Life in the ‘Gothic Wonderland’ has never been easy for Duke students—between challenging academic courses, pressure to have a thriving social life and the overarching goal of effortless perfection, it’s no surprise that many undergraduates face problems with their mental health.
Complicating the issue? The fact that Duke’s resources for assisting students—including Counseling and Psychological Services and DukeReach—are often lacking, according to students interviewed by The Chronicle.
Some say that the Duke administration is not making students’ psychological health a priority.
“The administration and Duke as a whole can do a better job of understanding students’ mental health needs,” said senior Thomas Klug, president of Peer for You, a group that allows students to anonymously receive advice on their mental health concerns. “I think Duke often treats mental illnesses as more of a liability than as something it needs to address. It would rather sweep the issues under the rug than try to deal with them.”
CAPS’ limited resources
Many students’ complaints regarding mental health care on campus involved the office of Counseling and Psychological Services, which they said does not have the resources to adequately serve students.
Pooja Mehta, Trinity ‘17, said that CAPS doesn’t have enough counselors to provide sufficient care for students.
“Everyone in CAPS is booked to the nines seeing patients,” she said. “It’s not a reflection on CAPS as much as the way the University prioritizes the mental health of students.”
Before coming to Duke, Mehta had been seeing a therapist for her mental health needs and began to recover, so she stopped treatment. While at Duke, she realized she needed to visit a service provider and turned to CAPS. She started having sessions with a therapist once every two weeks, but soon learned a truth many students have come to know—CAPS isn’t designed to provide long-term care.
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She said that because they couldn’t keep seeing her on a regular basis due to limitations in staff numbers, they referred her to an off-campus provider.
“CAPS is to help patients through short-term things like day-to-day stressors or just general on-campus things,” she said. “Bigger, long-term mental health problems require relatively intensive care.”
Sophomore Alex Chan had a similar experience with CAPS. Chan initially visited CAPS because she was feeling sadness and loneliness, which she recognized as symptoms of depression. She just wanted someone to talk with, she said.
Although Chan noted that CAPS tries to accommodate everyone, she was only able to get an appointment once every two weeks—which she says wasn’t adequate for what she was going through.
“That’s not really enough for anyone,” she said. “So much changes in two weeks, especially in a college environment.”
Then her therapist told her that there’s a max number of visits CAPS can provide students with, Chan said.
It felt like being shut out and left without a safety net.
She has continued to go to walk-in hours for therapy services, but was told by her therapist that after this semester she can’t go to CAPS anymore and must find an outside provider. Now she’s forced to use her remaining CAPS visits wisely.
“It’s like some weird game where I have to play my cards right,” Chan said. “Do I really need CAPS or should I save it for another time?”
Danielle Oakley, director of CAPS, told the Chronicle that CAPS does not have a session limit, but they’ve found that most students “self-select” to attend sessions between four and six times.
However, CAPS providers attempt to determine whether students’ issues can be resolved in the short term or if they will require long-term care.
“What we do try to figure out is if a student can be seen around that session time,” Oakley said.
For Chan, it seemed contradictory that Duke could build a new student health center if CAPS doesn’t have enough resources to meet students’ ongoing needs.
“Duke is pouring their money into the external look and making it appear very peaceful, but there’s not the resources,” she said. “It’s definitely something Duke can improve on. I wish they hired more counselors instead of spending millions on a new wellness center.”
Oakley noted that although Duke is well-resourced compared to many of its peers, no schools have sufficient resources to deal with the multitude of mental health problems afflicting college students.
Currently, CAPS has 26 permanent staff members, with five serving in administrative roles and five as psychiatry staff, she said. Not all of them work full-time.
Oakley explained that for students who need long-term or weekly care for a significant period of time, CAPS has a referral coordinator who helps students make connections with providers in the community.
Many of these therapists accept students’ insurance if they are on the student health plan. However, problems can arise when students are on their own health care plan, which may have high deductibles. In those cases, CAPS has a fund that can help students’ with co-pays, and students can also work with financial aid to get loans.
