On the Brink

Allison,* Trinity '99, was diagnosed with severe depression while still in high school. She sought therapy and was on an antidepressant for a year and a half before matriculating to Duke. She came hoping the problem would remain part of her past. "I though that no one could tell," Allison says. "I was wrong."

When a Duke professor's daughter--an undergraduate at the University of Michigan--recently killed herself, the issues of suicide and mental health hit the Duke community for the first time in several years, begging the question, "How well prepared is Duke to deal with such a crisis on its own campus?"

In terms of numbers, Duke has been fortunate. Since 1996, four students have committed suicide--well below the three-per-year national average at peer institutions--says Director of Counseling and Psychological Services Jim Clack.

In an academic year, CAPS receives reports of about 12 suicide attempts. Approximately 20 percent of the students who use CAPS report some kind of suicidal intent or thoughts.

In an era when student stress levels have reached unprecedented heights and when counseling has become generally accepted by mainstream America, Duke has succeeded in providing its student body with psychological assistance. But the system is not perfect. Not all CAPS patients have stories that end happily.

All patients begin the process by filling out a questionnaire that attempts to assess their attitudes and mental state on a variety of issues.

Then a counselor conducts a one-on-one intake interview--standard procedure at many universities.

During the initial session, counselors attempt to address the issues raised in the questionnaire, much like a physician.

"I explained, quite distressed, that this would be a problem because I couldn't financially handle it on my own and didn't want to bring my father and his money into the middle of it all, since money issues with him tended to exacerbate my anxiety and make me more depressed. I asked [the counselor] if I could just come see a [CAPS] counselor a few more times. She said, ONo.'"

Why could CAPS not see a student like Allison?

"You might equate us to the general practitioner of the mental health world. We're not equipped to do major surgery," Clack says, adding that the program refers just six percent of its cases to outside psychiatrists, and only when special attention is needed.

Staff numbers are not an issue, with two CAPS members hired in the last year. More than 11 counselors and a small intern staff place Duke's program within the 75th percentile of universities, says Clack.

But taking on the small percentage of severely ill students monopolizes the counselors' time. "At [the University of Texas at Austin], there were no limits on how many times a student could see a counselor. We discovered there, that because of our system, 15 percent of the students were using 70 percent of the counselors' time," Clack says. Duke's CAPS tries to see students no more than once a week to ensure resources are available for as many undergraduates as possible.

CAPS is not obligated to provide treatment. "When a student comes in, they are given a set of forms that guarantee their confidentiality and also explains that CAPS does not guarantee treatment," Clack says.

This lack of a guarantee is one of the most frequent complaints about CAPS, but the policy works to keep services available. Still, when a semester starts, students begin to feel the academic crunch; by the second month, CAPS has a wait list. Clack said the list can skyrocket, especially during exams.

Elizabeth, Trinity '00, sought CAPS' help when she felt depressed. After drinking heavily during a semester abroad, Elizabeth was diagnosed with clinical depression and prescribed Prozac. When she returned to Duke, she could not see a counselor for weeks. When she finally did, she said she found her counselor inattentive, focused on lecturing her and more interested in resuming her Prozac course than providing further treatment. She stopped going to CAPS.

Her condition worsened and the next spring, she attempted to commit suicide. Her roommate found her after she had swallowed a bottle of medication, forcing her to have her stomach pumped. At the insistence of her parents and a dean, she returned to CAPS.

Despite the long waiting period and her disconnection with her counselor, Elizabeth does not blame CAPS for the escalation of her problems. "[CAPS] gave me good advice and I did not listen to all of it," she said. "They seemed not to have the time to follow up on me. I wish the course of treatment had been more proactive."

Clack, too, wishes that CAPS had more resources, but even with its problems, CAPS is not without success stories.

Brian, a senior, recently began going to CAPS for his depression. "Absolutely CAPS has helped me, and continues to help me," he says. And while Brian's condition may not be as severe as those of Allison or Elizabeth, he does not feel his condition has received a lower degree of care, but was treated in a manner to best fit his needs.

"Some students come in here expecting us to tell them the answers. And that isn't how counseling works," Clack says. Most students who seek help understand that, and with growing public acceptance of mental health care, are taking a more active role in their treatments. Clack notes that when CAPS' course of treatment ends, students fill out another questionnaire. Ninety-five percent of students report improvement.

As for suicidal students, Clack is pleased with CAPS' results but says that care for a suicidal person often begins with friends and roommates, as in Elizabeth's case. He feels the Duke community as a whole looks out for suicidal behavior.

For Allison, it ended up taking the cooperation of her family, her academic advisors and CAPS to make her well again. She did go to the psychiatrist CAPS suggested but found that he was unable to assist her. Her condition worsened. "I started shaking uncontrollably, a symptom that increased over the next month or so until I would lie in bed convulsing all night. I couldn't type, write or hold on to my silverware. I was too embarrassed to go out in public."

CAPS was there to help. Despite the usual end of the semester backlog, CAPS saw Allison immediately after a sympathetic dean intervened. She was able to finish the semester and with medication, overcome her symptoms. And though later diagnosed with manic depression, she has since learned to control her condition and, like Elizabeth, credits CAPS for helping her overcome her problem.

The hardest part of measuring CAPS' success is that its results are not publicly visible, but are in the students who get up and go to class every day, and who with treatment and counseling, manage to recover the will to live.

*Allison, Elizabeth and Brian are pseudonyms for students who spoke to TowerView on the condition of anonymity.