Today, a jury in Woburn, Mass., heard the closing arguments of a trial in which Melanie G. Northrop, a social worker at Harvard’s Counseling and Mental Health Service, stands accused of causing the Sept. 2015 suicide of Luke Z. Tang ’18.

Tang never sought help from Northrop. He did from two other CAMHS employees: a psychologist to whom Tang disclosed a previous suicide attempt over the phone, and a social worker who met in person with Tang the next day and who arranged for his admission in the psychiatric hospital McLean the day after.

Northrop is Harvard’s full-time case manager, and she entered Tang’s life as his. She tracked Tang’s hospitalization for the University, communicated regularly with McLean on the University’s behalf, and helped determine if he would return to campus. After Harvard decided that he could, Northrop was tasked with providing Tang with “access to resources” while being a “point of contact” for the university.

Northrop met with Tang three times before the summer but not the following fall, when former Lowell House Resident Dean Caitlin Casey, who had put Tang in a room nearby her apartment, made herself his academic advisor, and reminded him of his “care contract,” which Harvard required him to sign and which conditioned his enrollment on attending counseling, found his dead body in a storage room Lowell House’s basement.

In 2018, Tang’s father filed a complaint against Harvard, the former Resident Dean of Freshman Catherine Shapiro, Casey, Northrop, and a CAMHS psychiatrist who has denied knowing about Tang until after his death. Superior Court Justice Brent A. Tingle dismissed the allegations against Harvard and its administrators in 2022, finding that they had satisfied their duty to care for Tang. However, he allowed the case against Northrop to proceed.

Northrop’s legal situation reflects the largely unresolved question of the role that universities should play in the lives of students experiencing mental illness and disability. Behind it are landmark anti-discrimination laws such as the 1990 Americans with Disabilities Act as well as decades of litigation brought against universities for not only noncompliance with these laws but also negligence in the care of their students.

It was only in 1957 that “Colleges Discover the Need for Mental Health,” as reads the title of the first chapter of a book, “Mental Health in College and University,” by the former director of Harvard’s health services Dana L. Farnsworth. He had a clear message for Harvard: “Our young men and women with good minds deserve something better on the part of those of us who plan their educational experiences than a ‘sink or swim’ attitude.”

67 years after Farnsworth’s book, the University’s relationship with the mental health of its students remains fraught as the presence of a mental health crisis at Harvard has become clear and undeniable to administrators, faculty, students, and alumni. In 2020, a report initiated by then-provost Alan M. Garber ’76 found that 31 percent of undergraduates thought they had depression, 30 percent thought they had an anxiety disorder, and 6 percent had seriously thought about taking their lives in the past year.

To address the needs of students, Harvard employs a team of 34 social workers, counselors, psychologists, and psychiatrists in CAMHS and offers the “CAMHS Cares Line,” where students can speak to a “CAMHS Cares Counselor” at any time. Since 2022, when the service was criticized for having therapy wait times of up to six weeks, the service has hired 16 new clinicians and instituted a virtual telehealth counseling program that has received visits from thousands of students.

Still, Harvard’s policies around students with severe mental health issues can seem like an opaque, high-stakes web of rules. Students may be placed on involuntary leave due to behavior that “poses a direct threat to the health or safety of any person, or has seriously disrupted others,” or after any hospitalization that “raises serious concerns about the student’s health or well-being.” Regaining entry to the College requires proof of “productivity,” meetings with CAMHS, and letters of support from providers and employers, to name just a few requirements.

Students who find themselves mentally unwell at Harvard are caught in a world of contradictions. Flyers from university wellness campaigns (“We’re All Human!”) adorn dorm hallways, and students receive emails from administrators reminding them of the University’s “commitment to providing comprehensive care to our community.” Yet students who pursue help and who the University subsequently decides are too unwell to remain on campus are required to leave, upending otherwise consistent features of their lives.

How did we get here?

The answer to this question lies in the complicated, constitutive history of stigmas surrounding mental illness, the nature of its own illegibility, and the legal system, which frames the obligations universities have — and don’t have — to students with mental health disabilities. At the same time as civil rights law demands that universities appropriately accommodate students with disabilities, gaps between laws and their implementation make the process of reform at universities painstaking.

