Princeton, Interrupted

One afternoon midway through the fall of her freshman year, Mary ’10 was walking through her common room when her roommate turned to her and said, “It’s great how you’re so happy all the time, Mary. I love that you’re always smiling.”

Mary stared at her roommate in disbelief.

“I just looked at her, thinking, ‘Are you serious?’ ” Mary recalled. “Every day I come in and walk through this common room and go straight to my room, take out my sushi, sit down on my bed and cry. Do you not hear me? Do you not notice?”

As studies have shown college mental health problems increasing dramatically over the past decade, the University’s Counseling and Psychological Services department has struggled to expand its resources to meet the growing needs of students like Mary. On a campus where mental health issues are frequently stigmatized and not often discussed openly, University Health Services (UHS) has been trying to improve visibility and outreach to build trust and connect with the campus community. But these steps may be too small and too slow for many students, who said they find the current services and improvement efforts inadequate and ineffective.

Mary struggled a lot her freshman year with adjusting to college life — living with roommates instead of family, structuring her own time, tackling a challenging course load and making new friends in an unfamiliar environment. By the winter of her freshman year, she was skipping many of her classes and spending most of her time in her room, crying.

“There were a lot of times when I would leave a social event or a meal or something, and, before I even got into my dorm, I was already starting to cry,” said Mary, whose name, like those of all students interviewed for this article, has been changed to protect her privacy. “I was just trying to hold it in until I could get to my room, which was sort of this safe space where no one would notice me, where everything would be ok.”

Often, as she lay in bed late at night, unable to sleep, Mary would go online to the McCosh Health Center website and read about the counseling services offered there.

“Usually, I was looking at the McCosh website at night, when I couldn’t call them except in cases of emergencies,” she explained. “But those were also the times when things were really hard and I was most desperate for help. So I would write down the number and keep it around and plan on calling during the daytime, but then I wouldn’t.”

One afternoon in February 2007, Mary finally made the call to McCosh to schedule a counseling appointment, more than halfway through her freshman year.

Gaining student trust

UHS has been working to help students like Mary feel more comfortable making that call. Reforming counseling services to seem more appealing and welcoming is an ongoing struggle for McCosh, which many students regard with distrust and hostility.

“McCosh is fighting an uphill battle,” said Anna ’07, who also approached UHS for help during a difficult freshman year. “There are so many rumors and so many expectations on campus about who they are that in some ways, whether or not they are welcoming, it will take them a long time to build up their reputation.”

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John Kolligian, the director of Counseling and Psychological Services, said he and his staff try to make themselves as accessible as possible to all students, regardless of their level of mental distress.

“We’ve tried to point out what our services are and that you don’t have to be in a crisis to come,” he said. “We’re here even if you’re struggling with just a mild adjustment issue.”

While many of the students interviewed expressed gratitude to UHS for helping them through difficult times, others said the experience left them bitter and resentful toward McCosh and a system that did not seem focused either on making personal connections with students or on providing emotional — rather than pharmacological — assistance.

Following her first counseling appointment at McCosh, Mary started seeing an on-campus psychiatrist. She waited three weeks for a 30-minute appointment with a staff psychiatrist, who then prescribed 10mg of the anti-depressant and anti-anxiety drug Lexapro at their first meeting. Mary said she was grateful for the medication but that she failed to form any kind of connection or bond with the doctor.

“When she was explaining why she was prescribing me Lexapro … she mentioned that a lot of the other drugs make you gain five to 10 pounds after taking them for a year,” Mary recalled. “I guess that’s a big concern around college girls, and it’s a concern for me, too, but at the time I was like, ‘Are you serious, have you been listening to me? I don’t want to wake up in the morning. I don’t care if I gain five pounds.’ Also, from what I’ve read online, I think Lexapro does make you gain weight.”

Mary’s resentment toward McCosh and her psychiatrist grew with each periodic 15-minute follow-up appointment.

“Going into the beginning of sophomore year, I remember, I would not make an appointment until I looked at my pill bottle and saw I was running out,” she said. “That was the only reason I could imagine for wanting to go there.”

“I started thinking of McCosh as the place where I go to get the pills I need to function, not where I get interaction or understanding,” Mary added.

Several other students also said they failed to form personal connections with the counselors they met at McCosh, citing the random assignment of therapists to students as a possible source of this problem.

“They don’t do personality screenings when they pair you up with a counselor, they just give you the first available person,” Jessica ’10 said. “You don’t have the option to go around and choose a psychologist the way you do in the real world.”

None of the students interviewed said they had thought it would be possible to request a different counselor, though Kolligian said that UHS does permit this.

