University Student Mental Health

Version 2In these uncertain and anxiety-provoking times, our universities have an increased responsibility to support student mental health and wellbeing. This is not about the issues of “spoiled and coddled” Gen Xers, helicopter parents, and the endless debates over the use of trigger warnings in higher education. This is about having a positive impact on not only our future workforce, but also our future leaders and change agents.

William Pang, a second-year student at McGill University in Montreal, wrote a moving NYT op-ed piece “The Season to Be Stressful” (December 19, 2016). He discusses his experience of learning to deal more effectively with overwhelming anxiety exacerbated by the highly competitive atmosphere of his university. He states, “I don’t think we should demonize an entire generation as reliant and narcissistic. We should instead celebrate a generation that is coming to realize the importance of initiating conversations about our mental health.” It is dismaying to read through the NYT comments to Pang’s op-ed piece with so many people basically telling him to buck up and become an adult.

The photo above is of me with the amazing UK nurse and PhD student Josephine NwaAmaka Bardi  with her social media campaign, “Raise Awareness of Mental Health in Higher Education” (#RAMHHE)  I met NwaAmaka Bardi this past September in Seville at the 5th Annual International Health Humanities Conference: Arts and Humanities for Improving Social Inclusion, Education and Health. She also works in the area of mental health cafes as an effective alternative community mental health service. London’s Dragon Cafe is a good example of a creative, welcoming, and supportive community cafe with a focus on mental health and wellbeing. It would be great to have a similar community cafe open to university students.

Universities UK is developing a mental health framework for universities to embed mental health and wellbeing across all university activities with the goals to decrease stigma and increase access to a variety of mental health and wellbeing services. (See: “New Programme to Address Mental Health and Wellbeing in Universities” December 2, 2017.) They point to the need of “getting universities to think about mental health and wellbeing across all their activities, from students and teaching, through to academics and support staff.” It doesn’t end with the provision of mental health and support services for students but needs to permeate the entire campus.

Doris Iarovici, M.D., a psychiatrist at Duke University Counseling and Psychological Services has written a book titled Mental Health Issues and the University Student (Baltimore: Johns Hopkins University Press, 2014). Although geared towards college mental health professionals, it includes useful information on the variety of mental health issues that our students face in universities—from anxiety, drug and alcohol problems, sexual assault, eating disorders, and relationship problems, to depression, suicide, and schizophrenia. She concludes by stating, “If we provide a range of services, including individual, group, and community programs, we will be in step with the goals of health care reform to focus on both prevention and optimizing outcomes.” p. 219

A Place To Stop


Stop (Photo credit: Swamibu)


In our narrative medicine course we have moved into group presentations. On the first day of the quarter I had students sign up to be in one of eight groups to work on group projects and to do a group in-class presentation. I picked eight topics, using the list of topics (keywords) from NYU’s Literature, Arts, and Medicine
as a guide. The eight topics I chose this summer were: Aging, cancer, death/dying, disability, drug addiction, infectious disease, mental illness, and racism. The group assignment was to research and expand upon the topic resources listed in the NYU database—to approach this as if they were doing an in-service training on the topic at their work site. I asked them to produce a one-page (front and back) handout of their favorite resources, along with two to four possible in-class writing prompts and reflective questions. Each group was given 45 minutes to present on their topic and to lead the class in discussion and reflective writing. (Note: our class sessions are four hours long, although we don’t typically go quite that long).

This past week the first two groups did their presentations (on aging and cancer) and both did an excellent job. The groups used an interactive PPT presentation, weaving in poetry, prose, artwork, comic books, YouTube videos, and movie clips. I was impressed by the range and depth of their presentations and class discussions, as well as their application of the close read drill adapted from Dr. Rita Charon’s work. Group members also shared some of their personal stories related to their health topic and did this in a moving but professional way.


When I was planning this narrative medicine summer course, I was resistant to the idea of building in group projects. As a student I always preferred to have individual assignments since I could then control the time commitment and the outcome. I knew that the majority of my students in this course would be busy with their nursing jobs and families as well as with school. But a colleague convinced me to use group projects, saying the students were used to them and that what they came up with was typically of high quality. I have purposefully allowed time at the end of each class session for students to meet in their groups for planning purposes and I stay around to answer any questions that may arise. Some groups have also set up online discussion boards on our course website to facilitate their group planning. (In my mind, this is the only really useful function of online discussion boards.) That seems to have worked well for them so they don’t have to meet in person outside of class.