Mehta said that CAPS needs to do more to make sure students can properly connect with outside providers. Some have issues finding transportation to these off-campus professionals, she noted.
“If you don't have resources to provide long-term care, make sure students have resources to have long-term care,” Mehta said.
She suggested that CAPS should try to set up a transportation system to ease the travel burden on students, but recognized that CAPS doesn’t have the funding. Change is needed from a higher administrative level, she said.
Senior Katie Anderson—who requested that her name be changed because she didn’t want to reveal her mental health issues—went to CAPS for help with her depression but became dissatisfied with the counselors she saw and requested a referral off-campus, where she thought the standard of care would be better. Her health insurance was able to cover the costs, but she noted that this is not the case for all students.
Having to find the time in her schedule to make the trek off-campus was difficult for her and often discouraged her from even attending the sessions.
“It was hard at first and took a lot for me to go,” she said. “It was a 20-minute walk in between classes.”
New walk-in hours
For those students trying to utilize CAPS’ services, a main complaint in past years has been the long wait times that often discourage students from seeking treatment.
However, Oakley explained that since June, students can walk into CAPS anytime between 9 a.m. and 4 p.m. and ask to see a counselor. A staff member will have them fill out forms on an iPad and then meet with them for 15 to 20 minutes to gather information about what’s going on and assess any risks or safety concerns.
“We wanted to make sure we were reducing barriers so students didn’t have to set the appointment to come in, but also so that we’re capitalizing on seeing students at the time they want to start treatment,” Oakley said.
Previously, students would have to call and make an appointment, which might mean waiting two or three weeks to see a provider. Now, students can immediately be assessed to determine which kind of therapy will be best for them. This could be individual counseling—typically 45 to 50 minutes with a therapist—or group sessions.
“Not everyone who comes needs therapy, they may just need skill-building,” Oakley said.
She noted that the feedback she’s received from faculty and staff has been very positive. Faculty know they can simply tell a student to head over to CAPS instead of instructing them to call and make an appointment.
But this doesn’t mean wait times at CAPS have been eliminated. The wait to see a counselor after that initial consultation, is about two weeks, Oakley explained. When the wait time is longer than that, no-show rates start to rise, she said.
“We work really hard to keep it under two weeks, but sometimes during the semester it goes over that because of resources,” she said. “It’s like every campus in the U.S.—no one has enough resources, and we’re trying to figure out creatively what to do with resources that we do have.”
Klug said the new walk-in hours are an improvement, since before students would have to wait long periods unless they admitted to the CAPS staff that the need was crucial or that they might hurt themselves.
Mehta also voiced frustrations with the previous wait times. She would sometimes spend weeks encouraging friends who were in need to seek out CAPS. When they finally did, they were often slammed with a month-long wait.
“Now you can walk into CAPS at any time during the day,” Klug said. “Just having access to that care is a great resource.”
Staff member diversity
The inadequate number of staff members at CAPS is a problem, but so is the lack of diversity in the ones they do hire, students said. The demographics of the staff do not reflect that of Duke as a whole.
At a community forum in November 2015, students called into question CAPS’ diversity—particularly the fact that the department had only one Asian-American counselor at the time.
Klug explained that in his experience with CAPS, many of the therapists are white professionals, cisgender and straight. Although there have been some improvements in recent years, the staff is still not representative of the Duke community, he said.
“My therapist did not understand at all what I was going through just because of that identity variable,” he said. “You can be as trained as you want, but at the end of the day it’s really hard to empathize and understand what someone may be going through if you haven’t dealt with that issue.”
Junior Tatyana Bidopia, president of Duke’s chapter of the National Alliance on Mental Illness, said that she thinks hiring more diverse staff needs to be a priority for CAPS.
“It’s something that should be on their radar,” she said. “It’s important for students to be able to identify with their counselor.”
Despite the student complaints, Oakley said she thinks CAPS has made significant progress in this area recently. They’ve made five hires in the last three months, and all of those are people of color. She noted that they now have two Chinese therapists, two providers from southeast Asia and several who identify as black, along with therapists with various sexual orientations.
