Some days are better than others

Content warning: detailed discussion of struggles with mental illness and suicide

For Lisa*, exam season last spring was about as daunting as it could possibly be. In a short span of time leading up to the end of term, she had witnessed the deaths of two of her closest friends. And yet she still felt the aching pressure of exams. In her own words, she had no time to grieve.

By the end of the school year, she had “completely shut down.” Luckily for her, the free mental health services accessible through UofT presented an opportunity to get better.

That was not the case for grad student John.* A year-long struggle with severe depression almost ended his academic career. John’s registration with Accessibility Services had lapsed, meaning that he no longer qualified for academic accommodation for his condition. After being unable to complete his year end assignments, only a tremendous effort to appeal to the university administration on the part of John’s father — a professor at the university — would prevent him from failing out of school.   

John feels that if he had been in a debilitating car accident, rather than suffering from debilitating mental illness, the university would have been quicker to assist him. Had his father not had the time, expertise, and resources to advocate on his behalf, John thinks it likely that he would have had to forfeit his education.

Experiences like those of Lisa and John beg the questions: what is it like to struggle with mental illness at U of T? What support is there for students? And what happens when there are barriers to access?

The state of mental health care

When considering mental health, you cannot look at an institution like U of T in isolation.

It is estimated that more than 1 in 5 Canadians will suffer from some sort of mental illness during their lifetimes, however, according to the Mental Health Commission of Canada, only one in three people experiencing these problems will seek treatment.

Both medication and psychotherapy – such as individual or group talk therapy – have been shown to be effective treatments for mental illnesses. For those living in Ontario, however, the level of difficulty in accessing these treatments may challenge the fundamental concept of universal healthcare.

Services received from a psychiatrist – a physician who specializes in psychiatry– are covered under the Ontario Health Insurance Plan. Due to high demand, and low supply, however, it is exceedingly difficult to access treatment.

The services of psychologists and other trained professionals are, in the vast majority of cases, not covered by OHIP. The costs for these services range routinely between $40 to $180 an hour.

“That’s a feature of the government’s… decision to not fund that,” said Dr. Thomas Ungar, Chief of Psychiatry at North York General Hospital, and an associate professor in U of T’s department of Psychiatry. “If you have an employer who covers that as part of your benefits, some people have access. If you have the income to cover it privately, you do it. If you don’t have the income… you cannot get that without paying.”

“Covered, or even affordable services… are few and far between,” adds Katrina Snider, an occupational health therapist with the Canadian Mental Health Association. “The ability for people to access services is definitely really difficult, especially if they don’t know where to go in the first place.”

While some therapy services not provided by medical doctors are covered under OHIP, Snider said the wait times for these can be as long as two years.

All this clearly indicates that the mental health services U of T provides for its students exists under immense pressure to fill the gap in services not currently covered by our public health system. For the over 80,000 students who attend U of T, the Student Life fee grants them access to psychiatrists, psychologists, and other trained mental health professionals.

Last year, about 7,500 students attended 26,000 appointments at the Health and Wellness centre or other on-campus locations. Why did they reach out? What did they experience? What can these experiences tell us more broadly about how to address mental health in society?

Finding help

After the deaths of her friends, Lisa spent much of 2014 shut down emotionally. She suffered from anxiety, and a grief whose symptoms were very similar to those of depression.

Lisa described her experience as one of “acute anxiety… there were moments I would just skip classes, I was too anxious and afraid to be there for some reason.” “I would skip going out with friends. I would skip things, because of… this really deep social anxiety… It’s just pure fear.”

While her anxiety is a hard thing to explain, it involved over thinking how others perceived her and everything she made. She kept in minimal to no contact with all but her best friends.

“It was very difficult that year, but I had to make a change, you know?” After several months of researching for available mental health services, Lisa contacted U of T’s Counseling and Psychological Services (CAPS) in January of 2015. CAPS has since been consolidated into Health and Wellness at U of T. 

