Identifying and Addressing the Mental Health Needs of Online Students in Higher Education
89% of colleges and universities in the United States offer online courses and of those institutions 58% offer degree programs that are completely online (Parker, Lenhart & Moore, 2011).Providing online student services is an important component of these distance programs and is often required by accrediting bodies. Health and wellness services for online students are especially essential, as college students are accessing mental health services for severe problems at increasing rates on college campuses (Gallagher, Sysko, & Zhang, 2001). This paper outlines how institutions of higher learning can prepare faculty to identify mental health needs of online students and suggests effective administrative policies and programs to address these student needs.
Online enrollments were less than 10% of all students in 2002 when the Sloan Foundation began their annual surveys on the topic.By 2011, 32% of all enrolled post-secondary students were taking at least one online course and the numbers have been increasing steadily (Allen & Seaman, 2013). The rising percentage of online students has led to awareness by college administrations that these students have the same needs as students in a traditional classroom setting. Students who want to learn online also want to access their student services online. For learners enrolled in online programs, and living in geographically distant locations, internet access to student services is essential. These students' needs have resulted in revision of college and university policies and the creation of extensive web-based services for technical support in online courses, enrollment services, financial aid, and library resources.
An area of student services that is lagging behind in online availability is Health and Wellness, especially Mental Health services (Jones, 2006). In 2012, the American College Health Association (ACHA) annual survey found that some of the factors students reported as impairing academic performance included anxiety (20%), depression (12%), stress (29%), and alcohol/drugs (6%). The survey did not distinguish between online and face to face enrollees. A student experiencing mental health difficulties that affect his/her attendance, coursework, and grades may be enrolled in either type of course. All students can experience periods of stress-related anxiety and mood alteration; and early intervention can prevent these issues from worsening. Severe mental illnesses such as Major Depression, Generalized Anxiety disorder, Schizophrenia and Panic disorder occur in 26% of the U.S. population in all age groups (Kessler, Chiu, Demler, & Walters, 2005). In fact, 75% of mental illnesses first occur before age 24; the average age of onset is 18 to 24, when young people are often attending college (Kessler, Chiu, Demler, & Walters, 2005).
Retention of online students is also a priority concern for administrators of distance education programs and 5% of students who fail to complete degree programs drop out due to mental health problems (Kessler, 1995). In college students who have a diagnosed mental illness, 85% never complete a degree (Kessler, 1995). The 5.6 million students participating in online education have lower incomes, and are of a minority race, at rates much higher than that of on-campus classroom students (Schaffer, 2011) which puts them at greater risk for mental health issues (World Health Organization (WHO), 2012).
In a traditional classroom setting faculty have the ability to visually observe students, and interact face to face. This direct, experiential contact with students enables faculty to perceive mental health warning signs such as deterioration in hygiene, tardiness and absences, mood changes, bizarre behaviors, and altered levels of attention. In online educational settings the direct sensory contact with students is missing and the student is often at a distant geographic location. Thus, online educators need strategies for identifying mental health problems in their students, resources available to offer the distance student, and institutional policies addressing mental health and student performance. This article focuses on these topics.
Identifying Mental Health Issues in Online Students
Struggles with mental illness or serious emotional stress, can cause pervasive difficulties for college students, and often affects their academic functioning (Kitzrow, 2003). Research shows that an average of 12% of college students experience serious psychiatric difficulties (Reifler, 1971; Schwartz, A.J., 2006). These problems include diagnoses of clinical depression, Schizophrenia, Bipolar disorder, and anxiety disorders (Schwartz, A.J., 2006). Medications prescribed in student health centers to treat anxiety and depression increased by 800% in the 1990's (Caulfield, 2001). Of ;the students who accessed services at college and university counseling centers, 16% had symptoms of anxiety, mood disturbance, attention difficulties, and behavior problems that interfered in the their academic performance, but were not severe enough for the diagnosis of a serious mental disorder (Schwartz, A.J.,2006). Short-term adjustment problems related to grief, traumatic events, substance abuse and life stress are also common in the student population (Kitzrow, 2003).
