DEGREES OF DISTURBANCE: THE NEW AGENDA

Report written by:
Ravi Rana University College London.
Eileen Smith University of Hertfordshire.
Julie Walkling University of North London.

1. A Working Group to investigate the impact of increasing levels of psychological disturbance amongst students in higher education was set up following a national meeting of Heads of University Counselling Services. This was the outcome of a discussion in which considerable concern was expressed about an observed increase in the number of students with severe psychological problems, many of whom were presenting to counselling services and/or coming into conflict with their institutions. At the meeting in October 1997, the perception by university counsellors of an increase in emotional and behavioural disturbance amongst students presenting to counselling services was confirmed by many heads of service. The meeting considered it timely to investigate this matter further and to bring the increasing level of mental health difficulties, and their consequences, amongst university students to wider attention.

2. There are significant difficulties in establishing common definitions in the field of mental health. While the picture is clearer for the adult population, the situation with regard to data collection on the extent of mental health problems among young people[1] and the categorisation of those problems on a standardised basis, remains highly unsatisfactory (CAMHS Report, 1997). This uncertainty notwithstanding, there is a general consensus that mental health problems among young people are rising (Rutter and Smith, 1995; NHS Health Advisory Service, 1994). This report addresses observations of an increase in psychological disturbance amongst university students. The term "psychological disturbance" is used here to encompass a wide range of problems, including psychiatric illness, behavioural disturbance and psychological and social difficulties, which may seriously and adversely affect the ability of students with such problems to pursue their studies adequately.

3. While there is broad agreement from counselling services that the severity of emotional and behavioural disturbance amongst university students is increasing, statistical evidence in support of this consensus is, as yet, extremely limited. In part this is attributable to the stigma and fear still In part this is attributable to the stigma and fear still attached to mental illness which leads to failure of disclosure by both the sufferers and those around them; fear of mental illness also prevents some individuals from acknowledging problems and seeking appropriate help. For example, only a small proportion of students who apply for higher education indicate on their UCAS application that they have a disability on mental health grounds. UCAS figures show a fairly unchanging picture in recent years of around 0.05%. In 1997 this percentage referred to 163 students (of 322,282 students accepted), or approximately one-and-a-half new students each year per higher education institution, who reported a disability on mental health grounds. This is at great variance with reports from counselling services. The Working Group has therefore drawn upon oral and written evidence from a wide variety of sources to investigate this issue including government statistics where available, current research funded by the Higher Education Funding Council for England (HEFCE)[2], reports from experienced counsellors and heads of services, and reports from practitioners and specialists in related fields.

4. The report from this Working Group is also a response to recent government policy on higher education which advocates widening access (for example, the Dearing Report, 1997) but fails to acknowledge the broader impact of this policy with regard to extra support needs. For example, a recent Department of Health report[3] stated that, "there is evidence of an increase in poor mental health in children and young people…particularly in young people who are socially disadvantaged". The report added that, "there are marked inequalities in who suffers most from mental health problems; for example men of working age who are unskilled workers are more than twice as likely to commit suicide than men in the overall population and women are more likely to suffer from anxiety, depression, phobias and panic attacks…similarly, women born in Sri Lanka, India and the East African Commonwealth countries are 50% more likely to commit suicide than women as a whole". To date, reports from the Department for Employment and Education (DfEE) and other bodies have not adequately recognised the additional resource implications of widening access to higher education for young people and individuals from socially disadvantaged groups.

5. The government's recently announced changes to the Care in the Community policy were driven by failures in previous policy to meet adequately the needs of people with acute mental health problems and to protect the public; these changes are directed towards provision for individuals likely to be at risk of serious harm to themselves or to others. Whilst this is a welcome move, it does not address the situation of those with severe mental health problems who fall into the ‘serious yet not likely to harm others' category. This is often the group of people for whom there is little provision and who are often of most concern to university counselling services.

6. This report contains oral and written evidence (italicised) from counselling service staff working in higher education. In order to protect the confidentiality of individuals, identifying details have been removed or changed and examples are not attributed.

   [1] Definitions of ‘young' vary from study to study and in different services, with upper age limits ranging from 18 up to 30 years.

   [2] See Appendix I

   [3] Our Healthier Nation: a contract for health. Presented to Parliament by the Secretary of State for Education. London: Stationery Office, 1998, p76 point 4.37

   B.

   THE CONTEXT

   Widening Access

7. Developments in access to higher education are to be welcomed. Many very able people have been denied the opportunity to study in previous years, and their inclusion is right and proper. With appropriate support systems in place, higher education has an important role in enabling individuals with psychological problems to develop their personal, social and intellectual abilities more fully and, therefore, to make a greater contribution to society.

8. The promotion of widening access to higher education in government policies and, more recently in the Dearing Report, means an increase in the actual number of students who will proceed into higher education. For the year 1998/99 approximately 31% of school leavers are expected to enter higher education. In addition, there are a number of initiatives from the Higher Education Funding Council to promote access into higher education. Many higher education institutions have doubled or tripled student numbers without any commensurate growth in support services.

9. This policy explicitly states that the Government's priority is to "…include those who have been under-represented in higher education"[4]. This means that greater numbers of students from ‘non-traditional' backgrounds will enter universities, for example, Asian women, African Caribbean students, mature students, students with families, students who are the first in their family to enter higher education, disabled students, and students with experience of psychiatric illness. These students, who have been disadvantaged in many respects, often require greater support than those from more ‘traditional' backgrounds.

10. However, despite the potential impact of widening access to include these groups, plans for corresponding expansion of the support services provided by higher education institutes have not been adequately developed. This has resulted in greater pressure being placed upon existing services and academic and administrative staff.

11. The Disability Discrimination Act (DDA) (1996) has provided an impetus for positive changes of policy. The act defines disability as "a physical or mental [5]impairment which has a substantial long term effect on a person's ability to carry out normal day to day activities". A recent discussion paper from one university has summarised the urgent need for universities to respond to the mental health related issues raised by the DDA:

    Until recently, issues of mental health might have seemed irrelevant to higher education save as an area for research or as part of the curriculum. Institutions could lawfully choose not to recruit or retain staff or students with mental health needs. The direct experience of most staff in higher education of supporting people with mental health needs was therefore limited; and the policy/ procedural framework that might provide support reflected the premise that mental health was not part of the institutional agenda.

