The university’s role in shaping students’ experiences of mental health and distress.
Chapter in Mahon, A. (2022) The Promise of the University: Reclaiming, Humanity, Humility and Hope. Singapore, Springer.
In ‘Confronting the Dark Side of Higher Education’, Bengtsen and Barnett (2017) carefully draw into the foreground a number of instances of darkness within the university. Enveloped in this darkness are ‘challenges, situations, reactions, aims and goals, which cannot easily be understood and solved by agendas of quality assurance and professionalism of higher education’ (p.114). These are ‘less easy to catch in the spotlight and define in functional and explicit terminology’ (Bengtsen & Barnett, 2017, p. 115). Moved by the foregrounding exemplars of Bengtsen and Barnett, and the accounts of a number of university students who shared their experience of navigating higher education with a mental health difficulty, this chapter aims to explore the darkness that occupies the space between the ‘functional and explicit terminology’ of mental health, or ‘disorder’, and lived experience. It begins by orienting us to the mechanistic world view quietly inherent within our efforts to respond to the ‘crisis’ of mental health, both on campus and society, and the kinds of ‘problem/solution’ thinking that such a world view, often helpfully, engenders. Alongside this world view lies the story of John1, a second-year undergraduate student, whose story offers a powerful insight into a more contextualised world view or conceptualisation of mental health - one that allows for the elaborate range of circumstances and adversities that led him to struggle with his mental health. This chapter does not aim to ascertain whether one world view is more ‘right’ about mental health than another but rather to demonstrate the darkness that is created in the prizing of one world view, one truth, over another.
Mental disorder and mechanism
The total cost of disorders of the brain [in Europe] was estimated at €798 billion in 2010. Direct costs constitute the majority of costs (37% direct health care costs and 23% direct non-medical costs) whereas the remaining 40% were indirect costs associated with patients’ production. [...] In terms of the health economic burden outlined in this report, disorders of the brain likely constitute the number one economic challenge for European health care, now and in the future. (Gustavsson et al., 2011, p. 920)
In 2018, Director-General of the World Health Organisation, Dr Tedros Adhanom Ghebreyesus, launched the Special Initiative for Mental Health (2019-2023). The aim of this special initiative is to enable ‘all people achieve the highest standard of mental health and well-being’ through, policy, advocacy, a focus on human rights, and funding to ‘scale up quality interventions and services for individuals with mental health conditions’ (WHO, 2018, p. 1). The development of the special Initiative was prompted by growing concern at the large number of people suffering from mental disorders worldwide. The WHO (2001) estimates that 25 per cent of people will experience a mental health condition at some point in their lives and that, globally, 264 million people are affected by depression alone (GBD 2017 Disease and Injury Incidence and Prevalence Collaborators, 2018). Other research presents similar findings. Prof Ronald Kessler and his colleagues conducted a household survey of over 9000 people living in the US and, using a DSM-IV diagnostic interview, determined that in any one year, 26.2 per cent of American adults reported symptoms that would qualify them for a diagnosis of mental disorder. That amounts to more than 57 million Americans with a mental disorder in any given year (Kessler et al., 2005). The authors go on to conclude that ‘about half of Americans will meet the criteria for a DSM-IV disorder sometime in their life, with first onset usually in childhood or adolescence‘(Kessler et al., 2005) .
Universities too have reported increasing numbers of students with mental disorders. In the US, the American Psychological Association (Eiser, 2011) have described as ‘alarming’ the increase in the number of students seeking help for serious mental health problems at campus counselling centres. While they describe the increase as a ‘crisis on campus’, the APA also highlight how the percentage of students with mental disorders is ‘probably even higher’ (Eiser, 2011, p. 18) owing to the suspected number of struggling students who do not come in contact with campus health centres. Ireland too has seen an increase in the number of students with diagnosed mental health conditions registering with university disability support services. During the 2009/10 academic year, students with mental disorders represented just 2% (n=111) of students registered with their third level disability support service (Ahead, 2010). Within just eight years this proportion had increased to 15.1% (n=2217) with mental health difficulties second only to specific learning disabilities such as dyslexia in the numbers of students registered for disability support (Ahead, 2018).
