Mental Health within Higher Education: Challenges and Recommendations
Reprinted with permission.
In the throes of madness, people need a form of peace to hold on to like an anchor while they discover their innermost serenity. Even in their most tormented nights, consumers armed with the right skills, resources, and support can identify techniques to self-manage their internal chaos and external dysfunction. This presentation will give readers with mental illness the tools necessary to self-manage their own frustration tolerance throttle, and will also provide trauma- and peer-informed training material to practitioners to help patients regulate their thinking and feelings while tuning into their mental status and internal barometer for healthy living after discharge from a state hospital center or other mental health facility. Consumers should feel empowered to live peacefully and independently, regardless of their chosen path to serenity, even when the world before them becomes too chaotic to live in without medical or psychiatric intervention.
I often hear, working in mental health and also as a person carrying a diagnosis, a term that is both misused and overused, infantilizing, and laden with ableism: “high-functioning.” Clinicians use it to categorize and label people who they feel are doing well and have their diagnosis managed. But the concept is a myth, and one that is as misleading as it is dangerous to consumers labeled by it. Sure, some folks carrying a mental health diagnosis are managing just fine in their lives. But this is an entirely different phenomenon. People carrying a diagnosis who are not symptomatic are instead “in remission.” The term “high-functioning” does not appear in the DSM-5. Instead, the DSM uses the expression “in remission, partial remission, sustained remission etc.” to describe the status of people’s active or inactive symptoms.
The term “high-functioning” doesn’t carry any stable meaning. From clinician to clinician, due to the term’s inherently valueless status, it will shift and take on a whole new meaning to inaccurately and ineffectively describe a mentally ill person’s general situation. Practitioners use it to talk about a patient’s capacity to work, perform ADL’s (Activities of Daily Living), relate with others, and generally, to describe how “well” a person is doing.
But “well” isn’t a clinical term either. So why do people continue to use the term “high-functioning”? I suspect it is rooted in the application of the DSM-4 when there was once a GAF (Global Assessment of Functioning) to evaluate how a person managed across different domains of living and how they “function” in these areas. A low score gestured to a person struggling to perform basic life functions and a high score signaled that the consumer was managing their illness well. The GAF was not only used to score and diagnose, it was used by government agencies and disability determinists to rate a person’s general prognosis, and even predict if they would need government assistance. A low score might mean a person carrying a diagnosis would receive disability payments, or a high score disqualify them from services.
This is where the myth began to emerge in the field of mental health. The GAF score’s application and implementation in clinical practice was as rife with inaccuracies and misuse as it was unhelpful in determining the real clinical picture of the person diagnosed. Inter-rater reliability between clinicians was low, and the scores were often unreproducible from the same clinician using the scale multiple times, evaluating the same person’s health at different times with the same health status and client reporting.
When I was talking with a therapist years ago who was still using the GAF to evaluate my own health in a treatment plan review, I would joke, “What is my GAF this time?” Since I was a clinician, and I knew the how ineffective and inaccurate the GAF score truly was, I would question my therapist’s score. If I was scored at a 70, I would say: “You know, I think I am really at 75,” and my therapist would clumsily go over the scale with me and we would pick out a number that seemed more representative of how I was doing. But this number was only a marker, as well as a lousy diagnostic tool which continued to be used by many government agencies to award people much-needed services like case management and housing services.
At the crux of it, the term “high-functioning” carries with it an assumption: that the person carrying the diagnosis is doing just fine. Clinicians, caregivers, family, and friends use this term to justify in many cases the untimely termination of assistance and the elimination of not only benefits but the enrollment of patients into programs to maintain their progress. The so-called high-functioning patients are left to their own devices when they have reached a point in their recovery where they can be independent. Many of them fall back into the system and become symptomatic because their programs, Medicaid, or disability is cut-off and they are left to navigate their lives without the help they have been accustomed to due to their condition. In many cases, chronic patients find their inactive symptoms become active again, and they may become even more symptomatic when they relapse. Those without services are at risk of going into “free-fall” because they aren’t connected to treatment anymore and are supposedly recovered. Often these are the patients who fall through the cracks of the system.