    However, changes in the legal, funding and educational frameworks create a new agenda for institutions of changed responsibilities and expectations. (Marcella Wright, 1998)

12. The requirements of the Act in effect mean that universities must develop a comprehensive approach to meeting the needs of disabled people. These developments are already impacting on support services in both positive and negative ways. For example, student counselling services are being consulted more frequently with regard to the development of policy; however, they are also being asked to make more and more assessments with regard to the current or future mental health status of students. The DDA is already perceived as increasing the numbers of disabled students entering higher education, including students with mental health problems, and this augers major changes for many universities.

13. Many universities now have disabilities officers to assess and support the needs of disabled students. However, much of the work relating to disabled students is based on students disclosing their needs. Anecdotal evidence suggests that students with mental health problems are much less likely to identify themselves than students with physical disabilities. In addition, many students develop psychological difficulties after they have started university.

14. The impetus for new initiatives for the development of support for students with psychological difficulties is currently coming from the disabilities sector. HEFCE funded projects have been established, and some conferences and seminars are being held for those working with disabilities services. Most of these developments have followed on from the introduction of the DDA and have been confined to the disabilities sector; as yet however there have been few initiatives from other areas concerned with student welfare.

    [4] Higher Education in the 21st Century – Response to the Dearing Report, DfEE, 1998, p7

    [5] Italics added

    Educational Context

15. Financial pressures on students have increased because of changes in policies on fees and grants necessitating, in many cases, students taking up paid work during their studies. For a significant number of students, the additional strain can precipitate psychological disorders. The pressure to secure jobs in order to repay loans and debts accrued during studies also becomes intense during the student's final year of study and, along with the strain of final year examinations, greatly increases the burdens upon students during their final year. In a preliminary study, ‘Student finance and mental health', Roberts, Golding and Towell (1998) reported their findings that:

    ...poorer mental health was significantly related to difficulty in paying bills as well as to longer working hours outside university. In addition, we found that people had considered abandoning their course of study for financial reasons had significantly poorer mental health, poorer perceived general health, lower vitality and poorer social functioning. All the effects we observed were far from small. Given the current picture of widespread economic problems in the student body, these findings suggest that large numbers of students may be at risk.

    In addition, a recent report from Roberts et al (unpublished) has noted that:

    …[for students] being in debt was significantly associated with knowing people involved in prostitution, crime or drug dealing to help support themselves financially.

    The following example is illustrative of the damaging impact that financial difficulties may have on the psychological well-being of students. medical student in her final year of study had gone to her GP complaining of severe headaches and difficulties in concentrating on her studies. Medical investigations failed to reveal any physical cause and she was referred to the university counselling service as suffering from "stress". She eventually admitted to her counsellor that she had been working in a bar three nights a week as well as during weekends throughout the term. She explained that she had taken up paid work after her father had been made redundant and her family was no longer able to support her financially. She had not told her GP or her tutors about her work in the bar because she had been afraid that they would tell her to give it up. While she was aware that her paid work was seriously interfering with her medical studies and that she was exhausted, she could see no alternative if she wanted to continue at medical school.

16. The fact of increasing numbers of both full-time and part-time students since 1992 has created a much busier, less personal study environment which requires that students possess greater degrees of mental robustness and an ability to work independently. For many students, teaching staff are distant people to whom it is hard to gain access and it is possible for students to undertake their studies with few, if any, staff members being aware of their psychological well-being. In many cases this is because the number of students on some courses is very large and the amount of time that academic staff have available to interact with individual students is comparatively small. This is in direct contrast to the situation that prevailed before 1992 and the general expansion of student numbers in higher education. The resulting deterioration in the quality and quantity of pastoral care traditionally provided by teaching staff has had adverse consequences for many students and indeed for many academics. Teaching staff are often frustrated by their inability to help through time constraints or because they have no personal contact with many of the students they are teaching. The following example demonstrates how increasing demands upon academic staff have led to changes in their roles.

    A tutor in a department whose intake of students had doubled over the past three years, without a commensurate increase in staff, reported that he had had to reduce drastically the time he had available to see individual students. The damaging effects of the decline in his personal contact with, and knowledge of, his students came to his attention when he was told about the attempted suicide of one of his students. This particular student, who had become severely depressed, had stopped attending classes early in the first term and half way through the second term had taken an overdose. Fortunately he had been found in time. The tutor, who had been extremely distressed by this event, observed that in previous years he would have known his students individually and would have noticed when a student was not attending classes and been able to follow this up.

17. Changing demands on academic staff have reduced the time available for pastoral duties. There has been a shift in course structure and delivery towards modularity in many institutions. While this shift has ushered in greater flexibility for students, significant disadvantages have included the loss of a stable peer group for students and greater discontinuities in contact between staff and students, creating further difficulties for academic staff in following the progress of their students. In a similar vein, changes in fee structures have led to more students studying part-time. While this development may reduce some pressures, the overall student experience is, inevitably, more fragmented.

    In many universities escalating demands on academic staff as a result of the Research Assessment Exercises, and concomitant pressures to increase publication rates, have also contributed to an erosion of the time available for staff-student contact.

    An additional source of pressure in many institutions has been a requirement upon staff to generate income.

    Societal Shifts

18. Increased instability in family life due to various factors, including high rates of marital breakdown and uncertainty around employment, has been reflected in higher levels of insecurity in students, especially those coming directly from school. There have been a number of recent studies highlighting the breakdown of the traditional nuclear family. The Office for National Statistics (1998)[6] reported that more than one in five children now live in a single parent family by the age of five; the National Child Development Study[7] estimated that one in eight children will experience life in a step-family. There is increasing evidence that the breakdown in traditional family structures leads to greater psychological vulnerability amongst the children in those families. For example, research funded by the Joseph Rowntree Foundation7 concluded that more than 12% of stepfathers and 20% of their partners were depressed, twice the rate of depression found in other families. In their report of studies on the effect of family life on the mental health of children and young people, MIND (1998) state that, "...poverty and family discord seem to be the most important factors in increasing risk of childhood mental health problems...and are likely to occur when the parents are unemployed, divorced, living alone or homeless." The situation is particularly difficult for students who have been in care. Social Services support stops at age 16 and there is no specialist late-adolescent psychiatric service. There are many other students who have no stable home to return to as a consequence of parental divorce or other factors. The level of support required by these students is often higher than those with a traditional stable family background. In many ways, universities are filling gaps left by the decline of traditional family structures.