Rose (2006) notes that, where once mental disorder was counted in terms of the population of mental hospitals, today such counting is ‘no longer confined by the walls of the asylums’ (p.486). In his 2006 lecture given at the Institute of Psychiatry, Kings College, University of London, Rose attempted to explore some of the reasons for the increasing proportion of the population reporting, or meeting the criteria for, mental disorder. He proposes five interlinked theories for what he calls the ‘expansion’ (p.474) of mental disorder. The first theory is that we are quite simply more mentally disordered than in the past or, as he puts it, ‘there is just more of it about’ (474). Second, Rose suggests we may be more aware of mental disorder and better at recognising, describing and diagnosing it. The language of mental disorder is more available to us. Third, he points to an increase in what sociologists term ‘moral entrepreneurship’ or people who want to address ‘a neglected source of misery only they can identify and conquer’ (p.474). Rose’s fourth point relates to what he terms ‘today’s favourite culprit’ ‘Big Pharma” and their role in ‘distorting our perception and treatment of mental disorder’. It is Rose’s fifth point, however, that is perhaps most relevant to this chapter – that is the reshaping of our discontents in the form of the dominant biomedical narrative or what he refers to as the ‘psychiatrization of the human condition itself’ (p.474). The reframing of human experiences, thoughts, feelings, and/or difficulties as signs or ‘symptoms’ of illness or disorder. This reshaping of discontents in a psychiatric or biomedical form is marked, in Rose’s view, by a ‘problem/solution complex’ (p.480). Using the example of depression, Rose deconstructs the problem/solution complex as one which:
[...] simultaneously judges mood against certain desired standards, frames discontents in a certain way, renders them as a problem in need of attention, establishes a classification framework to name and delineate them, scripts a pattern of affects, cognitions, desires and judgements, writes a narrative for its origins and destiny, attributes it meaning, identifies some authorities who can speak and act wisely in relation to it and prescribes some responses to it (Rose, 2006, p. 480).
Thus Rose (2006) presents dominant biomedical constructions of ‘depression’ as narrative efforts to simplify the complex. In the most straightforward terms, these efforts embody ‘ways of making aspects of existence intelligible and practicable’ (p.480). It is perhaps no surprise, therefore, that the policy used to govern universities’ response to the mental health needs of students reflects the intelligible and practicable nature of this more ‘mechanistic’ (Pepper, 1942) world view.
University mental health policies predominately reflect the “best practice” (Department of Education and Skills, 2019, p. 14) ‘Continuum of Support’ model for identifying and responding to distress amongst students (National University of Ireland Galway, 2008; University College Cork, 2019; University College Dublin, 2019). Consisting of either three triangular tiers, this model recognises the needs of ‘all students’ (the ‘all’); ‘at risk students’ (the ‘some’); and students with diagnosed mental disorder (‘the few’). Owing to the increase in the number of students diagnosed with mental disorder, a group purported to represent ‘the few’, a greater emphasis has been placed on prevention and early intervention in university environments in order to inhibit the movement from level one (all students) to level two (‘at risk’) and/or to level three (mental disorder).
Evidence from epidemiology suggests that in the case of common disorders, the use of only individual or targeted approaches (i.e., treating those with disorder or preventing disorder in those at high risk) will have little effect on reducing the overall number with disorder. There will always be plenty of new cases of disorder to replace those who have been helped.(Huppert, 2009, p. 108)
Prof. Felicia Huppert, in her 2009 paper entitled ‘A new approach to reducing disorder and improving well-being’, promotes the ‘prevention is better than cure’ approach to mental disorder. Huppert’s theory is that if we can improve the mental health and well-being of all people, what she refers to as the ‘population mean’, a smaller proportion will go on to develop mental disorders. Her suggestions for improving the population mean include programmes for ‘the development of positive attitudes and behaviours and of resilience in the face of adversity’, ‘programs [sic] which reduce stress in the workplace’ and working with the media to ‘provide more positive role models who display valued character strengths and prosocial behaviours’ (p.110).