Lisa was assessed by CAPS in late January, called back in February, and began her therapy in March. Considering that she had heard stories of students waiting up to eight months, Lisa found the entire process “very fast,” and very helpful.

Though she met with a psychiatrist in case medication was required, so far Lisa hasn’t needed any; rather, she’s gotten by with the help of psychotherapy services. “I had individual therapy from March, like I said, till about June, early June. And then, from the rest of June until August, I had group therapy, so it was like workshop at CAPS.”

“The one thing I would say is, I wish the individual therapy was longer, because three months of individual therapy is nothing,” she said, voicing her only real criticism. “But then I understand, as well, because of the amount of students they need to attend to.”

With easy access and no cost, Lisa considers the services offered by U of T to be of generally high quality.  “I do want to go back, there are some things I need to touch up on. But, I would say I am [better]” she explained. “I’m more confident now, I’m controlling the anxiety. I’m more open with my emotions, to friends and family… I don’t know, I just feel better.”

Lost in the system

“Generally, [its] debilitating. It’s hard to function, it’s hard to go to class, it’s hard to keep up with work and talk to other people,” said Sara, a first-year student at U of T battling depression.

Like Lisa, Sara also sought out mental health services through the university, and she too cites the lack of cost as a major benefit. “I didn’t really have the opportunity to do that before,” she said. “If you don’t go to the ones that are subsidized, then you have to pay for it… university was the first time where it’s all covered.”

Sara receives regular counseling with a psychologist at her college. The health professionals at U of T have not prescribed medications. “They’ve told me its not severe enough… because the side effects would outweigh the benefits” she explained.

Living in residence, it was her don with whom Sara first spoke about finding help. On the whole, she feels members of the U of T administration have both treated her positively, and put in a good effort to help her find the right care.

While she is very happy with the care she is receiving, Sara is also critical of the process she had to go through to get help. “I need to tell someone this,” she said, “…. [G]etting there in the first place is kind of hard.” “For many people, you need to go and call. And you are the first one that’s calling, it’s not your don… it’s you.”

For a person struggling with mental illness, this first step can be the most difficult.

Sara cites the hours of the Health and Wellness Centre – it’s open Monday, Wednesday, Friday from 9 am to 5 pm and Tuesday and Thursday from 9 am to 7 pm – as one problem, since these hours for her are filled up by classes. When Sara was able to find time to call the office, she was unable to get through.

“So first of all I can’t call them, I can’t schedule appointments, I can’t move appointments around. Then when I do call them, I’m placed on hold. And I’m placed on hold a couple times, the call is dropped. Like it’s been really, really hard to get through to them.”

Despite these challenges, Sara, like Lisa and John, described herself as lucky.

“I have a support system through the administration and the people at [my college] but for the people that don’t?” Sara trailed off, the weight of her question in tow. 

“I wish they would have a better system of contacting them, and… less bureaucracy.”

On stigma, and reaching out

“Sadly, stigma about mental health remains one of the biggest barriers for people accessing, and going for help for what would otherwise be very treatable conditions,” says Dr. Ungar. “It’s a big barrier to the quality of care that they get, and to the health outcomes that they get.”

Dr. Ungar has written extensively on the stigmatization of mental health, which he says are not only prevalent, but also damaging.

“One of the things that I think is behind it is that people have this incorrect belief that mental health problems are not real.”

Katrina Snider echoes Ungar’s comments: “There’s a lot of people out there that still don’t accept mental illness as a growing problem in our society.” “It can be scary for people to even reach out, because they fear that they’ll be judged, or stigmatized, or discriminated against… especially if you don’t even know where to go, right?”

The university runs regular mental health literacy programs so that its faculty and other administrative staff are literate and can help eradicate stigma, and approach students dealing with these struggles from a place of understanding, according to U of T assistant vice-president of student life Lucy Fromowitz.

According to Fromowitz, demographics are also relevant, as many university students are at an age where mental health problems tend to emerge. “It is primarily having to understand the numbers,” she said. “Seventy per cent of mental health problems or illnesses begin in childhood or adolescence.”

