Overwhelmed: Why Students Are Unhappy with Yale’s System of Mental Health Care

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// WEEKEND

55 Lock Street, commonly known as Yale Health among the University’s students, overlooks New Haven’s Grove Street Cemetery like the Death Star hovered in George Lucas’s night sky.

Black and jagged, the building was completed in 2010 after three years of construction. According to a newsletter released by Yale Health that fall, the new health center was 60 percent larger than its predecessor, “with more than double the examination rooms, more space in the diagnostic imaging area, and increased space for minor procedures.” The same pamphlet touted the relocation with the headline: “From a ‘hole in the ground’ to ‘wow;’ Yale Health Center continues great service in a new home.”

The inside of Yale Health suggests a more complicated reality. At the end of a brightly lit hallway on the building’s third floor is the Mental Health and Counseling Department (MH&C), which addresses the psychological concerns of Yale’s almost 12,000 total students. Inside the waiting room, there are 11 brown chairs, a modern-looking coat tree, and a barrier of opaque glass that separates the department from the building’s other facilities.

More than 50 percent of undergraduates will find themselves in this room during their time at Yale. Lorraine Siggins, the department’s chief psychiatrist, reported in a publically available memo in September that MH&C sees about 20 percent of undergrads each year. (Siggins declined to comment for this article, citing “time constraints” in a November email.)

The numbers are even higher for Yale’s graduate and professional school students, 25 percent of whom visit MH&C yearly. They are also growing; visits have doubled since 1998, now surpassing 20,000 per year. All Yale students are entitled to 12 individual counseling sessions annually, and a mental health clinician can always be reached for emergencies through the Acute Care Department.

With the rise in appointments have come longer wait-times and more reports indicating insufficient quality of care at MH&C. Based on more than two dozen interviews with University officials, student leaders and alumni, these concerns about Yale’s mental health services finally seem to be making waves within the administration.

As pressure mounts to reform MH&C from every level of the student body, the 2013-14 academic year appears to present an opportunity for Yale to more actively address mental health. Still, such reforms may take longer than many students are willing — or able — to wait.

“Negative Perceptions Are Prevalent”

On December 12, the Office of the Secretary and Vice President for Student Life, headed by Kimberly Goff-Crews ’83 ’86 LAW, sent an email to all Yale students, which said “discussions and collaborative efforts have been underway at all levels” to improve mental health on campus.

“Living and working in this type of environment, it is normal for students to feel anxious about academic and social pressures,” the email stated. “However, the culture at Yale seems to discourage acknowledging vulnerability; rather, many students feel additional pressure to be ‘effortlessly excellent’…This expectation is not realistic and not healthy.”

The email did not specify measures for reform beyond updating the MH&C website with more information about mental health care, nor did it mention students’ most pressing concern of all: meeting patient demand in a reasonable amount of time.

Yale Health employs 28 mental health clinicians — including social workers, psychologists, and psychiatrists — 22 of whom work full-time. Given Yale’s student population, this means there are approximately 425 to 550 students for every clinician at MH&C. This means Yale has about twice the number of mental health professionals per student than do schools of similar size, based on 2012 data from the Association for University and College Counseling Center Directors (AUCCCD).

A Yale College Council (YCC) report on mental health published last October revealed that this ratio, while favorable, doesn’t tell the whole story. Authored by three Yale College students, the report compiled data from what it called 50 “structured interviews” with student leaders and administrators, and from a campus-wide, anonymous survey, to which roughly 20 percent of undergrads responded.

The report included findings about Yale’s campus culture and resources surrounding mental health. Of students who completed the survey, 39 percent said they had sought the services of Mental Health and Counseling — the reasons for their visits ranged from depression and anxiety to eating disorders and academic stress.

“We do acknowledge the limitations of the data we’ve collected,” Reuben Hendler, one of the YCC report’s authors, says, referring to sampling biases in the survey and interviews. “But that in no way means we can’t learn a lot from it.”

The report also contained data on students’ perceptions of the quality of care offered at Yale Health, with 31 percent of students rating their experiences as “poor” or “very poor.” Moreover, over half of respondents said they would be “unlikely,” “very unlikely,” or “unsure” about approaching MH&C if they wanted professional counseling.

