College Students in Trouble

One out of every nine students in our colleges, says DR. JAMES PAULSEN, “is sufficiently emotionally disturbed to need medical leave, hospitalization, or extensive and intensive psychiatric treatment.”Dr. Paulsen is psychiatrist in chief of the Student Health Service at Stanford University. He is also a member of the Palo Alto Medical Clinic and a clinical assistant professor of psychiatry at the Stanford Medical School.

ONE out of every three students who enter college fails to graduate. One out of nine is sufficiently emotionally disturbed to need medical leave, hospitalization, or extensive and intensive psychiatric treatment. What is the meaning of these facts? Are students similar or dissimilar? Mentally healthy or disturbed? They are all these things, and more.

At Stanford University the freshman year is perceived by many with undue terror. The origin of this anxiety is complex, arising from hereditary endowments and liabilities, parental influences, family social and economic circumstances, variations and style in education, and personal development. In these matters, students show remarkable differences. At college, however, students share the advantages and vicissitudes of communal living, the homogeneity of academic pressures and stresses, and the mores characteristic of the late-adolescent college group. The spectrum extends from the Ivy Leaguer to the beatnik, with all the social, emotional, and behavioral implications. Even so, the majority of students are physically and emotionally healthy, reasonably mature, and reasonably certain that college will be an exciting, stimulating, and challenging experience.

In fantasy, college is conceived by the student to be a source of enlightenment, tolerance, and protection. Since this is predominantly but not totally true, modification must occur to accommodate reality. What reality? That of academic demands, the increasing briskness of peer competition, and whatever social structure and style of students are characteristic of the individual college or university. Students complain about the amount of themes, term papers, and exams, required reading, and suggested reading or writing that they must do. As one student said, “If I do all that is required, I can’t hear famous people who come to Stanford to talk or lecture, go on dates, or travel.” He had been at Stanford for seven months, but had not visited San Francisco. Another student commented, “I was valedictorian of my class and thought that I was hot stuff until I realized that in one of my math classes there are about twelve other valedictorians, most of whom make me feel silly. I used to be confident and assured, but now I almost feel inferior.” Grades are a constant source of anxiety. A sophomore girl, in an initial interview, stated, “Basically, I feel apathetic toward college. It’s like high school. They want me to conform and do what I’m told, so I did. I concentrate on grades — if you don’t have the GPA [grade point average] you can’t get into a decent graduate school — and I’ve become asocial. Now I have trouble writing, and I’m afraid of failing.”

The vast majority of students are poignantly concerned with these problems as well as with the administration of the college.

There is often a gnashing conflict between the individualized mores of students and the traditionalized mores of an institution in regard to sex, drinking, and ingroups, such as fraternities. The Stanford Daily, a student publication, frequently contains articles and letters from students who complain about and attack what they feel to be inequities and inconsistencies in policy. One student editorial discussed “The Stanford ParentAway-From-Home Syndrome,” commenting that “moral values are a private matter. And they vary greatly among individuals. Thus, we do not understand why some administrators think they should enforce their morality on all of us. . . . Some might argue that Stanford will be a better place by expelling the moral violators in question. A member of the Men’s Council has a perceptive reply to this: ‘The [academic] excellence of Stanford is not proportional to the number of virgins on campus.’ ” The editorial commented further on the matter of expulsion: “After all, the harm done to the student from expulsion should be compared to the negligible good done to the university.”

This article could apply to innumerable colleges in this country. Students are challenging moral and value systems which they feel are inflicted on them, and they resent being restricted and punished because their value systems differ from those of administrators. A punitive administrator at any level can be an enormous source of student frustration, despair, and fear, as well as a stimulus for student aggression. The entire situation is complicated by parents who often feel compelled to dominate their sons and daughters. The faculty invites students to be open, flexible, and to seek experiences in their approach to academic and campus life. All assume that the student’s task is to work out the conflicts and problems involved. Amazingly, the majority do: others falter.

Many are unable, intellectually and emotionally, to perceive themselves as separate from parents, peers, and professors. Such a dilemma results in confused identifications, stormy interpersonal relationships, and not infrequently an amorphous fear that “something is wrong.” Often the student becomes acutely aware of anxiety, confusion, and fear. “I just don’t know what I want — I seem to have no direction, no goals.” Many times this crisis represents the discovery and awareness of new values, attitudes, and knowledge which conflict with parental and educational influences. At Stanford, a freshman course in Western civilization can be a dynamic and dramatic source of stimuli in creating value conflicts in a student. The importance of this development cannot be exaggerated, and hopefully is experienced by all students to some degree. At the time of the crisis, an hour or two with an empathic faculty member, a counselor, administrator, or psychiatrist may diminish the emotional intensity of the situation to a point where it can easily be handled by the student. This is one vital form of maturation.

