with a Big Brother phenomenon?"

This range of advising possibilities leavesmany tutors unsure of the extent they are expectedto intervene.

Identifying problems "is part of your job, butis an ill-defined part of your job," concludesMark A.J. Taylor, a four-year Winthrop Houseresident tutor. "It is not something you arealways qualified to do."

Lewis and Dingman are working to "clarify" therole of the resident tutor by drafting a "commontext" as a guideline.

But while College administrators are spendingtheir time drafting a document which many sayoutlines the most obvious of duties--like takingmeals in the House dining hall and attending Housefunctions--the most difficult part oftutoring--recognizing students with problems,remains unchanged.

"There are students who aren't strugglingacademically but have emotional and personalissues," says Anne M. Joseph, a two-year QuincyHouse tutor.

Teaching The Fellows

Students spend more time each week in classwith TFs than with their resident tutors, andcounselors say one of the first signs of studentdistress is academic lethargy.

But scrutinizing the reasons behind a missedsection or a late paper raises the recurringquestion of what is too much intervention.

According to Dennis N. Skiotis, coordinator ofundergraduate studies of the history department,TFs "should notice a pattern" of problems.

After "two or three extensions and assignmentsare still not being turned in," a TF should reportthe incident to the head tutor, who then reportsproblems to the senior tutor--who is responsiblefor keeping track of reports concerning theHouse's 400 to 500 students.

"At that point, the House senior tutor carriesthe ball," he adds. "The senior tutor is[technically] the one who lives with and knows astudent as a person, although I kind of doubt thatmyself."

Susumu Kuno, head tutor of the linguisticsdepartment, says the size of his concentrationaffords his 25 undergraduates extra attention.

Yet Kuno says the support only goes so far--andcasual contact is different from officialintervention, which goes through the House seniortutor's office.

"We cannot take any legal responsibility forchecking how students are doing," Kuno says. "Idon't think it should be a full responsibility. Wecan't. We just don't have the manpower. The Housesystem is designed to do that. They have the staffand the specialists."

Departments do often try to equip their tutorsand teaching fellows with proper preparation forclassroom crises by holding retreats to discussstudent problems, others send TFs for training atthe Derek Bok Center.

But only half of the College's TFs go to theBok Center, and the Center's extensive teachingfellow handbook emphasizes TF accessibility, notoutreach.

"If a student comes to you with a personal oremotional problem, you may decide to be asupportive listener even if you do not want togive advice," the handbook reads.

In cases of emotional problems, it is up to TFsto decide to listen, advise or steer clear oftroubled students.

An Alternative

Between lack of interest and superficialtraining, having a tutor or TF who is cognizant ofa students' problems is contingent at best,unlikely at worst.

But whether it is a College official or thestudent who expresses concern about the student'slife, the next step is a referral to trainedcounselors.

While recognizing that it is a necessary partof any medical approach to mental health, Kadisonbemoans a system of counseling where there is "anemphasis on pathologizing emotional problems."

A warm, welcoming living room--complete withfireplace--is "more user-friendly," Catlin says,making "the Bureau of Study Counsel a very goodpsychotherapy center."

Dr. Charles P. Ducey, director of the Bureau ofStudy Counsel (BSC), says his organization has aneasier time meeting the emotional needs of itsstudents.

Ducey says more than 50 percent of BSC'svisitors enter on their own volition--without areferral.

"The fact of the matter is that we have alwaysbeen more accessible. We do not quickly label.Students feel like, `They don't label me here,'"Ducey says.

Dealing with student needs on a human--notclinical--level help Ducey and his staff unearththe emotional problems that often underlie theacademic issues that prompted the initial visit.

"We're not here to tell you what to do," Duceysays. "We're here to resolve interferences so youcan enjoy your life."

But while homey, the BSC is not equipped tohandle long-term care, and, more significantly, itis not open to graduate students, who this yearhave vigorously protested inadequate advising inthe wake of two suicides of their peers.

Making House Calls

The sterility of UHS and the uncheckeddisinterest of many House tutors suggests asolution that combines training with comfort:bringing professionals into the Houses.

UHS is now trying to emulate its low-keycounterpart to the extent a managed care systemwill allow, giving doctors "credit" for hoursspent outside the office and inside residentialHouses.

It is important to "figure out more ways formental health services to spend more time withpeople in the House," says Catlin, who agrees withDucey's belief that "tutors are not designated asmental health watchdogs."

Rubin would like to see moreprofessionally-trained mental health specialistsworking as resident tutors as a way to increaseaccountability and their commitment to thestudents.

"People aren't held fully accountable. Housesare reluctant to let a tutor go," she says.

By chance, two licensed psychologists areliving in Leverett House, to whom tutors andstudents turn.

The doctors advise administrators how to handledelicate situations and refer students to outsidecare.

Hopefully, this system will prevent anotherDunster House, 1995.

