Over the last two decades, mental health and suicide-prevention efforts have blanketed the nation, targeting young people at home and on campus with campaigns to raise awareness, combat stigma, and steer them toward treatment.
And over the last two decades, students have responded. More and more have been diagnosed with depression and anxiety. More and more say they’ve experienced suicidal ideation and self-harm. More and more are reporting other forms of mental distress and, more and more, are actively seeking help.
One result: College and university counseling services are swamped. At some schools, the wait time for a session can be as much as six weeks. Mental health staffers are taking on a flood of appointments, sapping their energy and strapping them for time. Many counselors are exhausted, their own mental equilibrium disrupted by the constant demand. Many directors are, too, juggling the needs of students and employees along with administrative concerns.
“People are burned out. People are leaving the field,” said Nance Roy, chief clinical officer at the Jed Foundation, a suicide-prevention effort targeting teens and young adults. Job-vacancy postings for counseling-center staff and directors are everywhere.
“Most counseling centers are overwhelmed with the number of students that want to be seen, and they don’t have the capacity to see them,” she said. “And it raises the question of what is the role of a counseling center on campus? Are they supposed to be community centers and have unlimited resources? It’s a question that’s really the question in terms of how to manage it.”
That question, and an array of possible answers, is now being mulled by those concerned with campus mental health, from the professionals tasked with aiding students to the students themselves. Everyone can see the crush. Everyone recognizes the plight of counselors. But there’s no consensus on how to proceed, because the approach so far — outreach and treatment, treatment and outreach — has ramped up the strain on counseling centers and those who staff them. Meanwhile, more and more young people are in more and more distress: According to the Centers for Disease Control, the suicide rate among 10- to 24-year-olds increased more than 57 percent from 2007 to 2018.
No one takes such numbers lightly. The challenge lies in figuring out how to lower them. How to ease students’ pain. How to foster student wellness, support counseling staff, and nourish campuses as a whole — which are, in essence, communities that mirror society and the paradigm of treatment that has held sway for decades.
Some see funding as the answer: more resources, more counselors. Some, widening the lens beyond the usual narrative, are asking what the broader community can do to ease the stress on centers. Some hope to steer the conversation away from counseling and other treatment to a more all-encompassing view of mental health on a continuum of well-being, one that casts the complexities of youth in more developmental and less diagnostic terms. Some are calling for all of that: More resources, more across-campus efforts to pitch in, more developmental dialogue and efforts promoting wellness. And with that, more attention paid to the mental health needs of those tasked with counseling students.
But something, they all say, needs to be done.
“The place we’ve reached puts us all in kind of a difficult situation,” said Ben Locke, formerly the senior director of counseling and psychological services (CAPS) at Pennsylvania State University. On the one hand, more students are seeking services — which he sees as a positive. “On the other hand, we’ve kind of convinced everybody that every emotional crisis they’re experiencing requires professional help — and that’s not the case. So how do you step away from that mindset? It’s tricky.”
“What’s the chicken, and what’s the egg?”
Locke is the founder and past executive director of the Center for Collegiate Mental Health (CCMH), a Penn State research effort that collects data across counseling centers. He doesn’t want to deny any student their own experience, their understanding of their own needs, as they seek help. But he wonders about the propensity to classify those needs as illness; perhaps, he said, the swelling numbers of youth reporting mental health problems signify something else.
Chewing on this, he referred to a 2017 New Yorker article on early tumor detection that noted South Korea’s implementation of widespread screenings for thyroid cancer. While diagnoses soared, death rates stayed the same — not because the detected nodules weren’t cancer, the piece explains, but because only some cancers lead to illness. The issue wasn’t misdiagnosis but overdiagnosis.
In the same way, Locke said, “If you screen human beings for the presence of mental health distress, yes, you will always find it. Does that mean that they’re sick? Does that mean that they’re mentally unwell? Probably not.”
The result, Locke said, is “a crisis of access as opposed to a mental health crisis”; his successor at CCMH, Brett Scofield, called it “a crisis of capacity.” With demand outpacing supply, the impact falls on counselors.
Whether and how they’re experiencing burnout is “a complex question, and one that we don’t have data on,” Scofield said. But anecdotally, at least, stressors seem to be associated with higher caseloads and less flexibility.
Which can all add up. Not for everyone everywhere, and not always. Situations vary across individual counselors and campuses, some of which provide better support and more resources, both human and financial. And not all observers call it “burnout.” In formal research and informal conversation, different terms are used to describe a maxing-out among college and university clinicians, and different remedies are being weighed in response. But the goal is the same: How to lend helping hands to students when those hands are already full?
The answer, in Roy’s opinion, “is to move the needle” away from a focus on counseling centers to a broader and more holistic approach. Others shared similar views, including those who hold a more middle-of-the-road attitude when it comes to the existing biomedical paradigm. But at no point, in on-the-record interviews with 19 people, did anyone say: This is how to fix everything, full stop. If the last two decades of campus mental health efforts proved anything, it’s that a single approach alone won’t solve the problem.
Many institutions of higher learning had already been wrestling with such topics when, in 2019, University of Pennsylvania counseling director Gregory Eells died by suicide. His death startled his colleagues, prompting soul-searching and new efforts to step back and take a look at current approaches and expectations.
“It really talked to how vulnerable, and how weighed down, caregivers are,” said Jan Collins-Eiglin, who has years of experience as a clinician and director and now serves as advisor with the Steve Fund, which advocates for the emotional and mental well-being of students of color. As she travels around campuses, she can see that counselors are “suffering as much as the students are. And so, what is the solution for that? And when you feel isolated, you’re all alone, all of this darkness just hits you. How do you really handle that?”
