STUDENT MENTAL HEALTH : What Not To Do
At times it feels like every few weeks there is another headline relating to a fresh tragedy. Another case where a student has died from suicide. There are dozens of factors which have led to an increase in pressure on students at university – many are political in nature and the purpose of this post is not to make a political statement but rather to highlight the issue and to point to where, almost as a matter of routine, decisions were taken which could have led to another tragedy. This post tells the story of something which happened at a relatively high-profile institution within the UK. Some details have been deliberately framed in such a way as to maintain the anonymity of the student at the heart of it – the story is shared with their permission on the condition they remain anonymous. This story is an example of Bad Practice. It is a How Not To Do Student Support.
The student at the centre of this story was in their second year. They have a diagnosis of learning difficulties. They had done well in their first year and had a good academic record. At the end of October of their second year, they began suffering from panic attacks, and a return of issues around anxiety which they had suffered from when they were at school. Friends noticed they occasionally seemed out of sorts. Steadily things were beginning to build up.
By February the emotional fatigue of panic attacks and anxiety meant they were getting behind with work – particularly with one assignment. The panic and the anxiety were severe, and they began to suffer from intrusive thoughts about self-destructive behaviours. They were struggling with thoughts of self-harm and suicide. It was almost hand-in day. They knew they could not get their work completed by the midday deadline. They applied for an extension, writing that they knew it was late to be making the application (in fact, department policy states that ECA requests can be submitted up to 24 hours before the hand in without problem, and may still be considered after this time). They sent an e-mail to their tutor as a courtesy explaining what was going on, including that they had been having a mental health crisis and had only really faced up to it in the preceding few hours but were seeking treatment urgently. It was at this point where things started to do seriously wrong.
Their tutor’s reply was, in summary, ‘this isn’t my problem and I shouldn’t have to deal with this.’ The student had, in their e-mail, set out they had already applied for ECA through the correct process – but were effectively berated by the tutor for contacting them. It should be noted at this point – the student’s e-mail clearly stated that the student had been struggling with self-destructive impulses.
The department’s response was to tell the student they had to submit something by the 12 noon deadline or they would fail the unit. This went against all published department policy including that issued to students at the beginning of term (and general university wide policy) which states that late work is penalised by a set percentage per day up to 3 days after the deadline, but not rejected.
It needs to be emphasized at this point that the student was seeking help. A mental health first aid assessment showed they needed treatment as a matter of urgency. And still the department pressured them to submit by the deadline or fail – even though this was against department policy – and despite knowing the student was struggling with thoughts of suicide.
They were eventually granted a short extension, submitted the work and passed the unit. They were given time by the doctor they saw at the Student Health centre to consider whether they wanted to try medication or counselling, or a combination of both. They felt they were coping with things generally okay, although the panic attacks never stopped, and the anxiety began to build again. By May of their 2nd year they were at a crisis point and suicidal. Work was piling up and exams were approaching. This was a crisis and as they had been before they had been being open with their department about how they were managing. They submitted forms for extenuating circumstances and told their department everything as they had before.
It needs to be emphasized at this point – the student was suicidal, suffering from suicidal ideation on a daily basis, and struggling to cope. An independent mental health assessment at this point showed them as being a severe risk to themselves.
The department’s first response was to warn them that if they had to resit exams they would not be able to start their next year. The same e-mail reminded them that they were required to provide evidence that the reasons stated were truthful. It was further implied that the ECA would be denied because their status as a registered disabled student meant they should get short extensions as needed through another office. The student had never been told this, and the department had made no mention of this when they had previously submitted ECA forms.
The department’s second response, while granting a short extension, was to tell the student they were misusing the ECA system because it ‘wasn’t for long term conditions’ and to ‘use the support services the university offers’.
The student had at the same time attempted to contact their tutor to advise them of the situation – and again received a reply which stated that this was not the tutor’s problem and frankly they were ‘lucky to get a reply at all’.