CAPS also has a race equity strategic plan that takes diversity concerns into consideration, she said.
Graduate students as providers
Several students raised concerns about CAPS’ practice of having graduate students see patients, questioning their experience level and qualifications.
Oakley explained that they have three providers who are psychology interns. These individuals have completed their programs and are in their last year of training.All are supervised by licensed professionals.
For Anderson, having a graduate student as her therapist contributed to her decision to seek an off-campus provider. She said that although she knows the student was qualified in some way, it was not the help she was looking for.
“I was like, this is a serious issue that I’m having and I’m not getting real help,” Anderson said. “It felt like I was being used as a test.”
Chan noted that her therapist was a Ph.D. student close to her in age. This meant the provider could relate to her struggles but she said the whole experience was slightly weird.
“It felt like talking to friend rather than someone who could give me real advice,” she said.
Complaints from students about receiving care from grad students are very rare, Oakley said.
“We bring very, very skilled people,” Oakley said. “If we had any concerns about our interns’ ability to do this work, we would not have them see students.”
Stigma around CAPS
Students also noted that the stigma about receiving services from CAPS can prevent undergraduates from seeking help.
Chan explained that when she first went to CAPS, she didn’t tell anyone besides her closest friends and her mom.
“CAPS has this certain stigma around campus and has become a joke rather than a resource people take seriously,” she said.
Receiving therapy is something students make jokes about, and there’s an association between CAPS and a mental institution, she said. This makes it hard for students to initiate that first visit, especially if they think they might run into someone they know in the office.
Mehta noted that mental health is not given as much attention as it deserves because some people don’t believe it’s a real affliction. At Duke and in society, focusing on one’s mental health isn’t a priority, she added.
“If a student is stressed and if a student needs long-term care, it’s easy to shrug it off and say, ‘of course you’re stressed, you’re in college,’” she said.
Duke has a culture of “effortless perfection,” Klug explained, which makes it seem like everyone can accomplish things easily and prevents people from talking about their insecurities.
To combat this, Peer for You offers a service in which students can send messages anonymously to peer responders who will answer their questions within 24 hours. It’s a space to support students in need but also alert them to resources on campus like CAPS or DukeReach, a comprehensive case management service.
Klug noted that Peer for You is more appealing to some students because it allows them to talk with people their own age and doesn’t require them to identify themselves.
“We provide a stepping stone to students who may need those resources,” he said. “They may feel more comfortable talking anonymously, which you can’t do with CAPS or DukeReach.”
Bidopia from NAMI, who is also on a mental health advisory council that works with CAPS, explained that CAPS often has difficulty reaching students because they’re reluctant to seek treatment. Future efforts should target the period between students realizing they have a mental illness and actually stepping into the CAPS office.
Some students need an extra push, which could take the form of online scheduling or an anonymous way to receive services, she said.
Oakley noted that stigma can prevent some students from seeing therapists. The number one reason students visit CAPS is because of anxiety, followed by depression.
“There’s a lot of pressure that comes from being here,” she said. “Schools that are more academically competitive have higher utilization rates for mental health services.”
About 14 percent of students at Duke utilize mental health resources each year, which is similar to the utilization rate at Northwestern University and Vanderbilt University, Oakley said. Public schools are typically in the six to eight percent range.
Some students are also predisposed to mental health issues because of genetics or have situational issues that are not resolved, she noted. In addition, factors like racism, sexism and xenophobia negatively affect students’ psychological states, leading to low self-esteem and increased depression and anxiety.
Oakley acknowledged that some students do worry about encountering people they know in the CAPS office.
“We encourage them to talk with their counselor about how to handle that,” she said. “If the other person is here, it means they’re struggling as well.”
Stigma can also come from professors, many of whom are not familiar with mental health issues.
Amy Powell, director of DukeReach, explained that some faculty are better than others at handling students with mental health issues, which she said could be related to the subjects they teach.
