BREAKDOWN

and was at the same time advised to consult the Health Service. He did this reluctantly, but did eventually accept treatment. His academic output gradually improved, and he eventually graduated

sity,

by Dr. ANTHONY RYLE

upper second

degree.

DIRECTOR OF THE

with

SUSSEX UNIVERSITY

CASE

HEALTH CENTRE

rather similar academic Roger, except that she spent all her picture waking hours attempting to work but was never able to complete anything to her own satisfaction, and for this reason was unwilling to hand in most

an

3/SHEILA

Sheila

presented

a

to

us

start

Offered

some

by looking at four students who form of breakdown.

of the work which she did achieve. Complaints and pressure from tutors was met with protestations of guilt and of firm intentions to improve. She, too, was finally persuaded to attend the Health Centre.

?ASE 1/ALISON Alison

to university from a South London School. By the end of the first month ?t her first term, she had written one brilliant had failed to attend two tutorials, had been ePorted to the proctors for being out at night r?m her guest house without permission, and had the Health Service. In the fifth week this term she went to see her Dean and said she came

^rammar

JSsay,

^suited ^anted

to leave the University, but he persuaded to stay. In the same week she went to see her ?ctor and said she did not think she ought to take P his offer of therapy because it would be a waste his time, but again she was persuaded to con'nUe to attend. On the Saturday at the end of that eek she took 60 codeine tablets and was admitted j0 hospital. She returned and remained at the for the rest of that term, but seldom

,er

..

^'Versity ontributed to r?ugh en

a

was silent or flippant psychotherapy sessions. She

tutorial and

most of her

left university.

?ASE 2/R0GER ^oger

t

admitted to university with glowing from his headmaster. He had been the boy at a minor public school and came to with two grade 'A' and one grade B at 'A' levels. His first year's work was disbut adequate, but in his second year stopped handing in essays, withdrew from social including the rugger club of which he been a staunch and spent much of was

^estimonials ^Versity

^asses appointing levities e

?

^

member,

time prolonging or inventing trivial tasks or in engaged in equally trivial conversations e coffee bar. He was finally warned that his work ?tild have to improve if he was to stay at univer-

CASE

4/KATHERINE

Katherine was never in any trouble from the academic point of view. She sailed through her course to a first-class degree. Over the same period, however, she had a series of miserable affairs with

all of which left men for whom she did not care, her disgusted with herself and at times making her take refuge in drink. In her second year she became Followpregnant and obtained an illegal abortion. and came ing this, she became deeply depressed also conto the Health Service. At that time she the from books Library. fessed to stealing I would regard these four cases as fairly typical of the psychiatric case load of a doctor working in student health. How far were the troubles of these students related to their lives before univerof sity, how far were they due to the problem making the transition, how far were they the effect of the university upon them? Before these questions can be answered we need to know more about the four cases than has been presented so far. (I should make it clear that these are composite or considerably modified case histories.) Alison was the youngest of three children, but her parents had quarrelled for as long as she could remember, especially on account of her father's extravagance and drunkenness. Alison was left behind in the family when the elder brother and sister left home, and she saw her role as being to a duodenal protect her mother (by now ill with ulcer) and yet to attempt to preserve the parents' marriage. As she grew older this task seemed increasingly impossible. From the age of 16 she of the house, spent more and more of her time out leading a promiscuous life in which she got involved with men who were usually foreigners 'so 3

would be sure to go away'. From 17 onwards, she had had attacks of fainting and it was on account of a recurrence of these that she consulted the Health Centre soon after her arrival at uni-

they

versity.

This girl had learnt to dissociate herself from her feelings and from some aspects of reality, and this dissociation became more extreme in the new environment of the university. When she was with other people she felt she was no more than a puppet playing whatever part they demanded. Adjustment to the new, competitive and rather vague role of student was too much for this damaged personality to cope with; she responded with depression and hysterical symptoms. Her previous stressful relationships prevented her making real contact either with her tutors or with the doctor who was treating her. Roger's model school career was the result of a wholehearted submission to the demands made on him by an ambitious school and, earlier, an ambitious father. Breathing the freer air of the university, he discovered for the first time a capacity to say 'no' to the demands made; true freedom appeared to consist only in doing this. This was not a conscious revolt; he still overtly wanted to be a good student and please his tutors, but he found his capacity mysteriously blocked. At the same time he stopped playing rugger because he had become anxious that his penis was undersized and that he would be mocked by his fellows. It was clear from his account that he had always avoided any close relationship with girls. This story is an example of what has been called the decompression syndrome. In this case the removal of external authority was followed by an unconscious defiance of the internal authority which he had derived from his childhood. Only when he was able to see and begin to express more directly the hostility which underlay his passive compliance was he once more able to find his capacity to work and, in due course, a greater ability to relate to others. The third case, Sheila, though presenting a similar academic problem, spent most of her waking hours desperately trying to produce her work out of a need to please her tutors, just as she had previously tried to please the school teacher/ mother who had breathed down her neck throughout childhood as each educational hurdle loomed up. As well as being preoccupied with trying to work, she spent much of her time tidying her room, collecting her records into meticulous piles, and in carrying out various obsessional rituals, such as hand washing. She was never able to hand in to a tutor more than half a page of notes. It was only with prolonged treatment and the repetition of her 4

second year that she was able to overcome he' obsessional mechanisms enough to work satis factorily and also to begin to live something lik' a student's life. The fourth case, Katherine, had been an on? child brought up by her mother. Her father hai 3 been absent during her early years and after o" and mother later divorced the brief return left, of mental cruelty. Katherine saw he' mother as both the victim of her father's desertion, and as her father's persecutor, and she herse'1 repeated in her various sexual relationships the* same two roles. Through treatment and through her experience of mourning after her abortion, sh' began to find the possibility of having good thin? inside herself and of finding something deservi^ of trust in men.