Combing through all the contributing factors — all the causes, all the data pointing to all the intertwined mental health challenges of students, counselors, and directors— does not lead to any tidy explanations or solutions. Such factors also reflect and embody the wider conversation around mental health management, a sprawling umbrella that can include the biomedical approach (which may be limited, on many campuses, to physicians staffing the health center) along with short-term counseling sessions, more long-term psychotherapy, and broader wellness initiatives.
Bryant Ford, who has decades of experience as a campus therapist and now serves as associate dean of community life and inclusivity at Dartmouth College, said it’s difficult, even impossible, to separate out all the many causes currently affecting campus populations. Students pouring into counseling centers, counselors and directors scrambling to cope, everything exacerbated by COVID-19 — the strands all braid together.
“What I don’t know is how much of this is actually trends that we’re seeing, and how much of this has sort of been revealed to us because of the pandemic. . . . There’s just a lot of complexity behind some of this,” he said. “And it’s really hard to get a sense of what’s the chicken, and what’s the egg.”
“Not the same job you got hired for”
Still, there’s a ton of data. Data on students, data on counselors, data on directors.
According to CCMH, the last eight years have seen a 6.9 percent increase in students at campus counseling services who say they’ve had serious suicidal ideation at some point in their lives — bringing the total, right now, up to 36.9 percent.
Further, the latest report also shows that students’ lifetime counseling experiences are similarly on the rise, with around 60 percent of students who seek campus services saying they’ve had previous treatment — an increase of more than 12 percent since 2012-2013. The organization’s data over the same span indicate anxiety and depression have also been increasing, with 24.1 percent citing the former as their “top concern,” 18.3 percent the latter. Meanwhile, the percentage of students reporting a traumatic event has gone from 31 percent to 42 percent.
Other research bears this out. In a 2018 study tracking 10 years of data from the annual Healthy Minds Study surveying college students’ mental health, the authors ticked off increases across the board: From 2007 to 2017, the survey saw upticks in rates of treatment (19 percent to 34 percent) and students with lifetime diagnoses (22 percent to 36 percent). “The prevalence of depression and suicidality also increased,” they wrote, “while stigma decreased.”
In the 2020 iteration of the study, 41 percent of all students reported lifetime diagnoses of mental disorders; 39 percent of them, some form of depression; 34 percent, anxiety. Twenty-four percent said they were on psychiatric drugs in the past year. In the same span of time, 13 percent reported suicidal ideation; 23 percent engaged in non-suicidal self-harm.
“It’s clear that more students than ever are reporting a lot of distress — a lot of feelings of depression and anxiety, more thoughts of suicide,” said the University of Los Angeles’ Daniel Eisenberg, director of the Healthy Minds Network and author of its 2018 trends study. “I think it’s still a little bit of an open question as to what that means — because, you know, one explanation would be that young people are more aware of mental health symptoms, and more open to talking about them, and even reporting them on a survey. I think that probably explains at least some of the uptick.”
That said, “I think it also probably does reflect greater levels of distress that are separate from just the willingness to report.”
Whatever the cause, however it’s defined, all of that puts a load on counseling services. If you crunch the math on workloads, it comes down to caseloads per clinician — how many sessions each counselor at a given campus is expected to handle. A Clinical Load Index (CLI), developed at CCMH, shows annual caseloads ranging from 30 to 310 for the average 40-hour-per-week clinician (providing 24 hours of direct clinical care) within the 567 centers providing data.
That yawning gap between low end and high end underscores a considerable disparity in the experiences and stress levels of counselors, with some of them handling reasonable workloads and others teetering under a heap of professional obligations. For many, the inflation of caseloads and other duties has been gradual: A drip-drip-drip of more sessions, more walk-in shifts, more screenings, more outreach duties and other non-counseling job requirements.
Locke uses a few different metaphors to explain this. Imagine, he said, if someone told you to drive five miles per hour faster every day. Or imagine this: “Every morning when you get up, somebody adds five pounds to the bag you have to carry.” Eventually you’d be dragging around a 60-pound weight.
If you were hired to lug it around from the start, that’s one thing. But for many counselors working today, he said, “The job you’re responsible for today is not the same job you got hired for 20 years ago.”
“Burnout is incredibly real”
As interviewee after interviewee pointed out, the work is heavy as is. Listening to students’ stories and absorbing their burdens can become another kind of burden, especially when those in need are in an extreme state or even at risk of suicide — and especially when the counselor in question is tired, isolated, or in distress themselves.
“That ‘burnout’ word is very, very prevalent,” said Stephen Elfenbein, a counselor with the Shaw Wellness Institute at Colgate University who also coordinates drug and alcohol services. Although he doesn’t see it in his current role (“swearing to God, I don’t”), he hears about it from friends and colleagues at other campuses or outpatient clinics — and he’s observed it himself in previous jobs.
“Burnout is incredibly real,” echoed Erica Riba, director of higher education and student engagement for the Jed Foundation. “I have unfortunately seen people leave higher education. We don’t want that.”
A licensed clinical social worker, she previously served as a therapist at Eastern Michigan University and Wayne State University. Asked if she observed burnout herself, she replied; “Oh, yeah. I saw it in my work.” Assessing risk, assessing center resources, factoring in the safety of students in crisis and the needs of others: It’s a lot. “You’re daily doing your best to support people for their mental health — and it can be common for people to forget about what they’re going through, and their own mental health.”
That became especially notable throughout the COVID pause, as social interaction — and with it, therapy — turned virtual, increasing screen time and exacerbating isolation for students and counseling staff alike. In a way, the experience became a lesson in human nature and the urge to connect.
“I believe that the connection is so critical to our human condition that a sense of disconnect — the inversion of that — lays a foundation for all kinds of feelings. . . . whether it’s sadness, or exhaustion, or fatigue, or lack of motivation, or any of it,” said Harry Rockland-Miller, a onetime consulting partner with Greg Eells and former longtime counseling director at the University of Massachusetts, Amherst. He’s also co-author, with Hamilton College counseling director David Walden, of a recent Mantra Health whitepaper on college-provider burnout in the thick of pandemic.