    [6] The Guardian, 17th June,1998

    [7] The Guardian, 10th June 1998

    Community Resources/Health Provision

19. The Care in the Community policy and the creation of Health Trusts have radically altered traditional systems of mental health provision, making them less accessible in many cases. A number of student counselling services have reported increasing difficulty in establishing medical responsibility for students with severe mental health problems, especially for those who study away from home. The following example is typical of the confusion that can arise.

    Support in her home town was being sought for a young student who had been experiencing severe mental health difficulties to the extent that she had been hospitalised for a number of weeks. Her university counselling service was told that because the student had registered with a doctor in the locality of the University her records had been transferred there. Consequently it was considered that she was no longer a patient at the surgery near her parents' home although this was her permanent non-term time address. Counsellors were caught between their local Health Trust's insistence that the student should ‘go home' in order to receive the support she needed and the Trust in her home town insisting that she was no longer their responsibility.

20. While it may be entirely appropriate for students who have received treatment for psychiatric problems within the NHS to be referred to university counselling services for counselling and support during the course of their studies, there are some reports which suggest that university counselling services are being used inappropriately by over-stretched NHS services. There sometimes appears to be an implicit assumption that university counselling services will be able to make up for shortfalls in the provision of psychological treatment and support within the NHS. The following two examples highlight some of the problems arising from this position.

    A student enrolled at a university several hundred miles from his home, having been advised that this would be a rehabilitative experience after his long periods in a psychiatric unit. The admitting university was unaware of the student's history because the student had been told that it would help him to make a ‘fresh start' if no-one knew of his past. Unfortunately within the first week the student suffered a major psychotic episode which led to him being hospitalised and having to defer his entry into the university. Subsequent discussions between the counselling service and his local health centre allowed a number of support measures to be put into place which enabled the student to cope with the pressures of university when he returned the following year.

    One university counselling service had been working for two years with a student with increasingly severe mental health problems. These culminated in a number of incidents involving the police and a long period in a psychiatric unit. The counselling service was not approached by medical staff treating the student and was therefore surprised to receive a long medical report stating that the student had been diagnosed with a personality disorder, was about to be discharged and that the university counsellor who had been working with her would now be responsible for her care.

21. Even where good liaison and co-operation between university counselling services, GPs and local psychiatric services exist, in some regions current NHS resources are such that unless a student is a danger to themselves or others, often the only provision immediately available is medication and follow-up appointments at comparatively lengthy intervals. As subsequent appointments are often with a different psychiatrist - because of the rotation system of training within psychiatry - continuous assessment and appropriate care are frequently difficult to obtain. At present, in some areas, there appears to exist a void in provision and those who come into association with a disturbed person are in the invidious position of needing a crisis - such as a mental breakdown or suicide attempt - in order to gain access to hospital services. The following example is illustrative of this problem.

    Counsellors at one university struggled to obtain an appropriate NHS referral for a young student in the early stages of mental illness. Discussions with her psychiatrist and community psychiatric nurse made it clear that specific treatment at an early stage would likely be effective in arresting and possibly reversing the progression of her condition. However, resourcing levels meant that as she was not a danger to others, and not currently a danger to herself, she could not be given access to the help she needed. She was not classified as ‘ill enough' although all agreed that her condition was likely to deteriorate and become harder to treat as she grew older. Subsequently, this student became more disturbed and was hospitalised for a month. She was discharged because of a pressure on beds. She subsequently came into conflict with the police and social services through a number of incidents. She has since dropped out of university.

22. The inadequate provision of mental health services for young people has been documented in a government Health Committee Report on Child and Adolescent Mental Health Services (1997). The report concluded that:

    Child and adolescent mental health services have historically been neglected as a priority area within the NHS. There remain major weaknesses in the commissioning and provision of CAMHS. The Government itself admits that there are problems and the service is "patchy".

    In February 1999 the Department of Health went some way towards recognising the underfunding of CAMHS by increasing the current annual budget of £150 million by an additional £85 million, to be spread over three years.

23. Young Minds, the young people's mental health charity, called together a working group of experts from the health service, education, social services and the voluntary sector in June 1998. The meeting reached the following conclusions about the needs of 16-25 year olds:

    Current provision for this age group is very patchy. Young people may go to their GPs but often get an unsatisfactory response. There were concerns at the disparity in the high proportion of young women using mental health services - including counselling - as compared with young men. This may in part be to do with the unsuitability of services for young men. The co-ordination between services in relation to this group was recognised to be very poor. Social Services Departments do not work with this age group at all.

    There are some important messages from research in relation to this age group. The prevalence of psychiatric disorders in 16-25 year olds has increased and disorders such as depression, schizophrenia and eating disorders are likely to be in their most acute phase during this stage of life.

    Services for this group need to cater for its particular needs and should not parallel existing provision. These needs relate to the transitions that are being made around this time, e.g. leaving residential care, developing sexual relationships, coping with work patterns. This age group is ambivalent about sources of help and is struggling with feelings of dependence and independence. Some specialist services are therefore needed, with staff who have a developmental focus. Fragmentation of service provision can be a problem but more appropriate gateways are needed. New models may be needed.

    C.

    THE NATURE AND PREVALENCE OF MENTAL HEALTH PROBLEMS AMONGST STUDENTS

24. There is not as much hard information about mental health problems among students as we might wish. However, there is a body of research on the incidence of mental health difficulties in young people from which conclusions about the likely prevalence of mental health problems among students can be drawn. By far the most comprehensive study is Rutter and Smith's 1995 'Psycho-Social Disorders in Young People'. This examines and weighs evidence from a wide range of cross-national European studies. Rutter and Smith define psycho-social disorders as "crime, suicide and suicidal behaviours, depression, eating disorders (anorexia nervosa and bulimia), and abuse of alcohol and psycho-active drugs" (1995: 763). They conclude that, "the prevalence of all of the disorders in young people has increased in the post-war period except that there is insufficient evidence to come to a firm decision on eating disorders" (1995: 779), and point out that, "it is striking that the rise in psycho-social disorders over the last 50 years is a phenomenon that applies to adolescents and young adults and not to older people" (1995: 807). Rutter and Smith state that: "Suicide accounts for a far higher proportion of all deaths among younger than among older people" (1995:770). They draw particular attention to the increase in the suicide rate in young men:

    ...there were substantial increases in rates of suicide among young males aged 15-34 between 1970 and 1990. ...Among young females, there was a much less marked upward trend up to 1980 but a slight decline after that. The suicide rate is 2-3 times as high among young males as among young females, and the effect of recent trends is to increase the gap (1995: 779).

