Beautiful Minds Seminar

Paper for Seminar 1 by Ravi Rana

Widening participation will result in the mental health profile of the student population approximating more closely to that of the general population. This entails a more ‘normal’ spread of presenting problems and also a likely increase in demand for mental health care from within the student community in terms of absolute numbers.  The current situation with regard to the mental health needs of students is that they are met partially through NHS services and partially through student counselling services. In most parts of the country these provisions are independently configured.

The provision of mental health care for students in this form has come about largely in an unplanned and ad hoc fashion and, when students formed a small part of the population, worked reasonably well.  The situation today, and for the foreseeable future, is very different.  The government expects that by 2010 half of the young adult population (those aged 16-24) will be students. (While efforts to boost the number of mature students continue, the vast majority of students in higher education will still be young people.)

It is likely that it will no longer be feasible to deliver mental health services to such a large section of the population in a haphazard way and planning and co-ordination between higher education and NHS services will become increasingly necessary. In thinking about how to improve collaboration between the services, I believe that two important issues require clarification.  First, what sort of mental health services are necessary for the majority of students and, second, who is best placed to provide these. 

There are a number of factors to consider in thinking about what sort of mental health services are necessary and I want to mention some of these briefly, no doubt these will come up for further discussion later.

·        The first, and to my mind most significant, point to consider in our thinking about how to attend to the mental health needs of students is the fact that most students are young people on the threshold between adolescence and adulthood and that many of the problems they present are related to this. They are caught up in the latter stages of developmental processes characterised by their struggle towards independence and the evolution of a personal sense of identity. This is inevitably a turbulent period and the fluidity of this situation makes people of this age vulnerable to developing a severe mental illness. On the other hand, it also affords an opportunity for new growth, a chance to find new solutions to old problems. With these themes paramount in thinking about what type of support and treatment services we offer, the ‘ideal’ intervention with the majority of students might be one that supports and fosters the ongoing process of adolescence with dependence on counsellors or therapists kept to a necessary minimum. However, a significant number of students do not negotiate this period of vulnerability adequately and proper provision for monitoring, assessment and support for students with severe mental health problems will need to be considered.  I will say more about this later. 

·        A second important factor in thinking about provision for students is the importance of responding swiftly to requests for help from students.  Most students seek counselling when a crisis point is reached, that is, when they cannot find a way of moving forward on their own and they recognise that they are in need of help. In these circumstances, a fast response to their needs is important and, if timely, a brief period of counselling is often sufficient to get them back ‘on track’. If they have to wait too long for help because of lengthy waiting lists, they may give up and withdraw, taking with them an experience of their efforts to obtain help having been frustrated. Of course, no service can expect to provide instant access. However tolerance levels amongst adolescents are much lower than amongst adults and this has to be borne in mind in the design and provision of services for students. Counselling that is accessible when the student wants and needs it is much more likely to be effective than that which comes available weeks or months later, not least because of the more ready access to feelings which may not have yet been obscured by the development of a system of defences. In determining what constitutes a reasonable response time, the structure of the university’s academic year as well as the timing of the student’s request for help have both to be taken into account.

·        A third factor relates to the frequent changes of address that many students effect, often within the same academic year.  This can cause difficulties in accessing local NHS services, which are geographically sensitive.

·        Academic life carries with it particular pressures related to the processes of learning and study and to performance. Sensitivity to, and expert knowledge in dealing with, these pressures is necessary in provision for students.

·        Another factor that needs to be borne in mind relates to the temporal parameters of most universities. In recent years some universities have shifted away from the traditional structure of the academic year, however many have retained this basic format.  One consequence of this is that there are seasonal changes in the level of demand that students make upon services and this can be difficult for services external to the university to accommodate. For example, many students return home outside of term time which may cause attendance problems for standard 12 month services.  In addition, students may be registered with two GP’s, at home and at university, which can lead to confusion and also, to neither Health Trust being willing to assume the responsibility for provision of care.

·        Related to this is the importance of support through critical times in the academic calendar. 

Having outlined briefly some of the factors that I believe are important in determining appropriate mental health provision for students, I now want to turn to the second issue of who is best placed to provide these services.

My own view is that mental health services for the student population should ideally be provided through specialist services within the university and that these should be supported, as necessary, by the NHS. Given the pressures on ordinary NHS mental health departments, it is unreasonable and unrealistic, with the best and most enlightened will in the world, to expect them to be able to make special provision for the unique needs of the student population.