‘A Long History of Discrimination’

Legislation preventing discrimination against people with disabilities is the primary force governing the relationship between universities and students with mental illness. Today, the most significant of these laws are Section 504 of the 1973 Rehabilitation Act and the 1990 Americans with Disabilities Act. Although both define disability as being a “physical or mental impairment,” the application of these laws to mental illnesses lagged, in part because of evolving cultural understanding about what mental illness is.

According to Ira A. Burnim ’73, senior counsel for the Bazelon Center for Mental Health and former Crimson photo chair, the ADA and Section 504 have always clearly applied to not just physical but mental disabilities, but the laws have not always been used in that way.

“It took a while for covered entities and the public to realize that,” he wrote in an emailed statement.

The ADA’s origins illustrate this. In April 1988, when Representatives Anthony L. Coelho and Major R. Owens took the floor to introduce the ADA to the House of Representatives, the word “mental” was used only twice in the context of disabilities, both times followed not by the word “illness” but instead by “retardation.”

Indeed, the definition of disability was one of the most contested aspects of the ADA. Senator William L. Armstrong thought the definition of disability was too broad and worried in particular about the inclusion of “mental disorders” and disorders with a “moral content,” by which he was referring mostly to homosexuality.

Meanwhile, in the House of Representatives, New York Democrat Chuck Douglas worried that people with mental illness would endanger their coworkers, and proposed excluding mental illness from the definition of disability for that reason. And the initial draft of the ADA that emerged from the Energy and Commerce Committee excluded people with mental illness from the definition of disability. Committee members worried that the ADA’s protection of people with mental disabilities would preclude train conductors from being able to evict riders causing significant disturbances from the train.

This particular effort to exclude mental disabilities from the ADA caused an “uproar in the disability community,” wrote the National Council on Disability in its 1997 book uncovering and tracing these contestations around the ADA.

Today, the definition of disability in the ADA includes mental impairments that “substantially limit one or more major life activities.” In addition to the actual text of the ADA and Section 504, regulations issued by agencies like the Justice and Education Departments clarify what the statutory language in those major laws should mean in practice and in context-specific cases.

However, ADA protections for people with mental illnesses used to be more limited. A series of Supreme Court cases in the late 1990s and early 2000s established that whether an impairment qualifies as a legal disability depends on how treatment or other supports improve the condition. For example, if someone with depression was taking psychiatric medication, they might not be found to qualify for ADA protections. This only changed in 2008, when Congress passed an act “to restore the intent and protections” of the ADA that reversed this outcome, clarifying that the ADA was written with a broader scope and definition of disability than the Court had been finding.

Even so, these protections are not always well communicated. Monica Porter Gilbert, the Policy & Legal Advocacy Attorney at the Bazelon Center for Mental Health Law, recalls attending conferences and explaining to fellow attendees that if you have anxiety or depression, you can get an accommodation the same way that someone who uses a wheelchair or has dyslexia can. She was met with confusion and a lack of familiarity with protective laws’ applicability to mental disabilities.

“There is a long history of discrimination against individuals with mental health disabilities,” explains Deborah A. Dorfman, the Executive Director of Disability Rights Connecticut. “Those translate into unfounded fears, stereotypes, and stigma.”

‘The Incentive to Enforce’

The language of the ADA is very clear, says Gilbert: Universities cannot discriminate against people with disabilities, exclude them, or have policies that result in exclusion. And they must provide reasonable accommodations for students with disabilities.

Yet the passage of the monumental pieces of federal legislation outlawing discrimination does not mean that all institutions immediately comply. “What students need to know,” says Susan Stefan, a nationally recognized scholar and litigator for people with mental health disabilities, is that laws “are not self-enforcing.”

The mechanisms by which this enforcement actually happens, she says, include student activism and media attention.

“Student pressure, and the publicity by the Harvard Crimson, and student disability groups — all of those things are needed to give the laws their power, to give the regulatory agencies the incentive to enforce them,” she adds.

A series of lawsuits invoking civil rights language have slowly spurred universities and the government to action.

One of the first lawsuits related to university mental health was brought against Princeton in 2014 after the university removed a student from campus following his suicide attempt. The student immediately sought treatment after his attempt and was transported to a hospital. Following school policy, Princeton required that student to leave campus, even as his psychiatrist urged the school that doing so “could be detrimental to his health and well-being.”

The student filed a lawsuit against the university in which he remained anonymous, alleging that Princeton had violated the ADA, the Rehabilitation Act of 1973, and the Fair Housing Act Amendments in failing to accommodate his disability.

