When students leave campus to go home due to mental health reasons, they are faced with a complex and stressful web of procedures and difficult choices which at times are beyond their control.

UPDATED: April 28, 2014, at 1:55 a.m.

This article was originally published in The Crimson’s 2013 Commencement Year in Review issue last May. It is being reprinted as the first in a three-part series on mental health at Harvard and has been edited to reflect the passage of time since its original publication. Part II ran April 29 and Part III on April 30.

David was thriving at Harvard. In his time on campus, he had excelled in classes that he loved and pursued extracurricular activities about which he was passionate. When he was diagnosed with clinical depression in fall of 2012, he did not skip a beat, seeking treatment using mental health resources provided by Harvard University Health Services.

Yet despite taking advantage of all of these opportunities, David decided not to return to Harvard in the fall of 2013. He is taking a leave of absence from Harvard this academic year, in part to address mental health concerns.

“At Harvard we have everything that we could ever want to be happy, but we’re not quite,” David said. “And we think that perhaps if we could step out for a while, we might be able to figure out what that is and come back and be happy.”

In the past two years, the issue of emotional and psychological well-being has dominated discussions about student health at Harvard. At a student rally in Harvard Yard, a town hall discussion hosted by administrators, and in private settings, students have sought to grapple with the usual sources of pressure, as well as the added stressors of several undergraduate deaths, including two that administrators identified as suicides.

Again and again in these conversations, community members turn to the topic of going home for mental health reasons.

For a handful of students each year, Harvard’s environment is too much to bear. In search of wellness, these undergraduates leave Harvard, returning home to a world without the worries of college life. But before they go, students must navigate a complex and often stressful web of choices and procedures that at times are beyond their control.

AN INHOSPITABLE ENVIRONMENT

When My Ngoc To ’14-’15 was hospitalized at McLean Hospital for suicidal thoughts, she felt torn about whether or not to stay at school or take time off. If she decided to go home, UHS would require her to seek some form of care before returning to campus. To would also have to engage in a productive activity for a period of stability, which usually lasts six months. When she was ready to come back, she would have to meet with UHS for an intake interview and then petition the Administrative Board with proof that she was ready to return to life at Harvard.

“It was a hard decision to make,” said To, an inactive Crimson editorial editor. “My doctors definitely wanted me to go home, but my family didn’t quite understand what depression was.”

In the end, however, the pressures of life at Harvard outweighed the costs of going on leave.

“I felt like if I went back to school, it would have just been worse because it would have spiraled,” she said.

To is not alone. Students and administrators say they agree that the pace of Harvard life creates an atmosphere that can often be hostile to a student’s recovery from mental illness.

“This is not a place to get well—not because we don’t have the resources,” John “Jay” L. Ellison, the secretary of the Ad Board, said plainly. “It’s because to be a student here, you are pulling in problem sets. You’re writing papers.”

In many cases, students and administrators say the best option can be to take time off from school.

“Leaves offer a chance to press the reset button on a term so students can return at a later time and be better able to make the most of their time here,” said Sharon L. Howell, who works with students as the resident dean of Adams House.

Dean of Student Life Stephen Lassonde, who previously worked at Brown and Yale Universities, said that this environment is characteristic of many of Harvard’s peer institutions.

“There’s no selective university in the country that’s...a good place to get better,” he said. “I think for some students, they chose a too difficult selection of courses, but for others it’s the way they’re spending their time outside of the classroom.”

Howell said that a hectic lifestyle can directly impact a student’s recovery, as going to therapy is often seen as “one more thing they need to do.”

For David, who requested that his name be changed, this pace of life was one of the primary reasons that led him to take a leave of absence.

“Very often I would devote my time to extracurriculars and say to myself, ‘It’s okay that I’m not going to be happy today. It’s okay that I’m not doing what I want to today. I’m doing this because I want to be happy tomorrow,’” he said. “I think I realized that if I kept living like that, 30 years would go by before Irealized that tomorrow wasn’t going to be there.”