This emphasis on resilience-building is reflected in Ireland’s national policy for mental health ‘Sharing the Vision’ (2020):
Positive mental health builds resilience so that people can adapt to challenges and adversity, get the most out of life and maintain a positive sense of wellbeing and self-worth, combined with a sense of control and self-efficacy. [...] It involves moving control towards the community through educating the wider public about mental health and wellbeing and mental health difficulties, and providing structural supports that encourage resilience.(Department of Health, 2020, p. 25)
Resilience building, educating the public and programmes to reduce stress in the workplace, like the ‘problem/solution complex’ (Rose, 2006), are components of a wider, mechanistic, world view (Pepper, 1942). With roots in Cartesian philosophy, the mechanistic world view, as described by Pepper, has played a dominant role in shaping Western culture, values, and scientific thought (Lyddon, 1989). Mechanism, in the meta-physical sense, is the belief that natural wholes (particularly living things) are like complicated machines composed of discrete parts related to other parts in some systematic way. This world view sees events as the products of the transmittal of forces (Pepper, 1942; Sarbin, 1986). As Sarbin (1986) points out, ‘modern science has taken this world view as its metaphysical foundation – a view that supports the scientist’s search for causes’ (p.6). Causes, or reasons for distress, enable the development of solutions. One solution for increasing rates of mental disorder is prevention and early intervention. The development of resilience. Workplace stress reduction programmes. While the ‘normative assumption’ of a mechanistic world view may be that the uncertainty around the causes of disorder and distress ‘will be overcome by the eventual discovery of new findings, rules, laws, methods, procedures, experiments’ (Adamson, 1997, p. 135), we are left with the reality that ‘in most cases, no one is sure precisely what the cause of a mental health problem is’ (MIND, 2016, p. 12; Thomas, 2014).
Furthermore, while we may not know the precise cause of mental disorder, it is clear that ‘many common mental disorders are shaped to a great extent by the social, economic, and physical environments in which people live’ (World Health Organization and Calouste Gulbenkian Foundation, 2014, p. 8). The conditions and context into which one is born shape, in no small measure, the likelihood of experiencing mental distress. The role of context, particularly socio-political context, in shaping mental health, is evidenced most vividly in the story of John – an undergraduate student who shared his story as part of hermeneutic phenomenological study of the nature and meaning of psychological distress amongst university students in Ireland (Farrell, 2017).
“I’m trying to give life a go”: John’s story and contextualism
John is a twenty nine year old undergraduate university student. He describes growing up in a household where both parents were unemployed and on social welfare as growing up in ‘the underclass of society’ (p.32). His mother had schizophrenia which went undiagnosed until John was 19: ‘that was horrendous living with that and not knowing what was wrong with her’ (p.4).
She used to constantly talk to herself and talk to other people in the kitchen or in the sitting room where there was no one there. She used to turn her back to us and scream real loudly and scream at us to leave the room because she was having a conversation with people and bang the doors to put us out of the kitchen or sitting room because she was busy talking to someone even though there was no one there (p.31).
In addition to his mother’s schizophrenia, both John’s parents had significant alcohol problems.
Sunday, Monday and Tuesday were very depressing days in the house, always were very depressing days. (p.4)
His mother’s mental illness, parent’s unemployment and alcoholism and the family’s dependence on social welfare, made for an upbringing defined by ‘poverty and deprivation’ (p.4). John, his parents and two brothers lived in a small three-bedroom semi-detached house in a council estate. He described how the house was ‘over-crowded’ (p.4), a situation compounded by his grandmother moving in when John was a little boy. John’s grandmother ‘had her mental health issues as well’ (p.4) which John says led to her sexually abusing him and his older brother when they were kids. Over the course of the interview John provided some graphic examples of the enormity of the neglect and abuse he received as a child which will not be recounted here. Today he feels ‘angry’ that his teachers and the many social workers who regularly called to the house ‘didn’t spot anything’ (p.31).
I think deprivation or abuse, they are too nice of words to describe what we went through.
Independence was John’s main goal in life. He described how, as a child he dreamed that he ‘would become this independent man with enough money to be independent, not wealthy, or rich or that, but just secure and safe in one’s self’ (p.25). He started working in a local factory at the age of 12, added a second job in a bike shop at thirteen and by the time he was sitting his Junior Cert exams John was working seven days a week between his two jobs. At 16 John got a job on a building site, often skipping school to go to work. After work John would go to the pub with the ‘older builders’ (p.8) he worked with.
By being able to go to the pubs and drink regularly like I thought I was a grown man or an adult by the time I was 15 or 16. It made me feel good. I wasn’t on top of my school work. I was never really good at school and the only place I really felt strong and good and confident in myself was when I drank a lot (p.9).
