Abstract
BACKGROUND:
A university education is becoming ever-more important in preparing for employment in the knowledge-driven economy. Yet, many university students are not able to complete their degrees because they experience mental health problems during the course of their higher education. Despite the growing numbers of students seeking help, there is limited knowledge about the issues that these students face.
OBJECTIVE:
The purpose of this study was to understand the range of individual, interpersonal, and environmental factors that affect the lives of university students living with mental health problems.
METHODS:
The study was based at a large public university in Canada. Semi-structured interviews were conducted with 19 students with self-identified mental health problems. Their narratives were analyzed using grounded theory methods and a model was developed which drew upon social-ecological theory.
RESULTS:
Findings depict student experiences as a function of the self (individual factors), the social (interpersonal factors) and the school (environmental factors) and their interrelations.
CONCLUSIONS:
Interventions must be designed to address all three of these areas and their interrelations. The model can be used to guide universities in designing interventions; however, a fourth level that incorporates a university policy that values and supports student mental health, should be included.
Introduction
Much research points to the general up-skilling of today’s workforce as well as employers’ needs for highly educated and skilled people [1]. A university education provides the fundamental knowledge, skills, attitudes and abilities that students need to become lifelong learners and critical thinkers, so that they can find their place in the current knowledge-based economy. But many students embarking on a university education with hopes of a degree and a productive future are finding themselves derailed by mental health problems. There is a need to understand the issues these students face in their university experience so that they can be supported in realizing their potential for a fulfilling career.
Concern for the mental health of university students has grown over the past several years, as reports of students in distress mount. While there is some uncertainty about whether the incidence and severity of mental health conditions have increased amongst this group, it is clear that growing numbers of postsecondary students are coming forward to seek help [2, 3]. In one American study, the number of students seen with depression doubled over a 13-year period and the number of suicidal students tripled [4]. Student surveys confirm the high rates of mental health issues on campus, as well as their seriousness. A survey of 51 US postsecondary institutions that yielded over 28,000 student responses revealed that 45% of respondents felt “things are hopeless,” 50% felt “overwhelmed by anxiety”, 30% were feeling “so depressed it was difficult to function,” and 7% had seriously considered suicide in the previous 12 months [5]. A systematic review of 11 articles on students with mental health issues identified anxiety, depression, eating disorders, self-harm, obsessive compulsive disorder, and psychotic disorders as the most common problems [3].
The growing problem of students’ poor mental health has generated a number of interventions and initiatives in recent years as postsecondary institutions struggle to find solutions to this very complex problem. In Canada, for example, the Ontario provincial government recently funded a province-wide, 24-hour-a-day, 365 days a year helpline to provide support for college and university students with mental health concerns [6]. Technology-based interventions, such as internet-based cognitive behavioral therapy aimed at reducing test anxiety, are being investigated as a means of addressing student needs in the face of service shortages [7]. Evaluations of mental health services have been undertaken with the aim of quantifying mental health service use and identifying factors associated with help-seeking and access [8]. Despite the proliferation of programs and evaluation initiatives, the problem of poor mental health amongst university students persists.
For the most part, research in this area focuses on students as the unit of analysis – on the cognitive and emotional difficulties of students experiencing mental health issues [9, 10], and their academic outcomes [11]. This research tends to rely on models of behavioural change; it calls for increased services and new strategies to enhance individuals’ help-seeking behaviours and coping methods. Important as all of this research is, it encourages the view that the problem is situated only in the student. It places the onus for change on the student to adjust to university life.