Two things particularly struck me from the in-class presentations and discussions. One was the number of students who had personal experience with either a close friend or family member or a patient who was given a diagnosis of a serious cancer over the phone or in a voicemail message. We talked about how insensitive that is and what nurses can do to influence physicians, nurse practitioners, and other healthcare providers to think through how to give bad news in a more supportive way. The other thing that stood out to me in the class discussion was a comment a student made that this narrative medicine class is “A place to stop and to process these things we don’t get to process.” Other students said they agreed with what she said and talked about how nurses are so much into the care giving role, not only at work but also in their personal lives, that having a time and space to stop and reflect on how it is affecting them is a powerful thing.


Ah yes. There were really three things that struck me during last week’s class session. The third was that this is all heavy stuff to process and write about and how much environmental context matters—as in the actual physical classroom setting. We have a nice smallish amphitheater classroom with excellent acoustics, state-of-the-art audiovisual equipment that is easy to use, reasonably comfortable chairs and tables, and a full bank of windows looking out over a grassy marsh full of birds. I’d forgotten what a pleasure it is to teach in a classroom with windows. It also helps that it is one of the loveliest summers in Seattle’s history. Teaching this narrative medicine course in a windowless classroom in the middle of a Seattle winter would have a much different feel.



Cultivating Empathy

Three Way Mirror
Image via Wikipedia

I’m continuing on my line of thought from my last post “On Reflection,” and have been considering how reflective practice and its counterpart of empathy can be taught in nursing school. How can we do a better job of helping students grow in emotional and moral maturity? How can we as health care providers and teachers do a better job of growing in our emotional and moral maturity?

Maura Spiegel who teaches in the Columbia University Narrative Medicine program gave a talk “Reconceptionalizing Empathy” last fall at the Narrative Medicine workshop I attended. She maintains that empathy cannot be taught, it can only be cultivated, and that a common mistake for health care providers in thinking about empathy is the idea that “I can know you—or that empathy can be a conduit into a patient’s inner life.”  The psychoanalyst Donnel Stern maintains that empathy is an interpretation like any other observation, and that empathy is often implicit knowing or “pre-reflective unconscious, an unthought known:” a dimension of experience which is in some sense known, but not yet available to reflective thought or verbalization.”

Metaphor, poetry and art speak directly to our implicit knowing—they are, in Maura’s words, “mediated sources of understanding.” In health care, this is where narrative medicine and the medical humanities step in. Attentively watching movies, reading novels or poetry—or writing and reading our own stories—can tap into the sources of empathy. Language can become an ally again, and the experience of empathy can be made available for reflection. Making more room in nursing curricula for narrative medicine/nursing would be one way to help cultivate empathy in students—and perhaps even in faculty members.

Being able to access empathy and then to reflect on the experience are important skills for nurses. Certain patients or health care situations will affect us more than others. It is easier to have empathy for patients we assess as being “like us” in whatever aspects. Patients, groups or populations viewed as “the other,” are more difficult to have empathy for.

I recently read a collection of essays called The Other by Ryszard Kapuscinski (Verso, 2008). Over his long career as a journalist, he traveled throughout the developing world, reporting on major wars and revolutions. Kapuscinski was influenced in his thought by the philosopher Levinas, who is known for the phrase, “the self is only possible through the recognition of the Other.” Kapuscinski extends that thought by writing, “…the Other is a looking glass in which I see myself, and in which I am observed—it is a mirror that unmasks and exposes me, something we would prefer to avoid.”

Whenever we talk about “The Other” or “Othering” in nursing education, it is almost always in the context of working with patients and groups from “other cultures” or who have stigmatizing conditions such as schizophrenia. We don’t do a very good job at helping students to use their own inevitable discomfort in looking in that mirror to see what is reflected back, to see what is exposed. Sometimes these sorts of issues get handled by students in reflective journals in their clinical rotations, and sometimes it gets discussed in small group seminars—but those times are very few and almost seem to happen by accident. They aren’t explicitly cultivated. One of the problems that I see is that nursing faculty aren’t very comfortable in looking in the mirror themselves, so they aren’t able to model that for students. Encounter Groups for nursing faculty sound like a horror movie in the making, and continuing education conferences on how to cultivate empathy are close behind in the shudder index. One promising change may be that the next generation of nurse educators will be—well—younger, and perhaps more widely educated, more well-traveled, and further along on the emotional and moral maturity scale. That’s my hope.