The responses to Rockland-Miller and Walden’s survey were stark. One of its questions: “Are you experiencing some form of burnout?” A whopping 90 percent of surveyed clinicians and 92.4 percent of surveyed directors replied “yes.”
“It’s not a double-blind placebo-controlled study. Not a random sample,” Rockland-Miller said. There were limitations, and he wants to be cautious. “But, yeah, it was really striking to me. . . The results just — well, you saw them. They were really powerful.”
Even pre-COVID, burnout was already a cause for concern, a topic of discussion, and a subject of research. In 2018, Gregory Lee Bohner’s paper explored the metrics in The Relationship Between College Counselor Work Responsibilities and Burnout, his dissertation for Kansas State University. Now director for disability services at Union University in Jackson, Tennessee, he used various metrics to analyze burnout and test various hypotheses — and developed a “College Counselor Activity Rating Scale” to measure counseling and non-counseling work duties specifically. None of the results point to any simple explanation of causes or definition of “burnout.”
But the gist of his findings: If counseling staff maintain more of a sense of meaning in their work, they’re generally in a better psychological space than those who feel less. It’s not a question of more non-counseling duties at small campuses versus large — which isn’t the case — or even the effects of such duties themselves.
“Perceived workload and administrative activities were positively correlated with burnout,” he wrote, “but finding meaning in one’s work was negatively correlated.”
“You’re holding all the mental, emotional stress of the students”
In a phone interview Bohner expanded on this, noting a change over the decades in the role of campus counseling, in the students who access it, and the expansion in the type and scope of work that counselors do. It boiled down to perceived workload — how the work was understood by counselors, and whether they performed it with that critical sense of meaning.
“That stands out,” Bohner said. “Because you can have all these different things that you’re doing, but so long as you don’t have that high perceived workload, that’s not going to be connected to the burnout.”
The deeply felt idealism that brings people into the field is one thing, Bohner said. The skills required in learning to switch off feelings at the end of the day are another. Some people might have trouble leaving those feelings at the office, and that’s where burnout becomes a danger. “They don’t quite learn how to build that boundary and to turn it off,” he said.
Bohner calls this his “empathy chip.” At some point in the day, he needs to switch it off — or at least down.
A different metaphor for burnout hit him right then on the phone. “You get done camping, you’re all out of wood. And you either go out into the forest and grab some more — and keep the fire burning,” he said, “or it’s burned up.”
For many clinicians feeding the fire, that sense of meaning described by Bohner — even beyond that, a sense of mission — drives them as they navigate the surge in caseloads and all that it means. That’s why they’re in the business: to help people heal. “There is a sense of calling for many people in the field,” Rockland-Miller said. That sense of purpose “keeps us moving forward.”
But helping people heal isn’t easy, he said. “You’re holding all the mental, emotional stress of the students.” Anxiety, trauma, substance abuse — all of those individual student needs. Add to that the needs of the wider community — faculty, professional staff, other groups. “You’re holding a lot, right?” All of that “can’t be held alone by the counseling center.”
Those on the outside can see it, too. “Largely, I see a workforce that has gone into this work because they cared deeply about people — and they cared deeply about students,” said Alison Malmon, founder and executive director of the student mental health awareness organization Active Minds. But they can’t be expected to carry everything; there needs to be a more public-health approach. Some campuses are doing that. Others, she said, “are not doing as good of a job.”
As Bryant Ford remarked from Dartmouth: “I wonder sometimes, do they really understand how difficult this work can be? And what kind of impact it can have on its employees? . . . Do you really know what it means, understand what it means, to sit and sometimes hold what some of our students are experiencing?’’ And no, he said, “I don’t know if it’s understood.”
All of this is especially true for counselors of color. They are, to put it bluntly, in demand.
“Oh, my God, that’s an understatement,” said Jan Collins-Eaglin. “They are in so much demand that it burns them out.”
In her various clinical roles, “Students would come to see me because I’m a counselor of color — and I was happy to see them. But then you have all these other students that have to be seen also. So how do you begin to balance who sees who? How do we balance this? Do you have the capacity to have specialized services? Do you have the staffing to have specialized services? And that poor therapist,” she said. “Because it really gets to be a whole lot.”
The preference of BIPOC students for BIPOC clinicians is in particular relief at predominantly white institutions, where a young person of color is likely to feel even more isolated. With a shared understanding of systemic racism, poverty, and trauma, “There’s an ease with which they can communicate,” said Ford, who’s African-American. Such counselors “know what it means to feel marginalized or feel dismissed — and there’s something about knowing someone may have traversed that area that they’ve gone through. There’s a sense of bonding and feeling comfortable.”
But in a counseling profession that’s also predominantly white, most campuses have difficulty hiring, and then retaining, caregivers with that shared experience. And that means more work for those already on staff. “Sometimes it does become challenging,” Ford said. If there aren’t enough counselors of color, “Then everybody is clamoring to see them. It can increase caseloads. And that can also increase the stressors that are also associated with the work experience.” On top of caseloads, counselors are often deeply involved in outreach.
Asked what she observed from her work at the Steve Fund and her many years as a counselor of color, Collins-Eaglin zeroed in on the student’s perspective: “What we see happening is that, with everybody else — like everybody else — mental health issues are rising. And that’s consistent across the board. What isn’t consistent is the fact that we have unequal access to services and understanding about those services.” BIPOC students “are marginalized in ways that others aren’t. Accessing services is a real issue, right? It’s a big, big, big issue — and, from my perspective, a social justice issue.”
College campuses are, in a way, microcosms of society at large, contained academic biodomes featuring the intricate dynamics, etched-in hierarchies, and diverse, interweaving social groups that can be found in any community, small or large — with the same implications surrounding representation, identity, and access.