Social ecological theory provides an alternative approach to understanding the challenges of being a student with a mental health problem; it allows a broader look at the variety of other factors that affect the student’s experience. Social ecological theory characterizes environmental settings as having multiple physical, social, and cultural dimensions, each of which can influence health outcomes [12]. At the same time, it acknowledges that health is influenced by personal attributes and that individuals play an active role in modifying their own health behaviours. In this approach individuals are situated within their environments and the level of congruence between individuals and their surroundings is an important predictor of health and well-being. Thus a focus on only one of these elements (e.g., student behaviour) is seen as inadequate. Examining the range of factors that influence the individual – social interactions, cultural values, community norms, public and institutional policies and procedures – rather than individual behaviours alone has the potential to call forth a range of multi-level interventions [13]. Thus, the purpose of this study is to broaden our understanding of the dynamic interplay between the environmental and personal factors that shape the experiences of university students with mental health problems. We draw on narratives of students living with mental health problems to gain this understanding.
Methods
The research was conducted by two faculty members and six graduate students in a master’s level health professional program. The faculty members had experience in teaching mental health content and carrying out research in the area. In their faculty role, they also guided students who had experienced mental health problems. The graduate students who chose the topic for a required research project appeared drawn to it because of experiences with themselves, friends, or family. The experiences and insights of this research group led to an inquiry directed at the interrelations among various personal and environmental factors, rather than at the students themselves. In light of this perspective we chose to use a qualitative approach that would enable an understanding of the challenges, supports and coping strategies of university students with mental health problems.
Participants were recruited from within a large, research-intensive university in a major urban centre in Canada. Notices were posted around the campus and email messages were broadcast by various campus list-servs inviting students over the age of 18 years, who identified themselves as having mental health problems, to participate. A formal diagnosis was not required so that students who were experiencing mental health problems but had not yet been formally diagnosed could be included. Students interested in participating contacted the researchers who explained the study in detail. For those who wished to proceed, a time and place for a private interview on the campus was set. Written consent was obtained prior to the start of each interview. A total of 19 students were interviewed: 15 females and four males, aged 18–32. The higher number of females mirrors the increased numbers of women seeking help for mental health problems at large [14]. Along with a limited amount of demographic information (age, year of study, program of study) students described/named their mental health problems. They included: depression, anxiety, anorexia nervosa, and bipolar disorder. Students were from undergraduate and graduate programs in both arts and science and the professions. Ten of the 19 students were the children of first-generation immigrant families.
Interviews were semi-structured and included questions such as: How do your mental health problems affect your life as a student? How do you manage on a day-to-day basis? What was your experience of seeking services for your mental health problems? How would you describe the academic environment of the university? Interviews, which lasted one hour on average, were digitally recorded and transcribed verbatim. The qualitative software NVivo 8 was used to organize and store the data.
The data were collected by four masters-level students who were trained for their role as peer interviewers and researchers. Research on peer interviewers supports the notion that they are particularly valuable with populations who may not be as forthcoming with more experienced or orthodox researchers [15]. In our study, having peer interviewers likely helped to minimize the power differential between researcher and participant and might have facilitated the rich and free-flowing interview that resulted between fellow students. To enhance the trustworthiness of the data and subsequent interpretations, the peer researchers kept journals of their thoughts, feelings, observations and interactions as well as notable contextual information. Under the supervision of the two faculty members, interviews were coded as they were collected by each of the peer researchers. Interviews continued until a point of saturation was reached; where no new information was forthcoming. Ethics approval from the university’s Health Sciences Research Ethics Board was granted at the start of the study and renewed annually as data collection continued.
Constructivist grounded theory methods, which communicate how participants construct their worlds, were used to analyze the data. In constructivist grounded theory research, the researchers bring their knowledge of the social constructions of the concepts under study [16]. In the case of our study, the team’s research and scholarship had exposed them to many ways of understanding mental health, including social ecological theory, which they considered an appropriate lens for viewing the data that emerged. Qualitative researchers have demonstrated how using a theoretical framework within a constructivist grounded theory approach provides a concentrated investigation of participants’ lived experiences, while also allowing for new themes to emerge [17]. Similarly, in our study, while the social ecological approach provided a framework, the theory that emerged was grounded in participants’ collective experiences.
