An Epidemic of Anguish

Cassie Smith-Christmas and Margaret Go have something terrible in common: Both have family members who killed themselves while attending prestigious universities. In both cases, the students went to the campus counseling center before taking their own lives. But that’s where the similarity ends.

When her younger brother, Ian, told a counselor at the College of William & Mary that he was feeling suicidal, says Ms. Smith-Christmas, the response was quick and decisive: An administrator called their parents that day and forced her brother to leave and seek professional help. After five days in a mental hospital and a couple of weeks on academic leave, he returned to the campus and tried to catch up on his work. He felt rejected, fragile, and overwhelmed, his sister says. Just a few days after he returned, in April 2010, his body was discovered in his parked car.

At the California Institute of Technology, where Ms. Go’s son Brian was a junior, the reaction to his suicidal thoughts was very different. After he wrote an email message in late April 2009 to a counselor questioning whether he had the "will to go on," the counselor told him she couldn't meet with him for a few days.

A week later, after he had gone up to a rooftop and threatened to hurt himself, he sought out a dean, who referred him that day to another counselor. That counselor determined it was safe for Brian to go back to his dorm and recommended that he return for more counseling, which he did. At his request, university officials say, they did not contact his parents. On May 17, Brian was found dead by suicide.

Ian and Brian’s stories demonstrate two different campus responses to troubled students. College officials won’t comment on specific cases, citing privacy laws. But R. Kelly Crace, associate vice president for health and wellness at William & Mary, says the college typically asks students to withdraw if the campus environment is deemed "too toxic" for them. Before they can return, the students must prove that they've received the help they needed, he says.

The Go family sued Caltech and its counseling staff for malpractice and wrongful death — and while they settled with the counseling staff, a judge dismissed their suit against the university and its administrators. "We had stars in our eyes," acknowledges Ms. Go, who had suggested that her son visit the campus counseling center after he became devastated over a breakup with his girlfriend. "I thought: elite school, elite everything."

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Judy Asbury, a Caltech spokeswoman, says, "Brian did report that he had contemplated suicide but denied that he continued to have suicidal feelings." The university made the same point in its legal response to the suit, saying its counselors had determined that Mr. Go was not "imminently suicidal." It also said that, from a legal perspective, "universities and their administrators have no general duty to protect students."

Families often expect campuses to provide immediate, sophisticated, and sustained mental-health care. After all, most parents are still adjusting to the idea that their children no longer come home every night, and many want colleges to keep an eye on their kids, just as they did. Students, too, want colleges to give them the help they need, when they need it.

And they need a lot. Rates of anxiety and depression among American college students have soared in the last decade, and many more students than in the past come to campus already on medication for such illnesses. The number of students with suicidal thoughts has risen as well. Some are dealing with serious issues, such as psychosis, which typically presents itself in young adulthood, just when students are going off to college. Many others, though, are struggling with what campus counselors say are the usual stresses of college life: bad grades, breakups, being on their own for the first time. And they are putting a strain on counseling centers.

Colleges are trying to meet the demand by hiring more counselors, creating group-therapy sessions to treat more students at once, and arranging for mental-health coordinators who help students manage their own care. A couple of colleges have even installed mental-health kiosks, which look like ATMs and allow students to get a quick screening for depression, bipolar disorder, anxiety, and post-traumatic stress.

But there is no consistent, nationwide standard of mental-health care on campuses, says Victor Schwartz, medical director of the Jed Foundation, which promotes emotional health among college students. "There are places functioning as top-of-the-line," he says, "and some that are extremely rudimentary."

Just how much should parents and students expect of colleges when it comes to mental-health care? Campuses are first and foremost educational institutions, after all, not health-care providers. Mentally ill students can pose substantial challenges — not just to an institution’s resources, but also to their own ability to succeed academically, to their safety, and even to the safety of the campus.

"There is a real sense of responsibility, that part of our job and mission now is the whole student, not just the education of the mind," says Beth A. Pontari, chair of the psychology department at Furman University. "Our job is to produce better-functioning people. But when you have students who are more medicated and have been seeing a therapist since they were 12, that is very difficult."

Dan Jones, who has directed the counseling center at Appalachian State University, is a past president of the Association for University and College Counseling Center Directors. What’s happened at Appalachian State is a window on the demand for mental-health services in higher education.