“Bingo,” said Collins-Eiglin. “We represent what’s out there.”
Students of color are already reluctant to use campus mental health services. “When they go to the counseling center — or if they go — who do they see? . . . What we hear from students is: ‘I’m not going there. They don’t understand me.’”
Marcus Hotaling, counseling-center director at Union College in Schenectady, NY, and president-elect of the Association for University and College Counseling Center Directors (AUCCCD), said he comprehends the need for diverse staffing. “I do think it’s important,” he said. “Representation matters. It is important that we do our best to offer resources and support services that students can identify with.”
“That feeling of neglect and being ignored is no longer there”
At campuses both large and small, the call for greater representation acknowledges students across a rainbow of identities, LGBTQ included. While smaller institutions with tighter budgets might have a harder time hiring staff that reflects them all, regular diversity training is now the norm for campus services, Hotaling said; education of counselors has become more inclusive and identity-minded, as well.
Such priorities mark a notable and ongoing shift in the history of college counseling, which has transformed and expanded in significant ways over the last century. Twenty years ago, Shannon Hodges of Niagara University published University Counseling Centers at the Twenty-First Century: Looking Forward, Looking Back, but much of the article’s content is as relevant now as it was when it first appeared in the fall 2001 issue of the Journal of College Counseling.
Around 100 years ago, counseling was principally academic — the bailiwick of professors advising students. After World War II, with veterans returning, it expanded to include vocational training. In the decades that followed, counseling became more specialized and distinct from the work of student affairs, focusing on personal and mental health matters and moving into the more humanistic realm with talk therapy trained on listening. Later in the 20th century, as the medical model and its focus on psychopathology became dominant, an emphasis on psychiatric diagnoses and treatment emerged on many campuses.
The more developmental approach pushed back as best it could — emphasizing the transition from adolescence into adulthood and the “interpersonal, emotional, physical, and spiritual” changes that typically characterize the college years. That emphasis, which Hodges calls “a remnant of the early days of the field,” remained a hallmark of the profession and its many splintered subgroups as more and more counseling centers served more and more students. By the turn of the 21st century, the diversification of the student body and, with it, the gradual metamorphosis of counseling itself, meant that counselors were addressing a wide range of needs for a wide range of students.
In the two decades since, needs grew. Duties expanded to meet them, and needs grew more. As they did, another “chicken and egg” conundrum came to the fore as research highlighted continually worsening mental disquiet among undergraduates.
John Miner, a partner in College Health and Counseling Services Consulting and a psychiatrist who worked on staff and served as counseling director for Williams College, noted Richard Kadison’s 2004 book, College of the Overwhelmed: The Campus Mental Health Crisis and What to Do About It, which “really sprang out of” the massive National College Health Assessment survey and its first batch of results from four years earlier.
The data “pointed to this notion of students being overwhelmed and really stressed out by being in college,” Miner said. Since then, “There’s kind of been an ongoing argument in the field whether students are more disturbed than they were in the last generation” — or whether young people, parents, and society itself are simply changing in how they frame and address experiences.
Do the numbers showing an increase in anxiety and depression indicate an actual downturn in student mental health? Or do they represent a “much more open” culture, and an increased willingness to talk about it?
David Reetz, CAPS director at Rochester Institute of Technology and 2020-2021 president of the AUCCCD, sees it as a change in language and a matter of students feeling more at ease in discussing their mental health. In previous generations, he said, someone might have identified a challenging state as “academic stress — worrying about being able to learn the material, struggling with group dynamics and group projects, being anxious about a presentation in class.” Nowadays, “students are more inclined to label that as mental health distress.”
He also cited the Obama-administration drive for more accountability in higher education, which cranked up the pressure on universities and colleges to produce numbers on all facets of education and campus life. Mental health services, formerly under the radar, felt compelled to meet demand and maintain accountability.
Maybe 15 years ago, he said, most university and college counseling directors “would say that they were there as kind of an afterthought. They were doing their own thing. They were underfunded. And we were just not valued.”
And now? “That feeling of neglect and being ignored is no longer there.”
“Perfectionism is in the water everywhere”
Counseling centers have swollen in footprint and prominence, their literal growth mirroring their ever-expanding role.
For a long time, at most colleges, health services in general were located on the periphery of the campus. At a smaller school, it might have been staffed with a nurse. What’s more, Miner said, “Nobody knew who went to the health services. Nobody wanted to know who went to the health services.”
But over time, health “became more centralized on campus, and there was kind of a push to integrate services and reach out more” — rather than simply wait for people to show up. Those services grew, with “all of those fields hiring more and more people. And the number of students utilizing those services kept growing, and growing, and growing, as well.”
Just look at the buildings themselves. “Wellness centers are gleaming structures with all these things — that’s a big selling point for colleges,” said Miner’s consulting partner Gerard Fromm, who teaches at the Yale Child Study Center (and, like Miner, is affiliated with the Erikson institute at the Austen Riggs Center in Stockbridge, Mass).
Not too long ago, Hotaling said, a counseling center “never got calls before from parents asking what services were available as they were looking at what college to pick.” But the reduction in stigma, combined with the advent of “helicopter” parenting, means that primo mental health services can now give an institution bragging rights — even promoted in emails and on campus tours. Because of that, “They’re now calling in March, saying, ‘My son, my daughter, my child is considering Union, and we want to see what services are available.’”
The upshot: Pressure in all directions. Pressure on colleges and universities, especially the priciest ones, to be full-service operations. Pressure on directors to keep upper management happy while tending their own staffers and figuring out how best to make do with the resources they have — in many cases, while also handling some individual sessions with students themselves. Pressure on counselors to provide all care, to meet all needs, to be all things for all students.
