5

Moving Forward

As emphasized throughout this report, there is an urgent need to attend to student mental health and substance use because (1) they are critical factors in determining student success (Eisenberg, Golberstein, and Gollust, 2009; Shankar and Park, 2016; Topham and Moller, 2011), (2) students at all types of institutions of higher education and in all fields of study are reporting increasing numbers of problems with mental health and substance use (Lattie, Lipson, Eisenberg, 2019), and (3) colleges are consistently reporting that the demand for mental health services exceeds the supply. The increased prevalence of mental health and substance use problems has many academic leaders and policymakers describing the situation in near-crisis terms and looking for solutions.

This chapter aims to provide those leaders, as well as agencies that fund efforts to improve student mental health, with evidence-based approaches for addressing the major issues confronting institutions as they try to meet the growing demand for mental health and substance use services among their students, building on the already proven effectiveness of campus counseling centers (McAleavey et al., 2017). The challenge for the committee in offering these approaches is that there can be no one-size-fits-all solutions given the diversity of institutions, their institutional and financial capacities, and their specific student populations. For example, a community college with a predominantly commuter student body is likely to encounter a very different constellation of issues and have different resources available to deal with them than a four-year university. Within other groups, such as large public land-grant institutions, HBCUs and TCUs, and liberal arts colleges, each institution will need to find strategies to support its unique populations without regressing to the modal demographic group and identities. There are also enormous differences among the students who attend these

colleges and universities with respect to financial resources, access to health care, whether they have health insurance, and, if they do, the quality of those health plans. Research has also documented differences in the prevalence of symptoms and use of services across race and ethnicity, socioeconomic background, gender identity, and academic discipline (Eisenberg, Hunt, and Speer, 2013; Lipson et al., 2016). When appropriate, this chapter points out interventions designed for specific types of institutions or student populations as well.

In the committee’s judgment, based on its information gathering activities, there are multiple proven approaches for intervening around mental health and substance use issues and promoting student wellbeing in ways that will positively affect student success. For that reason, the committee is not advocating a single “ideal” that all institutions of higher education should adopt or strive for. Rather, the committee includes in this chapter a discussion of the major issues confronting institutions of higher education as they strive to better meet students’ needs and ways those problems or barriers to progress might be addressed.

INSTITUTIONAL CULTURE AND POLICIES

Institutions of higher education must establish and/or maintain a culture that accepts and supports, to the extent possible, students experiencing problems with mental health and substance use and fosters a sense of wellbeing for all students. For some institutions, this will require a significant culture shift. The culture starts with the institution’s leadership—the president and board of trustees. Without institutional support and leadership, progress in providing needed supports may allow too many students with problems to fall through the cracks. The Okanagan Charter is one useful guide that can help colleges and universities embed health into all aspects of campus culture and climate, as well as promote collaborative action to create a health-promoting environment (Okanagan Charter, 2015).¹

Changing Institutional Culture

Developing a Campus Culture Focused on Wellbeing

The committee acknowledges how difficult it is to change any organizational culture and climate, and those within institutions of higher education are no different. Nonetheless, the committee recognizes that accomplishing difficult tasks is a hallmark of the U.S. higher education enterprise (see Box 5-1). One framework for culture change, known as collective impact, requires that everyone on campus shares a common agenda, is provided with a coordinating structure, engages in mutually reinforcing activities, participates in continuous communication, and

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¹ Additional information is available at https://collegehealthqi.nyu.edu/20x30/frameworks/okanagan-charter (accessed April 29, 2020).

agrees on shared measurement systems to evaluate and boost progress (Christens and Inzeo, 2015; Poleman, Jenkes-Jay, and Bryne, 2019; Slusser et al., 2018). The committee believes that general approach applies here.

The committee also believes that the unequal impacts of the COVID-19 pandemic and the call to action in response to the killing of Black men and women by police reflect the long-standing disparities that BIPOC and those of low socioeconomic status experience daily in American society. The protests and public outcry in response to these events have created an environment in which the public may be more willing to engage in further steps toward dismantling racism and systemic oppression. It is in the spirit of this moment that the committee believes that academic leaders have an important role to play in bringing together the different communities on campus to address those aspects of institutional culture that do not support the mental health and wellbeing of all students, particularly students who are BIPOC or who come from other underrepresented groups.

RECOMMENDATION 5-1

Institutional leaders, starting with the president and board of trustees or regents, should articulate the importance of creating a culture of wellbeing on their campus, one that recognizes the range of individual behaviors and community norms that affect wellbeing, acknowledges the magnitude of mental health and substance use issues on campus, addresses the stigma associated with mental illness and substance use disorders, and provides a range of resources to support students with different levels of need.

The stakeholders required to create and/or maintain this kind of culture must go beyond the administrators, counseling center staff, and offices within student affairs. It requires the entire faculty,² staff, and student body working together to recognize the importance of the following (Byrd and McKinney, 2012; Chen, Romero, and Karver, 2016):

• validating, respecting, and supporting individuals in all their identities,
• attending to the demand for mental health and substance use services that now exists and is likely to grow,
• proactively addressing student mental health and substance use,
• creating and/or sustaining a campus culture and environment that minimizes stress and promotes the emotional wellness of everyone on campus,
• discussing, acknowledging, and acting to correct existing systems that harm individuals and pose risks to their wellbeing

Creating and Sustaining Cross-Campus Coordination, Collaboration, and Leadership That Support a Culture of Wellbeing

One approach that institutions have used to address other cross-campus concerns such as diversity, equity, and inclusion efforts; mentoring and teaching; and security concerns on campus has been to establish a campus-wide action commission with representatives from faculty, students, staff, and administrative units. These action commissions have an effective leadership structure (it may be a single leader or a small group, depending on the needs of the institution) and a clear charge to build or maintain a culture that supports student wellbeing. Thus, a standing, campus-wide commission might be one such mechanism for creating a campus culture that supports students’ mental health and wellbeing. This approach can be a strong first step toward ensuring there is cross-unit

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² Faculty here include tenure- and non-tenure track faculty, as well as adjunct faculty, part-time faculty, lecturers, and other instructors, with admission that many of these positions do not receive the same kind of training, support, and benefits as full-time, tenure-track faculty. Additionally, community colleges and other colleges and universities that have a higher percentage of adjunct faculty, part-time faculty, lecturers, or other instructors may not have received the same kind of professional development and support as their full-time, tenure-track peers.

communication and collective buy-in to promote culture change and establish a compact of shared responsibility.

RECOMMENDATION 5-2

Leadership from all segments of the campus community is needed to promote a culture of wellbeing.

• Institutions of higher education should establish and/or maintain a team or teams that involves all sectors of the institution’s community that coordinates, reviews, and addresses mental health, substance use, and wellbeing concerns.
• Any approach should have shared responsibility for addressing issues that negatively affect student wellbeing, a clear leadership structure and mandate, appropriate access to financial resources, and a charge to develop and implement an action plan to promote and support student wellbeing.