During this time the student had attended an appointment with the support offered only to be told their appointment had been cancelled as their case was not urgent. This was on the same day they were in crisis.
It should be emphasized here that the department had been aware of concerns for the student’s wellbeing for 4 months. The department had been aware in February that the mental health problems the student was suffering from were a relatively recent development and had not been fully diagnosed. They were aware that the student was disabled, with learning difficulties, and that no additional provision relating to their mental health issues had been put in place. This meant that the student’s situation fully met with the criteria listed as acceptable for ECA stated in the department policy – because no adjustments had been made for the new circumstances (despite the department having been aware on multiple levels for 4 months). The student was placed under both pressure to submit work and pressure to produce evidence they in fact were in crisis.
It should be noted here that this department’s particular policy states that if suitable evidence of both the circumstances and that the student sought support is not submitted before the extension deadline the ECA request will be withdrawn. In this case the extension granted was less than a week. At that point the average wait time for an appointment with the student health centre was 9 days – and the student was told in this time that unless their case was urgent they would not be seen. An independent mental health assessment listed their risk on the same day as near critical.
The student was left terrified of requesting extenuating circumstances for exams they took less than a few days after starting medication, the side effects of which were making it difficult for them to concentrate. They were also nervous of ever requesting extenuating circumstances, regardless of what those circumstances might be. They were treated, rather than as a student or simply as a human, as a problem.
Throughout the attitude of the department was to add to the pressure, going outside of the department policy on late work to pressure the student to submit work, and ignoring the fact the student was having a mental health crisis. On multiple occasions the student made the department aware they were struggling with self-destructive impulses, thoughts of self-harm and suicide. The continued pressure was to submit the work, and at the same time submit more paperwork to prove that there was a real issue. A vulnerable student was bullied out of seeking help. The support they tried to access undermined the seriousness of their mental state. The department and certain individuals implied they were contributing to their own problems, that their problems weren’t actually serious, or tried to pass responsibility on to others. They showed they had no idea how to deal with a student in crisis. The primary concern was procedure and form filling. Instead of actively supporting the student there was deflection of responsibility and victim blaming. If it had not been for outside interventions this incident could well have ended in another death. This failure is just one amongst the many. Change needs to happen and happen soon – we can do so much better than this.
Having heard this student’s story, here are some suggestions which can help promote best practice.
In this student’s story there were numerous points where a better approach would have prevented the situation from becoming as severe as it did. It is worth noting that for a large section of this case the student in question was dealing with the same tutors and the same individuals within their department. Therefore, it would only have taken a brief re-reading of the student’s e-mails to see what had previously been said. The tutor was made aware on at least three occasions that the student was suffering from mental health issues – and knew they were in crisis. There were three approaches which made things worse.
The first was to ignore the issue – to treat the student as if they were not in crisis, and to not attempt to understand that the student was likely to be struggling emotionally and therefore that a degree of emotional tact and diplomacy was called for. It takes a lot for a student to admit to a tutor they are having mental health issues. Few will do so lightly. While some may claim that some students will feign mental health issues in order to gain extensions surely the risk that the odd case of feigning a problem is worth it versus the risk that a student in crisis may die as a result of their mental health issues? Therefore, if a student comes to you struggling with their mental health – believe them and take them seriously. Do not be dismissive.
The second was to blame the student. Yes, there are cases where a student’s personal choices may have contributed to their situation, but in these circumstances, it is unlikely to help. When the individual is in crisis, it is not the time to pull apart their situation and tell them that they should have done things differently. In many cases they will already be acutely aware of this. The priority should instead be to support them through the crisis and build in space to reflect on how things could be done differently afterwards.