She believes that the shortcomings in the university’s current mental health provisions come down not to the services available, but rather to communication between the institution and it’s students.

“There are these processes in place, but do students connect to the processes? And that’s really where our biggest challenge at U of T,” said Fromowitz, “is to keep students informed of what they need to know, when they need to know it, when every student needs to know something else at a different time.”

She remarked that the administration tries to improve all avenues of communication, from websites to course syllabi, in order to reach students.

“This is a critical job that many of us have, because telling students about these processes when they are doing fine isn’t a good strategy, because they never assume they are going to need a petitions process, or they’re going to not be well.”

Breaking down, slipping through

By the onset of winter in 2013, John had been receiving medication and therapy for depression and anxiety for many years. John had first been affected by depression a year and a half into his undergraduate studies. He had left Toronto, where he was born and raised, to attend school elsewhere, but this experience eventually led him to return home and enrol at U of T.

John got through the intervening years; his family could afford to send him to a psychologist for talk therapy, and despite still having intermittent – and sometimes serious – difficulties with depression and anxiety, his academic career was on track.

John did not need to use the treatment options that the university offered, but he did initially register with Accessibility Services ­— the U of T department that handles accommodations for students with physical and mental health related disabilities.

“What that means in my case is almost nothing,” says John. “It means that I can, if necessary, get extensions on papers.”

The registration process involves a long form that must be filled out by a healthcare professional. While this was not difficult for John, who was already seeing a therapist regularly, he sees this process as a major barrier for others.

“Getting someone to feel comfortable enough to go to that desk, it’s hard,” John explained. He talked about the “anxiety that comes with feeling like you have to prove it to people, and whether you are deserving of that label and the accommodations that go with it, or whether you are just being a whiny bitch who can’t… get shit done.”

Getting the form filled out can also be costly — $200 in his case. “It’s going to take them two hours to get through it,”John pointed out, and added “Most therapists are psychologists, and they are not free.”

Accessibility Services also requires students to repeat this process every year. While students can now do this through email, John recalls that he was asked to repeat the initial registration process. When he began graduate studies at U of T, in the fall of 2013, the thought of going through the process again stymied John. “I wasn’t even depressed [at the time],” he said, “but even so, the form feels scary.” He didn’t re-register.

Although John began his graduate studies excited and refreshed, his depression soon resurfaced, producing a sorry reminder of his undergraduate experience. 

“It was a crushing disappointment,” he said. “Part of it was letting myself get way too invested in [the work]… where I was burning myself out emotionally.” Things first began to slip in the fall, and worsened as the year went on. “It really started cascading I guess in February. I made it until March break, middle of March… and then everything really went to hell. I started missing classes like crazy, I started not turning things in.”

By this point, John was suffering from severe depression. “When I get depressed, even the process of communication is fucked,” he explained. John didn’t answer the emails from his instructors asking what was wrong.

John’s academic life was not the only place where his depression manifested: he stopped going to regular appointments with his therapist, and lost touch with close friends.

John was unable to pull things together and go back to Accessibility Services in time to register his illness; he missed the deadline to request extensions beyond the end of the term by about one week. “So then it became not about getting extensions, but about getting retroactive medical leave for a year. That would, one, make me not fail, and two, let me have the year off.”

But he was in no state to go through the necessary process, that would make this happen. “I would absolutely have failed out,” he said, were it not for the fact that he had someone who could advocate, and do this work, on his behalf.

How is it this hard?

Professor Smith* has taught at U of T for over a decade. He is also John’s father.

“[My son] just wasn’t able to do the things that he loves to do for himself, that had nothing to do with school work,” said Smith, “so I could see that he was not going to be able to do any of these things that they were asking him to do.”

“I see this with other students as well: there are these… requirements in place which don’t look unreasonable… except if somebody is depressed and finding it difficult to do anything, then you have this whole series of steps to go through and… people often just give up.”

Appealing on behalf of his son, Smith found the responses from the administration unsympathetic at first; if John was having health problems, then the requisite notification should have been given earlier, before grades were due.