    However they point out that "the rate of suicidal behaviours, unlike suicide, is much higher among females than among males" (1995: 779). Their conclusions about depression are:

    The most impressive evidence for an increase in rates of depression comes from comparing different birth cohorts and cross-sectional community surveys. These comparisons suggest that rates of depression are higher among people who are young now than they were among young people 20 or 30 years ago. It is not yet know whether rates of depression in later age groups have also increased but it seems probable that they have not. After the age of 11, the rates of depression are higher among females than among males by a factor of about 2:1. However the difference in rates between the sexes is possibly gradually reducing over time, with the rise in depressive disorders probably marked in young men (1995: 778).

    About the use of alcohol and drugs, they find:

    It is certain that the post-war rise in overall alcohol consumption implies a considerable rise in consumption among young people. In the case of illicit drugs the picture is dominated by young people, so that overall rises in consumption are largely rises in consumption among young people. Boys use more of all substances, with the exception of tobacco, than girls, but there is some evidence of a trend towards convergence in levels of use between the sexes. (1995: 778)

    They discount certain popular explanations for this increase in psycho-social disorders. They do not, for example, link it to social disadvantage, poor physical health, unemployment, the adverse effects of the mass media or a decline in moral values. They do, however, point to the need for further research in this area.

25. The Health Committee of the House of Commons reporting on Child and Adolescent Mental Health Services in 1997 also agreed that, "the evidence that there has been some degree of increase in mental health problems in the UK, as in other countries, seems compelling." (1997:xi)

26. The Mental Health Foundation study entitled Suicide and Deliberate Self Harm (1997) draws on a number of recent British studies to compile the following statistics:

    Between 1980 and 1990 the suicide rate for men aged 25-44 increased by approximately a third, but in men aged 15-24 it increased by 85% (1997: 5)

    There is consistent evidence of high suicide rates among certain sub-groups of young Asian women, particularly those of Hindu or Sikh origin. (1997: 7)

    Research carried out in the United States suggest that suicide rates for young lesbians and gay men may be considerably higher than rates for young heterosexual men and women (1997:8)

    An estimated 40-50% of people who kill themselves are thought to have made previous attempts. Follow up studies of teenagers who have taken overdoses show that up to 11% will subsequently kill themselves (1997:10).

    An estimated 100,000 people per year are referred to hospitals in England and Wales for deliberate self harm. Approximately, 19,000 of these are young people...Recorded incidents of deliberate self harm are three to four times more common in women than in men, and more common in younger adults. (1997:10).

    The Mental Health Foundation publication points out that figures for suicides are usually underestimates. A number of deaths recorded with cause undetermined are thought to be suicides.

    In addition, recent figures from The Office of Population Statistics suggest that young men in Scotland are especially vulnerable; they report a suicide rate that is 50% greater than that of young men in England, rising to 70% in some deprived areas.

27. The Samaritans, in a recent study cited in the Guardian in March 1997, suggest that nearly one in five young women has tried to kill herself before the age of 25. Although more boys succeed in killing themselves, the figures show that 17% of girls have tried suicide compared with 8% of boys.

28. The Mental Health Foundation is currently undertaking a national enquiry into the mental health of children and young people. This enquiry has taken evidence widely and is expected to publish its report in April 1999. In February 1999, the Foundation published a preliminary report, ‘The Big Picture', which draws attention to the increase in mental health difficulties in children and young people and argues for increased funding.

    International Studies of Students

29. A number of international studies have been conducted on the prevalence of mental health problems in university students. Columbia University surveyed a group of students between 1986 and 1988 in order to assess mental health concerns. Depression was a major concern for 40% of the students surveyed; 29% reported anxiety, phobias and panic attacks as major concerns. (Myra Woolfson, 1997)

    At the University of Wisconsin a study was conducted on all students presenting to the Counselling and Consultation Service in the spring 1995 semester. The aim of the study was to examine the links between those students who were suffering from depression and academic impairment. They found that 92% of the students showed signs of academic impairment manifested as missed time from classes, decreased academic productivity and significant interpersonal problems in their department. Of those, 16% were mildly depressed, 43% moderately depressed and 41% had severe depression. (Myra Woolfson, 1997)

    British Studies of Students

30. The Research Sub-Committee of the Association of University and College Counselling produces an annual survey on the state of counselling in Further and Higher Education. The survey is sent to all FE and HE institutions and includes a question about whether, in the respondent's perception (the respondent is usually the Head of the Counselling Service), the proportion of seriously disturbed students using the Service has decreased, remained the same, or increased. In 1995/96, 62% of university counselling services reported an increase in psychological disturbance among the students they saw. Only 2% said it had decreased. In 1996/97 63% reported an increase, none a decrease. The Research Sub-committee is in the process of implementing a national scheme for rating the severity of student problems as presented to counsellors. Data from this scheme will eventually enable a more accurate assessment of changes in the level of psychological disturbance amongst students across the UK.

31. For a number of reasons vice-chancellors are reluctant to release figures about student suicides. There is anecdotal evidence to suggest that the wish to avoid potentially harmful publicity may be an important consideration. Don Foster's [8]investigation and report on the level of students' stress and suicide rates in 1995, was hampered by difficulties in obtaining data from universities. The conclusions of his report therefore are based on incomplete evidence. Nevertheless they indicate that the total number of suicides, allowing for the expansion of student numbers, has risen four-fold as shown below.

    Academic	Student	Number of	Ratio per
    Year	Population	Suicides	100,000
    1983/84	167,100	4	2.4
    1989/90	244,095	11	4.1
    1993/94	329,606	32	9.7

32. Preliminary data are becoming available from HEFCE funded projects investigating students' mental health needs.[9] For example, the project at Leicester University analysed responses to questionnaires from 1620 students (a 77% response rate). The results of this survey indicated that 40% of students were concerned with issues related to depression and that 23% were worried about managing anxiety, phobias or panic attacks. Almost one half of the students who responded to the questionnaire had concerns about self-esteem and confidence while coping with feelings of loneliness affected one third.