The third was to instinctively shift the blame and make the situation ‘someone else’s problem’. It may be out of a desire for self-protection, or out of a commitment to correct procedure, but too often in these cases there is an element of ‘passing the buck’ as to who is directly responsible for directing the student towards the support they need. While structures vary from university to university, it might be worth asking the question ‘Why has this student come to me with this?’ While the answer may frequently be prosaic – you are teaching them the course in question for example – even in these cases there may be an underlying element here based around the idea that it is ‘because they trust you.’ And in each case, there is a fundamental element in which the student is putting their trust in you by revealing something which is hard to admit. The stigma of mental illness is real. It has made an appearance in countless tragedies. Therefore, many students may struggle with opening up about what exactly is causing the problems with their work. If they have done so, this disclosure deserves to be treated with respect.
A further error made by the department was a failure of nuance and understanding which prioritised procedure over an understanding of the person. While there was a strong probability that if the student in the above account did need to re-sit it may delay or change their plans for the next year, the key word was if. The student had not failed the unit, or the year, but was already being treated as if they had. While they would need to know this at some point, questions have to be asked as to whether while they were still clearly still in crisis was the correct time to do so. There is also a question over whether pressuring students to supply supporting paperwork within a very short deadline, during time given them to finish their assignments is appropriate. It may be that in future policy frameworks around extensions should be adjusted reduce the additional pressure to produce additional paperwork – especially given the fact that existing pressures on student health centres and the NHS mean that delays can happen due to factors outside of the student’s control. The commitment to procedure over consideration of the student’s mental state can often simply make the situation worse. It is notable that in the case above that while the student was being actively pressured to produce evidence they were seeking help no-one they dealt with asked if they were okay or how they were coping.
In terms of institutional approaches there are a few factors which need to be taken into consideration in terms of future policy making. Firstly, better communication between departments and student support services as a whole – within the boundaries of confidentiality – would greatly help in these situations.
Secondly, better communication between services to support disabled students and academic departments. It is notable in this case that the student was entitled to extensions through their disability – but they had never been informed of this, nor had they been reminded of it by their department when they first applied for extenuating circumstances.
Thirdly, a possible reconsideration around the structure of policies regarding provision of evidence regarding extenuating circumstances may be in order, depending on existing policy.
Fourthly, there needs to be greater understanding within academic departments that mental health is as significant and as serious as physical health. For example, within the NHS an individual with a severe mental health crisis is regarded as being a medical emergency. This is often far from the treatment that students suffering from mental health crises receive from their academic departments.
Fifthly, there is a need to consider than the distinction between ‘long term conditions’ and ‘short term conditions’ is often arbitrary, and often not related to what support may be available or how long students may need to wait to access appropriate support. It is worth noting that the student in the case described above was in a crisis, but due to the overstretched nature of student support their attempts at seeking support were delayed. A degree of common sense and communication is needed.
It is easy for an institutional mindset to lean towards policy, procedure and data over the person. It is a depressing fact in and of itself how often the tragedies of death from suicide amongst students are reduced to statistic to be tacked on to the end of the latest tragedy when each has impacted on dozens of lives.
In terms of personal approaches there are effectively four key points worth considering, primarily for those who teach.
Firstly, make sure you know if any students in your classes have disclosed a disability or long-term mental health condition. If they have, make sure signpost any additional support available – don’t assume that because they have a disability they will automatically know that it is there. Also, and this should go without saying, if you offer support – keep to those arrangements.
Secondly, remember while it is natural for students to blur into each other over time, they are a person and not a problem. It is all too common, especially for disabled students, to end up feeling like they are treated as a problem rather than a person.
Thirdly, keep in mind, as has been stated a number of times in this post, that mental health problems are as serious and debilitating as physical health issues. If a student comes to you for support, they have come to you because they trust you. Respect that trust.
Fourthly, a student’s choices over support are their choices. No student should ever be pressured to use support that doesn’t work for them. No student should be pushed to seek one solution over another. Some students may benefit from a particular method, be it mindfulness, exercise, CBT, or other therapy, some students may benefit from medication, some a combination of both. No student should ever be made to feel shamed or pressured over these choices.
In all likelihood someone reading this will be a student struggling with mental health issues. If you are that person this is for you - You are not alone. It may feel like it, or it may feel like too many things and people are crowding in on you. Don’t be afraid to seek support – that is what student support services are there for – to support students. You aren’t wasting their time. You are entitled to receive the support you need to be able to study and to give it your best shot.
