Community Mental Health Iournal Volume 2, Number 1, Spring, 1966
PREVENTIVE
PSYCHIATRY
ON
THE
COLLEGE
CAMPUS
JOHN E. KYSAR, M.D.* American colleges lose half their students in the four years after matriculation. This high attrition rate with its waste of brainpower and cost in human well-being suggests that our institutions of higher education are not very conducive to optimal development of students. Especially those who begin the race for the diploma from the lower end of the socioeconomicspectrum are disadvantaged from the start. Recently, attention has been focused across the nation on the failures of the educational process at lower levels. However, the negative consequences of college failure or dropout for individuals and for society are no less than the consequences of dropout from the secondary schools. It is probable that in half or more of all the dropouts and flunkouts from American universities, psychosocial difficulties are an important factor in the failure. Preventive psychiatric measures on the campuses could reduce both educational losses and future psychiatric casualties. These preventive measures and the role of mental health professionals in colleges are elaborated. When social scientists look at American colleges today they are apt to view them as a system of institutions and practices which are not very conducive to optimal development of the great body of the student population. For example, Riesman and Jencks (1952, pp. 75-77) wrote of our colleges as "personnel offices, feeding properly certified employees into business and the professions." Again, they depicted colleges as "gatekeepers to the upper middle class" and higher education as an "initiation rite for separating the upper middle from the lower middle class." Psychiatrists also view with some misgivings the effects of our higher educational organizations. Whittington (1964), former director of mental health services at the University of Kansas, has spoken of colleges as training grounds for participation in adult life, altogether too much like military
training camps. In a satirical vein he described how a visitor from another planet would perceive our colleges. The man from Mars or Venus would view with some astonishment the way we march our youth off to the campuses each September, run them through assembly lines of registration with much confusion, and proceed to drill them in intellectual exercises which often seem to them alienated from their present interests and future pursuits. Bower (1963), who was a consultant on school mental health with the National Institute of Mental Health, wrote of the apparent need of our society through its schools to classify some individuals as failures in order to preserve the feeling of superior accomplishment for others. Thus our colleges maintain a constant pressure on the student by means of holding over his head the threat that he will be labeled a failure in the competitive race for the diploma. The visitor from another planet would almost surely be appalled at the waste of brain-power and the cost in human wellbeing due to the method of higher education still perpetuated by our affluent Great Society; a method which takes in millions of young people, but which regularly eliminates half of them as unfit. They come into college full of hope that they can find a place in the future in keeping with the American vision of the good life. But, as attested by Summerskill's (1962) authoritative article on college attrition rates, American colleges lose half their students in the four years after matriculation. The attrition rates vary from 12% to 82% in 35 studies reviewed by Summerskill. Another comprehensive study (Brode, 1964) also concluded that our present college mortality rate is about 50%. It can be argued that these figures are deceiving and inaccurate, that many dropouts later gradu-
*Dr. Kysar, a social psychiatrist, is Associate Professor of Psychiatry, and Director, Health Service, University of Illinois at Chicago Circle, Chicago, Illinois. This paper was presented at the Illinois College Mental Health Conference at Northern Illinois University, March 4, 1965. 27
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THE COMMUNITY MENTAL HEALTH JOURNAL
ate from another college. However, the between their interests and goals and those calculations take into account such sources of the college. They typically give as the of error and still the result is an overall main reason for leaving college, "lack of mortality rate of about 50%. interest in studies." Possibly, it is a good There are differences between small and sign in terms of the assertiveness and nonlarge public and private schools. Small conformity of college youth that half do not comfort may be taken from the fact that fit themselves into the slots provided in one's own institution may be less afflicted higher education. Nevertheless, the net with the "virus of dropoutism" than other result from both an educational and a universities. Or, one may view higher edu- mental health standpoint is undesirable. A cation as the prerogative of the elite so that judgment has been rendered by themselves it is only right and just that the attrition and/or the institution that they are not rate is high. But the youth of today are suitable for business or the professions. In caught between the demands of parents and America today this is almost equivalent to society for ever more education on the one categorizing them as second-class citizens, hand and the impersonal process of elimi- since a diploma is so essential for the most nation on the other. The rejects are cast desirable vocations and for social and ecoaside, stamped as defective or inadequate nomic position. by the standards of higher education. Or The underlying assumption on which colperhaps that is too harsh on the colleges, leges operate is that the dropouts are lackbecause some students surely do play a part ing in intelligence or diligence for studying. in casting themselves aside. (The fact is Little consideration is given the many comnot ignored that some students need a mor- plex factors which importantly influence atorium, a period away from college pres- learning ability. A Darwinian, survival-ofsures in which to establish more firmly the-fittest philosophy prevails so that the their identity and goals. These students may college implicitly tells the student that he return with renewed determination. They either sinks or swims; and if he can't swim do not, however, constitute a large part of at the prescribed speed, he is destined to the dropout group.) Though it is recog- sink toward the bottom of the economic nized that the student contributes by his pool. Those students who begin the race behavior to his elimination, this paper will from the lower end of the social and ecoconcentrate on the part played by the nomic spectrum are disadvantaged from the start. college in this process. By the time he comes for an exit interview, the student flunkout or dropout may WHOSE FAILURE--STUDENT OR COLLEGE.9 rationalize that he really doesn't want a Particularly now that the wave of postcollege degree after all. He would prefer some other career not requiring a diploma. World War II babies has reached college Thus many dropouts leave quietly, accept- age, so that colleges have a selectivity ing their fate and restructuring their aims. higher than ever, there is little justification But more than a few are filled with resent- for this survival-of-the-fittest philosophy ment. They may internalize this anger which rejects so many. The rationale for (blaming the self), resulting in feelings of this method of elimination seems more in defeat and depression; or they may ex- terms of the need of the college system than ternally direct it (blaming some aspect of in terms of what is really best for the stuthe system), resulting in defiant, rebellious dents. The need of the college system seems attitudes. Either way is apt to be maladap- to be that of reducing its intake of students to more manageable proportions. Thus, it tive and unhealthy. A major portion of these dropouts are takes in more than it can digest, then renot so much academically lacking, nor are gurgitates half back to the community as they below the successful students in intelli- though they were uneducable. Recently, society has been focusing atgence and scholastic potential. Rather, they are unable to find sufficient congruence tention on the failures of the educational