It is important not to construe this situation as emotional problem or illness, which would lead to complications in diagnosing, reaction, and treatment. Erickson has named this process the “postadolescent identity crisis,” partially because it is most frequently observed in freshmen and sophomores.

STUDENTS bring to the campus a host of acquired and borrowed prejudices, rigidity in thinking, and numerous varieties of inept behavior habits. These function as historical ghosts which obstruct performance and increase the burden of adjustment. Some students have fixed neurotic traits or patterns, a few utilize psychotic defenses, and all possess the idiosyncrasies which differentiate humans. With some the family has imperiously denied the existence and function of emotions and has persistently converted feelings to intellectual postulates.

For the student, the campus mission is to be academically brilliant and dominate in competition, to date the campus beauties, to get pledged to the best fraternities, and to go, man, go. And go he does:

A 22 year old, “fifth year” male senior was referred by an Internist in the Health Service because of chronic exhaustion without evidence of physical illness.

The student’s father, a successful engineer, typifies the image of a World War I success story: a dashing officer (combat and Place Pigalle), subsequently married to a beautiful woman, involved in challenging work, prominent in civic affairs, and continuously interested and very involved in his developing family, The mother is described as kind, generous, somewhat flighty and occasionally “nervous” but active as a housewife and willing to let father make most decisions, certainly the major ones.

The son breezed through high school and initially excelled in college. He joined an even “better” fraternity than his father, went steady with one of the most popular girls on campus. He also worked some evenings and week-ends, selling in a local department store, to “be self supporting — Dad pays tuition, but I pay the rest. We want it that way.”

In his senior year, the course work seemed more difficult and maintaining his B average took far greater effort. Mild insomnia developed and graduation was postponed by taking a personal leave for two quarters. On return, he continued previous activities. In addition, he began an “affair” with a girl from another college whom he met at a party. The insomnia returned, but now was utilized for late-dating, since he continued the relationship with the local girl. He began drinking more than usual at fraternity functions and became loud and aggressive. Matters deteriorated and he was referred. During the initial interview he was restless, at times agitated, cried most of the time, and readily agreed that a medical leave should halt the whole process. It did.

If the pressures exceed needs and capabilities, an emotional crisis develops. In many cases these pressures build inexorably during the first year of the undergraduate or graduate curriculum. These are critical periods, and symptoms often develop which should serve to communicate to the individual and his environment that overburdening exists. Typical symptoms are difficulty in concentrating and studying; insomnia; somatic complaints, such as fatigue, headaches, digestive trouble; apathy or depression; and nervousness. Students frequently see these symptoms and problems as variants of intellectual difficulties and flagellate themselves with recriminations — “I’m not intelligent enough,” or “I’m unworthy of my parents and Stanford.” In almost all cases at Stanford, the opposite is actually true. Sufficient intellectual endowment is the case and rarely the exception. But parents and students seek solace in believing that intellectual, medical, or surgical ills are the bases of the problems, and they ignore or deny emotional factors. While this is an understandable refuge, it complicates matters and invariably delays treatment.

If many problems of students are emotional, how common are such problems? A reasonable estimate is that 8 to 12 percent of the students are severely troubled and will endure marked complications in function during their college period. Another 10 to 15 percent are mildly to moderately troubled, but without serious impairment in function. A remaining 20 percent could benefit from professional contact, if only for an hour or two. The latter group often utilizes counseling, either from a counseling center, from administrators, or from select members of the faculty.

After World War II, counseling centers grew prodigiously at many colleges and universities. Treatment may range from an hour in the counseling center to long-term psychotherapy, obtained on a private basis. A tablet or two of medication may relieve paralyzing anxiety regarding examinations. This happens frequently. A medical leave may be necessary as a form of bailout for the desperate emotionally and academically incapacitated student. The gamut of services includes short-term therapy (about ten to twenty hours), either individual or group and sometimes both; temporary use of tranquilizers or antidepressants (used with caution); and counseling.

