Brain Break
Friends describe Janie as an incredibly focused individual, an academic powerhouse, and a “beast” in the athletic arena. In high school, she was a star student-athlete and a nationally ranked swimmer. In college, she has continued to swim for Harvard while rowing for the Radcliffe lightweight crew team.
“I went to a really competitive high school, so I always expected myself to do well,” she said on the phone from her home in New York. This extraordinary drive shaped Janie’s approach to college, and to life. On Monday, she had just returned home from running the Boston Marathon. It was her first time near campus since February.
Janie’s trouble began during Reading Period last fall. The stress of an overwhelming workload—four final papers and three final exams—began to mount; Janie suddenly felt herself losing control over functions that were once habitual.
“Everything just started to slow down, and that just got me even more frustrated,” she recalled.
She described the end of last semester as a downward spiral. Reading became a challenge; articulating thoughts and communicating with friends followed suit. Meanwhile, she withdrew from loved ones. She had been previously diagnosed with clinical depression, but this was a new and frightening experience.
It felt as if her brain were shutting down. “I couldn’t speak anymore,” she said. “I was writing papers and I had nothing to say...I was getting into this really vicious cycle.”
Reflecting on this period, Janie said her emotions peaked at what amounted to an “existential crisis.”
“[I thought,] ‘I can’t write because I can’t think and if I can’t think, why am I alive?’” she said. “It was a huge spiral; it was the biggest kind of slippery slope you could imagine.”
Janie said that while part of her knew she was being irrational, she clung to this reasoning in an attempt to make sense of things. She tried to rationalize her emotions, and became overcome by negativity and self-doubt. During this depressive episode, her supportive family was a lifeline. At the time, Janie felt wracked by guilt.
“I thought, ‘What am I doing here?’” she said. “‘I’m just such a burden to everyone,’—I became extremely suicidal.” Janie returned home after final exams profoundly exhausted. “I was hanging by a thread, and that thread just broke when I got home,” she recalled. She was constantly thinking of death and dying.
At home, Janie sought counseling from a psychiatrist who advised her to take a break from Harvard. She disagreed. She had performed exceptionally well the previous term despite her ordeal. In addition, winter crew training was approaching. She thought the structure and social nature of crew would only help her readjust.
When she returned to campus, however, Janie again felt disconnected from her peers.
In February, she decided to visit Mental Health Services at UHS for an intake session. In the preliminary assessment, Janie relayed her whole story—including her thoughts of suicide. The therapist was concerned. She asked Janie to schedule a follow-up appointment.
But even with her suicidal thoughts and the concerns of those around her, Janie was reluctant to suspend her life at Harvard. She had excelled here and wanted things to work out at school—especially after already having taken a leave for health reasons the previous spring.
A COMMON CRISIS
Despite her sense of isolation and her qualms about a second leave, Janie’s missing semester wasn’t very exceptional among Harvard students. According to the five-year statistics released by the Administrative Board, between the 2004-2005 and 2008-2009 academic years, the board granted 1,229 leaves of absence.
According to UHS Chief of Mental Health Dr. Richard D. Kadison and Director of Behavioral Health and Academic Counseling Dr. Paul Barreira, the numbers of students who are hospitalized for psychiatric reasons, return from hospitalization, or take medical leaves have remained relatively consistent over this period.
Numbers aside, Janie didn’t want to lose another semester of crew, academics, and time with her friends.
Yet on that day in the campus health center, Janie’s options significantly narrowed. The UHS intake session had taken a greater toll than she anticipated.
“I think I had been starting to feel better after crew and after meeting my friends,” Janie said. “This intake session dredged up everything I’d been feeling in finals period.”
So she reverted to a habit she had developed over winter break: she went down to the first floor of UHS and locked herself in a bathroom, away from everyone and alone with her thoughts. By the time her cell phone rang, it had been five hours, yet she had no idea so much time had passed. Her parents were on the other line. They threatened to call the police if she wouldn’t tell them her location.
Even Janie’s thoughts of ending her life reflected a somewhat common experience among college students in her position. In a study of 28,000 students on 66 campuses released one year ago by The Center for the Study of Collegiate Mental Health at Penn State University, one in four respondents who sought on-campus mental health assistance reported seriously considering suicide.
In the Harvard context, however, Janie’s case raised a more distinct alarm.