We can do so much better in terms of supporting students (and indeed, colleagues) with mental health issues. Students are people and not numbers. Support is more than policy and procedure. Access is more than a statement – it’s a continual process.
In summary – look out for each other, students, staff and academics. Support each other. Build and rebuild a research community which nurtures new minds, fresh ideas and inventive research and above all cares for all its members, regardless of role. We need to be more kind.
By February the emotional fatigue of panic attacks and anxiety meant they were getting behind with work – particularly with one assignment. The panic and the anxiety were severe, and they began to suffer from intrusive thoughts about self-destructive behaviours. They were struggling with thoughts of self-harm and suicide. It was almost hand-in day. They knew they could not get their work completed by the midday deadline. They applied for an extension, writing that they knew it was late to be making the application (in fact, department policy states that ECA requests can be submitted up to 24 hours before the hand in without problem, and may still be considered after this time). They sent an e-mail to their tutor as a courtesy explaining what was going on, including that they had been having a mental health crisis and had only really faced up to it in the preceding few hours but were seeking treatment urgently. It was at this point where things started to do seriously wrong.
Their tutor’s reply was, in summary, ‘this isn’t my problem and I shouldn’t have to deal with this.’ The student had, in their e-mail, set out they had already applied for ECA through the correct process – but were effectively berated by the tutor for contacting them. It should be noted at this point – the student’s e-mail clearly stated that the student had been struggling with self-destructive impulses.
The department’s response was to tell the student they had to submit something by the 12 noon deadline or they would fail the unit. This went against all published department policy including that issued to students at the beginning of term (and general university wide policy) which states that late work is penalised by a set percentage per day up to 3 days after the deadline, but not rejected.
It needs to be emphasized at this point that the student was seeking help. A mental health first aid assessment showed they needed treatment as a matter of urgency. And still the department pressured them to submit by the deadline or fail – even though this was against department policy – and despite knowing the student was struggling with thoughts of suicide.
They were eventually granted a short extension, submitted the work and passed the unit. They were given time by the doctor they saw at the Student Health centre to consider whether they wanted to try medication or counselling, or a combination of both. They felt they were coping with things generally okay, although the panic attacks never stopped, and the anxiety began to build again. By May of their 2nd year they were at a crisis point and suicidal. Work was piling up and exams were approaching. This was a crisis and as they had been before they had been being open with their department about how they were managing. They submitted forms for extenuating circumstances and told their department everything as they had before.
It needs to be emphasized at this point – the student was suicidal, suffering from suicidal ideation on a daily basis, and struggling to cope. An independent mental health assessment at this point showed them as being a severe risk to themselves.
The department’s first response was to warn them that if they had to resit exams they would not be able to start their next year. The same e-mail reminded them that they were required to provide evidence that the reasons stated were truthful. It was further implied that the ECA would be denied because their status as a registered disabled student meant they should get short extensions as needed through another office. The student had never been told this, and the department had made no mention of this when they had previously submitted ECA forms.
The department’s second response, while granting a short extension, was to tell the student they were misusing the ECA system because it ‘wasn’t for long term conditions’ and to ‘use the support services the university offers’.
The student had at the same time attempted to contact their tutor to advise them of the situation – and again received a reply which stated that this was not the tutor’s problem and frankly they were ‘lucky to get a reply at all’.
During this time the student had attended an appointment with the support offered only to be told their appointment had been cancelled as their case was not urgent. This was on the same day they were in crisis.
It should be emphasized here that the department had been aware of concerns for the student’s wellbeing for 4 months. The department had been aware in February that the mental health problems the student was suffering from were a relatively recent development and had not been fully diagnosed. They were aware that the student was disabled, with learning difficulties, and that no additional provision relating to their mental health issues had been put in place. This meant that the student’s situation fully met with the criteria listed as acceptable for ECA stated in the department policy – because no adjustments had been made for the new circumstances (despite the department having been aware on multiple levels for 4 months). The student was placed under both pressure to submit work and pressure to produce evidence they in fact were in crisis.