Student researchers coded the transcripts, first on a line by line basis using an open coding approach to generate initial concepts. Next, axial coding connected related codes and assembled them into meaningful categories or conceptual families. Finally, through a process of selective coding, these relationships were formalized into themes which were then organized into a theoretical model [18]. At regular intervals, each student researcher discussed their coding and categorization of data with the faculty supervisors so that differing views could be shared and a consensus built. Codes were constructed, compared and merged. As a final step, two additional research students as well as the two supervising faculty members synthesized the entire data set and constructed a model. The rigor of the analysis was enhanced through ongoing discussions of the data across researchers. Denzin [19] identifies the use of multiple investigators studying a particular phenomenon as an important form of triangulation. The analysis reflected the range of perspectives expressed by all participants, including those that conflicted with one another. Trustworthiness was also ensured through triangulating the data that emerged with existing literature [16].
Findings
The theoretical model depicted in Fig. 1 presents the central themes of this study. These themes reflect participants’ perspectives on their individual challenges and capacities interacting with and influenced by the social and cultural environments in which theyfunction as students. The model shows the experiences of university students with mental health problems as a function of the interrelations between the self, the social, and the school: the self refers to individual factors such as students’ understanding of their illnesses and the self-management strategies that they adopt; the social refers to interpersonal factors including social support, stigma, and family issues; and the school refers to environmental factors including the adequacy of services, the culture of the university and expectations for coping. While the themes intersect with one another and have boundaries that are fluid and overlapping, they are presented separately here for the sake of clarity. The model supports the idea that environments and cultures interact with individual capacities to influence roles and behaviours. To be effective, these domains must be congruent with one another; the environment must be supportive of students’ needs and students must feel comfortable in their efforts to adapt to it.
The self: Understanding and managing the illness
This theme was comprised of two sub themes: the difficulty recognizing and understanding symptoms as indicative of mental illness, and the many self-management strategies that help students cope.
The challenge of recognizing and seeking help for mental illness. Students spoke about the difficulty they experienced in drawing boundaries between mental illness and responses to the everyday stresses of multiple demands. Mental illness is often episodic, ambiguous, and difficult to recognize; as a result, students are often uncertain of when they need to seek out support. Participants described the slow and tentative process of coming to the realization that they were ill and in need of help:
I thought I just needed more sleep or I just needed to review my stuff better but months went by and my performance really wasn’t great and so I was just running my head into a brick wall repeatedly. A few months ago I was having bad panic attacks. I’ve had them before but I didn’t realize. I just chalked it up to nerves but it was really bad a few months ago so I just had to take the leave.
Because mental illness can be difficult to distinguish from “moodiness” or other commonly experienced emotions, and because it often lacks “hard” signs, there was a tendency to consider it a passing state, rather than an illness per se. One participant, who had been hospitalized for depression, stated:
I didn’t take it seriously and to some degree I still don’t because I’ve been imbued with that understanding of depression since I was in middle school or high school, that it’s just a fickle set of emotions, it’s not a real issue.
The student went on to explain how the nature of the illness was such that it depleted her energy and motivation to seek help:
I felt too unmotivated to seek anything of my own accord. I mean it took like weeks to drop my courses even though it was a very simple decision in hindsight. I just didn’t get out of bed. The thought didn’t occur to me to do something that was in the least proactive or productive.
Self-management: knowing what helps. Many students described how they manage their mental health issues. They emphasized the importance of engaging in activities that could divert their attention from the stress they were experiencing, and provide them with a sense of accomplishment or even pleasure. Activities such as cooking, part-time work, dancing, volunteering, social outings, physical exercise, drawing, writing, or playing music offered a positive experience and relief from the illness. One student said, “My body takes over when I have nothing to do; that’s why I get more anxious in the summer,” while another noted, “Last year I didn’t have a job and was only taking three courses so I had a lot of free time and it was a lot of time to mope around.” Another coping method was finding strength in religion and some involved adopting maladaptive habits such as drugs, tobacco, or alcohol use.