To change the system, we must fundamentally alter the language and the very meaning of words used in clinical practice. Once the language is stabilized and more accurately used to highlight a person’s clinical picture, we can begin to assimilate a new lexicon to talk and think about the way mental health treatment is handled by the experts and also by people with a vested interest in a loved one or family member.
Criminalizing Mental Illness
Many articles on the internet, in newspapers, and in mental health forums talk about increasing violence in the community stemming from inadequate mental health awareness, access to treatment, and laws surrounding forced treatment. Even more abundant is writing on people with severe and persistent mental illness in the corrections system due to a fundamental misunderstanding of their needs for rehabilitation. In some cases, the mentally ill are remanded to jail without offending due to bed shortages in psychiatric hospitals. Whatever the reason people with a mental illness intersect with the courts, and/or corrections departments, the manner in which law enforcement handles and interacts with the mentally ill must change. I am talking about the police, courts, judges, lawyers, and people charged with the processing of mentally ill people suspected to have committed crimes and thus, under the auspices of criminal justice system for rehabilitation.
There is also a rising number of articles on school shootings, violence in our university system, and other unfortunate incidents rooted in, again, a fundamental lack of awareness of mental health issues associated with students in general, and more importantly, the developmental and systemic underlying factors that explain why university students may be in crisis. Most traditional college students entering college between ages 17–19 have never have been diagnosed with a mental health illness. However, there is no question many people go undiagnosed in high school and suffer from depression, anxiety, and other serious mental health issues without treatment. These are students entering college without support services or insight enough into their mental health to get help when they need it since they have never been in crisis before. For most students living away from home for the first time in their lives, or just attending college in their own community as a commuter, research suggests the risk of having a new mental health disorder going undiagnosed during their college years is high, especially if they were never diagnosed in high school. For students with a previous diagnosis, I recommend securing mental health service early on and even before matriculation into college. Many treatment centers, in rural areas especially, have long wait lists for services, and treatment options are sometimes few and far between.
In my case, as a student in upstate New York at Binghamton University, I already had an existing diagnosis from high school. Suffering from some anxiety and depressive symptoms, I was advised to find services in college. The irony though, and the important lesson from my college experience, wasn’t that my existing illness went untreated. The problem instead was the emergence of a new diagnosable condition and totally new disorder: schizophrenia. In most cases of this disorder, the symptoms begin to activate in early adulthood, and for most traditional college students, these are the years that people are truly at risk of becoming sick.
I was connected to treatment already, aware of my existing illness, and knew how to get help when I needed it. But back in 2008, when my schizophrenia became activated, I wasn’t aware of my symptoms and their impact on my behavior and perception. I was an English major applying to graduate school, very eager to learn and connect with the professors of my classes in the English department. There is no question that I stood out among other students, if not for the large volume of time spent on campus and in the department offices, then for speaking with staff or walking around campus all day and into the night. As my condition developed, and I began to unravel, I was even more visible to the staff. I was in the department offices so often and behaving so bizarrely that the department contacted the dean and the university ombudsman to enact a set of rules and establish boundaries between me and the department staff.
Some staff members suggested I had a mental health problem, and indeed, I was sent for an evaluation to determine if I was safe to continue as a student, but, alas, I passed the evaluation, and returned to the classroom the same day more confused than ever, and frustrated and angry with staff for suggesting there was an issue with my behavior. In my eyes, I was simply trying to continue as a student after being rejected for further study in graduate school. I thought I was in uncharted territory, and I guess, in some respects, I was, because students who get rejected from graduate school are usually not already enrolled as a student in the college’s bachelor’s program and quite often, if they are, they do not continue their schooling upon completion of their degree. But I kept going, applying for non-matriculated graduate courses and other classes to stay connected to the university and figure out a path to acceptance into a graduate program. While retrospectively, even after my recovery, my logic doesn’t seem completely irrational, it was bizarre and distressing to the staff involved at the time. However, I still didn’t get connected to the treatment I needed so desperately at the time. Instead, one day, when I entered the department office, the graduate secretary of the English department called the police. Believing I was a victim, I didn’t think they would respond to her call. I was wrong, and within minutes, I was approached by the university police, who handcuffed me in the department corridor and walked me out of the building.
