December 8, 2006
Fouth Installment in the series on Troubled Children
Off to College on Their Own, Shadowed by Mental Illness

By Lynette Clemeston

Her mother called it a negotiable proposition. But to Jean Lynch-Thomason, a 17-year-old with bipolar disorder who started college this fall, her mom’s notion to fly from their home in Nashville to her campus in Olympia, Wash., every few weeks to monitor Jean’s illness felt needlessly intrusive.

“I am so totally aware of the control you have over me right now,” Jean said, sitting in her parents’ living room one evening last June, before coolly reminding her mother of her upcoming 18th birthday. “In a few months the power dynamic is going to be different.”

For Chris Ference, 19, who is also bipolar, the fast-approaching autonomy of his freshman year held somewhat less appeal. His parents had always directed every aspect of his mental health care. Last summer, over Friday night pizza at his home in Cranberry Township, Pa., he told them that assuming control felt more daunting than liberating.

“If it was up to me, I would just have it so you could make those decisions for me up until I was like, 22,” he said. “I mean, you’ve raised me well up to now. You know me better than anyone.”

The transition from high school to college, from adolescence to legal adulthood, can be tricky for any teenager, but for the increasing number of young people who arrive on campus with diagnoses of serious mental disorders — and for their parents — the passage can be particularly fraught.

Standard struggles with class schedules, roommates, and sexual and social freedom are complicated by decisions about if or when to use campus counseling services, whether or not to take medication and whether to disclose an illness to friends or professors.

Keeping a psychiatric disorder under control in an environment often fueled by all-night cram sessions, junk food and heavy drinking is a challenge for even the most motivated students. In addition, the normal separation that goes along with college requires new roles and boundaries with parents, the people who best know the history and contours of their illness.

Like Jean and Chris, young adults approach the move to a new life differently, some with defiant independence, some with avoidance. Each approach, say psychiatrists, counselors, dormitory assistants and other campus leaders, comes with its own risk.

The students who are most dependent on their parents may be dangerously unprepared for the inevitable stresses of college life. On the other hand, students who are adamant about doing everything on their own may be afraid to reach out for help when they stumble.

For parents, the anxious pride at seeing children go off to college is often tinged with fear that their child might fall apart, spiraling into depression or becoming suicidal. Are they going to therapy as they promised? Are they taking the right dose of medication at the right time? Should they as parents inform the school that their child has an illness? Is a fight with a roommate part of a normal transition to college life or a sign of impending trouble? Does an emotional e-mail message written at 3 a.m. represent a transitory moment of turmoil or a reason to get on an airplane?

Once teenagers legally become adults, which in most states happens at age 18, they, not their parents, assume control over decisions about therapy and medication. If trouble arises, parents may or may not hear about it because college counselors are bound by confidentiality when dealing with adult students.


The Trauma of Separation
For Jean, as for many teenagers coping with mental disorders, just getting through high school was an ordeal. After experimenting with home schooling, a high pressure prep school and an outdoor learning academy geared to nature activities, Jean, a bright student with inconsistent grades but high SAT scores, decided to forgo her senior year and find a college that would take her without a high school diploma.

She was accepted at Evergreen State College in Olympia, Wash., a nontraditional college of roughly 4,400 students that issues written evaluations in place of letter grades.

Evergreen’s environmental focus — the campus has its own organic farm, composting program and a contest for commuters who bike, walk or carpool to campus — felt like a good fit for Jean, who is passionately committed to the environment and social justice.

A consciously quirky teenager who sews her own clothes (to avoid crass consumerism, she says) and who prefers bus trips to flying (to avoid contributing to the pollution caused by air travel), Jean is disarmingly straightforward and self-aware.

She said she stopped taking medications when she was 14 because the side effects left her feeling “out of whack and emotionally inauthentic.”

She is determined to stay off medications during college, and she devoted considerable advance thought to possible triggers for her illness, like the long rainy winters of the Pacific Northwest.

“I don’t feel vulnerable about this transition because this is very much my decision,” she said. “This is a very autonomous move, very much me structuring my own life. I feel like I am putting myself in a situation with really clear intentions.”

