Opening the mental health files

Freshman move-in day had come and gone just a few weeks before, but late one September night in 1994, Catherine Koppel found herself driving back to Yale, and to her son, Matthew, from her Larchmont, N.Y. home. "He was very upset," Mrs. Koppel said. "He called me and he said he just couldn't cope anymore.... He was suicidal." Mrs. Koppel attempted, by telephone, to make an appointment for Matthew with an on-call psychiatrist at the Urgent Care division of University Health Services. Rules of confidentiality stated that Matthew had to appear in person to make his own appointment, so Mrs. Koppel rushed to New Haven to accompany her son to UHS.

"He went in [to his consultation] alone. A little while later he came out and smiled at me, and said, `It's nothing, Mom. It's just freshman anxiety.' I had been expecting him to come out with either a prescription or to be sent to a hospital. But they told him that all freshmen go through this.

"The floor went out from under me. It was a horrible feeling. I thought, I must be stupid, I misread Matthew's signals. Now I think of that psychiatrist and think, `That's the person who misread Matthew's signals.' " Matthew Koppel, BR '98, committed suicide this past July; Catherine Koppel spoke at her son's Battell Chapel memorial service last week.

In telling a story of mental or emotional illness, there are no clear lines: they are drawn, blurred, and crossed. Discerning between a bad case of the blues and clinical depression, deciding when crisis is pitched high enough to warrant a breach of confidentiality--these are decisions made hour to hour, day to day, by doctors at the UHS departments of Mental Hygiene and Urgent Care, as well as by parents, roommates, friends, and deans. At the center of it all are a surprising number of people--one in three undergraduates seeks counseling at Mental Hygiene--who need help but may be too afraid, too proud, or simply unable to ask for it.

A black hole

"I didn't go out, I didn't want to talk to people. I couldn't speak--it was so much effort to say a word, because I knew I would have to say another. I couldn't complete a thought.... I really started to hate my roommates. I'd be sitting in our common room, watching them get dressed up to go out, and I hated them for being able to function. I remember leaving my entryway on this gorgeous day and seeing these girls outside laughing, and I couldn't understand what they could be laughing about. I didn't remember how to laugh."

Anna*, a junior, was not a stranger to depressive episodes. "I would always have a day or two every six months or so when I felt like I was falling into a black hole," she said. But when these dark moments began to come more frequently last year, and mindful of a history of clinical depression in her family, Anna made an appointment with a psychologist at Mental Hygiene and was scheduled for an "intake" session.

"The intake appointment serves as an evaluation: what is the basic problem concerning the student," Dr. Lorraine Siggins, chief psychiatrist at Mental Hygiene, said. "We want to assess what the student's concerns are so that we can weigh our options in terms of treatment." Family medical history, as well as the patient's own record of illness and drug and medication use, are charted, and a therapist is assigned to the patient.

The conclusions the psychologist draws from the session are, necessarily, subjective. "A lot is up to the clinician's judgment," Mark Whisman, a professor in the department of psychology, said. "There are no well-established predictors for what will work between treatment A, versus treatment B, versus medication. It comes down to what the clinician thinks is best and what the [patient] is looking for."

The intake session constitutes the crucial first step in short- or long-term therapy, but proved confusing for some students. "I was a little upset after my intake because I didn't know it was an intake," Anna said. "I really tried to open up to who I thought was my therapist, telling her all these problems and experiences from throughout my life, and then she's like, `Okay, we'll process this and we'll find you a therapist.' " Henry, a recent Yale graduate, found similar frustration with his first regular appointment. "I told [my therapist] my story, and she says, `I know this might be hard for you, but I have to assign you to someone else because I'm leaving in a few months.' After I had totally spilled my guts."

"[Mental Hygiene seems to] hire young doctors who like to leave as soon as they can," Becky, a senior, said. "My therapist left for another position over the summer. I had to switch therapists this year, which was stressful.... It would have been nice to know she was leaving."

Siggins, who has been with the department for 30 years, said that the rate of turnover "is sort of variable. There are people who have been here 10 years; there are people who are in and out in a year or two. We like to have a mixture of new people and people who have been here awhile." Since 1993, 10 psychiatrists have joined the department and four have departed; among clinical psychologists, four have arrived and two have since left. In just five years, the department's staff--including several social workers and counselors specializing in sexual problems and substance abuse--has grown from 22 to 38 members.

In loco parentis

"It's weird to get plugged into a bureaucracy so quickly," Emma, a junior, said. "I go to my dean one day hysterical, and the next day I'm going through all this procedural stuff. It didn't seem very human."

Emma broke down shortly before Thanksgiving break during her sophomore year. "I had been depressed for a while. My friends knew but no one really talked about it. I found out that a paper was due that I didn't know about because I hadn't been going to my classes. I freaked out, went to my dean, said, `I want to drop out of Yale. I don't want to be here any longer.' " Her dean called in Emma's college `liason,' a clinician who acts as an intermediary between the dean and Mental Hygiene. "So I go to see her the next day, and then she referred me for an intake appointment with another psychologist, then I was referred again to what she called the `appropriate' psychologist. At that point it was just too much; I decided not to go." Emma sought outside help with a private-practice psychologist.

"Different deans use their liasons in different ways," Steven Lassonde, Dean of Calhoun College, said. "If we have a one-time problem that we need consultation on, like a serious roommate problem, we'll call the liason. We don't have appointments with the liason continuously." Saybrook Dean Paul McKinley, DRA '98, added, "The benefit of the liasons is a sense of continuity. They have dealt with issues specific to the college and they know the community."