Very much visible and now on everyone’s radar, I found myself handcuffed to a pole in the university police barracks, crying uncontrollably, and very agitated. If my illness then wasn’t taken seriously by the department or university staff, it certainly wasn’t handled well afterwards by the police on campus. The charge was loitering, and the original document detailing the incident’s summary, crime, and participants is the image above this article’s title in this journal entry. It summarizes no real crime, just the mishandling of my mental health condition, and yet another missed opportunity for connecting this writer to a mental health service or intervention that could have identified my new condition before it worsened further. Instead, I was left to my own devices, feeling like a victim, and totally petrified of the staff on campus. Certainly, I was not going to go to them for help. Even If I thought I had a problem moving forward after being arrested, I wouldn’t go to staff to address it. I was left isolated, agitated, and totally without treatment, help, or an intervention by the university that could have halted the progression of my schizophrenia before full blown psychosis and state hospitalization.
On a global level, what happens to students who are not on the campus radar? These are the students I talked about earlier, the undiagnosed high school students at risk of going without treatment in college. Are these students, too, left to their own devices if they are in crisis on campus? These are the students I fear for, the students without a voice, support, insight into their own mental health, or access to treatment when the time comes. They may have anxiety disorders from stress, depression, and in cases like mine, schizophrenia, among a catalog of other conditions that college students are more at risk for and prone to due to systemic systems issues with treatment on campus and developmental organic risk for brain disease and mental illness. In my case I had a therapist, and still, my diagnosis went untreated and misidentified by school staff and my own therapist. I cannot imagine what might have happened if I didn’t have any help at all, or people observing my communication with school staff and reporting on my behavior at department meetings. While the way the department handled my situation was abysmal, it was still handled on some level. Indeed, there was some level of oversight, however clumsy, regarding the treatment of my condition by staff and my therapist in the community communicating and coordinating with the university. If I had gone without any assistance, like many students in college do, this article’s conclusion might have been different. But until colleges have adequate mental health services and approach individuals with a mental health diagnosis, or suspected diagnosis, with dignity and respect, students will continue to be the very first victim of the society’s criminalization of mental illness.
When I returned to the Binghamton University a year later as a graduate student in social work, I spoke with the staff of the English department and learned the very next year, another student had a serious mental health crisis. The staff informed me that this student’s situation was handled more appropriately, and that the extreme nature of my crisis and its unfortunate outcome had signaled to them that mental health crises require a different approach than when I was spinning out. We learn from our mistakes, at a macro level as a society and at a micro level as individuals. In the case presented here I would hazard to say mistakes were made by both the system at the university level and by individual staff involved with handling my situation in the department. There is no question events unfolding in Binghamton in 2008 and events that followed mirror a larger fundamental problem in our approach to mental health systemically in the higher education system and as people who intersect with the legal system as a result of their mental health diagnosis.
Reprinted with permission. Originally appeared in: Guttman, M. (2019, December). Mental health within higher education: Challenges and recommendations. Psychreg Journal of Psychology, 3(3), 50-62. DOI: http://doi.org/10.5281/zenodo.3558906.
About the Author
Max Guttman’s battle with Schizophrenia began at New London University in his last semester of college. Max was discharged from Greater Liberty State Hospital Center in July of 2008, after spending six months there. His recovery was swift, but not painless, and certainly difficult. Today, Max teaches Family Oriented therapy to social work students at Fordham University at Lincoln Center in Manhattan. Mr. Guttman blogs daily on his site mentalhealthaffairs.blog and for psychreg.org. Mr. Guttman has published several journal articles on recovery and mental health, and three books: University on Watch, Small Fingernails, and Wales High School. He is also a board member of the newspaper CITY VOICES. Max currently sits on the CAB committee (Consumer Advisory Board) for the Department of Mental Health and Hygiene in NYC. He also participates regularly with the RAC (Regional Advisory Committee) for the Office of Mental Health (OMH) as a peer advocate.