"We want to be proactive, not reactive," saysJohn E. Dowling '57, outgoing master of LeverettHouse. "We want to solve problems before theybecome real problems."

Dowling says, "They will not treat, but theywill talk"--more than what is available in mostHouses.Paul S. Gutman, IllustrationJoshua H. Simon

Dr. Randolph Catlin Jr., outgoing chief ofmental health services at UHS, says his departmenttries to train receptionists to ask studentswhether they need help immediately, or whether thehelp can wait. Catlin admits that this is not afoolproof plan, as the system relies on thestudents to take the initiative.

Even if a student does take that next step andsolicits urgent attention, Nadja B. Gould, aclinical social worker at UHS, says appointmentscan be limited.

Mental health services offers urgent care foran hour at 9:30 a.m., 12:30 p.m. and 3:30 p.m.While students can see a therapist on a walk-inbasis at these times, they are not assured a fullhour appointment, Gould says, because otherstudents might be waiting.

Patients can schedule a follow-up appointmentfor further treatment, but that sets them on theroller-coaster ride of UHS managed care: busytherapists and an emphasis on diagnosis.

UHS qua HMO

Recognized by peer counselors, administratorsand fellow counselors as one of the most effectivetherapists at UHS, Gould is also one of thebusiest.

In addition to her regular duties as a clinicalsocial worker and therapist, Gould supervises fiveof the College's peer counseling groups, is thefirst person on call for rape crisis situations,supervises pregnancy counseling and the AIDSsupport group as well as teaches medical studentsand oversees psychiatry students.

"It's difficult when students call or e-mailme," Gould says. "Right now, I'm booking for theend of June."

UHS mental services saw 12 percent of theUniversity's students--at 26,000appointments--last academic year.

Dr. Richard D. Kadison, the new chief of mentalhealth services at UHS, says every student whowants an appointment gets one. To accomplishthis--and manage costs--UHS has established agradient of care.

Students with less pressing needs get shorterappointments, and UHS recommends that manystudents who cope with similar long-term problemspursue group therapy, instead of individual visitswith UHS doctors.

Though he describes group therapy as "verypowerful," Kadison says managed care and studentservices mix "like oil and water."

"The more accessibility, the more flexibility,the better your mental health services," Catlinsays. "[But] there are limitations because of theneed to maintain a managed structure--there has tobe cost containment."

Limited accessibility is not the only problemstudents face when dealing with the UHSmanaged-care behemoth; because they are a medicalservice, many health professionals say UHS has todiagnose students, stamping their file with someclassification.

"We try to work around that problem," saysCatlin, who works to find the "least troublesome"label--"adjustment reaction" rather than "neuroticcondition."

Catlin acknowledges that his office oftendiagnoses a problem "when all they're doing isgrowing up."

Holes in the House

The problem of mental health care at Harvardbegins long before the first appointment, however.Most students visit UHS on referrals, not entirelyon their own, making House tutors and teachingfellows (TFs) the first line of defense.

But it is a line with cracks.

Resident tutors, the foot soldiers of the Houseadvising system, must juggle their classes, jobsand lives with knowing 20 to 40 students wellenough to detect early warning signs ofdepression, eating disorders or substance abuse.

Julia S. Rubin '84, a resident tutor in QuincyHouse for the past six and a half years, saystutors are often too consumed by their ownambitions to concentrate on advising.

"The Houses select graduate students who are inthe midst of high powered careers or in the midstof establishing high-powered careers," Rubin says.

Moreover, she says the University seemsindifferent to tutors who fail to do their jobs.

"You practically have to slap the House in theface with not doing your job [before they let yougo]," Rubin says.

Matters are made worse, tutors say, by thequality of training tutors receive during atwo-day orientation in September and monthlyCollege-wide tutor meetings during theyear--mandatory meetings which arepoorly-attended.

The plan for next year: those meetings willlikely only be held two or three times a yearstarting in the fall, according to Thomas A.Dingman '67, associate dean of the House system.

Administrators are wary of giving tutors themisimpression that training--be it a week or aday--makes them qualified mental healthcounselors.

But Rubin says if administrators want tutors toact as the first line of defense, they shouldsponsor a more extensive orientation, similar tothe Freshman Dean's Office week-long proctortraining program.

"You need people who can deal with a variety ofindividuals in a pressure-filled situation" sheadds. "I don't think a 24-year-old graduatestudent is necessarily equipped to do thatalways."

Added to this are conflicting messages from theadministration, which maintains there aresituations where tutors should intervene but isnot particularly clear when that time is.

Dean of the College Harry R. Lewis '68 saystutors should not be "diagnosticians."

"The standards of normalcy at Harvard are verybroad," Lewis says. "To what extent do studentswant the College to be negligent or to what extentdo we end up with a Big Brother phenomenon?"

This range of advising possibilities leavesmany tutors unsure of the extent they are expectedto intervene.

Identifying problems "is part of your job, butis an ill-defined part of your job," concludesMark A.J. Taylor, a four-year Winthrop Houseresident tutor. "It is not something you arealways qualified to do."