In a 2009 interview with The Crimson, Barreira said that because the proportion of Harvard students who receive mental health services is higher than the national average, the percentage that report seriously considering suicide is much lower than the national statistic. Janie’s openness about her suicidal thoughts, then, was relatively rare among UHS patients.
Furthermore, in recent years the College has had reason to focus on students expressing thoughts of self-harm or suicide. In 1998, the family of an undergraduate sued the University three years after their daughter had been stabbed to death by her Dunster House roommate, who committed suicide after the attack.
The student’s family claimed that the College should have recognized the roommate’s instability when she missed three exams and exhibited erratic behavior. The murder-suicide gained national attention and is often cited as a turning point for mental health services at Harvard. In the past two decades, there have been nearly 20 alleged suicides on Harvard’s campus.
In December 2009, the family of John B. Edwards III ’10 filed a lawsuit that implicated UHS in their son’s apparent suicide, citing misconduct on the part of UHS prescribers.
According to the complaint, a nurse practitioner prescribed Adderall to treat Attention Deficit Hyperactivity Disorder. He was also prescribed two antidepressants: Prozac and Wellbutrin. In addition, Edwards was taking Accutane, a powerful anti-acne drug. Three of these drugs have been linked with heightened suicide risk. In Edwards’ case, that the suicide happened on campus led to its direct association with Harvard.
Both Edwards and Janie’s cases indicate conflicts between availability, responsibility, and expectations of Harvard’s resources with respect to its students. Decisions regarding students’ well-being on campus are rarely black and white, and can involve a tempest of competing narratives and interests.
Similarly, the factors behind a Harvard student’s leave of absence highlight opposing priorities of the multiple parties involved.
On a primarily residential campus where most students live far away from their family and doctors at home, it falls to the College to both assess and address mental health concerns. But Harvard is first and foremost an academic institution, and while the administration’s goal of protecting students is clear, the Ad Board’s limited scope and the lack of clear communication with students often transforms concern into discipline.
CLOSING THE GATE
When Janie finally revealed her location, friends ushered her back to urgent care. The therapist on call was the same woman she had seen for her intake hours before. She and a psychiatrist on duty told Janie that she wasn’t safe on campus.
Janie was admitted to a Boston hospital for four days, during which she discussed options with her Resident Dean. After her stay, Janie temporarily returned to campus for Shopping Period, but selecting courses just didn't work out.
So Janie relented to the leave. Her previous departure had been for both mononucleosis and depression, but was treated as more of a physical recovery. This second leave was clearly a mental health case, but since it was also classified as voluntary, Janie expected to have a similar experience with the College this time around.
When she returned home, however, Janie was served what she calls “the coldest, most robotic letter [she’d] ever received” from her Resident Dean. The letter outlined the terms of her leave, including regular therapy for six months, 40 hours a week of consistent work, and interviews with both the Ad Board and with MHS. This time would be different.
Janie is still on leave, at least through summer. The Ad Board will eventually decide whether or not she can return.
Although Janie’s choice to go on leave was officially voluntary—she signed forms and made the decision herself—her return is another matter. Whether the absence is a voluntary or involuntary one, the student’s return to school must be approved by the Ad Board. Students like Janie might be granted leaves of absence, but that doesn’t mean they are necessarily guaranteed a pass to return.
Janie’s case, though unique, is just one of many in a broad array of experiences among students subject to leaves of absence. According to the 2009 Student Handbook, students may be asked to consider a leave of absence for a host of reasons, including medical health, criminal behavior, outstanding debt to the College, risk to the community, incomplete courses or unfulfilled requirements, failure to submit proof of immunization records, or failure to register for a term.
By removing a student, a leave of absence limits the College’s liability. At best, a leave can allow a student time to reflect and recover outside of the pace of College life, and, if the student has the resources, to access long-term care at home.
When a student requests to return after a mental health-related leave, as in Janie’s case, the Ad Board seeks an assessment from UHS of whether or not the student followed expectations and demonstrates readiness to return.
According to John D. “Jay” Ellison, secretary of the Ad Board, the Board’s consideration regarding a particular student does not take into account the details of their case or care— in an effort to preserve a student’s confidentiality —but rather a more concise assessment from UHS of whether or not the student followed expectations and demonstrates readiness to return to the community. While the Ad Board generally votes in accordance with UHS recommendations, Ellison says they have disagreed in the past only when a student does not seem entirely fit to return to a full load of courses or the various stressors of residential life.