“If you’re working with faculty in psychology, you’re likely going to get someone who understands mental illness—but if you’re working with someone in computer science who may have never had that difficulty, they might come at it with a different approach and be uncomfortable approaching that topic,” she said.
Much of this variation comes down to the education Duke professors receive about mental illness. Although DukeReach does faculty training, they can’t mandate that professors attend—and many don’t because of their busy schedules. The DukeReach office also sends out folders to each department with resources so that faculty can look at it on their own time.
“I think certainly CAPS would be open to talking with faculty,” Powell said. “Because faculty are so busy we need to be creative in finding ways to train them on how to handle students' mental health issues."
Tom Szigethy, associate dean and director of the Student Wellness Center, said that faculty and staff can play a major role in combating stigma on campus. High-achieving professors can perpetuate the “effortless perfection” idea that is common among undergraduates.
“It’s up to us to be the example in that regard,” he said. “There needs to be a level of conversation with staff and faculty about the real-life struggles they may have gone through.”
Compared to UNC
There are plenty of complaints about CAPS from the Duke community—but once you step outside of the Duke bubble, are the issues plaguing the office unique? Looking at the University of North Carolina at Chapel Hill’s resources yields insights into the state of mental health services on college campuses outside of Duke.
Maureen Windle, associate and clinical director for Counseling and Psychological Services at UNC, is responsible for the day-to-day operations of the counseling services there.
In 2007, the department began operating a walk-in model—similar to what Duke adopted this year—because they could not keep up with student demand and always had a waitlist. Now, they are open for students to drop in each weekday.
“We have a commitment that every day we will see every student who walks in regardless of the number,” she said.
In the past few years they have seen a jump in walk-ins, with the highest being 48 in one day. Like at Duke, students initially talk with a provider for about 20 minutes—or longer if there’s a crisis—and then evaluate their next step.
This could be one of their group therapy programs, setting up time with an individual therapist or connecting students with a referral coordinator. As to Duke, students who need long-term care are directed to off-campus providers. CAPS at UNC sees students regularly for one semester at most.
“We have a brief psychotherapy model,” Windle explained. “We’re looking at students and seeing if we can provide a brief therapy inside of a semester.”
Most students are satisfied and interested in ending their experience with UNC’s CAPS in three to five sessions, she said. Others take between eight and 25 sessions to complete their care.
She noted that they are committed to diversity and have a “reasonably diverse” staff with black and Latinx psychologists as well as LGBTQ+ providers.
Although stigma around mental health certainly exists on the UNC campus, Windle noted that it has been significantly reduced in recent years due to the efforts of student groups like Stigma Free Carolina. In addition, UNC’s statistics show that a demographically representative portion of UNC’s student body is utilizing their resources.
They’ve seen a sharp increase in students visiting within the past three years—a sign of reduced stigma—but creates problems for serving the volume of individuals. Like many colleges across the country, they don’t have funding to hire more providers or expand their services, Windle explained.
“We need more resources as the demand continues to grow, but we don't know if we’re going to get those resources,” Windle said. “We’re busting out of the seams in this building.”
For Duke students disenchanted with CAPS, DukeReach presents another option for addressing mental health concerns—either for themselves or their friends.
Powell, who has been the director of DukeReach for nine years, explained that the office invites students who have concerns about their peers to contact them so the DukeReach providers can reach out and ensure that the student in question is receiving adequate support.
Students can submit DukeReach reports through an online portal, by calling or by emailing. In the portal, there’s an option to anonymously submit a report—but the office encourages students to provide their information.
“We have found that it’s more helpful for students we meet with to let them know where the report generated from,” Powell said.
From there, one of DukeReach’s three case managers will reach out to the student and invite them to meet so they can go over the issue and what possible solutions might be—this could mean setting up an appointment at CAPS or referring them to an off-campus therapist.
The most common issues reported to DukeReach reports are anxiety, depression and difficulties connecting at Duke. Some students also express worries about their friends’ substance use or disordered eating.
Anderson noted that DukeReach was very helpful in connecting her with an off-campus provider for therapy.