At Stanford, the Student Health Service medical group contains eleven physicians, two of whom are full-time psychiatrists. A third-year psychiatric resident is present half-time. The Counseling and Testing Center and the Stanford Medical School Psychiatric Clinics, located elsewhere on campus, provide about twenty-five psychiatrists, clinical psychologists, and psychiatric social workers who are involved with students, at least part-time. The result is a rather substantial professional group which is accessible to the 15 percent of the student population who have some contact during the course of a given year. About one third of these students are self-referred, and the remainder are referred by other physicians, administrative personnel, peers, friends, and faculty. Of the approximately 1500 students seen yearly, about 60 percent experience resolution of their problem in one or a few sessions. About 20 percent require contact of from ten to twenty hours. The remaining 20 percent receive long-term therapy, which may include periods of hospitalization lasting from one to three weeks. These professional contacts are not always continuous; intervals of several months, or even years, are not unusual. What is vitally important is that function, academic and otherwise, is maintained during treatment, which offers, for the majority, enhancement to style and quality of function.

SUICIDE, in our culture, is never a cool issue and is intensified by social taboos. Student health statistics vary, but about one to two students per ten thousand per year commit suicide. This is a higher percentage than exists in the noncollege population of the same age group. As a cause of death in the college population, suicide is close to automobile accidents, which in some cases are forms of disguised suicide. Allegedly the Scandinavian countries possess the highest suicide rate, but suicide is socially more acceptable in Scandinavia than in the United States. In our country many suicides are signed out as accidental deaths. Since suicide is a finite act, our therapeutic interests are necessarily directed toward suicide attempts, which are quite common. Such attempts are a silent plea for help and ought to be regarded as exactly that. However, people may be beguiled into thinking that such attempts are mistakes or of little consequence. Nonsense. At Stanford about twenty known suicide attempts occur yearly, in a student population of ten thousand. If disguised attempts were known, the total would probably be fifty or more. Such an incident churns the environment:

She was raised in an upper middle class community and is the eldest of several children. She was initially guided, then manipulated, and finally dominated by her mother. By subtle means the daughter was “encouraged” to associate with select friends, attend the “proper” schools and finally to matriculate into the college where her mother had triumphed.

In college, the daughter’s academic progress was carefully watched, and appropriate courses were chosen for her by mother. The “messages” were quite clear: follow instructions and resist not. This the daughter did, faithfully, until she became a senior. Then sabotage. She became involved not with one “proper” boy friend, but two. She joined and actively participated in many extracurricular activities (as did her mother). She functioned like a merry-go-round and the pressures mounted. There was danger of failure academically, she became indecisive and confused about social and personal involvements, and, late one evening attempted suicide.

In the hospital, she described herself, “I don’t know who I really am, what I really want, or where I am going. I think things and worry and when I feel things I can only cry. I can’t say yes or no — I’m like a puppet.” Her anxiety and depression diminished on hospitalization. Plans were being formulated when her parents arrived.

Mother quickly “took over.” She phoned people voraciously, gave instructions to all, and manifested no emotional responses or reactions; she seemed like iron. But the “deed” had been done and a crack appeared in the umbilical chain.

The daughter’s academic schedule was modified, decisions about boy friends and activities were indefinitely postponed, and arrangements were made to begin psychotherapy. The long process of emancipation began.

A rational environment responds to need. This does not spontaneously solve emotional problems but certainly helps to redirect their course and provides opportunities to evolve new, original, and constructive patterns. This, ultimately, is the major goal of all psychotherapy.

Sex is another big issue at the university. In a way, contemporary attitudes are vestigial from the Victorian era, when rigid, denying, and superficial attitudes prevailed. Freud immersed himself and his theories in this atmosphere and valiantly attempted some restoration of order. Because his success remains partial, he is maligned, misquoted, and misunderstood, even by alleged disciples. The Viennese psychoanalyst never contended that sex is the cause of neuroses, but rather that sexual factors play a role in the formation of neuroses. In America, subsequent psychiatric developments of Adolf Meyer and Harry Stack Sullivan stressed the biogenetic, social, and interpersonal factors in mental illness, thereby delegating to sex a role similar to that of other symptoms. Sex cannot be the problem; it is merely symptomatic of other far more significant problems. An abbreviated case history of an eighteen-year-old male will illustrate:

“I am a sex machine. I was born wealthy and given endless social and educational opportunities. My passion in life is sex.

“My parents are intelligent, informed people and are quite intent about my progress and welfare. They know nothing about my ‘private life.’ Occasionally I hint at it, and sometimes I think that they can guess what goes on, but it is never discussed. We smile, but don’t talk about such things.

“At twelve, I attempted sexual intercourse. At thirteen, with a different girl a year older, I succeeded. Since then, it is just a matter of with whom, when, and how. During the past few months I think of sex so often that I can’t concentrate on my studies. I’ve lost interest in reading. My mid-term grades are low. Lately I indulge in what you call perversions, which some girls like, but I really don’t enjoy this, or anything. I feel lonely and restless and realize that something important is missing. I can’t feel anything personal toward a girl, and sometimes it is as if she isn’t there. I don’t want this to go on.”

