Adrift in dark waters

It was a lazy Sunday afternoon. Paul Sander, principal lecturer in psychology at the University of Wales Institute, Cardiff, was at home flicking through his work e-mails. "I saw one e-mail sitting in my inbox and I almost didn't open it. It was from a male student - a very needy individual who I'd accepted at face value and tried to help.

"I opened it, read the first sentence and thought: 'It's Sunday. I'm not going to read any more of this.' Instead, I waited until Monday before I read the full text. The student was threatening to kill himself. He didn't tell me where he was, or how he was planning to do it. I felt so glad that I hadn't read it. I wouldn't have known where to start in trying to track him down. It would have totally ruined my weekend."

This is a dramatic example, but it's not untypical of the sorts of problems facing academics in all disciplines: how to cope with the 600 per cent increase in the number of students declaring a mental-health problem. In 1994-95, just five students in every 10,000 declared an issue with their mental health. By 2004-05, the figure had risen to 30 in every 10,000, according to figures from the Higher Education Statistics Agency.

For many of these students, mental-health problems culminated in suicide. Between 1990 and 1999, 1,482 students committed suicide, according to Understanding and Promoting Student Mental Health, a report from the University of Strathclyde.

About 60 per cent of students with mental-health difficulties turn to their personal tutors for help, and 34 per cent go to other academic staff, according to the Strathclyde report. Just 7 per cent of students with mental-health difficulties find their way to university counselling services.

"Tutors are on the front line when it comes to student mental health - and not all of them are happy," says Alastair Wilson, senior research fellow at Strathclyde and co-author of the report on student mental health. Some academics feel underqualified to provide counselling. Others don't want the added responsibility. A few are rightly concerned about the consequences.

More extensive research into student mental health and preoccupation with suicide has been conducted in the US. One survey found that 24 per cent of students had thought about attempting suicide and that 5 per cent had actually tried to commit suicide, according to Papyrus, a British charity dedicated to the prevention of suicide among young people.

Suicide clusters have served only to emphasise the vulnerability of students: at Michigan State University, six suicides occurred within three months, according to a Papyrus report, followed by several between 1992 and 1994 at the University of Oxford and a group at the University of Edinburgh in 1999-2000.

Changes in the student demographic may account for part of the increase in mental-health disorders, according to the Strathclyde report. More mature students, working-class students and students with non-traditional qualifications are going to university - with precious few extra resources to cater for their needs.

"It's about understanding that you are dealing with people who are more vulnerable than an eight or nine-year-old child," says Phillip Hodson, an experienced psychotherapist, broadcaster and fellow of the British Association for Counselling and Psychotherapy.

"These people are doing many things for the first time: first love, first sex, first discovery of sexual identity. Having your heart broken at that age can feel like the end of the world."

Duncan Wu, professor of English at Georgetown University, was a tutor at St Catherine's College, Oxford for seven years before he took up his current post in the US. In June 2006, one of his former students committed suicide by hanging himself.

Oxford afforded the student the luxury of one-to-one teaching. It was relatively easy for Wu to pick up on the student's emotional vulnerability. "If you are teaching someone one to one, you are in a position to be attentive to a person's state," Wu says.

The student kept his depression private, preferring to "retire from company rather than, in his view, blight it" - in the words of his parents and sister. But Wu had already had experience of suicide: his best friend committed suicide while they were at sixth-form college.

"I supported him by investing as much emotional and psychological energy into the act of tutoring him as I could. I felt he was quite a remarkable young person."

One-on-one tutoring is a pipe dream at most universities. "Some institutions assign more than a hundred students to a tutor," Wilson says. "I worked at one university where I was in charge of the pastoral care of 130 students. At any one time, I might have ten to 15 students with emotional difficulties. Looking after them would take an afternoon out of my week. It was impossible to sustain.