Princeton sought to dismiss the lawsuit, calling it “patently meritless” and criticizing the student for wanting to “hurl his accusations from beneath a cloak of anonymity.” But these attempts were unsuccessful, and the lawsuit spurred the Department of Justice to review Princeton’s policies.

In 2016, Princeton settled with the Department of Justice, agreeing to change some of its mental health disability policies to comply with the ADA, including revising its leave of absence policies to set a high standard for imposing a mandatory leave, providing annual training on the ADA and mental health disability discrimination, and offering clear instructions on how students could request modifications to university policies.

In a press release announcing the agreement, then-U.S. Attorney of the District of New Jersey Paul J. Fishman said that “students with disabilities move closer to achieving full equality and integration into places of higher education” through the agreement. Then-head of the DOJ’s Civil Rights Division Vanita Gupta called on other universities to center student voices in similar reforms. “By working directly with students with disabilities to determine appropriate accommodations, colleges and universities can meet their obligations under the ADA,” she said.

Other settlements with the DOJ at the University of Tennessee in 2016 and at Brown University in 2021 followed Princeton’s. In both instances, the universities agreed to change their leave of absence policies to comply with the ADA.

Two recent lawsuits at Stanford and Yale brought by students and alumni successfully changed the school’s mental health policies as well.

In 2018, three Stanford students and the Stanford Mental Health & Wellness Coalition sued the school, alleging that its mandatory leave of absence policy violated the ADA, Section 504, and the Fair Housing Act. Just a year later, the students and the coalition reached a settlement with the university.

The settlement includes the text for Stanford’s new involuntary Leave of Absence policy, which gives more agency to students and their treatment providers and institutes checks and balances on university administrators who make involuntary leave decisions. The settlement also compensated the students for the cost of their representation by Disability Rights Advocates.

In 2021, at Yale, the suicide of freshman student Rachael Shaw-Rosenbaum set off long-simmering frustrations about strict withdrawal and readmission policies that left students fearful that seeking help might mean never being able to return to campus. In the wake of her death, a group of students and alumni founded the organization Elis for Rachael to advocate for less stringent policies.

Elis for Rachael and two Yale students, Alicia Abramson and Hannah Neves, filed a class action complaint against Yale in 2022, alleging that the school discriminated against students with mental health disabilities. They alleged that Yale’s policies and practices violated the ADA, Section 504, and other federal anti-discrimination statutes. Nine months after filing the lawsuit, the Elis for Rachael, the students, and the university reached a settlement, which included ending the withdrawal and readmission process and replacing it with a leave of absence process that was simpler for students.

Still, gaps frequently exist between the agreement reached in a lawsuit and its implementation, says Gilbert. She adds that there is often ambiguity about whether an anti-discrimination law would apply to a particular university’s practice of, say, failing to adequately publicize the services and accommodations available to students with disabilities, or having a dearth of counselors of color. Those conditions are not ideal, Gilbert says. But do they warrant a lawsuit?

Another path for altering university mental health policies is through Congress. In 2022, the day after the Elis for Rachel filed its lawsuit, Senator Ed Markey (D-Mass.) sent an open letter to the Department of Education and U.S. Attorney General Merrick Garland asking that the agencies respond to a series of questions about mandatory leaves of absence.

In May of 2023, Markey and Rep. Katie Porter (D-Calif.) introduced the Student Mental Health Rights Act to require the Department of Education to publish guidelines on how universities can comply with ADA as well as the legal obligations these institutions have to their students. The legislation has not advanced further in either the House or the Senate since being introduced.

“We are in the midst of a mental health crisis,” Markey wrote in a statement to The Crimson. “I am proud to lead the call to our federal agencies to protect higher education students’ civil rights.”

Stefan believes sustained student advocacy can also produce change. “The best solution is for the students themselves to get together to organize,” she says. “You understand it better than I do; you’re there.” She adds, “You’re the ones who need to figure out what you need, and learn about the difficulties of negotiations with the powers that be.”

Stefan says that students should make cross-disability alliances whenever possible.“When students with disabilities have organized, there have been some remarkable successes,” she says.

‘Wreak Damage on Promising Students’

With the law and student mental health comes another problem: liability. Gilbert explains that the structure of many colleges means that universities come to occupy an outsize role in students’ lives, often controlling not only their education but their living space and their health care as well. Given these circumstances, she asks, do students qualify as adults? Is it appropriate to expect the university to act as a quasi-parent?

