Navigating the Caregivers

D. almost didn’t get help.

It was his first year at Harvard and he couldn’t sleep well, he constantly felt anxious and college life seemed too overwhelming to deal with.

When he finally worked up the courage to go to University Health Services (UHS) mental health service, he says he was disappointed with the care he received.

“The psychologist was like, ‘You’re a worrier, aren’t you?,’” says D., who was later diagnosed with anxiety disorder. “She didn’t take me seriously.”

She then sent him to a psychiatrist who prescribed Valium, which was ineffective. D., a Harvard senior who asked that his full name not be used, stopped taking the drug.

It took more than a year for him to return to UHS.

“I thought maybe there was some hope,” he says. “But it was the same terrible result. They didn’t say anything helpful to me—I went to two appointments and stopped.”

Another year passed before D. decided to look for help again, this time at the Bureau of Study Counsel. Up until this point, he hadn’t known that the bureau provided therapy.

“The moment you step in, it’s an entirely different place,” he says. “This woman sat down with me and said, ‘Let’s talk,’ and we spent the next eight months talking.” She later referred him to a UHS prescriber and D. began taking Zoloft.

“The drug and the talk at the Bureau of Study Counsel has completely changed my life,” he says.

D. says that even after four years of experiences with the bureau and UHS, he’s unclear about the distinction between the two services.

“I still don’t know what is for what—no one knows,” he says. “I think it’s atrocious. If I had found out about the bureau freshman year, I would have been so much happier and more successful at college.”

D.’s experience underscores the confusion—and potential for a breakdown in the system—that results from Harvard’s decentralized approach to mental health care.

There is no office at Harvard responsible for coordinating mental health services across the University.

“Mental health services at Harvard resemble a symphony orchestra of talented performers, but without a clear conductor and with all musicians playing different music,” concluded the 1999 Provost’s Committee on Student Mental Health Services.

The bifurcation of mental health care at Harvard has allowed students to slip through the cracks as they try to navigate a complex system while also dealing with their own conditions.

And like D., many students don’t know the differences between UHS and the bureau—or that the bureau provides mental health care at all.

The College’s Best-Kept Secret

The white, wood frame building with crimson shutters at 5 Linden St. is fairly nondescript. Only a small white sign that reads “Bureau of Study Counsel” Out of 30 students interviewed in Adams Dining Hall one night last week, only two knew that the bureau provided any kind of counseling for mental health issues. Some knew it provided academic tutoring. Most had no idea what the bureau did at all.

“They do tutors, study skills, stuff like that,” Jordan M. Stevens ’05 said.

“They have a reading class, and stress management type stuff,” said Sarah M. G. Otner ’06.

“I had no idea why the bureau was there,” said Katherine T. Kleindienst ’05, who went to UHS to get help for depression.

But although students are largely unaware of the bureau as a mental health resource, 931 students from the Faculty of Arts and Sciences received psychotherapy there last year, according to Bureau of Study Counsel Director Charles P. Ducey.

That comprises about a third of total student mental health visits. So why don’t more students know that the bureau is a major center of psychological counseling?

“I’m very happy to have the bureau’s mission fuzzed up,” Hyman says. The ambiguity allows students to use its resources while avoiding the stigma often associated with mental illness.

Ducey says that the bureau does not hide its mental health services.

“We’re straightforward about what we offer,” he says, “it’s just that we offer a whole lot of different things.”

But by including therapy as one of a variety of services—including tutoring, procrastination workshops and a course on reading and study strategies—some say that the bureau deters some of the students who most need its help, says Sarah J. Ramer ’03, former co-chair of the Mental Health Advocacy and Awareness Group (MHAAG).

“There’s sort of a nebulous, fluffy focus that doesn’t do much to help people who are beyond stress,” Ramer says. The bureau “doesn’t always reach the people who need the most help.”

But even critics of the bureau’s amorphous mission concede that its wide focus allows the bureau to have much less of a stigma than UHS.

Having the bureau as a more approachable option for mental health care provides another entry point for students to get help.“We hear and see how hard it is to take the leap, to seek services in the first place,” Ducey says. “I think it’s fairly clever that Harvard offers two portals to enter into mental health services.”

Mission Creep

But Hyman and Dean of the College Benedict H. Gross ’71 believe that the bureau has strayed too far from it’s original mission.