"It got to the point where a student would turn up in a distressed state, wanting only to talk to me and no one else - and I would just try to contain the conversation. I didn't have the time. I would try to refer them on to a counsellor, but some of the support services would insist that the students refer themselves. I ended up filtering students out. I felt squeezed to the edge."

Wu sympathises. "I don't think academics should be expected to counsel students with mental-health needs. It takes years to train to be a counsellor. It is a very skilled job. Universities must accept that looking after students with mental-health issues is the duty of the university. It is not a duty they can pass on to hard-pressed lecturers who have other things to do with their time."

UWIC's Paul Sander says: "We have a large number of needy students with huge health problems and family problems. Because I teach psychology, students seem to expect me to have answers to their emotional needs. You start off engaging with them and then wish you had never started. They seem surprised when I say: 'I'm a teacher. I'm not in a position to help you.'

"But I do engage when I think it's appropriate. I had a Muslim female student who suddenly withdrew from the course. Later I heard that she was being held against her will in her family home. I wrestled with my conscience then eventually called the police. To my astonishment, a policeman came and met me - then he went to the girl's home to take a look. He spoke to the girl, and she said she was OK. He asked her if she needed help, and she said 'no'.

"Later it turned out that she was being held against her will. Her family wanted her to enter into an arranged marriage. When the police turned up, it gave her family the frighteners. They realised their daughter had friends 'in high places'. Eventually she transferred to another university and found other relatives to move in with. I know this because she keeps in touch by e-mail. She is still fighting off the arranged marriage but will probably graduate with a first-class degree.

"I was worried that I'd acted inappropriately. I'm aware of gender issues for a start. I usually ask a female colleague to be with me when I see particular students - and I hadn't with this student. I also managed to get hold of the address of her family unofficially - by finding it among the Ucas forms in the school office. In the end I was so frightened by the whole experience, I wrote the whole thing up and stored my account with the dean."

Jane Wilson, principal lecturer in psychology at the University of Glamorgan, says students can be quite demanding, especially of lecturers whom they regard as open and sympathetic. "Sometimes they'll expect me to offer advice to them in front of 180 students."

Psychology students are particularly prone to prediagnosing their own problems, she says. "They'll come to me and say: 'I've got this anxiety disorder.' They'll expect 'expert' advice. Or they'll disclose personal information about their mental health in the middle of a seminar. I change the subject if they do it in the middle of a tutorial. It is not a therapy session. I'll speak to them after and tell them it's not an appropriate place. Or I'll say: 'I sense you are feeling bad. Let's find someone you can talk to safely about this."

Glamorgan is 12 miles from Bridgend, which has seen the deaths of 17 teenagers in the past year. This has made lecturers at the university particularly wary, Wilson says.

"In the past, personal tutors did get involved, but now they are more aware of the dangers of getting it wrong and of trying to engage in therapeutic interventions that they're not qualified to do. The assumption by the university is that we don't get involved - but it's not been discussed formally."

The lack of clarity means that lecturers are left feeling responsible for a student who has turned to them for help, even once they've been referred. "There is no understanding of the pressure you are under as a human being," Wilson says. "I end up giving students my home phone number - just in case."

Alternatively, lecturers are deterred from helping students again. As Sander said of the student who wrote him an e-mail threatening to commit suicide: "You start off being engaged, then you end up wishing you'd never started.

"That e-mail to me was the beginning of the end for him," Sander says. "He was a very needy individual - universities just don't have the resources."

Sander says he has had better results from the hands-off approach. "I had a third-year student whose project I was supervising. I got to know him just through the regular contact. I noticed that things were getting bad for him. I said, 'I can't help you, but you need to go and see a counsellor.'

"He came up after and said he wished he'd known about the counselling service before. Academics shouldn't try to function beyond their capabilities. There is an ethical issue in that."

Hodson, from the BACP, is sympathetic. To academics he offers the following advice: "You are not a psychiatrist. If you read your job description, you shouldn't be diagnosing depression. But for the sake of your conscience you need to know a bloke (or woman) who does.