By the time he was 22 John was living alone in Dublin ‘with no friends, isolated and no qualifications or no education’ (p.12). It was during this time that he first attempted suicide:
The hopelessness of life - why struggle through all this? What was the point? What was the point of all this torture? You know, constantly not having money, having no support and not knowing how to live, not knowing how to integrate and seeing, just seeing people that I went to school with go on to college and get on with their lives whereas I was really stuck in a rut (p.12).
It was John’s G.P. who first referred him to the local specialist mental health service. After meeting with the psychiatrist John was diagnosed with depression and prescribed anti-depressants. While he acknowledges the medication ‘worked’ (p.12), John felt that it was failing to address the issues underlying his hopelessness and depression.
I started taking the tablets but, OK they did help, but my circumstances were still very hard (p.19).
It was the money he received as compensation from a road traffic accident that offered John a means of changing his circumstances. That money gave John ‘the power to be able to go and have a hot lunch everyday’ and live in ‘warm, clean, quiet’ accommodation where he is ‘never cold, I’m not living in dampness and I have money for food’ (p.20). It was in one such apartment that John met a housemate he would later describe as a ‘mentor’ (p.29). This man was ‘fascinated’ (p.6) by John’s life and his view of the world and it was he who first suggested to John he use his compensation money to ‘try going back to college’ (p.6).
He really emphasised the importance of education that it’s like gold, that it doesn’t matter whether you have a house, a car, what you have. He said to me ‘If you get your education nobody can take it away from you’ and that’s why I want to get it, I want to get something that nobody can take away from me (p.29).
John’s friend suggested he wasn’t ‘able for college’ (p.29) right away but that he should begin with a level four qualification and ‘build it up’ (p.29) from there. John successfully completed his level 4 certificate, was offered a place on a university access programme which, in turn, led him onto his honours degree course at that university.
It was whilst doing the first course that John was diagnosed with dyslexia. He says he ‘always knew’ that something was wrong, that he ‘just wasn’t able to process information’ (p.18) at the same rate as those around him. While knowing what was wrong has enabled John to seek support with his reading and writing, his dyslexia ‘bothers’ him at times: ‘Not being able to keep up with what is being communicated can be hard in life, hard in my day-to-day activities’ (p.26).
He feels that his undiagnosed dyslexia negatively impacted his schooling as a child and reduced his confidence in his ability to learn and do well in school. When studying on the university access programme, John says he ‘always got positive feedback’ (p.22) which really boosted his confidence: ‘I suppose when you’re hearing those words, positive words, for nine months... I said to myself ‘actually people see me differently’ and ‘I can do this’, you know? It made a big difference’ (p.22).
John describes as essential the support of one university GP with whom he has built a relationship. He continues to ‘drop into’ (p.20) this G.P. every few weeks for a chat which he feels ‘is really maintaining my mental health’ (p.21). He says that without this, and the other supports he receives in college, his ‘life would fall apart within 24 hours’ (p.20). He puts his success in college ‘down to the people around me. I really believe in support. I’m merely an individual that can’t function without the help of other people’ (p.23). He believes that other students who have had opportunities that he never had growing up, take the support they have around them ‘for granted’ (p.23) whereas for John the smallest amount of support ‘makes a big difference’ (p.28).
Education, for John, is a way of ‘breaking the circle’ (p.16) of ‘poverty, hopelessness and helplessness’ (p.7). This raises the stakes, placing John under additional pressure to complete his degree: ‘I don’t feel I have broken it yet because if I don’t make it through college it’s back to social welfare and back to the crap houses and bad health, you know?’ (p.16). While he struggles at times, John is thriving on the support he is receiving and is ‘really enjoying’ his time in college: ‘I really like this new life’ (p.24).
I don’t want their [his parents] lives, you know? I don’t know what my life is going to turn out like or what way my life is going to go but at least I’m trying to give life a go (p.16).
John’s experience can be, and was, shaped as a mental disorder. He was diagnosed with depression and prescribed anti-depressant medication The doctor didn’t do anything about that [poor living conditions], no one did anything about that, he just gave me medication (p.13).
While he admits that ‘OK, taking tablets may have worked for me’, he is keen to attribute his success to the financial boost offered by compensation for an accident he was involved in, and the resulting improvement in living conditions, coupled with the support of a handful of individuals he met along the way.
