Under Pressure

Harry Fowler headed to Stanford University in fall 2017 with an impressive list of accomplishments: an A student in high school who competed in the National Chemistry Olympiad, ran track and cross country, and performed in the school’s drumline.  

Fowler, who goes by the gender-neutral pronoun “they,” grew up in Beaumont, Texas, a racially divided city an hour east of Houston. Fowler wanted to succeed at Stanford and make the town’s Black community proud.    

Fowler had endured bouts of depression since eighth grade and decided to take advantage of Stanford’s free mental health services. “I checked myself in for an appointment, because I was just like, ‘Yeah, I want to kind of rid myself, be perfect, rid myself of suicidal ideation.’” That October, Fowler went on an antidepressant for the first time. 

But the medication didn’t have the intended effect. One morning in November 2017, Fowler woke up in their dorm room feeling drastically worse. They felt intense thoughts of suicide. They managed to get through the day with the help of friends who checked in on them. When, that evening, Fowler told their residential assistant what was going on, the RA called the campus mental health center.  

It was late, and, Fowler remembers, the RA told them there were no counselors or psychiatrists on-call. Instead, the person who answered the phone at the mental health center said Fowler would need to go to the hospital. So Fowler followed the RA outside to wait for the police escort, which at that time was Stanford’s policy for getting students in a mental health crisis to the hospital.  

Two campus police officers showed up. For Fowler, who is Black, it was frightening. They texted some friends for help: “Come outside so [the police] don’t try anything sketchy.” 

Fowler changed their mind. They didn’t want to go to the hospital. But it was too late. Fowler no longer had a choice.  

Across the country, colleges and universities are facing a huge increase in the number of students who need mental health care, and many schools aren’t prepared to handle the growing demand. A national survey of college students in 2020 found that nearly 40 percent experienced depression. One in three reported having had anxiety, and one in seven said they’d thought about suicide in the past year. In a survey of directors of college counseling centers in 2020, nearly 90 percent reported that demand for their services had gone up in the previous year. At the University of Richmond, for example, enrollment at the school has remained flat during the past 15 years, but the number of students seeking campus counseling services in that time has doubled.  

It’s not just students. Even before the pandemic, more Americans were experiencing mental illness, particularly anxiety and depression. The nonprofit Mental Health America reports that in 2017-2018, nearly 20 percent of Americans reported experiencing a mental illness, an increase of 1.5 million people over the year before.  

The problem is especially acute among young people. In 2019, nearly 30 percent of people between ages 18 and 25 reported a mental illness. In 2020, the Centers for Disease Control and Prevention reported, one quarter of 18- to 24-year-olds surveyed reported having seriously considered suicide in the previous 30 days. 

Exactly what’s causing the increase in mental anguish among young people isn’t clear, though theories abound. Some studies and experts suggest a correlation between social media use and increased anxiety and depression. Sociologists have pointed to social media’s undermining of teenagers’ self-esteem, particularly among girls. Experts also contend that overprotective parents — so-called helicopter parents — who won’t let their kids fail have contributed to a more fragile generation. By not letting kids experience disappointment or face their anxieties, these theories go, kids don’t learn how to deal with them. Some experts also suggest that as a society, we have over-pathologized normal human emotions, leaving young people with the idea that they need a therapist to deal with every rough breakup or bad test score.  

And then there’s the decreasing stigma around mental illness. A study using data from the Healthy Minds survey, an annual multi-school survey looking at issues including mental health on college campuses, suggests that young people find it far more socially acceptable to talk about mental health, which makes them more likely to seek services.   

Whatever the reason, the rising demand has put many schools in a difficult position, with limited budgets to address the growing student need. With demand for mental health care at all-time highs and continuing to increase, schools have been left scrambling for answers.

‘I thought I might drop out’

Outside their Stanford dorm that night in November 2017, Harry Fowler was refusing to go to the hospital. More police officers showed up and surrounded Fowler so they couldn’t leave. The officers handcuffed Fowler and put them in the back of a squad car. This was standard procedure at Stanford, as in many states, at the time, for officers accompanying a person in a mental health crisis to the hospital. For Harry Fowler, though, it was trauma on top of the stress and anxiety they were already feeling.