J o r m E. KYsxa
29
process at lower levels. It is only a matter more often to provide avenues for social of time until there is demand for more and psychological growth which support careful examination of the attrition rates the intellectual process. Learning for learning's sake; education of universities. The negative consequences of college failure for individuals and for as a value per se whether or not it is related society are no less than the consequences of to one's fellow students, to the working world outside, or to the life ahead, is dropout from the secondary schools. When the process fails it is usually de- easily accepted by the youth from an upper fined as a failure of the student himself. middle class home. This concept finds supSeldom is it seen as failure on the part of port from his background in the family, the system, the college, and its methods. among his peers, and in the atmosphere of But the college may fail to nurture and to the high school he attended. However, stimulate the student and to provide safe- though he may have the admission qualiguards against his being disillusioned and fications, the student from the lower middle dropped. Officials and faculty sometimes or lower class is relatively deprived, culturaccount for the dropout with the hackneyed ally and educationally. Identification with explanation that "he lacked the motivation the goals of the university and the objec. for study." Motivation for study, however, fives of his professors are much more diffiis not a drive free of all other forces. Moti- cult for him. vation is a dynamic concept subject to inSchools, such as the state universities fluence by psychosocial factors, including which admit many students from the lower faculty, parents, peer groups, institutional socioeconomic groups, should especially inatmosphere or morale, etc. It must be corporate into their program measures to remembered that the reasons of the average counter the alienation from upper middle 17-18 year old for going to college are not class mores and values which so often leads very profound or very firmly held, so that the lower class youth to leave college. It shifts in attitude toward college work read- should be realized that higher education ily occur. Particularly in the first year for generally reflects upper middle class values some youngsters, a setback on a single and styles of living. The student from the exam, a period of puzzlement in one course, lower socioeconomic status faces the proba quarrel with parents or friend of the lem of adapting not only to academic presopposite sex, a rebuff by dormitory mates, sures but, in addition, to a culture at or a host of other apparently slight trau- variance with his indigenous one. The term mata may turn the tide. cultural shock has come into widespread In theory, there is a general consensus usage to denote the emotional disturbances that the goals of higher education include in an individual in transition from one social and personal development along with reference group to another. This concept the intellectual. Helping students to find is invoked to understand the troubles of some congruence between their interests the foreign student. But it is seldom fully and those of the institution should be sub- appreciated that, within the framework of sumed under these goals. But how is this our own American society, there are many really implemented by the colleges? Op- disparate subcultures; the movement from portunities for social participation in one to another may also precipitate a growth-promoting activities and organiza- degree of cultural shock. tions, opportunities to satisfy the important PREVENTION AT COLLEGE need at this age of establishing some friendPreventive psychiatry is concerned with ships with depth and persistence, opportunities not only to accumulate knowledge the prevention or amelioration of those but to search for meaning--these are often strains which may lead to emotional breaknot present in very great degree on the downs. These strains are biological, intracampuses. Although colleges fail sometimes psychic, familial, and social. Some are to serve up intellectually appetizing courses more accessible to modification with present and methods of teaching, they fail even day knowledge and techniques than others.
30
THE COMMUNITYMENTAL HEALTH JOURNAL
Our knowledge of the causes of mental illness is far from complete, but it is sufficient enough to know that the application of principles of prevention could significantly reduce the high cost of the ravages of mental illness to individuals, families, and society. Preventive measures are particularly effective at crucial stages in the life cycle when the stresses on the person may be great and the vulnerability to breakdown high. Late adolescence and young adulthood, i.e., college age, is certainly one of these crucial stages. The college youth faces many critical problems, which hardly need reiteration. Either his personality, still only partially formed as he enters college, will crystallize in ways which promote future health and productivity, or in ways which are maladaptive and set him on the road to probable trouble. Preventive psychiatry on the campus is aimed at the failure of the college as well as the failure of the students. As Bower (1963) has expressed it: "Prevention has to do with the quality and the degree of effectiveness of the institutions of society in providing each person with increments of ego strength and personality robustness for coping with the 'slings and arrows' of life." If the goal of the college is to promote learning and intellectual achievement in the students, it cannot ignore the affective and cognitive mental health factors which directly affect how and what the student learns in school. If the college really cares about educating as many as possible of its annual intake of students, it cannot afford to overlook the mental health factors. It is probable that in half or more of all the flunkouts and dropouts, psychosocial difficulties are an important cause of the failure. Farnsworth (1959), a foremost authority on college mental health, asserted that in some institutions the proportion of students who leave college because of emotional conflicts is considerably more than half. Summerskill (1962), in his excellent review of studies on dropouts from many institutions, concluded that the majority of students leave college for nonacademic reasons. He added that among dropouts,
ascribed by college records to "academic failure," there are many cases in which the underlying problems are psychological, parental, social, or financial. King (1964) reported that dropping out of college is most often a symptom of some kind of emotional conflict as well as the inefficient utilization of a social resource. Putting the label psychosoeial difficulties on a million or more of the annual flunkouts and dropouts from college may sound radical. Some educators may also feel skeptical about whether anything can be done about it. Their knowledge about people with such problems may make them feel that it is not a matter for schools to become involved with on a large scale. "We are not mental hospitals or clinics," they may say. But when it was stated that half the dropouts have psychosocial difficulties, it was not meant that these are severe cases, requiring long, expensive treatment. Colleges need not be turned into mental hospitals; but colleges can be made social institutions with an educated heart. A recent editorial in School and Society (Brickman, 1965) stated: Student sources have attributed departure from college to various reasons, such as personal problems and dissatisfaction with the faculty . . . . There can be little doubt that the administration of colleges and universities cannot be deemed a success under circumstances of large-scale dropouts. . . . What is needed is constant vigilance to note, at the earliest opportunity, those students whose difficultiesmight lead to an early departure from the college. [p. 3] These comments by a prominent educator point toward the need for preventive psychiatry on the campus.