One troublesome aspect of societal culture in the United States, which is also present at our institutions, is the pernicious stigma surrounding mental illness and substance use. Addressing stigma is a critical component in promoting mental health and wellbeing among all students. For an individual, the stigma related to mental illness and substance use issues has a number of possible influences, including their family’s views and history; interpretations and lessons from cultural, religious, and spiritual connections; social norms; and their peer group’s beliefs and actions (NASEM, 2016). General efforts to reduce stigma around mental health and substance use programs aimed at all students through awareness campaigns and wellbeing efforts are one way to combat the impact of stigma. See Box 5-2 for an example of an evidence-based mental health treatment program.

As colleges and universities seek to end the stigma tied to mental illness and substance use, institutions of higher education should review how their own systems may enhance stigma, create barriers, or otherwise fail to serve students from groups that have not been well-served by mental health services in the past. Many colleges and universities, as well the broader U.S. health care system, have long had both direct or implicit biases against BIPOC, women, SGM individuals, and people with many other identities. Given these historic barriers and biases (DeLisa and Lindenthal, 2012; Harrison-Bernard et al., 2020; Nivet, 2015; Ong et al., 2011), campuses must ensure that their current services welcome, respect, and provide inclusive services to all students. This includes providing services for students who return to campus as older adults, as well as those with dependents and those who have served in the military. As noted later in this chapter, the Equity in Mental Health Framework, developed by the Jed Foundation, the Steve Fund, and McLean Hospital’s College Mental Health Program, is an accessible resource for schools seeking to promote mental health and wellbeing among students of color and other underrepresented student populations (Steve Fund and Jed Foundation, 2017). This framework provides academic institutions with a set

of 10 actionable recommendation, free resources, and supporting toolkits, as well as key implementation strategies to help strengthen their activities and programs to address the mental health disparities facing students of color and other underrepresented student populations, such as sexual and gender minorities (see Box 5-3 for specific framework case studies).

In developing the framework, the Steve Fund, Jed Foundation, and McLean Hospital’s College Mental Health Program carried out a nationwide survey of campus programs intended to support mental health and wellbeing among students of color in an effort to identify promising practices. The framework organizes these promising practices in a five-tiered structure based on the extent to which a program: (1) had a specific focus on mental health and emotional wellbeing; (2) had a specific focus on college, graduate, or professional students of color; and (3) utilized evidence-based practices. The survey identified a single tier 1 program out of a total of 84 programs that included both an empirical evidence base and a specific focus on mental health in students of color (see Box 5-3 for a description of the tier 1 program and several tier 2 programs). The report writes: “Whereas the majority of programs had collected some type of data (typically, qualitative feedback or student satisfaction), the lack of systematic program

development efforts left the questions of efficacy and effectiveness unanswered in the vast majority of these tailored interventions.”

There is a clear need for additional research on strategies and practices that can support the mental health and well-being of students of color. Nevertheless, the committee endorses the use of the Mental Health Equity Framework as a foundation for practice and encourages each individual campus to set additional priorities, strategies, and actions to ensure an equitable and inclusive culture.

CHANGING INSTITUTIONAL POLICIES

Policies for Medical Leave and Re-enrollment

Institutional medical leave and reenrollment policies, when they exist, can serve as barriers for students whose mental health or substance use problems are

severe enough that they lead the student to withdraw from school at least temporarily. Many institutions limit how long a student’s leave of absence can last before they must reapply for readmission. In addition, withdrawal from school can affect financial aid. However, the Americans with Disabilities Act (ADA) mandates that students with disabilities, including those related to mental health and substance use, have the right to reasonable accommodations for their disability. Such accommodations include extra time on exams or assignments, the ability to withdraw from specific classes, and leaves of absence that allow for reenrollment (Martin, 2017). The COVID-19 pandemic has also highlighted the ability for higher education to adopt virtual tools and other teaching modalities that may continue to accommodate students with disabilities.

Since 2011, the Department of Education’s Office of Civil Rights, which is responsible for enforcing ADA provisions, has allowed institutions of higher education to require an involuntary medical leave for students with a mental health issue. The proviso indicates that students must be allowed to reenroll in school upon providing certification from a medical professional that they are fit to return to the school community (see Box 5-4). Students who take a voluntary medical leave for a mental health issue should also be allowed to reenroll in school under the same proviso. In the event that a student returns to campus and has ongoing mental health issues, learning disabilities, or other challenges covered by the ADA, the campus is required to provide academic accommodations and make reasonable modifications of policies to remove barriers for the student (Baselon et al., 2008).

An important step toward creating an integrated approach to supporting students would be to establish a closer collaboration between academic affairs and student affairs. While every campus has a different arrangement of staff and division of responsibilities, campuses that build an intentional bridge between academic and student affairs increase the chances for students with mental health concerns or substance use to succeed (Nesheim et al., 2007).

RECOMMENDATION 5-3

Institutions should ensure that their leave of absence and reenrollment policies and practices will accommodate the needs of students experiencing mental health and substance use problems and the time needed for effective treatment and recovery.

• Institutions should implement methods to reduce and/or alleviate the financial burden on students related to medical leave and other issues related to course completion.
• Academic affairs and student affairs units should develop collaborations to share information appropriately, while also respecting a student’s right to private/confidential treatment, in order to support students at the intersection of mental health and academic concerns.

PRIORITIZING MENTAL HEALTH AMID FINANCIAL CONSTRAINTS

As the committee noted in Chapter 1, and emphasized again here, the U.S. postsecondary educational system is one of the few systems in the nation, other than the military, whose stakeholders expect to provide low-cost or free treatment for those within its community with mental health and substance use problems. When the costs of providing that care rise, colleges and universities have few options to keep pace. Raising tuition or reallocating resources from other campus priorities are two such options, but both have proven unpopular with stakeholders. Academic institutions are therefore caught between the need to expend more resources on student wellbeing while not increasing the overall cost of education.

Economic pressures increased operating costs, and greater market competition are an ever-increasing set of challenges for U.S. institutions of higher education. A 2014 survey of college and university board chairs and presidents, for example, found that about 60 percent believe the financial stability of higher education is moving in the wrong direction (Selingo, 2015). This situation has been made worse by the COVID-19 pandemic, which forced colleges and universities to effectively close their campuses for educational and research purposes and move to online instruction in the spring of 2020. In addition, the report notes that the cost of student services and student facilities, such as campus counseling centers, represent a major concern to university presidents.

Tuition revenues have plateaued in recent years, with Moody’s Investor Services reporting that flat enrollment, rising tuition discount rates, and an emphasis on affordability contributed to limited growth in net tuition revenues (McCabe and Fitzgerald, 2019).³ For public universities and community colleges, declines in federal, state, and local support are further stressing budgets. Forbes, in its sixth report on the financial health of private, not-for-profit colleges, reported that “the overall financial wellbeing of colleges has deteriorated and many are in danger of closing or merging” (Schifrin and Coudriet, 2019). Prior to the start of the pandemic, the largest community college system in Pennsylvania eliminated its counseling service, despite the acknowledgement of need, due to loss of funding related to declines in student tuition and eliminating licensed counselors with the intent to bring on student advisors with a greater focus on career planning (Anderson, 2019). Moreover, the COVID-19 pandemic is causing further financial stresses for many of the nation’s colleges and universities (Associated Press, 2020; Capatides, 2020; Pannett, 2020). In spite of these economic pressures, the committee believes that mental health, substance use, and wellbeing issues are sufficiently important that increased funding will have to be devoted to them.