One outcome, said Vanderbilt University counseling director Todd Weinman, has been an “the erosion of boundaries” in college counseling, which historically etched a line between therapist and student. Formerly, a student would meet a counselor in strictly delineated sessions of maybe 45 or 50 minutes, slowly building a special therapeutic relationship. Now, “It’s all access, all the time, and kind of treating mental health as you would a primary care office.”
Weinman, close friends with Eells, was on a Zoom call with Greg’s wife Michelle. Reflecting on her late husband, she recalled something he often said about the system — and all the loaded expectations being heaped upon counseling services. So many people expect the campus medical and counseling “to fix all their needs, and provide these services that society doesn’t provide.” Instant medical care, instant mental health counseling — none of that is available in the outside world “unless you go to the E.R. And even at the E.R., you don’t get immediate counseling services. So they have this pressure — the university and the center — have this pressure to provide services and fix things that don’t happen anywhere else.
“He said this, of course, more eloquently than I did,” she added. “But it’s true.”
“Yeah,” Weinman said. “Perfectionism is in the water everywhere.”
“You don’t even notice what you’re carrying”
For counseling service directors, it all adds up.
“In some ways, all the trauma becomes a little bit cumulative . . . We’re absorbing it without really knowing it,” said Weinman. Managing staff, navigating work dynamics, juggling through-the-roof expectations: that takes a toll. “You don’t even notice what you’re carrying.”
Consider Eells himself, a beacon in the community and admired — loved, even — for his vitality, charisma, and passion for the cause of student mental health. Co-author of a book on the healing powers of nature (Nature Rx: Improving College-Student Mental Health, with Donald A. Rakow) and a public speaker known for his TEDx talk on resilience, Eells had worked for years as CAPS director at Cornell and was serving in that capacity at the University of Pennsylvania when, two years ago, he died by suicide.
In that tight community, many were friends with Eells, had worked beside him, or had met him at some conference or other. Even those who hadn’t were familiar with his work. “Everybody knew him. Greg had a personality that just shined through,” said Marcus Hotaling. His death “was definitely a shock to the system.” Commented Jan Collins-Eiglin: “It shook all of us who were his friends.” At a counseling-service conference held after Eell’s death, Fromm said, “the depression was palpable.”
In her Zoom call with Weinman, Michelle Eells described a man who “liked to be connected . . . He loved to be around people, with people. He’d have a party every day, if he could.”
As humble as he was charismatic, he was also physically imposing — 6’2” and around 250 pounds, much of it muscle. Riding his bike to Cornell, five hilly miles each way, he was known for his “freakishly large calves.” At home, they called him “Mr. Incredible.” He never stopped feeling committed to his work or rewarded by it, she said. Even up to the end.
But suicides are complex. The reasons behind them aren’t straightforward and can’t be unpacked easily — or, more often, at all. Eells’ wife, friends, and colleagues are all loath to blame work or pinpoint one stressor over another. Michelle Eells, for one, does not characterize what happened to him as “burnout.” But whatever the causes, his suicide sparked dialogue among his colleagues, prompting focus groups, workshops, and countless informal conversations brainstorming ways to help counselors and directors while also meeting student needs.
“Everyone struggles, okay? And you may never know what someone is struggling with,” Riba said. This is something she’s long known. But Eells’ suicide — “wow, it was a total shock to the colleagues around him. All of us.”
Said Hotaling: “I think that was the first time people were saying, ‘We need to be talking about our own health. Because who’s helping the helpers?” For years now, “We were looking into the resiliency and self-care of college students. . . . Now, how do we do that for everybody helping the students? Whether that be faculty, whether that be administrators and health care providers?”
For Michelle Eells, the chief takeaway is even more searing and plainspoken: “There needs to be change.” Dwelling on the lessons of her husband’s death, she quoted a sentiment conveyed by many, in more or less the same words.
“If this can happen to Greg,” she said, “then it can happen to anyone.”
“I think our world has gone mad”
College students have long been wrestling with that same, plainspoken admonition.
Emma Smith, a junior at Drexel University in Philadelphia, was in high school when she first ran across statistics identifying suicide as the second-leading cause of death for youth and young adults. She thought, “This is such a big issue. Why aren’t we talking about this more?’”
In school, she attended an event with Malmon, who founded Active Minds after her brother Brian died by suicide. Smith was amazed and relieved to witness someone speaking openly about mental health. Feeling invigorated and empowered, she sought out the Drexel chapter shortly after arriving on campus. She now serves as co-president, reaching out into the student body with efforts aimed at outreach and open communication.
Smith is open about her own mental health issues — a diagnosis of anxiety, an episode of depression. Talking about it is more normalized now than, say, when her mom was in college. But stigma is still an issue. Openness still needs to be encouraged. Asked whether she would classify the waves of students accessing services as a crisis, she replied: “Yes. I think I would.”
For her, those suicide statistics brook no argument. “That’s, like, the final thing,” she said. “I don’t know how to say it. . . . If people are dying at that rate? High suicide? That shows so much is going untreated.”
Which raises a big question: Why?
Why are suicides continuing to spike? And why are young people in such distress to begin with?
Could the reasons be iatrogenic — that is, the treatment itself? A 2014 study by Danish researchers showed suicide risk increases according to the level of a person’s psychiatric care: from 5.8 times higher for those on medication to 44.3 times higher for those who’ve been admitted as an inpatient.
But could other factors, societal factors, be playing a role? Could racism, poverty, and other systemic issues be contributing to malaise? Could the cause be global warming, political extremism, social unrest — or all of that? Perhaps, some say, it’s life in this particular epoch of history, riddled with uncertainty and strife.
“I think our world has gone mad, and I think that has significant implications for all,” said Nance Roy at the Jed Foundation, “but especially for young people. . . . I think it’s a scary place right now.”