Founded in 1946 by William G. Perry ’35, a professor at the School of Education, the bureau was originally a service mainly to help students with academic and adjustment issues.

But as the number of students with mental health problems increased over the years, the bureau began to treat students with more serious concerns.

“I think that the bureau has moved in to treat some of this demand,” Gross writes in an e-mail. “This was a departure from its original mission of tutoring and counseling for the usual problems of adolescence and adjusting to college.”

Hyman calls this shift “mission creep.”

“The bureau had its mission increased,” Hyman says. “It sort of started to creep to help people who had more and more serious illness.”

But Hyman says that the bureau should not be treating students with clinical mental illnesses.

“While a lot of students like what [bureau clinicians] do when they show up with depression or other issues, we feel that on balance, students should be getting the agreed-upon best treatments,” Hyman says. “And the people trained to do that are in UHS.”

None of the clinicians at the bureau can prescribe medicine. There are no psychiatrists on staff.

“The broad world has reached a consensus on how to treat depression,” Hyman says. “That’s really what we owe people—the best-tested therapy set that we know, the best-tested treatment.”

He says that for mild to moderate depression, patients should have the choice of either a specific kind of short-term therapy, called cognitive-behavioral therapy, a selective serotonin reuptake inhibitor (SSRI) medication, or sometimes both. This is the type of treatment offered at UHS, he says.

Hyman says he would like to see the bureau continue its work with academic counseling, and refer students with clinical mental problems to UHS.

The catch, Hyman says, is that many students really like the bureau. There is an “enormous amount of consumer satisfaction,” he says.

The challenge, he says, is finding a way to move student care “in a way that doesn’t feel like a rejection.”

But Ducey, who is a psychologist, disagrees with Hyman. He says that the bureau can handle full treatment for most students.

“We do think of ourselves as one-stop-shopping,” he says. “Most students, when they really get into therapy, find that medication is no longer an issue.”

Ducey says that in some circumstances the bureau does refer students to UHS for prescription medication.

The role of the bureau is one of the main focuses of the Student Mental Health Task Force that was convened in December.

“We want to be able to keep the Bureau of Study Counsel focused on its role as one portal of entry for students to get help, but also to be able to use all the mental health services that are available to provide treatment,” Dr. Paul J. Barreira, chair of the task force, told The Crimson in December.

The task force is expected to report its recommendations in April.

Where Do I Get Help?

The head of the Bureau of Study Counsel reports to the dean of the College. The head of UHS reports to the University provost. But there is no person or office responsible for overseeing mental health services at Harvard College.

In fact, there is only one administrator who sits over both branches of mental health services: University President Lawrence H. Summers.

A 1999 University-wide committee highlighted the need for centralization as one of its main recommendations for improving mental health care at Harvard. Five years later, few of the committee’s recommendations have been put into place—partially, critics say, because there is no centralized authority to affect change.

“You have to do this all together, you cannot do it in pieces,” says Clarice J. Kestenbaum, a professor of clinical psychiatry at Columbia University. “I would just take a weekend retreat, and get the entire program shaped up, computerized, with connections between everyone, all together. One weekend would do it.”

Students with experience inside the system agree.

“You cannot just do this all piecemeal,” says MHAAG founder Jeremy R. Jenkins ’97-’98.

Mental health advocates say the solution could lie in a centralized office with information about all services available and advice about which to choose. Such an office would coordinate all the individuals on campus who might play a role in helping students with mental health problems.

“There should be a central office that’s looking at it not only from a clinical point of view, but what’s the academic and social impact, and how do we deal with residential, security and confidentiality issues,” Jenkins says.

That’s analogous to the mission outlined for the Office of Sexual Assault Prevention and Response (OSAPR) when it was formed last spring.

The Committee to Address Sexual Assault at Harvard, headed by Professor of International Health Jennifer Leaning ’68, recommended that a centralized office be created to provide 24-hour support for victims and to coordinate campus resources for the prevention of sexual assault.

Leaning is also a member of the committee currently examining mental health on campus.

The OSAPR has also created a website that includes a comprehensive list of all services where a sexual assault victim could find help.

Although the bureau’s website does include a section on UHS, the UHS mental health services website does not mention the Bureau of Study Counsel at all.