Initial screening interviews with students at the counseling center increased by 65 percent from the fall of 2009 to the fall of 2014, and individual therapy sessions rose by 50 percent over the same period. The number of students who said they had thoughts of ending their lives more than doubled, to 400 last fall, among a total enrollment of about 18,000. In the academic year just past, three App State students killed themselves. Nationally the number of college-student suicides has remained about the same, but it is the second-leading cause of death, after accidents.

The counseling center at Appalachian State limits students to about a dozen individual therapy sessions a year, although counselors have the discretion to extend that limit. Until this past academic year, the center usually had a waiting list with as many as 80 names. Students typically waited more than a week before a counselor could see them. But in January, the center added a full-time staff member plus several part-time therapists, eliminating the waiting list.

Other institutions have been unable to keep up. Surveys indicate that nearly one third of college counseling centers have waiting lists.

Are students just more troubled than they used to be? In a 2013 paper called "Perfect Storm for Counseling Centers," which Mr. Jones has shared with fellow directors, he lays out the forces behind the rising demand for college mental-health services. Mass shootings in 2007 and 2008 by mentally ill students at Virginia Tech and Northern Illinois University, respectively, prompted many colleges to cast a wider net to identify troubled students — and send them to the counseling center. Campuses now have threat-assessment teams to watch for disturbed students. Professors are on alert for students who exhibit troubled behavior in the classroom.

In an interview, Mr. Jones says students do seem less resilient today than in the past. "They haven’t developed skills in how to soothe themselves, because their parents have solved all their problems and removed the obstacles," he says. "They don’t seem to have as much grit as previous generations."

Students also are under greater pressure to perform, experts say. Some have been building their résumés since high school, earning top grades and spending hours practicing and competing with athletic teams and perfecting extracurricular skills.

In addition, as mental illness becomes less of a stigma, more students are arriving on campuses having already seen therapists — and taken medication — while in high school.

Jessica Schwartz will be a senior at Appalachian State this fall. She has been seeing therapists since she was 13 and began attending group counseling sessions and individual therapy at the university during her junior year. She has also continued working with a therapist in her hometown via Skype. Ms. Schwartz suffers from depression and anxiety. Her father was mentally ill and took his own life a few months ago, she says. "Coming to counseling at App State has really helped me find the tools within myself to be my own magic wand."

But students at many colleges have been frustrated with the quality of mental-health care on campus. And they are letting administrators know.

At Tulane University, after Shefali Arora ran through the 12 sessions of on-campus therapy allotted each student, she was left on her own to find further care. "They said, ‘Here’s a list of therapists.’ But I didn’t have a car," says Ms. Arora. She struggled to find a new therapist, balance her medication for bipolar disorder with drugs she was taking for birth control and allergies, and persuade professors to give her extra time to complete assignments.

"I told my professors, ‘I’m bipolar, I haven’t slept in days,’ " she recalls. "A few really understood, but most didn’t. I had to drop out of one class, take a lot of C’s, and just muddle my way through."

After deciding to take a semester of medical leave, Ms. Arora tried to commit suicide just before graduating last December. When she recovered, she created a Google document called "Dear President Fitts" and invited students to write about their experiences with Tulane’s counseling center. The document was a lightning rod for dissatisfaction, growing to 56 pages. She sent it to Tulane’s new president, Michael A. Fitts.

"The issues were very familiar — the ever-increasing needs of students wanting to access services and a somewhat challenged staff," says J. Davidson Porter, vice president for student affairs. "And the need for intensive or long-term therapy versus what a college counseling center can provide."

Starting this academic year, Tulane — which attracted media attention last year because of three student suicides — has made a variety of changes. Students can now get up to a dozen therapy sessions per year. The counseling center, which closes at 5 p.m. each weekday, has contracted with a local mental-health service to provide an evening hotline. Tulane also has named an administrator to help students find therapists in the community who can provide long-term care. And it has bolstered the team of social workers who, among other things, help students communicate with professors about mental-health troubles that may have caused them to miss class or perform poorly.

"We are a private institution with a high tuition, and that drives expectations of families," says Mr. Porter. "They expect us to have high-class services across the board. But how do colleges and universities respond in ways that recognize that we have thousands and thousands of students? How do you provide what you can but have appropriate limits?"