grounds

Are students especially prone to breakdown? With these four illustrative cases in mind now turn to consider some more gener2 0 questions, looking initially at some statistics the incidence of psychiatric trouble in students. Students are more prone to successful suictf1 than others in the same age group. At Oxbri# the ratio is 7-10 times, and at other university 3-6 times the national rate for the age grouf Nobody knows for certain why this is so. Thef' are no simple associations of suicide with faili^' or with the time of examinations. One to 2% of students will be admitted to mental hospital within the course of their thre' years studying. This figure is a bit lower than J rate for their contemporaries in the population & the This can be explained by large. probably can

?

that psychiatric and emotional disorders in schof children often lead to underachievement, so 1 this respect students are positively selected mental health. It is also possible that the bet^ medical facilities available to students reduce ^ number requiring hospitalisation. Something like 20% of students will consult, bl a little under half this number will need treating for emotional or psychiatric problems over three-year university course. As psychiatric facf ties for this age group outside university af

lamentably

sparse,

no

comparative figures

can

}

obtained, but the evidence of general pract^ surveys suggest that comparable consultation ra'1 found in the population at large. Rather students get treatment, of course, both becaU' of the availability of services and also beca^1' intellectual impairment due to emotional problem is more critical for the student attempting to than it is for those in most other occupations. are

Motional

causes

of work

difficulty

University

entrants in Britain today represent of their age group, an elite selected for intelligence and achievement. Virtually none of this gr?uP will fail at university due to lack of adequate intellectual capacity. The problems of those fail are those of motivation, personality and rriental health. The dropping out or failing and students are a mixed group in nom two main sub-sections can be recognised.

^

/o

^nder-achieving ne

group consists of undermotivated, stable exThese students may lack that degree of anx,'ety which mobilises effort, or they may lack Motivation and be prone to be distracted by other

perts.

The other group consists of the psychia^ivities. sub''cally disturbed. This category has the obviously ill, for example those (a) groups ith delusions due schizophrenia, slowing of two

;

to

and poor concentration due to depression ?r confusion and disorganisation due to anxiety as Case 1 above); (b) students who are not obvi?Usly ill but who have a neurotic conflict interferes with their relationship to tutors or their comIltrnent to university. (Cases 2 and 3 above are Gf this category.) In the case of the

'nking

^arnples eriously ill

student, time away from university often indicated, and not all of them will be ,aPable of returning. In the case of the neurotically ?volved student, psychotherapy and assisting s

offer the understand what is going bUtorschance of overcoming the neurotic work kpt to

*?0ts

on

of

As the

difficulty

in the

individual

histories above indicate, nearly all disturbed individuals come marked by emotional stress. Human resi iis remarkable, but the experience in childhood case

^Vchiatrically ?nies e^ce

major parental

,

Slt%

frojy1

or deviance (and pos vulnerable temperament)

discord

the inheritance of

a

UtlcJerlies the great majority ^ychiatric disorder. In such

of cases of serious cases it is not the

they diversity ,r?m,

come come to, but the family they that explains why certain individuals break 0vvn. In the milder cases this is less definitely so, here institutional factors can be of importance.

transition I

transition

th^

from

adolescent into adult is the to the extent

development and, earlier, infantile conflicts were cr'ses

incompletely

resolved, this is likely to be a stormy one. Some conflict and stress is normal at this age. Going to university presents a particularly abrupt challenge, pitching the individual into a competitive society in which recognition of his personal, sexual and academic achievements can only be won by his own endeavours. Moreover, the role of student is a vague, transitional one, less capable of providing a framework for individual identity than that of most

occupations.

For this reason, the

identity

crisis (in Erikson's terms) is the classic disorder

of the age group. The American student who consulted his university health service because he was worried 'because he had not yet had his identity crisis and wondered if he was normal' may not be an

apocryphal

case.

Many of the minor emotional

disorders of the important neurotic work block group are the result of an interaction between factors in the institution and problems in the individual. In the course of normal personality development through infancy and childhood, conflicts occur around three main areas: (a) dependstudents

including

v. independence; (b) compliance/defiance v. co-operation; (c) competition, exposure and measurement. In analytical terms these stages represent the oral, anal and genital phases of development.

ency

Universities vary in how much dependence and how much independence they foster or permit, they vary in the extent to which they exert pres-

sure and impose obligations and they vary in how far they probe, expose and measure their students. To some degree, however, the university is bound to take up a position capable of kindling conflict related to all three of these areas and to this degree may cause a recandescence of neurotic conflicts in the student. Because no two students are alike, there is no simple solution which a university can adopt to avoid the provocation of working problems of this sort, for even problems which appear identical in academic terms may require quite different sorts of response from the tutor if the student is to be helped. To promote one cannot rely upon any simple university must show both concern and sophisticated understanding if the problems

mental health

recipe;

the

of individual students are detected and remedied early.

to

be prevented

or

working in this context has a double and opportunity. On the one hand to help the individual student who is suffering or failing, on the other hand to help make the institution sensitive, tolerant and supportive to vulnerable individuals. In this sense, University Health Services are a model for an occupational mental health service which one may hope other instituThe doctor

responsibility

tions will copy. 5

.

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