Hard Choices

In February of her first year at Harvard, "Melissa" realized that something was wrong. She couldn't get her work done. She couldn't even leave her room.

Her friends convinced her to visit Room 13, a peer counseling group. But sitting on the cozy couches in the Grays basement was not the therapy she needed.

"I actually felt more helpless," she says. "They were nice, but they didn't know me."

It took some coaxing, but her friends persuaded her to set up an appointment with the mental health clinicians at University Health Services (UHS).

They offered her a pill.

Uncomfortable with the idea of taking drugs, she left, determined never to return.

But as her depression worsened, Melissa--whose name has been changed to preserve her privacy--turned to the Bureau of Study Counsel (BSC), a non-hospital based counseling facility staffed with psychologists rather than psychiatrists.

She says they offered her meaningless talk. So Melissa made no more appointments with 5 Linden St.

During exams, just a few months later, she was hospitalized for a week in Stillman Infirmary, diagnosed with clinical depression. She was in danger of failing out of school.

And Melissa is not the only one. All too often, students report, Harvard's mental health resources fail to fulfill their needs. The results, they say, can be devastating.

In November, the office of Provost Harvey V. Fineberg '67 released a report on the status of Harvard's mental health resources documents what students have known for years through their friends' experiences and their own: UHS is often inaccessible and removed from the undergraduate community. Although mental health services remain less than ideal, UHS says it's doing its best to respond to the report, especially by making more resources available to students.

More geared to student needs, the BSC has provided patients with what they haven't found at UHS--opportunities to chat with counselors for long periods of time. But other students say BSC therapy is often all talk--and little help.

Until these problems can be solved, students say they're not sure where to turn.

The Quiet One

This May marks the five-year anniversary of the infamous murder-suicide in Dunster House, in which Sinedu Tadesse, Class of 1996, stabbed her roommate, Trang Phuong Ho, also Class of 1996, and then hung herself.

A year after the incident, a report surfaced Tadesse's Harvard file contained a letter she had written to a UHS psychologist saying she was "desperate" with emotional problems. It did not seem that Harvard ever took action directly in response to the letter. She had been in UHS therapy for three years.

No one knows for certain how--and even whether UHS--failed Tadesse. Such is the nature of clinical depression and other mood disorders. The types and methods of treatment vary widely from person-to-person.

But the fact that she even sought help at UHS is unusual.

When "Jennifer," now a junior, had some family problems two years ago, she began to feel extremely depressed.

But in her darkest days, she never thought of turning for help.

"I actually had to start feeling better before going to UHS," says Jennifer--whose name has been changed at her request. "It isn't made all that clear how it all worked."

Eliot House Tutor Logan McCarty, an outspoken supporter of UHS mental health resources because his personal experiences have been positive, admits getting people to seek help may be the most difficult step in the process.

When UHS is not easily accommodating, people may give up, he says.

"Someone who's hesitant to seek help may not be willing to do all they need," McCarty says. "Once a student came to me and said, 'I tried, but I couldn't get an appointment.' So I went in and said, 'You get him an appointment tomorrow.'"

Mental State

UHS Mental Health Services (MHS), tucked away on the fourth floor of Holyoke Center, offers comprehensive mental health services provided by psychiatrists, psychologists, registered nurses and social workers. Specific services offered by UHS range from drug therapy to emergency care to support groups.

Mental Health Services Chief Richard D. Kadison says that unlike the BSC, MHS deals with a large variety of psychological issues, and its psychiatrists have the authority to prescribe drugs.

The BSC, by contrast, often helps students with academic difficulties, as well as emotional problems through individual therapy and special group sessions.

In Kadison's comparison of the two resources, he writes, "students are sometimes drawn by the 'feel' of each place, depending on whether they are attracted to a modern, professional-looking setting or to an informal, homey one."

For issues that are primarily academic, developmental or interpersonal in nature, students are encouraged to use the BSC.

UHS, in contrast, is intended for students who have illnesses that could be corrected by medication.

Both centers supervise the peer counseling and peer education groups, like Room 13, Peer Contraceptive Counselors and ECHO.