Social media usage, and its effect on sleep patterns, was one more potential cause for stress cited by those interviewed; another was the parallel downturn in real-world social interaction, which is always critical in developmental terms as teenagers inch toward adulthood. David Reetz, with the AUCCCD, cited The Freshman Survey of incoming American students in breaking down the causes of student anxiety. Conducted each year by UCLA, it has shown a shrinking allotment of time that they spend with their peers. Asked about their last year in high school, students are reporting less and less experience in high school clubs, athletics, volunteerism — and other forms of socializing.
“All of that time engaged in social interaction is diminishing,” Reetz said, who also noted a 2019 study. “So of course, when they come to campuses, they’re gonna be anxious, because they have less experience in those social interactions.” Talking to peers, engaging with faculty, all of it. “And there’s a learning curve there. And that’s a notable part of this increasing anxiety — that learning curve. Now, is that a mental health disorder, or is that a normal developmental process?”
On top of that: the pandemic.
According to Hotaling, Union College is currently seeing a spike in the number of first-year students accessing services. From the first week of term until Oct. 1, he said, the college saw a jump of “85 percent in the number of first-year students we’re seeing, and a 20-percent jump in the number of appointments we’ve had. So that means the majority of our clients right now are first-year students.”
The reasons why, he postulates: “They haven’t really had normality in a year and a half. Their last normal year was two years ago. Now, all of a sudden, we’re throwing them back into full-time student (life), and classes, and adjusting to college, and overcoming the pandemic, and trying to meet people with masks on their faces. And all sorts of things.”
Smith agreed. “COVID was like a collective trauma,” she said. “But there’s always going to be a student who’s struggling, and we always need to keep that in mind.” And even if students are using the language of mental health to describe stressors that generations past might have identified as academic or social, well, they’re still feeling it.
“I think if you’re reaching out for help and going to therapy — and it’s already stigmatized at that level,” she said, “there’s a reason why you’re reaching out.”
“Crisis is in the eye of the beholder”
Which prompts another big question: What would help? What would ease the pain of students and the impact on counselors? What should colleges do?
Smith had a few answers. For a start: “More counselors. Honestly, just expanding the whole counseling center. They’re really overworked, and, like, the pressure on them — I really empathize with them. . . The counselors try to do the best they can with what’s given to them.”
Others concurred. But many are cautious on this front, both recognizing that students need access and acknowledging that efforts to ramp up that access haven’t solved the problem so far. For years now, students have been in crisis; services needed to expand. But students are still in crisis; services still need to expand.
As a response to the crush of appointment requests, institutions across the country are now instituting some form of triage — a method of screenings, assessment, or stepped care that identifies those in acute need and re-routes others toward less-immediate treatment. Students trying to access mental health services aren’t all suicidal, profoundly depressed, or in some other state requiring immediate care. But some are, and any student who feels in danger needs to be heard. As the Jed Foundation’s John Dunkle put it: “Crisis is in the eye of the beholder.”
Dunkle long served as CAPS director at Northwestern University. There, he said, “the number of crisis appointments were far outsurprassing the number of other appointments” — and so they trained their energies on those most urgent demands. “If a student is expressing it as a crisis, then we had to focus attention there, because it could potentially be someone at high risk.”
But the result can be a bottleneck in longer-term or even shorter-term treatment as counseling centers drop everything and respond — something Dunkle has heard from colleagues across the country. According to the AUCCCD’s 2020 survey, the average time for a first appointment is four business days; the wait for a follow-up after a triage appointment is seven days; at schools with between 15,001 and 20,000 students, it’s 10 business days. Other research and news accounts note even longer wait times: At the University of Arizona, a Daily Wildcat story from late 2019 quoted a student who had to wait six weeks for an appointment. Other accounts assert the same, or more. (And in its 2019 survey, the AUCCCD listed a “maximum wait time” of 54 days for schools with 10,001-15,000 students.)
“Six weeks. . . . that’s a long, long time,” said Alison Malmon.
Sometimes, students themselves don’t recognize the seriousness of their own mental or emotional state. “You don’t always know the answer to that question until someone helps you see how severe it’s gotten,” she said. “I don’t think it’s an issue of triaging.” Whether they’re suicidal or not, “By the time somebody calls a counseling center for help, it’s extreme for them.”
Riba described it this way: “Every student matters. Every student, no matter the situation. . . . We have to commend students for taking that step and wanting to talk about it. It could be that they’re in a panic or a crisis, and need to be seen immediately.” Or maybe they just need to share. “But counseling centers need to create that space.”
“It’s a see something, say something kind of thing”
All such programs — triage, by any other name — still put the onus on counselors. They still follow the established treatment paradigm, routing students toward campus centers for aid, assessment, and counseling. Crisis mode is one thing; broader support is another. Further ramping up CAPS funds, some say, can only do so much.
Jan Collins-Eaglin regards the allocation of more resources as good news. “But the other piece of that is you can’t resource your way out of this situation,” she said. Institutions of higher learning should be considering alternate models of care, weighing the diverse and complex range of students’ needs. “You’ve gotta think about it differently.”
Which raises yet another big question: What does that mean? What would thinking about it differently entail? Given the shifting aims and arc of counseling on American campuses, what should the next phase be? For many, the long view requires something beyond that treatment-oriented model — something that nudges campus mental health into more broadly human territory.
“I’m not saying that we shouldn’t be giving treatment,” said Brett Scofield at CCMH. “But there are students, certainly, where there are alternative routes that might meet their needs — that’s not a professional, long-term, mental health intervention. Faculty supports. Peer supports. There’s connection with others. There’s other support services on campuses. There’s online wellness support services. So there’s alternative pathways where, I think, people can get supportive care outside professional interventions — and faculty could be a part of that.”
This point — that not only counselors should be helping students in need — was made, with similar urgency, by people in positions both on campus and off.