“It’s fair enough that at least some of the professors had written emails to him, and he had not responded. But the nonresponse was itself a symptom of the mental health problem, which was depression, which leads to the incapacity to do things that normally would be perfectly reasonable to expect.”

Smith chalks up these problems partly to the bureaucratic administration that is characteristic of large institutions like U of T. However, some of it also has to do with suspicion of mental health issues in general.

“I think there is an excessive concern for preventing somebody from getting away with something,” he said, adding, “there is a background [of] skepticism on the part of faculty and perhaps the administration, about the reality of mental illness, and worry that this will be used as… an excuse.”

Smith still encourages students to reach out for help if they are experiencing any kind of mental health problems, despite the barriers. “You have people who are depressed and aren’t able to get their act together and do the things that they have to do to get the status, and so they take the course of least resistance which is to withdraw, to drop out, simply to disappear… I’ve certainly had students over the years who’ve just disappeared.”

For Smith, the appellate process was a “tremendous investment of effort” that involved never accepting no for an answer, and pushing the appeal to higher and higher levels, until a sympathetic ear was found. John was eventually granted a year away from school, and his grades were given a pending status.

And though he would spend much of the remainder of 2014 in a depressed, sometimes suicidal state, John was eventually able to connect with a psychiatrist who diagnosed his specific illness, and changed his medication. Once he was well enough to complete the coursework for 2014, John returned to his graduate studies at U of T.

He also made sure to register with accessibility services this past September.

John’s story reveals the way a person’s — and a family’s — resources matter. “I spent hours drafting the appeals,” Smith recounts. His job put him in a position where he could devote the necessary time and energy, and gave him a familiarity with the institution with which he was negotiating. “I’m an academic, I know how to write this… and I know what language they need. If he had ‘normal’ parents, even if they were very committed, they wouldn’t know what to say.”

“It worked out fine for [John] in the end. But it can’t be okay that that’s what it takes to work out fine, because it’s not going to work out fine for most people.”

“I didn’t want to be in a mental ward”

“It just sort of snuck up on me, I guess,” said Vik,* a first-year commuter student at U of T, talking about the depression that began to emerge in his final year of high school, and which continues to affect him.

His family doctor diagnosed him with depression this past August. Two weeks later, he was hospitalized after what was deemed an ‘attempted suicide.’

“They just put one label under any overdose,” he explained. “So if you overdose, you are suicidal, and you need to be under supervision and be hospitalized.” The drug in question was Zoloft, a common antidepressant. Vik says that the overdose was not severe, and that he probably would have recovered without emergency care.

Hospitalization lasted two weeks, where he was placed in the mental health care unit. “That was supposed to fix me, but it just made me more paranoid I guess,” he said.

For Vik, it is not easy to categorize his overdose. He described it as being motivated by “a mix of wanting to get better and wanting to feel worse. That sounds really weird, but I think that’s the best way to put it.”

He described his depression in terms of feeling worthless, and as if nothing matters. Starting university was a positive change, at least insofar as his studies gave him a much needed distraction. Still, Vik said, “In the first month and a half I didn’t really socialize, I didn’t talk to anyone.”

Vik sought help from U of T’s mental health services soon after he began university. He was given information on other mental health resources closer to his home, and a list of phone numbers to call in case he needed help.

He was also given an appointment with a psychiatrist working at the university. “In the first session, I was sort of too cool,” he said. “They asked me how I was doing and… what I’ve been doing to cope with my anxiety and depression and stuff. And, I didn’t really lie about that.”

“But then they asked me if I was suicidal or not, and obviously I lied about that because if I said ‘Yes’ then they would have to inform the authorities, right? Because I’m a ‘danger to myself’ if I was.”

Vik confirmed that he did have suicidal tendencies at the time he spoke to the U of T psychiatrist, although at that point the feelings were not as severe as they had been during the summer. Mainly, Vik wanted to avoid being assessed using a Form One, an application qualified medical practitioners in Ontario can use to order involuntary hospitalizations. Form One is typically reserved for instances in which a patient presents a danger to themselves or to others.  

