'When College Is Not the Best Time'

September 15, 2010

We've all heard the clichéd description of college as "the best years of your life." For those of us whose undergraduate years are a distant memory, the idea may seem ludicrous -- or, at least, too demoralizing to entertain -- but there's no denying that college students tend to enjoy an unusually high ratio of freedom to responsibility, and that many high schoolers come to anticipate a positively Elysian experience.

For some students, then, the reality of college comes as a rude shock, and one with which they're totally unprepared to cope. From psychiatric issues (which have become more common -- or at least more commonly identified -- among college students in recent years) to academic overload to plain old homesickness, many college students find themselves facing stress or unhappiness they didn't expect, from sources that may be totally new -- and they may not realize just how normal that is.

At least, that's the view taken by David Leibow, assistant clinical professor of psychiatry in Columbia University's College of Physicians and Surgeons and assistant attending psychiatrist at New York-Presbyterian Hospital and New York State Psychiatric Institute. Leibow's new book, What to Do When College Is Not the Best Time of Your Life (Columbia University Press), addresses some of the problems that students are most likely to face, and offers frank advice on how to handle them; the book also includes a final chapter intended for the parents of struggling students

Inside Higher Ed interviewed Leibow via e-mail to get his thoughts on the issues students are most likely to face, why they arise, and what can be done about them.

Q: What inspired you to write a book on this topic?

A: The inspiration for What to Do When College is Not the Best Time of Your Life began with a phone call from a distraught mother requesting an urgent appointment for her son, a college junior, who was coming home for the Thanksgiving vacation. "I've never seen him this way," she told me. "He's so depressed he's not sure if he can carry on."

I had received many phone calls like this one from distraught mothers over the years. And they all had two things in common: (1) their child was floundering in college to the point of despair; (2) the parents had no clue.

These were capable, motivated students, and loving, appropriately involved parents. So why were these kids floundering and why were they keeping their parents in the dark?

The answer, I realized, was shame. They were ashamed because they believed — wrongly — that they were the only one of their peers having problems. And they were ashamed because they believed — again wrongly — that as proto-adults they ought to be able to handle these problems on their own. Because of their shame, they didn't inform their parents that they were having problems, or ask for help from anyone at school. They buried their heads in the sand and hoped for the best until their problems became seemingly insurmountable.

I wrote my book for college students and their parents as an antidote to this shame. I wanted to reassure them that problems in college (as in the rest of life) are normal, to give them some insights and practical suggestions to deal with these problems, and to provide guidance on when to seek professional help.

Q: What are some of the primary reasons why college might not be the best time of a student's life?

A: There are many reasons that college is a disappointment: homesickness, relationship disappointments, financial worries, losses or conflicts at home, medical illnesses and the whole panoply of psychiatric disorders that arise when people are in their twenties — anxiety, depression, insomnia, body-image problems, etc.

But the biggest problem — both as cause and consequence of unhappiness in college — is academic floundering.

When asked by the 2009 American College Health Association-National College Health Assessment whether any experience in the past year had been traumatic or very difficult to handle, 44.2 percent of the students named academics. That number is 10 percent higher than any other stressor, including problems with finances or intimate relationships.

College students want to succeed. They want to fulfill their own ambitions and make their parents proud. If their grades are low, and especially if they're forced to delay graduation or drop out, they feel demoralized and ashamed. Plans for further education are scrapped; career aspirations are abandoned; life trajectories are thrown off-course. If they were meeting their own expectations academically and had a few friends, most college students would be happy. And they'd be in a better position to deal with the other challenges that inevitably come along.

Q: The book focuses on fairly major issues of mental and emotional well-being, along with academic problems. Of course, there are other reasons why a student might not be happy in college; how did you decide which topics to include?

A: I chose problems that were specific to college or, if not specific, were at least very common in college. So, for example, I spent considerable time on academic problems and insomnia but very little on schizophrenia or transgender issues. I avoided covering in detail topics that change rapidly and can be looked up easily online or in sources specifically devoted to those topics. For that reason, I discussed in depth the pros and cons of taking medication but didn't go much into the pros and cons of which medication to take.