“The responsibility of addressing student mental health issues on campus is really a community issue, and can’t just be the counseling center,” Dunkle said. Added his colleague, Nance Roy: “Not every student on campus needs direct clinical care. But they can all certainly benefit from support, from a warm hand.” And that warm hand could belong to anyone. “Security folks, dining hall people, I mean, you name it. Everyone on campus has a role to play — not to be therapists, but to be caring human beings.”
Maybe a professor notices a student has gone silent in class. Maybe someone else, on some other corner of the campus, notices an absence or alteration of mood. “Reach out,” Roy said. “It’s a ‘see something, say something’ kind of thing.”
As basic as that sounds, putting it into place isn’t easy — because many people don’t know exactly what to say.
“How do you learn to just check in with people?” asked Bryant Ford at Dartmouth. “Because people question whether or not they know how to ask the right question.”
“People are so afraid to say the wrong thing that they don’t say anything at all,” said Alison Malmon, noting that 67 percent of college students tell a friend that they’re suicidal before telling anyone else. Given that statistic, she asked, “What kind of tools and language can we arm students with?” Awareness is rising, stigma is decreasing, “and yet nobody has ever been taught what words to use.”
Active Minds has developed one approach, Validate Appreciate Refer (VAR), which it highlights online and promotes on campuses. Everyday observation, conversation, and compassion are the keys. As the website explains: “Someone doesn’t need to be in a crisis to seek help; you don’t have to be an expert to provide help; and help can come in many different forms. Being there for someone in a moment of need is what it’s all about.”
Other organizations are promoting similar toolkits and training methods urging people to speak up — and, when they do so, what to say. Advice varies. But in general, open-ended questions (“How are you?”) are encouraged; more specific ones (“Are you depressed?”) are discouraged. Trainings are short, sweet, compassionate, direct. Nothing too time-consuming. Nothing too complicated.
An assortment of other efforts are being promoted and pursued. Jennifer Howard’s 2015 piece in the Chronicle of Higher Education, “Faculty on the Front Lines,” looked at “rapid-response” initiatives that engage faculty in different types of crises and quoted Reetz on the need for more campuses to train them. The Jed Foundation also offers materials for professors, staff, and other non-health professionals — ways to educate the community on suicide prevention, language skills, listening skills, and more.
From the wellness center at Colgate, Stephen Elfenbein works with students on Active Minds programs — including the anti-suicide initiative Send Silence Packing — and other campus programs. Many such efforts are focused on prevention, mindfulness, self-care (“sometimes, the students need to give themselves a hug”) and positive engagement, stressing a whole-community model and mindset on issues from sexual violence and drug prevention to broader issues of mental health and wellness.
From his standpoint, it just makes sense.
“It’s a campus-wide problem,” he said, “so we’re gonna find campus-wide solutions.”
“There’s room for us all to grow”
But the campus is only a piece of it. For many, the larger target for change is society itself — combating the idea of “mental health” as a topic only addressed in terms of the treatment model, and only for those in crisis. Emma Smith, for her part, wishes therapy were considered a preventative measure “for every phase, every part of the spectrum, even if you feel you’re in the best place mentally.”
As Malmon expressed it: “Our goal is to change the culture around mental health— and in some environments, that means starting a conversation around mental health. Because it may be an environment, or a school, where no one is talking.”
The aim is to get people conversing about it in normal ways, on normal days. Not just now and then — say, because it happens to be World Suicide Prevention Day, each Sept. 10, or National Depression Screening Day on Oct. 7. “But also because it’s Thursday,” she said. “And mental health exists on Thursday, too.”
And that, for Malmon and others, is a critical element of the quest to reframe mental health: It isn’t just a concern for those in crisis. No one thinks that way about dental or medical health, she said. No one assumes that only diabetics need to eat mindfully, or only cardiac patients need to exercise. Mental health, stretched along a continuum, is everyone’s concern.
“It’s part of our overall well-being. . . . It’s every day, taking care of what’s going on in your mind. If we wait until something is wrong, we’ve missed a lot of time to help teach coping skills, and help people to feel great, and to thrive.”
She spoke of her brother’s own struggles, which he battled silently for too long. Eventually his family learned of two weeks when he failed to get out of bed, missing all of his classes at Columbia and saying he had mono to anyone who asked. No one questioned that. Back then, she said, “It was okay to have mono.” But it wasn’t okay to feel depressed, and he couldn’t find a way to tell anyone.
He died by suicide in March of 2000. Malmon, then a psychology and sociology major at Penn, created a student group — what became the first chapter of Active Minds — the following year. She founded the nonprofit in 2003.
So in her view: Yes, students nowadays “are just more open about their struggles.” One student might say they’re having a lot of trouble with a roommate, and another might say they’re grappling with anxiety — “and those two things might be the same situation.” But at least, she said, they’re talking about it.
“There has been an evolution in the acceptance of mental health as being a challenge — or something to take care of, something to acknowledge — in the past five to ten years that didn’t exist in the years prior to that.”
That same change, she added, can and should occur for the people staffing counseling centers — a point that emerged repeatedly in interviews. Caretakers are on that same mental health continuum. They should be taking note of their own needs, and each other’s, along with those of students.
Often, Riba said, counselors forget to do that. They forget to take vacation days, sick time, even lunchtime. They forget to get up from the screen in between telehealth sessions. They forget to stay hydrated. They forget to indulge in exercise and activities that make them happy. All of that needs to be part of the message. “Now, more than ever, we have to prioritize self-care, prioritize our own mental health. We need to recognize that mental health is health,” Riba said, noting an MTV initiative and website employing that four-word phrase.
“Therapists, psychologists, physicians, lawyers, everyone: We need to make sure that we’re checking in on our colleagues and that people have resources that they can access as well. . . You can take notice when your colleagues are struggling,” she said. “There’s room for us to all grow.”