It should be noted here that this department’s particular policy states that if suitable evidence of both the circumstances and that the student sought support is not submitted before the extension deadline the ECA request will be withdrawn. In this case the extension granted was less than a week. At that point the average wait time for an appointment with the student health centre was 9 days – and the student was told in this time that unless their case was urgent they would not be seen. An independent mental health assessment listed their risk on the same day as near critical.
The student was left terrified of requesting extenuating circumstances for exams they took less than a few days after starting medication, the side effects of which were making it difficult for them to concentrate. They were also nervous of ever requesting extenuating circumstances, regardless of what those circumstances might be. They were treated, rather than as a student or simply as a human, as a problem.
Throughout the attitude of the department was to add to the pressure, going outside of the department policy on late work to pressure the student to submit work, and ignoring the fact the student was having a mental health crisis. On multiple occasions the student made the department aware they were struggling with self-destructive impulses, thoughts of self-harm and suicide. The continued pressure was to submit the work, and at the same time submit more paperwork to prove that there was a real issue. A vulnerable student was bullied out of seeking help. The support they tried to access undermined the seriousness of their mental state. The department and certain individuals implied they were contributing to their own problems, that their problems weren’t actually serious, or tried to pass responsibility on to others. They showed they had no idea how to deal with a student in crisis. The primary concern was procedure and form filling. Instead of actively supporting the student there was deflection of responsibility and victim blaming. If it had not been for outside interventions this incident could well have ended in another death. This failure is just one amongst the many. Change needs to happen and happen soon – we can do so much better than this.
Having heard this student’s story, here are some suggestions which can help promote best practice.
In this student’s story there were numerous points where a better approach would have prevented the situation from becoming as severe as it did. It is worth noting that for a large section of this case the student in question was dealing with the same tutors and the same individuals within their department. Therefore, it would only have taken a brief re-reading of the student’s e-mails to see what had previously been said. The tutor was made aware on at least three occasions that the student was suffering from mental health issues – and knew they were in crisis. There were three approaches which made things worse.
The first was to ignore the issue – to treat the student as if they were not in crisis, and to not attempt to understand that the student was likely to be struggling emotionally and therefore that a degree of emotional tact and diplomacy was called for. It takes a lot for a student to admit to a tutor they are having mental health issues. Few will do so lightly. While some may claim that some students will feign mental health issues in order to gain extensions surely the risk that the odd case of feigning a problem is worth it versus the risk that a student in crisis may die as a result of their mental health issues? Therefore, if a student comes to you struggling with their mental health – believe them and take them seriously. Do not be dismissive.
The second was to blame the student. Yes, there are cases where a student’s personal choices may have contributed to their situation, but in these circumstances, it is unlikely to help. When the individual is in crisis, it is not the time to pull apart their situation and tell them that they should have done things differently. In many cases they will already be acutely aware of this. The priority should instead be to support them through the crisis and build in space to reflect on how things could be done differently afterwards.
The third was to instinctively shift the blame and make the situation ‘someone else’s problem’. It may be out of a desire for self-protection, or out of a commitment to correct procedure, but too often in these cases there is an element of ‘passing the buck’ as to who is directly responsible for directing the student towards the support they need. While structures vary from university to university, it might be worth asking the question ‘Why has this student come to me with this?’ While the answer may frequently be prosaic – you are teaching them the course in question for example – even in these cases there may be an underlying element here based around the idea that it is ‘because they trust you.’ And in each case, there is a fundamental element in which the student is putting their trust in you by revealing something which is hard to admit. The stigma of mental illness is real. It has made an appearance in countless tragedies. Therefore, many students may struggle with opening up about what exactly is causing the problems with their work. If they have done so, this disclosure deserves to be treated with respect.
