Mental Health Issues and the University Student

4. The Psychiatrist’s Role in College Mental Health

As the nature of the college counseling center has changed over time, so too has the role of the psychiatrist in providing mental health care to university students. Yet at the same time, some of the challenges we face now are not that different from those our predecessors grappled with as they tried to define best models of care. A brief historical perspective can help ground our understanding of our roles as we move forward. The mental hygiene movement, which swept college campuses at the beginning of the twentieth century, focused on preventing emotional problems through an emphasis on developmental and contextual factors,1 in contrast to a more medical, pathology-oriented model. This not only separated counseling from student health, and at times from psychiatry or “mental health centers ,” but also sometimes led to tensions between these models of care. Some of these tensions persist today. Psychiatrists usually served limited roles within counseling centers or were housed at student health clinics. At many univer­ sities, they didn’t have a role on campus at all but worked in the community surrounding the university and were available to students as needed. In more rural or impoverished parts of the country, this remains the model today, and access to psychiatric care for students is limited. The community mental health (CMH) movement of the 1960s advocated Chapter 4 The Psychiatrist’s Role in College Mental Health The Psychiatrist’s Role in College Mental Health  23 for a more integrated model of care, uniting the mental hygiene ideals with new knowledge about the clinical care of psychiatric illness. Paul Barreira, a psychiatrist who now heads Harvard University’s Health Services, has written and spoken at national psychiatric meetings about how the principles of CMH are particularly relevant to college mental health services. First, CMH prin­ ciples posit that services be community based, for a well-defined population. Second, CMH models pay attention to general well-being, through prevention strategies and educational programming. Third, clinicians working within the system must be able to accurately and rapidly identify more serious emotional problems and appropriately refer for treatment. Last, the clinicians within the system must also be capable of providing evidence-based treatment that meets current standards of care. All these clearly apply in the care of university students , since the university represents a well-defined community. Barreira emphasizes that services must be culturally informed, must invite student participation , and must periodically undergo evaluation. In the last decade there’s been an increase in the numbers of psychiatrists working in college mental health. Groups such as the American Psychiatric Association and the National Network of Depression Centers have formed task forces to focus specifically on this topic. Fellowship programs in child and­ adolescent psychiatry are increasingly interested in including emerging adults within their scope of care. The role of psychiatrists in providing care to this population is growing. The Psychiatrist on Campus According to the 2011 National Survey of College Counseling Center Directors (NSCCCD), which represents 228 centers across the United States, 64% of centers have access to on-campus psychiatric consultation. Some of these psychiatrists work within counseling centers and some within student health clinics . The exact role of the psychiatrist depends somewhat on the location of his or her appointment and varies between institutions according to how well staffed the institution is. Many universities have only one on-campus psychiatrist , and that person may work only part time. That often limits their role to medication evaluation and management and crisis evaluation. But psychiatrists, whose training emphasizes the bio-psycho-social aspects of emotional problems and mental illness, have much to offer college students— and the university community—beyond medication management. Although tight resource allocation may not allow many to practice much traditional psy- 24  The Student in Context: The Interdependent Campus chotherapy—most campus psychiatrists do not have the time to carry a case­ load of weekly, hour-long therapy cases even if working in a brief therapy model—the most effective psychiatric approach to working with students calls for a psychotherapeutic stance even within the 20- to 30-minute medication management visit. This is what often makes the difference in a student’s decision to take or not take a particular medication, or to follow another recommended course of treatment. Twenty-three-year-old Li, a Chinese international first-year graduate student, is referred by the student health service physician for...