Mental health services in universities
University and College Counselling, March 2020

It is becoming increasingly widely recognised that young people are now more susceptible to mental health problems than previous generations probably ever were. Young women appear to be particularly affected, with a percentage of those with a common mental disorder in the age group 16 to 24 rising from 20 per cent in 1993 to up to 28 per cent in 2014.¹ And that figure is already five years out of date. In 2018, Universities UK reported that there had been a fivefold increase in students disclosing mental health conditions since 2007.² Suicide rates have also increased, becoming the most common cause of death in young men under 50.³ Among UK university students, suicide rates have also been on the increase, rising from 108 in 2001 to 134 in 2015.² The 2015 NUS Survey also revealed that 33 per cent of respondents acknowledged that they had had suicidal thoughts.⁴

This clearly worsening situation has naturally provoked discussion of why it is happening, as well as a number of initiatives to try to address it. However, it would be reasonable to assume that the success of any action on mental health would depend on how accurately the causes of the problem have been understood.

Pressures on young people

While this article will focus on university students, it is important to acknowledge that there are factors that are likely to be adversely affecting the mental health of young people in general. Two main suspects seem to stand out. In the first place, the move towards judging schools’ performance on academic attainment and thus creating league tables of success, which has been established for well over a decade, has potentially had a very negative side effect. Pupils have had to undergo more frequent testing, on a more narrowly defined set of criteria, throughout their school career. One potential result of this is that children and adolescents become more conscious of how they are being permanently scrutinised and compared. The likelihood is that the pressure on schools has been translated into pressure on pupils, with a corresponding new pressure on their self-esteem. One impact is that less academic subjects, interests and activities have been given lower and lower priority. The net result is an educational system that puts greater stress on young people, and makes it more likely they will feel that their self-worth is dependent on exam success.

The other usual suspect for increased stress on young people is social media. A recent Horizons report quoted statistics from the NHS of nearly 30 per cent of teenagers with a mental health disorder spending more than four hours a day on social media, compared with 12 per cent of those without a disorder. ⁵ This of course tells us nothing about whether the social media use is a cause or effect (or both) of mental health issues. It does however seem to be consistent with a view of social media having the potential for, as the Horizons report expressed it, ‘…increased feelings of inadequacy in the face of pressure to be seen to be popular and socially successful.’ It would be hard to argue that Facebook, Instagram and similar platforms have not massively increased the degree to which young people feel on show, subject to judgment, and under pressure to appear attractive, happy and successful.

To the two potential culprits of educational pressure and social media, other factors might be added. One is the effect of the UK Government’s policy of financial austerity for almost the past decade. Young people of generation Z, (those born since the mid 1990s), have become adults in a world of restricted opportunities, uncertain job prospects, insecure employment and shrinking public services. The vote to leave the EU has resulted in a sense of even less opportunity, and more division and feeling unheard. This all adds to the stress that young people now experience.

The effect of the climate emergency on the hopes of young people for the world and their future also has to be taken into account. The impact on young people’s outlook of dire warnings about the climate and the threat to the future of the planet has not been fully explored. It would be naïve however not to think that pessimistic predictions about the prospects for humanity would not create anxiety and stress for young adults.

When we come to focus on the particular stresses facing university students, it is easy to see that, while many of them will have been able to cope well with the academic pressures of school, they are also likely to be subject to a much higher level of expectation. This might often have originated from parents, although not uncommonly inadvertent or disguised, but has often been exacerbated by schools, ever conscious of success rates. For many students, it has been fully absorbed into an imperative to get a ‘good’ degree, (minimum 2:1), with a sense that their future absolutely depends on it.

The other main cause of stress for students is financial pressure. Since the removal of grants and their replacement with loans, the increase in fees, and the imposition of interest on the loan, financial pressure has become a major problem for students. The student money survey in 2018 reported that 78 per cent of students worry about being able to live on their money, and 46 per cent say that their mental health suffers as a result.⁶

What do we mean by ‘mental health problems’?

