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Mental health experiences of undergraduate college students in outpatient treatment

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Mental health experiences of undergraduate college students in outpatient treatment

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Content Running head: COLLEGE OUTPATIENT EXPERIENCES

1

Mental Health Experiences of Undergraduate College Students
in Outpatient Treatment
Erin E. Hickey
Educational Counseling
Master of Education
University of Southern California
May 12, 2017

COLLEGE OUTPATIENT EXPERIENCES 2
Table of Contents
Abstract…………………………………………………………………………...…………..…..5
Chapter One: Introduction………...………………………………………………………..…..6
Theoretical Approach…………………………………………………………………...………9
Chapter Two: Literature Review………..………………………………………………..…...17
Mental Health…………………………………….……………………………………………17
Stress and Emotional Intelligence.………………………………………………………19
Treatment Programs…...………………………………………………………………………21
Historical Background………………………………………………………………...…22
Residential Treatment Centers (RTCs)………………………………………………..…23
Post-Program Care……………………………………………………………………….24
Outpatient………………………………………………………………………….……..25
Help Seeking and Support……………………………………………………………….…….27
Stigma……………………………………………………………………………………29
Ecological Frameworks…………………………………………………………………….….30
Summary……………………………………….………………………………………………33
Chapter Three: Methods……………...…………………………………………………..…....35
Sampling…………………………………………………………………………….…………35
Procedures………………………………………………………………………….…………..37
Interviews………………………………………………………………………………...38
Data Analysis……………………………………………………………………………….….38
Trustworthiness of Data…………………………………………………………………….….39
Bias………………………………………………………………………………………39
COLLEGE OUTPATIENT EXPERIENCES 3
Limitations………………………………..………………………………………..…….39
Threats to Validity and Bias…………………………………………….………….……41
Minimizing Threats and Limitations…………………………………………….………41
Chapter Four: Findings……………..….…………….…………………………………..…....43
Introduction to Narratives……………………………………………………………………...43
Figure 1. Narrative Demographic Information………………………………………...………44
May………………………………………………………………………………………45
Steph……………………………………………………………………………………..50
Bopo……………………………………………………………………………………...54
Jill……………………………………………………………………………………...…59
Common Themes…………………………………………………………………….………...64
Figure 2. Common Themes………………………………………………………….…………65
Shame…………………………………………………………………………………….65
“It’s Not Real” ………………………………………………………………………..…67
Relapse…………………………………………………………………………………...68
Help Seeking…………………………………………………………………………..…70
Chapter Five: Discussion…………...……………………………………………………..…....72
Ecological Model Analysis……………………………………………………………….……72
Individual………………………………………………………………………………...73
Interpersonal…………………………………………………………………………..…75
Institutional………………………………………………………………………………76
Cultural/Ideological.. ……………………………………………………………………77
Physical…………………………………………………………………………..77
COLLEGE OUTPATIENT EXPERIENCES 4
Ideological………………………………………………………………………..77
Stigma……………………………………………………………………77
Acknowledgement……………………………………………………….78
Future Research………………………………………………………………………..………79
Recommendations from Participants……………………………………………………..……80
To Practitioners………………………………………………………………………..…80
To Students………………………………………………………………………………81
Practice and Policy Implications…………………………………….…………………………82
Concluding Thoughts……………………………………………..……………………………84
References…………………………………………………………………….…………………85
Appendices………………………………………………………………………………………95
Appendix A. Recruitment Flyer…………………………………………...…………………...95
Appendix B. Interview Protocol…………………………..…………………………...………96
Appendix C. Informed Consent Form……………………………..…………………………107
Appendix D. Student Resources Information Sheet Categories…………………………...…111

COLLEGE OUTPATIENT EXPERIENCES 5
Abstract
The rise in mental health issues for college students is something that cannot be ignored. In 2014,
the number of adults in the U.S. with any mental illness (meeting DSM-IV criteria and occurring
at least within the past year) was 43.6 million and of this population, traditionally college-aged
adults (18-25 years old) account for 20.1% (Center for Behavioral Health Statistics and Quality,
2015). Although some quantitative literature exists on undergraduate college student mental health
and treatments, there is a lack in literature on qualitative studies and studies of college students
specifically in outpatient care. This research presents a qualitative study of college student
experiences with mental health issues who are enrolled in outpatient treatment programs. By using
an ecological model to investigate the effects that different settings and interactions in students’
lives have on their management of their own mental health, a deeper understanding of student
experiences can be constructed for consideration by higher education professionals and counseling
professionals who work with and treat this student population.