A detailed discussion of his past relationships with his parents revealed that he received from them every material benefit, but little emotional warmth and merely fragments of communication, particularly about feelings and sex. Because he could not profit from emotional relationships with his parents, he chose a common form of relating interpersonally and pursued it with the unrelenting zeal of a juvenile Don Juan. When referred for therapy, he asked that I write to his father to explain the need, since he felt unable to communicate directly with him. The letter I received from his father was quite hostile and hid no resentment that his son sought help from a psychiatrist. The father stated at length the opportunities which had been given his son and expressed amazement that anything could be wrong. It seems obvious that the boy has far more insight into his, and the family’s, problems than his parents, and that he is motivated to seek change. He will.

The future of attitudes about sex in our American culture is dependent on what we intend to do in changing what is now a potpourri of distortion, overemphasis, and intolerance. Images of masculinity and femininity, synthetic values about cosmetics and hair styles, advertising, movies which emphasize and focus on abnormalities as if these were representative of people are caricatures of naturalness and sincerity. I am bewildered by parents and others who fervently attempt to convince people that youth is preoccupied with and endangered by sex. One distraught mother informed me that she would rather see her son dead than living in San Francisco’s North Beach. He wanted to quit school, live there, and write. She said he would take up narcotics, live with a prostitute, and get syphilis. She seemed puzzled when I asked her how she knew this would happen. Her response was, “But don’t all people who live there do those things?” Some parents are so involved in their own fantasies and problems about sex that they unknowingly provide abnormal impetus for youth. This is equally true regarding academic performance, when parents relive their own anxieties and fears vicariously in their children. Case histories are filled with examples in which parents need youth to fulfill their unfulfilled lives or be imitations of themselves. Youth is entitled to the opportunity to be different, to experiment, to progress, and yet to be accepted. Most individuals resent and fear rejection.

Students need acceptance, tolerance, and help. If these needs are unduly frustrated, whether intellectually, emotionally, or behaviorally, conflicts arise. If campus pressures are added to internal ones, such as identity development, fears of inferiority and failure, concerns about examinations and grades, or competition in being accepted to graduate and professional schools, then the student machine begins to dissociate or collapse. I know several students who discuss abstruse topics with professors, delusions and hallucinations with me, and life and feelings with no one. They are alone and afraid, yet function academically. One student said he made an appointment to discuss psychiatric views on existentialism; we soon were discussing his fantasies about murder. Another was referred for academic nonperformance, but the more significant issue was his obsessional fears, of two years’ duration, of “going insane.” Rarely does a student literally go berserk and have to be hospitalized. When this happens he is usually placed on medical leave, and psychiatric treatment is initiated. Almost all such cases return to the campus in six to eighteen months, and function well. Occasionally a second episode occurs, and medical leave is again expedient. In my experience, such second episodes are less severe and ot shorter duration, particularly if reasonably adequate treatment was obtained during the initial episode. Some students rather abruptly quit school, enter one of the services for periods of six months to four years, and then resume. Some work, often at laborious and menial tasks, because they are not trained specifically for anything. And, of course, some students are expelled. One overstimulated male was expelled, following a rather long series of antisocial indulgences, because he entered a women’s dormitory to proclaim that he was prepared to relieve any and all “from the burden of virginity.” Numerous attempts had been made previously to refer him for counseling and treatment, but such efforts were adroitly deflected. To problems which exist, many add the greater problem that this reality is unacceptable or denied.

TREATMENT of emotional problems is possible, and prevention can occur. I would suggest the following methods:

1. Utilize assessment procedures, such as psychometric tests and interviews, prior to beginning college. This would help to indicate, at least to some extent, which students need help with emotional and behavioral problems. Such a survey must be separate from usual admission procedures, confidence must be maintained, and any information obtained given to health service or counseling center personnel.

2. Increase mental health services in colleges and universities (from a preventive standpoint, it is necessary to initiate programs in grammar and high schools) and broaden referral techniques.

3. Expand the liaisons between students, faculty, administration, alumni, boards of trustees, and the community. At one institution, alumni groups are invited to live on campus for oneto two-week periods, as an in-service training program. Reports indicate that such alumni are astounded and enlightened regarding changes in campus life.