There exists no single page online—save a PDF file of a pamphlet buried on the Provost’s website—that lists all the services a student could utilize for mental health care.

Hyman says a central office might not be the right answer, but that the task force will consider it as a possibility.

Ducey says that he thinks a central office is impractical.

“If there were one centralized office, it would be very hard for them to know all the mental health providers,” Ducey says.

Hyman and Gross both say that one way to better direct students to mental health resources is to improve education for House tutors and senior tutors, so that they can help guide students into the right care.

File Sharing

The decentralization of Harvard’s mental health services makes it doubly important that individual clinicians from the bureau and UHS communicate with each other.

The University Mental Health Coordinating Board was created as a result of the 1999 provost’s report to bring together representatives of the two care providers to communicate with each other and to update Hyman about mental health services.

And last year, UHS and the bureau implemented of a “coordination of care” system to allow clinicians at the bureau and UHS who see the same student to communicate with each other about the student’s treatment.

Nearly every student who walks through the door at either of the venues signs a form allowing clinicians to consult about the patient.

“Virtually 100 percent of students sign it,” Ducey says.

But actual records of a student are still kept by the individual venue the student uses—a situation that can be particularly critical if a bureau patient goes to UHS during urgent care hours.

“That’s just impossible—we just can’t have that,” Hyman says of the current inability to share files when a student is in urgent care. “That could be life threatening.”

The task force is looking at ways to solve this problem, possibly by electronically sharing files.

“We probably need to get legal consultation about not only that, but whether its electronically possible,” Ducey says.

Slipping Through the Cracks

With no central source of oversight, and services diffused across different segments of the University, it’s not hard for a troubled student to get lost in the system.

After seeing a UHS therapist for six months, Kleindienst decided to abruptly end her treatment.

“When she was like, ‘Go make an appointment at the front desk in two or three weeks,’ I just left,” Kleindienst says. “I wondered if she’d ever contact me, but I haven’t seen her or heard from her since.”

Kestenbaum, a past president of the American Academy of Child and Adolescent Psychiatry, says that there should be one mechanism for following students through various care options.

“There should be a record, saying, here, this student went to this doctor and then this doctor, and here’s a list,” Kestenbaum says. “There should be a list for students of everything that’s offered with a little description of the different therapies—it should all be in one place where you can see what’s available. Kids shouldn’t have to search it out on their own, they should be available to look at it, like on a grid.”

D., the Harvard senior with anxiety disorder, says that the patients have to carry too much of the responsibility.

“I feel that once the patient gets his foot in the door, you shouldn’t have to seek treatment out,” D. says. “People should advise you, and that never happened.”

Charles L. Black ’04, who examined mental health services at the College last fall, agrees that there needs to be a centralized system to track and follow up with students.

Black informally surveyed House open lists about students’ experiences with mental health services.

“There needs to be some sort of way of tracking people’s progress,” Black says. “We don’t want people going to UHS, getting scared off and committing suicide. We can’t have the problem of people getting lost in the system.”

Kadison admits that UHS does sometimes lose track of students.

“Our policy is to follow up appointments with an e-mail—that’s what’s supposed to happen. But unfortunately, not everyone does it,” he says. “Sometimes students are just sent to the front desk to schedule appointments. Some providers don’t feel comfortable with the system.”

Kadison estimates that two percent of students come in for an appointment and then don’t receive a follow-up e-mail or call.

About 25 percent of students who visit UHS mental health services come in only once, Kadison says. He has also instituted a policy of e-mailing students to remind them of previously scheduled appointments, an improvement which he says has cut no-shows in half.

“We were losing 3,000 visits a year—15 percent of all appointments—it was a big loss and we’ve made major progress on that,” Kadison says.

But some say that in order to get adequate care, students need to be aggressive and focused—exactly what many troubled students in need of the most care cannot be.

A Harvard senior says that after reading articles about MIT student Elizabeth Shin, who committed suicide in 2000, he was struck by the similar pitfalls in the Harvard system.

“No one was keeping track of her when she was going in and out of these resources…the system failed her,” he says. “I also had some problems sophomore year, and when I read about her, it really scared me, because probably the exact same thing would have happened to me, except I came from a background where I was well-informed and proactive about taking responsibility to stay in treatment when I needed it.”

—Staff writer Katharine A. Kaplan can be reached at kkaplan@fas.harvard.edu.