College Consolidates Mental Health Care Services

In a major reorganization of the University’s mental health-care system, its two major providers were placed under a single director who is charged with better coordinating mental health treatment and outreach at Harvard.

The recommendation emerged in a February interim report from a task force convened in December. The document resolved that a central leader for both the Bureau of Study Counsel and University Health Services (UHS) Mental Health Service (MHS) was necessary to eliminate the disconnects and overlapping roles of the two facilities.

“The way they grew up at Harvard, they’re sitting in different silos,” said Student Mental Health Task Force chair Dr. Paul J. Barreira. “If you looked at comparable places, they run a continuum, and that’s what we’re aiming to do.”

The task force and restructuring of mental health facilities have materialized in a year in which mental health has been under particular scrutiny.

“It’s remarkable that a university like Harvard would make such a public debate of this issue,” said Barreira, who also has been chosen to be the superviser of mental health services and outreach on campus starting July 1.

A six-month Crimson investigation published in January found that bifurcation of mental health care at Harvard has allowed students to slip through the cracks as they try to navigate a complex system while also dealing with their own conditions.

It also noted that inconsistent and inadequate training of residential tutors and faculty members hampers the ability of those who know students best to advise them on how to get help.

And the increasing cost of health care nationwide has manifested itself at Harvard in an assembly-line like system that takes in, treats and nudges out students too quickly in some cases.

A 1999 Provost’s Committee on Mental Health report concluded that “mental health services at Harvard resemble a symphony orchestra of talented performers, but without a clear conductor and with all musicians playing different music.”

SEARCH FOR SOLUTIONS

In December 2003, Dean of the College Benedict H. Gross ’71 and University Provost Steven E. Hyman convened the Student Mental Health Task Force to jump start the implementation of previous studies’ recommendations.

“Our task is not to rethink what has been done before,” task force member Elizabeth J. Quinn ’04 said in December.

The committee met from December to April to review a broad range of material, including the Provost’s 1999 report and an internal study on the Bureau and MHS.

“I was really impressed at how the administrators and clinicians who are there really do know the problems with UHS and the Bureau,” task force member and former Mental Health Advocacy and Awareness Group co-chair Caitlin E. Stork ’04 said after the task force’s first meeting. “They actually do have really detailed information on all the problems, and don’t know how to fix them.”

The task force also held outreach events and solicited comments online from students.

With a mandate to look at both the treatment side of mental health—principally at the University’s two main mental health care locations, the Bureau and MHS—and the outreach and prevention facet, particularly in Harvard’s residential Houses, the task force released an interim report on treatment recommendations, including the move for a centralized head, in February.

The final report of the task force, which will address residential and academic aspects of mental health care and prevention in addition to issues discussed in the interim report, had not been released when this story went to press, though a draft of this report was obtained by The Crimson.

Barreira stated that one of the group’s primary aims would be to reevaluate the position of the Bureau within the school’s care structure, to ensure that it functions as a complement to the MHS.

“We want to be able to keep the Bureau of Study Counsel focused on its role as one portal of entry for students to get help, but also to be able to use all the mental health services that are available to provide treatment,” Barreira said in December.

The task force was also charged with determining the most effective methods to increase awareness of mental health resources and to lower the stigma of seeking treatment.

“Somehow we’ve got to advance people’s education and awareness about getting treatment for a mental health problem,” Barreira said in December. “People want to pretend they don’t need treatment.”

THE VIEW FROM THE TOP

On July 1, Barreira will take over as Director of University Counseling, Academic Support and Mental Health Services, implementing the recommendations from the task force he chaired.

Barreira’s familiarity with the issues facing campus mental health services will inform his work from the start, Hyman said.

“He is in some sense a proven quantity through his very skillful leadership of the task force, which will allow him to hit the ground running, which is very, very important,” Hyman said in May.