“I remember just the stares I got from being escorted by police, because I’m sure people thought I was a criminal,” Fowler recalled.  “It still bothers me to this day.” 

The officers brought Fowler to Stanford Hospital, where they were admitted on an involuntary hold. There they tried to explain that they’d been prescribed an antidepressant a few weeks earlier; Fowler thought it might be making their depression worse. Suicidal ideation is a side-effect of some antidepressants. They wanted help getting on the right medication, they said.  

They stayed in the hospital for a week. During that time, an assistant dean from the school came to see them. “‘You’ll probably have to take a year off,’” Fowler recalled the dean saying. “No, that cannot happen. I cannot go back home,” Fowler remembered replying.  

But Fowler mistakenly believed that if they wanted to get out of the hospital, they’d have to agree to the leave. So Fowler signed the papers agreeing to take a leave from Stanford. Fowler’s mother flew in from Texas, packed up their dorm room, and took them home. Fowler was devastated.  

“It made me feel like a failure,” they said recently. “I didn’t know if I was going to stay in college. I thought I might drop out.” 

Back home in Beaumont, Fowler felt like they’d let down the Black community. “I felt as if I’ve failed them,” Fowler said. “I saw myself as like a beacon of hope. And I had just fallen apart because of my mental illness.” They went off the antidepressant they blamed for their problems and went back to handling their depression the way they had since middle school: gutting it out on their own. Fowler stayed in their room and studied calculus to keep their mind off their troubles.  

Meanwhile, back on campus, two of Fowler’s fellow students were pushing for change. Kane Zha and Molly Irvin had gotten interested in mental health their first year at Stanford. They’d trained as peer counselors, taking phone calls at The Bridge, an anonymous helpline on campus staffed by students. And the need was great. Irvin said she remembers taking three suicide calls in her first month of counseling. 

She could refer callers to the counseling center. But sometimes students would tell her they didn’t want anybody official from the university to know they were in a crisis; they were afraid of being forced to take a leave of absence. 

By the time they were sophomores, Zha and Irvin had dealt with many such calls. They decided to do something more than just help individual students. Attorneys at Disability Rights Advocates in nearby Berkeley were thinking the same thing.  

Students with mental illness are protected under the Americans with Disabilities Act. Like a student who uses a wheelchair or is visually impaired, students with mental illness are guaranteed accommodations for their disability under federal law. That might mean changing a student’s housing, reducing a course load, or offering extended deadlines for assignments.   

Schools aren’t supposed to require a leave of absence until all other reasonable accommodations have failed. But looking at college campuses around the country, the attorneys had been surprised at how “either bad or nonexistent some of the policies were when it came to accommodating students with mental illness,” said attorney Stuart Seaborn of Disability Rights Advocates. (If a person is a threat to themselves or others, colleges are allowed to remove students or have them hospitalized against their will.)  

In May 2018, Disability Rights Advocates filed a lawsuit against Stanford, demanding the school stop its “punitive, illegal and discriminatory treatment of students with mental health disabilities.” The university, the lawsuit said, had pressured students with mental illness into taking leaves, rather than trying to find a reasonable accommodation for them. The plaintiffs in the case were three students (under pseudonyms) and the Mental Health and Wellness Coalition, the organization run by Molly Irvin and Kane Zha. 

Stanford wasn’t the first school to get sued for this kind of response to a mental health crisis. In a case that was much watched by schools around the country, a student named Jordan Nott filed a suit against George Washington University in 2005.  Nott had been a straight-A student in his sophomore year when he began thinking about suicide and checked himself into the hospital. Like Stanford did with Harry Fowler, the university forced Nott to take a leave of absence. The case was settled the following year for an undisclosed amount. Yet colleges continued the practice.  

Reading an underground student newspaper online at home one day, Harry Fowler came across a story about the Stanford case. It made them feel a little better, they said, since “up to this point ... I put a lot of blame and guilt on myself.” Now, Fowler understood, it was a much bigger problem.