“Negative perceptions of MH&C are prevalent,” the report stated. “Some students fall through the cracks.”

Paul Genecin, director of Yale Health since 1997, acknowledges that students’ experiences of MH&C vary, but says Yale Health has quality control measures in place, such as an annual review of clinicians, a member services department, and yearly accreditation by the Joint Commission — a non-profit organization that certifies roughly 20,000 health care programs in the United States.

“It is a fact of student health across the land: If you ask students what they think, you will find a number of people exercising their critical faculties,” Genecin says. “You can trade out us and put in ‘Athletics,’ ‘Dining,’ ‘Libraries’ — there’s always a seeming disconnect between how people look at a service versus how it actually is.”

In order to assuage students’ expressed concerns, the YCC report outlined three major recommendations for MH&C: communicating more effectively about appointments, expectations, feedback, and mental health education; hiring additional therapists; and possibly referring certain students to outside clinicians.

Specific measures included allowing students to schedule appointments over email, instituting mandatory telephone check-ins with students who miss an appointment or wait more than a week to be assigned a therapist and creating “an accessible, well-publicized way for students to provide feedback.” Hendler, one of the authors, says he is confident the report will be given “serious consideration” by the University.

Genecin states the YCC report did “a good job” of addressing some of the misinformation among students about MH&C’s services. He admits Yale Health should do more public outreach, but adds that his staff is primarily dedicated to patient care, and so cannot focus on outreach as much as they would like. When asked about the long wait times some students experience, Genecin responded that “no health care system can have perfect access to resources” and that doctors must prioritize patients based on the severity of their conditions.

“I’m much more concerned with treating students who need serious intervention,” he explains. “The question is not what percentage of students did you see in x number of days, it’s what percentage of students did you see who really needed help.”

But such an approach has led to a dissatisfaction with MH&C that extends well beyond the College: on the same day the YCC released its report, Yale’s Graduate Student Assembly (GSA) and Graduate and Professional Student Senate (GPSS) released their own mental health report, according to which 32 percent of participants in an annual GPSS survey said they were “somewhat dissatisfied or worse” with the University’s mental health services. Ultimately, this was “the strongest student concern with the Yale Health Plan” in 2013.

Yale: “A Rough Place To Be Sometimes”

For Julie Botnick ‘14, scheduling an appointment at Mental Health and Counseling was a daunting task. In an October 21 Yale Daily News opinion column, “Don’t neglect us,” Botnick wrote that she sought treatment at MH&C during her sophomore year for a chronic mental disorder.

Botnick became frustrated, however, when she waited over a month to be assigned a permanent clinician after her “intake” appointment — an hour-long evaluation session typically made within three days of a student contacting MH&C.

When Botnick finally saw someone, the clinician was a social worker and not a psychiatrist as she had requested, whom she said seemed “bored and unresponsive.” She stopped visiting MH&C after “two or three sessions,” and was never contacted afterwards to see if her condition had improved.

“It was a waste of my time,” Botnick remembers. “I can’t believe they had never been so busy before and didn’t know what volume of people to expect. They need to meet the demand, no excuses.”

Multiple factors may explain why students like Botnick experience long wait times and variable quality of care at MH&C. Notably, Yale Health’s triage system prioritizes students who feel they are in dire straits and can articulate it. According to Genecin, those who express suicidal thoughts or the intention to harm themselves are “seen immediately,” which necessarily delays other appointments.

Nonetheless, as Genecin himself acknowledges, these are rare cases; most students present with an “extremely broad” range of concerns that do not require emergency treatment.

After intake, each patient is given the contact information of a MH&C clinician, and a schedule is created that is reviewed within five weeks, Siggins, the head of the department, stated in the September memo. Students on medication are scheduled a check-in appointment after four to five weeks of treatment, and Siggins reported that only “about 10 percent” of patients wait longer than two or three weeks to see a clinician.

Additionally, in her September presentation to the Yale Health Member Advisory Committee — a feedback group composed of about 20 undergraduate, graduate and professional school students, and Yale Health staff — Siggins said her department offers group therapy to students waiting for individual appointments, with about a dozen groups currently running.

But Genecin concedes that many students are uncomfortable with group treatment because they would prefer confidential, one-on-one therapy. Moreover, students can only join groups in which they do not know anyone else. While in line with clinical best practices, this requirement poses significant logistical problems for a student body as well connected as Yale’s.