Despite the numbers of students experiencing mental health problems, faculty in higher education are not confident in their ability to identify difficulties or to know when problems warrant a counseling center referral (Schwartz, L.S., 2010). However, faculty generally believe it is their role to intervene when students display problems that interfere with academic performance such as poor attendance, falling asleep in class, failing to complete assigned work and/or being disruptive to the class (Schwartz, L.S., 2010). For professors of online courses, the primary academic issues that cause concern are students failing to complete assignments on time, a lack of presence in online discussions and failure to respond to emails/phone calls (Russo-Gleicher, 2013). Sometimes these problems are due to mental health concerns, and Sharkin (2006) suggested that it is "generally preferred to err on the side of overreaction when you are concerned about a student; early intervention can help reduce the chance of a student's problems turning into a crisis situation later on" (p. 52).
In his book "College Students in Distress: A Resource Guide for Faculty, Staff and Campus Community", Sharkin (2006) provided a number of helpful guidelines for using patterns of repeated behaviors to identify warning signs of mental health issues in students:
- Patterns of atypical behavior: this is behavior that is "out of character for a particular student" (p.23)
- Patterns of unusual behavior: behavior that is abnormal or bizarre, even in the college community; such as paranoia, ongoing magical or fantastical thinking, or actions which interfere with the learning atmosphere.
- Patterns of poor academic performance: distressed students often fall into a cycle of emotional issues resulting in academic problems leading to worsening emotional distress and worsening academic performance.
Sharkin's (2006) guidelines for faculty are readily adaptable to an online course environment as shown in Table 1. In the online setting, changes in habits of hygiene, dress, or physical behaviors cannot be observed; but changes in a student's online behavior, quality of work, or content of discussion posts are amenable to assessment by faculty. If a change in student performance is sudden, disruptive to the online discussion, disrespectful of peers and faculty, or results in failing grades; some degree of intervention by the instructor needs to be considered. Sharkin (2006) emphasized that faculty should not feel a need to diagnose or solve the student's problem, nor counsel them. Initial intervention by faculty is accomplished by speaking to the student privately about the professor's concern (Sharkin, 2006).
Warning Signs of Mental Illness or Emotional Distress in Online Students
(a change from the usual)
ACADEMIC PERFORMANCE PROBLEMS (Sharkin, 2006)
Emails are accusatory, manipulative, sexually inappropriate or threatening
Late assignments from beginning of course
Sudden deterioration in quality of work
Discussion post contents are:
Bizarre, fantastical, paranoid, disruptive, confused, or show disorientation
Failing quality of work from beginning of course
Abruptly begins turning in late assignments
Student clearly seems out of touch with reality
Not returning emails or phone calls
Becoming disrespectful in discussion posts
Not turning in work at all
Stops responding to email
Not re-doing work when given an opportunity
Content of work becomes negative/dark/odd in tone
Ongoing display of anxiety about assignments
When an instructor identifies the need to address a mental health concern with an online student the conversation will most likely be via email or phone. Faculty should be clear, matter of fact, and to the point about the behaviors of concern. The course expectations can be reviewed as well as the necessary criteria for the student to continue in the course. Non-judgmental acceptance of the student's state of mind is helpful for encouraging conversation about the problem. For example a comment like "It seems as if you are having a rough time" or "I sense that you are really stressed out" shows concern without confrontation. Student responses to faculty contact can range from relief, to panic, to defensiveness and anger. If anything in the conversation leads the faculty member to be alarmed or have increased concern about the student, then the academic discipline process can be initiated, the student can be offered campus resources for assistance, or referred for counseling and medical consultation.
Teachers of online courses may be the primary connection between the student and the university and are in a unique position to be of assistance for mental health problems. The student may even independently report mental health struggles to the instructor and request assistance. Faculty that are familiar with services for distance students and are supported by solid institutional policies can be a great source of help for distressed students.
Best Practices in Mental Health Resources for Online Students
In general, according to the Western Interstate Commission for Higher Education (WICHE), Western Consortium for Educational Telecommunications-Learning Anywhere Anytime Partnership (WCET-LAAP) project, the same array of services that exist for on-campus students should also be available to distance students (Shea & Armitage, 2000b). Comprehensive student services for online students need to be accessible via the internet from any geographic location, and include self-service capabilities, as well as assistance and/or information abilities. Services also must be available to students with disabilities. WCET-LAAP project authors note that services designed primarily for distance students become valued and utilized by on-campus students too, due to convenience of access (Shea & Armitage, 2000a). Online student services need to be highly visible, have active links to related sites and pages, be focused on student needs, and always provide contact information for reaching a live person for assistance (Shea & Armitage, 2000a).