An important coping strategy discussed by some students was the ability to reframe their illness as a growth-promoting experience. Some were proud that they had learned to function despite their illness and even felt that they were at an advantage compared to their peers. One student said, “I guess I would say it has almost made me a better person since I feel I have gone through all these things in my life and all these challenges...” For another, having been ill meant learning new problem-solving strategies. The student reported finding “better ways of dealing with others and dealing with those problems I’ve experienced my entire life but never knew how to cope with properly.” Still another reflected on how she might eventually come to think about her illness as something that would enhance her life:
I don’t actually hope for it to be gone completely but I just want to learn how to manage it more wisely I guess and to think about, be able to embrace myself more... accepting my weaknesses and accepting myself as a valuable person.
Participants reported that having some control over their lives within the university setting was another important means of managing. The ability to change pre-determined arrangements, including course loads, class times, and exam scheduling, allowed them to better meet their needs. Many students described having to cut back their course load which ultimately meant an additional year of study with its increased financial costs. Avoiding certain classes was important for many students; for some, large classes, deemed to be impersonal, were to be avoided while for others small classes, where one could not be part of the background, were more difficult. Still others feared classes that required participation, as speaking out was anxiety-provoking. One student stated, “A good chunk [of the course] is a participation grade so I lost a lot of marks and at first I was too shy and anxious to talk to the professor about my grades … ”
Despite the stress involved, simply being at university seemed to be protective for some students. They felt buoyed by academics and found university a means of gaining a sense of accomplishment that they did not want to give up. One student summed up the situation by saying, “I absolutely love the university experience.” Another noted how finding the right course energized her following an episode of illness; she explained, “I loved what I was learning, the class was really engaging and it was the perfect platform to bounce back.”
The social: The importance of social support, family issues and the impact of stigma
Two subthemes characterize the impact of social factors on the experiences of students with mental health problems: the importance of social support and the negative impact of stigmatizing beliefs and attitudes.
The importance of social support. Students emphasized the importance of support and the strength they gleaned from good relationships. One student described the support provided in a learning group that she attended saying, “we were all studying together and it’s just, having people there studying with you is better than studying alone … Now that I’m part of this first year learning community, that’s probably like the most helpful thing I’ve ever done.”
Friends helped students feel “normal” even if the friends lacked a full appreciation of the illness, while family relationships were supportive if there was a good understanding of the illness and problematic if there was not. Students of immigrant parents found it difficult to share their issues within their families, given their different cultural expectations. One student reported, “I come from a very conservative, Indian background. [My parents] thought I was putting on an act. They thought I was rebelling. I was not … there’s a lot of ignorance out there.” Another student stated, “I don’t really talk to them about anything like this. I think it’s just in Asian culture we don’t do it. They don’t know that I have been seeing psych services.” The student went on to note the added problem of the pressure she felt to excel at school: “I just have this thing where I have to please my parents. It’s an Asian thing, you have to do well for your parents, you know - for them to be proud of you. Stuff like that.”
Not only were some families unable to be supportive to the student with mental health problems, but some needed support for themselves, which placed a greater burden on the student. One student described how her father was only able to find menial jobs, and the family soon became despondent. The student described, “The breadwinner in our family was pretty much in a state of despair, everybody else took on the same mood... we were all really angry, really bitter people.”
Stigmatizing beliefs and attitudes. Students sensed from others the belief that mental illness is not “real”. The perceived lack of legitimacy in the minds of others led to students’ reluctance to disclose their mental health issues to their family, friends, professors and classmates. Participants felt that students with physical health issues were treated with much more sympathy and support than those with mental health problems. Because of the perceived scepticism, students felt they needed to “prove” their illness to demonstrate to professors that they were in need of assistance:
I suppose mental health issues are taken with a degree of lightness, so I mean if I said I had been in the hospital because I had been seriously injured they [my professors] would have been directly and immediately more understanding. But because I told them I was in the hospital a couple times because I had been experiencing depression - I suppose because depression deals with such a wide spectrum in terms of severity, and it’s totally situational and dependent on the person who is dealing with it - there’s no objective way to measure it. So I suppose they were a little bit more demanding of not only appropriate documentation but rigorous, concrete documentation.