“I think that was the best thing DukeReach did, they referred me to really good people off-campus,” she said.
Senior Ashley Kelley, who has struggled with an eating disorder, said that DukeReach is a fantastic program because they give students a case manager who checks in with them multiple times a semester and can communicate with their academic dean if they need time off or an extension on assignments. She noted that she still keeps in touch with her case manager.
“You can tell them stuff you wouldn’t tell your dean,” she said. “The case manager is the only person you have to tell.”
She added that DukeReach is often an underutilized resource because not enough students know about it.
Senior Caroline Guidry has similarly positive views of DukeReach. After expressing that she was considering transferring out of Duke, one of her friends referred her to DukeReach and Powell—who Guidry said is a “lovely woman.”
“Her interaction with me is, ‘what can I do?’” Guidry said. “I’ve used her as a support for years now. It’s helpful for someone like me.”
However, there is the risk that someone will refer a friend for a perceived problem when in fact that individual is not suffering.
Anderson noted that those situations are awkward because the student in question still has to attend the meeting.
“They make you go and if you’re busy or [the meeting is] going to make you feel bad, it could be a problem,” she said.
But she added that it makes sense the office would respond this way, since they need to follow up on every concern.
Powell noted that false referrals have happened before, but that they still encourage students to submit reports just in case, so the office can at least reach out.
“Unless there are safety concerns, if the student says ‘no I’m good,’ we typically just explain that someone was worried about them,” she said. “We make sure they have resources in case something comes up in the future.”
Leaves of absence
If students can’t find the right mental health resources on campus or need additional care, many choose to take a leave of absence from school.
But for some, the process is less than restful. Kelley, who took a medical leave of absence for Fall 2015, called the restrictions and requirements of the process “a nightmare.”
Several students noted that they felt like they were pressured into taking leaves of absence rather than remain on campus.
Klug said that he felt like his dean pushed him to take a leave, which may have been because Duke considers students with mental illnesses to be a liability.
“It’s much easier to kind of push it away and not invest time and resources than to actually invest the resources,” he said.
Although Duke’s environment does not always emphasize healing and self-care, some students may encounter more difficulties at home than on campus, Klug said. Instead of pushing students to take time off, Duke should do a better job of taking care of those who do want to stay.
Powell explained that the process for taking time off is administered through a student’s academic dean and that the Office of Student Returns readmits students. DukeReach often interacts with students when they are considering taking time off or after they return to help ease the transition back. She noted that most students who take leaves of absence do so for mental health reasons.
“When students are to the point when they’re depressed or anxious and it’s affecting their ability to perform academically, I think that’s typically why students would choose to take a medical leave,” she said.
Sabrina Thomas, director of the Office of Student Returns, declined to comment for this article and directed The Chronicle to the information on OSR’s website.
Working while on leave
One of Kelley’s main complaints with the leave process was that students on medical leave are expected to take part in a job, internship or volunteer work while recovering from their mental health issues in order to be accepted back into Duke.
The Office of Student Returns website includes a checklist for returning students’ applications—one item of which is a personal statement and short essay questions. One portion reads, “Explain how you have spent your time away from Duke (e.g. medical treatment, paid/volunteer work, academic course work, other activities) and how these experiences have been productive and helpful to your understanding of what changes must be made in order for you to succeed as a Duke student.”
Kelley said she was “infuriated” by the fact that she felt she had to get a job while on leave. Because she was in a residential care facility for treatment, she had to get a waitressing job at night that she said interfered with her ability to get better.
“If somebody takes a semester off, you can’t get treated, get a job and feel better,” she said. “It’s just not feasible. That was really frustrating.”
Guidry noted that the expectation to have a job or volunteer work was a source of anxiety during her time away. She chose not to do any part-time studies, but did get involved with a youth soccer program toward the end of her leave.
Living in a remote part of Louisiana also limited her options for work or college classes.
“I explained in my application that there wasn’t much I could do,” she said. “I spent most of the time focusing on my health. That part just didn’t make sense to me.”