In Janie’s case, this means the Ad Board’s verdict will likely focus on her compliance rather than just the assessment of her therapist at home or her own sense of readiness. And even then, she might not be allowed to return.
“After dealing with [my Resident Dean] and the Ad Board and the [clinician] at MHS for the last couple of months, I realized I wasn’t an individual in Harvard’s eyes, but rather a liability,” she said.
In a sense, the process of taking a leave is intentionally generalized. While the event is specific to the terms of a student’s leave, the process is relatively anonymous. Students do not appear before the Ad Board because Board meetings do not allow for dialogue or questioning.
Although UHS is often flexible on terms if they feel the student demonstrates stability in concrete ways, the expectations—six months of consistent work and a period of care—are standardized along the lines of what is considered helpful for the average student. Furthermore, UHS consults the Ad Board, which makes the final decision on matters.
In the general context of mental health concerns at Harvard, history has only encouraged administrators to err on the side of caution. Because resources are seriously limited at Harvard, this often translates to suggesting a leave.
“If we have a case where a student is considered capable of coming back, but can’t resume full studies, we hesitate.” said Ellison. “Harvard is an academic institution, not a mental institution or a halfway house.”
ADMINISTRATING ABSENCE
But while Harvard is first and foremost an academic institution, in practice it takes on other roles and considerations involving a student’s life and well-being.
As members of the Ad Board and advocates for students, Resident Deans are liaisons between the College and the students in their care. “We serve as experts on both sides,” said Sharon L. Howell, who is the Resident Dean of Adams House.
Howell’s office in Adams seems almost designed for meditation; there is plenty of open space, a high ceiling, and large windows. It is decorated in pale earth tones and furnished with comfortable couches. She has a warm, open demeanor and speaks with the comforting cadence of a therapist.
This quality is an asset in her role; as Resident Dean, she is often called upon to engage with and represent students struggling with mental health concerns.
Because of the dual nature of their role, in cases of leaves of absence, Resident Deans can end up navigating a complicated set of priorities, attempting to balance sensitivity to the individual student, concern for the student’s effect on his or her environment, and respect for official policies of the College.
“We want students to understand that the position we’re in is not adversarial—it’s an educational board,” said Howell. We’re not writing them off and saying ‘Go away.’ We’re saying, ‘Here’s what we think makes sense for you to do, and we expect you to come back; we expect you to learn from it.’ ”
In 1890, the Faculty of Arts and Sciences established the Administrative Board. To this day, the Ad Board is responsible for the application and enforcement of undergraduate academic regulations and standards of social conduct. The Board includes the Allston Burr Resident Deans of each House, the Freshman Resident Deans, and the Dean of the College, as well as other officials whose roles involve student life and undergraduate education. All meetings and discussions of the Ad Board are confidential.
The Ad Board acts on different types of petitions and cases, categorized as routine and special petitions, disciplinary cases, and academic reviews.
In the fall of 2005, the College obtained the right to force medical leaves of absence for students if the care they required seemed to exceed the reach of campus resources. But while many students interviewed for this piece described their leaves as involuntary, all leaves of absence decided by the Ad Board are officially recorded as voluntary in the records. This includes Janie’s.
Only the Dean of the College can place a student on an involuntary leave. According to Ellison, this is extremely rare. In statistics released by the Ad Board, this scenario has only occurred twice in the past five years.
LIFE IN LIMBO
Now, after three months of rest and therapy, Janie said that her psychiatrist at home supports her case and feels confident she is stable enough to return in the fall.
Furthermore, Janie recently received her dream summer opportunity—a grant to perform botany research abroad.
But the opportunity is through Harvard, and she must clear her participation through the Ad Board. When Janie told her clinician at MHS about the grant, the response was discouraging.
“She was like, ‘We gave you a list of things to do, and if you don’t comply, you’re going to have a tough time coming back,’” Janie recalled.
In truth, Janie hadn’t fulfilled her side of the contract—that is, to prove six months of work and stability before returning to school.
However, when she returned home to New York, she spent a couple of weeks focused on recovery. After that, it took months to find employment. Both work and volunteer opportunities were incredibly scarce. “The economic climate is horrendous,” she said. “I [was] looking for four weeks, and could not even find a part-time job.”