Barreira’s job is vital not only for its ability to look at mental health services broadly, but also for its ability to integrate a leader whose attention is wholly devoted to improving the Harvard system, he added.

“The first and most important thing is that now we’re going to have some person who wakes up every morning thinking about the whole range of mental health issues—we just haven’t had that before,” Hyman said. “It’s really critical.”

Barreira will be responsible for allocating mental health resources more efficiently across the University, and creating a system which organizes diverse resources into a seamless system.

His role will also include organizing further training of faculty and residential tutors—including the establishment of tutors dedicated to mental health in upperclass Houses—and planning the annual Caring for the Harvard Community outreach events.

Beyond that, Barreira will aim to organize the disparate groups across the University meant to work with students with prevention or treatment of mental health issues, including the freshman wellness representatives, the Administrative Board and United Ministries.

TREATING THE BUREAU

When the task force suggested having a single director, before Barreira was chosen to take on the position, UHS Director David S. Rosenthal ’59 began to supervise both MHS and the Bureau.

Previously, the Bureau reported to Gross, and MHS reported to Rosenthal and Hyman.

The reorganization aims to relieve the Bureau of duties outside its original mission that have crept into its day-to-day responsibilities.

As the number of students with mental health problems increased over the years, the Bureau has begun to treat students with more serious concerns.

“I think that the Bureau has moved in to treat some of this demand,” Gross wrote in an e-mail in January. “This was a departure from its original mission of tutoring and counseling for the usual problems of adolescence and adjusting to college.”

Hyman calls this shift “mission creep.”

“The Bureau had its mission increased,” Hyman said. “It sort of started to creep to help people who had more and more serious illness.”

Hyman said in January that the Bureau should not be treating students with more serious mental illnesses.

“While a lot of students like what [Bureau counselors] do when they show up with depression or other issues, we feel that on balance, students should be getting the agreed-upon best treatments,” Hyman said. “And the people trained to do that are in UHS.”

And as the MHS assumed some of those responsibilities and becomes more closely tied to the Bureau administratively, the interim report stressed the importance of maintaining it as a separate option for students seeking care.

“It would be a mistake to think that the Bureau has now disappeared and that it is now a part of UHS,” Barreira said. “We want an array of services where everyone is working together.”

A BUREAU OF ITS OWN

Both Barreira and the task force interim report maintain that the keeping the Bureau as a separate entity is vital, because of its unique services and reputation for being easily approachable.

But the Bureau’s 11 full-time counselors wrote in a March letter that even if its self-contained structure is maintained, wrapping the Bureau up with MHS under a single leader will undermine its mission as a non-clinical setting.

The letter stated that the new organizational structure may destroy the Bureau’s mission.

“If the Bureau is subsumed within a medical system, its distinct niche within the community will disappear, and before long, the Bureau and its educational niche will disappear with it,” the letter stated. “While the Bureau may remain in name and address, its distinctive nature and role will inevitably cease to exist.”

The Bureau provides a range of counseling and therapy services, in addition to academic tutoring, stress management and procrastination workshops, and a course on reading and study strategies.

Many say that its broad focus and friendly, home-like atmosphere makes the Bureau a point of entry into mental health care that seems much less daunting than the more clinical option of the MHS.

The March letter stated that the Bureau counselors felt that their concerns may not have been fully heard or addressed by the task force.

“We fear that the integration of the Bureau and UHS will irreparably disrupt and damage the intricate ecosystem of Harvard’s community in ways that may be hard for the Administration to anticipate,” the letter said.

The counselors also expressed concern that the restructuring will “have a paradoxical effect of closing out a large part of the very student population the task force is hoping to better serve,” particularly those students who tend to shy away from mental health services.

“In particular, international students and minority students are among the many students who typically do not seek counsel in a clinical, medical setting because they do not regard their difficulties as mental health issues,” the letter said.

Rosenthal said at the time that the administrative unification would benefit both facilities, and that the Bureau would remain its own organization.