This student summed up the matter by stating, “unless people can see physically that there’s something wrong with you, I don’t think you can expect to garner much sympathy.”
A lack of legitimacy is but one manifestation of the stigma of mental illness that students shared. They reported other, more blatant examples as well. One participant described how she came to realize the deeply ingrained negative attitudes towards mental illness during a discussion with her supervisor about a story, then in the media, of an individual with mental illness acting violently. She explained, “... [my supervisor] was basically like ‘anyone who has a mental illness should be...incarcerated, put away.” Some students revealed that they themselves held stigmatizing beliefs about mental illness; for example, one participant told of how she refused to attend a local mental health facility, stating, “I said the people there are crazy.” One student shared her feelings of isolation that she thought stemmed from stigma:
I feel there is a need to label things,... pathologize it in order for it to be considered anything... Why do we have to label it? Why do we have to ‘other’ someone in the process, put them in ‘that’s that and this is me’. The impact of that on the whole atmosphere of learning I think is just, it’s very isolating and I think that’s the reality of stigma. Can I pinpoint that I’ve experienced stigma directly? I feel it but I don’t know.
Some students appeared to have internalized the negative beliefs that they found pervasive and turn them against themselves, in a form of self-stigma. One student commented, “I had a lot of shame, and shame, I mean, it’s like one of the worst emotions, to feel shame”. Another described his situation metaphorically by explaining, “[medications are] there to help with the symptoms but they’re not going to remove the underlying rot”. The sense of hopelessness and despair was expressed by one of the students from an immigrant family who said, “I thought maybe death was better. I didn’t see the purpose anymore.... my academic success is what my family feeds on and if I can’t offer that to them what can I offer?” For yet another, becoming the “other” – the person with mental illness – was almost incomprehensible:
I’ve never judged anyone with mental health issues, so I never assumed anyone would judge me. But when I was thinking about it myself I was kind of like oh, man! I had issues. What?! It just didn’t really line up with how I really thought about myself. I never thought that I would be this person.
The school: Less than adequate services and a competitive culture with high expectations for coping
Students’ perceptions of the environment and its effects on their mental health centered around two subthemes: the adequacy of services, and the culture of competition and high expectations.
Less than adequate services. While some students had positive experiences, services were largely seen as less than adequate, difficult to access, and of variable quality.
Participants reported that students are generally not aware of mental health services. They expressed their own lack of awareness about what services were offered and how they could benefit from them. One student stated:
I thought of this later but I probably could have contacted Student Health Services, maybe gone in to the doctor and then maybe could have been referred to a psychiatrist. But in the moment, I didn’t know where to turn.
Many of the participants who did use student services had less than ideal experiences. They spoke of finding it “a daunting process” to access services. When they did manage to be seen for counselling, some felt they were not listened to, that their needs and concerns were not taken into consideration, and that a trusting therapeutic relationship was not developed. Participants who had chosen not to use, or to stop using, campus mental health services, were very vocal. They felt that campus services prioritize the medical management of mental illness over other approaches, and this was, in their view, insufficient. Their negative experiences with the system were internalized and made them feel worse. One student stated, “I’m a lost cause, that’s how I felt. If psych people can’t fix me that just sucks.” Some acknowledged that their needs and those of “the system” might not always mesh. For example, one student who was receiving guidance from her advisor, thought that competing priorities may have had a part to play in the counselling she received. She stated, “I know that [my advisor’s] also working with constraints and it may not necessarily be my best interest [she has] in mind – [she may be thinking about] her stats, and her agenda may not be mine.”