"You also need to be able to say - without sounding like a bossy parent - 'I'm worried about you,' rather than 'Why in the fuck can't you get up in the morning?' or 'You are disrupting my class.' And to be able to suggest to students that going to a GP or a counsellor is a strength, not a weakness."

Hodson also warns academics to watch out for signs of what he calls "masked depression". "Just because a young person looks all right, it doesn't mean that he or she is all right. It is a matter of judgment, not a science. But if you have any instinct or inkling that something is wrong, it is better to suggest help and risk being rebuffed than do nothing."

An easy way to tell if a student is suffering from masked depression is to do a simple test, Hodson says. "Say to the student: 'If you suddenly had £50, would your life be improved?' If the student is suffering from clinical depression and needs help, their answer would be 'no'. But if the student is going through a reactive depression (suffering unavoidable unhappiness linked to a life event), the answer would probably be: 'Yes, £50 would make a great deal of difference.'

"It is not good enough to see someone's pain and then cross over to the other side of the road," Hodson says.

"If you look in a student's face and you see that they are in pain, strike up a conversation without getting too deep. Say: 'How's it going?' Or: 'Are you finding the pressures tough?' rather than saying: 'Are you about to kill yourself?' But if someone says: 'I feel I could end it all', then ask: 'Why? Have you decided to do something? What have you decided to do?'

"Some academics are turned off by the idea of doing this. That's a very British response, and it is reasonable. After all, it's an area outside our competence zone. But you can get confidence in this zone," says Hodson.

"Any tutor who doesn't want to do that is in the wrong job. Teaching is a people's game, not a process. Go and do some research with rats."

Martin Anderson, associate professor in mental health at the School of Nursing at the University of Nottingham, agrees. "My view is that we are here for the students. Academic interests are a priority, but if anything is going to infringe on that we have an obligation to try to help."

Anderson says he is used to counselling students. "My research is in the field of suicidal behaviour. I train nurses and mental-health nurses. I can be a bit of a magnet for students.

"If a student comes to me, I always try to get a handle on what's going on and offer appropriate attention. I get a range of problems - from someone who has been locked out of their house to a student who has just lost someone to a sudden death or a student who is self-harming."

The key, Anderson says, is for the tutor to map out a "plan of care". This means knowing what services are available and how they all fit together.

Steve Page is manager of student-support services at the University of York. He describes his job as "being responsible for the emotional, psychological and mental-health issues of the university students". In September, he plans to launch a new "open-door" policy to students at the university.

With the help of a £34,000 grant to fund "one and a bit extra staff positions" the support services will be able to assess students as soon as they present themselves. Page expects the number of students seeking help to increase from 400-450 to 600-700.

Under Page's open-door policy, students who come into the student-support centre will be assigned a case worker, who will be given the job of co-ordinating the treatment plan.

The relaunch has been given added impetus by the suicide of Laura Gerstel, a 20-year-old third-year biochemistry student who killed herself in November. Her body was found by her housemates shortly after she'd written on her Facebook site: "Laura is thinking: 'if only ...'."

It was the police who contacted the university's support services. Gerstel's student housemates needed help - they'd only just found the body. "It was the early hours of the morning, but we got three members of staff to them within the hour," Page says. "Our support services were able to take the housemates to a suitable place to give them blankets and phones and cups of tea."

Page is reluctant to discuss the details of the case because the inquest has not yet taken place. But he will discuss the aftermath.

"I'll be going along with Laura's housemates when they give evidence to the inquest. Inquests can be traumatising as well as cathartic. It can be deeply upsetting if you are asked to re-live what happened."

Laura's death hit the campus hard, leaving friends grieving. Websites such as Forget-Me-Not carried tributes to her, some from students and friends - others from strangers. Amid this, some of Laura's tutors were struggling to bear up under the strain.

"We offered a degree of support to one tutor in particular," Page says. "Laura's death was a real loss to them, and they needed to feel that it was OK to feel it. It's about reminding staff that when they have worked with a particular person and that person dies, it is OK to have feelings."