EARLY, SHORT-TERM THERAPY Prevention in psychiatry is a relatively new concept. For most of its history, psychiatry has been preoccupied with prolonged treatment of people whose mental funetion has been rather extensively impaired. Many people associate psychiatry with scores of hours of analytic therapy in the office or months in a mental hospital. However, in recent years, the focus of psychiatry has shifted to an emphasis on
JOHN E. K Y s ~
31
prevention. It is recognized that our society point of view. Not that there are always can never provide enough psychiatric per- solutions--we are not prophets or masonnel and facilities to give really adequate g i c i a n s - b u t usually support and help can therapy if we wait until impairment is be given to the problem-solving abilities of severe. Then personality malfunction has the student himself so that he is better able reached the point where the patient requires to cope with the conflicts and arrive at a many hours of professional time in an office modus operandi. Particularly with compeor hospital and has to have a thorough re- tent help in the incipient stages, the new construction of a mental-emotional life equilibrium may be better than the old. which has been thrown into complete dis- The student may learn and change in a array. constructive direction so that his ability Thus one of the main objectives of to meet problems may be strengthened. modern psychiatry has become prevention This kind of approach---early recogniof such severe impairment. This prevention tion and short-term therapy with acute recan be accomplished chiefly by the early actions has been aptly named crisis counrecognition and early treatment of emo- seling. Even as little as one or two tional problems. In the beginning stages, interviews can be helpful and a majority before the disintegrating effects of anxiety of college students with psychiatric proband depression produce a spreading, spiral- lems can be significantly aided with no ing pathology, many psychiatric problems more than five visits. College youths are can be treated effectively with short-term generally not so resistant, their personalitherapy. Therapy begun early can stem the ties are not so fixed, and they are more tendency toward regression. It can usually open to new understanding of themselves keep the healthy aspects of the personality and their struggles in life as compared with working fairly well while the sick part is adults. out for repair, so to speak. Thus, a complete A SOCIALMOVEMENT breakdown does not occur. The way back to optimal, healthy functioning is preCollege is an ideal locale for preventive served. psychiatry and crisis counseling. It is posIn college students one can see the value tulated that the future psychiatric casualties of the principle of early recognition and as well as the educational losses in our short-term therapy quite clearly. Students country could be significantly reduced by so often come to the office of a professor, a programs of preventive psychiatry in our dean, counselor, or a health service doctor universities. The cost of such psychiatric with acute reactions to some recent stress. services would be substantial but the cost They have failed an exam, lost a boy friend, to our society of incomplete educations and clashed with parents, been ostracized from later prolonged treatment of severe mental the in-group of their peers, or suddenly illness is staggering. discovered something about themselves that Realization of this great cost in both has shaken the foundations of their self- human and financial terms has been image. It is hardly necessary to list the registered at the highest level in our nation many kinds of acute problems which de- in recent years. President Kennedy, in 1963, velop so often in students. The present delivered a major message to Congress on purpose is rather to stress the urgency mental illness. This led to the enactment of which is felt by the student: the common the Community Mental Health Act of 1963 feeling that he must find some solution, and a similar hill on Mental Retardation in some relief from the situation. 1964. Federal legislation in the anti-poverty Often this is seen by older heads as the field is also related. It recognizes the effects impatience of youth. And so it is. Youth is "of social disorganization, unemployment, intolerant of acute unhappiness and im- and underprivilege on individual and fampatient for relief. This can be turned to an ily health. The recent massive federal aid advantage, however, from the mental health to education similarly reflects an awakening
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THE COMMUNITY MENTAL HEALTH JOURNAL
to the damaging impact of cultural and educational deprivation. All these add up to a major social movement in our time toward an effort to reduce mental, social, and academic disability. With children in elementary and secondary schools, the interference with school progress by social, economic, cultural, and family factors is being emphasized. Furthermore, the significance of successful school experience for adult adjustment is recognized. Heroic efforts are under way to enable potentially disabled, handicapped children to develop fully and to minimize their handicaps. Perhaps it is time that colleges also awaken to the need for greater efforts to salvage the potentially disabled, i.e., those who have the basic prerequisites for higher education but who flunkout or dropout. Yet, there has so far been little sign of a comparable broad program at the college level to deal with the interference with school progress by social, psychological, and family factors. Only here and there do a few universities have first-rate mental health services and adequate preventive psychiatry programs. What can colleges do about it? More especially, what can they do without devoting to mental health large sums from their already strained budgets? A mental health clinic with an adequate staff within the framework of the health service or other appropriate division of the college is the first step. A staff sufficient to provide crisis counseling and short-term therapy need not be prohibitively expensive, especially when measured in terms of its benefits. One way of keeping the cost manageable to the college is to charge all students a few dollars per semester specifically for this service. Another way is to charge a fee only to users, i.e., students and their parents who obtain diagnostic and treatment service.
measures. These need the unambivalent support of the faculty and administration. The next step is sensitization of the key authorities in the college community to student emotional problems (Barger & Hall, 1963). Many of these key people are already quite aware of the kinds of crisis which occur in students. Most health service doctors and nurses, vocational and educational counselors, advisors and deans are experienced and alert to student conflicts and troubles. However, some key figures in the college structure may not be very sensitive and skillful in their contacts with troubled students. Others, though sensitive, may not feel competent to do "crisis counseling" without some training. Thus, conferences for key faculty and administrative otScials conducted by the mental health service are needed to educate them to greater perceptiveness and ability in handling students in distress. One of the questions which would be dealt with in such conferences is which kinds of problems warrant referral to the mental health service? Actually many student troubles can be managed successfully by these key college people. But a mental health service could provide consultation in those cases of a more serious or complex nature. The college psychiatrist does not really want to take over the counseling of every troubled student. Obviously, he would soon be swamped. Rather, he and his mental health team can multiply the usefulness of their special knowledge and skills if they give consultation to the other key people who do counseling in the college. The early recognition of the student with the potentially serious problem and his prompt referral for early treatment by the mental health service would thus be facilitated. The student with the less serious difficulty would receive prompt remedial attention by other faculty, buttressed with consultative support by the mental health profesADDITIONAL STEPS TOWARD PREVENTION sional. A next important step is actively seeking But a mental health clinic, adequately out maladjusted or troubled students. staffed, is only the first step. The applica- Instead of waiting until the student comes tion of the principles of preventive psy- to someone with his problems, methods of chiatry involves a number of additional identifying students in distress would be
JOHN E. KYs.m developed. Some will not come to anyone for help until they are in desperate straits or until the trouble has been brewing for a long time. No method of identification is perfect; but the use of psychological screening tests, reports of faculty and dormitory counselors in contact with the student, even routine evaluation of all students whose grades are down can detect many of the college youth who are developing problems. A good number of problems thus identified can be prevented from progressing into major psychiatric difficulties and quite a few would-be college dropouts can be helped to continue and complete this vital stage in their life career. One further resource for identification of troubled students, usually overlooked by colleges---even those few which do have psychiatric services and preventive programs--is parents. At the University of Illinois at Chicago Circle, there is an awareness of this resource because it is a commuter university (Kysar, 1964). The students are not living on campus but with their own families. We are finding that parents can be among the first to notice signs of disturbance, can notify the health service, and can give valuable information about the current problem and past history of the student. We are experimenting with drawing parents into conjoint therapy along with the student. This type of approach appears promising when, as frequently is the case, a major part of the student's difficulty is conflict with his parents. If only the student is seen, only part of the problem is being attacked. In fact, progress may be blocked by subtle sabotage of the student by neurotic parents or a stubborn impasse between student and parents. In many colleges, part of the student population commutes and another part has parents living not far away so that this parent resource may be worthwhile. Even those some distance away, through letters, vacation, summer contacts, etc., may be aware of disturbances in the student. Not many schools give parents any encouragement to bring these to the attention of the college. Most parents are confused about what to do and where to turn.