There were also some students who described positive experiences with the services available. As one participant reported, the services “helped me to actually talk to someone again... it was my first positiveexperience.” Others found that the medication provided was helpful for their illness and for sleep issues, as well as general coping.
The recommendation to increase the number and availability of services was common amongst students, but one student took an opposing position, suggesting that increasing services simply marginalizes students further and diverts attention away from the problems embedded in day-to-day life on campus and the environment that supports it:
By making [services] more robust are we ‘othering’? Are we taking away the responsibility [from the university]? Are we creating segregation?. Does the need to create more services mean that there’s a need to push people outside when the issues are right here?
A competitive culture with high expectations forcoping. Participants in this study saw the university as a generally unsupportive, competitive environment. With grades a major focus, they felt there was little sense of community. They described the pressure that the work brought in various ways: “overwhelming, the amount of work” … “everything comes at once”... “I feel like I’m so burdened with these things that I have to do it’s like I can’t even enjoy myself... there is always that constant tension that there are other things I need to do” … “[the university] rides you pretty hard”. One student commented on the ramifications of that pressure, saying:
There was probably a two-month period where I didn’t even go out once with friends. I just devoted myself to school and academic work. And I guess that sort of caused the depression and the anxiety. It’s anxiety because you wake up and you do the same thing, and you’re never sort of done the work.
Another recalled the irony of the situation saying, “I hadn’t actually performed badly as of yet. I was worried that I was going to.”
Some students were surprised to find that the university was not more inclusive and that theirexpectation – for a broader acceptance of mental illness in that environment – was not met. One student commented, “The institution itself is the Ivory Tower. It’s power. It’s not an inclusive society. It’s always been exclusive, historically.” Referring to the need to raise awareness of mental illness, and the position of the university in society, another student said, “If we can’t do anything about it, then seriously, who can? Like we are known for education, so if we can’t teach people, who else will, right?”
Disappointment came not only from experiences of the university environment as a whole but also from interactions with professors and staff, who were perceived to embody the culture of success and competition:
I feel like they’re out to get you and they couldn’t care less. Like there’s one or two that I talk to that are more approachable, but the impression that I get is that they just want to do their research.
It is noteworthy that while many students found their relationships with professors less than helpful, there were several who described positive experiences:
I had to get my exams deferred and I had to get my assignments deferred. Now luckily for me I had very, very understanding professors. They probably thought okay, she’s really, really sick. So I didn’t have any problems from the university. Everyone was really nice … I think they were really afraid of me!
Participants spoke about the (false) assumption that mental illness is not an issue at university. One stated that what was conveyed to him by other students and faculty was the assumption that “if you’re at [university], you must be extremely smart and everything about you is normal.” The expectation that all students should be able to cope presented a barrier to accessing services. Many students chose to hide their illness for fear of being seen as weak; they wanted help but found it difficult to overcome the expectation that they should be able to go it alone. In deciding to hide their illness, some felt like imposters. They needed to choose: to fit in and not disclose (and therefore not access services) or to disclose and access services, but not fit in. One student explained:
I still don’t really want a lot of people to know about my eating disorder so for me to go up to my TA or go up to my professor and be like I need this extension and this is why, it’s kind of like, ohhh, I don’t really want to tell you, but I need it so I don’t really know what to do.