Janie said she understood the purpose of the work requirement—to prove sustained stability—but in practice her options were limited. In the meantime, she has structured and planned her daily activities. She trains for three hours each morning, reads, journals, and collects data for the Botanical Garden nearby. She is an Organismic and Evolutionary Biology concentrator, and volunteering at the Garden substitutes for an educational experience. She is also currently enrolled in a creative writing class.
But many of Janie’s engagements are useless for proving stability; she said they can’t be documented in a manner acceptable for consideration by the Board.
WHEN A LEAVE IS FOR GOOD
“This may sound cold, but my job is not to care about the specific circumstances of a student’s case,” Ellison said. “I need to know what their requirements were, and if they complied.”
For John, compliance has been a recurring issue.
“I’m not sure how much help I’m going to be to you. My case is a little unusual, in part because I don’t plan on coming back,” said John, glancing out of the window at 1369 Coffee House in Inman Square as he picked at a cranberry scone.
Although John is an American citizen, he grew up in England. He speaks slowly, with a resonant, Mid-Atlantic gravity that settles somewhere in the American South.
After graduating from secondary school, John was admitted to Harvard’s class of 2008. As is common in the British school system, he deferred for a year. During his gap year, John worked for IBM and traveled throughout Southeast Asia.
“In hindsight, the fact that I went to a school where I was treated like an adult at 16, worked for a year, and traveled the world before I came to Harvard was terrible preparation,” he said.“I got a little too addicted to being grown up.”
For John, freshman fall at Harvard was a culture shock. Writing had been his strength; he recalled once winning £600 for an essay. At Harvard, he found himself failing all of his courses—including Expository Writing.
As the semester drew on, John found himself facing academic probation. His grades weren’t getting better and his options were limited. “There’s a rip cord you can pull, jump before anything happens,” he said. “If you left before exam period, you could erase your past, academically.” So he pulled the cord. “What I didn’t know was that absolutely everything counts toward your final record.”
John has taken two leaves of absence due to academic reasons, but he’s never strayed very far from campus. On both leaves, he has remained in Massachusetts.
“I think technically I am still on [a leave],” he said, though he concedes that he isn’t sure. “Then I’d be in the class of...2013? I don’t even know.”
John still lives in Cambridge. He now resides near Inman Square and works at a brokerage firm. He has only one Harvard semester on record, although he has technically been on campus for three. He characterizes his first leave as voluntary, the second, involuntary. Prior to his second leave, he had spent the year resisting suggestions from deans to visit the Bureau of Study Counsel and seek mental health services.
While he acknowledges that pride played a role in his response to administrative intervention, John resented that the administration was trying to apply a standardized process to his unique case.
“First it’s a disciplinary problem, as if you’re not trying enough,” he said. “Then it’s a mental health issue. No one could tell me why [I was struggling] though.”
Reflecting on his experience, John perceives his leaves of absence as disciplinary measures rather than solutions to a problem.
“It’s kind of a one-size-fits-all system,” he said, “It wasn’t very productive for me.” On his leaves, John met the standard requirement to demonstrate stability by holding a paying job. In fact, he took on several jobs in succession; he spent nine months working in a sheet metal factory, bartended, and taking on other temporary employment in Massachusetts. But while he was meeting the College’s expectations, he wasn’t addressing its academic concerns.
“When you take a leave and return, it raises the stress level; it raises the stakes,” he said, explaining that he doesn’t see how he could return to Harvard and not fall into the same pattern again.
John describes his decision to leave Harvard for good as a “narrative issue.”
“Do I want to be the guy who stuck around for three years and they let him back or the guy who left on his own?” he said.
THE COMPLICATIONS OF SEEKING CARE
Lisa, who requested her real name not be used for this article, took a semester leave after a two-week admission to McLean Hospital in the spring of her sophomore year. Like Janie, Lisa was asked to consider a leave after telling her therapist about thoughts of hurting herself.
“I was kind of under the weather,” she said. “I think it was a liability issue…I understand that the University is not a hospital or a mental institution.”
Over the summer following her leave, she returned home. There, she took a physics class while receiving regular care.
“I had the whole summer in a low-stress environment...I was sort of anxious to return to Harvard,” she explained. “I think for a lot of students [who go on leave] you feel like you’re behind.”