NOT GETTING BETTER

While students and administrators agree that Harvard’s atmosphere contributes to the problem, they sometimes disagree about whether UHS can fight that problem adequately.

UHS, which houses its Student Mental Health Services on the fourth floor of the Holyoke Center, is part of a broad network of mental health resources on campus, including peer counseling, the Student Mental Health Liaisons program, and wellness tutors in the Houses.

For some students, UHS is the symbol of an extensive system that despite its efforts cannot do enough to keep them healthy here on campus.

Emily, a College sophomore, chose to seek treatment for her mental health issues through UHS. When she decided to go home toward the end of last spring, she was both thankful that UHS professionals had spoken to her earlier about “navigating the system” and disappointed by the actual care she received.

“It felt like my issues weren’t being taken seriously because I wasn’t suicidal,” said Emily, who also requested a pseudonym.

David, too, was disappointed by the treatment he received through the University in the fall of 2012. After a few months, he switched to a private practitioner, a change he said was motivated in part by what he saw as lackluster care at UHS.

“My psychiatrist, for example, forgot my name two or three times. There were mix-ups related to prescriptions,” David said. “It was pretty clear that the people who were treating me were doing their best, but were overworked and not in the position to provide any quality care.”

In an emailed statement to The Crimson in May 2013, HUHS Director Paul J. Barreira and SMHS Chief Katherine A. Lapierre wrote that UHS is prepared to help with any “minor or serious, newly acquired, or long-standing” mental health concerns. And in a Crimson op-ed published in March 2013, Barriera wrote that many UHS patients said that “once they were in the system they felt that they received great care.”

In the op-ed, Barreira shared the results from three national leaders who conducted an outside review of SMHS, which found that “there is a perception that SMHS is not working solely for the administration.” This view that SMHS is responsive to students has led “the University community [to trust] that the SMHS is there for the care of students,” he continued.

But David expressed concern that UHS is not working solely for the student and sees itself also working for University administration.

“[HUHS has] to weigh on one hand the health and medical interests of the patient, but on the other hand the safety and liability concerns at the University,” David said, later saying that in his opinion UHS makes decisions “in a medical context for non-medical reasons” to safeguard Harvard from potential liability.

LOOMING LIABILITY

Lawsuits against universities have sparked controversy across the country over student suicides, including some against Harvard, MIT, Cornell, and Wesleyan.

The Harvard case surrounds the death of John B. Edwards III ’10, who was a sophomore interested in medicine and training to run the Boston Marathon when he committed suicide in November 2007. In his lawsuit, Edwards’ father contends that the treatment of his son by UHS did not meet medical standards.

In the midst of these lawsuits, Peter F. Lake ’81, a professor at Stetson University College of Law who specializes in higher education law, said that “liability is in the back of people’s minds” when students on campus are dealing with mental health issues.

Yet Ellison said that Harvard only considers “the behavior of the student” and that the risks of being held liable “never” play a role in the decision to send a student home.

Despite what Ellison says, Harvard faces significant legal risk at every step in the process while the student is still on campus. But everything changes when that student goes home.

“You stop the clock on liability when the student leaves,” said Michael A. Olivas, the director of the Institute of Higher Education Law and Governance at the University of Houston.

In particular, Harvard faces liability when it decides whether to forcibly send students home for mental health issues, Lake said.

These instances of involuntary leave rarely occur, however. At Harvard, as well as nationally, only a tiny percentage of students who go on leave for mental health reasons are forced out. Barreira and Lapierre wrote that in mental health cases, “the decision to take a [leave of absence] is the student’s to make, hopefully with the advice and counsel of mental health clinicians as well as their deans.”

In fact, as of 2013, only one student had been placed on an involuntary leave of absence from Harvard for mental health reasons in more than a decade, according to Ellison, and that student eventually asked to convert to a voluntary leave.