At Colgate, Elfenbein said, a “group supervision model” allows counselors to meet with their supervisors and each other to discuss all the issues they’re facing. “And you can vent about it. You can seek solutions . . . We care deeply for the students, and for each other. And I would say we support each other.”
The key, there or anywhere, is “practicing what we preach about self-care. . . . We need a break, and I think, also, we need a connection. I think that’s something we always are working on.”
“We can’t ever be a totally solo ship”
In the second half of that Mantra Health article exploring the spikes in COVID-era counselor burnout, the authors steer toward implications and recommendations for those who run, and staff, psychological services. They urge “togetherness,” the nurturing of relationships with colleagues and the nourishment of support; “boundaries,” emphasizing work-life balance, outside activities, and sleep; and “openness,” calling for clear policies and connection with professionals in equivalent roles.
“For example,” it says, “directors may feel that their unique position makes it challenging to present their own fatigue or uncertainty to their staff or supervisors.” It then advises: “Join a community of other directors.”
This is a recurring theme. For directors in particular, simply talking about their mental health isn’t easy — wedged, as they are, in a middle-management role between the clinicians they supervise and the administrative higher-ups who set goals and establish the policies they’re charged with implementing. What’s more, they generally have no director-colleagues on campus with them.
As Todd Weinman said: “It’s the sort of system where you’re the chief mental health officer,” working to create a healthier community and managing a team. “It’s definitely a sense of, ‘Oh, God, I don’t want something to go awry below me, but I don’t want something to go awry on campus. … It’s just hard.” Whatever happens, “It’s your job to fix it. . . and I think Greg and all of us feel like ‘If we don’t fix it, no one will.’”
Charisma, drive, and natural leadership skills help. But many directors rose to the job from their positions as counselors; and part of their new role means absorbing all of their clinicians’ stresses, all of their work experiences, without being able to share any of their own with immediate colleagues. Which means the people they can most naturally connect with — the people who would most easily understand — are under their supervision. And directors can’t tell them what’s going on.
“This is why organizations like AUCCCD are so invaluable,” Rockland-Miller said, “because you can talk to professionals who are shoulder-to-shoulder with you, without that kind of worry. . . You need to make room for it. It’s just really important, and we can’t ever be a totally solo ship, right? We need to have support. We need to have people we can speak with about our uncertainties, or things we’re trying to sort out.”
After Greg Eells died, there was a lot of sorting out. There still is. Earlier this year, Miner and Fromm organized workshops for counseling directors as a way to address grief over his death and stress over their work. The sessions were designed to help them understand and articulate “what they knew but didn’t know about their situations,” Fromm said, adding: “We’re seeing people who are almost despairing about all that’s coming their way . . . and don’t have a way to bring what they’re learning to those above them, to kind of help guide the institution.”
Two half-day workshops were held this past May. After one of them, a participant summed up the effects with three words: “I’m well now.”
“And it was stunning,” Fromm said. “Stunning.”
“We’re all in this together”
For those who work in counseling, none of this is surprising. Being human means yearning to communicate with others — during a pandemic, or anytime. Erica Riba spoke to this, emphasizing the power of belonging and connecting, the nature of community, and the culture that encourages it. “We have to drive home a culture of caring — of everyone involved in a student’s life.”
“On a community level, what if we did that?” asked Daniel Eisenberg of the Healthy Minds Study. “What if we could change the community in a way that students feel a greater sense of belonging? They feel more a part of the campus community. . . . They feel less discriminated against — feel they have more connection with their peers and with the campus community?”
He continued, “The reality of actually improving it — it’s not simple. It’s not basic.” It doesn’t operate “on an individual or a group level.” It needs to be coordinated across all corners of the community at large — a call for change now being voiced with increasing urgency.
“What we’re striving for — in an optimal way, in an aspirational way — is a community of care. Community of care,” said Rockland-Miller. “And the counseling center is a critical part of that, but certainly not the only part of that. It’s a community thing.”
Weinman stated it plainly. “We’re all in this together.”
Ben Locke stated something else, just as plainly, about life and its many jagged parts. It tells an age-old story.
“If you’re a human being, you will die,” he said. “And along that pathway you will experience health problems. If you’re a human being, you will experience distress. You will experience loss. You will experience periods of happiness, sadness, and grief — and those are not mental health failures. . . . So my perspective is: How do we move back toward understanding that?”
In Greg Eells’ talk on resilience, he opens with a quote from the Buddha: “Life is Dukkha,” which is commonly translated as “suffering.” But that’s too simplistic, he says. A better translation would be “a bone slipped out of socket” — or “a wheel with a hub that’s just a little bit out of center. At a very core way, the Buddha is describing what it means to be human.” How we bounce back from that out-of-whack bone or wheel hub: That, Eells says, is resilience.
Two years after his death, the counseling community is still working on the bounce-back — still trying to rethink the collective wisdom surrounding campus mental health, still searching for some new way forward, with some new narrative, in the midst of so much hurt.
Erica Riba recalled the last email from him, which included a link to his TEDx talk. She had known him during his time at Cornell, she said. Trained as a clinician, she followed his webinars and appreciated his gifts for educating the field.
His death affected her. Affected the team she worked with. Affected so many others. She wants his family to know “how great he was, and how much he taught those who were wanting to be in the field — how to do this work with empathy, and courage, and humility. I really learned so much from him.”
All of his work on college mental health, all of his energy, all of the ways he reached people and inspired them: “He was transformative.” Is he still teaching? “Yeah,” Riba said. “He is.”
Weinman is also looking to his late friend for guidance. Eells was a man of hope, he said. He always believed that things could get better. He always had faith. But in the aftermath of his suicide, what could that that mean? “How do we channel Greg’s optimism in the face of such a difficult event?”
He isn’t sure.
“I do find myself channeling him and trying to do that,” Weinman said. “But it ain’t easy.”
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.