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³ Net tuition revenue is a key financial indicator since it serves as the foundation for most college and university budgets. Financial pressure mounts on an institution if its net tuition revenue does not rise as quickly as expenses or inflation.

Prioritizing Funding and Services for Mental Health on Campus

RECOMMENDATION 5-4

Institutions of higher education and the government agencies that support them should increase the priority given to funding for campus and community mental health and substance use services.

• National, state, and local funders of higher education should incentivize colleges and universities to effectively provide support for students’ mental health and substance use problems.
• In their budgets, hiring, programming, expectations for serving students, and assessment/evaluation activities, institutions should make mental health a higher priority on campus. They should also work more directly with state and local governments, where relevant, to help bring this about.
• To ensure that mental health and emotional wellness services are prioritized, institutions should consider reallocating existing institutional funds to support counseling centers, support the increased use of online mental health services (when appropriate), and support data collection on the need for and use of mental health services by students.
• Institutions should actively collaborate with local health care services and facilities and community providers, for example, by considering hiring staff to help students navigate and manage off-campus services.

States should modify insurance laws or regulations, or provide administrative guidance, to enable institutions to use general funds and/or designated health fees for expenses that are not covered by students’ personal insurance.

Making a Value Case for Addressing Student Mental Health Problems

The assumption that bolstering the capacity of the counseling and psychological services centers and creating other programs aimed at improving student mental health only adds to existing financial burdens is not necessarily true given that colleges and universities lose revenue when students drop out because of mental health or substance use problems. A 2018 survey by the Association for University and College Counseling Center Directors (AUCCCD) found that “counseling services have a positive impact on retention, as measured by student self-report,” with 63.2 percent of counseling center clients reporting that counseling services helped them stay in school (LeViness et al., 2018). Other studies have also documented this relationship between counseling services and student retention, including Lee et al. 2009, who conducted interviews and collected data on counseling services for a total of 10,009 students from a large public university in the northeastern United States. The authors found that “counseling experience is significantly associated with student retention: students receiving counseling services were more likely to stay enrolled in school.”

In fact, public health economists associated with the Healthy Minds Network, based on research on the effectiveness of mental health care and on the economic returns to education, have calculated that a counseling center treating 500 students a year will help an average of 30 students remain enrolled in college (assuming a rate of $20,000 per student-year)—thereby increasing tuition revenues by $1.2 million over two years⁴ (Samuels, 2019). In addition, by completing their degrees, those 30 students’ lifetime earnings would increase by an estimated $3 million.⁵ In addition to the monetary benefits of reducing attrition, accreditation services consider graduation rates in their reviews. By comparison, the researchers found that the “cost of providing mental health care for 500 depressed students would be no more than $500,000 based on standard estimates for the cost of psychiatric medication or brief models of psychotherapy” (HMN, 2013). Healthy Minds Network has created a return on investment tool that institutions of higher education can use to explore the economic benefits of investing in student mental health, which is available at http://healthymindsnetwork.org/research/roi-calculator. The tool includes assumptions that can be customized for the institution, for example, school population size, departure/retention rate, prevalence of depression, and alternative assumptions about the program’s effectiveness in reducing depression (HMN, 2013).

Addressing Insurance Billing—One Approach for Raising Funds to Increase Capacity and Meet Demand

One option for funding mental health services is for colleges and universities to seek reimbursement by health plans for services rendered. Many colleges and universities require their students to have health insurance, yet few bill insurance companies for services rendered and instead cover the entire cost for those services themselves. A survey conducted by AUCCCD found that only 4.4 percent, of responding institutions billed third parties for their services (LeViness et al., 2018). There are many reasons that counseling centers do not bill insurance, including:

• concerns about student confidentiality when students are on their parents’ insurance plan
• the cost involved in setting up billing infrastructure and credentialing providers
• the fact that many counseling centers have robust training programs that would have difficulty billing insurance
• concern about adding another barrier (cost) to seeking mental health care, especially for students and families with high deductible plans

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⁴ This assumes 60 student-years of tuition at $20,000 a year.

⁵ This assumes an additional $50,000 per college year of earnings.

• the difficulty in some areas for mental health providers to get on insurance panels, and
• billing expenses exceeding returns, impact on training programs, the low reimbursement rates and burdensome requirements for pre-authorization for care, submission of treatment plans, and concurrent care review that drive many providers in the community from insurance panels in the first place.

The time, expense, and human resources needed to create the infrastructure to bill insurance companies is usually well beyond the capabilities of smaller institutions and community colleges. Moreover, colleges and universities that do not mandate that students have insurance coverage that meets specific requirements will have uninsured students who cannot afford services that require payment; even those that have insurance (from another state or with a particular carrier) may be out of network or otherwise challenged in paying for services while at college.

In the context of these concerns, the fact remains that many families already pay insurance carriers for coverage of services that colleges and universities provide, and that colleges and universities largely do not have access to these funds. Meanwhile, some institutions that do not bill for services struggle to adequately fund mental health service provision, while other institutions provide exceptional levels of service without billing. While institutions that do bill for services have added a revenue stream, they must still deal with the problem of increasing capacity to treat all students in need of services.

RECOMMENDATION 5-5

Institutions of higher education should work with insurance companies and health plans and federal, state, and local regulators to remove barriers to seeking reimbursement for student mental health and substance use costs for covered students.

• Insurance companies should keep up with market rates for reimbursement to incentivize more providers to accept insurance carried by students, support providers from institutions of higher education in becoming paneled quickly, and communicate and improve the confidentiality measures in place to dependent subscribers between the ages of 18-26 to ensure that they can seek services using their parents’ insurance and be afforded the confidentiality they are entitled to receive.
• States should modify insurance laws or regulations, or provide administrative guidance, to enable institutions to use general funds and/or designated health fees for expenses that are not covered by students’ personal insurance for charges incurred at student health and counseling services. This is commonly referred to as a secondary payor provision in coordination of benefits.

There are solutions to each of these issues, but they require action by state legislators and insurance regulators, and in some cases the federal government, to ensure that services provided by higher education institutions can be covered. For example, states that do not require health insurance for students could amend insurance laws to allow different charges for people with and without health insurance in higher education. State insurance regulations or university fee plans could also be changed to include additional privacy protections for adult dependents on their parents’ health plans and to require insurance companies to empanel providers at colleges and universities that are delivering health services to their students.

UNDERSTANDING THE STATE OF STUDENT MENTAL HEALTH AND WELLBEING ON EACH CAMPUS

While colleges and universities share a similar set of challenges in supporting student mental health, the issues, priority areas, and available resources on campus vary substantially across institutions. In addition, every campus would benefit from identifying the local and regional mental health and substance use prevalence trends, service providers, and additional resources to fully inform referral practices, programming, and policies (Othman et al., 2019). Assessing the mental health and substance use treatment needs of a given population—a student body in this case—has been a significant problem and is different and more difficult than evaluating general “wellness.” Surveys of incoming students can provide some baseline information related to a broader sense of wellbeing; however, these data have limited use in identifying specific mental health issues.