33
They would welcome the chance to bring the problem to someone at the college, even if special fees were charged. A NEW ROLE FOR THE PSYCHIATRIST
In the foregoing program, based on the principles of early case-finding and prompt treatment, the psychiatrist is departing from his traditional role in clinical practice. In practice he restricts his interest to those individuals who come to his office, clinic, or hospital for diagnosis and treatment. But in the college preventive program he accepts responsibility for helping all students, not only those who have defined themselves as having an emotional illness or maladjustment. Thus, the psychiatrist is concerned with those students who are not yet suffering any symptoms or signs of mental disorder. He directs this concern toward investigating and reducing harmful influences and toward increasing the adaptive capacity of students so that the rate of new cases of emotional disorder, and the rate of failures or dropouts, will be lessened. Special effort may be given to certain high risk groups, which may be the focus of particular harmful influences. For example, the college psychiatrist may realize that a certain minority group in the school is socially rejected and ostracized. Devising ways to integrate this group with the main body of students on the campus may nip in the bud some of the developing cases of maladjustment. Actually, some excellent preventive approaches have already been developed on certain campuses. Carefully planned freshman orientations and systems of using upper classmen as a corps of big brothers or sisters are applications of sound social psychiatric principles which should be expanded. For vocationally-oriented students more work-study programs, which integrate education with the world of business and industry, are needed. For social science majors community action projects, which bring students face-to-face with problems of people, are commendable in terms of personality growth as well as incentive for
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THE COMMUNITY MENTAL HEALTH JOURNAL
education. There will never be enough mental health professionals (and probably not enough other faculty advisors and counselors either) on most campuses to provide one-to-one therapy for all the students who need help. Therefore multiple approaches, including efforts to improve the milieu and enhance the mental health of the community of students, are indicated. This brings us back to the important point that, in carrying out prevention on the campus, the psychiatrist will have a role which is not just in terms of troubled individual students. He will consider the entire field of forces operating in the college community as they affect the mental health of students. His methods will include direct diagnosis and treatment of some individuals. In addition, he will indirectly foster the contributions of other caregiving persons and services of the institution through individual and group consultation with them. As a final step, the psychiatrist may eventually reach a position of acceptance by the leaders and administration of the college so that those who establish the policies, which govern the functioning of the organization, may consult him. They may ask his views on matters which pertain to the mental health of the students. The mental health implications of their decisions will be taken into account before putting into effect a course of action which may have some repercussions on the welfare of students. In this latter step, the psychiatrist and his mental health team must have a thorough understanding of the particular college. They must know it as a social system with its peculiar allocations of status and role, its patterns of leadership in students and faculty, its pathways of communication and balance of power, the values and goals of various groups, its history and evolution with special attention to the ways in which changes have occurred (Caplan, 1964). In all this, the objectives would be the modification of the interaction of forces which influence student behavior. This modification is aimed at decreasing the number of disturbed, maladjusted, and failing students. The goal is to encourage,
by all possible means, those who are faltering so that they may have support from their milieu. This will enable more of them to cope with their problems successfully. They will soon stand on their own feet and in turn contribute to other faltering students and to the college community. At the risk of overstating the case and sounding as if the idea is that everyone should graduate from college and that no nongraduate could ever accomplish anything, it will be stated that every failure is a missed opportunity for a greater contribution to our society. As the President (Henry, 1965) of the University of Illinois recently said, "We must constantly remember that the statistics cited are thousands of human personalities, thousands of individual careers which should be brought to fulfillment. . . . " REFERENCES BARGER, B. & HALL, E. Higher education and mental health. Proceedings of a conference at the University of Florida, September, 1963. BOWER, E. M. Primary prevention of mental and emotional disorders: a conceptual framework and action possibilities, elmer. 1. Orthopsychiat., 1963, 33, 834-848. BRICKMAN,W. W. College enrollments and dropouts. Sch. & Soc., 1965, 93, 3. BaooE, W. R. Approaching ceilings in the supply of scientifie manpower. Science, 1964, 143, 313. CAPLAN, G. Principles o1 preventive psychiatry. New York: Basic Books, 1964. FARNSWORTH, D. L. We're wasting brainpower. Nat. educ. elss. 1., 1959, 48, 42-44. HENRY, D. D. The state of the university, 196465. Faculty Letter, Univ. of Illinois, January, 1965. KINC, S. H. Emotional problems of college students: facts and priorities, elmer, ass. univ. pro/. Bulletin, 1964, 50, 328. KYSAR, J. E. Mental health in an urban commuter university. Arch. gen. Psychiat., 1964, 11, 472-483. I{IESMAN, D. & JENCKS, C. The viability of the American college. In N. Sanford (Ed.), The elmerican college. New York: John Wiley,
1962. SUMMERSKILL, J. Dropouts from college. In N. Sanford (Ed.), The elmerican college. New York: John Wiley, 1962. Pp. 628-641. WHITTINGTON, H. G. The ethical responsibility of the mental health practitioner to his college. Paper read at Amer. Coll. Hlth Ass., Kansas City, April, 1964.