At Stanford, a faculty-staff group has been meeting weekly to consider “value development on campus.” On alternate weeks, ten to fifteen students are invited to the luncheon meetings. From this, the following was published in the Stanford Daily: “A number of members of the Faculty and Staff have become aware of a need, expressed and unexpressed, for contact with students at a different level than classroom and office hours seem presently to afford. Questions of the relevance and meaning of our intellectual efforts toward personal standards and ‘real-world’ values seem to be of great concern. The need has also been expressed for an environment for discussion of these values in which expertise and GPA can be set aside, and student and professor can accept each other on a more give-and-take relationship, and one in which the student can take more initiative in probing these basic questions.”

Social and emotional barriers between faculty and students need serious modification. Student teas, professors’ at homes, and other inadvertently formal gatherings are generally avoided by students, who criticize “the lack of opportunity to really talk with someone.” Dissension between students and administration, a relatively new and vital development on the American scene, can be decreased, but this will hardly occur if the administration tends to assume a pontifical role. At Stanford, the inclusion of students in faculty and administrative committees having to do with student functions is a positive move in a profitable direction. It is imperative, however, that these students be participating members.

NOTHING assails the human mind more vigorously and viciously than the human mind. This seemingly endless process begins with childhood doubts and fears, is aggravated by adolescent concerns and uncertainties, and endures in the adult in spite of the veneer of social sophistications and pretenses. The doubts and fears remain; guilt is often added. An emotional trilogy is formed, and the battleground is the student’s cerebrum. If parents presume greatness and genius for their son or daughter, then the situation is cemented in a bitter disparity between the rigid expectations of parents and the tremulous skepticism of students, who frequently have multifarious doubts about their abilities. A student may ruthlessly question his creative endowment as he endeavors to cope with reality and a mysterious entity called the creative process. For the college student, nothing is sought and guarded more vigorously and viciously than the creative process. What is the creative process?

Mozart and Sibelius described it as a fuguelike ecstasy state in which their compositions were manifest to them in final structure; Michelangelo and Beethoven conceived germinal ideas which required considerable molding and sweat for development. The enigma of creativity defies elucidation. Since the creative process is unknown, numerous theories claim it, including a curious one which suggests that neuroses, or psychic suffering, must be prerequisites for creativity. I am impressed by the prevalence of this belief in students, which is at least evidence of rationalization and is at most a myth. Students of the so-called applied sciences, such as mathematics, physics, and engineering, rarely believe this myth, whereas students in the humanities and fine arts commonly do. The argument presented, often eloquently, is that emotional conflicts are fuel, substance, and spiritual essence to creativity and that if such conflicts were partially resolved or eliminated, the creative elements would wither or perish. It is the opposite which occurs. Function, of which creativity is one noble style, is impaired, distorted, or withered by the presence and obstruction of mental turmoil.

Some students believe that certain powerful drugs, such as LSD-25, mescaline, psilocybin, or even alcohol, can not only facilitate the enhancement of creativity but may miraculously infuse greater potency into the marriage of mental anguish and creativity. These drugs are toxins to the body and do not release latent genius. One confused undergraduate male took large doses of mescaline to “free creativity and emotions.” So disturbed did he become that medical leave was invoked, which freed him from student status. He also gave sessions to other students who were, in his estimation, troubled and inhibited, stating that his insight and knowledge ought to be used to help others. Another student took about four hundred morning glory seeds (currently popular in pharmacological seances). He increased the degree of his chronic anxiety, developed ideas of references, and experienced an exacerbation of previous fears about homosexuality. These symptoms occurred during a party when about live students took the seeds. He was given a potent tranquilizer, a phenothiazine, and therapy was initiated. He improved, symptomatically.

The picture is not always dismal. These drugs are important and, under well-controlled circumstances and supervision, potentially quite useful. They can be an adjunct to certain situations in psychotherapy, a research potential, or, as Julian Huxley suggested, “a means of encouraging evolution of the mind and mental processes by new experiences.” Few will doubt the need of mankind to experience new possibilities in dealing with either creativity or emotional problems.

The participation of students in the Peace Corps as well as freedom marches and sit-in demonstrations is evidence that their activities are not restricted to campus matters and that some students are serious and sincere. There is a rumor that individuals who are themselves to some degree emotionally disturbed participate in such activities. If this were true, then such a form of mental illness would be an evolutionary process, since the goal of these activities is social improvement. While most students complacently follow the trails and swamps of the past, a vibrant minority seek change and progress. They actively seek extracurricular functions such as student government, judicial, and faculty-student committees as a means of enhancing maturity and contributing to college development.

An integrative environment, family and college, can induce progress toward intellectual, emotional, and behavioral maturity in students. Disparity in such integration is manifest in emotional problems and waste. One of the greatest needs in people is respite from the onus of mental illness; one of the greatest needs of mankind is the control of hostility and aggression. The college community is one crucial environment where such needs can be met and where much work can be done.