RECOMMENDATION 5-6

Institutions of higher education should conduct a regular assessment (preferably at least every two years) that addresses student mental health, substance use, wellbeing, and campus climate. The data generated from these assessments should be compared to peer institution data (as available for disaggregation). Analysts should create a data collection system that allows for disaggregation by unit, program level, and student identities. This assessment should include the extent that students are aware of and know how to access available resources, both on campus and in the local community, to address students’ mental health and substance use problems.

• At the end of the academic year, institutions should review the many data points collected about their clinical trends and utilization as a way to understand how resources on campus can be used most effectively. These data would include the percentage of students who received treatment at the institution, the percentage that went outside of the institution for treatment, and the percentage of students that report needing help but did not seek or receive it, and should be further analyzed across demographic and identity groups.

• Funding agencies and private organizations should provide grants to under-resourced institutions, notably community colleges, Historically Black Colleges and Universities, and Tribal Colleges and Universities, to collect, analyze, and share data with the goal of implementing findings.

In addition to general climate assessment, there are a number of screening tools and instruments that colleges and universities can consider for assessing student mental health as a means of connecting students to mental health services before a crisis emerges. For example, the Counseling Center Assessment of Psychological Symptoms (CCAPS) instruments, developed by the Center for Collegiate Mental Health (CCMH) at Penn State University, is a frequently used measure for assessing mental health functioning of students seeking treatment through counseling centers (Locke et al., 2010). In addition, CCMH offers CCAPS-Screen, “a mental health screening instrument that assesses the most common psychological problems experienced ... including a critical item related to the report of suicidal ideation within the last two weeks.”⁶ Another set of measures and associated data can be found through the Healthy Minds Network. HMS also provides a campus-wide measure of student mental health and substance abuse issues, as well as a national assessment of mental health and substance abuse treatment needs (Lipson et al., 2019b).⁷ Assessments of mental health literacy and peer-to-peer counseling referrals may be useful in the community college setting (Kalkbrenner, Sink, and Smith, 2020).

The American College Health Association’s National College Health Assessment, an annual survey of college student health that includes mental health and substance abuse (Cain, 2018), provides a national perspective on the mental health and substance use issues that students face. In addition, the World Health Organization’s World Mental Health International College Student (WMH-ICS) Initiative provides estimates of the prevalence of mental disorders, the adverse consequences on the personal, social, and academic levels of these disorders, patterns of help-seeking for these disorders, and barriers to treatment based on a representative sample of colleges and universities across the globe (Auerbach et al., 2018).

Beyond the screening tools described above, there are new methods for assessing the percentage of students who have mental health and substance use issues. One approach, for example, uses computerized adaptive testing (CAT), based on machine learning techniques, to determine what question from a

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⁶ Additional information is available at https://ccmh.psu.edu/ccaps-screen (accessed September 29, 2020).

⁷ As noted in Chapter 1, the committee has found that much of the information on the incidence of mental health and substance use problems among students come from self-reports and not actual diagnoses by mental health professionals. Numerous investigators have pointed out that self-report data can be strongly biased and may not accurately reflect the true incidence of those issues among students in higher education (Dang, King, and Inzlicht, 2020).

large number of possible questions to ask an individual based on the answer to the proceeding question rather than having every individual answer every question included in an assessment vehicle. Using this technique, researchers have developed the CAT-mental health (CAT-MH) suite of 10 CAT. (Gibbons et al., 2007; Gibbons and deGruy, 2019; Gibbons and Hedeker, 1992; Graham et al., 2006). The University of California, Los Angeles, uses CAT-MH to screen all its undergraduates for both overall assessment and to triage students for further care. A similar screening tool is offered by the American Foundation for Suicide Prevention. This online program⁸ is being used by mental health services at institutions of higher education, including community colleges and undergraduate, graduate, medical, veterinary, and other professional programs. Individuals can anonymously communicate with the program’s counselor to receive recommendations, feedback, and support for connecting to available mental health services.

INSTITUTIONAL CAPACITY TO PROVIDE NEEDED SERVICES

Once an institution has determined the extent of mental health and substance use issues among its students, there are four critical steps that follow: determining the scope of services needed to meet the measured demand; assessing what resources the institution has available on campus and in the community to meet that demand; assessing how existing resources are deployed and how effectively they are meeting mission objectives; and closing the gap between what is needed and what is available at the institution and in the community. Colleges and university budgets will constrain the scope of services available on campus, so each institution should evaluate the mixture of services available on campus, in the local community, and online—to support student wellbeing and provide care for those students in need. Institutions may decide to pay particular attention and allocate funding for specific types of treatment in the event there are no services available in the surrounding community.

The committee recognizes that the availability of financial and personnel resources to enact changes necessary to better meet students’ wellbeing, mental health, and substance use treatment needs will likely be a major constraint, especially in the short term given the financial impact of the COVID-19 pandemic on institutional budgets. Nonetheless, the committee believes that institutions of higher education should give greater priority to addressing students’ mental health, substance use, and wellbeing issues given that the stress of the pandemic, economic instability, and increasing social isolation will continue to affect students’ lives. Institutional commitment and leadership are essential elements moving forward.

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⁸ Additional information is available at https://afsp.org/interactive-screening-program (accessed June 24, 2020).

Leadership from higher education is not enough, however. Moving forward successfully also depends on local, state, and federal policies that allocate resources and mandate the ways they should be utilized. Therefore, some of the solutions recommended here depend on policy changes at one or more levels of government. However, given that university leaders today are likely analyzing the use of resources in the face of the financial challenges wrought by the COVID-19 pandemic, the time is ripe for those leaders to include identifying resources and opportunities to improve the mental health and wellbeing of their students.

In the wake of COVID-19, the American Council of Education surveyed nearly 200 college and university presidents regarding their major concerns in response to the pandemic. The results from April 2020 indicated that 51 percent of university presidents already provide mental health services for their students and did not have the resources for additional support. Thirty-five percent stated that they have existing services and planned to invest more resources, while 12 percent stated that they do not currently offer clinical services, but are considering additional options to address student mental health and substance abuse in light of COVID-19 (Turk et al., 2020). This survey, which does not include community colleges and is not representative of the entire scope of this report, does reflect the reality that even in a global pandemic, 63 percent of the leaders surveyed recognized the need for resources; however, they did not necessarily have the means to increase clinical support.

In addition to these concerns, there are not enough mental health and substance use professionals in the country to meet the needs of the general population, with some regions experiencing greater shortages than others. In particular, there is a severe, nation-wide shortage of providers who are both participating providers with insurance plans and accepting new patients. Institutions of higher education often suffer from the same problem, lacking a sufficient number of mental health professionals to care for their student population. The Health Resources and Services Administration projected in 2016 that the supply of workers in mental health professions would be short by some 250,000 individuals by 2025 (Health Resources and Services Administration, 2016). Already in 2020, two-thirds of primary care physicians report having difficulty referring patients for mental health care, compared to roughly one-third for referrals to other specialties (Bishop et al., 2016).