Fowler clicked on a link to the law firm’s website to write a thank you note to the attorneys. They were surprised to get a note back asking if they would join the lawsuit. Fowler agreed. 

In October 2019, after nearly a year and a half of negotiations, Stanford and Disability Rights Advocates announced a settlement. The new leave policy, which took effect in January 2020, says that if a student has to take a leave, a staff person will be assigned to guide them through the process. (Unlike the old policy, which didn’t mention the word accommodation, the new policy uses it 19 times.)  

Students now have a two-day revocation period during which they’re allowed to change their minds about taking leave. Stanford officials declined interview requests for this story. The university also later changed its transportation policy. Now, students who have to be taken to the hospital are accompanied by paramedics, rather than handcuffed and escorted by the police.  

In the long run, though, student and legal advocates hope the real answer will be that fewer students need to take leaves, and that other schools will take Stanford’s experience to heart and change their rules.  

Harry Fowler returned to campus in fall 2018 and started their freshman year over again. Fowler has spent this summer interning at a law firm and plans to return to Stanford this fall for their senior year. Still, they have refused to use campus mental health resources again. Fowler has lost trust in the system. 

Colleges in a bind

As a child, Alexandra Marello frequently had terrible belly aches, and she often felt like she was going to vomit. Neither Marello nor her parents realized it was anxiety, though. So it wasn’t until she was in high school that she received counseling, and even then, not much of it.  

The problem got worse when she attended Skidmore College in upstate New York. She was in a dance class one day her freshman year when she had her first panic attack.  

“My face got really red, and I started feeling shaky and faint,” she recalled. She left class, hyper-ventilating and crying, and called her father, who told her to go to the counseling center.  

Marello walked in and asked to see a counselor. But Marello didn’t have an appointment, and, since she wasn’t feeling suicidal, the staff told her that her situation didn’t qualify as an emergency. The receptionist told her to come back later.

The person she spoke to offered to connect her to therapists in town, but finding a therapist who would take her family’s insurance was hard, as was getting into town for appointments. She said her family couldn’t afford it. Marello said she thinks counseling should have been included in her school fees.  

Marello isn’t alone. From small liberal arts colleges like Skidmore to big public universities like Ohio State, students say they need mental health care. And they expect the schools to provide it.

Philip Glotzbach, who retired as president of Skidmore last year, says that during his 17 years at the school, he heard from students and parents who were putting what he calls a “new level of demand” on schools, asking for more and more services.  

The problem, as he sees it, is that the answer isn’t more staff. “My metaphor for this is that it’s like freeways in Los Angeles. The freeway is clogged, so you add a lane. Well, two weeks later, that lane is clogged as well, until you add another one. I mean, you can't build your way out of the problem,” he said.   

Part of the challenge for schools is that it’s not just students in life-threatening crises who are asking for more help. Plenty of them are like Marello: They feel sad or anxious or overwhelmed and may even have been treated previously for mental health issues. But they aren’t having suicidal thoughts or have serious diseases such as bipolar disorder or schizophrenia.  

Still, many schools are at least trying to respond to the demands by expanding services. The American Institutes for Research reported that student services, which includes counseling and mental health centers, has been one of the fastest growing areas of college spending in the past decade. There are reasons for schools to figure out how to address the issue. Students who are having a hard time with their mental health are more likely to drop out, which is bad for the schools and bad for students.  

The year Marello got to Skidmore was a tough one for the college. Two students had died that year. Neither of the deaths had to do with mental health, but they were traumatizing, especially in such a small community. The counseling center was under renovation, and school officials knew it was short-staffed.  

When Marello talked to her friends, she learned she wasn’t the only one having trouble getting mental health care on campus. Valerie Janovic, who’s from Long Island, was also a freshman at Skidmore that year. She and Marello met in a music class and started talking. Soon, their mental health came up.  