Students had their own ideas of what was needed to improve the culture, to make it more inclusive and accepting of people with mental health issues. Many of their suggestions for increasing support and decreasing the stigma of mental illness focussed on improving campus awareness. They wanted magazine articles, blogs, and a special newspaper column devoted to the topic. It was noted that, despite the knowledge that one in five people will be affected by mental health issues in their life, “in the mainstream experience of university life, it’s not something you’re exactly exposed to as an ordinary student.” Participants noted that it was important to seek out people who could provide hope and images of success. One student suggested that there needed “to be a club or something... it should be known to people who are going through this thing, things like this, that they can get help, it’s not the end of the world.” Another participant suggested that the university could cultivate optimism and support through sessions that would connect students with others who have struggled and succeeded:
I think if I had somebody to say everything was going to be fine, then I would have been ok because everybody that I had heard of, that especially came to university with eating disorders, especially the people that I was in treatment with, they all had to leave halfway through because they all relapsed, and I was like, whoa! I don’t want that to happen to me. I needed hope.
Taking a different approach to changing the culture, one participant suggested that students take more control in altering the social environment. She reflected on how “top-down” change that is initiated by institutions tends to be resisted whereas “grassroots organisations tend to generate a sort of individual empathy, more than that sort of resistance that tends to be reactionary against institutions.”
Discussion
The experiences of our participants can be seen as a function of individual, interpersonal, and environmental factors and their inter-relationships. The themes generated from the narratives of the students have led to a model that conceptualizes a dynamic interplay of the self, the social, and the school. These findings are consistent with, and lend further support to the social ecological approach, pointing out the critical importance of considering individuals and their multileveled contexts. Stokols [12] noted in his original discussion of the benefits of a social-ecological approach to promoting health that it could “recognize the influence of multiple settings on well-being and incorporate multichannel interventions” (p. 292-293). However, in a recent review describing health promotion interventions derived from social ecological theory, Golden and Earp [20] acknowledged that few are aimed at multiple levels. While their review is limited by having selected articles from one journal only, the concern they point out is important to acknowledge: for the social-ecological approach to be useful, multilevel interventions are critical. Similarly, interventions within a university must be integrated into its very fabric in order to construct a psychologically healthy environment in which everyone, including those with mental health issues, can thrive.
Our finding that students have difficulty recognizing their mental health problems, seeking help for them, or mobilizing their inner resources to enact problem-solving strategies, is not new. Much research has reported on delayed help-seeking amongst youth and studies suggest that they are less likely to access support if they hold beliefs that they should be able to sort out their mental health problems on their own [21]. Our participants’ full potential appeared to be restricted by the expectations of others, and by the institution itself, that they should be able to cope simply by virtue of being at university. This finding points to a need for greater congruence between the self, the social, and the school; increasing students’ comfort in seeking help must be aligned with a social and cultural environment that includes and supports these students.
Students expressed frustration with their own and others’ lack of understanding of mental illness and linked this to their failure to seek help in a timely way, or at all. This finding points to the importance of enhancing mental health literacy, defined as “the knowledge and skills that enable people to access, understand and apply information for mental health” [22, p.2]. Interventions that increase mental health literacy - for example, Australia’s Mental Health First Aid Program – have been shown to be successful [23]. Universities would benefit from an increased focus on mental health literacy to help students, faculty, and staff increase their understanding of their own and others’ mental health issues.
A somewhat surprising finding in our study was the degree to which many students had learned to self-manage their illness. In particular, they recognized the importance of engaging in activities that decreased their stress. The value of psychologically disengaging (i.e., taking your mind off the problems at hand) has been supported in a recent study of 178 individuals faced with the challenge of managing multiple responsibilities for work, family and school [24], while a systematic review of 30 prospective studies [25] reveals that engagement in meaningful activities can promote psychological and spiritual well-being and ward offdepression.