Of course, the "in loco parentis aspect" of a dean's responsibilities, as McKinley put it, makes each dean the most vital link between undergraduates and any department of UHS. A dean's dual roles as academic authority and dispenser of advice can't help but occasionally collide, especially in cases of mental or emotional illness. Like a therapist during an intake session, much comes down to judgment calls. "I know these students as individuals, and we're not all wired the same way," Lassonde said. "The question I have to ask is, `When do I make an exception to the rule?' I need to be consistent... Of course, I'm not equipped to handle every problem I see. It's my job to point out what help is available. I'm more of a traffic cop."

Davenport Dean Susan Wennemyr said, "My goal is to approach academic and personal problems with the same voice. It's all a matter of choices and consequences. The student has to make a choice."

But as Emma learned, one of the most pernicious aspects of depression is the paralysis it causes--the inability to make choices. "I wanted an easy way out. I hadn't left my room in weeks. I wanted someone to say to me, `You have to go home.' I wanted to be in a position where the choice would be made for me," she said.

When Henry sought his dean's counsel during a depressive episode in his freshman year, he felt he wasn't offered any choices at all. "It was a serious depression. My therapist termed it clinical depression and adjustment disorder. I just wouldn't want to talk to anyone. I would go to sleep when the sun rose, wake up at maybe 11 at night. I was missing classes, dinner--my roommates thought I was a freak."

After seeking therapy at Mental Hygiene, Henry "decided that it was important that I tell my dean my story. We weren't very familiar with each other, but he knew I was getting into trouble. I had a language class and I was going like once a week, never turning in any papers, not going to my other classes.... So I make an appointment to see my dean and I tell him everything. I tell him the whole fucking story. And he says, `You'll get over it.' And then he told me I had to go to my language classes. That was his main priority. I felt trivialized."

"She kept saying, `I'll give you a Dean's excuse,' " Emma said of her encounter with her college dean. "I didn't care. She saw it from an academic standpoint: your classes are at stake. But once I was talking to people from Mental Hygiene--and this was a good thing, despite everything else--academics didn't come up at all."

Strictly confidential

"Therapy [at Mental Hygiene] is I guess what phone sex is all about," Henry said. "You're less inhibited but you're with a real person nonetheless, but there's a weird clinical surreal aspect to it. They keep that professional distance going on. There's not too much of that Ordinary People kind of feeling. You don't call them up because you're feeling bad.

"It helped because [my therapist] was trying to get me to realize that what I was doing and feeling wasn't abnormal, that it did merit this therapy."

"I had a really positive experience with my counselor," Nicole, a junior, said. "It was just the outlet I needed. He would ask leading questions and I would just start babbling. Then he would start pointing out different perspectives that I could see my experiences in." Termed cognitive restructuring, the department's approach "is an eclectic model--we're trying to speak to each student individually," Siggins said. "We observe how people think about things and then offer alternative ways of seeing them, focusing on current issues and relationships."

Both Mental Hygiene and the college deans pride themselves on the strict anonymity they guarantee to students seeking help. "We have to make sure confidentiality is respected," Siggins said. "If a dean or a parent is informed, the student may feel resentment, and that might turn them off therapy later when they're on their own. It's important that that doesn't happen, because we find that depression is often episodic." Exceptions are made, according to Siggins, "if someone's life seems to be in terrible danger."

While Siggins confirmed that a student must "physically come over to the clinic" in order to receive treatment, she maintained that "there is no policy stating that one person can't make an appointment for another," though Catherine Koppel said this was precisely what she was told during her son's first crisis at Yale. "Obviously my son had told me he was in trouble, so it was too much to the letter of their law to tell me I couldn't make an appointment for him," Mrs. Koppel said. "I wasn't doing anything on my own assumptions."

A year later, in September 1995, Matthew attempted suicide in his dorm room in Branford; he then took a leave of absence. "When Matthew came back, no one from Mental Hygiene called him, no one from the Dean's office checked up on him." Mrs. Koppel added, "There just doesn't seem to be any safety net there."

"A bell should have gone off," Nicole said of her own depressive episode, during her freshman year. "I was sleeping so much. There were two weeks when I did not come out of my room except for meals. I'd be up until seven in the morning, brooding, then go to sleep until dinner. My T.A. for French--I missed 26 of her classes that semester. That should have sent a red flag to my dean....The anonymity of it all bothered me."

"If a student had come to me with a problem and I had recommended that they see [a counselor at] Mental Hygiene, I would not feel comfortable calling them afterward to check on how they were doing," Dean Lassonde said. "They may feel as though that were an invasion of their privacy." Dean Wennemyr solves the quandary thusly: "If I refer someone [for therapy], I tell them to make an appointment with me for a few weeks later."

`I'll snap out of it'

The percentage of Yale students who seek treatment for mental or emotional illness is roughly the same as Harvard's rates; surprisingly, freshmen are not disproportionately represented among these ranks, according to Siggins. Yale's overall numbers are considerably higher than those of, for example, State University of New York-affiliated schools; according to Dr. Susan Gale of the SUNY Student Counseling Center, about 20 percent of SUNY students seek therapy. Though many would be anxious to point out the pressures of unusually competitive academic environments as detrimental to emotional health, Mrs. Koppel called Matthew's anguish "self-inflicted. It wasn't Yale. He set standards for himself that he could not meet. Matthew would get very angry at himself, call himself lazy. I would say, `You're not lazy; you're sick.' "

"I didn't even tell my best friend [that I was depressed]," Anna said. "I would have felt like I was whining, like it's not a real problem. And I still sort of feel that way. I feel like, it's just silly. I'll snap out of it."

"This illness is a very perverse illness, because the person who has it, he can't see what's going on," Mrs. Koppel said. "Someone else has to show him that he's sick."

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