PREVENTIVE
PSYCHIATRY
ON
THE
COLLEGE
CAMPUS
JOHN E. KYSAR, M.D.* American colleges lose half their students in the four years after matriculation. This high attrition rate with its waste of brainpower and cost in human well-being suggests that our institutions of higher education are not very conducive to optimal development of students. Especially those who begin the race for the diploma from the lower end of the socioeconomicspectrum are disadvantaged from the start. Recently, attention has been focused across the nation on the failures of the educational process at lower levels. However, the negative consequences of college failure or dropout for individuals and for society are no less than the consequences of dropout from the secondary schools. It is probable that in half or more of all the dropouts and flunkouts from American universities, psychosocial difficulties are an important factor in the failure. Preventive psychiatric measures on the campuses could reduce both educational losses and future psychiatric casualties. These preventive measures and the role of mental health professionals in colleges are elaborated. When social scientists look at American colleges today they are apt to view them as a system of institutions and practices which are not very conducive to optimal development of the great body of the student population. For example, Riesman and Jencks (1952, pp. 75-77) wrote of our colleges as "personnel offices, feeding properly certified employees into business and the professions." Again, they depicted colleges as "gatekeepers to the upper middle class" and higher education as an "initiation rite for separating the upper middle from the lower middle class." Psychiatrists also view with some misgivings the effects of our higher educational organizations. Whittington (1964), former director of mental health services at the University of Kansas, has spoken of colleges as training grounds for participation in adult life, altogether too much like military
training camps. In a satirical vein he described how a visitor from another planet would perceive our colleges. The man from Mars or Venus would view with some astonishment the way we march our youth off to the campuses each September, run them through assembly lines of registration with much confusion, and proceed to drill them in intellectual exercises which often seem to them alienated from their present interests and future pursuits. Bower (1963), who was a consultant on school mental health with the National Institute of Mental Health, wrote of the apparent need of our society through its schools to classify some individuals as failures in order to preserve the feeling of superior accomplishment for others. Thus our colleges maintain a constant pressure on the student by means of holding over his head the threat that he will be labeled a failure in the competitive race for the diploma. The visitor from another planet would almost surely be appalled at the waste of brain-power and the cost in human wellbeing due to the method of higher education still perpetuated by our affluent Great Society; a method which takes in millions of young people, but which regularly eliminates half of them as unfit. They come into college full of hope that they can find a place in the future in keeping with the American vision of the good life. But, as attested by Summerskill's (1962) authoritative article on college attrition rates, American colleges lose half their students in the four years after matriculation. The attrition rates vary from 12% to 82% in 35 studies reviewed by Summerskill. Another comprehensive study (Brode, 1964) also concluded that our present college mortality rate is about 50%. It can be argued that these figures are deceiving and inaccurate, that many dropouts later gradu-
*Dr. Kysar, a social psychiatrist, is Associate Professor of Psychiatry, and Director, Health Service, University of Illinois at Chicago Circle, Chicago, Illinois. This paper was presented at the Illinois College Mental Health Conference at Northern Illinois University, March 4, 1965. 27
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THE COMMUNITY MENTAL HEALTH JOURNAL
ate from another college. However, the between their interests and goals and those calculations take into account such sources of the college. They typically give as the of error and still the result is an overall main reason for leaving college, "lack of mortality rate of about 50%. interest in studies." Possibly, it is a good There are differences between small and sign in terms of the assertiveness and nonlarge public and private schools. Small conformity of college youth that half do not comfort may be taken from the fact that fit themselves into the slots provided in one's own institution may be less afflicted higher education. Nevertheless, the net with the "virus of dropoutism" than other result from both an educational and a universities. Or, one may view higher edu- mental health standpoint is undesirable. A cation as the prerogative of the elite so that judgment has been rendered by themselves it is only right and just that the attrition and/or the institution that they are not rate is high. But the youth of today are suitable for business or the professions. In caught between the demands of parents and America today this is almost equivalent to society for ever more education on the one categorizing them as second-class citizens, hand and the impersonal process of elimi- since a diploma is so essential for the most nation on the other. The rejects are cast desirable vocations and for social and ecoaside, stamped as defective or inadequate nomic position. by the standards of higher education. Or The underlying assumption on which colperhaps that is too harsh on the colleges, leges operate is that the dropouts are lackbecause some students surely do play a part ing in intelligence or diligence for studying. in casting themselves aside. (The fact is Little consideration is given the many comnot ignored that some students need a mor- plex factors which importantly influence atorium, a period away from college pres- learning ability. A Darwinian, survival-ofsures in which to establish more firmly the-fittest philosophy prevails so that the their identity and goals. These students may college implicitly tells the student that he return with renewed determination. They either sinks or swims; and if he can't swim do not, however, constitute a large part of at the prescribed speed, he is destined to the dropout group.) Though it is recog- sink toward the bottom of the economic nized that the student contributes by his pool. Those students who begin the race behavior to his elimination, this paper will from the lower end of the social and ecoconcentrate on the part played by the nomic spectrum are disadvantaged from the start. college in this process. By the time he comes for an exit interview, the student flunkout or dropout may WHOSE FAILURE--STUDENT OR COLLEGE.9 rationalize that he really doesn't want a Particularly now that the wave of postcollege degree after all. He would prefer some other career not requiring a diploma. World War II babies has reached college Thus many dropouts leave quietly, accept- age, so that colleges have a selectivity ing their fate and restructuring their aims. higher than ever, there is little justification But more than a few are filled with resent- for this survival-of-the-fittest philosophy ment. They may internalize this anger which rejects so many. The rationale for (blaming the self), resulting in feelings of this method of elimination seems more in defeat and depression; or they may ex- terms of the need of the college system than ternally direct it (blaming some aspect of in terms of what is really best for the stuthe system), resulting in defiant, rebellious dents. The need of the college system seems attitudes. Either way is apt to be maladap- to be that of reducing its intake of students to more manageable proportions. Thus, it tive and unhealthy. A major portion of these dropouts are takes in more than it can digest, then renot so much academically lacking, nor are gurgitates half back to the community as they below the successful students in intelli- though they were uneducable. Recently, society has been focusing atgence and scholastic potential. Rather, they are unable to find sufficient congruence tention on the failures of the educational