Promoting supportive environments in which people take care of one another in conditions that are safe, stimulating, satisfying, and enjoyable has been the focus of much research on promoting mental health [26]. However, many of our participants found that they lacked social relationships or had unsupportive relationships, and that the environment was less than welcoming. Given the large body of evidence that now supports the link between social support and health, our findings highlight an area that warrants focussed intervention. The importance of what we have called the social, is highlighted in a study of 1,378 college students by Hefner and Eisenberg [27] who found social support an important correlate of depression, anxiety, suicidality, and eating disorders. Efforts to facilitate the development of supportive networks should be enhanced. For example, opportunities for mutual support for both social and academic purposes have been shown to be effective when offered through learning communities, which depart from the traditional emphasis on individual knowledge and performance and instead promote a culture of learning through a collective effort [28]. Learning communities have been found to foster friendships, develop academic and personal skills, and enable collaborative learning [29]. Such supportive student environments may have the added advantage of promoting early detection and intervention for mental health problems. When students come together in a culture of support and acceptance, they are more likely to look out for one another, know when each other seems ‘not him or herself’, talk more openly, and enlist help when needed. This gatekeeping role of student peers can be particularly helpful to students who wish to disclose their mental health issues only to their friends [2].
Students had many ideas about how the university could pave the way for greater support and improved coping: they suggested increasing campus awareness, promoting linkages with role models, decreasing pressure, and modifying services to better address needs. Students living with mental health problems have expert knowledge based on their lived experiences and their voice needs to be heard in the planning, implementation and evaluation of efforts aimed at improving student mental health [15].
Our findings point to the detrimental effects of perceived stigma and marginalization experienced by students. That the arenas in which stigma surfaces are multiple has been supported elsewhere in relation to adolescents with mental health disorders [30].The social and cultural factors that underlie the sense of isolation experienced by students need to be addressed so that they do not stand in the way of disclosure, help-seeking, and requests for accommodations; actions that are potentially transformative. Asking for help, for example, counselling and accommodations, is a complex social process. It involves weighing decisions about one’s place in the university, one’s self identity and whether to risk becoming engulfed by the stigmatizing beliefs of others. As has been found in work settings, the individual with mental health issues has a difficult choice to make [31, 32]. For students to feel comfortable accessing the accommodations and supports they require, they must feel safe in their environment. Universities, which are known to promote social justice and propel societal change in other arenas, are well placed to lead the way to cultural change in this area. Difficult as it may be for a culture that values academically successful, competitive students to also be inclusive of those who experience difficulties, the university environment is the ideal place to implement evidence-informed methods for doing so. Addressing stigma will mean greater acceptance and understanding of students experiencing mental health problems which, in turn, increases the level of congruence among the self, the social, and the school and enables students and university support systems to work more collaboratively.
The findings of this study support the notion that strategies to address student mental health would benefit from a multilevel rather than an individual approach. What is absent from our model, however, is the policy level, and this is an important level to address [33]. While our data did not attempt to shed light on university policies directly, the implications of the findings are that the university’s commitment to mental health should be more visible. Once there is policy in place that supports the legitimate right of students with mental health issues to a university education then the way is paved for the culture and the services to change. Outreach to students, service delivery, faculty-student communication, supports, and accommodations can be enhanced, and information can be more effectively disseminated to all.
There are a number of strengths and limitations of this study. Having data collected by peers (i.e., fellow students) is a strength given that participants were likely to be more open in discussing their concerns, with both parties “speaking the same language.” This rapport likely facilitated greater disclosure and a richer description of the student experience. Volunteer bias in the sample may explain some of the students’ expressed dissatisfaction with the current system and their readiness to come forward. The study sample included those who self-identified as having a mental health problem, however, virtually all of the participants reported that they had had a diagnosis.
Conclusion
Many students with mental health problems are unable to realize their academic and ultimately their career potential, not only because of the mental health problems they may be experiencing, but also because of the social and cultural climate of which they are part. Improving opportunities for the success of these students calls for a multidimensional approach that promotes mental health through interventions at the level of the self, the social, and the school. In addition, a policy statement that values and protects students’ mental health and declares the university’s commitment to the issue is needed. This study provides some evidence that listening to the student voice can help universities to lead the change; to take ownership and responsibility for the well-being of all of their students, including those with mental health problems.
Footnotes
Acknowledgments
We wish to thank the participants of this study who so willingly shared their stories.