While there are these fairly universal pressures on young people and on students in particular, there is also a huge range of adverse experiences that have had a damaging impact on individual students. By far the most fundamentally important of these is abusive treatment (emotional, sexual and physical) by parents, step-parents, family members and others. Other factors include: bullying and psychological abuse in school and college; rape and sexual assault and harassment; the death of parents, family members or friends; physical illnesses and conditions (or the impact of other family members with such conditions); neurological differences, such as autistic spectrum disorder or condition; dyslexia (which might have been manageable and undetected in school but then becomes problematic at university level), dyspraxia, attention deficit disorder; relationship problems, rejection and loss; sexual difficulties or dysfunction, (including the effect on relationships of the use of internet porn); problems arising from overuse of, or dependency on, recreational drugs and alcohol; issues arising from sexual identity, and gender identity; issues concerning racial identity, and so on. Many of the above experiences may also have had a negative effect on the individual’s ability to establish or consolidate a sense of their own identity and self-worth.

Any of these potentially damaging or challenging experiences might result in symptoms that are associated with poor mental health, and the degree of psychological damage caused will correspond to the position on a spectrum of disorder that might range from low mood, anxiety and depression through self-harm and eating disorders, to suicidal thoughts and personality disorders. As well as this range of psychological and social dysfunction, and overlapping with it, there are more severe manifestations of mental ill health, such as bipolar disorder, psychotic episodes, drug-induced psychosis and schizophrenia. Particularly with regard to this more severe range of psychological disorders, there continue to be debates about the degree to which genetic inheritance might play a causal role. However, even where there is a clearly established correlation between a genetic component and the incidence of a specific mental disorder, the role of the social environment in helping to trigger the latent disorder is generally recognised as key, even if we still cannot accurately quantify it.

What this means is that when we talk of ‘mental health problems’, we are simply using a catch-all, umbrella term that mixes up specific mental health conditions with all kinds of symptoms and indications of mental and emotional distress.

The medical profession has always sought to clarify this confusion by categorising disorders and applying specific criteria for diagnosing them. In many branches of medicine, this is absolutely vital in order to deliver the correct and most effective treatment. Equally, in the mental health field, and particularly with more severe mental disorders, accurate diagnosis and prescribing the right medication can make the difference between someone being able to get on with their life, and someone being completely unable to cope or live independently. However, with the far broader range of common reactions to adverse previous (or current) psychological or social environmental factors, diagnosis is a much less exact science, because the complexity of those reactions does not fit the disease model. Becoming anxious about mixing with people, or losing the sense that your life has purpose, are not diseases. Furthermore, what the diagnosis approach tends to do in practice is to focus on the symptoms as if they are the disease. Depression is the clearest example of this. If someone goes to see their doctor with persistent low mood, negative thoughts, lack of energy and motivation, a diagnosis of depression may well be made, and antidepressant medication therefore considered, without there necessarily being any understanding about what might be the cause of those symptoms. This is not to accuse doctors in general practice of a lack of awareness of psychosocial factors. GPs are generally very aware of such factors, and are keen to refer their patients to talking therapies wherever possible to address the underlying issues. However, such referral routes are limited, and guarded by strict criteria, while antidepressants are readily available, and doctors are bombarded with advertising from drug companies stressing how effective their products have proved to be. Patients’ own experience of antidepressants have very often been much less positive, and finding the right medication for the right person is a matter of trial and error, based on very little real understanding of the processes and factors at work in each individual. Sometimes this works; sometimes it doesn’t; and when it doesn’t, this can be demoralising and debilitating for the person, and also serve to discourage others from using medication.

A more recent development that makes diagnosis in mental health even more problematic is the tendency for people, particularly young people, to self-diagnose. Any internet search engine can easily lead someone to conclude that they have depression, or a bipolar disorder, or borderline personality disorder (emotionally unstable personality disorder). Having an accurate diagnosis of a clearly defined condition is helpful, even vitally important, as we have noted, but thinking that problems are due to a mental disorder can also be counterproductive. A diagnosis of social anxiety disorder, for example, might offer a justification for avoiding social interaction, which only reinforces the belief that mixing with people will create unmanageable anxiety.

How have universities responded?