I focused on clinical subjects, like laziness, friendship, romantic relationships, depression and body-image problems, where I have expertise and perhaps some fresh insights. And I eschewed subjects, such as the organization of student health services or the importance of remedial courses, in which I have no particular expertise, or where the issues are sociological or political rather than clinical. I discussed race but only as it pertains to identity formation and friendship not as it pertains to education policy. I discussed the cultural tyranny that equates thinness and beauty but offered no cultural remedies, except to reassure young women that they're not alone in feeling oppressed by it. I talked about the types and uses of therapy but also when therapy might be unnecessary or even harmful. I told parents how they can help their struggling students but not how to raise their children.

In short, I tried to focus on topics that I know well and on which I have something fresh to offer. And I tried to approach each topic from a sound, mainstream clinical perspective rather than from a polemical or encyclopedic one.

Q: The book details treatment options for various psychological problems commonly faced by college students, such as depression, anxiety, and insomnia; you even describe various medications for these disorders, and their individual advantages and drawbacks. Do you worry about college students being diagnosed or medicated too much?

A: The answer is yes — and no.

Let me start with the no. The truth is that most young people put on antidepressants and other common medications for depression, panic disorder, etc. get substantial benefit. College students are under tremendous time constraints. They can't wait months to feel better and most (certainly not all) medications have tolerable side effects and work quickly.

The decision to start a student on Lexapro (the most commonly prescribed medication), for example, is based on the presence of a set of persistent and debilitating symptoms — hopelessness, fatigue, impaired cognition, sleep and appetite disturbance, etc. — not on whether the depression was triggered by some traumatic event. This agnosticism about the relevance of ostensible causes is rightly disturbing to critics of medication who view as normal depression that arises in the context of, say, academic failure or parental divorce. Unfortunately for this viewpoint, the best scientific evidence supports the use of antidepressants in major depression even when there is a precipitating event.

Of course, the precipitating event needs to be addressed psychotherapeutically. But therapy and medication are not mutually exclusive. And needless to say, not all psychiatric or psychological problems need medication. Many respond to psychotherapy alone. (I go into the indications for therapy in detail in my book.)

It does concern me, however, when students are rebuked or mocked for "resorting" to medication to deal with psychiatric problems, especially when their suffering has consequences for their academic performance, self-confidence and future livelihoods. The treatment of serious psychiatric conditions is no place for puritanical nostrums about the ennobling or educational effects of misery.

But, to return to your question: yes, I do have concerns about the over-diagnosis and over-medication of college students.

My concerns are threefold:

(1) Many (not most, but many) clinical syndromes of college students are developmental. Though painful, and though sometimes resembling real psychiatric diagnoses like depression, they are the natural consequence of leaving childhood and beginning the transition to adulthood. They do not rise to the level of psychiatric disorder. They're self-limiting and crucial for psychological maturation.

The problem is that deciding whether a problem is a true psychiatric disorder or "merely" a developmental challenge requires considerable clinical sophistication. The consequences of making the wrong call are considerable on both sides. That's why students should find a skilled clinician to help them sort it out.

(2) Some psychiatric medications have troublesome side effects that produce their own set of problems. And sometimes those side-effect problems are as big as the problem they were prescribed to treat. Weight gain and loss of libido come to mind. So again it takes considerable clinical sophistication to weigh the pros and cons of medication, especially in marginal cases, and to help the student make an informed decision.

(3) Medication is a signifier of psychiatric illness. To the extent that students are using illness consciously or unconsciously as an excuse to avoid taking responsibility for their actions or doing their schoolwork, psychiatric medication may delay the moment when they confront their academic or other difficulties.

The worst outcome of the inappropriate use of psychiatric medication would be that the student comes to see herself as an invalid and uses medication and all it symbolizes as a crutch.

Let me conclude by saying that these three caveats about using medication should be addressed in a respectful, informed dialogue between the student and a qualified psychiatrist. Most students and therapists will choose the correct treatment when given all the relevant facts and options.

Q: You write that psychiatrists and other therapists may make "the honest mistake of mislabeling work avoidance as psychological illness." Is this a common error? And how does one distinguish between the two?

A: This question returns us to the issue of shame.