Keywords: mental health, college, IOP, outpatient, ecological model
COLLEGE OUTPATIENT EXPERIENCES 6
Chapter One: Introduction
Over the course of almost two decades, there has been a rise in mental illness among
college students and an increase in the complexity and severity of the mental health issues
students are experiencing (Benton, Robertson, Tseng, Newton, & Benton, 2003; Blanco et al.,
2008; Ketchen Lipson, Gaddis, Heinze, Beck, & Eisenberg, 2015). In the past decade, students
self-reporting any form of depression increased from 18% in 2007 to 19% in 2016, major
depression increased from 9% in 2007 to 11% in 2016, and generalized anxiety went from 6% in
2007 to 21% in 2016 (Healthy Minds Network, 2016). This data points to an increase in mental
health issues on a national level across many different factors such as race, gender, citizenship,
and year in school. Despite the increase in the number of students with mental health issues,
mental health treatment utilization has remained low for college students (Ketchen Libson et al.,
2015). Whether or not the student is experiencing low, moderate, or severe mental illness, there
are almost always harmful effects if left untreated for long periods of time (Wang et al., 2005).
Of the college students with mental health disorders, the gap in treatment has been reported to be
as high as 80% or more, with one study finding 45% of students had at least a twelve month
prevalence of any mental health issue and another finding only 24% of students received
counseling for any mental health problem within the past year; these factors should be of more
concern to counselors and treatment professionals when thinking about individual student needs
and campus climate (Blanco et al., 2008; Eisenberg, Hunt, Speer, & Zivin, 2011; Ketchen Lipson
et al., 2015). As such, the purpose of this study is to qualitatively examine the lived experiences
of college students with mental health issues as they manage their mental health with the support
of outpatient treatment. The operational definition of outpatient treatment refers to non-
residential enrollment in a treatment facility under professional care for mental health, or a
COLLEGE OUTPATIENT EXPERIENCES 7
combination of consistent group and individual therapy to support mental health. Outpatient
programs and treatment in the various outpatient settings stated may include social and academic
support elements as well.
For the purposes of this study, I define mental health issues as those addressed by the
National Alliance on Mental Illness (NAMI) (n. d. b), encompassed under the following
umbrella: any depression disorders (including bipolar disorder), any anxiety disorders, attention
deficit hyperactivity disorder (ADHD), borderline personality disorder, dissociative disorders,
eating disorders, obsessive-compulsive disorder (OCD), posttraumatic stress disorder (PTSD),
substance use disorders, schizoaffective disorder, and schizophrenia. This list is not an
exhaustive list of all mental health conditions that may be considered a protected disorder under
legislation or participants’ and readers’ personal feelings toward mental health. The phrases
“mental health issues,” “problems with mental health,” and “mental illness” will be used
interchangeably, although the author acknowledges that the participants of this research and the
subsequent readers will not unanimously identify with these definitions nor agree with their
interchangeability as well. Further definitions from a review of the literature will be provided in
Chapter Two of this study.