33. An increasing number of university counselling services have been engaging in research.
    • The University of Hertfordshire Counselling Service carried out research in 1995/96 using the SCL 90-R, a well-validated and extensively researched self-administered 90-item questionnaire, which screens for a broad range of psychological problems. The results showed that more than three quarters of students consulting the service in one three-month period scored so far above the norms established for non-patients as to be defined as at psychological risk.

    • These results are in line with research findings on levels of distress in students presenting to Counselling Services at Sheffield and Cambridge Universities (Mathers et al. (1993) and Surtees et al. (1998)). Mathers et al found ‘a relatively high level of psychiatric morbidity' and that ‘almost half of the clients had been troubled by their problem for more than one year'. Surtees et al. too found GHQ scores above the norm, a high incidence of previous consultation for psychological difficulty (almost 40%) and that 45% of the sample had considered suicide with 6% reporting attempts.

    • Three universities, Manchester, Napier and Coventry, have been piloting the use of the Clinical Outcomes Routine Evaluation measure developed by the Leeds Psychological Therapies Research Centre and the CORE systems group. The measure gives an indication of levels of distress, well-being, problems, functioning and risk. It meets criteria of being general in its application, easy to use, client and counsellor friendly, nationally credible, reliable and a means of gathering minimum necessary data for effective service evaluation and outcome research. The CORE system is now being adopted nationally across a range of mental health and psychological therapy provision. Several more universities are now joining in with this form of service evaluation of their counselling services. Provisional results from Manchester indicate that scores from students seeking counselling suggest as high levels of distress as those presenting for help within the NHS. The CORE system allows targeting of provision for those at most risk.

34. Annual Reports from different university counselling services draw attention to the degree of psychological difficulties that some of their students are experiencing. The 95/96 report for one university described 35% of those seen for counselling as having severe difficulties which they understood as including those who had attempted suicide, or with strong suicidal tendencies; those who have needed psychiatric assistance or who have suffered a breakdown; those who are seriously disturbed and in need of long-term help. The 96/97 report of another service classified 28% of students seen as having severe difficulties and 63.5% as having moderately severe problems. Of the students seen by this service, 11% had come with a previous psychiatric history, 24% had consulted their GPs for mental health difficulties and 22% had had previous counselling outside the university.

35. Ann Heyno, Head of the Counselling and Advisory Service at Westminster University, contributed an article to a national newspaper (The Independent, October 1997) on the rise in student suicide and the possible reasons for this phenomenon. She reported that in her service in 95/96, of 531 students seen, 197 (or 37%) had discussed suicide. Clearly a distinction must be drawn between ideation and positive intent but this is nonetheless a worrying statistic.

    [8] Liberal Democrat Spokesman for Education

    [9] see Appendix I

    D.

    INSTITUTIONAL ISSUES

36. A small, but nonetheless significant, number of students with mental health difficulties will have a considerable impact on other members of their university - on the members of their class groups, on academic and administrative staff. Examples of this include students who threaten, or succeed in, suicide, students who become psychotic, or students who become violent or abusive. Such students may take up an inordinate amount of time and cause a great deal of anxiety to other students and staff. This is particularly the case if they do not recognise that they have a problem and are unwilling to accept appropriate help.

37. Some students with mental health difficulties contravene the disciplinary codes of their universities as a consequence of which formal action may need to be taken. For many staff who are responsible for these students, this creates problems in finding an appropriate balance between discipline and support and can lead to inconsistencies in the application of disciplinary codes. This may result in a confusion of boundaries for students.

38. It is extremely important to note that universities do not simply receive students with mental health difficulties. The structure and culture of many institutions has considerable impact on the mental health of its members', both staff and students, and may make a considerable contribution to exacerbating or reducing existing difficulty. Student life in itself imposes extra pressures on young people. The level of support for practical, emotional and academic concerns can make a huge difference to students. This issue is discussed further in Section E.

    E.

    ACADEMIC SUPPORT AND GUIDANCE: THE QUALITY OF THE STUDENT EXPERIENCE

39. Traditionally universities have supported their students via a cohesive personal tutorial system. In recent years, with the expansion of student numbers, the drive towards efficiency gains, and casualisation, tutorial systems have become very stretched in most institutions. This seems to be especially true for those that have modularised their courses. A number of observers have commented on this including Rivis (1996) and McNair (1997).

40. Students requiring academic guidance usually turn to academic staff. Research and experience has shown that this is also true for a majority of students who require help with other than academic problems[10]. As ratios of staff:student numbers have increased, students are finding it increasingly difficult to access academic staff, who in turn report concerns about having insufficient time to support adequately their students[11]. This has the effect of compromising support systems for students with acknowledged mental health problems and of slowing down the identification and quick referral of students experiencing difficulties which may be related to mental health. It also contributes to a culture that requires increasing levels of personal robustness from students, thereby placing even more pressure on those who are psychologically fragile.

41. Increasingly institutions are placing great importance on the quality of the student experience. For the individual student, their ability to access a member of their academic staff, someone who has personal knowledge of them and can offer guidance and support, will be paramount in their appraisal of the quality of their experience. Anecdotal evidence and experience suggests that this is a substantial factor in student satisfaction.

42. In a University of Hertfordshire survey of academic staff in 1996, a large majority of the respondents stated that they wished to assist students with pastoral needs as much as possible. Many staff voiced concerns about a lack of clarity within the institution about what the expectations upon them were, as well as concerns about the lack of time available for such support. This mirrors recent research by Manthorpe and Stanley at Hull which also drew attention to anxieties amongst academic staff regarding the lack of adequate training and support in relation to their pastoral duties (anecdotal evidence suggests this view is widespread across institutions). The researchers comment that this will inevitably percolate through to, and adversely affect their support function in relation to students.

43. A number of statutory and governmental bodies have published guidelines regarding student support and guidance. HEQC have published a series of papers (1994, 1995a, 1995b) stating that students should expect "access to reliable and valid academic advice and guidance" and "regular access to a designated personal tutor, or academic advisor" who should be able to provide a range of guidance including "referral to other sources of advice and support" (quoted in McNair 1997). The Charters for Higher Education state that students should "receive well informed guidance from [their] tutors and careers staff and access to counsellors" (quoted in Rivis 1996).