Janovic had been in a crisis one day when, like Marello, she’d gone to the counseling center. As had happened with Marello, the receptionist told her to make an appointment and come back in a few weeks, a response Janovic found unacceptable.  

“A few weeks is a long time to wait if you’re going through something,” she said.  

When Janovic was still feeling terrible a few days later, a friend suggested she call the school’s mental health hotline, to see if she might get help sooner that way. Janovic says the person who answered asked whether she was suicidal, and when Janovic said she was not, the person hung up on her.  

Asked about that, Julia Routbort, Skidmore’s associate dean of student affairs for health and wellness and a licensed psychologist herself, said that though she can’t comment on any clinical interaction, including hotline calls, hanging up on a student in distress would go against hotline protocols.  

Soon after, Janovic said, she realized she needed to do something. The counseling center, which at one time had offered unlimited counseling sessions, was so overbooked that unless a student was in a life-threatening crisis, she would have to wait weeks to see a counselor. By that time, Janovic and other students realized, the immediate need would have passed. She spoke to the head of the counseling center, who referred her to the dean of students, who told her to talk to the president.  

She wrote President Glotzbach a letter, which she left with his secretary.  

Janovic says when she didn’t hear back from him, she and Marello decided to start a petition. They asked for three things: another psychologist, which would bring the total number of clinicians to five; a crisis counselor for students who needed help on the spot; and a 24-hour hotline that would advise students in crisis, even if they weren’t having suicidal thoughts.  

Janovic and Marello collected signatures on campus and online. They managed to get 50,000 of them. Skidmore’s population is just over 2,500 students so presumably most of them were not connected to the school. 

Then they held a protest on campus that drew about a dozen students. After the protest, Valerie led the group to the president’s office, where she and her fellow protestors were invited in. Glotzbach said he told Valerie the school was in the process of hiring another counselor and was contracting with an outside company to offer a 24-hour crisis line. (The school has since done both.)

Different schools have taken different approaches to the problem. More and more have been moving to models like Skidmore’s, offering limited one-on-one counseling but more general wellness programs and other resources.   

Janovic, who considers the new hire and the new hotline a win for her campaign, still ended up transferring to Brandeis the following year. (She says Brandeis had many of the mental health supports she wished Skidmore had had.) Marello later ended up in the hospital after what she calls a nervous breakdown. When she was released, she still had to wait for an appointment at the counseling center but did eventually connect with a therapist on campus. Since graduating, she is back living in New York City, where she has found a new therapist and is generally feeling better. (Being in the city makes accessing a therapist easier, since transportation is no longer an issue like it was at Skidmore. And she has gotten help paying for therapy through a government program.) 

Skidmore may have — for the time being — found a way to manage its counseling problems.  The larger question remains, though, for Skidmore and for schools around the country. Many college administrators say schools shouldn’t be large-scale providers of mental health care.  

“Colleges, universities cannot be an environment where when you show up, you get a therapist,” Glotzbach said. “We can provide resources that help a young person make that transition from late adolescence to early adulthood. … I think that’s got to be the model. And so the resources that we provide, need to be oriented toward that goal.”

No mental healthcare

It was his own mental health crisis that got Daniel Ford, a former Marine and student at Northern Virginia Community College, thinking about his fellow students and their mental health.

Ford, who had served nine years all over the world, realized he needed help the night he gave his wife a bloody nose in his sleep because he was “having ... a flashback to when there was a dude attacking me.” Services at the Veterans Administration were booked for months, but Ford’s wife found a social worker who volunteered with veterans. 

The experience got Ford thinking about what mental health care was offered on campus. The answer? None. Virginia Community Colleges aren’t alone in this: In 2020, a fifth of community college presidents surveyed by the American Council on Education said their campuses didn’t provide mental health services.  

In one of his classes, Ford met Jessica Bauer, a fellow student who was a Navy veteran. Bauer had dealt with depression, and like Ford, had started wondering what services were available for her fellow students.  

Ford and Bauer soon learned about Policy 6.4, which states that Virginia’s community colleges “do not provide mental health services.”  