Powell explained why Duke wants students to engage in activities during their leave.
“Doing something meaningful and useful with the time away that demonstrates they are able to function shows how they will do when they return,” she said. “I think it’s helpful to be engaged in something.”
Other students took issue with Duke’s policy that students cannot be on campus while taking medical leave.
OSR’s website notes that students on medical leave forfeit the privileges afforded to enrolled undergraduates.
“During your separation, you cannot enter University residential buildings, participate in student activities or access student resources and services,” it reads.
If students do plan to be on campus for some reason, they must contact their academic dean for written permission. Those who do not follow the policy may jeopardize their chances of returning to Duke.
Kelley said she feels like this policy penalizes students, even though they didn’t do anything wrong, and isolates them from their network of friends.
During her leave, Kelley—who is originally from Hawaii—stayed in the Durham area for treatment and lived off-campus. She noted that her entire support system was on Duke’s campus, and she couldn’t visit them.
“My option was to sneak onto campus or just decide I don't get to have friends,” she said.
She pointed out that she was treated more strictly than the general public, who are allowed to visit the Duke Chapel and walk in the gardens.
Being able to visit campus can help students evaluate if they are ready to return, Anderson noted.
Powell explained that the policy is designed to help students disengage from the campus community during their treatment.
“It’s helpful to remove a student from the current environment that was really difficult for them,” she said.
Several students said that when they felt ready to return to Duke, the readmission process was difficult for them.
Kelley noted that she struggled when writing the application essay about why she should be allowed back at Duke, explaining that it brought back negative memories regarding her illness.
“That’s not a great experience,” she said. “For mental health, the issue is not gone, it’s just being managed.”
She also pointed out that the application asks for a recommendation letter from the place where students work or volunteer. This can be difficult for students who don’t want to disclose the reasons they left school.
Guidry noted that when she was submitting her return application she did not receive adequate communication from the Office of Student Returns.
“It’s a nightmare to get in touch with them,” she said. “I emailed them multiple times without a response.”
The decision made by the office on whether or not to readmit students can have a drastic impacts on their lives, which leads to lots of anxiety, Guidry said.
She noted that she felt like it was easier for her to apply to Duke as a first-year than it was to return.
Anderson had similar issues with the office’s lack of communication, noting that the entire return process was stressful for her and also felt like applying to college for the first time.
She said that the semester before she returned, she wasn’t able to register for classes at the appropriate time because she hadn’t received a response from the office about her application.
Although Anderson frequently called and emailed the office, she received no responses, and the office did not tell her when she would know if her application had been accepted or rejected.
“It seemed to me like they were very disorganized, and it wasn’t very respectful of the students,” she said.
She was eventually accepted back into Duke, but was one of the last people in her year to register for classes.
Guidry noted that suffering from a mental health issue on Duke’s campus can be a lonely experience and that it’s difficult for many students to reach out for help. She suggested removing barriers posed by a lack of communication and long wait times.
“You don't want to make it more difficult for a person to get effective treatment and stay well, and that’s what [the barriers] did,” she said.
Oakley noted that in the future, she would like to see Duke develop a more formalized 24-hour crisis response line for students to call after hours, beyond the dean-on-call system that Duke currently has in place. She also would like to hire more staff members so that students’ wait time for a CAPS appointment is always under two weeks.
Student groups on campus—like NAMI, Peer for You and Neurocare—are also helpful in providing students with resources and reducing stigma, Oakley said. She added that she hopes to connect more with them to enhance community engagement.
“We want to work with student groups in figuring out how we can train all students to recognize, respond and refer a peer in distress,” she said.
For Mehta, the key to improving Duke’s mental health resources is putting a human face to the issues.
She called on the Duke administration to put more time and money into caring for students with mental illnesses.
“If someone is fighting for better access for mental health resources, they’re not fighting for some abstract ‘one-in-four,’ they’re fighting for me,” she said. “If the Duke administration can see it’s Pooja and Julie and Jordan, these are the students that need these resources, it’s more humanizing—and I think that is kind of the missing link.”