A memorial outside the Tulane University School of Law on February 2, 2015. Student Sara LaMont was allegedly shot by her classmate and boyfriend Wajih Mazloum, who then killed himself. (Kathleen Flynn, NOLA.com/The Times-Picayune via Landov)

Late last November, as Tulane’s campus was winding down for Thanksgiving break, University President Michael Fitts sat on an airplane, reading through a sheaf of documents. In his hectic first year on the job, Fitts was crisscrossing the country, introducing himself to donors and alumni associations. But in this quiet moment midair, the former law professor finally had time to focus on his students.

What he read deeply moved him, but also left him worried. Fitts was only a few months into his new job, and five of his students were dead, three of them by suicide. Here in front of him was a 28-page compendium of students’ firsthand accounts of their experiences with his school’s mental health system. It was jarring and disturbing.

The stories depicted a campus in a full-blown mental health crisis. Students struggling with anxiety, crippling depression and other serious mental illnesses said they weren’t receiving the help they needed from the overloaded campus counseling center, which has a hard cap on how many times a student can see a therapist. Students wrote about falling into a hole of despair, wanting to die, and feeling as if no one at Tulane wanted to help.

Some of them directly criticized Fitts, saying he didn’t seem to care enough about what was obviously a dire situation. “I have never seen you on campus or heard about you meeting and getting to know our students,” one wrote. Another said Tulane felt like a “very expensive deathtrap” — a pressure-cooker of an academic and social environment with limited mental health support.

The new president says he had not realized that so many Tulane students were in so much pain. And he only learned about it because a Tulane senior named Shefali Arora took it upon herself to solicit stories from her peers on social media and methodically gather them into a public Google document to chronicle the campus’s mental health crisis.

Shefali Arora in her home in Deerfield, Illinois on February 5, 2015. (Photograph by Alyssa Schukar for Yahoo News)

Arora took this step in response to the latest student suicide, which had shaken the campus just a few days earlier. Mary Travis, a popular and artistic sophomore from Texas, committed suicide in her dorm on Nov. 22, shocking her friends and sorority sisters, some of whom had gone out with her just the night before. In September, Daniel Rupert, another sophomore, killed himself in his dorm room, devastating members of his fraternity and other groups of friends. A public health graduate student took her life off campus in October. (Two students died as a result of accidents over the same period, adding to the grief. Benjamin Burlock, another sophomore, accidentally fell in a dormitory to his death. And Andy Joseph, a junior, died in an accident caused by an epileptic seizure.)

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“The comments were very helpful for me in getting the sense of the pain out there and also what were the issues in the uppermost in people’s mind,” Fitts recalled.

He tapped out a reply to Arora on his iPhone, apologizing for his “grueling” travel schedule, which prevented him from interacting with students as much as he would have liked to. “We are definitely talking about ways we can support all members of Tulane who may be at risk,” he wrote. “On a separate note, I also am vowing to try to be more visible and available on campus, including eating at Bruff [Commons Dining Hall] more often.”



Since then, Tulane has rolled out some small changes to its mental health services to address student criticisms, and finally held a public memorial, called “Tulane Cares,” outside the student center for the five who died. But the changes fall short of what many students wanted, and are unlikely to meet the staggering need for mental health services on campus.

(Source: National Survey of College Counseling Centers 2014)

Tulane provides a snapshot of how universities across the country are struggling to face up to their students’ overwhelming mental health issues. It’s Tulane’s turn now to search for answers, to announce some reforms to its counseling center, to vow to “destigmatize” mental health issues on campus. But tomorrow, it’ll be another university. No college is immune. The problem is growing, and it’s universal. Universities are welcoming a generation of students who are more anxious than ever, and who appear to be cracking under the weight of the growing pressure to get into a good college and then to pay for it. Society burdens kids with this pressure, and then sends them off to college to deal with it. At the heart of the wrenching debate is a touchy question: How much responsibility do colleges really bear for the psychological well-being of their students?

More and more students are showing up to college already struggling with one or more mental illnesses. Today’s college freshmen are significantly more likely to report that they are struggling with depression than even their predecessors of just five years ago, and college counseling centers are bending and nearly snapping under the pressure of serving kids with serious mental health issues. Nearly 95 percent of college counseling directors said their campuses have a greater number of students with “severe psychological issues” than ever before, according to a 2014 survey. Thousands of students were hospitalized for psychiatric conditions by counseling centers that same year.