The demand for mental health care amongst students has been steadily rising and much of this growing burden has fallen on student counselling services, most of which are not adequately resourced to deal with the increase in number of students presenting with severe mental health problems.  Some part of this stems from the fact that waiting lists for the treatment of mental health problems within the NHS are lengthy – for example, in Tower Hamlets, where I work, waiting times for psychological services can be as much as six months for assessment and perhaps a further year for treatment.  Again, in my previous work within student counselling, the local NHS psychotherapy department would refer students to us because of their lengthy waiting list.  For the reasons I have already outlined, waiting times such as these are inimical to adequate, let alone ideal, mental health care for students.  Moderate mental health, if unattended, often seriously impairs a student’s capacity to function adequately.  This, in turn, threatens the continuation of their studies. The potential loss of their functional identity as a student carries with it associated losses – for example, social relationships and accommodation are both likely to be disrupted.   The cumulative effect of these additional losses can only serve to augment the original problem, and may turn a moderate problem into a severe one. This outcome serves no-one’s interests: apart from the potential tragedy for the young person him/herself, the university may lose a student; the NHS may end up with yet another patient with severe mental illness. 

As I have said, pressures upon adult mental health services in the NHS are such that existing demands cannot be met and this situation is likely to become worse. One consequence of this is that services are under pressure to direct their resources to patients whose needs are already considered to be severe. At least one large mental health trust in North London is presently discussing with their commissioning bodies (the Primary Care Trusts) the necessity of tightening their eligibility criteria for community mental health services to those with Severe and Enduring Mental Health problems.  To put it plainly, students with moderate problems who are still managing to continue with their studies are not a priority.  Added to this, there is now an enormous amount of administrative work that accompanies referral and treatment within the NHS and this bureaucratic burden makes for difficulties in the provision of quick response services other than for emergencies. 

There is, in my view, another powerful reason for locating the main provision of mental health care for students outside of the NHS and within the framework of the university.  I do not believe that it is conducive to the emotional development of young people to become mental health patients within the NHS unless there is absolutely no alternative.  The unfortunate reality is that becoming a patient in this context continues to carry with it strong associations of dependence and passivity and responsibility for one’s mental welfare is, to a greater or lesser extent, ceded to professionals. (While constant guidelines and arguments are put for more enlightened services, they are difficult to effect under current financial and staffing constraints.) At the level of psychological development, the main developmental themes through adolescence and early adulthood concern the evolution of a capacity to think for oneself, essentially the development of an independent mind.  This is entirely congruous with the educational remit of the university, where the capacity to think for oneself is promoted and encouraged.  This confluence of purpose makes the university an ideal environment place for many young people whose personal history has failed to equip them adequately for adulthood and who might otherwise break down or collapse under the ordinary demands of adult life. While the primary aim of universities is not, of course, therapeutic, the atmosphere of the university is one that encourages thinking and the cultivation of understanding and, as such, one might hope it would be more conducive to psychological growth and development; for some students, it might provide a second chance to develop some of the tools they will need later in life.

When a student’s mental health problems are sufficiently severe that they are no longer able to function as a student, they may be appropriately directed to the mainstream NHS.  However, while they are able to manage their studies, even if precariously, then I think that the most effective place for them to receive help is from within the university, with the support of external services such as the NHS. 

I would like to propose that, in its thinking about the effective and efficient provision of mental health provision for students, the government should consider the deployment of resources into front-line counselling services within universities. By this I do not mean the introduction of NHS mental health departments or units within universities. Rather I would envisage a joint venture between higher education and the NHS in which existing student counselling services might, in consultation with local NHS agencies, be expanded and reorganised to enable them to provide for the majority of the health care needs of students. One potential model for such partnership is where psychiatric sessions are directly funded to support a student counselling service.  Some services already have this structure. Liaison psychiatry initiatives may offer another model.

Formal assumption by student counselling services of an increased level of responsibility in relation to the mental health care of students would mean a greater scrutiny of competencies within student counselling services and might also mean that certain bureaucratic measures, for example ones akin to the Care Program Approach in the NHS, and other mechanisms to ensure good practice such as protocols for risk assessment, ‘key working’, and so on would become necessary.  (I understand that some of these are already integrated into some services.)

In conclusion, I believe that a working partnership between higher education and the NHS would be of mutual benefit to both agencies– for example, in terms of improving student retention and in the prevention of severe mental illness.  As I have already said, I do not think that this can be achieved without the considerable overhaul of existing student counselling services and while major changes in the structure and provision of services will inevitably arouse anxiety and concern, I think that radical change is necessary as well as desirable if student counselling within higher education is to continue to play the more significant role in the mental well-being of students as I think it should.

ã Ravi Rana 2002