Forced hospitalizations authorized under a Form One cannot extend beyond 72 hours and involuntary treatment or medication can only be administered in an emergency, or with the consent of a ‘substitute decision maker,’ usually a family member.

“Its a challenge, but you don’t do it lightly,” said Ungar of the Form One process. “You do it with your complex professional judgement.” He called it an act of compassion and kindness, and one that often saves lives.

“I can understand how people sometimes get scared — that if they share what they are going through, we will just send them to the hospital,” said Snider, who herself lacks the legal power to put a patient under a Form One. “We have to take those things seriously… at the end of the day, we are really looking at their best interests. We don’t want them to follow through with a plan.”

She added that a distinction is meant to be made between passive and active suicide ideation. “Someone just sharing suicidal thoughts, at least in the team I work with, does not necessarily mean that they are going to be formed and sent to the hospital.”

It is hard to say what exactly would have happened to Vik had he responded differently to the psychiatrist’s questions, and he is not entirely sure himself, but the fear of hospitalization definitely affected his decisions.

“I wanted to go through university, and just lead like a normal life,” he said. “I didn’t want to be in a mental ward, just in a white room.” Having spent time in just such a place in the summer, Vik didn’t feel like going back.

Vik told Health and Wellness at U of T what he thought they wanted to hear. He does admit that talking to them about his problems did help him feel somewhat better. He still takes medication, but he stopped seeing the psychiatrist in early October.

Now, he does his best to cope on his own. “For me, fighting depression is just trying to distract yourself.” He does this mostly by delving into his studies. “When I’m not studying, I’m like just a dark cloud.”

He tries to sit at the front of the class, as this allows him to concentrate better on lessons; sitting in the middle or the back makes it easier for “dark thoughts” to surface.

It is not easy for Vik to explain what dealing with his depression is actually like. He described lectures as “pretty fun,” but then later added that he doesn’t really enjoy school beyond the distraction it provides.

“I don’t really enjoy anything… I can lead a normal life, and I can put on a face that makes it seem like I am happy, but,” he explained, “depression is just always in the back of your head… no matter what you do, no matter where you are… it’s always in the back of your head trying to claw its way up at the front.”

Vik is trying to make friends, surround himself with positive people, and make a habit of studying in groups instead of by himself. Thinking about the future also helps. “My outlook is that, like, one day, maybe in the near future, I do surround myself with positive people, and I … can look back at this time period as just a phase in my life.”

Asked if he thought was going to be okay, he quickly says “No, I don’t think so,” but added, “Oh, okay. I thought you were going to say ‘am I going to commit suicide?’” He laughs as he says this. “Am I going to be okay? I’m getting better.”

Part of me, not all of me

The one thing Vik doesn’t want is to be patronized or pitied, a sentiment echoed by others interviewed for this piece. “I definitely don’t like pity. Pity is horrible,” said Lisa. She wants people to seek help when they can, and not to avoid using a treatment like therapy because they don’t feel their issues are “severe enough to qualify.”

“It’s always in the back of your mind, but it’s not always at the forefront of your life,” said John. For example: even during the nearly year-long depression that saw him leave school and stop speaking to his friends, John still had more than one romantic relationship — a fact that may be surprising, but one that, in his words, others should see as “an illustration of the way depression isn’t a singular, totalizing thing.”

John is upfront with people, especially with possible partners, about his depression, but he doesn’t like the idea of being someone’s guinea pig, or of having to explain depression to them. “Read a book, there’s a lot of them,” he said.

“I feel like people have a tendency to characterize whatever you do as a function of what you are going through internally,” said Sara. She said we should take people as a whole, and not reduce them to their mental illness.

“It’s kind of patronizing. It’s not deliberate, I know that. They would never voluntarily do that kind of thing. It’s just that, ‘Oh she’s doing this, she’s overcoming her thing, like go her! Yay!’ Like, no.”