Dealing with the Shortage of Mental Health and Substance Use Professionals

At the same time that there is a shortage of mental health and substance use professionals, demand for mental health and substance use services on college campuses has been rising steadily for several years (CCMH, 2017, 2020a) (see Box 5-5). As a result, institutions of higher education have been struggling to meet the rising demand for mental health and substance use services, which

exceeds capacity in many institutions. (Thielking, 2017). In 2018, some 43 percent of the 571 college and university counseling centers surveyed by the AUCCCD increased the number of staff positions in counseling centers, while less than 9 percent lost staff positions (LeViness et al., 2018). However, more than half of the counseling centers reported having one or more positions turn over during the previous year, with institutions noting that “low staff salaries and problematic center work conditions were factors in a significant proportion of this turnover.” (LeViness, 2018, p. 1).

The most direct approach for increasing capacity is to commit institutional funding for mental health and substance use services and hire more staff to deliver those services, including psychologists, psychiatrists, professional counselors, social workers, nurse practitioners, case managers, and physician assistants with experience in the area of mental health and substance use. However, increased hiring may not be a realistic solution for many colleges and universities to pursue given limited budgets, building space availability, and challenges in hiring qualified staff.

Bridging Campus and Community Resources to Increase Capacity

Students who cannot get the treatment they need through on-campus centers are increasingly seeking to access community-based care, when it is available. However, institutions of higher education can further support these students by ensuring that mechanisms exist to strengthen both treatment capacity in the community and continuity of care when students are referred off campus so that they do not fail to access care. One example is McLean Hospital’s College Mental Health Program. This program “bridges the gap between a psychiatric hospital and multiple campus settings in an attempt to address the specific needs of college student-patients across levels of psychiatric care and diagnostic areas/programs,” (Pinder-Amaker and Bell, 2012, p. 174). It also addresses a barrier that exists for many institutions, in that they may not know what resources exist in their communities or may not have arrangements with community mental health and substance use treatment resources to serve their students in need.

The problem of insufficient capacity is particularly acute at the nation’s community colleges, where counselor to student ratios are nearly half those of baccalaureate degree-granting colleges. According to the Steve Fund, only 10 percent of community college students, at most, use on-campus mental health and substance use services (Primm, 2019). A survey of community colleges and four-year institutions in California found that community college students had more severe mental health concerns and fewer on-campus mental health resources than four-year college students (Katz and Davison, 2014). Some rural communities also face challenges related to health care broadly, with limited access to hospitals, specialty providers, and mental health services in their region (Kirby et al., 2019; O’Hanlon et al., 2019).

If an institution relies on community-based treatment options to help meet its students’ demand for services, it should promote mechanisms to match students to community resources and enable them to use those resources easily, rather than leave students on their own to find and access community resources. There are several for-profit vendors of referral programs that can match students to community providers, as well as provide health and wellness services. Therapy for Black Girls, for example, is a free online service that aims to both reduce the stigma of treatment and help African American women, including students, find local community-based therapists. In 2019, the American College Health Association issued guidelines for institutions that are thinking of turning to outsourcing to student health needs⁹ (ACHA, 2019c).

While outsourcing can in some cases provide students with access to a wider range of specialists and more highly trained staff, there are a number of potential disadvantages to outsourcing mental health services that institutions need to

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⁹ Available at: https://www.acha.org/documents/resources/guidelines/ACHA_Outsourcing_College_Health_Programs_May2019.pdf (accessed September 20, 2020).

consider in moving forward with this approach to expanding capacity (ACCA, 2020), including:

• An excessive focus on psychopathology at these services rather than modalities more appropriate for stress-inducing developmental challenges that colleges students often face.
• Possible session limits that may fail to produce significant clinical improvements.
• Students having to bear financial responsibility for services resulting from limits on insurance coverage.
• Reduced ability for students to network with student affairs and residence life staff.
• Potential reduction in outreach efforts and educational programming on the part of the institution that may promote mental health and prompt students to use on-campus counseling services.
• Reduced responsiveness of the institution to on-campus emergency situations, particularly those warranting immediate personal interventions when there are threats to self or others.

Using Telehealth to Increase Access

In addition to increasing connections to local providers, another method to increase students’ access to mental health and substance use services is via telehealth and internet-based psychotherapy treatment programs (Berger, Boettcher, and Caspar, 2011, 2014; Kraepelien et al., 2019; Păsărelu et al., 2017). Notably, the COVID-19 pandemic has forced therapists and their clients to adopt this model during a time of widespread social distancing. This sudden transition has not always gone smoothly, but it does present an opportunity to identify best practices.

The Higher Education Mental Health Alliance has produced a guide to telehealth that outlines the potential benefits, limitations, and legal and ethical concerns regarding such services (Higher Education Mental Health Alliance, 2014), and the American Psychological Association has published guidelines for providing telepsychology services (JTFDTGP, 2013). Additionally, the American Psychiatric Association has developed best practice recommendations and identified special considerations for college students around the use of telehealth during the pandemic (American Psychiatric Association, APA Committee on Telepsychiatry & APA College Mental Health Caucus, 2020). Telehealth may on the one hand broaden access to services but can also pose equity concerns if all students do not have equal access to reliable broadband services. In addition, there is likely to be significant variability in the competence of psychotherapists to conduct telehealth sessions. Moreover, the effectiveness of telehealth across the broad range

of mental health and substance use issues has not been studied in anywhere near the level of detail that traditional therapy has been. This suggests that some caution is appropriate in too widely recommending a telehealth approach.

On the other hand, expanding the use of internet-based therapeutic programs could provide an option that many students, including students of color and those from underrepresented populations, may prefer over face-to-face counseling. Tele-mental health approaches may also be particularly useful for rural or small colleges or for community colleges, where students may lack transportation to reach off-campus sites or where the distance to the nearest provider might be too far to travel. Additionally, by making specific forms of behaviorally focused mental health services readily available within the primary care setting, psychiatric consultation through telehealth to primary health care providers can serve as a mechanism to improve access. Using telehealth, the potential pool of therapists to refer to can potentially be state-wide, rather than limited to the local community. As institutions build capacity for care via telehealth and other internet-based services, it will be important to conduct ongoing assessments of outcomes and experiences.

The Imperative to Provide Equitable Support to Students of All Identities

As colleges and universities work to determine how to increase mental health services, leadership should ensure that the personnel, resources, and programs are inclusive of the identities of individuals represented on the campus and historically underrepresented in academia. Programs should review the use of language, images, and examples to decrease bias, reduce harm, and to ensure representation. Exclusionary language and imagery can pose harm to students’ sense of belonging, harm their mental health, and create a sense of alienation from others on campus. For non-binary students and students who are sexual and gender minorities, forms that limit gender selection to “female” and “male,” for example, suggests that their gender identity does not exist or is not important enough for recognition.