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process at lower levels. It is only a matter more often to provide avenues for social of time until there is demand for more and psychological growth which support careful examination of the attrition rates the intellectual process. Learning for learning's sake; education of universities. The negative consequences of college failure for individuals and for as a value per se whether or not it is related society are no less than the consequences of to one's fellow students, to the working world outside, or to the life ahead, is dropout from the secondary schools. When the process fails it is usually de- easily accepted by the youth from an upper fined as a failure of the student himself. middle class home. This concept finds supSeldom is it seen as failure on the part of port from his background in the family, the system, the college, and its methods. among his peers, and in the atmosphere of But the college may fail to nurture and to the high school he attended. However, stimulate the student and to provide safe- though he may have the admission qualiguards against his being disillusioned and fications, the student from the lower middle dropped. Officials and faculty sometimes or lower class is relatively deprived, culturaccount for the dropout with the hackneyed ally and educationally. Identification with explanation that "he lacked the motivation the goals of the university and the objec. for study." Motivation for study, however, fives of his professors are much more diffiis not a drive free of all other forces. Moti- cult for him. vation is a dynamic concept subject to inSchools, such as the state universities fluence by psychosocial factors, including which admit many students from the lower faculty, parents, peer groups, institutional socioeconomic groups, should especially inatmosphere or morale, etc. It must be corporate into their program measures to remembered that the reasons of the average counter the alienation from upper middle 17-18 year old for going to college are not class mores and values which so often leads very profound or very firmly held, so that the lower class youth to leave college. It shifts in attitude toward college work read- should be realized that higher education ily occur. Particularly in the first year for generally reflects upper middle class values some youngsters, a setback on a single and styles of living. The student from the exam, a period of puzzlement in one course, lower socioeconomic status faces the proba quarrel with parents or friend of the lem of adapting not only to academic presopposite sex, a rebuff by dormitory mates, sures but, in addition, to a culture at or a host of other apparently slight trau- variance with his indigenous one. The term mata may turn the tide. cultural shock has come into widespread In theory, there is a general consensus usage to denote the emotional disturbances that the goals of higher education include in an individual in transition from one social and personal development along with reference group to another. This concept the intellectual. Helping students to find is invoked to understand the troubles of some congruence between their interests the foreign student. But it is seldom fully and those of the institution should be sub- appreciated that, within the framework of sumed under these goals. But how is this our own American society, there are many really implemented by the colleges? Op- disparate subcultures; the movement from portunities for social participation in one to another may also precipitate a growth-promoting activities and organiza- degree of cultural shock. tions, opportunities to satisfy the important PREVENTION AT COLLEGE need at this age of establishing some friendPreventive psychiatry is concerned with ships with depth and persistence, opportunities not only to accumulate knowledge the prevention or amelioration of those but to search for meaning--these are often strains which may lead to emotional breaknot present in very great degree on the downs. These strains are biological, intracampuses. Although colleges fail sometimes psychic, familial, and social. Some are to serve up intellectually appetizing courses more accessible to modification with present and methods of teaching, they fail even day knowledge and techniques than others.
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Our knowledge of the causes of mental illness is far from complete, but it is sufficient enough to know that the application of principles of prevention could significantly reduce the high cost of the ravages of mental illness to individuals, families, and society. Preventive measures are particularly effective at crucial stages in the life cycle when the stresses on the person may be great and the vulnerability to breakdown high. Late adolescence and young adulthood, i.e., college age, is certainly one of these crucial stages. The college youth faces many critical problems, which hardly need reiteration. Either his personality, still only partially formed as he enters college, will crystallize in ways which promote future health and productivity, or in ways which are maladaptive and set him on the road to probable trouble. Preventive psychiatry on the campus is aimed at the failure of the college as well as the failure of the students. As Bower (1963) has expressed it: "Prevention has to do with the quality and the degree of effectiveness of the institutions of society in providing each person with increments of ego strength and personality robustness for coping with the 'slings and arrows' of life." If the goal of the college is to promote learning and intellectual achievement in the students, it cannot ignore the affective and cognitive mental health factors which directly affect how and what the student learns in school. If the college really cares about educating as many as possible of its annual intake of students, it cannot afford to overlook the mental health factors. It is probable that in half or more of all the flunkouts and dropouts, psychosocial difficulties are an important cause of the failure. Farnsworth (1959), a foremost authority on college mental health, asserted that in some institutions the proportion of students who leave college because of emotional conflicts is considerably more than half. Summerskill (1962), in his excellent review of studies on dropouts from many institutions, concluded that the majority of students leave college for nonacademic reasons. He added that among dropouts,
ascribed by college records to "academic failure," there are many cases in which the underlying problems are psychological, parental, social, or financial. King (1964) reported that dropping out of college is most often a symptom of some kind of emotional conflict as well as the inefficient utilization of a social resource. Putting the label psychosoeial difficulties on a million or more of the annual flunkouts and dropouts from college may sound radical. Some educators may also feel skeptical about whether anything can be done about it. Their knowledge about people with such problems may make them feel that it is not a matter for schools to become involved with on a large scale. "We are not mental hospitals or clinics," they may say. But when it was stated that half the dropouts have psychosocial difficulties, it was not meant that these are severe cases, requiring long, expensive treatment. Colleges need not be turned into mental hospitals; but colleges can be made social institutions with an educated heart. A recent editorial in School and Society (Brickman, 1965) stated: Student sources have attributed departure from college to various reasons, such as personal problems and dissatisfaction with the faculty . . . . There can be little doubt that the administration of colleges and universities cannot be deemed a success under circumstances of large-scale dropouts. . . . What is needed is constant vigilance to note, at the earliest opportunity, those students whose difficultiesmight lead to an early departure from the college. [p. 3] These comments by a prominent educator point toward the need for preventive psychiatry on the campus.
