The director of Harvard University Health Services on creating new models for students’ mental and emotional health

Paul J. Barreira, M.D., Henry K Oliver Professor of Hygiene, has been the director of Harvard University Health Services (HUHS) since 2012. For the previous eight years, he led Behavioral Health and Academic Counseling at HUHS and was an associate professor of psychiatry at Harvard Medical School.

Despite his long tenure in the Ivy League, Barreira hardly fits the stereotype of the change-resistant academic. Barreira believes the traditional model for treating college students for a range of emotional and behavioral health issues is broken. His views on how to engage the academic community in partnering with health centers to address student mental health are anything but “old school.”

Dr. Kaitlin Gallo, a clinical psychologist and former undergraduate mentee of Dr. Barreira’s, recently interviewed him on the subject.

Their exchange follows.

Dr. Kaitlin Gallo: You have been on the front lines of student health, especially emotional and behavioral health, for many years. How do you see the field changing?

Dr. Paul Barreira: I would say there are two areas where it is changing. One is the volume and frequency of students who want to come in and receive services.

The other is the chronicity and severity of the problems that students are experiencing. We had 40 psychiatric admissions last semester. We used to have 20 in a year and the number has been increasing over the last five years. It’s not just a spike, it’s a trend.

KG: How do you handle that as a university mental health service?
PB: We have come to the realization that we can’t just hire more counselors. We need to change the model because the traditional model for providing services simply doesn’t meet the needs of our students.

I think of this as a bell-shaped curve. On one end, there are the students coming in for three or fewer visits – many of whom are having normal human reactions to stressful events.

A number of these students could have a conversation with someone outside of the health service, within the academic community, that could satisfy their need to express their problem and think about ways to relieve their distress.

On the other end of the bell-shaped curve, there are students who need a higher level of care who should be helped by mental health professionals who can provide more intensive services in the community outside of Harvard.

In the middle of the curve are the majority of students who can benefit from meeting with a mental health provider for a shorter course of treatment or on a more intermittent basis.

If we can create opportunities in the learning environment to have supportive conversations with the students who need a less intensive level of care, and if we can ensure that people who need a higher level of outpatient treatment can reliably get that care in the community, then we have created the capacity for students in the middle of that bell-shaped curve, who are struggling with depression, anxiety and panic attacks, to get the right course of care.

Right now, what’s happening is we can’t see students for 7 to 12 visits on a regular basis because the volume is so high on either end. So, in many ways we’re saying that the learning community will have to actively participate in making this change. The health services can’t do it alone.

KG: So how do you go about making these kinds of changes?
PB: We need to foster a culture within the learning community which supports helpful conversations about the real stresses of student life. A few years ago, we stumbled on something in my work with graduate students that I’ve been searching for for 10, 12 years. It is a tool that engages the graduate departments and the professional schools in talking about behavioral health and wellbeing.

It came about quite organically when I was invited to speak to a group of Harvard economics graduate students following a death by suicide of one of their colleagues at MIT. I was talking about suicide, including information about the rates and causes of suicide, but the only data I had pertained to undergraduates. After the meeting, two students approached me and said, “we need to get data on graduate students in econ.” I said “great, let’s do it.”

We worked together to create a survey instrument that incorporated typical clinical screening tools, all the measures you would recognize.

But what was unique about the survey was that students wrote specific questions about the learning environment and factors they thought would make a difference in emotional wellbeing. Then they marketed it to their fellow students. The response rate was 60 percent.

That was the “aha” moment for me. The way to engage all the departments and all the schools is to partner with the students to create a university-wide survey that includes the usual screening measures but also poses department and school-specific questions about the learning environment. After completing the process with the economics grad students, we partnered with the life science students, then law students to create a survey tailored to their unique experiences.

We’re using the survey for three primary purposes: One is measuring and comparing rates of different types of distress. Not only do we learn the rates, for example, of depression and anxiety in each school, but we can make comparisons across schools.

A second purpose is to use the survey data as an intervention tool. The student or students who have worked with me to construct the survey can join me in presenting the data to deans, faculty and administrators.
And that is the beginning of a conversation in which participants pose questions such as: “What can we do in our school or department to improve things? What is the role of the health center?” In essence we’re using the survey tool to facilitate a conversation that has been hard to initiate.

How does this relate to the problem I outlined earlier? We’re exploring how to best utilize resources in health services and in the schools so that people get what they need, not necessarily what someone thinks that they need.

The third function for the survey is as an evaluation tool. Once we make changes to the environment, we can survey again and see if those changes have made a difference in the type or rates of student distress.

KG: Is there something about today’s students that makes this broader approach to student wellness even more important?

PB: College health professionals have begun to observe that as a group, students who are entering college today and who eventually go on to professional and graduate schools, have less well-developed coping skills than previous cohorts of students. A consensus is building that students are coming in with what I consider two large gaps.

One is the gap between their intellectual development and their relative emotional development. Being incredibly smart does not help you with intense negative affect if you don’t have sufficient emotional coping skills. Students may resort to cutting, disordered eating, excessive drinking, sexting or other unhelpful behaviors in an attempt to manage uncomfortable thoughts and feelings. A significant number of students engage in these or other possibly dangerous behaviors.

The second gap is much more common. It is the gap, or discrepancy, between how we present ourselves publicly and how we feel about ourselves privately. This gap is often exacerbated by social media. Each gap can exist alone or in combination with the other and both are associated with emotional distress.

KG: Do schools need to do more from a leadership perspective to nurture emotional development overall?
PB: Yes. I think that, traditionally, schools like Harvard, emphasized intellectual development and performance, sometimes at the expense of personal development. I say to my colleagues and administrators here and at other schools that unless the university or college says openly “we have a responsibility to help you in your emotional and personal development and we are offering ways you can achieve that,” then these gaps are more likely to be maintained.

Dr. Gallo has an A.B. in Psychology from Harvard, and a Ph.D. in Psychology from BU.