June 11, 2013

Mental Health and Learning: Fostering the Emergence of an Integrated Person

Richard P. Keeling, M.D.

The need to provide care for students with serious psychological problems continues to dominate discussions about mental health in higher education. Although anecdotal, observational, and epidemiological data now suggest a leveling off of trends of greater acuity, intensity, and complexity in students’ mental health needs, campus counseling centers continue to experience high demand and often struggle to ensure access, meet clinical needs, and respond effectively to crises. Policy questions, from the advisability of visit limits to when and how to refer students needing longer-term care to off-campus resources, highlight philosophical debates about the reasonable limits of institutional responsibility and reflect the influence of available resources. Leaders of counseling centers, faced with the need to allocate limited resources as effectively as possible, understandably prioritize urgent clinical demand, risk assessments, crisis response, and triage. Traditional lower-intensity personal and group counseling for common minor concerns, psycho-educational programming, and outreach—once the primary work of counseling centers—have lost importance and resources on many campuses; many counselors fear that more outreach will only mean more demand and more stretch on human resources. 

High quality, compassionate, and ethical clinical services for students with recognized mental health problems are, however, not the whole answer to the question of how best to understand and respond to students’ psychological and counseling needs. The argument is not that “too many resources are going to students with serious problems” (though that may be true in some instances) or that “we need to reallocate some resources to outreach” (though that may also be true in some instances). The real argument—and the pressing reason to reconsider mental health policy in today’s academy—is about the critical linkage of healthy minds with readiness to learn, and the impact of readiness to learn on student outcomes, from engagement and achievement to persistence and completion. 

To begin an exploration of that argument, consider just one example of the haunting, lyrical poetry of one of America’s finest writers: “The Belle of Amherst,” Emily Dickinson. Please read—and, ideally, read aloud—the painfully beautiful words of her poem, “I felt a funeral in my brain.” Notice how she describes the impact of depression on thinking and knowing. 

I felt a Funeral, in my Brain,
And Mourners to and fro
Kept treading – treading – till it seemed
That Sense was breaking through –

And when they all were seated,
A Service, like a Drum,
Kept beating – beating – till I thought
My Mind was going numb –

And then I heard them lift a Box
And creak across my Soul
With those same Boots of Lead, again
Then Space began to toll,

As all the Heavens were a Bell
And Being, but an Ear,
And I, and Silence, some strange Race
Wrecked, solitary, here –

 …And then a Plank in Reason, broke,
And I dropped down, and down,
And hit a World, at every plunge,
And Finished knowing – then –

Imagine, now, the impact of depression on any student’s ability to learn—on academic achievement, engagement with campus life and learning, persistence in school, retention, and graduation. “Finished knowing,” Dickinson writes. How, exactly, does one study when she “feels a funeral” in her brain? What term paper is written creatively, or cleverly, or at all, when “Mourners, to and fro/Kept treading – treading – till it seemed/That Sense was breaking through”? What student activities, leadership responsibilities, community service projects, or discussion groups engage a student when he feels “Wrecked, solitary, here“? What happens to learning when “a Plank in Reason” breaks? 

We have long known that students sometimes have great psychological pain, that they often endure it (and too often without treatment), that it can affect the quality of their college experience, that it may interfere with their learning, and that it can keep them from staying in school. We are now able to fit those observations in a conceptual framework based on our growing understanding of learning itself.

In Learning Reconsidered, (American College Personnel Association & National Association of Student Personnel Administrators, 2004) scholars and practitioners promulgated a revisionist view of learning, holding that the historical view—which had been ardently incorporated into the structure and organization of institutions of higher education—was insufficient to explain or support the student experience or to create a functional framework for understanding and advancing student learning. That view separated academic learning and student development, and the organization of campuses, in parallel, segregated academic from student affairs; it influenced generations of faculty, Student Affairs professionals, and students themselves. Student development and academic progress became seen as separate ends, usually with independent ways and means. Students, who had little choice, adapted by ignoring (or at least not mentioning) their bodies, emotions, and personal histories in class and by playing along with the dysfunctional belief that their minds had little place in so-called “extracurricular activities.” 

But every field of research and study that explores the process of learning has now come to the conclusion that learning happens in more or less the same ways always and everywhere, in or out of the classroom, and that it involves simultaneous, inextricably linked internal and external processes; Jane Fried, Ph.D., famously summarized this in saying, “We learn about ourselves and the world at the same time.” It is this integrated internal and external activity that supports the major work of learning—which is meaning-making—and that allows learning to be transformative. 

Creating space for transformative learning is one of the great necessities, and one of the most important challenges, of higher education. Consider the words of Jane Tompkins, Ph.D., writing in her 1996 book, A Life In School: What the Teacher Learned.

The curriculum of American education, kindergarten through graduate school, is externally oriented…Every freshman can tell you that Socrates said, “Know thyself,” but is she or he given any way to carry out the charge? Undergraduates, you may say, are preoccupied, but their self-preoccupation is a function of the stage of life they’re at; they want to ask the big existential questions, and they want to know themselves in the Socratic sense. But instead of giving them the means, or the incentive, our present system sidelines this hugely important phase of human development…Whoever wants to know herself is strictly on her own (p. 221). 