Anna North ’13, a first-year student at Yale’s School of Public Health and a former Freshman Counselor (FroCo) in Silliman College, says although she was offered group therapy after her individual appointments ran out as an undergrad, she was ultimately disappointed with her experience.

“Hardly anybody will be able to benefit from [group therapy] because they start at a random time and are really disorganized,” North says. “Last year, I tried to join a group, finally got into one, and then found out one of my friends was in it so I wasn’t allowed to join.”

However, Stephanie Tubiolo ’14, a current FroCo in Silliman College, believes group therapy helped her cope with depression and an eating disorder, which developed after her work supervisor, John Miller MUS ’07, a School of Music employee, committed suicide in 2011. Tubiolo says everyone in her therapy group received the attention they needed, adding that the counselor in charge facilitated discussions without interfering with the group dynamic.

“It was a really rewarding experience to say I had this issue and someone else would say, ‘That happens to me all the time,’” Tubiolo explains. “Especially at Yale where so few people are willing to show their weaknesses. It’s a rough place to be sometimes.”

Tubiolo also speaks highly of individual counseling sessions, which she says taught her to “pick [herself] up” on difficult days and now seem like “one of the best decisions [she has] ever made.”

She says she was surprised by the YCC report’s findings about variable quality of care at MH&C, but admits that not everyone feels immediately comfortable with their clinician because of therapy’s subjective nature.

Siggins reported that 25 percent of students start to feel better after three or four visits to MH&C. But inevitably each year, the department sees busy times, such as between Thanksgiving and winter breaks, when the stress of final exams and papers may negatively affect students’ mental health.

“I feel like it’s gotten a bit worse in recent years,” University Chaplain Sharon Kugler maintains. “Students are now stressing two weeks into the semester rather than six. Then we get into Reading Week and everything goes to black.”

Addressing the Information Gap

Administrators like Kugler play an important role in getting certain students to receive treatment at Mental Health and Counseling. In an environment with a high demand for services and a limited supply of clinicians, residential college masters, deans, freshmen counselors and chaplains can significantly accelerate the intake process by advocating for students.

“If something gets to a level where day-to-day support from deans, administrators, and friends is not going to help, then we contact MH&C,” Jeffrey Brenzel, Master of Timothy Dwight College, says.

Many undergraduates do not know where to go until they face an acute situation. As the YCC report outlined, students may be “confused about how to navigate [Yale’s] extensive network of resources.

Such confusion is unsurprising: Yale resources include everything from student organizations like Walden Peer Counseling, Queer Peers, Peer Liaisons (PLs), Communication and Consent Educators (CCEs), Freshman Counselors (FroCos) and Mind Matters — a mental health awareness group — to institutional resources like MH&C, the Sexual Harassment and Assault Response & Education (SHARE) Center, the Chaplain’s Office, the Resource Office on Disabilities, the Office of LGBTQ Resources and the four cultural centers. Currently, comprehensive information about campus resources is not centralized.

“I felt like FroCo training was the first time where I fully knew about Yale’s mental health resources because it was my job to know,” Margaret Coons ’14, a Silliman FroCo, recalls. “People going through emergency situations might not have the luxury to wait.”

Five current FroCos said freshman orientation should include more information about Yale’s mental health resources and campus culture. Although every FroCo must meet with the staff of MH&C and participate in mental health role-plays before freshmen arrive on campus, Michael Sherman ’14, a FroCo in Pierson College, says he was disappointed with this year’s training.

“When we did the role-plays,” — simulations of students approaching FroCos with mental health concerns — “the professionals who were there gave almost no feedback and left it up to the group,” he says. Sherman added that a mandatory tour of Yale Health was part of orientation, but because it was scheduled on Labor Day, there were no officials present to greet and guide freshmen. “We quickly realized we were the tour guides and we didn’t know the adequate information.”

Anna North ‘13, the alumna at the School of Public Health and former FroCo, agrees with Coons’s assessment of the information gap, adding that she was “extremely nervous” the first time she visited MH&C during her sophomore year because she didn’t know what to expect. North, who was experiencing regular anxiety attacks, only approached MH&C once she felt she was on the verge of leaving Yale if nothing changed.