EARLY, SHORT-TERM THERAPY Prevention in psychiatry is a relatively new concept. For most of its history, psychiatry has been preoccupied with prolonged treatment of people whose mental funetion has been rather extensively impaired. Many people associate psychiatry with scores of hours of analytic therapy in the office or months in a mental hospital. However, in recent years, the focus of psychiatry has shifted to an emphasis on
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prevention. It is recognized that our society point of view. Not that there are always can never provide enough psychiatric per- solutions--we are not prophets or masonnel and facilities to give really adequate g i c i a n s - b u t usually support and help can therapy if we wait until impairment is be given to the problem-solving abilities of severe. Then personality malfunction has the student himself so that he is better able reached the point where the patient requires to cope with the conflicts and arrive at a many hours of professional time in an office modus operandi. Particularly with compeor hospital and has to have a thorough re- tent help in the incipient stages, the new construction of a mental-emotional life equilibrium may be better than the old. which has been thrown into complete dis- The student may learn and change in a array. constructive direction so that his ability Thus one of the main objectives of to meet problems may be strengthened. modern psychiatry has become prevention This kind of approach---early recogniof such severe impairment. This prevention tion and short-term therapy with acute recan be accomplished chiefly by the early actions has been aptly named crisis counrecognition and early treatment of emo- seling. Even as little as one or two tional problems. In the beginning stages, interviews can be helpful and a majority before the disintegrating effects of anxiety of college students with psychiatric proband depression produce a spreading, spiral- lems can be significantly aided with no ing pathology, many psychiatric problems more than five visits. College youths are can be treated effectively with short-term generally not so resistant, their personalitherapy. Therapy begun early can stem the ties are not so fixed, and they are more tendency toward regression. It can usually open to new understanding of themselves keep the healthy aspects of the personality and their struggles in life as compared with working fairly well while the sick part is adults. out for repair, so to speak. Thus, a complete A SOCIALMOVEMENT breakdown does not occur. The way back to optimal, healthy functioning is preCollege is an ideal locale for preventive served. psychiatry and crisis counseling. It is posIn college students one can see the value tulated that the future psychiatric casualties of the principle of early recognition and as well as the educational losses in our short-term therapy quite clearly. Students country could be significantly reduced by so often come to the office of a professor, a programs of preventive psychiatry in our dean, counselor, or a health service doctor universities. The cost of such psychiatric with acute reactions to some recent stress. services would be substantial but the cost They have failed an exam, lost a boy friend, to our society of incomplete educations and clashed with parents, been ostracized from later prolonged treatment of severe mental the in-group of their peers, or suddenly illness is staggering. discovered something about themselves that Realization of this great cost in both has shaken the foundations of their self- human and financial terms has been image. It is hardly necessary to list the registered at the highest level in our nation many kinds of acute problems which de- in recent years. President Kennedy, in 1963, velop so often in students. The present delivered a major message to Congress on purpose is rather to stress the urgency mental illness. This led to the enactment of which is felt by the student: the common the Community Mental Health Act of 1963 feeling that he must find some solution, and a similar hill on Mental Retardation in some relief from the situation. 1964. Federal legislation in the anti-poverty Often this is seen by older heads as the field is also related. It recognizes the effects impatience of youth. And so it is. Youth is "of social disorganization, unemployment, intolerant of acute unhappiness and im- and underprivilege on individual and fampatient for relief. This can be turned to an ily health. The recent massive federal aid advantage, however, from the mental health to education similarly reflects an awakening
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to the damaging impact of cultural and educational deprivation. All these add up to a major social movement in our time toward an effort to reduce mental, social, and academic disability. With children in elementary and secondary schools, the interference with school progress by social, economic, cultural, and family factors is being emphasized. Furthermore, the significance of successful school experience for adult adjustment is recognized. Heroic efforts are under way to enable potentially disabled, handicapped children to develop fully and to minimize their handicaps. Perhaps it is time that colleges also awaken to the need for greater efforts to salvage the potentially disabled, i.e., those who have the basic prerequisites for higher education but who flunkout or dropout. Yet, there has so far been little sign of a comparable broad program at the college level to deal with the interference with school progress by social, psychological, and family factors. Only here and there do a few universities have first-rate mental health services and adequate preventive psychiatry programs. What can colleges do about it? More especially, what can they do without devoting to mental health large sums from their already strained budgets? A mental health clinic with an adequate staff within the framework of the health service or other appropriate division of the college is the first step. A staff sufficient to provide crisis counseling and short-term therapy need not be prohibitively expensive, especially when measured in terms of its benefits. One way of keeping the cost manageable to the college is to charge all students a few dollars per semester specifically for this service. Another way is to charge a fee only to users, i.e., students and their parents who obtain diagnostic and treatment service.
measures. These need the unambivalent support of the faculty and administration. The next step is sensitization of the key authorities in the college community to student emotional problems (Barger & Hall, 1963). Many of these key people are already quite aware of the kinds of crisis which occur in students. Most health service doctors and nurses, vocational and educational counselors, advisors and deans are experienced and alert to student conflicts and troubles. However, some key figures in the college structure may not be very sensitive and skillful in their contacts with troubled students. Others, though sensitive, may not feel competent to do "crisis counseling" without some training. Thus, conferences for key faculty and administrative otScials conducted by the mental health service are needed to educate them to greater perceptiveness and ability in handling students in distress. One of the questions which would be dealt with in such conferences is which kinds of problems warrant referral to the mental health service? Actually many student troubles can be managed successfully by these key college people. But a mental health service could provide consultation in those cases of a more serious or complex nature. The college psychiatrist does not really want to take over the counseling of every troubled student. Obviously, he would soon be swamped. Rather, he and his mental health team can multiply the usefulness of their special knowledge and skills if they give consultation to the other key people who do counseling in the college. The early recognition of the student with the potentially serious problem and his prompt referral for early treatment by the mental health service would thus be facilitated. The student with the less serious difficulty would receive prompt remedial attention by other faculty, buttressed with consultative support by the mental health profesADDITIONAL STEPS TOWARD PREVENTION sional. A next important step is actively seeking But a mental health clinic, adequately out maladjusted or troubled students. staffed, is only the first step. The applica- Instead of waiting until the student comes tion of the principles of preventive psy- to someone with his problems, methods of chiatry involves a number of additional identifying students in distress would be
JOHN E. KYs.m developed. Some will not come to anyone for help until they are in desperate straits or until the trouble has been brewing for a long time. No method of identification is perfect; but the use of psychological screening tests, reports of faculty and dormitory counselors in contact with the student, even routine evaluation of all students whose grades are down can detect many of the college youth who are developing problems. A good number of problems thus identified can be prevented from progressing into major psychiatric difficulties and quite a few would-be college dropouts can be helped to continue and complete this vital stage in their life career. One further resource for identification of troubled students, usually overlooked by colleges---even those few which do have psychiatric services and preventive programs--is parents. At the University of Illinois at Chicago Circle, there is an awareness of this resource because it is a commuter university (Kysar, 1964). The students are not living on campus but with their own families. We are finding that parents can be among the first to notice signs of disturbance, can notify the health service, and can give valuable information about the current problem and past history of the student. We are experimenting with drawing parents into conjoint therapy along with the student. This type of approach appears promising when, as frequently is the case, a major part of the student's difficulty is conflict with his parents. If only the student is seen, only part of the problem is being attacked. In fact, progress may be blocked by subtle sabotage of the student by neurotic parents or a stubborn impasse between student and parents. In many colleges, part of the student population commutes and another part has parents living not far away so that this parent resource may be worthwhile. Even those some distance away, through letters, vacation, summer contacts, etc., may be aware of disturbances in the student. Not many schools give parents any encouragement to bring these to the attention of the college. Most parents are confused about what to do and where to turn.