Both time and money are shared concerns for students who take mental health leaves and hope to return to campus. Historically, this has been a problem specifically for students who were required to withdraw for a period, and were therefore no longer enrolled in the College. These students would lose access to insurance and resources on campus, meaning that they were on their own for care once they left Harvard.
In the case of a mental health scenario, this poses a paradox.
“It has been such a difficult conversation to have with students, to tell them [they] need to go away, and have therapy, but [they] don’t have any insurance.’” said Howell. “It’s a little surreal to ask students to go home to Kansas and away from the ready-at-hand resources and require them to get regular help that isn’t available.”
Howell, like all Resident Deans, must maintain a delicate balance between advocating for her students and representing the body that decides their cases.
According to Kadison and Barreira, students on medical leave have the option to continue supplemental insurance coverage for two consecutive semesters while away, including medication benefits. While this policy is limited to the services offered by Harvard’s partial Blue Cross Blue Shield coverage, it allows Harvard officials to help students negotiate resources outside the campus.
Ellison said that in cases of students on leave who have alternative insurance, Harvard attempts to find appropriate care. But the process cannot always fully address cases in which a student’s access to resources and finances outside of Harvard are limited.
In Lisa’s case, this policy would not have made a difference. Her doctor back at home did not accept insurance. “I was lucky to be able to afford that,” she said.
To students, leaves seem to focus on the imperative to remove an individual from Harvard rather than the qualities of their destinations. The College cannot guarantee that a student’s alternative environment will be more beneficial to them than campus. While students are not required to return home on their leave, going elsewhere might involve other stressors. Janie is in a stable environment at home, but she sees her leave as the source of lost opportunities; John spent most of his time off living alone in Cambridge and far from his family, and finances were a recurring issue.
RETURNING TO CAMPUS
Sometimes, the return to Harvard can be the most challenging part of the process. When she was gearing up to come back to campus, Lisa felt refreshed, but the return to an environment that had proceeded in her absence wasn’t quite what she expected.
When Lisa returned to Harvard, she sought care outside of UHS, citing mixed and, at times, negative experiences with the strained system. But after the 12 visits allowed under Harvard insurance, she had to pay her new therapist out of her own pocket. “It was expensive. Eventually I couldn’t pay for it anymore,” she said.
“It was sort of weird because some people didn’t know I took time off; sometimes I would make something up or not tell them the whole story,” she said, speaking at a fast, energetic clip. “I once told someone that all my grandparents died.”
Lisa’s return also involved academic adjustment. As a Biochemistry concentrator, she found herself “bumped off” from her course schedule. She joined the student-run Mental Health Awareness and Advocacy Group, which she eventually co-chaired, and sought regular care on campus.
Her affiliation with MHAAG gave her insight into mental health resources at Harvard and a greater appreciation for how common leaves and mental health concerns were among students.
But Lisa is aware that her openness about the nature of her leave is relatively rare in the Harvard community. In a clinical setting, and at home, she could be more open. “I wasn’t the only Harvard kid [at McLean], for sure,” she said. On campus, however, “I [felt] like some people want to hide.”
Now Janie eagerly awaits her chance to readjust to campus. She recently found a part-time job at a restaurant, working the night shift. But given the time frame, she won’t be able to accept the Harvard grant, and she will have to continue working through the summer. Her new goal is to return in the fall, in time for swim season. After she realized her chances of accepting the grant were low, Janie called her Resident Dean. He told her to be patient—many of the members of the Ad Board are older, he said, and to them six months is not a very long time.
“That just [made] me so angry,” said Janie. “To a 20-year-old who is eager to channel energy, who is eager to move on with an academic career, six months is a long time.”
Janie said she’s ready to come back to school, but that isn’t her decision to make.
She feels that the Ad Board’s decision to delay her enrollment conflicts with its mission to enrich her education. “As an institution, they’re the ones who are supposed to offer limitless opportunities,” she said, “but now they’re the only thing that’s limiting me.”
This article has been revised to reflect the following correction:
CORRECTION: April 23, 2010
An earlier version of the Apr. 23 FM article "Brain Break" incorrectly stated that the President of the University is a member of the Administrative Board, the College's primary disciplinary body. In fact, the President is not a member of the Board.