In the absence of such intentionality, some solutions might exacerbate mental health care disparities by further marginalizing those who may experience particularly high levels of stigma related to health-seeking behavior. Studies have found that the stigma around mental health and substance use treatment services is particularly high among students of color (Cheng, Kawn, and Sevig, 2013; Lipson et al., 2018; Liu et al., 2019a). Additionally, feelings of marginalization and isolation appear to be experienced at higher rates by BIPOC and SGM students (Cabral and Smith, 2011; NASEM, 2016; Wilson and Cariola, 2019). It is worth noting that COVID-19 may exacerbate the existing gap in health inequalities mentioned above. Students from these groups may also experience higher rates of stress related to disproportionately high infection rates and deaths among BIPOC communities.

The Center for Applied Research Solutions has developed a guide, trainings, and technical assistance for supporting students from diverse racial and ethnic backgrounds enrolled at California’s community colleges.¹⁰ This and the Equity in Mental Health Framework, discussed above, are resources that can serve as the foundation and as guides for colleges and universities, assisting them in creating more specific strategies to ensure service to the students on each campus.

Peer-to-peer support initiatives may be helpful in many ways for students of color, particularly when facilitated by a mental health liaison (Naslund et al., 2016). Research has shown that young people with personal and emotional problems and individuals from historically excluded communities are more likely to seek help from their friends and family than from other sources, including mental health professionals (Barker, Olukoya, and Aggleton, 2005; Offer et al., 1991). For international students, peer support may provide community and a sense of connection and may serve as a guide to understanding unfamiliar customs and social norms. In addition, graduate students with strong support from peers are significantly less likely to screen positively for anxiety and depression (Posselt, 2020). Whether and how a peer responds to someone developing mental health problems or who is in a crisis situation can make a difference as to whether appropriate professional help is received. The 12-hour Mental Health First Aid course¹¹ (Kitchener, Jorm, and Kelly, 2017) is specifically designed to train people, including young adults, to provide appropriate help to a person developing a mental health problem or in a mental health crisis (Hadlaczky et al., 2014; Jorm et al., 2019). Peer-to-peer initiatives are powerful not only in building a support system, but also at a more fundamental level, raising students’ knowledge and awareness of these issues and how they play out within their own campus communities (Sontag-Padilla et al., 2018a). However, it is critical to recognize that a consequence of programs designed to raise awareness and empower community members to refer students of concern, is likely to be increased demand for mental health services. Therefore, when considering the implementation of programs such as these, institutions should be prepared for subsequently addressing a growth in demand for services.

Making appropriate mental health services more available in primary care settings can also facilitate students’ access to mental health care and improve coordination between mental health and primary care providers, both on campus and in telehealth services. While some forms of mental health care should be considered for integration with primary care, institutions should also recognize that mental health care is a highly specialized field of independent practice that can exist independently of the primary care environment.

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¹⁰ Additional information is available at http://cccstudentmentalhealth.org/docs/SMHP-Diverse-Racial-Ethnic-Students.pdf (accessed April 27, 2020).

¹¹ Additional information is available at https://www.mentalhealthfirstaid.org/take-a-course (accessed June 24, 2020).

RECOMMENDATION 5-7

Institutions of higher education should work to ensure students have access to high-quality mental health and substance use treatment services. These services can be provided either on campus or in the local community. In order to ensure students have this access:

• After conducting a needs assessment and reviewing available mental health resources on and off campus, institutional leadership should attempt to measure and define the “gap” between need for mental health care and capacity for care. That gap should then be examined for solutions from multiple angles but especially long-term funding strategies and/or community partnerships.
• Institutions of higher education should design and implement culturally responsive services and programs to serve the needs and identities of all students.
• Colleges and universities should make behaviorally focused mental health services more readily available in primary care settings to facilitate students’ access to care and improve coordination between mental health and primary care providers, both on campus and in telehealth services.
• Institutions of higher education should create collaborative relationships in the community that will increase clinician diversity to better serve diverse student populations.
• If counseling centers rely on community-based resources to meet the mental health needs of their students, they should consider investing in case managers/resource navigators to help students connect with these community-based resources.
• Institutions can make wide use of telehealth options for those populations and situations for which it is appropriate.

DEVELOPING FACULTY, STAFF, AND STUDENT CAPABILITY TO SUPPORT EMOTIONAL WELLBEING AND MENTAL HEALTH

As noted in the introduction to this chapter, it takes everyone on campus to contribute to an environment that fosters student wellbeing, helps protect students from developing mental health and substance use issues, and helps facilitate students’ access to services that would benefit them. All those who are in regular contact with students have an important role in this effort. At some institutions, particularly community colleges, faculty are likely to be the only staff members with whom students interact on a regular basis. Faculty-student interactions are also a critical factor in student persistence to program completion and graduation (Boone et al., 2020; Lillis, 2011; Wirt and Jaeger, 2014), and the quality of support from faculty is clearly related to student wellbeing (Baik, Lacombe, and Brooker, 2019; Posselt, 2018a).

However, one result of the narrow focus of current training in Ph.D. programs¹²—the primary training ground for faculty—is that most faculty have not received any formal training to help them create student-oriented learning and research environments where a diverse set of students will thrive (Posselt, 2020). To the contrary, the classroom and lab can be sites in which students experience discrimination, harassment, even assault—often on the basis of marginalized social identities (Lane, 2016; Rojas-Sosa, 2016; Wadsworth, Hecht, and Jung, 2008). At the same time, a major factor contributing to high graduate student attrition rates is a poor relationship with a research advisor, with neglect, exploitation, and even abuse being common complaints, particularly from students from underrepresented populations (Brunsma, Embrick, and Shin, 2016; Curtin et al., 2013; Ong et al., 2011; Spalter-Roth and Erskine, 2007).

Much like the broad diversity and inclusion considerations discussed in the National Academies report Graduate STEM Education for the 21st Century (NASEM, 2018a), the culture of many institutions of higher education and their incentive structures—at both the disciplinary level as well as tenure and promotion within instiutions—have been poorly aligned with creating inclusive environments. Many doctoral students working in the arts and humanities experience isolation and may not have regular meetings with their research advisors. On the other hand, individuals in lab-based programs who share equipment and facilities may encounter interpersonal tensions with other members of the lab or face different challenges working with a principal investigator. Work environments matter greatly for creating a culture of wellbeing (Levecque et al., 2017).

Faculty Can Help Address Student Mental Health Issues

There are several ways in which faculty can help students deal with mental health and substance use issues without directly providing counseling or other treatment services themselves. Most faculty, however, are unaware they can help. Even if they do know this, few faculty have received the training needed to identify problems, refer students for help, and provide students with the means to bolster their wellbeing on their own. Some faculty also have concerns about possible liability issues associated with getting involved. The committee stresses that faculty and staff should not be trained to provide therapy themselves and staff or act in the place of licensed mental health care providers. Instead, faculty and staff should focus on designing learning environments and adopting behaviors that prioritize student learning, emphasize wellbeing, and recognize early signs of distress in students.