But when these cases do crop up, to avoid a lawsuit Harvard must never send someone home involuntarily if they are not dangerous to themselves or others, and it must always send them home if they are, said John Dayton a law professor at the University of Georgia and the director of the Education Law Consortium.

Still, Lake cautioned that it can often be a mistake to send home mentally ill students, even dangerous ones, to avoid liability.

“A very, very small number of people who exhibit mental health issues represent danger to themselves or others,” Lake said. “A lot of people who are potentially dangerous are actually better off with [the University] than off at home.”

CHOOSING THEIR OWN FATE?

Administrators often draw a clear line between voluntary and involuntary leaves of absence. But in fact, some students say that some voluntary leaves of absence are less voluntary than they seem.

Ellison acknowledged that there are times when students feel that circumstances have snowballed to a point at which they have “very little choice” but to go on voluntary leave. Ellison said that oftentimes students feel that taking a voluntary leave of absence is a better way to go.

“Even though they look the same [on a student’s record], students do feel like a voluntary [leave of absence] is the better choice,” Ellison said.

Emily decided to take leave from school in part because she was concerned that she would eventually be required to leave by the administration.

“I wanted to [take time off] on my own terms,” she said.

The school and mental health professionals can also encourage students to take time off, legal experts confirmed.

Even though she was not forced to leave the school, Emily said that doctors in UHS strongly recommended that she withdraw, significantly influencing her decision.

In addition, a loophole in the Student Handbook raises questions about involuntary leaves at Harvard. An obscure exam policy shows that Ellison’s claim that Harvard has only forcibly sent one person home for mental health reasons between at least 2002–2013 underreports the number of students whose mental health status has contributed to a mandated leave of absence.

In fact, Ellison acknowledges, a student’s mental health situation plays a significant role in the Ad Board’s evaluation of whether to forcibly send a student home for academic reasons.

According to the Student Handbook, the Dean of the College may place a student on involuntary leave if he or she “has been granted make-up examinations, or extensions of time beyond the end of the term, in two or more courses.” According to Ellison, students in this situation face an Ad Board vote on whether or not they should be allowed to continue.

In cases in which these students are struggling because of their mental or physical health, the Ad Board, with consultation from UHS, will determine whether they think students can sufficiently take make-up examinations while also taking a full-course load the next semester. If the Ad Board decides that a student cannot manage this, the Board may say that the student should not be allowed to continue, though Ellison noted that this decision is “not a punishment.”

Typically, most students who miss two or more exams are permitted to return, including 26 of the 28 cases in the 2012–2013 academic year. But Kate, a College freshman who requested anonymity, had a different experience.

During exam period in the fall of 2012, Kate went to UHS to seek help because she was cutting herself. She was soon voluntarily admitted into McLean Hospital, where she stayed for five days. Her stay at McLean forced her to miss two exams, which her resident dean said she could make up when she returned in the spring. So Kate went home, scheduled meetings with a psychologist, and booked flights back to Cambridge, happy to be back home, but also eager to finish her freshman year.

In January 2013, just days before she was to return to school, she received an email from her resident dean informing her that the Ad Board had already reviewed her case. They had decided she was not fit to come back to Cambridge for the spring. Kate appealed the decision twice and was denied both times.

When asked about Kate’s case, Ellison defended the policy, saying it was designed with students’ best interests in mind.

“We don’t just say, you can’t come back because you’ve got two make-up exams,” Ellison said, adding that he was not commenting on this case specifically. “We say, based on the information that we’ve got from medical professionals who know about the situation, what the concerns are, we don’t think you’re ready to come back.”

And although Kate was placed on leave against her wishes, she sounded a note of optimism about going home.

“I do think that taking time off has been a growing experience, has been a teaching experience,” Kate said. “I’m going to return to Harvard with a newfound appreciation."

—Staff writer Steven S. Lee can be reached at steven.lee@thecrimson.edu. Follow him on Twitter @StevenSJLee.

—Staff writer Dev A. Patel can be reached at dev.patel@thecrimson.com. Follow him on Twitter @dev_a_patel.