Jean’s parents, Amy Lynch, 52, and Phil Thomason, 53, were hesitant when Jean, the younger of their two daughters, refused to take medications after eighth grade. Her childhood and early adolescence had been a whirlwind of depression, rage and experiments with different medications and treatments.

But when Jean was about 14, Ms. Lynch and Mr. Thomason said, she began to seem more stable. Her developing coping skills, combined with reports about negative side effects of psychotropic drugs in children, persuaded them to acquiesce to her demands to ride out the swings of her illness drug free.

They said they believed Evergreen would be a good college for Jean. Still, the move — to someplace so far from home — made them anxious. In the months before Jean left, Ms. Lynch said she wanted her to go back on medication to smooth the adjustment to college life, a suggestion that Jean adamantly rejected.

Ms. Lynch worried that Jean took for granted the tacit stability of being at home.

When Jean’s depression sets in, she tends to close herself off from people. At home, Ms. Lynch said, “I can look at Jean and know in five minutes what’s going on with her and how to respond to it.”

At such a distance it will be difficult to catch the signs.

“I feel like we’re doing a high-wire act,” she said, “and I am not sure we have a strong enough net.”

Rummaging through the accumulated possessions of adolescence in her bedroom over the summer, Jean singled out the items that she could not leave without: her sewing machine, her coffee maker, the social justice posters that covered her wall. With her mother out of earshot, she acknowledged that she understood her parents’ angst. “I get that this is intense for everyone,” she said. “I do.”


Hesitant to Leave the Nest
The uncertain months between high school and college were also anxious ones for Chris Ference and his parents.

Still groggy from an early morning drive to campus, his husky 6-foot-2 frame jammed into an auditorium chair in the student union, Chris shifted uncomfortably as a freshman orientation coordinator welcomed new students and their parents to the Behrend College, a Pennsylvania State University satellite campus in Erie, Pa.

“Today really is the first day of your freshman year of college,” the cheery administrator told the group on a June morning more than two months before the start of fall term.

Chris had initially been reluctant to go away to college. Though eager to leave the rigid structure and peer pressure of high school, where he told few friends about his illness, he preferred the idea of living at home during college and commuting to an engineering program in nearby Pittsburgh.

It was his mother, Debbie Ference, a service director with the southwestern Pennsylvania division of the National Alliance on Mental Illness, an advocacy group, who nudged him to move away.

He chose Behrend for its strong engineering program and small student body of about 3,700.

A boyish and fidgety teenager who likes heavy metal music, Xbox games and anything having to do with electronics, Chris said he had given little advance thought to his new responsibilities in college.

Just days before his orientation, he listened passively as his father, Michael Ference, and Ms. Ference talked about his care at school. They wondered aloud about whether he would be able to continue seeing his longtime therapist in Pittsburgh, more than two hours away. They raised the possibility of putting an advance mental health directive in place, so that they could be contacted if Chris was ever in crisis and unable to consent to parental notification.

They discussed how they worried about the possibility of Chris mixing alcohol with his medications. Chris huffed in annoyance and told them he was “smart and moral enough” not to fall into that trap.

The fact that Chris was willing to engage in the discussion at all was a sign, they said, of progress.

Chris was first hospitalized and received a diagnosis of bipolar disorder at age 10 after a severe episode of depression, mania and suicidal thoughts. He was hospitalized again briefly in sixth grade, after the lithium that had stabilized him for two years became ineffective.

But successful therapy and medication since then have kept the illness at a manageable level. He graduated from high school with honors, and in his senior year saw his therapist only every six weeks. A recent medication adjustment has left him able to feel and express more than he has in years.

“This whole move is like a coming-out process,” said Mr. Ference, 50, a service coordinator for families with autistic children. “Up to now it’s been all parental motivation. But I think this is a healing process for him after so many hard years.”

In a 2005 national survey of the directors of college counseling centers, 95 percent of counseling directors reported an increase in students who were already on psychiatric medications when they came in for help. While universities grapple with how to serve the growing number of students with mental disorders, students are taking the initiative by helping one another.

Active Minds, a student-led mental health advocacy organization founded in 2001 at the University of Pennsylvania, now has 56 chapters at schools including Georgetown University, Columbia University, the University of South Florida and the University of Maryland.