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They would welcome the chance to bring the problem to someone at the college, even if special fees were charged. A NEW ROLE FOR THE PSYCHIATRIST
In the foregoing program, based on the principles of early case-finding and prompt treatment, the psychiatrist is departing from his traditional role in clinical practice. In practice he restricts his interest to those individuals who come to his office, clinic, or hospital for diagnosis and treatment. But in the college preventive program he accepts responsibility for helping all students, not only those who have defined themselves as having an emotional illness or maladjustment. Thus, the psychiatrist is concerned with those students who are not yet suffering any symptoms or signs of mental disorder. He directs this concern toward investigating and reducing harmful influences and toward increasing the adaptive capacity of students so that the rate of new cases of emotional disorder, and the rate of failures or dropouts, will be lessened. Special effort may be given to certain high risk groups, which may be the focus of particular harmful influences. For example, the college psychiatrist may realize that a certain minority group in the school is socially rejected and ostracized. Devising ways to integrate this group with the main body of students on the campus may nip in the bud some of the developing cases of maladjustment. Actually, some excellent preventive approaches have already been developed on certain campuses. Carefully planned freshman orientations and systems of using upper classmen as a corps of big brothers or sisters are applications of sound social psychiatric principles which should be expanded. For vocationally-oriented students more work-study programs, which integrate education with the world of business and industry, are needed. For social science majors community action projects, which bring students face-to-face with problems of people, are commendable in terms of personality growth as well as incentive for
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education. There will never be enough mental health professionals (and probably not enough other faculty advisors and counselors either) on most campuses to provide one-to-one therapy for all the students who need help. Therefore multiple approaches, including efforts to improve the milieu and enhance the mental health of the community of students, are indicated. This brings us back to the important point that, in carrying out prevention on the campus, the psychiatrist will have a role which is not just in terms of troubled individual students. He will consider the entire field of forces operating in the college community as they affect the mental health of students. His methods will include direct diagnosis and treatment of some individuals. In addition, he will indirectly foster the contributions of other caregiving persons and services of the institution through individual and group consultation with them. As a final step, the psychiatrist may eventually reach a position of acceptance by the leaders and administration of the college so that those who establish the policies, which govern the functioning of the organization, may consult him. They may ask his views on matters which pertain to the mental health of the students. The mental health implications of their decisions will be taken into account before putting into effect a course of action which may have some repercussions on the welfare of students. In this latter step, the psychiatrist and his mental health team must have a thorough understanding of the particular college. They must know it as a social system with its peculiar allocations of status and role, its patterns of leadership in students and faculty, its pathways of communication and balance of power, the values and goals of various groups, its history and evolution with special attention to the ways in which changes have occurred (Caplan, 1964). In all this, the objectives would be the modification of the interaction of forces which influence student behavior. This modification is aimed at decreasing the number of disturbed, maladjusted, and failing students. The goal is to encourage,
by all possible means, those who are faltering so that they may have support from their milieu. This will enable more of them to cope with their problems successfully. They will soon stand on their own feet and in turn contribute to other faltering students and to the college community. At the risk of overstating the case and sounding as if the idea is that everyone should graduate from college and that no nongraduate could ever accomplish anything, it will be stated that every failure is a missed opportunity for a greater contribution to our society. As the President (Henry, 1965) of the University of Illinois recently said, "We must constantly remember that the statistics cited are thousands of human personalities, thousands of individual careers which should be brought to fulfillment. . . . " REFERENCES BARGER, B. & HALL, E. Higher education and mental health. Proceedings of a conference at the University of Florida, September, 1963. BOWER, E. M. Primary prevention of mental and emotional disorders: a conceptual framework and action possibilities, elmer. 1. Orthopsychiat., 1963, 33, 834-848. BRICKMAN,W. W. College enrollments and dropouts. Sch. & Soc., 1965, 93, 3. BaooE, W. R. Approaching ceilings in the supply of scientifie manpower. Science, 1964, 143, 313. CAPLAN, G. Principles o1 preventive psychiatry. New York: Basic Books, 1964. FARNSWORTH, D. L. We're wasting brainpower. Nat. educ. elss. 1., 1959, 48, 42-44. HENRY, D. D. The state of the university, 196465. Faculty Letter, Univ. of Illinois, January, 1965. KINC, S. H. Emotional problems of college students: facts and priorities, elmer, ass. univ. pro/. Bulletin, 1964, 50, 328. KYSAR, J. E. Mental health in an urban commuter university. Arch. gen. Psychiat., 1964, 11, 472-483. I{IESMAN, D. & JENCKS, C. The viability of the American college. In N. Sanford (Ed.), The elmerican college. New York: John Wiley,
1962. SUMMERSKILL, J. Dropouts from college. In N. Sanford (Ed.), The elmerican college. New York: John Wiley, 1962. Pp. 628-641. WHITTINGTON, H. G. The ethical responsibility of the mental health practitioner to his college. Paper read at Amer. Coll. Hlth Ass., Kansas City, April, 1964.