44. A series of research studies by Rickinson and Rutherford (1995) and Rickinson (1997, 1998) has demonstrated the important contribution of tutoring and counselling to student retention and completion rates. This research drew attention to the high levels of psychological distress which students may experience at important transition points in the university experience[12]. Counselling intervention was shown to be effective in reducing the level of psychological distress significantly with the clinical group (1997). The studies also demonstrated that the provision of appropriate personal and academic support made students less likely to withdraw from courses; they also noted that tutors needed support and training from a central counselling service to be effective in their role. In considering the implications of this research for institutions in higher education, Rickinson has pointed to the valuable contribution which a professional counselling service can make to the following institutional goals:

    a) the enhancement of the students' university experience;
    b) the containment of students who are psychologically vulnerable (high levels of psychological distress may precipitate suicidal action);
    c) the facilitation of students' engagement with, and successful completion of their degree programme;
    d) the development of an integrated institutional approach to student support and guidance (such an approach fosters a close and creative relationship between the support and guidance systems in academic departments and the central support services, and includes an understanding of the interrelationship between personal and academic development);
    e) the provision of staff development and training programmes for academic staff responsible for undergraduate students, to support them in their important tutorial role. (1998:101)

45. Teaching subject reviews pay considerable attention to the quality of student support and guidance. As these ratings affect positions in league tables and can influence funding, senior managers within institutions pay close attention to these figures. Student support and guidance is one of six categories under which courses are assessed and we are currently awaiting the detail of new standards for student support to be set by the Quality Assurance Agency.

46. Graduate employability is an increasingly important goal in higher education today. Self-management skills, including the ability to cope effectively with stress and life difficulties, are essential requirements of graduates in today's job market.

47. It is useful to state the point that many students with mental health problems are extremely able academically and may be very high achievers.

    [10] E.g. a recent study at Leicester University (funded by HEFCE) indicated that 54% of students turned firstly to their personal tutor for support with personal concerns other than academic work.

    [11] An example of this can be found in recent research (part funded by HEFCE) carried out at Hull University looking at support for students with mental health problems.

    [12] E.g. two final year groups, (1) a clinical group of 43 students presenting for counselling and (2) a cross-faculty control group of 63 students not receiving counselling, registered levels of psychological distress which placed them in the "at risk" category for psychiatric illness (using the SCL 90-R psychometric instrument).

    F.

    RECOMMENDATIONS

48. The primary intention of this document is to promote discussion. It is our hope that senior managers within individual institutions, officers of higher education funding and regulatory organisations, and representatives of the medical and care professions, will find this document thought provoking. The Heads of University Counselling Services group recognises that the issues presented in this document, which have been raised consistently by its members, are complex and would welcome debate and collaboration with relevant bodies in addressing these concerns. Key areas for consideration are described below.

49. National co-ordination is necessary for some interventions. We welcome the recent CVCP/AMOSSHE initiative in developing a set of institutional guidelines relating to mental health and the HEFCE funded research projects mentioned earlier. We would suggest that the CVCP and HEFCE continue to provide leadership and:
    • acknowledge fully the resource and funding implications of widening access in relation to the incidence of mental health problems amongst the student population
    • take proper account of the weakening of the personal tutorial system caused by increased student numbers and the impact of the Research Assessment Exercises on academic staff
    • develop strategies to deal effectively with this changing situation in higher education
    • undertake further research to examine issues relating to the care of students requiring ‘cross-modality' support. Although these students are at one extreme of the continuum of mental health, they often make intensive demands on resources; also, they are often the individuals who are most harmed by their experiences of ‘care', both within and without the institution. Such research should be done in consultation with HUCS, disability networks and the AUCC Research Sub-Committee
    • undertake systematic collection and collation of data, both quantitative and qualitative. This is needed at a national level if we are to gain an accurate reflection of the situation and evaluate our interventions.

    We would suggest that the QAA take into consideration the points raised in this report in their current formulation of quality measures for student support.

50. We would suggest that individual universities should:
    • develop and implement cultures, structures and policies to promote mental well-being for both students and staff. This not only assists in the prevention of mental health problems but also contributes to a healthy working environment and reduced levels of stress. This benefits staff and students as well as supporting health and safety policies and good human resource management[13].
    • encourage increased awareness amongst academic and support staff regarding the broad issues in dealing with students (and colleagues) with mental health problems; improved communication is required within institutions to facilitate more appropriate responses.
    • support their counselling services in developing and maintaining compatible safe and ethical practices in regard to mental health issues. This might be achieved with reference to the new AUCC Services Recognition Scheme, the AUCC Guidelines for University and College Counselling Services and the recent UCoSDA publication, ‘Benchmarks for Quality Standards in University Counselling Services' (1998).

51. We would suggest that counselling services should build on existing good practice to make the following contributions:
    • supporting students who are distressed or disturbed
    • supporting those who are concerned about the mental health of such students
    • liaising with other mental health professionals in the community and, where appropriate, working with medical, psychiatric and nursing staff attached to their institutions and in local hospitals
    • assisting in the formulation and development of institutional policies and providing feed back to institutions about the implementation of such policies
    • fostering better communication between counselling services and statutory and voluntary agencies in order that their respective roles and boundaries can be clarified to foster more effective co-operation wherever possible
    • working in partnership with other areas of the institution in order to help students make the most of their learning opportunities
    • offering training to other staff to help raise the general level of personal tutorial support within institutions, for example, workshops, and link with institutional teaching programmes for staff.

52. In conclusion, we would suggest that the issues we have raised in this document have implications for all members of our universities and that a comprehensive policy embodying principles of good mental health should be developed and implemented in all universities.

[13] For example, The Health Promoting University as a framework for positive mental well-being and enhancing student experience. Mark Dooris, Health Promoting University Co-ordinator, University of Central Lancashire, 1998.

AUCC ADVISORY SERVICE TO INSTITUTIONS. 1998. Guidelines for University and College Counselling Services.

AUCC RESEARCH SUB COMMITTEE. Surveys of Student Counselling in Further and Higher Education.

BERTOCCI, D., HIRSCH, E., SOMMER, W. & WILLIAMS, A. 1992. Student Mental Health Needs, Survey Results and Implications for Service. Journal of American College Health Association 41:2-10.

FOSTER, D. 1995. A Report on the Level of Student Stress and Suicide Rates, Liberal Democrat Spokesman for Education. House of Commons.

HEALTH ADVISORY SERVICE 1994. Suicide Prevention: the Challenge Confronted, London. HMSO.

