“Behavioral Health” is a term that encompasses both mental health and substance use, which are highly intertwined. The focus of this essay is the role the college environment plays in understanding mental health and substance use among college students. COVID-19 is clearly a chronic stressor, with devastating effects on health, well-being, and employment. In the past two years we have collectively experienced a crisis in mental health with rising rates of depression, anxiety, and suicide as well as a dramatic increase in drug use and overdose deaths. Adolescents and young adults have experienced the highest levels of distress and mental health problems. In addition, minority students of color experienced the trauma of racial violence, police brutality, and daily evidence of inequality, injustice, and marginalization.
Stress is central to understanding the impact of both COVID and marginalization, and social supports and social relationships help us to understand and respond to mental health problems as well as substance use and abuse. Sociologists play a major role in understanding the relationships between the social environment, stress, social support, and health (both physical and mental); these linkages are referred to as the stress process model. The college environment can both exacerbate and help alleviate stress; it can also provide the social supports students need to cope with the stress they do experience.
Mental Health and Substance Use
Mental health problems, be that distress or a specific disorder, create an existence that is painful and frightening to both the individual experiencing them and those in their close networks. Anything that provides comfort, sleep, or a pleasant feeling is welcome; alcohol and drugs can provide that escape, even if only momentarily. However, long-term or consistent self-medication will lead to addiction. At the same time, there are also substance induced mental health issues, including increased levels of anxiety, depression, psychosis, and suicidal ideation. Researchers and clinicians in behavioral health point to the need for positive social supports to combat the isolation experienced by those experiencing behavioral health problems.
A key problem with treatment for both mental health and substance abuse is our fragmented behavioral health-care system where providers operate in silos, trained in either mental health counseling or substance abuse treatment. Further, reimbursement is tied to a specific diagnosis of either mental health or substance abuse; is the primary problem a mental health issue, or is it the drug use? Funding for integrated programs and cross training of providers to deal with co-occurring mental health and substance abuse is lacking, despite numerous recommendations and protocols about the need for both. I worked extensively in Charlotte, North Carolina, with local groups of providers to develop integrated programs and cross-trainings with support from various funding agencies. Despite notable success, we were never able to develop a sustained funding stream.
COVID-19 exacerbated the failure of our fragmented health-care system, and less than one percent of the initial relief funding was directed toward behavioral health. Clinics and providers were driven to telehealth due to lockdowns and the need for social distancing, leading to even higher levels of distress and social isolation and providing a conducive environment for increased use of alcohol and drugs. We have seen the results of that disaster with a substantial increase in drug overdose deaths as reported by the Centers for Disease Control and Prevention. College campuses abruptly closed, with many students returning to live with families or isolated both on and off campus. The social isolation and disruption of social relationships quickly led to increasing rates of behavioral health problems among young people, both globally and in the United States. Students experienced anxiety, depression, and the loss of sleep that exacerbates these common mental health problems. Minority students faced even higher levels of stress and resulting mental health problems due to the on-going conflicts over racial injustice and difficulty communicating with campus-based counselors.
The College Environment
College drinking has long been perceived as a normative aspect of the college environment—as expected element of the college experience. The social context of college life, unsupervised weekend activities and parties, athletic programs and events, and expectations for community service have a significant impact on the norms surrounding college drinking. However, not all colleges are the same, and George Dowdall in his book College Drinking: Reframing a Social Problem (Praeger 2008) describes how each campus has its own culture with considerable variation in institutional approaches to college drinking. What is unique about college drinking is that drinking begins and is reinforced among peer groups, and excessive drinking is an outcome of continued social pressure. However, recent data (Monitoring the Future Survey on Drug Use, 2020) show declines in college students who used alcohol in the past month (six percent decrease) and significant declines in binge drinking from 32 percent to 24 percent. The lead investigator of the Monitoring the Future panel research (John Schulenberg) attributes the decline to COVID-19 and the simple fact that college students had fewer opportunities to drink with friends. However, the same data point to record high levels in daily use of marijuana, as well as increased use of hallucinogens (LSD and psilocybin mushrooms). Non-college aged youth had a slight decline in daily use of marijuana, although annual use was comparable to that of college students with historically high levels (43 percent and 44 percent respectively).
What about the misuse of prescription drugs, such as opioids and stimulants on college campuses? More and more students come to campus with a “diagnosis” of ADHD and in need of mental health accommodations to complete their coursework, and the ready availability of prescription drugs has led to reports of abuse. In discussing the use of opioids for pain, I was struck that almost all of my students had been prescribed opioids for removal of their wisdom teeth. Our students have grown up in a high school environment where taking a prescription pill is an acceptable aspect of our “pill for every ill” culture. Synthetic opioids, such as fentanyl, are also available, which has led to a very disturbing increase in drug overdose deaths among teenagers. However, the 2021 Monitoring the Future data show a decline in the non-medical use of prescription drugs and opioids among teens and a significant decline in nonmedical use of amphetamines among college students (with rates remaining the same for non-college youth).