Is There A Doctor in the House?

It all sounds good on paper, but the provost's report says UHS has a reputation for being extremely inaccessible because it is seriously understaffed.

According to Rosenthal, between one and two out of every five students use MHS during their undergraduate careers. At the Holyoke branch of MHS, there are 18 staff members--a mix of psychiatrists, registered nurses and social workers, some full-time and some part-time.

But with such high demand for so few clinicians, securing an appointment can be quite the ordeal.

UHS has promised improvements with a new rule guaranteeing regular first-time visits within 7 days, urgent visits within 24 hours and daily emergency walk-in hours.

After students become UHS regulars however, obtaining a time slot becomes more difficult.

Melissa began to take an anti-depression medication called Zoloft and agreed to continue UHS therapy after her hospitalization, but says she was not satisfied with the consistency of her meetings.

"Once you've been going there regularly, you can see them maybe once every three weeks for a half hour," she says.

So Jennifer began to schedule different appointments with multiple clinicians, in order to get treatment on a regular basis.

But after having to see four UHS psychiatrists in nine visits, she gave up.

"I try to make appointments with the same person and it's just impossible," Jennifer says.

Kadison says it is policy to keep patients with a clinician who knows them.

"The goal is the fly paper system--we try to have the person continue with who they traditionally see," Kadison says.

Others say patients don't really need a weekly appointment.

"Will," a male junior, has been pleased with his amount of interaction with UHS.

"[My nurse] continued to give me medicine every three weeks," he says.

The Late Shift

Kadison and Director of UHS Dr. David S. Rosenthal '59 say UHS is aware of the scheduling difficulties and has made a concerted effort to improve.

Students like Melissa and Jennifer experienced the old UHS, and Rosenthal says that students with similar problems today will have better interaction with MHS.

"Although the report was only issued six months ago, we are seeing

significant progress on a number of fronts," Fineberg wrote in an e-mail message. "In January 2000, I [formed] the University Student Health Coordinating Board, which is charged with overseeing and advising on the full range of counseling and developmental services at Harvard."

Kadison says HMS is working to improve its services, especially by the eliminating the staffing shortage.

"We are about to post a new position for a clinician to be hired in time for the fall and are reviewing staffing needs during the summer for additional staffing," he wrote in an e-mail message. "We are also planning to 'dial up and down' staffing so more staff are available during the predictably busy periods in November though December and mid March through May."

Both Kadison and Rosenthal cite the new computer scheduling system as a step in the right direction.

By looking at the screen, people can instantly discern each day's openings.

On a sample day, there were 103 hours available for patient visits, and 11 percent--11.25 hours--were still open for appointments.

"You can access mental health services 7, 24, 365," Rosenthal says. "Those are the numbers. We're always here."

Instead of the freelance mental health professionals MHS used to employ, for the past year, there has been a regular night clinician at UHS.

If a student needs a little more help, the on-call physician will come to UHS to talk to the student in person

UHS has also attempted to shuffle staff hours to be more attuned to student needs. Creating more emergency appointments in the early evening, when students are more likely to need help, has aided these efforts.

"We still have a ways to go," says psychiatrist Winthrop A. Burr '65, a longtime practitioner at UHS. "We're hoping there will be an increase in staff. Who's going to pay for it is always the question."

"We need more staff so we can provide more services," Burr adds. "College students need things to be available on short notice. They need to be seen fairly intensively for a short period of time."

Burr concedes that appointments have not always been easy to come by.

"I think things are better for students now," Burr says. "We were always pretty responsive in an emergency way, but people had to wait a number of weeks for a second visit."

The report recommended that students with more serious problems be able to receive weekly visits for three or four months.

But Kadison says this is not feasible for all patients.

"We can't promise people they can be seen every week," he says. "We have limited resources."

UHS' standard procedure has set lengths for specific appointments. An initial visit to UHS can last one hour, but subsequent visits can be anywhere from 15 to 45 minutes.

Some doctors, however, refuse to schedule the quarter-hour appointments, saying nothing of substance can be accomplished in such a short period of time.