As I've said, most students want to do well in college. But college students are no more exempt from procrastination, distractibility, perfectionism, grandiosity, wishful thinking, avoidance and just plain laziness than the rest of us. Before it becomes stimulating and rewarding, academic work is lonely, daunting, tedious, time-consuming, laborious, frustrating and unpleasant. In short academic work is work. Small wonder then that some students might try to avoid it. In high school they may be able to get away with not working. In college — not so much.

When they start to flounder, some college students will deal with their shame by using depression or ADD or substance abuse as an excuse. The vast majority of students with these ailments get better with treatment or accommodations. Only a few appropriately treated students don't get better. And some of those may be using their illness as a pretext for avoiding work or as a way to deal with their shame.

The fact that a few students use their illnesses as an excuse is not meant to give license to college professors to crack down on every kid who asks for an extension because they're being treated for depression. It's meant as a warning to students and therapists to face up to the possibility of malingering. Otherwise the student is in danger of believing his own rationalizations and becoming a chronic invalid.

Q: "In my experience," you write, "most depressed college students who are doing poorly in school are depressed because they're doing poorly, not the other way around." How did you arrive at that conclusion? Is your stance an unusual one?

A: Most — but not all — of the cases of depression that I see in college students, especially in students who avoided work in high school and have no family history of depression, are the consequence not the cause of poor academic performance.

This was not what I had expected. Based on my experience with adults, I had expected the depression to be the cause not the consequence of the poor work performance.

Since my observation is anecdotal, it might not reflect the wider consensus. And certainly the depressions of college students have to be taken seriously regardless of whether they're primary or secondary. But based on experience with many students over thirty years, it makes sense to me that they would be the exceptions to the rule that depression precedes poor performance. The adjustment young people have to make in order to cope with college-level work is greater than any other transition they've hitherto had to make. Couple that with a history of poor work habits, high personal and parental expectations, withdrawal of the structure of high school, and a unique post-adolescent propensity for shame, and it becomes obvious why college students get depressed when they flounder academically — and why they might want to use "depression" as an excuse for why they're failing.

The young man I referred to above, whose mother phoned me just before Thanksgiving, was just such a case. He wanted to propose that his depression had caused his poor performance. But his history revealed only sporadic academic effort in elementary and high school and considerable time playing video games and procrastinating in college. Nevertheless, because of his shame, it took several months of psychotherapy before he could admit that he needed the "depression" as a sop to his conscience, and as an explanation to his parents and teachers, for why he wasn't performing.

It's worth noting that a psychotherapy that didn't deal with this so-to-speak malingering, would not have worked any better that medication to cure this depressive symptoms. Until he was able to face up to his shame about not doing his schoolwork — and begin to develop the discipline and structure he needed to succeed—he would not have been able to relinquish the excuse of depression. When he did do those things, the depression disappeared of its own accord.

This is a tricky, high-stakes clinical call. It's probably easier and less risky to go with the flow and treat the depression as an autonomous problem. The upside of doing so is that you won't under-treat any cases of major depression. The downside of treating the depression as cause rather than consequence of academic floundering is that the student might not push himself to buckle down, and perhaps never complete college.

Q: Should colleges be doing more to identify and assist unhappy or struggling students? What changes would you like to see?

A: The answer is a definite yes. I wrote a blog article in Psychology Today detailing why I think colleges should provide training on how to study at the college level. I won't repeat my whole argument here. But suffice it to say that if academic floundering is the biggest cause of college unhappiness (which it is) and if training on how to study would increase the likelihood that students would study (which it would), it's regrettable that universities don't provide this instruction.

In the meantime, there is nothing to stop professors from providing lecture notes before class and discussing how they and other specialists study and produce work in their particular disciplines. It would improve their own popularity and the success of their students if professors reached out to students who were skipping classes or failing to hand in assignments. There's also no reason that instructors can't give reading and other assignments that are meaningful and require a reasonable time to complete—and that they give quick and helpful feedback on those assignments.

Many college students have told me that their motivation and enthusiasm mirrors that of their professor. Professors who are unprepared, unenthusiastic, slow to return assignments, unduly harsh or unduly lax bring out the worst in their students. Professors who are prepared, enthusiastic, responsive and fair bring out the best.

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