The result of general ignorance about MH&C is that rumors circulate among undergrads regarding the consequences of receiving treatment, North claims, which may deter some students from seeking help. Such rumors include being sent to the Yale-New Haven Psychiatric Hospital, where treatment could become expensive, and being asked by the University to take a medical leave of absence, which could threaten a student’s chances of graduating on time.

It’s no wonder then that for many students, a certain deal of anxiety surrounds scheduling an appointment at MH&C. Robert Peck ’15, a former staff reporter for the News, had a Kafkaesque experience there during his sophomore year, when he had to wait over three months to be seen by a permanent clinician.

Now a YCC representative on the Yale Health Member Advisory Committee, Peck says he was told he would get to see a clinician within a month of his intake appointment in November 2012. When that did not happen and he returned home for winter break, Peck emailed his intake counselor but received no response. And when he called MH&C in early January, he was simply told that December was always a busy time.

It was not until his dean called MH&C several weeks into the spring semester that he had an official appointment scheduled for February.

“You would think that was the end of it, but then the therapist I was assigned decided not to show up for work on the day of my appointment,” Peck remembers. “I was so thoroughly poisoned by the experience that I left and didn’t go back.”

Peck admits his condition was not as severe as those of others he has spoken with, but says it would be unacceptable for Yale Health to define success only in terms of treating its most pressing patients.

“Of course Yale Health is probably better than many [university health care] programs in the country, but that doesn’t get them off the hook for not fully helping the student population here,” he asserts. “If we’re to have faith in our university, for a service we pay for through tuition, there has to be some legitimate reason they can’t meet demand in a timely fashion. So far, I haven’t heard what that is.”

“A Legitimate Reason”?

A potential answer to Peck’s question may involve how the University determines Yale Health’s annual budget, which Stephanie Spangler, deputy provost for health affairs and academic integrity, currently oversees. She previously served as Director of Yale University Health Services from 1990 to 1995.

In November, Spangler declined to comment on the magnitude or percentage that Yale Health’s expenses make up of the University’s overall budget, but said Yale Health’s four biggest costs are medication, staffing, hospital expenses and those to outside providers and delivery systems.

Genecin and Lorraine Siggins are the two people primarily responsible for managing the budget for mental health, Spangler said. Although Genecin declined to provide specific budgetary figures, which total in “the millions of dollars,” he notes that a significant amount of MH&C’s funding comes from the endowment, through donors who specifically want to support Yale’s mental health services.

However much money is allocated to MH&C, the University’s limited finances and budget priorities may impede changes to Yale Health for some time. As of June 2013, Yale faced a $39 million budget deficit, which University President Peter Salovey and Provost Benjamin Polak announced in mid-November would need to be reduced through cuts to administrative departments. At the time, Genecin told the News that Yale Health is always looking for ways to contain costs, and that budget pressures fluctuate throughout the year.

Reuben Hendler, one of the YCC report authors, admits that hiring extra clinicians at MH&C would cost more than other reforms, but says it would be “the silver bullet” to lowering student wait times. In turn, Hendler explains, undergrads would have more positive perceptions of Yale Health. “It’s simple: If there are more therapists, then people can be seen more quickly,” he says. “Obviously that takes resources. We think those resources are well spent.”

“Barring unforeseen circumstances, I expect we’ll be talking about adding more staff as the new residential colleges are built,” Genecin says. The two new colleges are scheduled to be completed in August 2017, which will allow Yale to admit roughly 15 percent more students each year, bringing total undergraduate enrollment to more than 6,000.

Genecin declined to speculate as to whether the ratio of mental health clinicians to students would also change.

Ernest Baskin GRD ‘16, chair of the Yale Health Member Advisory Committee, says he is optimistic that mental health resources on campus will improve, but maintains that it will take “broad student initiatives” to make the Yale Corporation aware that mental health is such an important issue. “It needs to be heard by the trustees who control the purse strings and can influence the allocation of funds, at the very highest level of decision-making,” he asserts.

For now, at least, those hopes may not be far off.

“One thing in the [YCC] report that concerned me was the observation that students could be unhappy here and feel they have to hide it,” Spangler says. “We have a great opportunity to change that.”

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