The National Alliance on Mental Illness has 30 campus affiliates, with 18 more in formation, groups that are set up as student clubs and are financed by school activity budgets and fund-raisers. Programs like the Jed Foundation, a suicide prevention program, and National Depression Screening Day, held each October, offer additional resources.

While the overall message from the groups and programs focuses on the potential for success, students who have been through the transition of leaving home for college say it is also important to be honest about the challenges.


Difficult Experiences
Stacy Hollingsworth, an honors student at Rutgers University who suffers from major depressive disorder, dropped out of college in the fall semester of her sophomore year after the routine aspects of college life left her so incapacitated that she became suicidal and was hospitalized.

At home in Old Bridge, N.J., she could retreat to the isolation of her bedroom when she was depressed — an impossibility in her crowded dormitory. The staggered class schedule left her lacking a dependable rhythm. Even getting dressed and walking to the cafeteria became an insurmountable task.

“I was in excruciating pain. I couldn’t breathe,” she said.

Though she had been suffering from depression since her early teens, she hid her struggle from family and friends. She sought counseling help for the first time in college, but still could not cope.

After a two-year absence and the loss of $15,000 in state scholarships, Ms. Hollingsworth, now 22, is back at Rutgers finishing her degree in exercise physiology and psychology. She is founder of the Rutgers’ affiliate of the National Alliance on Mental Illness, one of the organization’s newest student chapters.

At 37, Robert C. Haggard III, who three years ago founded a chapter of the same organization at Washburn University in Topeka, Kan., is still working on his bachelor’s degree in studio art.

During his first attempt at college, right out of high school, Mr. Haggard said, “I wasn’t honest with myself that I needed assistance.”

He tried to blunt the increasing severity of his bipolar disorder with alcohol, a common tactic for students with psychological disorders, experts say.

He was on academic probation when, in 1992, he withdrew from school. He struggled though several jobs, a variety of medications, and a suicide attempt at age 29 before he started to get his condition under control.

It has only been within the past four years, he said, that he has gained stability. “I study during the day, sleep at night, eat right and maintain a lot of structure and routine,” he said. “It sounds simple, but it can be a hard place to get to.”

Dr. Richard Kadison, chief of mental health services at Harvard, said there were things students with mental illness could do before starting college to increase the chances of a manageable transition.

Most important, he said, is establishing local health support on or near campus.

Maintaining a relationship with a counselor from home can be helpful, but “you don’t want to end up in an emergency talking to someone at school that you have never laid eyes on,” Dr. Kadison said.


Last-Minute Worries
After the opening session of freshman orientation at Behrend College back in June, Chris Ference disappeared into a pack of students to begin selecting his classes.

His mother headed in the opposite direction and wandered into a session on student support networks led by Sue Daley, the director of the counseling office. She listened intently as the counselor talked about problems students had encountered in recent years.

She winced when the counselor related the story of a young woman who had a psychotic episode the previous year, during which she ripped tiles from her dormitory room ceiling because she believed the F.B.I. was monitoring her.

“We sent her home so she could get her emotional self together,” Ms. Daley told the group.

After the session, Ms. Ference complained that it sounded as if the goal of the counseling center was to get the “crazy kids” out of the way.

“I was offended by that,” she said to Ms. Daley. “I want to be comfortable enough with this school that I know you will take care of my son.”

In the car on the way home from the campus visit, Ms. Ference mentioned her discomfort with the counseling presentation.

“We definitely have to put some outside counseling support in place, just in case you don’t like it there,” she said to her son.

Looking through his thick pamphlet of brochures from the day, Chris responded, “Hey, we get a discount on computers and iPods!”

Ms. Ference took a hand off the steering wheel to rub at the stress headache pulsating at her temple.

About the same time in June at Bongo Java, a trendy coffee shop near her home in the Belmont-Hillsboro section of Nashville, Jean Lynch-Thomason pulled out a tattered journal, held together with silver duct tape. A picture of herself in the third grade, taped to the cover of the thick diary, stared back at her as she gathered her thoughts.

As she prepared for college, she had been writing in the journal several times a day.

More pensive than during the previous meeting when she matched wits with her parents about her desired independence, Jean confessed that she had been thinking quite a lot about her move in the fall.