HEILENSTEIN, E., GUENTHER, G. & HERMAN, K. 1996. Depression and Academic Impairment in College Students. Journal of American College Health Association 45: 59-64.

HEYNO, A. 1997. Why do our Students Fear Failure More Than Death? Independent, 2nd October 1997.

HOOD, V. 1995. Preliminary Report. Unpublished.

HOUSE OF COMMONS. 1997. Fourth Report of the Health Committee on Children and Adolescent Mental Health Services, London. HMSO.

MATHERS, N., SHIPTON, G. & SHAPIRO, D. 1993. The impact of short-term counselling on general Health Questionnaire Scores. British Journal of Guidance and Counselling 21: 3 310-318.

MCNAIR, S. 1997. Getting the Most Out of HE: Supporting Learner Autonomy. Sheffield. DfEE.

MENTAL HEALTH FOUNDATION. 1997. Suicide and Deliberate Self Harm. London, Mental Health Foundation.

----- 1999. The Big Picture. London, Mental Health Foundation.

MIND: THE MENTAL HEALTH CHARITY. 1998. Children and Young People and Mental Health.

NATIONAL COMMITTEE OF INQUIRY INTO HIGHER EDUCATION. 1997. Higher Education in the learning society.Report of the National Committee of Inquiry into Higher Education. Chair: Sir Ron Dearing. London: NICHE.

NICOLL, R. 1997. Young Women at Risk of Suicide, The Guardian.

OSTER, D. 1995. Report on the Level of Student Stress and Suicide Rates. London.

RICKINSON, B. 1997. Evaluating the effectiveness of counselling intervention with final year undergraduates. Counselling Psychology Quarterly, 10: 3.

RICKINSON, B. 1998. The Relationship between Undergraduate Student Counselling and Successful Degree Completion. Studies in Higher Education, 23: 1.

RICKINSON, B. & RUTHERFORD, D. 1995. Increasing undergraduate student retention rates. British Journal of Guidance and Counselling, 23: 2.

RICKINSON, B. & RUTHERFORD, D. 1996. Systematic monitoring of the adjustment to university of undergraduates: a strategy for reducing withdrawal rates. British Journal of Guidance and Counselling, 24: 2.

RIVIS, V. 1996. Personal tutoring and academic advice in focus. London. HEQC.

ROBERTS, R., GOLDING, J. & TOWELL, T. 1998. Student finance and mental health. Psychologist, October 1998.

ROBERTS, R., GOLDING, J., TOWELL, T. & WEINREB, I. (unpublished) The effects of students' economic circumstances on mental and physical health.

RUTTER, M. and SMITH, D.J. eds. 1995. Psycho Social Disorders in Young People: Time Trends and their Causes. London. John Wiley & Son.

SURTEES, P.G., PHAROAH, P.D. & WAINWRIGHT, N.W.J. 1998. A follow-up study of new users of a university counselling service. British Journal of Guidance and Counselling, 26: 2 255-272.

THE HIGHER EDUCATION QUALITY COUNCIL. 1994. Guidance and Counselling in Higher Education, London. HEQC.

----- 1995a. A Quality Assurance Framework for Guidance and Learner Support in Higher Education.London. HEQC.

----- 1995b. Guidelines on the Assurance of Credit-based Learning. London. HEQC.

UCoSDA. 1998. Benchmarks for Quality Standards in University Counselling Services. Editors: Peter Ross and Colin Lago.

UNIVERSITY OF MANCHESTER AND UMIST COUNSELLING SERVICE. 1997. Internal document.

WHITEHOUSE, C. 1998. Student Psychological Health. Results of an extensive survey conducted at Leicester University, Notes from Presentation to Student Well-being in Higher Education Conference, 1998.

WORKING PARTY ON STUDENT PASTORAL SUPPORT STRUCTURES AND PROCEDURES. 1996. Report of Survey of Staff. University of Hertfordshire. Internal document.

WRIGHT, M. 1998. Paper for Staff and Student Affairs Committee re proposed working party to consider mental health related issues within the university. University of Hertfordshire. Internal Document.

YOUNG MINDS WORKING GROUP ON CHILD AND ADOLESCENT MENTAL HEALTH SERVICES held on June 24 1998, Summary of Notes.

APPENDIX I

HEFCE Funded Mental Health Projects: Brief overview of five projects.

These projects aim to develop the awareness and effectiveness of academic and support staff in higher education in responding to the mental health needs of students.

HULL UNIVERSITY: Responding Effectively to the Mental Health Needs of Students. Project Contact: Nicky Stanley on 01482 465965, e-mail n.e.stanley@comhealth.hull.ac.uk

Project aims include:

• The administration of a survey of academics' experiences in supervising students with mental health difficulties. The survey examined the difficulties academic supervisors encounter in responding to students' mental health needs and explored links between academic staff and support services.
• The facilitation of a series of regional focus groups to explore issues such as students' perspectives, the interface between support services and academic staff, professional training courses, the needs of international students and the experiences of administrative staff.
• The development and pilot of a joint training course for student support and academic staff at the University of Hull, which will be available to staff throughout Yorkshire and Humberside.

LANCASTER UNIVERSITY: Improving Support for Students with Mental Health Difficulties. Project contact: Clare Edwards on 01524 65201 x92039, e-mail c.e.edwards@lancaster.ac.uk

Project aims include:

• The development of a framework for student support staff to use when they are interviewing/talking to students who have identified mental health problems to help draw out valuable information about the student's support needs. The framework is being piloted at the moment.
• The administration of a small qualitative survey on a cross section of staff at the University to explore their experiences of student mental health problems and their training needs and concerns in this area.
• From the results of the survey and extensive research, a mental health policy for Lancaster university is being developed. This will incorporate practical guidelines which can be used by all staff and students and will accommodate severe, moderate and mild incidents and a directory of available services will be produced. The launch of the policy will be complemented by staff training.

LEICESTER UNVERSITY: Supporting Students with Mental Health Difficulties: A Whole Institutional Approach Project Contact: Paula Brady on 0116 252 5230, e-mail pmb6@le.ac.

Project stages include:

• Extensive surveys, which are currently being administered, of the psychological and mental health problems in the student population, to gain an idea of the scope and scale of problems experienced. Approximately 2,500 students will be surveyed.
  b) of all university staff (both academic and non academic) experiences and understanding of mental health issues in the student population. Approximately 2,500 staff will be surveyed.