Doing so is not impossible—the Healthy Universities program in the United Kingdom (Newton, Dooris, and Wills, 2016) and Australia’s Enhancing University

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¹² Ph.D. programs focus heavily on the development of research expertise to the neglect of knowledge and skills for managing instruction, people, and projects. The National Academies have recommended that these skills be added to all graduate training programs (NASEM, 2018a).

Student project,¹³ for example, are working to do so and could serve as examples for U.S. institutions of higher education to follow. Closer to home, the University of Texas at Austin’s unique Wellbeing in Learning Environments program “helps faculty make small shifts in teaching that could make a major difference in students’ mental health and wellbeing” (University of Texas at Austin, 2019). The National Association of State Mental Health Program Directors (NASMHPD) has issued a guide for staff and administrators that offers advice on recognizing signs and effectively engaging and accommodating students with mental health problems (Jones, Bower, Furuzawa, 2016a). The REDFLAGS model, which has been shown to have utility in community and four-year colleges, is one approach that gives faculty a simple mechanism to flag possible mental health or substance use problems (Kalkbrenner and Carlisle, 2019; Kalkbrenner et al., 2019).

The Red Folder at Penn State University¹⁴ is another method of sharing resources and providing support to faculty, staff, graduate student instructors, postdoctoral researchers, and others who work with students. Penn State designed this resource as a reference guide to recognize, respond effectively to, and refer distressed students for care (Penn State Red Folder). The Red Folder is a physical object, in addition to an online resource, that can serve as a quick reference with resources related to academic, psychological, physical, and safety-risk issues. The University of California also has a Red Folder Initiative,¹⁵ which provides customized information about common signs of student distress. The counseling center provides a brief training on the folder that includes guidance on emergency contacts, follow-up tips, and how to connect students with the most appropriate resources (UCOP Red Folder). Though the efforts described above are rooted in knowledge from peer-reviewed research, evaluations of these efforts that account for the diverse experiences of students from different demographic groups and in different institutional contexts will be important for understanding the efficacy of these approaches in supporting student mental health.

In addition to identifying students in need and referring them to campus resources, faculty can support student mental health by taking steps to design learning environments that prioritize student learning and wellbeing (see Box 5-6 for an example of a program promoting student wellbeing at the University of Texas at Austin). For example, faculty can make use of the resources provided by the Universal Design for Learning framework, which offers guidance on how “to improve and optimize teaching and learning for all people based on scientific insights into how humans learn.”¹⁶ Among the guidance offered by this framework

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¹³ Additional information is available at http://unistudentwellbeing.edu.au/framework (accessed April 30, 2020).

¹⁴ Additional information is available at https://redfolder.psu.edu/ (accessed August 26, 2020).

¹⁵ Additional information is available at https://www.ucop.edu/student-mental-health-resources/training-and-programs/faculty-and-staff-outreach/red-folder-initiative.html (accessed August 26, 2020).

¹⁶ Additional information is available at http://udlguidelines.cast.org (accessed November 12, 2020).

are strategies for (1) reducing threats and distractions that can undermine learning and (2) identifying pedagogical approaches that contribute to student stress. For example, research has shown that some approaches to active learning exercises in STEM classes can lead to student anxiety (Cooper et al. 2018).

Faculty can also support student wellbeing through effective mentoring; however, institutions of higher education, with few exceptions, have left mentoring to happen organically or on an ad hoc basis, as was noted in the 2019 NASEM report The Science of Effective Mentorship in STEMM (NASEM, 2019b). As that report details, good mentorship is an acquired skill and faculty and staff can learn the skills they need to become good, supportive mentors. The Entering Mentoring curriculum, for example, has been used to educate thousands of mentors in the United States (Pfund, Brandchaw, and Handelsman, 2015).

Taken together, what the committee envisions is an approach that would provide faculty with basic training in four areas:

1. how to identify, initiate conversations with, and refer to treatment those students who may be having problems with mental health or substance use
2. how to make learning environments inclusive and supportive of student wellbeing
3. how to model preventive strategies and coping skills in class
4. how to improve mentorship and pedagogical skills so that relationships and instruction support wellbeing.

To involve faculty more directly in efforts to address student mental health, faculty will require adequate support, including training, from the institution. For example, it is well documented that women and faculty of color bear a disproportionate burden of providing mentoring and student support, which extends to supporting student mental health. Therefore, there is a need to ensure that the responsibility and time for supporting students is equally distributed across faculty. To this end, faculty should be expected to and be rewarded for supporting students in this manner, including through formal evaluation processes such as tenure and promotion.

In line with recommendations from a recent NASEM (2020) report that examined promising practices for addressing the underrepresentation of women in STEMM, academia should similarly take steps to formally recognize, support, and reward efforts toward enhancing student wellbeing for faculty members, as well as those counseling staff who have taken on more of the service burden. Promoting student mental health is everyone’s responsibility to the extent possible.

RECOMMENDATION 5-8

Provide and require faculty training on how to create an inclusive and healthy learning environment.

• Provide and require faculty training about how to recognize students in distress and appropriately refer them to appropriate care.
• Provide mentor training, starting in graduate school, for all faculty, recognizing that good mentorship practices serve as a protective factor for student mental health.

Raising Mental Health and Suicide Awareness

In addition to developing capacity to address student mental health and substance use issues, institutions of higher education must take several other steps to benefit their students (Travia et al., 2019). The first is to reduce the stigma associated with seeking help for mental health and substance use issues. The California Community Colleges, for example, have used a suite of six online, interactive training simulations from Kognito, a for-profit entity, to reduce stigma and engage faculty, staff, and students in supporting those exhibiting signs of distress. The result was a 73 percent increase in the number of students that faculty, staff, and students referred to mental health services across 113 campuses (Kognito, 2016; Sontag-Padilla et al., 2018c). Other campuses have developed websites listing all available mental health and substance use resources on campus and in the community or used posters around campus alerting students how to access help if they are suicidal or otherwise suffering emotionally. This type of intervention would help to better align interventions designed to increase referrals with growing service capacity to accommodate increased referrals.

Institutions of higher education can also help prevent suicide, the second leading cause of death among U.S. college and university students (Liu et al., 2019; Turner, Leno, and Keller, 2013). Researchers suggests that “preventing suicide on college campuses requires a systemic approach supported by broad campus-wide cooperation. Students who die by or attempt suicide typically do not seek professional help before doing so, making outreach, faculty and staff training, and good referral systems even more critical” (Brownson et al., 2011, 2014). A comprehensive approach to suicide prevention includes promoting social networks and connectedness, improving access to mental health services on and off campus, identifying and assisting students who may be a risk for suicide, and being prepared to respond when a suicide death occurs (SPRC, 2020). These strategies, in conjunction with the policies and procedures that support them, are what constitute a campus-wide suicide prevention plan. Ideally, such a plan is embedded in policies throughout the college that are part of a larger plan to support student wellbeing. Numerous organizations have developed guides to help colleges and universities develop suicide prevention programs (JED Foundation and EDC, 2011; SPRC, 2004).