A further error made by the department was a failure of nuance and understanding which prioritised procedure over an understanding of the person. While there was a strong probability that if the student in the above account did need to re-sit it may delay or change their plans for the next year, the key word was if. The student had not failed the unit, or the year, but was already being treated as if they had. While they would need to know this at some point, questions have to be asked as to whether while they were still clearly still in crisis was the correct time to do so. There is also a question over whether pressuring students to supply supporting paperwork within a very short deadline, during time given them to finish their assignments is appropriate. It may be that in future policy frameworks around extensions should be adjusted reduce the additional pressure to produce additional paperwork – especially given the fact that existing pressures on student health centres and the NHS mean that delays can happen due to factors outside of the student’s control. The commitment to procedure over consideration of the student’s mental state can often simply make the situation worse. It is notable that in the case above that while the student was being actively pressured to produce evidence they were seeking help no-one they dealt with asked if they were okay or how they were coping.
In terms of institutional approaches there are a few factors which need to be taken into consideration in terms of future policy making. Firstly, better communication between departments and student support services as a whole – within the boundaries of confidentiality – would greatly help in these situations.
Secondly, better communication between services to support disabled students and academic departments. It is notable in this case that the student was entitled to extensions through their disability – but they had never been informed of this, nor had they been reminded of it by their department when they first applied for extenuating circumstances.
Thirdly, a possible reconsideration around the structure of policies regarding provision of evidence regarding extenuating circumstances may be in order, depending on existing policy.
Fourthly, there needs to be greater understanding within academic departments that mental health is as significant and as serious as physical health. For example, within the NHS an individual with a severe mental health crisis is regarded as being a medical emergency. This is often far from the treatment that students suffering from mental health crises receive from their academic departments.
Fifthly, there is a need to consider than the distinction between ‘long term conditions’ and ‘short term conditions’ is often arbitrary, and often not related to what support may be available or how long students may need to wait to access appropriate support. It is worth noting that the student in the case described above was in a crisis, but due to the overstretched nature of student support their attempts at seeking support were delayed. A degree of common sense and communication is needed.
It is easy for an institutional mindset to lean towards policy, procedure and data over the person. It is a depressing fact in and of itself how often the tragedies of death from suicide amongst students are reduced to statistic to be tacked on to the end of the latest tragedy when each has impacted on dozens of lives.
In terms of personal approaches there are effectively four key points worth considering, primarily for those who teach.
Firstly, make sure you know if any students in your classes have disclosed a disability or long-term mental health condition. If they have, make sure signpost any additional support available – don’t assume that because they have a disability they will automatically know that it is there. Also, and this should go without saying, if you offer support – keep to those arrangements.
Secondly, remember while it is natural for students to blur into each other over time, they are a person and not a problem. It is all too common, especially for disabled students, to end up feeling like they are treated as a problem rather than a person.
Thirdly, keep in mind, as has been stated a number of times in this post, that mental health problems are as serious and debilitating as physical health issues. If a student comes to you for support, they have come to you because they trust you. Respect that trust.
Fourthly, a student’s choices over support are their choices. No student should ever be pressured to use support that doesn’t work for them. No student should be pushed to seek one solution over another. Some students may benefit from a particular method, be it mindfulness, exercise, CBT, or other therapy, some students may benefit from medication, some a combination of both. No student should ever be made to feel shamed or pressured over these choices.
In all likelihood someone reading this will be a student struggling with mental health issues. If you are that person this is for you - You are not alone. It may feel like it, or it may feel like too many things and people are crowding in on you. Don’t be afraid to seek support – that is what student support services are there for – to support students. You aren’t wasting their time. You are entitled to receive the support you need to be able to study and to give it your best shot.
We can do so much better in terms of supporting students (and indeed, colleagues) with mental health issues. Students are people and not numbers. Support is more than policy and procedure. Access is more than a statement – it’s a continual process.
In summary – look out for each other, students, staff and academics. Support each other. Build and rebuild a research community which nurtures new minds, fresh ideas and inventive research and above all cares for all its members, regardless of role. We need to be more kind.