Mental health resources for distance learners should follow the above guidelines, but what services are really feasible electronically? Shea and Armitage (2000a) provided several examples of recommended practices in existence at some American colleges and universities:
- Pre-enrollment services: On the web-pages describing online programs and courses, self-assessment tools can be posted for students to evaluate their readiness for online programs. This "front-end" focus on the personality characteristics and work habits necessary for online academic success can possibly assist in preventing problems after admission and enrollment. One study, of mostly graduate school online students, found that students most at-risk for dropping out of online courses were those who were less motivated, had less-stable home study environments, and less computer confidence compared to successful online students (Osborn, 2001). These are factors which can stress an enrolled online student and lead to mental health difficulties as coursework progresses.
- Mental Health Education: Provide links to articles on issues common to college students (e.g. stress, fatigue, depression, anxiety, eating disorders, substance abuse)
- Crisis Services: Prominently display phone numbers for crisis and/or suicide hotlines (See Appendix).
- Self-help Services: Provide access to tools for self-evaluation, with accompanying articles on strategies for coping with common mental health issues.
- Referral to disability services: Provide links to the institution's office for students with disabilities. Online students who are new to college may have previously unaddressed disabilities such as attention deficit disorder or learning disabilities. Students with documented diagnoses of mental disorders are entitled to reasonable academic accommodations (Souma, Rickerson, & Burgstahler, 2012).
- Counseling services: Provide links to the campus counseling center and clearly state what services are/are not available to distance students. Feedback channels need to be in place to insure that students or faculty who make inquiries for services receive a personal response.
College administrators also need to have ongoing vigilance about keeping students informed about available student services. Research has suggested that distressed students are not always aware of the services available to them, especially if they reside off campus (Yorgason, Linville & Zitzman, 2008). A "once and done" approach at enrollment or in orientation is not sufficient for communicating campus services. Instead, regular alerts or reminders regarding services can be included in newsletters, on home pages, or in course syllabi.
Development of Institutional Policies Related to Health and Wellness of Online Students
Sadly, mental health services are not usually a priority for colleges or their students until a crisis occurs. Campus counseling center staffs often complain that they don't have the funding or support of administration to meet student mental health needs, and administrators question how such services support the educational mission (Mowbray et al., 2006). Raphael (2006) conducted an assessment of specific student services distance learners valued from their institutions. The authors found that personal counseling and self-help information were a low priority even for the students. In a study on retention of online students, Nichols (2010) determined that students undervalue available support services, but when there is an absence of support services, students notice, and often cite that lack as a factor in their academic withdrawal. Nichols (2010) stressed that high quality student services definitely improves student retention and satisfaction in the academic setting. Additionally, campus shootings and suicides have demonstrated that the mental health difficulties of a single student can impact an entire college community. Such incidents have prompted more attention on mental health issues and resulted in recommendations for school policies. Solid institutional policies can protect the institution, faculty, and staff from liability claims, guide employee actions, and should be inclusive of the online student's needs.
An excellent research-based resource for assisting colleges and universities in the development of mental health policies has been created by The Jed Foundation. This foundation is a non-profit organization with a mission to "promote emotional health and prevent suicide among college and university students" (www.jedfoundation.org). The resource, entitled Framework for Developing Institutional Protocols for the Acutely Distressed or Suicidal College Student (2006) recommends that institutions:
- Create a campus atmosphere that encourages students to seek/ask for help.
- Create policies that address disruptive student behavior and include steps for identification and treatment of underlying emotional problems.
- Create consistent policies between departments (academic affairs, faculty, and student services) and the institution as a whole for addressing student behavior and distress.
- Create policies for campus crises/disasters that include postvention (follow-up) services for staff and students
- Include counseling and health center staff in design of policies and protocols addressing mental health issues (JED, 2006).