“I didn’t stick with one-on-one counseling because I didn’t feel a connection with my therapist and I didn’t feel her approach was beneficial to me,” Jessica said. “I wanted to feel there was some shared understanding, and that is something I think McCosh is pretty weak at offering.”

Kolligian acknowledged that UHS could do more to help match students with counselors they feel comfortable with. He cited the recent addition of brief biographical blurbs including each counselor’s background and professional interests to the UHS website as a change intended to help students choose an appropriate counselor.

Meeting a growing demand

Besides the concerns about encountering an incompatible counselor, student resistance to visiting McCosh is exacerbated by the sense that UHS is overbooked and understaffed.

The first thing Mary encountered when she finally dialed the number for McCosh’s counseling services was a delay. She was offered an appointment for 10 to 12 days later, but she insisted that they see her sooner and was rewarded with an appointment for one week later.

“I had struggled so much with making this call in the first place, and I felt I was really opening myself up and making myself so vulnerable by calling,” she said. “To then be told ‘We can see you in 10 days’ just made me want to hang up the phone.”

Kolligian agreed that wait times for counseling appointments have been a problem in the past but said that significant progress has been made in this area since he came to Princeton in 2004, with the staff increasing more than 60 percent.

In the past five years, the mental health staff at McCosh has expanded from a clinical staff of 11 to 18 people, including psychologists, clinical social workers and psychiatrists.

Thanks to these staffing increases, “our waits for appointments of all different types have decreased significantly,” Kolligian said, adding that he could not release statistics on average wait times at McCosh.

The larger staff also helps the University meet the demands of a steadily increasing student population looking for mental health support. Counseling services currently treats about 20 percent of the student body, up from about 14 percent three years ago, Kolligian said. This trend is in line with statistics showing rising rates of mental health problems in college students across the country.

Joseph Salvatore ’90, a psychiatrist based on Nassau Street whose patients include many University students, said that “unfortunately, college health services across the country, including Princeton, have been struggling to keep up with this growing need for treatment.”

As the University works to meet this rising demand, the perceived emotional distress of students making appointments appears to greatly influence how long they must wait. Students who recalled indicating greater urgency while scheduling counseling appointments said they received more immediate treatment than Mary.

Jessica said she was able to scheduling a counseling appointment the same day she approached McCosh during her freshman year.

“I went in when I was in a really bad place,” she said. “I think I was crying, and I said to them ‘I need to talk to someone immediately,’ and that urgency really penetrated.”

The following fall, however, when Jessica went in search of a group forum for dealing with her sadness about her dying father, she was met with much more disappointing delays. She contacted McCosh after hearing there was a grief group for people coping with the loss of a loved one, Jessica said, only to be told the group wasn’t meeting that semester because of a lack of student interest.

A few months later, McCosh contacted Jessica to let her know the group would start up in the spring semester. Though Jessica found the group immensely helpful, the four-month delay left her frustrated.

“I had to actively seek out help,” she said. “I went in and said, ‘This is what I need. Can you give it to me?’ and they couldn’t until a semester later.”

Students who don’t find what they need at McCosh sometimes try other avenues. Psychology professor Michael Litchman, who is also a practicing psychologist, said students in his classes often come to his office hours to talk about their emotional or psychological problems, especially grade-related anxiety, troubled relationships and eating disorders.

“I refuse to get involved in a therapeutic relationship with my students,” Litchman said. “My role here is as a professor. I usually suggest they go to McCosh or, if they tell me they don’t want to go there, I’ve given some students names of off-campus professionals.”

Moving off campus

Many students take advantage of these off-campus options, whether referred to them by a third party or by McCosh. Students sent off-campus by UHS, however, are sometimes left resentful at what they perceive as the University’s disinterest in addressing their problems.

Anna was referred to an off-campus psychiatrist at her very first meeting with a McCosh counselor.

“Right off the bat, they pretty much said to me, ‘This is too serious, you’re going to have to go somewhere else,’ ” she recalled. “I knew that, as a student, I was entitled to 10 sessions, and that was what I expected, but I think the counselor thought I was going to need more long-term help and they were short-staffed at the time, so he just gave me a referral.”

Though she didn’t like the psychiatrist McCosh initially referred her to, Anna did, eventually, find an off-campus professional who counseled her for the rest of her time at Princeton. There was no follow-up from McCosh after her first, and last, appointment there.

More recently, Mark GS had a completely opposite experience. He saw a McCosh counselor regularly, every couple weeks for a year while he was dealing with concerns about his mother’s health. His very helpful longer-term counseling at UHS made him question its practice of outside referrals.