Three major lawsuits allege negligence, two at MIT and another at Harvard. After the 2000 suicide of MIT student Elizabeth Shin, her family filed a wrongful death lawsuit against MIT and several university healthcare professionals, administrators, and campus police offers. She had shown clear signs of suicidal ideation to faculty members and the university counseling service, but this received little meaningful attention before her suicide, her family claimed. A month before going to trial, Shin’s family and MIT settled for an undisclosed sum.

MIT did not settle a case brought against it a decade later by the family of Han D. Nguyen, a graduate student who took his life in 2010. Unlike Shin, Nguygen had not expressed suicidal intentions to anyone at the university. In 2018, Massachusetts's top court unanimously dismissed the case, writing that “no duty of care was created” that the university would have to fulfill. “Generally, there is no duty to prevent another from committing suicide,” the decision reads. The court did, however, outline a series of circumstances in which such a duty would be created, including a student expressing suicidal ideation to healthcare employees.

The Nyugen decision frames the case against Northrop now.

In these cases, the interwoven nature of the student-university relationship muddied the degree to which a college should be responsible for their students, who largely exist between adolescence and adulthood: no longer minors, but largely dependent upon their parents and/or the university for care. Presented with this ambiguity, courts have been largely sympathetic to the claim that administrators’ lack of healthcare training decreases their duty and capacity to care for students in crises.

As a result, a key paradox exists: The more a university knows about a students’ mental health issues, the more likely they are to be held liable for those struggles, and the more capable they are of supporting students. In simpler terms, liability concerns directly clash with universities’ incentive and capacity to support students.

Gilbert points out that if students don’t directly notify administrators of their disability, it does not trigger the university’s legal duty to provide accommodations and support for that student. But, she says, since the disability in question is not one that is immediately apparent, the student is forced to out themselves as they ask for help.

Jonathan Palumbo, Harvard’s Senior Director of Communications and Engagement, wrote in an emailed statement: “I would defer questions about a broader approach or policies outside of Harvard College to other institutions or perhaps to industry experts, researchers, medical professionals, and members of the academic community who study these topics.”

Stefan says that, as they navigate the presence of individuals with serious mental illnesses on their campuses, universities severely misdirect their energy when they target suicidality. “There are many very difficult pedagogical and policy issues raised by the presence of people with serious mental illness on college campuses,” she says. “The blanket policy of evicting or rejecting students who have gone for help for suicidality — who do not want to leave the campus — is not one of those difficult questions.”

In fact, she says, staying in school may often be a key coping mechanism for students in the midst of a serious mental struggle. “One of the things university administrators don't understand is that going to classes — being immersed in schoolwork, being surrounded by friends — is a coping mechanism for people with depression or serious psychiatric problems,” she says. “Staying in school may be the best possible thing for them, and asking them to leave may make their problems much much worse.”

Driven by liability concerns instead of pedagogy, she says, all those policies do is “wreak damage on promising students.”

“Those policies need to change,” she adds.

Regarding the College’s policies, Palumbo wrote in an emailed statement: “I would offer that we focus on putting the students’ interests and ability to succeed academically, socially, and personally at the College at the center of our policies and decisions.”

Of course, students can seek out mental health care through avenues not associated with their universities — potentially minimizing students’ worries about “outing” themselves and universities’ concerns about liability. This can be a challenge, though, as therapists and psychiatrists outside of a school’s coverage can be more expensive, and the process of acquiring this coverage can be more complex and time consuming.

This can be especially true in Massachusetts, where full-time students are required by law to have health insurance, and universities are required to offer a student health insurance plan or otherwise ensure that all students have a comparable plan. The coverage students often opt to receive through their schools creates a relationship between them and the mental health professionals they have easy access to that already involves their school.

‘The Public Manifestation’

Within and beyond the law, cultural difficulties in conceptualizing mental illness as a disability — stemming back centuries, manifesting around the time when the ADA and Section 504 were created, and continuing to today — underlie the ways that issues of student mental health remain invisible or illegible to institutional standards.

Harvard has recognized, at multiple points in the past few decades, a crisis or uptick in mental health issues among its students. In 2000, a provost-appointed committee gathered testimony of “the increasing fragility of students and apparent higher incidence of depression and serious mental illness.” Finding that the mental health services of then-University Health Services (now HUHS) seemed understaffed in comparison to those of peer universities, they recommended more emphasis on student care, extended hours, and extended attention to emergency care.