“This isn’t an integration into UHS—this is a one plus one equals three,” Rosenthal said. “This isn’t really putting everything under one roof.”

Placing both services under a single leader will ensure that the two do not waste resources providing overlapping services, and that students are referred to the place that can best meet their specific needs, Hyman wrote in an April e-mail.

“The reorganization enables us to make sure that, wherever students first go for help, they will be able to access easily and smoothly the assistance best suited to their needs,” Hyman wrote. “The Bureau and MHS are being brought together—each continuing to provide its unique services to students, but communicating and working together more effectively under a shared umbrella and a new leader.”

PRESCRIBING SOLUTIONS

The draft version of the final report obtained by The Crimson last week found that knowledge about mental health services varies among residential Houses, peer counseling groups, international students and graduate schools. It recommends that the administration should implement new methods—including online resources and new working groups—to distribute and reinforce this information.

The report advocated the creation of “mental health resource person[s],” each of whom could advise up to 40 designated first-years if students felt they were not getting adequate information from proctors or their primary care practioner (PCP).

The report also outlined improved methods for disseminating information, including cards given to each incoming first-year listing their adviser, PCP, mental health resource person and other resources.

“In this instance...redundancy is good,” the draft report said of outreach efforts.

The report noted the potential usefulness of structures already present within residential Houses, but stressed a need to ensure that these options are used consistently.

“The residential house system is a potentially invaluable resource to the students,” the draft report stated. “Inconsistency across the houses is great and a cause of frustration to students.”

The report found that the strength of the connections between Houses and mental health professionals also varies, in part, due to level of interest of House tutors and masters, and said that it should be improved.

A pilot program to increase education and support for tutors interested in specializing in mental health and wellness was also suggested in the report, along with increased training coordinated with sexual assault and alcohol education.

The report noted that even among peer counseling groups designed to aid students with mental health concerns, information about services available through the school is “not consistently known” and recommended more stable mentoring and supervision of these groups.

Among graduate students, knowledge of MHS and the Bureau’s services is also inconsistent and should be improved though the establishment of a working group.

“Some [graduate schools] have very well established mental health and academic support services, while others have virtually none,” the report stated.

The draft report also said that most international students, who represent 25 to 50 percent of the graduate student body, “find the process of adaptation very challenging” and that efforts to “demystify” UHS and ease the transition must be implemented.

The report concluded that moving forward, Barreira should convene an advisory group composed of students, faculty, administrators, residential staff, and academic support and mental health practitioners to keep him informed about mental health on campus and to vet new options to improve the system.

STAFF CHECKUPS

While the task force advocates increased awareness, it also recognizes the need to reexamine its existing staff.

The February interim report recommended that Bureau staff members become credentialed as clinicians through UHS, so that the Bureau can participate in professional peer review—a step that has began this spring.

Besides providing credentials to as many clinicians as possible, the administration has taken steps to begin beefing up staff levels.

In the last two months, Rosenthal has conducted a review of mental health personnel as outlined by the interim report’s third recommendation.

The review will guide the report recommendation for an increase in staff that could add more clinicians and counselors to not only MHS, where the problem is reportedly more acute, but also to the Bureau. Rosenthal wrote in an e-mail last week that Barreira will review the staffing study after July 1.

“The sense within the student community is that the level of clinical staffing at MHS is inadequate,” the report said.

Compared to a comparable system at Yale University, and taking into account the differences in student body size, Barreira said that “it was pretty clear that we are short” in staff numbers.

The interim report, released February 27 after Gross and Hyman pressed to have an early indicator of areas to begin work on, also called for more mental health clinicians in both offices and an overall improvement in the approachability of Harvard’s counseling services.

“Both Hyman and Gross really wanted—if we knew where we were headed—to have something sooner,” Barreira said after the interim report’s release.

—Staff writer Katharine A. Kaplan can be reached at kkaplan@fas.harvard.edu.