Faced with the evidence of increased incidence of mental health issues among students, the response by universities seems to have been largely two pronged: a public health approach to encourage healthy lifestyles, and a commitment to new technology to give information and help identify those most at risk. The lifestyle initiatives usually come under the title of wellbeing, and the distinction between wellbeing and mental health has become increasingly blurred. Originally, the concept of wellbeing was linked to positive psychology, and sought to promote a sense of being able to live well, even with a mental disorder. The problem that is caused by making mental health and wellbeing synonymous is that it creates the impression that a healthy lifestyle, including a good sleep pattern, healthy diet and regular exercise, is a protection against and antidote to mental health problems. Self-help books and notions of resilience are also recruited into this approach. The large grain of truth in this is that a healthy, balanced, active lifestyle is undoubtedly of great importance in maintaining a positive frame of mind. The problem, however, is that lifestyle and resilience are not sufficient in themselves to address the underlying causes of mental and emotional distress. In reality, the people who are suffering distress, the cause of which has not been properly understood or addressed, typically report that they don’t have the motivation to keep to their healthy lifestyle intentions. It’s not that wellbeing and self-help initiatives are not needed, but they cannot be regarded as a substitute for effective psychological intervention.

As young people are recognised to be an increasingly technologically savvy generation, generally conducting their social lives partly online through social media on their phones, it is understandable that initiatives to offer greater mental health support should seek to engage with them in the same way. The intention of such initiatives is to deliver relevant information and advice easily, but also to identify those who are particularly struggling and to signpost them to the appropriate services. Again, this is a welcome and necessary development, but as with the wellbeing approach, there is the danger that the universal, whole-population approach might be thought to be meeting students’ needs for mental health support, when actually the complexity of individuals’ difficulties is being overlooked. The particular risk is that the provision of useful information, advice and signposting might be given higher priority and better resourcing than the delivery of actual, personal, therapeutic help. The inescapable fact is that there is no point signposting ‘at-risk’ students to seek help if skilled, professional help is not readily available when it is needed.

Universal blanket solutions are always appealing to managers and organisations, as they are demonstrably doing something; if these solutions also involve the use of up-to-date technology, this adds to their appeal. However, when we stop to consider that the singular term mental health problems is, in reality, a spaghetti of symptoms, reactions, conditions and labels, then we recognise that all we might be doing is covering it with a bolognaise of healthy living and self-help advice, with a parmesan sprinkling of phone apps to stimulate the appetite. And this is not going to satisfy the real mental and emotional hunger of students.

What, then, is needed?

A new approach is required which takes account of the hugely varied emotional and psychological needs of students, as outlined above. It would then be possible to envisage a system of graduated provision, one that tailors input to different levels of need. This would lead to identifying exactly what education, help and advice all young people might need and from there to identifying what provision all students are likely to need, what services most students will need, what input many may benefit from, what type of interventions some students will require, and what specialist mental health intervention a small minority will have to access.

We can go further in describing these levels. We could, for example, conclude that all children and young people need a school curriculum that is broad enough to allow them to develop their interests and skills in their particular areas of strength, not just in academic hoop-jumping. We would certainly see the importance of making sure that the curriculum included education on emotional intelligence, respect and equality in relationships (online and off), on sexual relationships, and on sexuality and gender identity. Non-patronising information on the links between diet and physical and mental health could also be included. Certainly, the need to identify and interpret one’s emotional reactions, and to appreciate the value of talking about one’s problems would be underlined.

In universities, for all students, there is clearly a need for further initiatives to promote wellbeing through a balanced and healthy lifestyle that includes emotional self-care.

All students similarly need clear information on where to access every sort of advice and support.

Most students would benefit from peer support initiatives that could be based on social media. Given the origin of Facebook as a student scheme, universities could and should be the place where a positive, mutually supportive online culture might start to counteract the noxiously competitive effects of social media.

Many students will benefit from psycho-educational courses on subjects such as procrastination and exam stress, social anxiety, and managing low mood.

Some students will, without doubt, need trained professional counselling to be able to address their psychological difficulties sufficiently for them to be able to keep engaged with their academic work.

A small minority will need NHS psychiatric and specialist care, and the partnership between universities and local NHS services needs to develop into a close-working arrangement of constant liaison and shared responsibility.

In conceiving of graduated provision like this, it is however crucially important that the particular need of some students for skilled therapeutic help is not squeezed out between the general wellbeing needs of all students, and the specialist NHS treatment required by the most vulnerable. Quite simply, it is the therapeutic help provided by student counselling teams in universities that provides the means whereby students can begin to share their mental health concerns, and feel understood and supported, and so start conceiving of how they might be able to come to terms with the adverse experiences that have, to a greater or lesser extent, destroyed their emotional and psychological stability.

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