What has changed from back then to now is I am using that compensation [money] that I got from that accident to live in [name of city] and to educate myself. That has given me the money, given me the power, to be able to go and have a hot lunch every day and I’m living in accommodation I suppose what you would call middle class accommodation where it’s a gated apartment block and my housemates have gone to college, both of them. It’s a warm, clean, quiet, stable environment and I have a routine going. I’m never cold, I’m not living in dampness and I have money for food, and I have the supports around me here in college. Without those supports my life would fall apart within 24 hours (p.13).
In spite of everything he has overcome and his incredible efforts to ‘give life a go’ (p.16), John is clear that, if it doesn’t work out for him, ‘society will say it’s your hard luck’ (p.9).\
It doesn’t matter to society. Society will say it’s your hard luck, that’s your problem, you know. [...] All my experiences, my upbringing and that depravation and sexual abuse and neglect and emotional abuse, it means nothing. It just keeps you down. It leaves you at the bottom of the pile, you know, you can talk about it all day, you can talk about it with other people who have gone through the same experiences, but at the end of the day you are at the bottom of the pile (p.9).
John’s story offers raw insight into the manner in which our lives are shaped by context – particularly early context. It might perhaps, be less challenging to focus on John’s mental disorder, judge his ‘mood against certain desired standards’, delineate his distress and ‘prescribe some responses to it’ (Rose, 2006, p.480), than embrace the adversities and abuses John has suffered throughout his life and acknowledge the failures as complex and social rather than intelligible and individual.
Adopting what Pepper (1942) describes as a contextual world view, with its root metaphor of history, or as Sarbin (1986) proposes, narrative, can be disconcerting and discombobulating: ‘to those steeped in the traditions of mechanistic science, traditions that emphasise order, predictability, and causality, contextualism at first appears chaotic’ (Sarbin, 1986, p. 6). It induces a degree of existential uncertainty with which institutions, such as universities, struggle. Indeed, as the Clinical Psychologist and activist Jay Watts (2017) explains, ‘citizens who consider themselves ill are easier to manage than people who consider themselves maddened by toxic families and injustice’. In framing discontent and distress solely in terms of disorder, the ‘cause’ or ‘problem’ can be located within the individual and deflected away from the context within, and through, which that individual exists.
There is little political will to combine increasing mental distress with structural inequalities, though the association is robust and many professionals think this would be the best way to tackle the current mental health epidemic. (Watts, 2017)
These arguments in no way intend to dimmish the value, for some, in framing distress in terms of biomedical illness, but rather to highlight the plurality of world views by which experiences of mental distress might be framed and understood. Rather than forcefully trying to manipulate people’s distress into pre-cast disorder categories or treatment models, this chapter argues that the focus should, first and foremost, be on validating the lived experience of the person who is suffering. Some might choose to frame their distress as mental disorder, others the effects of trauma and/or chronic social inequalities and deprivation. What matters is not which world view or conceptualisation is more ‘right’ but rather which is more useful for the individual in framing and making sense of their experience of distress. The challenge for the university lies reconciling this plurality with its need to ‘evaluate, assess, manage and organise’ (Bengtsen & Barnett, 2017, p. 116). To create space for all world views, including those which appear ‘chaotic’ and to foster a culture of acceptance as well as institutional efficiency.
Acceptance, after all, is the great friend of good mental health just as writing over one another’s truth is the great enemy. (Watts, 2017)
This chapter has aimed to ‘catch in the spotlight’ (Bengtsen & Barnett, 2017), the crevices where stories, such as John’s, reside amidst the structures and mechanisms of the university as an institution. It has attempted, in contrasting two world views of the same phenomenon, to highlight the potential for experiences such as John’s to be enveloped by efforts to make ‘aspects of existence intelligible and practicable’ (p.480). This chapter calls for the courage to sit with the unintelligible. For the university to create space for more than one framing of mental disorder, more than one world view. It invites us to ‘plunge into a kind of darkness’ (Levinas as cited in Bengtsen & Barnett, 2017, p. 120) and discomfort that the stories of students such as John present and resist the urge to re-shape them in ways that suit the institution more than the individual. This chapter, as so many in this collection, invites us to sit with, and make room for, the darker, more context laden, aspects of human experience.
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