“McCosh can’t provide consistent counseling services to everyone at Princeton,” Mark said. “They have to spin some people off into the wider community, and I think they do an ok job of that, but I wonder what other solutions are available.”

UHS operates on a “time-sensitive short- to intermediate-term model,” Kolligian said, offering assessments and brief- to intermediate-term psychotherapy and pharmacology services. The 10-session-per-student limit has been abolished in recent years in order to communicate more flexibility to the student body, he said.

“We will work with students throughout any sort of a difficult period,” Kolligian explained. “At a point when it seems like they’re doing better, yet are still interested in psychotherapy, we will discuss with them referral options. There are times that we will bring up the possibility of an outside referral early on, but only in instances when it’s very clear that the student needs extended service.”

He noted that these immediate referrals may help students who need longer-term care find counselors who suit their needs more quickly. Seeking treatment off campus brings with it many financial considerations as well, though, since McCosh does not charge for any of its counseling services, while many off-campus professionals charge upwards of $100 for a single 45-minute session and may not accept insurance.

Salvatore said the majority of his undergraduate patients find him through referrals from the counselors at McCosh.

“McCosh is forced to function primarily as a triage center,” Salvatore explained. “Ideally, the University would have the commitment and resources to provide comprehensive care for their students and not have to refer to the community, but, until that transpires, community providers like myself are necessary complements.”

Stigmatization on campus

On campus, many students said they felt most uncomfortable bringing up these sorts of issues with other students and members of the University community.

“Princeton is so much about dealing with your problems on your own and being successful,” Jessica said. “There’s almost no space for discussions of mental and emotional weakness.”

These pressures to seem in control and capable are especially critical to graduate students whose peers are also their future professional colleagues, Mark said. In these cases, discussing mental or emotional problems may have serious long-term consequences.

“You don’t want to seem weak or unprepared or vulnerable in front of people who are judging you or your intellectual capacity,” Mark explained. “It’s a balance between how much a single person is a friend and how much everything you say becomes an aspect of your professional career.”

Even undergraduates said they avoid discussing mental health issues with friends while adding that the avoidance perpetuates campus-wide evasion of the subject.

“There are definitely people who are judgmental,” Anna said. “When it’s not talked about at all, everyone thinks that no one else has the issue, and once that’s broken it becomes more and more accepted.”

Several students said they tried to hide their counseling from their peers.

“I’ve run into people I know while I was there, and there’s always that awkward moment of ‘Hi … why do you need psychological help?’ ” Jessica said.

A run-in at McCosh may be even more uncomfortable for male members of the community, Mark said, especially given the on-campus assumption that women require more mental help.

“It seems like a lot of the ways mental health is sold or talked about on campus could be analyzed in gender terms,” Mark said. “Those eating disorder posters, the ways it’s talked about in terms of relationships, I could see why some of those things could be alienating to a guy.”

For men seeking mental health help, this presents additional hurdles and compounds their self-consciousness about feelings of vulnerability, Mark said.

“It’s like you’re thinking ‘I don’t feel I’m secure or successful enough, and now I have to feel like a woman to get these services,’ ” Mark explained.

The University counseling services treat a slightly higher percentage of women than men and graduate students than undergraduates, Kolligian said, though he did not have a more concrete numerical breakdown. He agreed that Princeton students of all demographics often struggle with acknowledging both to themselves and to others the extent of their mental distress.

“We have a great cohort of high-achieving, often perfectionist, ambitious students who might, at least in theory, have difficulty admitting that they’re not doing so well, whether it be in some aspect of academic or social or interpersonal life,” he said.

Kolligian said UHS is working to be “more creative” in the way it reaches out to students, adding that he thinks stress-management events with other offices, like the Carl Fields Center or the Office of Religious Life, are especially successful. “People struggle with the idea that they may have a mental health problem,” he said. “But most people are receptive [to the idea] that they have stress in their lives and could probably find better ways to manage their stress.”

The number of students coming to McCosh in search of counseling services is roughly in line with the rates at other universities, suggesting that this stigmatization of mental health problems has no greater impact at Princeton than at other schools, Kolligian added.

The variety of stresses at Princeton, however, may create a uniquely intense environment, students said.

“Princeton is about balancing a lot of things,” Mary explained. “The drug of choice is Adderall: the drug that makes you achieve more, not the drug that helps you function.”

Mary recalled telling a friend that her psychiatrist had offered to prescribe her some extra drugs to help her through a particularly stressful reading period. Her friend approved of the idea and suggested that Mary request Adderall from her doctor.

After a momentary pause, her friend asked casually, “Can you get some for me?”