With 218,000 students spread across 40 campuses, Virginia community colleges represent about half the students enrolled in public higher education in Virginia. 

But unlike those at community colleges, students at Virginia’s four-year colleges have access to mental health counseling, which felt like an equity issue to Bauer. 

“If I can't afford a four-year, I can’t go there. I’m still learning. I’m still trying to get my degree. I’m still trying to do all this stuff,” she said. “I still have the struggles, if not more, because it’s a commuter school and you work or you’re a parent or you have something else going on.”  

Community College students tend to be older and poorer, they’re more likely to be first generation and people of color.  

And they report more mental health problems than students at four-year institutions. A national survey by two academic research groups, The Hope Lab and Healthy Minds, found nearly half of community college students reported at least one mental health condition. That’s five points higher than four-year students. 

What really stuck out to researchers were the needs among younger community college students: More than half of students under 25 reported a mental health problem, 10 points higher than their peers at four-year schools. And two-year students were more likely to report that their mental health affected their academics more than six days in the previous month. 

Part of the reason for the disparity in services between two- and four-year schools, the community college officials say, is money. Four-year schools charge a student health fee, which community colleges don’t charge, explained Van Wilson, associate vice chancellor for student experience and strategic initiatives for the Virginia Community College System. “So as we think about ... how one might provide that service, a part of that formula is, how do you pass that cost along? And how would that impact access to post-secondary education?”

A year at a Virginia community college costs $4,600, about a third of what it costs to attend one of the state's four-year schools. They run lean.  

The decision to not offer mental health care at community colleges in Virginia came in the wake of the shooting at Virginia Tech. In 2007, Seung-Hui Cho shot and killed 32 students and injured 17 more before taking his own life. In the wake of the killings, Virginia’s State Assembly passed a number of laws related to mental illness, including one that required all colleges and universities in Virginia to set up threat assessment teams. These teams, made up of campus police, administrators and others, are intended to find and identify potential threats.  

While some schools expanded their counseling centers — Virginia Tech grew its center from 33 people in 2010 to 56 today — community colleges went in the opposite direction.  

After the shooting, “what was quickly realized was that the resources simply did not exist to offer [mental health care on campus] in a meaningful way,” said Jeff Kraus, a spokesperson for Virginia community colleges.  

Because all community college students are commuters, Kraus says, it makes more sense for students to get care through community mental health centers where they live. 

But Pat Lunt, who retired from Northern Virginia Community College as a dean in 2012, says that argument doesn’t make sense. Community college students don’t have time to seek care off-campus, Lunt said.  

“Some of our students, they would work all night and be tired in the morning,” she said. “You think they’re going to go to the mental health center in the city of Alexandria and get on a waiting list so that they could get medication? That’s not going to happen.” 

The options on campus for a student in crisis are minimal. A person can call campus police or fill out a form on the college’s website that’s part of its threat assessment system. Or, as of this year, they can look for a provider using a list on the college website, or scroll through a virtual self-care kit. 

Ford and Bauer were outraged with the options for their classmates. So in fall 2018, Bauer created a blog, printed T-shirts that said “Your Mental Health Matters” and launched the NOVA Mental Health Advocacy Group in between her classes.  

She began collecting signatures on a petition, and she and Ford met with deans and community college presidents. The answer, they were told, was to get state lawmakers on their side. 

With the help of a GoFundMe campaign and gas money from their professors, Ford and Bauer headed to Richmond to lobby. But without the support of the Virginia Community College System, the campaign soon fizzled out.  

Meanwhile, Jessica Bauer graduated from NOVA in 2019 and moved to California. Daniel Ford is just a few credits short on two associates degrees. (He took time off during the pandemic to work because he doesn’t like online classes.) Policy 6.4, prohibiting community colleges from offering mental health on campus, remains in place.

Update: On Sept. 23, 2021, the Virginia Community College System board voted to allow its colleges to contract with third-party providers to offer mental health services to students.

"Under Pressure" is one of three documentaries this fall season from the Educate podcast — stories about education, opportunity, and how people learn.