Creating space for transformative learning is also one of great necessities, and one of the most important challenges, for students. Think about it: learning about yourself, figuring out everything from identity to relationships, and defining personal values and goals while becoming liberally educated, acquiring specific disciplinary knowledge, and becoming prepared for life after graduation—all at the same time. From the most global perspective, though, that is exactly what higher learning is, offers, and promises: all of that at once (and students are shortchanged when we give them less, or only some of it). But problems or concerns that create challenges to flourishing—to students’ experiencing the fullness of their being and humanity—may not only undermine their health as whole people, but also restrain their readiness to learn…to explore, discover, be challenged, and even to remember. Empathic members of the faculty and caring Student Affairs professionals have long known that mental health problems, and especially depression, impair learning; they have seen what happens to students’ intellectual and emotional flexibility, excitement, creativity, and ability to soar.  

We must, then, begin to think of mental health problems as having effects and consequences beyond students’ internal psychic experience and suffering, and even beyond the ways in which that psychic experience affects others. Depression and other mental health problems cannot occur without causing simultaneous difficulty in learning—which is, after all, what colleges and universities have as their primary mission. Any residual doubts on these points are susceptible to quick resolution upon review of the established and emerging conclusions of the neuroscience of learning; functional magnetic resonance imaging (fMRI) and allied methods provide robust documentation of the sedating effect of depression on learning—people who are depressed learn less, less well, and less quickly than their peers. Extended over time, depression can undermine motivation, engagement, and the development of expertise in any area of learning. Correlative data from several university-based studies show the academic consequences: students who are depressed have lower GPAs (grade point average) and blunted levels of academic persistence and achievement than do their peers who are not depressed. 

Institutions of higher education cannot promote learning—cannot achieve their mission, accomplish their goals, or serve their entrusted societal purposes—without attending to the selves, and the mental health, of their students. How can we educate students in writing skills or prepare them to derive the next most elegant mathematical proof without addressing the emotional and psychological issues that affect their ability to engage? How can we create stronger learning environments without infusing social and cultural support for mental health? Jane Tompkins addresses this question of purposes, and the need for attention to students’ inner lives, in her book: 

I understand the argument that the university can’t do everything. Academic courses, it goes, are for the mind. Let the home and the church and the psychotherapist and the athletic program attend to the spirit and the body and the rest. We professors have our hands full…We can’t be therapists and doctors and spiritual directors, too.

What I am asking for is a more holistic approach to learning, a disciplinary training for people who teach in college that takes into account the fact that we are educators of whole human beings, a form of higher education that would take responsibility for the emergence of an integrated person (p. 218).

What would it mean for all of us who teach in college to be educators of whole human beings? To take responsibility for the emergence of an integrated person? What are the implications of that responsibility for mental health policy? 

  • Given the complex relationships of mental health, learning, student engagement, and the learning environment, we must make mental health into community property on every campus. Every office, dean, faculty member, administrator, teaching assistant, parent, and practitioner has an interest.
  • We must distinguish ownership from leadership. We expect mental health professionals and our counseling centers to lead our efforts to understand and respond to the needs of students with psychological and emotional concerns—but we cannot rest all the responsibility and accountability with them.
  • We must remember that not all students who could benefit from mental health services will come to the counseling center today, or any day. Students may not recognize, realize, or seek services for what Jane Tompkins would call trouble with the self. That means that we need to add to the traditional structure of campus counseling—the discreet, capable, and caring mental health professionals who work every day to address students’ needs—a community mental health model.
  • At the center of a community mental health model should be a web of caring services and a program of outreach, education, and preparation that, taken together, achieve several important goals: (1) eliminating fragmentation in supporting students’ health and learning; (2) conducting surveillance to recognize patterns in campus life that suggest the presence of mental health concerns among individual students, groups of students, or the learning environment itself; (3) providing outreach education to prepare all members of the campus community to recognize and respond to students with mental health concerns; (4) emphasizing case-finding—using surveys, presentations, self-assessments, activities, and special events—to identify students whose psychological well-being is interfering with their development, learning, and achievement; and (5) nurturing a supportive tone and attitude about mental health in campus culture to challenge stereotypes, undermine prejudices, and provide encouragement to students to reflect on their own mental health and seek services when needed.
  • We should respond to the linkages of mental health and learning in training staff who provide academic advising, counsel students who seek to withdraw from the university, or seek assistance with learning skills because of academic failure. Those contacts are opportunities to recognize and intervene in mental health problems. We can also monitor occurrences of injury, admission to detox facilities, sexual assault, academic and personal withdrawal from school, delay in graduation, significant drops in course load, and unexplained swings in GPA—not just traditional mental health indicators.

Of course we continue to need responsive, excellent clinical services; surveillance, case finding, and a commitment to student success, as essential as they are to our efforts to foster transformative higher learning, do not constitute triage, treatment, and referral. More counselors may be required, but we also need to better integrate primary care with mental health services; this promotes a holistic approach to delivering health care, responds to the reality that students with mental health problems often seek help first in primary care, and marshals the resources of primary care providers to recognize and refer students with mental health problems. Fundamentally, we need a system—some web of caring services that makes it more likely than not that students who experience symptoms or consequences of a mental health problem (whether those symptoms are personal, social, or academic in nature) will “stick” somewhere and find their way to one of the entry points for mental health care. In this way we can help produce better health and more positive academic outcomes for the greatest number of students possible. 

References

American College Personnel Association & National Association of Student Personnel
Administrators. (2004). Learning reconsidered: A campus-wide focus on the student   experience. Washington, DC. Available at www.naspa.org and www.acpa.nche.edu.

Tompkins, J. (1996). A life in school: What the teacher learned. Reading, MA: Basic Books.