Several sources emphasize that school policies must address the education of faculty and staff to identify mental health problems, and empower them to take appropriate action (Schwartz, 2010; National Mental Health Association/JED Foundation 2002; JED, 2006; 2011). There is general consensus that campuses need to insure that faculty and staff have ongoing training in the signs of distress and suicidality, and receive regular updates on campus resources available to address mental health needs. School policies outlining the steps employees are to take when they suspect a student has symptoms of mental illness empowers the staff to take action. Schwartz (2010) found in her research that while faculty could identify evidence of student distress, they tended to minimize the existence of mental health issues and described a discomfort with providing counseling center referrals. Those research findings imply that school officials need to design policies which encourage and normalize the identification and referral of students in distress.
None of the policy recommendations in the literature are specifically targeted at online students, but campus policies should apply to all students. The above policies are applicable to the needs of the distance student as long as there are resources available that can be accessed off-campus. Good campus policies must stipulate that all departments offering student services include access for residential and distance students alike. Fortunately, there are a number of no-cost, reputable internet and hotline resources that colleges can utilize for their geographically distant students; and which are also beneficial for students in residence (See Appendix).
As online programs continue to expand and the numbers of distance students increase, so does the need for a full array of student services available to online students. The incidence of mental health problems in students in higher education is similar to the incidence in the general population.The stress of college coursework can lead to emotional distress in students whether they are in traditional classrooms or in distance education classes. For these reasons it is essential that college and university administrators develop mental health and wellness resources for faculty and students. Investing in the creation of campus policies which acknowledge that mental distress and illness occur, and provision of training for faculty in dealing with these student problems, can increase the retention and success of online students.
Allen, I.E., and Seaman, J. (January 2013). Changing course: Ten years of tracking online education in the United States. Babson Survey Research Group. Retrieved from http://sloanconsortium.org/publications/survey/changing_course_2012
Caulfield, S. (Fall 2001). Depression on college campuses: A new challenge for student health services and counseling centers. Student Health Spectrum, Fall 2001, The Chickering Group, 18-21.
Gallagher, R., Sysko, H., and Zhang, B. (2001). National survey of counseling center directors. Alexandria, VA: International Association of Counseling Services.
Jed Foundation. (2006). Framework for Developing Institutional Protocols for the Acutely Distressed or Suicidal College Student. New York, NY: The Jed Foundation. Retrieved from http://www.jedfoundation.org/professionals/programs-and-research/framework
Jed Foundation (2011). A Guide to Campus Mental Health Action Planning. New York, NY: The Jed Foundation. Retrieved from http://www.jedfoundation.org/professionals/programs-and-research/campusmhap
Jones, S. (2006). Health and wellness services for the online student. Retrieved from www.onlinestudentsupport.org/Monograph/health.php
Kessler R.C., Chiu W.T., Demler O., and Walters E.E. (June 2005). Prevalence, severity, and comorbidity of twelve-month DSM-IV disorders in the National Comorbidity Survey Replication (NCS-R). Archives of General Psychiatry, 62(6):617-27.
Kessler, R.C., Foster, C. L., Saunders, W. B. & Stang, P.E. (1995) Social consequences of psychiatric disorders: I. Educational attainment. American Journal of Psychiatry, 152, 1026-1032. (cited by Sharkin).
Kitzrow, M. A. (Fall 2003). The mental health needs of today's college students: Challenges and recommendations. NASPA Journal 41(1), 165-179.
Mobray, C., Mandiber, J., Stein, C., Kopels, S., Megivern, D., Strauss, S.,…Lett, R. (2006). Campus mental health services: Recommendations for change. American Journal of Orthopsychiatry, 76(2), 226-237.
Nichols, M. (May 2010). Student perceptions of support services and the influence of targeted interventions on retention in distance education. Distance Education, 31(1), 93-113.
Osborn, V. (2001). Identifying at-risk students in videoconferencing and web-based distance education. American Journal of Distance Education, 15(1), 41-54.
Parker, K., Lenhart, A., Moore, K. (August 28, 2011). The digital revolution and higher education. Pew Internet and American Life Project. Retrieved from http://pewinternet.org/Reports/2011/College-presidents/Report/Overview.aspx
Raphael, A. (Summer 2006). A needs assessment: A study of perceived need for student services by distance learners.Online Journal of Distance Learning Administration, IX(II).
Reifler, C. B. (1971). Epidemiologic aspects of college mental health. Journal of the American College Health Association 19, 159-163.
Russo-Gleicher, R.J. (2013). Qualitative insights into faculty use of student support services with online students at risk: Implications for student retention. Journal of Educators Online 10(1), 58-90.