The good news is that the rise in mental illness has not translated into a higher suicide rate for college-aged adults, according to the latest Centers for Disease Control and Prevention data. (Suicide is the third leading cause of death among 15- to 24-year-olds.) The vast majority of people who attempt suicide have an underlying mental illness, but the relationship between the two is complex. Most who struggle with mental illness will never attempt suicide, but universities cannot be complacent about the risk. Knowing the problem isn’t unique to Tulane doesn’t bring much comfort to Fitts, who still must find a way to boost the psychological health of his campus — or risk losing more lives.

***

Last Halloween, Shefali Arora, just 21 years old, decided she wanted to die.

Arora had stopped responding to text messages and calls from friends, and hadn’t left her off-campus apartment in days. Her thoughts were turning more and more hopeless — as if she was in a dark tunnel without an exit.

Shefali Arora's medication prescribed for her bipolar disorder pictured in her home in Deerfield, Illinois on Thursday, February 5, 2015. (Photograph by Alyssa Schukar for Yahoo News)

“I kept it pretty intensely to myself,” she said.

A few nights before Halloween, Arora grabbed one of the many bottles of pills she had been prescribed by a series of doctors over the past two years to treat her bipolar disorder and swallowed too many of them. “Mom, I’m committing suicide,” she texted, and then closed her eyes.

Her mother called her daughter’s phone, frantically, but Arora ignored her calls. Arora, having second thoughts, called a friend who took her to the emergency room, and then she let her mom know she was on her way. There, Arora drank glasses of liquid charcoal to absorb the medication, and the next morning, she was transferred to a psychiatric ward in another hospital to recover, strapped to a gurney. (“Please don’t! I have to graduate,” she told the orderlies who came to take her away.)

Arora loves Tulane, but ever since she was diagnosed with bipolar disorder the summer before her sophomore year, it had become for her a barely tolerable place to be. The school was generous about letting her take time off when her psychological issues became too overwhelming, but Tulane counselors were also clear that she would not be able to receive the help she needed on campus. They expected a depressed teenager to find and coordinate her own mental health care off campus, with nothing more than a printout list of local psychiatrists and their telephone numbers to guide her. (Several other Tulane students said that they had also had this experience, and that they were left to their own devices when they needed more serious mental health help.)

At one point, right in the thick of midterms, near the end of her sophomore year, a college administrator told Arora she had to find a therapist within two weeks or leave campus. (The administrator checked in with Arora weekly when she returned to school after her mental health leave.) The college requires students who have taken time off for mental health reasons to remain in therapy for a year after they return, but it also bars them from using therapists at the student counseling center, on the premise that these students’ problems are too severe for the counselors to handle.

“I just can’t believe I’m the only one who goes through that. There’s got to be something in place for those who do.” – Shefali Arora

In Arora’s case, the rule just meant she wasn’t being treated at all, since she could not find an available psychiatrist in New Orleans who would accept her insurance. It felt to her as if Tulane didn’t want to deal with her or her problems, which only reinforced her isolation.

Luckily, Arora survived her attempt at suicide, but when a sophomore named Mary Travis killed herself in her dorm last November, Arora was shaken to the core. She didn’t know Travis, who had a reputation as a kind and smart girl, a popular and bubbly student at a college that rewards those traits. Arora realized other students needed help as much as she did — and that Tulane had to do something about it.

That’s when she started the Google document soliciting her peers’ stories and demanded a meeting with Fitts. Something had to change.

“I just can’t believe I’m the only one who goes through that,” she said. “There’s got to be something in place for those who do.”



***

At the center of the debate raging at Tulane is an issue that also crops up in the controversies over sexual assault on the nation’s campuses: To what extent is a college obligated to care for its students’ non-academic life and well-being?



Providing psychological support to college students is still a relatively new idea, even though student depression on campus is not. (William Faulkner was already writing about the suicidal Quentin Compson in 1929 in “The Sound and the Fury.”) College counseling didn’t really exist until the late 1940s, when the federal government created hundreds of counseling centers to help guide a new generation of G.I. Bill-funded students arriving on campus. By the end of the 1960s, about half of all colleges provided some mix of vocational advice and psychological help.