"Brief 15 minute visits are generally only scheduled if someone needs to check in around minor medication adjustments or someone has a quick question for his [or]her therapist and doesn't want to wait for a regular longer appointment time," Kadison says.

MHS treats retirees, employees and families who use the Harvard HMO in addition to students.

The provost's report states that UHS has about 21,000 visits a year from students, employees and retirees--only 68 percent of these are from students.

Often, UHS refers cases that need greater attention to outside therapists, but many students do not have the funds to pay for this extra counseling.

Kadison says that HMS has stayed attentive of student needs regardless.

"Our programming and hiring is very much focused on the needs of students," he says. "Most of the groups are oriented toward students."

The report says that HMS needs to take student concerns more seriously.

"Staff are participating in an ongoing customer service training to encourage a more welcoming attitude toward patients," Fineberg writes in the e-mail message. "UHS is engaged in more efforts to survey students about their care."

The Drug Bug

Another issue students say they have with MHS is the clinic's penchant for prescribing pills.

"Almost right away [the doctor] was prescribing medication," Melissa says. "I guess the main thing was that he wasn't listening to me. I was a problem to be fixed."

Melissa was so turned off by this push to medicate that she left when she needed help the most.

Similarly, Jennifer also recounts doctors' strongly urging her to take medication when she was merely searching for counseling.

"They wanted to give me a pill almost immediately," she says. "The person said, 'You know, these problems are recurring. You should be on some form of medication.'"

Her first psychiatrist asked her about her family's history of mental illness.

When she mentioned her father had experienced some bipolar symptoms as a result of post-traumatic stress disorder from Vietnam, the doctor thought he had hit upon the answer.

"As soon as I said it, his eyes lit up and it got written on a chart," Jennifer says. "So whenever I came in it said, 'So and so says you're bipolar. I have some problems with depression, but no mania."

"I didn't think I wanted a drug, but they insisted no matter how I felt," she adds. "The people at UHS have been trained to prescribe medication. They're not equipped to deal with day-to-day problems."

When Melissa finally had to go on medication to stay at Harvard, she says UHS was not forthcoming about what would come along with the medication.

"I've been having a lot of side effects--dizzy, drowsy, headaches," she says. "I was just getting really frustrated [that the drugs were] causing problems that seemed worse than my depression."

Kadison says UHS does not use medication more than the average college health facility.

He estimates between 15 and 25 percent of MHS patients are on some form of medication, but many come to Harvard already medicated.

"I simply don't believe it is an accurate perception [that UHS overmedicates]," Kadison says. "Our medication policies are similar to other student health services, and a lower frequency than many. We work hard to individually assess the needs of each student and provide appropriate care."

Kadison says psychotherapy is the preferred method of treatment and doctors only turn to medication when there is a medical need.

"They'll try to do a careful history. We try to gear the issue to what the student needs to work on," Kadison says of UHS procedure. "There's no rush to medicate people."

UHS psychiatrist Joseph P. Glenmullen, who is stationed at UHS' Law School satellite and has a private practice in the Square, recently published a book chastising doctors nationwide for over-prescribing pills.

Prozac Backlash details the dangers involved with the most heavily prescribed drugs--Prozac, Zoloft and Paxil--and argues that medication should only be used in conjunction with psychotherapy.

"You can't use [drugs] as the sole form of therapy," he says. "It doesn't address the underlying issue."

While he says he has not encountered over-prescription at UHS, he says it is particularly a problem at the college-age level.

The College Connection

Dealing with a varied group of patients, UHS sees more adults than students.

The provost's report found that MHS is often not in touch with the intricacies of students' residential life and how illnesses are affected by it.

And that's a reputation UHS--and the provost's committee--is uncomfortable with.

A list of senior tutors is now pinned directly above Burr's desk and he notes that he was assigned a specific liaison with the Freshman Dean's Office, Assistant Dean Philip A. Bean.

"We're really working on getting much more engaged with the college community," Kadison says. "We weren't doing much outreach a few years back, getting to know the issues better in residence."

UHS has assigned staff members to act as liaisons to each House.

But Rosenthal says he is not sure how much progress the programs have made.

He says the program is being evaluated this summer.