Wu agrees. After Heiney's death at Oxford, he struggled to find someone to turn to. "Support was there for the students, but if there is a criticism to be made it would be the lack of availability of counselling for lecturers. It wasn't easy to track down a counsellor at Oxford. I still feel upset about Nicholas's death."

Being able to turn to a well-organised student-support team is critical if tutors and lecturers are to continue in their role as "frontline therapists", says Isla Dowds, a former academic who is now manager at Rethink, a charity that deals with serious mental illness.

"I had an experience with an MA student who came to talk to me after a tutorial. He was concerned with his patterns of behaviour but couldn't bring himself to get help because of fear and stigma. I was very worried. I thought that one of these days I would go to work and find that he'd killed himself."

Dowds eventually got in touch with the student's parents - but only once she'd persuaded the student that this was a good idea. She did that with the help of a skilled mental-health worker who acted as an intermediary.

"Staff need to have somewhere to go and say: 'I've done what I can. You need to take this forward.' Assertive outreach teams can do that. They go out and find students who are at risk rather than waiting for them to refer themselves. They act as advocates."

But persuading the student to access support services is not always easy - especially if the building is in a very public place. "Where services are located and how they are marketed is crucially important," Dowds says. "Mental health needs to be brought into the mainstream rather than being left in a ghetto.

"There is fear of what it might mean and the shame attached to it. I had one student who thought that referral to a psychiatrist would mean being automatically admitted to hospital. She even went out and bought a dressing gown and slippers in preparation."

Page says that if a personal tutor at York has problems persuading an emotionally vulnerable student to seek help, the student-support centre dispatches one of its staff to the student's department. "The tutor can protect the student's privacy by keeping the identity of the student anonymous, but say: 'Look, I've had this conversation with a student and I'm worried.'

"This is not a breach of confidentiality. It is about seeking of support. But it is preferable to try to clear up the issue of confidentiality with a student before the student confides in you," Page says.

Coping with worried parents can be even more fraught. GPs, counsellors, nurses and clergy are bound by their own professional codes of conduct to maintain confidentiality - but tutors and lecturers are not. "We are told that we can't talk to parents," says UWIC's Sander.

"The reasoning is that all our students are over the age of 18 and are classified as adults. But I've been in situations where a parent rings me up worried about their son or daughter and I'm not allowed to answer. I find that very difficult. I've been reduced to saying: 'I can't answer that question but listen to my words carefully.' I then try to give them an answer without actually giving an answer. In other words, I talk in the third-person or hypothetically."

Theoretically, a student can sue the university if a personal tutor contacts their parents without their permission, says Judith Bray, senior lecturer in law at the University of Buckingham. But they'd have to prove that they were not deemed to be "at risk" either to themselves or to other people. It's a legally complex area.

As Alastair Wilson from the University of Strathclyde puts it: "Sometimes it is easier to contact parents when the student is dead than if they are alive."

Wilson's report into the mental health of students suggests that the university culture needs to change before lecturers can start seeing some relief in the numbers of students struggling to cope in the face of transition, challenge and change.

The impression of the report's authors was that students, rather than spending most of their time on campus, tended to come in for lectures and then leave again to pursue paid work or other commitments. This, the report says, has resulted in a "decline in the sense of community" and "contributed to the sense of isolation" felt by some students.

The traditional approach to providing education for students is based on nostalgia - not reality. University education used to be about providing stimulation for students with strong academic skills who were highly motivated to study.

"This is not remotely what students are like ... learning structures need to shift to accommodate what students are like ... we need to shift that culture quite radically," says Wilson.

But for those academics who continue to believe in the importance of operating an open-door policy - no matter what - Page offers one warning.

"Try not to create an expectation that you ought to be able to do things when frankly you can't. Sometimes things go wrong and won't work. We need to learn from that and not beat ourselves up about it."