In 2020, another provost-appointed committee executed a 15-month investigation. The report they produced concluded: “Our investigation confirmed that Harvard students are experiencing rising levels of depression and anxiety disorders, and high and widespread levels of anxiety, depression, loneliness, and other conditions. In addition, undergraduates reported high levels of stress, overwork, concern about measuring up to peers, and inability to maintain healthy coping strategies.”

Beyond “staffing a dedicated and diverse team to work on student affairs University-wide,” their list of eight actionable recommendations did not include any concrete suggestions to increase clinical resources, instead recommending that three more committees be formed and that they, along with various administrative stakeholders, “examine” and “address” issues identified and create mental health awareness campaigns.

It is clear that Harvard is, and has been, aware of the mental health crisis among its students — both the broader crises it continues to find in reports and in the acute tragedies of student suicides. So why, across the course of 20 years, has so little changed?

Stefan says that this is partially because lots of people struggling with mental illness suffer invisibly.

“I think there is a significant proportion of students who have anorexia or other eating disorders, who go through their entire university career and do well, and don't come to the attention of the university,” she says. “And that’s the way it’s always been.”

In a similar vein, she believes that students with mental health issues only become problems that universities have to address when their mental struggle is outwardly displayed — such as by disturbing people in their residential hall or by exhibiting sliding grades.

“It’s the public manifestation of psychiatric disability that the university is concerned with,” Stefan concludes. “Not actually the proportion of students at the university with significant psychiatric issues.”

Clarifying that he can only speak to the efforts of Harvard College, not colleges and universities writ large, Palumbo wrote in an emailed statement, “I would say that the health, safety, and wellbeing of our students is of the highest importance. We work closely with students and those who know them best on care plans that are specific to each student and refer students to experts and professionals who are trained to support them before, during, or after their time of need.”

However, Gilbert notes that recently stigma around mental health issues has begun to shift. A difference she observed between the Stanford case and the Yale case — five years apart, in 2018 and 2023, respectively — is that all student plaintiffs used pseudonyms in the former. In the latter, none of them did.

‘Taking Risks’

For decades, deep-rooted stigma against mental disabilities has embedded itself in a legal system that realized its capacity to advocate for those disabilities only gradually — specifically, with sustained grassroots activism.

What does the entanglement of law and society say about the power of legal advocacy in this area, as well as its limits? Both cases focus on universities’ civil rights duties to create more accommodating policies and cases alleging negligence share a core quality: they leverage the legal system to frame universities as institutions that have a responsibility for their students’ well-being.

Simultaneously, though, they work at odds. Universities could see negligence cases like Northrop’s to represent the very kind of liability they are trying to avoid, making them more hesitant to implement measures that civil rights cases demand. This tension asks: What would it mean to create a system where universities would be incentivized to care for their students?

Still, the issue cuts deeper than the university level. Rising rates of mental illness are paralleled by unprecedented, fast-changing social conditions. Harvard’s 2020 report on student mental health identified a set of “structural realities” that students currently face, including rising costs of education and living, a shrinking academic job market, and global warming.

Stefan explains what she means when she points out the potential power of student organizing. “Make good trouble,” she says, invoking the trailblazing civil rights activist John Lewis. “That requires taking risks.”

She adds: “People can come out and talk about their diagnoses for their own good and the good of people who are coming after them.”

By nature, mental health struggle and disability are experiences that can feel largely invisible and internal. But when students make their struggles legible to one another — at least to the extent that they can — the intrinsically collective nature of this crisis becomes easier to grasp.

67 years ago, Farnsworth made a similar observation about the interrelation of society and mental health in “Mental Health in College and University.” “It is an indication that our culture is changing so rapidly that our capacity to orient ourselves to it is being overtaxed without knowing more about our own personalities,” he wrote. “Thus neurosis becomes the characteristic disturbance of the age as infections were a century or more ago.”

Farnsworth called on universities directly to recognize the gravity of this new “characteristic disturbance.” In the last line of the book, he issued a warning: “If the colleges and universities will not or cannot take the lead in a matter so vital as the rapid development of the mental-health aspects of the behavioral sciences, neither we nor they will be left to contemplate the error.”

— Magazine writer Kate S. Griem can be reached at kate.griem@thecrimson.com.

— Associate Magazine Editor Graham R. Weber can be reached at graham.weber@thecrimson.com.