On the other side, the provost's report also charged that House officials should better learn how to handle mental health concerns when they arise.

Report recommendations include setting aside empty suites for students to use as "safe space," evaluating tutors' interpersonal skills and providing extensive training for all residential staff.

A Better Bureau

The BSC, which offers psychological and academic individual and group counseling, offers only 4,300 to 5,000 individual student visits in one year--a quarter of the volume UHS handles.

Yet because the resource is geared to students alone--no HMO patients or retirees--the BSC sees around the same number of students as UHS, just for longer periods of time and more regularly.

And because the staff is focused on student life, patients say, therapists are easier to develop a rapport with.

"It was never a problem for me to see [a Bureau psychologist] every week for an hour," Jennifer says.

Others have found what they were looking for at the BSC after off-putting experiences at UHS.

When "Tim," a junior male, began experiencing depression, his friends suggested that he see a therapist on a regular basis.

His appointment with UHS, however, was not what he was looking for. Tim, who asked that his real name not be used for this article, says UHS could not make time for him to see a therapist every week.

Tim is currently happily seeing a psychologist at the BSC.

"I was very turned off by UHS. It was sort of clinical--not a homey environment," he says. "At the Bureau they have toys and couches and it's friendly."

The Provost's report found that students do feel more comfortable in the BSC than in UHS.

"Its non-medical setting, its comfortable surroundings, and the possibility of accessing mental health services under the guise of academic tutoring contribute to the ease with which students seek its services without the stigma attached to care at UHS," the report says.

Kadison says the quality of both staffs is equally excellent, but the BSC's academic component allows students to use its services without any embarrassment.

"We provide very similar services in both places," Kadison says. "People who use both services find them both helpful."

Because the BSC does provide so much support for mental health problems, the committee recommended that it adopt the standards established for UHS, including provisions for emergencies, after-hours care and service review to ensure quality.

These suggestions may improve the aspects of the BSC that troubled Melissa and others in their interactions with the center.

The BSC's largest problem, students say, results from the fact that many people don't know what it is or what it does.

Tim, a vocal proponent of the BSC's services, had no idea what it did until earlier this year.

"It took me more than two years to even find out it existed," he says.

BSC Director Charles P. Ducey says the center was founded during a time when the stigma behind mental illness and psychological therapy was great.

"There's always been something you could call psychological services [at the BSC], but they weren't advertised as such," Ducey says. "The Bureau wanted to de-pathologize mental health problems--that's why it has the obscure name."

The BSC did not even include the words "psychological services" in any of its printed materials until Ducey's arrival in 1986.

Talk the Talk

Although people are generally positive about the BSC, some visitors, like Melissa, have found it unhelpful.

Jennifer says the BSC's techniques are often not as direct as she would like.

"There are drawbacks because sometimes you do want more of a problem-solving approach," Jennifer says. "Sometimes you hope there's someone out there who can do more than listen."

Before Will settled into UHS, he tried going to the BSC for a few months.

He says he accomplished little, if anything, during his therapy there.

"The person I had at the Bureau was pretty inexperienced," he says. "She was nice and really attractive, but I just saw through everything she was doing."

Ducey concedes that Will's experience reflects a BSC concern.

"It's true that there's a difference between real talk and empty talk," he says. "An experienced therapist will get you to speak from your heart, but some may not see the emptiness because the student isn't ready to deal with the issue."

He also emphasizes the importance of talk therapy as a way to get to the underlying issue causing the problem, rather than just attacking the symptoms.

"It's unbelievably common for students to be given drugs, put a band aid over problems," Ducey says. "The only way one solves problems is to deal with them directly."

But Jennifer says this creates a gap in mental health resources at Harvard. The BSC talks about issues without ever solving them, and UHS is equally unhelpful because it doesn't talk at all, she says.

"UHS almost ignores what you're saying," she says.

According to Ducey, the BSC is aware that some people have trouble with their form of therapy, but counselors are constantly peer reviewing one another to improve their techniques.

"We try to provide what people need," Ducey says. "We try to help solve the problem. At a place like this, students should expect to have their problems solved."