Shaffer, S. (2011). Online student demographics infographic. Retrieved from http://www.classesandcareers.com/education/infographics/student-demographics-infographic/
Schwartz, A. J. (2006) Are college students more disturbed today? Stability in the acuity and qualitative character of psychopathology of college counseling center clients: 1992-1993 through 2001-2002. Journal of American College Health, 54(6), 327-337.
Schwartz, L. S. (2010). Faculty role in responding to the acutely distressed college student. (doctoral dissertation). Retrieved from PQDT Open (AAT 3397181).
Shea, P. and Armitage, S. (2000a). Guide to developing online student services. Retrieved from http://www.adesignmedia.com/onlineresearch/Guide%20to%20Developing%20Online%20Student%20Services.htm
Shea, P. and Armitage, S. (2000b).Guidelines for creating student services online: Lessons learned. Retrieved from http://wcet.wiche.edu/wcet/docs/beyond/lessons.pdf
Shea, P. and Armitage, S. (2000c). WCET-LAAP Project beyond the administrative core: Creating web-based student services for online learners. Retrieved from http://wcet.wiche.edu/wcet/docs/beyond/overview.pdf
Souma, A., Rickerson, N., and Burgstahler, S. (2012). Academic accommodations for students with psychiatric disabilities. Seattle, WA: DO-IT, University of Washington. Retrieved from http://www.washington.edu/doit/Brochures/PDF/psych.pdf
WHO, (August 27, 2012). Risks to mental health: An overview of vulnerabilities and risk factors. Retrieved from http://www.who.int/mental_health/mhgap/risks_to_mental_health_EN_27_08_12.pdf
Yorgason, J. B., Linville, D. and Zitzman, B. (2008). Mental health among college students: Do those who need services know about and use them? Journal of American College Health, 57(2), 173-181.
Web-based Resources for Developing Mental Health Services for Online Students in Higher Education
Center for College Health and Safety: www.campushealthandsafety.org Resources for collegiate administrators as well as statistics and education for students and parents.
Counseling and Psychological Services, San Diego State University, published resource: A Faculty/Staff Guide: Enhancing Communication/Working with the Emotionally Distressed Student http://www.sa.sdsu.edu/cps/text_files/CPS_Faculty_Guide.pdf
Kristin Brooks Hope Center: http://www.hopeline.com/aboutus.html This organization's website has great resources for those in distress, educational material, and self-help information. They also sponsor: IMAlive, World's 1st Virtual Crisis Center: www.IMAlive.org a private web chat staffed by trained volunteers; the National Hopeline (1-800-422-HOPE); the Youth America Hotline (YAH) (1-877-youthline); the Graduate School Student hotline (1-800-GRADHLP) and a crisis center location/referral tool.
National Alliance on Mental Illness: www.nami.org Resources for individuals with mental illness and their families and friends. NAMI on Campus resources for students and families; resources for college faculty and administrators; and a great document, College Students Speak: A Survey Report on Mental Illness, which provides detailed data on what student with mental illness need from their colleges and universities. http://www.nami.org/Content/NavigationMenu/Find_Support/NAMI_on_Campus1/NAMI_Survey_on_College_Students/collegereport.pdf
Substance Abuse and Mental Health Services Administration (SAMHSA): http://www.samhsa.gov/index.aspx the government website has information on every aspect of mental health. They also sponsor: National Suicide Prevention Lifeline: 1-800-273-TALK (8255) http://www.suicidepreventionlifeline.org/; a treatment locator tool; and the 24/7 Treatment Referral Line (1-800-662-HELP).
The JED Foundation: http://www.jedfoundation.org/ a private foundation focused on preventing suicide and mental illness in college students.Utilizing research based interventions in their programs and resources which include: JED Campus, an assessment and planning tool for colleges and universities to improve student services; Ulifeline http://www.ulifeline.org/"an anonymous, online, confidential resource center for students", access provided free to colleges/universities; Half of Us http://www.halfofus.com a web resource for raising awareness on mental illness in young people; JED has numerous publications and web resources for collegiate administrators for improving campus services.
Online Journal of Distance Learning Administration, Volume XVII, Number II, Summer 2014 University of West Georgia, Distance Education Center
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