If we look to our future college students, the Monitoring Future 2021 data are encouraging, with declines in adolescent use of illicit drugs “the largest and most sweeping ever recorded in the past 46 years,” according to the December 15, 2021, report. Marijuana and alcohol use also declined as well as nonmedical use of opioids, tranquilizers, and amphetamines. This decline is also attributed to the pandemic, as adolescents simply lacked access to illicit drugs. However, the 2021 data show significant increases in a number of mental health indicators, with teens feeling depressed, anxious, angry, sad, lonely, worried, and having problems sleeping. Mental Health America also has data pointing to increased level of mental health problems and has a number of initiatives to provide supports to youth mental health, including information about peer supports and a wide variety of resources for BIPOC communities. However, drawing from what we know about the ways young people cope with stress, we need to anticipate that once college life returns to its pre-COVID “normal” many students with unmet mental health needs will find solace in the comfort of drinking and getting high with friends in the relatively unsupervised campus environment. What can we do to make our college environments a place for flourishing?
Providing Social Supports on Campus
Colleges are close-knit communities with multiple sources of peer pressure. Colleges are also based on norms of status attainment and competition which are inherently stressful for students struggling to master new skills and competencies. A trauma-informed approach is needed where all students have access to education, training, peer supports, and professional counseling when necessary. While most campuses provide counseling services, there is a notable shortage of behavioral health providers and this shortage will only worsen. Further, far too few counselors are trained in culturally competent care or sensitivity to the needs of marginalized students. Colleges must be proactive and work to meet the demand for behavioral health workers via expanded degree and internship programs.
Beyond the counseling center, colleges can also provide specialized programs for both substance use and mental health. Collegiate recovery programs are available for support for a variety of addictive behaviors. Colleges can also support peer-based mental health programs. Peer supports are critical as students are much more likely to talk to other students, and a peer is more likely to be around when s/he/they is needed. Peer supports provide community, help reduce stigma, and can promote a sense of normalcy. Peer supports can also be structured to serve the needs of culturally diverse students and can be integrated into academic programs and courses. An obvious step is to train graduate students to lead support groups, and to then assist undergraduate students as peer support specialists. Campuses can also involve students in advocacy training, empowering them to make changes needed in social systems and structures, starting with their campus environment.
Administrative support is essential for additional services to be established on college campus. A major hurdle is that colleges and universities often do not have campus-level data on mental health or substance use, and if they do it is not widely available. An ongoing thorough needs assessment should be a top priority. Resources can then be appropriately directed to areas identified by the needs assessment and include building an inclusive environment; having enough support staff; paying peer counselors and/or providing academic credit; and having visible suicide prevention and crisis response frameworks.
Students who are feeling suicidal should not have to go the webpage of the counseling center to know who to call, especially on weekends when crises are more likely to occur. Faculty can also take an important role in changing the campus culture. While we may well have to fail some students, we should not fail them when they need our help to survive. Faculty need to be trained to identify students who are struggling with behavioral health problems and familiar with campus supports and referrals. Once again, resources are needed, along with more teaching assistants; smaller classes; more experiential learning; opportunities for community involvement and internships; interaction and engagement with faculty research; and fewer institutional demands that do not address the core function of the campus—education broadly defined. College administrators also need to engage with the local community, especially residential proprietors and businesses which sell alcohol to reduce access to alcohol.
What Can Be Done?
To fail to address what may well be the tsunami of co-occurring mental health and substance abuse problems on campus could be yet another instance of institutional betrayal. Institutional betrayal first emerged in the psychology literature to refer to instances when those who are dependent on an institution experience some form of negligence or wrongdoing, the common example being universities minimizing claims of student sexual assault or harassment. The underlying moral issue is that students (and their parents) expect the institution to act in the student’s best interest, and when they do not (for example, a university mishandling a sexual assault claim) the individual feels betrayed and suffers secondary trauma as a result. Universities and colleges that fail to prevent negative experiences for their students may well exacerbate both mental health and substance abuse problems among their students. This is especially likely in those institutions of higher education where adverse events can negatively affect their “branding” of the institution as well as funding.
College administrators need to be proactive and create a supportive campus environment that builds upon an understanding of the stress process model and the interactions between stressors, social, supports, mental health distress, and substance use. Sociologists can play a lead role providing data as part of an ongoing assessment of behavioral health, as well in the creation of a flourishing environment on their own campuses by advocating for necessary social supports.
Any opinions expressed in the articles in this publication are those of the author and not the American Sociological Association.