The lived experiences of college students with mental illness is an area that deserves
more attention. In 2014, the number of adults (aged 18 and older) in the U.S. with any mental
illness (meeting DSM-IV criteria and occurring at least within the past year) was 43.6 million, or
18.1% of all adults (Center for Behavioral Health Statistics and Quality, 2015). Of this
population, traditionally college-aged adults (18-25 years old) account for 20.1% of the 43.6
million (Center for Behavioral Health Statistics and Quality, 2015). Mental illness frequently is
exacerbated or has its first onset during adolescence and emerging adulthood—the time that
COLLEGE OUTPATIENT EXPERIENCES 8
many students are attending college (Arnett, 2000; Eisenberg, Downs, Golberstein, & Zivin,
2009; Kim et al., 2015; Kirsch et al., 2014; National Institute of Mental Health, 2016; Pedrelli et
al., 2015). The stress of academics, meeting new people, and adjusting to a new lifestyle and
more unstructured schedule can trigger mental health issues, with various degrees of treatment
seeking by students (Blanco et al.; Brackney & Karabenick, 1995; Pedrelli et al., 2015). Mental
health issues can impact a student’s ability to successfully function in college, have
healthy/functional interpersonal relationships, and accomplish life goals and life activities
(Center for Behavioral Health Statistics and Quality, 2015).
A delay or complete avoidance of seeking help may contribute to a persistence of mental
illness and future occurrences of symptoms related to the mental illness (Blanco et al., 2008).
Eisenberg et al. (2009) insist that the “timely and effective treatment [of mental health issues]
may offer substantial long term benefits” to college students managing their mental health
experiences (p. 523). Of these benefits, college degree completion is included. Accordingly, in
NAMI’s (2012) report, 64% of college students dropped out of college due to mental health
issues, and 50% of those students did not seek out mental health services (Gruttadaro & Crudo,
2012). Students coming to on-campus support seeking help for their mental health issues
reported considering dropping out and having negative academic outcomes as a result of their
mental health issues; although, students who did receive mental health services had better
retention rates compared to the rest of the student body (Mandracchia & Pendleton, 2015; Turner
& Berry, 2000). Arria et al.’s (2013) study looked at college students with mental health issues
and their discontinuous enrollment, defined as “a gap in enrollment of one or more semesters,
which may or may not be followed by re-enrollment and degree completion” (p. 167). They
found that students who were diagnosed with depression during college or had depressive
COLLEGE OUTPATIENT EXPERIENCES 9
symptoms were more likely to be at risk for disruptions in enrollment and not completing their
college education, which ultimately effects graduation and retention rates for the college and
positive education outcomes for the student (Arria et al., 2013).
Seeking out help is an important coping and learning strategy that college students must
learn, and students with higher levels of mental health issues are a population less likely to seek
professional or social support, leading to issues in academic and personal life (Brackney &
Karabenick, 1995). Information pointing to perceived stigma is a leading factor in avoiding
seeking support (Gruttadaro & Crudo, 2012). For the purposes of this paper, stigma will be
defined as the unusual, immoral, bad, or “other” status that is assigned to individuals due to
bodily manifestations/markings or the social ignominy of being “different” (Goffman, 1963).
The prevalent mental health stigma that exists for students also points toward the various ways
students experience their mental health issues and how they assign meaning to symptoms,
diagnoses, and help seeking behaviors, with no one standard of conformity in existence
(Rosenbaum & Liebert 2015).
Theoretical Approach
Although an investigation of the psycho-social-cultural influences on student mental
health via an ecological model will be used as a framework for this study and discussed more in
depth in Chapter Two, the influence of student development and sociological theoretical
influence cannot be ignored in stating the current climate for college students with mental health
problems who are in outpatient care.