The pressure that colleges feel to offer comprehensive mental-health services is similar to expectations of them in cases of sexual assault. Students, parents, and the federal government demand that colleges respond promptly to rape complaints and adjudicate them fairly — including punishing offenders, regardless of whether the police are involved. But colleges aren’t necessarily outfitted for the job of judging rape, and many have stumbled. They are spending months, if not years, revising their policies to meet federal guidelines and trying to figure out how to handle cases while staying out of court themselves.

Just as colleges have been accused of failing to respond adequately to sex-assault complaints and of working primarily to avoid bad PR, they have been accused of acting in their own self-interest when it comes to students’ mental-health concerns.

For example, the University of Oregon prompted protests in March when it demanded that its counseling center turn over to university lawyers the therapy records of a female student who was planning to sue the institution for the way it handled her rape allegations. Jennifer Morlok, a senior staff therapist at the campus counseling center, had protested that demand to university administrators and to the U.S. Justice Department, saying therapy records should remain confidential no matter what. The university has acknowledged obtaining the student’s counseling records but says it did so legally. Now the U.S. Education Department has drafted guidance, saying student medical records should stay private with only a few, specific exceptions in cases where colleges that are sued need the information to defend themselves.

When it comes to students’ privacy, colleges generally say they will contact parents if they feel a student is in imminent danger of self-harm.

But Charles B. Anderson says the next step that some colleges take, insisting that the students withdraw, is a step too far. Mr. Anderson, a licensed clinical psychologist who has served as associate director of the counseling centers at both Virginia Tech University and William & Mary, says colleges’ concern over their own liability in such instances often trumps concern over students’ mental health. That threatens the integrity of campuses as places students can trust to treat their mental-health problems, he says.

In a Washington Post essay in May, Mr. Anderson wrote that too many colleges force potentially suicidal students off campus and into treatment by private hospitals or therapists simply to avoid lawsuits and potential harm to the campus’s stability and reputation. If students want to return after such a leave, they must prove that they have received care. In some cases, such as at some Ivy League institutions, they must apply for readmission.

"There is no therapeutic basis for such a policy. It is the antithesis of treatment planning and continuity of care," writes Mr. Anderson, criticizing "a strategy that treats students as a problem to get rid of rather than a person who is suffering and in need of care."

In fact, he says, the move can backfire. "When students get the idea that they are going to be mishandled by administration for reporting suicidality, it’s pretty clear that the next step will be to underreport symptoms or avoid the school’s mental health resources altogether."

After a Yale undergraduate killed herself in January, students protested college policies they said had contributed to her despair. She had written in her suicide note that she "needed time to work things out and to wait for new medication to kick in," but feared that if she took time off and withdrew from Yale, she would never be readmitted. Yale is in the process of changing its policy to ease readmission for those who take a leave for medical or personal reasons.

William & Mary requires students who leave for mental-health problems, whether voluntarily or at the request of the college, to prove that they have received adequate care off campus before they can return. Family members who protest such requirements often are acting out of fear, says Mr. Crace, the associate vice president, rather than out of concern for a student’s best interests. "This is a fear of losing one’s dream and path in life. When that starts to unravel, the fear is escalated," he says. "But part of our job is helping them move away [from campus] and focus on what is most right for them right now."

Ms. Smith-Christmas, whose brother went through that process at William & Mary and then killed himself shortly after he returned, doesn’t blame the college for her brother’s death. "At the end of the day," she says, "there was only one person who made that decision."

But she wishes the college had treated him differently — more the way it treated her when she was a student on the same campus five years earlier. She, too, was feeling desperate and, she says, William & Mary could very quickly have sent her home, as it did with her brother. Instead, says Ms. Smith-Christmas — who attended college before the shootings at Virginia Tech and Northern Illinois put everyone on high alert for mentally ill students — the campus simply set up counseling sessions for her. "It changed my life," she says, "in a very positive way."

Robin Wilson writes about campus culture, including sexual assault and sexual harassment. Contact her at robin.wilson@chronicle.com.

Clarification (9/4/2015, 11:52 a.m.): An earlier version of this article was unclear about Caltech administrators' response to Brian Go. The article has been updated to reflect that they referred him to a counselor the same day they learned he had threatened suicide, and that they respected his wish that they not contact his parents.