• Extensive reviews of all work undertaken in this area, nationally and internationally, to include literature and internet searches. A published bibliography of relevant literature will be produced.
• The use of the information gathered
  a) to assist in the production of guidelines and policies for the identification, support and, when appropriate, the referral of students experiencing psychological difficulties;b) to develop specific staff training packages for academic and support staff on ways of guiding and supporting students with psychological difficulties.

NENE COLLEGE OF HIGHER EDUCATION, NORTHAMPTON: Improving Support, Understanding and Information for Students with Mental Health Difficulties. Project contact: Joanna Lester on 01604 735500 x2402, e-mail jo.lester@nene.ac.uk Project stages to include:

• The promotion of mental health issues a) through producing and updating the information available to staff and students, including internet web pages and attendance at health fairs;
  b) via liaison with internal and external services concerned with mental health issues and drug and alcohol abuse.
• The development of guidelines and policies for staff supporting students with mental health difficulties with the guidance of a working group.
• The provision of assessments and support for students with mental health difficulties, including facilitating student groups for issues such as anxiety management.
• Liaison with staff on student mental health issues and the provision of staff development and training regarding mental health issues.

NOTTINGHAM UNIVERSITY: The Effects of Depression and Anxiety on Academic Achievement. Project Contact: Myra Woolfson on 0115 951 3695, e-mail myra.woolfson@nottingham.ac.uk

Project aims include:

• The provision of an estimate of the number of students on campus who may be suffering from a moderate or severe degree of anxiety and depression.
• The exploration with a number of academic departments about:
  a) how much is known about students who withdraw and the reasons for it;
  b) how much is known about student under-performance and what happens;
  c) what is known about the resources of help available to students.

• The provision of training and support in identifying students who may be at risk of anxiety and depression, including effective ways to respond to this.

The outcomes of the projects will be disseminated throughout the higher education sector via various methods including published papers, reports, conferences and work with relevant organisations, for example SKILL (National Bureau for Students with Disabilities).

APPENDIX II

To define exactly what we mean by disturbed is difficult. It is important to distinguish between that behaviour which is rebellious and challenging within an institution and that which is a result of serious and emotional disorder. This latter disturbance may not be easily contained by an institution and may result in threat or damage to self or others.

Examples that have come to our attention:

• A student being allowed to stay at college by a disciplinary committee, providing that s/he is seen regularly by the counsellor.
• Expectation of the institution that the Counselling Service should see a severely disturbed student with an extreme psychiatric history.
• Expectation of a college that an aggressive confrontation between a student and tutor should be resolved by a counsellor.
• Requests from a student already being treated by local psychiatric services for alternative help from the Counselling Service.

This section is particularly concerned with those students who arrive at counselling services inappropriately, either through self-referral or through referral by staff within the institution. Counselling services need to have clear codes of practice to assist them in correct assessment and matching of client needs with the resource. Likewise they need to be able to help their institutions in the development of college-wide policy.

Relationship within the Institution

Disturbed students will be experienced as difficult by the whole institution as well as the counsellor. The institution may look to the Counselling Service for help. This request may be made more in the way of inappropriate referrals than through discussion (BAC Code of Ethics and Practice for Counsellors B.6.1.2 and 6.1.4 - referred to hereafter as ‘Code').

Reasonable expectations of the institution:

• Professional concern from the Counselling Service including a willingness to pool knowledge and experience (Code B.1.5).
• That the Counselling Service will contribute to the development of policy.
• A willingness to contribute to the institution's understanding of its boundaries and limitations, e.g. some students will be too difficult to contain in a college. This contribution might include training for staff.
• That the Counselling Service will provide information about other agencies and services and be active in arranging referrals where appropriate.
• A willingness to offer support to staff or students who may themselves have been distressed by violent or bizarre incidents.

Unreasonable expectations of the counsellor:

• Responsibility for seeing students who are difficult for the institution but have not sought the counsellor's help. This is a clear management responsibility.
• That s/he be involved in a disciplinary or security crisis intervention role.
• Being expected to accompany students in medical emergency situations (Code B.4.3.3 and 5.1)
• That s/he be expected to give a diagnostic assessment of a student's behaviour which may be used by the institution against the student. Management must gain this information from the appropriate speciality, e.g. psychiatry, social work, legal professionals and police (Code B.1.3.1, 4.3.3, 1.6.3, 4.3.1, 4.3.2 and 6.1.7).

Code of Practice within the Counselling Service

A clear code of practice agreed within the Counselling Service and supported by the institution will allow for a more confident response to and assessment of students who should be seen elsewhere.

Questions to help the appropriate assessment of a client

• Has the client chosen to come to the Counselling Service either through self-referral or agreed through a third party? (Code B.4.3.2.)
• Does the client have realistic expectations of what the Counselling Service offers? (Code B.4.3.1 and 4.3.2.)
• Is there any previous or current psychiatric or medical history which might contra-indicate counselling?
• Are the capacity and resources able to match the need, i.e. expertise and training of counsellors, limitations of time and space available, proximity to the end of the course, long breaks, etc? (Code A.6 and B.6.1.2 and 6.1.4.)
• What are the client support networks?

Professional Links

• Is there any easy access to local medical and psychiatric services for consultation and referral? Appropriate professional liaison needs to be not only developed but maintained between other agencies who may be referral points a Counselling Service.
• Does the institution recognise BAC's Codes of Ethics & Practice? Institutions can effect this through organisational membership of BAC and through incorporation of the Code into Health & Safety Policy.
• Are there any clear channels for discussion and exchange of information with management, e.g. discussion on referral policies?
• Is there any opportunity within the supervisory relationship to focus on institutional dynamics as well as individual casework?

Conclusion

The population of our colleges is increasingly diverse and the traditional pastoral support available is becoming diluted or disappearing. Diminishing support structures lead to increasing pressures on counselling services.

In this climate, with greater numbers and less personal support, the disturbed student can provoke much anxiety which may be passed on to the counselling service to be handled. This sometimes inappropriate displacement of anxiety can be difficult to resist.

It is hoped that this section will assist counsellors and counselling services to think through their own internal practices as well as the relationship with the institution as a whole in order that negotiations with management can be held with more confidence.

This section should be read in conjunction with the BAC Code of Ethics & Practice for Counsellors 1 January 1998.

© BAC 1999