(Source: Higher Education Research Institute at UCLA)

Meanwhile, medical breakthroughs made antidepressants and other psychiatric medications widely available. A new generation of students, suffering from mental illnesses that might have prevented them from going to college in the first place a few decades ago, began showing up on campus and filling college dorms each year. Getting accepted to a good college has become harder over the past 15 years, so kids come more stressed and worn out than ever before from the race to get into college. Parenting styles have also evolved. Some college counselors say they see students who are less resilient than earlier generations and who are unable to cope with failure — from which they have been cushioned by their over-involved parents before they leave home at 18. Counseling centers have adapted; most of them now have psychiatrists on staff who can prescribe medication and other trained therapists who deal with anxiety and depression, the most common ailments on most campuses.

But staffing levels haven’t kept pace with the increase in students who need help. Recently, overwhelmed universities have begun to put limits on how often students can access their mental health services, to cut down on the weeks of waiting for appointments. Some college counseling centers mandate “resiliency training” courses that teach students how to deal with failure and setbacks before they are granted access to a counselor.

“Twenty to 25 years ago, counseling centers tended to see students as long as they needed to be seen,” said Robert Gallagher, who has been surveying the nation’s college counseling directors for decades at the University of Pittsburgh. “As the demand for counseling services increased, and the complexity of the problems that students were bringing to centers grew, many centers began to promote themselves as a ‘session-limited’ service, and much more staff training went into moving students through the therapeutic process more quickly.”

Now, 30 percent of center directors in Gallagher’s survey say they have limits on how many times students can be seen at their facility. An additional 43 percent said they promote their centers as a short-term counseling service, even if they don’t explicitly forbid students from using them long-term.

In September of 2012, the Tulane administration joined this trend. The school announced it was overhauling its system based on the recommendation of an outside consulting company, Keeling & Associates, that Tulane’s Counseling and Psychological Services (CAPS) become a short-term counseling service. “In order to serve the entire campus community, CAPS will offer the same services that have been offered in the past on a short-term basis. If you require long-term care, members of the CAPS staff will assist you in making the appropriate community connections,” the university announced.

Tulane students are now allowed to see CAPS therapists a maximum of 12 times during their four years at school. Those with more serious mental health problems that have resulted in hospitalization or the need to take time off school are barred from accessing CAPS except in cases of an emergency. Several students told me that the cap felt alienating to them and said that they would like Tulane either to offer more therapy or to give them more help finding treatment elsewhere.

Michael Fitts, Tulane's president, on Oct. 3, 2013, when he was still dean of the University of Pennsylvania Law School. (Matt Slocum/AP Photo)

“Obviously, universities are not in a position to provide long-term care for an entire university experience,” Fitts said in an interview in December. “We face the problem that everybody faces, namely the lack of enough mental health professionals and the availability of them.”



***

Tulane’s counseling center is located in a rundown building on the academic quad, a bit of a hike from the student dorms. CAPS shares space with the financial aid office at Tulane, and both have an air of office-park fluorescence that is unlike Tulane’s ultra-modern student center, for example, where manmade waterfalls cascade through the center of a glassy building.

Dr. Donna Bender, who became CAPS’ director this year, runs a staff of 17 full-time employees, including a couple of psychiatrists. In an interview in her office in January, she began to choke up as she talked about what it was like to lose five students in a single semester.

“We had a memorial toward the end of the semester, and one student got up and spoke on behalf of each of the five…” she trailed off, unable to continue. “Sorry,” she said, pausing to control her emotions and wipe her eyes. “It was very powerful, very powerful.”

“Obviously, universities are not in a position to provide long term care for an entire university experience.”

– Michael Fitts, Tulane President

In September, after sophomore Daniel Rupert committed suicide, Bender and another administrator gathered his fraternity brothers into a room in the student center and talked to them about how best to manage their grief. In November, after Mary Travis died, Bender set to work with other administrators to figure out who her closest friends were, reaching out to them and offering them therapy. Administrators wandered around outside Travis’s dorm, which is called Leadership Village, asking students if they needed help. So many students knew one or more of the five students who died last semester that CAPS formed a grief-support group to treat them.