“There is a lot more fear and anxiety about this transition than I am letting on,” she said. “We can set up all the protective measures we want and still there is just no way to tell what is going to happen, and man, that’s hard.”

She remained determined not to let her mother fly out to Washington to check on her. And she resolved to limit her own trips home, to cut down on unnecessary air travel.

But she said she felt confident that she had done the most optimal planning possible. She had decided to have an apartment by herself so that she could prepare her own vegan meals. Living alone, she said, would also afford her the privacy to sleep well and have the solitude she craves when her depression sets in.

That solitude, she added, might be a double-edged sword in a new environment where she would be more reluctant to engage with people during dark periods of depression.

“I am in a good, copacetic place right now,” she said. “But I also know that there is every possibility that things could go bad. I just sort of feel like if I get out there and don’t do well, then I am letting everyone down.”

Back at home soon after, she breezed past her mother, confident as ever.


A New Perspective
Three months after arriving on campus, Jean’s anger at her parents’ concern seems to have receded. Her mother’s hotly debated first visit came and went in October. There were no confrontations over medication, no accusations of heavy-handedness.

Mother and daughter said little at all, in fact, about the illness that has so defined their lives, and their relationship, choosing instead to ride bikes, work at a free store for the needy, and play in a fountain one night in the center of downtown.

“I’m more settled, I guess,” said Jean, who will turn 18 next week. She was surprised that she so enjoyed the visit. “I was in a good place. She was in a good place. My illness just didn’t particularly seem relevant.”

Some ideas that had made sense in the abstract — like living alone — felt unwise after she arrived in September and looked at a few apartments. When a friend from
Tennessee offered her a tiny crawl space of a room in an overcrowded home he shared with several other students off campus, Jean said it felt just right.

“It’s not like I’m going up to people saying, ‘Hi, I’m Jean, I’m bipolar,’ ” she joked. “But I’m surrounded by beautiful supportive people, and I know if I need it, they will call me out.”

She has maintained sessions by telephone with her therapist back home every two weeks. But she has also met people at the campus counseling center. She said she liked that they encouraged holistic as well as purely medical approaches to treatment, and that she would not hesitate to seek help there if the need arose.

Back in Nashville, Ms. Lynch said she may have underestimated her daughter’s ability to make good decisions for herself. The lushness and environmental consciousness of Evergreen and the surrounding area seemed to have a stabilizing effect on Jean, she said. There was not a trace of the early signs of mania or depression that Ms. Lynch could usually spot in her daughter well before others.

She said she had decided not to raise the issue of medication again. For now. “I may have a different answer a few months from now,” she said. “But what I know today is that she seems to have learned a lot about coping. And that’s how we get through this, by what we know any given day.”

Chris Ference has also changed since he packed his things and left home in late August. Sitting on the bed in his dorm room, sounding more mature than he had a few months earlier, he said the transition was smoother than he had anticipated.

But he was still working out some of the particulars of dealing with his bipolar disorder. He told his roommate about his illness in mid-October, only because a reporter was coming to their room for an interview.

“It’s cool. He’s cool. It’s fine,” he said, with a hint of wariness. “It’s probably good for him to know anyway, so he can understand it, in case I ever need him to help me out.”

Discreetly taking his medications in a dorm room typically crammed with engineering students until the wee hours of the morning is also a challenge. In an effort not to draw attention to himself, he said, he takes his two medications late at night, right before he lays his head down to sleep. If anyone notices, they have not let on.

He and his mother met with Ms. Daley, head of the counseling center, before school started. After the unpleasant encounter at summer orientation, Ms. Ference wanted some assurances that the school’s services were adequate. She left satisfied, she said, and Chris seemed comfortable enough with the counseling center to go there if he needed to.

Chris said he doubted he would need help from Ms. Daley or anyone else at the center. He has friends and is playing guitar in a band, he keeps his partying “under control,” and he loves his engineering classes.

He is under no illusions about his illness, he said. He knows it will be something that he has to learn to manage throughout his adult life.

“But things are just going so good,” he said. “So far.”


December 8, 2006
http://www.nytimes.com/2006/12/08/health/08Kids.html
by LYNETTE CLEMETSON