Lewis and Dingman are working to "clarify" therole of the resident tutor by drafting a "commontext" as a guideline.

But while College administrators are spendingtheir time drafting a document which many sayoutlines the most obvious of duties--like takingmeals in the House dining hall and attending Housefunctions--the most difficult part oftutoring--recognizing students with problems,remains unchanged.

"There are students who aren't strugglingacademically but have emotional and personalissues," says Anne M. Joseph, a two-year QuincyHouse tutor.

Teaching The Fellows

Students spend more time each week in classwith TFs than with their resident tutors, andcounselors say one of the first signs of studentdistress is academic lethargy.

But scrutinizing the reasons behind a missedsection or a late paper raises the recurringquestion of what is too much intervention.

According to Dennis N. Skiotis, coordinator ofundergraduate studies of the history department,TFs "should notice a pattern" of problems.

After "two or three extensions and assignmentsare still not being turned in," a TF should reportthe incident to the head tutor, who then reportsproblems to the senior tutor--who is responsiblefor keeping track of reports concerning theHouse's 400 to 500 students.

"At that point, the House senior tutor carriesthe ball," he adds. "The senior tutor is[technically] the one who lives with and knows astudent as a person, although I kind of doubt thatmyself."

Susumu Kuno, head tutor of the linguisticsdepartment, says the size of his concentrationaffords his 25 undergraduates extra attention.

Yet Kuno says the support only goes so far--andcasual contact is different from officialintervention, which goes through the House seniortutor's office.

"We cannot take any legal responsibility forchecking how students are doing," Kuno says. "Idon't think it should be a full responsibility. Wecan't. We just don't have the manpower. The Housesystem is designed to do that. They have the staffand the specialists."

Departments do often try to equip their tutorsand teaching fellows with proper preparation forclassroom crises by holding retreats to discussstudent problems, others send TFs for training atthe Derek Bok Center.

But only half of the College's TFs go to theBok Center, and the Center's extensive teachingfellow handbook emphasizes TF accessibility, notoutreach.

"If a student comes to you with a personal oremotional problem, you may decide to be asupportive listener even if you do not want togive advice," the handbook reads.

In cases of emotional problems, it is up to TFsto decide to listen, advise or steer clear oftroubled students.

An Alternative

Between lack of interest and superficialtraining, having a tutor or TF who is cognizant ofa students' problems is contingent at best,unlikely at worst.

But whether it is a College official or thestudent who expresses concern about the student'slife, the next step is a referral to trainedcounselors.

While recognizing that it is a necessary partof any medical approach to mental health, Kadisonbemoans a system of counseling where there is "anemphasis on pathologizing emotional problems."

A warm, welcoming living room--complete withfireplace--is "more user-friendly," Catlin says,making "the Bureau of Study Counsel a very goodpsychotherapy center."

Dr. Charles P. Ducey, director of the Bureau ofStudy Counsel (BSC), says his organization has aneasier time meeting the emotional needs of itsstudents.

Ducey says more than 50 percent of BSC'svisitors enter on their own volition--without areferral.

"The fact of the matter is that we have alwaysbeen more accessible. We do not quickly label.Students feel like, `They don't label me here,'"Ducey says.

Dealing with student needs on a human--notclinical--level help Ducey and his staff unearththe emotional problems that often underlie theacademic issues that prompted the initial visit.

"We're not here to tell you what to do," Duceysays. "We're here to resolve interferences so youcan enjoy your life."

But while homey, the BSC is not equipped tohandle long-term care, and, more significantly, itis not open to graduate students, who this yearhave vigorously protested inadequate advising inthe wake of two suicides of their peers.

Making House Calls

The sterility of UHS and the uncheckeddisinterest of many House tutors suggests asolution that combines training with comfort:bringing professionals into the Houses.

UHS is now trying to emulate its low-keycounterpart to the extent a managed care systemwill allow, giving doctors "credit" for hoursspent outside the office and inside residentialHouses.

It is important to "figure out more ways formental health services to spend more time withpeople in the House," says Catlin, who agrees withDucey's belief that "tutors are not designated asmental health watchdogs."

Rubin would like to see moreprofessionally-trained mental health specialistsworking as resident tutors as a way to increaseaccountability and their commitment to thestudents.

"People aren't held fully accountable. Housesare reluctant to let a tutor go," she says.

By chance, two licensed psychologists areliving in Leverett House, to whom tutors andstudents turn.

The doctors advise administrators how to handledelicate situations and refer students to outsidecare.

Hopefully, this system will prevent anotherDunster House, 1995.

"We want to be proactive, not reactive," saysJohn E. Dowling '57, outgoing master of LeverettHouse. "We want to solve problems before theybecome real problems."

Dowling says, "They will not treat, but theywill talk"--more than what is available in mostHouses.Paul S. Gutman, IllustrationJoshua H. Simon