The pool of affected students was enormous, and the deaths cast a pall over campus. “I can’t say that every student was connected to the students that we lost, but everyone knew someone who knew those people,” said Melissa Greenberg, a sophomore.

At the end of last semester, the Tulane administration investigated the circumstances around each suicide and concluded that none of the students had been denied care at CAPS or were unaware that CAPS existed.

“We do look at each of those cases individually, and we have not been able to determine that any of the completed suicides from last semester were connected to either a lack of provision of services or a sense of not being able to gain access,” the dean of students, Dusty Porter, said.

After the Google document went viral, however, the student government and other leaders began demanding changes at CAPS. At the top of the list was a call for more long-term therapy at CAPS.

“I can certainly understand why [long-term therapy] would be desirable,” Bender said.

Tulane is considering increasing the cap to 12 sessions per year per student, instead of 12 over all four years. Wait times for these appointments are three weeks or longer at peak times, however, and increasing the cap might make this worse.

Fitts and Porter both point out that the school is actually doing better than its peers in terms of the number of psychologists and therapists it employs. According to Porter, the school’s ratio of one counselor to every 794 students is significantly better than the average of 1 counselor per 1,743 students at other schools of similar size. The center is adding three more full-time staffers over the summer, including a psychiatrist.

The open letter Shefali Arora wrote to Tulane President Michael Fitts, on the school's mental health crisis. Dozens of students wrote about their own struggles. (Photograph by Alyssa Schukar for Yahoo News)

Fitts has been focusing on other ways to improve mental health on campus — and is still struggling to understand what’s driving the increasing mental distress among college students.

“Clearly, it is a pressured time to be an 18-year-old in the United States,” he said. “There are anxieties about your career, your personal life, that may not have been as true years ago.”

He theorized that the breakdown of religious and family support structures over the past few decades has left some kids feeling lost. The trend toward going to college farther away from home separates students from their social support networks even more. This is especially true for Tulane students, who are on average farther from home than students at any other college in the country.

Fitts said one part of his strategy to boost mental health on campus is to “really provide a community at Tulane” that could try to replicate what students lose when they leave their families and homes to come to New Orleans.

***

Two weeks into the new semester this February, as the campus attempted to leave behind a semester of grief and braced itself for Mardi Gras, a Tulane law student allegedly shot and killed first his girlfriend, another law student, and then himself in a murder-suicide a few blocks from the academic quad. Friends and family told the local newspaper they were shocked and confused — that they had seen no signs of trouble in the bright, 28-year-old student who had murdered his girlfriend.

At the heart of the wrenching debate is a touchy question: How much responsibility do colleges really bear for the psychological wellbeing of their students?

The news contributed to an atmosphere on campus that students described to me last semester as “dismal,” “horrifying,” “heartwrenching” and “depressing” — a dissonant gloom for the picturesque New Orleans school, where people come to party. The fresh round of tragedy has also added fuel to the debate about mental health at Tulane.

Fitts immediately sent out a campus-wide email Feb. 1, as soon as the law students’ deaths were reported.

“As we confront the tragedies that have befallen us over the last few months, our hope lies in coming together in support, understanding, care and love for one another,” he wrote. “I pledge to you that no effort will be spared by me or anyone in the university’s leadership as we seek the comfort and healing of our community.”



Arora read the email in shock, along with the rest of Tulane, but she was far away from campus by then. She had decided to finish her last semester at home near Chicago, where she could be near a therapist she trusted. Ultimately, it didn’t seem possible for her to stay at Tulane and stay healthy.

Shefali Arora, who recently graduated and is now an assistant coach for the Sky High Volleyball club in Crystal Lake, Illinois, illustrates the proper setting technique with a young player on Thursday, February 5, 2015. (Photograph by Alyssa Schukar for Yahoo News)

Correction: An earlier version of this article incorrectly stated that Tulane student Andy Joseph died on campus in an accident. Joseph died off campus. Also, CAPS Director Donna Bender's first name was incorrectly identified as Debra. Dusty Porter is dean of students, not dean of the college.