Along these lines, many institutions have established behavior intervention teams¹⁷ (HEMHA, 2012; JED Foundation, 2013). According to the JED Foundation, these teams “promote student, faculty, and staff success and campus safety by facilitating the identification and support of individuals who demonstrate behaviors that may be early warning signs of possible troubled, disruptive, or violent behavior” (Jed Foundation, 2016).

The main reason colleges and universities establish such teams is to “provide a mechanism for improved coordination and communication across a campus or system, especially when various departments are perceived to be or are actually operating in their own silos” (HEMHA, 2012, p. 3). Areas of concern, according to the Higher Education Mental Health Alliance’s guide for such teams, include psychosocial and mental problems that may “both interfere with adequate and successful functioning that, if unaddressed, might lead to a dangerous outcome to the student or the community” (HEMHA, 2012, p. 4). The appeal of this approach is the possibility of identifying problems and intervening before they become potentially dangerous (see Chapter 4 for more information about campus response to student death by suicide).

Account for the Importance of Communities in Shaping Student Wellbeing

Research has shown that communities, not solely individuals, shape health, and college and university communities are no exception (Slusser et al., 2018; Sontag-Padilla et al., 2018b; Weil, 2014). The healthy campus movement, ongoing at numerous institutions of higher education, is built on efforts to engage the entire campus population of students, staff, and faculty in building physical and mental health and wellbeing into a college or university’s culture.¹⁸ Examples of programs under way include Healthy CUNY at City College of New York, the University of California, Los Angeles’s Health Campus Initiative, Duke University’s DukeReach, The University of Texas at Austin’s Wellness Network, the integrated health and wellness program at Jefferson Community College in rural New York, Dartmouth College’s Mentoring with Purpose Program, and The University of Wisconsin-Superior’s Pruitt Center for Mindfulness and Wellbeing. National efforts are also taking hold, such as those promoted by Active Minds, the National Center on Safe Supportive Learning Environments, Healthier America, and Bringing Theory to Practice. The Gallup Organization even offers a “Wellbeing University Certification” that provides a tailored strategy to promote campus

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¹⁷ The focus of Behavioral Intervention Teams varies. Some campuses have one team that covers all issues, while others have specific teams for emergencies and threat management.

¹⁸ Additional information is available at https://www.acha.org/HealthyCampus/Implement/MAPIT_Framework/HealthyCampus/Map-It_Framework.aspx?hkey=bc5a1b28-ae96-4f06-b3ee-ed492441e7db (accessed April 28, 2020).

wellbeing.¹⁹ The common feature of all of these initiatives is that they recognize that institutions of higher education have the capacity to infuse health and wellbeing into their campus cultures, but only with the support and engagement of all of the siloed interests and communities that exist on campus.

Provide All Students with Formal Instruction on How to Develop and Maintain Wellbeing

One suggestion the committee received during its information-gathering activities was for institutions to develop a course for all entering students, graduate students, and professional students that teaches them how to maintain wellbeing, continually aspire toward being well, and overcome the inevitable challenges they will experience both in college and in life. It is not clear that an entire, semester-long course is required, but it is the committee’s judgment that every student should receive some formal education or training on the concept of wellbeing and how they might maintain it in the context of the pressures surrounding higher education. The issues may differ based on the program level (undergraduate, graduate, and professional) and could include custom features to address specific program elements, such as thesis work, field or off-site research, or comprehensive exams. This training, which might be deliverable through a web-based program (Ahmad et al., 2020), could also inform students as to what they should do when experiencing a mental health or substance use problem.

NASMHPD has a free toolkit for students who have received treatment for early mental health issues that offers specific modules with concrete advice on how best to obtain support on campus and thrive in their pursuit of higher education (Jones, Bower, and Furuzawa, 2016b). Other resources include Becoming a Master Student (Ellis, 2017), which provides diverse information focusing on whole-person development, and Kognito, which offers online student mental health workshops that engage students in role-play conversations with virtual humans. Kognito’s simulations have been used with Native Americans (Bartgis and Albright, 2016), Latinx students (Albright, 2018), veterans (Albright and McMillan, 2018), and SGM students (Marshall, 2016). It is important to note that there are many non- and for-profit entities entering the virtual space around mental health, and not all of the services have been created based on evidence (see Chapter 2 for additional information).

Institutions, including medical schools (Slavin, 2018, 2019; Slavin, Schindler, and Chibnall, 2014) and community colleges (Cuseo, 1997), that offer such courses have found they help promote a healthy transition to the institution (Choate and Smith, 2003; Ellis, 2017; Lockwood and Wohl, 2012). For example, Choate and Smith found that “the infusion of a wellness model into the

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¹⁹ Additional information is available at https://www.gallup.com/education/194297/student-life-outcomes-matter.aspx (accessed June 15, 2020).

curriculum of a required orientation course for first-year students was related to changes in student wellness,” as measured by a “quantitative analysis of student WEL score profiles and an analysis of students’ written reflections.” Students reported “that the wellness model enhanced their learning through increasing self-awareness, self-direction, recognition of the interrelatedness of all life areas, the identification of strengths and areas for improvement, and appreciation for the specific application of strategies for change” and demonstrated improvements in target areas for improvement, according to their WEL score profile, in areas such as stress management and nutrition (Choate and Smith, 2003). Similarly, Lockwood and Wohl found that “a lifetime wellness course can improve physical self-efficacy and promote changes in wellness behaviors, especially in the area of physical wellness” for students (Lockwood and Wohl, 2012).

An additional important role these courses play is to raise awareness about the resources available for students in need (Canby et al., 2015; Conley, Travers, and Bryant, 2013; Dvořáková et al., 2017; Parcover et al., 2018; Stephens, Hamedani, and Destin, 2014; Walton and Cohen, 2011). Such a class could also serve as a community-building activity that engages students in efforts to create a wellbeing-supporting culture across campus. Consistent with other recommendations, institutions should be aware that courses like these are likely to increase the demand for mental health and substance use services as a natural consequence of raising awareness of those services. Without education and raising student awareness, simply increasing access to services will not suffice.

RECOMMENDATION 5-9

As a part of formal orientation to college life, all students should participate in structured opportunities to learn about individual wellbeing and the cultivation of a healthy, respectful campus climate. This orientation should also include material on how to develop resilience in the face of inevitable challenges they will experience both in college and in life.

• To enable students’ self-awareness and resilience, training should acknowledge how behaviors such as sleep, nutrition, exercise, social media, and work can be both levers for wellbeing as well as affected by wellbeing.
• Training should also include information on how to recognize and address implicit bias, and about the essential role students themselves play in creating a community that supports each other’s wellbeing.
• Each institution should also periodically offer refresher or “booster” training on these issues.
• Institutions should regularly and widely provide guidance to students and faculty on mental health resources available on campus and in the community.

RECOMMENDATION 5-10

Institutions of higher education should recognize that there is no single approach to promoting wellbeing and dealing with mental health and substance use problems that will be appropriate to all student populations.

• Support services should be tailored to the unique histories, circumstances, and needs of individual student populations.
• Support services should recognize and respond to the fact that many students from diverse populations will have experienced interpersonal racism, systemic racism, and implicit bias both before and during their time in higher education.