University life has always fascinated me. My own experience of going to university was intense and positive, but many of the people I have met professionally have – perhaps by definition – described painful or damaging experiences. I was the first person in my family to get a university degree, and since that time I have been the daughter, sister, cousin, mother, aunt, friend, colleague and teacher of students and staff in a large variety of higher education institutions across the UK. I have observed a kaleidoscope of shifts and changes in different institutions and faculties, across the UK and over half a century.
More students than ever are now disclosing a psychiatric diagnosis. The report ‘Student Mental Well-Being in Higher Education’ (Universities UK, 2015) found that the proportion of students who declared a mental health condition doubled from 0.4% in 2007–8 to 0.8% in 2011–12. By 2018/2019, 4.3% of UK students (5.3% of females and 2.8% of males) disclosed a mental health condition to their higher education institutions (The Insight Network, 2020). This may not indicate increased rates of mental illness so much as increased willingness to seek support, as universities made concerted efforts to facilitate and normalise disclosure. One international study found that a fifth of university students (from 21 different countries though not the UK) had a mental health issue. Four fifths of these students had been diagnosed before they started at university (Auerbach et al., Reference Auerbach, Alonso and Axinn2016). More recently, the Dunedin Birth Cohort Study found that by age 18, half of the population meets criteria for at least one diagnosable mental disorder (Caspi et al., Reference Caspi, Houts and Ambler2020).
In my long career as a psychiatrist, I have developed a long-term interest in the welfare of students and other young people. I’ve worked variously in child and adolescent mental health services, adolescent and adult eating disorders services, trauma clinics, and liaison and psychotherapy settings, and have taught and supervised counsellors and mental health mentors in different universities. This is a single-author text not because I claim specific expertise in every key topic, but because the most successful aspects of my career have involved making connections and building networks. The intention is that each chapter (or in some cases a small group of two or three chapters) should stand alone. Readers can plunge into whichever topic they most need to consider, without having to start with this introduction and read through to the end of the book. I have avoided too much repetition by signposting readers to other relevant chapters within the text.
Since Cambridge University Press first invited me to write a handbook called Improving Student Mental Health the title has evolved further. There were already several excellent handbooks from the United States, where a great deal of research is focussed, but where the legal, welfare and cultural context is different. We decided to specifically address the UK experience, whilst obviously drawing on relevant research and experience from across the globe.
As I began to write, and to realise the importance of a ‘whole university approach’ to well-being and mental health, I asked for a further change in title, to ‘University’ rather than ‘Student’ mental health. In fact, this is a convenient clarification too, as US English tends to use the word ‘student’ to include children and teenagers attending school, as well as those in higher education.
I have devoted Chapter 13 to consideration of the roles and needs of academic and teaching staff in terms of mental health, but virtually all the chapter topics raise issues of staff responsibilities and vulnerabilities. I addressed Chapter 4 to the roles and concerns of parents and families, to validate their important stake in shaping university health. Alumni are also becoming increasingly important as investors in the financial and cultural health of their former institutions, and all taxpayers and voters in the UK are, to some extent, stakeholders in our universities.
I am glad I rejected the title ‘Student Mental Health’ because it now seems not only exclusionary but also somewhat condescending. It might imply that students are the objects of concern, and that mental health is something for others to address. We have seen a huge rise in the power of people with ‘lived experience’ of health conditions in the design of support and services. Collaborative work is a way to recognise the expertise and strengths as well as the vulnerabilities of the student age group as well as their experience of mental health and ill health.
It is important also to challenge the dichotomy of ‘us’, the adults and professionals who are ‘unflawed and powerful’ and ‘them’, the students and patients who are ‘vulnerable and young’. I was a patient before I even thought of becoming a doctor, and as a psychiatrist I am even more aware of my own psychological vulnerability. We are all likely to develop a diagnosable mental disorder at some point in our lives (Caspi et al., Reference Caspi, Houts and Ambler2020), whether we may be politicians, vice chancellors, professors, parents, domestic staff, secretaries or students.
At the same time, this book constantly has to debate the question of whether young adults should be expected to shoulder full adult responsibilities, or whether we are buying too much into what Terri Apter (2008) called ‘the myth of maturity’. A university is like a laboratory or a gym where young as well as mature adults can experiment in building their own society under carefully controlled conditions. Sometimes the question arises as to how much outside control is beneficial both in its own right, to enhance health and learning, and to protect against unhealthy outside influences.
Finally, I even questioned using the optimistic word ‘improving’ in the title. The book was commissioned just before the world unexpectedly went into lockdown. I became distracted from the project by my desire to join emergency clinical activity during the pandemic. When I returned to the book, I was appalled by the consequences of COVID and lockdown, particularly for university students. The group of people at lowest physical risk from COVID was obliged to pay the highest psycho-social penalty. The worst restrictions overshadowed the very years when they had expected to live out a major life transition.
As we emerged from the worst self-isolation, waiting lists for psychiatric services for young people had ballooned and there has been talk of a ‘mental health pandemic’ to follow the COVID pandemic.
I returned to my writing, fearful that existing research would be inadequate to the plight of the universities. Subsequent global and political events have added further concerns. The aspiration to ‘improve’ matters seemed arrogant. Even restoration to previous levels of mental health sounded ambitious. As we have moved into a ‘new normal’ though, it feels reasonable to return to the idea of ‘improvement’ even if this is from a new and lower baseline than before.
The commonest question from potential readers has been ‘who is the intended audience?’ If you are reading these words, then the answer is ‘you are!’ Those readers who are seeking a series of simple answers to the multitude of mental health dilemmas posed in university life will come away disappointed. I am disappointed myself and would have loved to come up with a series of training manuals on ‘How to be a Mentally Healthy Student’, ‘How to be the Perfect University Parent’, ‘How to Behave at all Times as an Effective Director of Studies’, and especially ‘How Ministers of Health and Education Can Legislate for Mentally Healthy Universities’.
Individuals and institutions are too diverse in terms of populations and resources, research is both inconclusive and constantly obliged to deal with new challenges and developments. Improvements seem to come about through dialogue and experiment, rather than as a series of getting right answers right away. Each chapter emerged as providing an overview of the overview of the context with vignettes to bring the topic to life. I tried to find examples of good practice and good progress as well as examples of unmet needs. I have concluded each chapter with ‘practice points’, which are comments and suggestions to different groups of readers.
This book has emerged as a basic overview of the state of UK university mental health in the 2020s. I hope it will inform those who need to get the best out of the provision that is there, and stimulate debate and action from all who have power to make improvements.