Looking at college student development, the transition to the college environment is
typically a transition from adolescence to adulthood. Sanford’s (1966, 1967) development and
challenge theory identifies how students mold their identity during college. In order to
COLLEGE OUTPATIENT EXPERIENCES 10
understand the formation, it is important to acknowledge that students go through a process of
differentiation and integration in the external college environment (Sanford, 1966). To be able to
maintain health and wellbeing during the college education process, students have to work for
the power and coping skills to survive within the college environment (Sanford, 1966). The basic
tenant of development and challenge theory, or as Patton, Renn, Guido, and Quaye (2016) refer
to as support and challenge theory, is that when a student lacks skills (associated with existing
knowledge and coping), the student will be challenged, and if appropriate supports exist and the
student is ready for the challenge, the student will be able to use adaptive responses to
successfully work through the challenge (Sanford, 1967; Sanford, 1968). Sanford (1966) also
stated that the external environment, the college environment, can affect integration. An
individual can adapt to one particular environment and achieve integration into that environment,
such as a high school or previous treatment setting, but, “this would hardly increase his potential
for handling future strains if his environment changed radically” (Sanford, 1966, p. 31). Positive
mental health, then, is not just an isolated quality distant from other qualities of an individual, it
is something that involves multiple other qualities and environments that the student is placed or
is an active participant in (Stanford, 1967). If students with mental health issues are trying to
adjust to college as a student while managing their mental health, then conflicts may arise. I
deduce that outpatient care is one way that the support can be made available for students with
mental health issues that incorporates the environmental change of going to college.
In a constructivist perspective, one cannot ignore context when looking at college
students managing their mental health. Students can understand the greater social context and
environment they are set in in relation to their own individual experiences (Mills, 1959).
Students subjectively experience their environments in college, which is understood by being
COLLEGE OUTPATIENT EXPERIENCES 11
able to see oneself in a current situation and environment, such as college students managing
their mental health, and understanding possible outcomes by seeing others in a similar
circumstance (Mills, 1959). The personal troubles of an individual may become a public issue in
the college environment, such as the disclosure of mental illness in a private setting becoming
public knowledge among peers without a student’s consent, and having the support of outpatient
programs and peers going through similar experiences frames the environment in a more
manageable setting (Mills, 1959).
Pursuing the research described above, I seek to explore the following research question:
What are the experiences of mental health for college students in outpatient treatment, and how
are they managing their mental health while in college?
College students with mental health issues are an at-risk population for not achieving
their desired educational attainment in college, which is the goal of many young adults (Drake,
Strickler, & Bond, 2015). Whether a student has any mental illness or not, there are many
demands placed upon college students to fulfill new roles and independence (Gerdes &
Mallinckrodt, 1994). If students are unable to seek support or create appropriate support
networks, they will be at risk to suffer socially, emotionally, and academically, as well as
compromise the students’ retention and graduation outcomes (Gerdes & Mallinckrodt, 1994;
Kitzrow, 2009). Gerdes & Mallinckrodt (1994) found that students drop out of college for
different reasons, but that among the students who dropped out in good standing, there were
signs of depression, an anticipated increased difficulty dealing with the new roles of being a
college student, and with being independent. Counseling treatment, such as cognitive therapy,
has been found to help the symptoms college students with mental health issues face, particularly
for depression and anxiety (Brackney & Karabenick, 1995). In this realm, Wilson et al. (1997)
COLLEGE OUTPATIENT EXPERIENCES 12
found that, even if it was only a few times, treatment in the form of psychological counseling
sessions (a form of outpatient treatment) had a positive impact on student success in college,
with a “14% retention advantage over their noncounseled counterparts” (p. 319).
The National Center for Education Statistics (NCES) (2016) reported that between 2003
and 2013, full-time student enrollment increased by 22% and part-time by 18%, and projected a
14% increase of college enrollment from Fall 2018 to Fall 2024 (Snyder, de Brey, & Dillow,
2016). When about half of the population of young adults are attending college (Snyder et al.,
2016), it is important to note that, according to Mojtabai et al. (2015), 11.4% more college
students would be able to graduate from college within a ten-year span if they were able to
secure the appropriate resources and treatment to help prevent and alleviate mental health
problems. Mojtabai et al. (2015) highlight that education is a means to impact society by
“[increasing] its standard of living, compete in global markets, and promote participation in civic
affairs” (p. 1583). There are many benefits to be reaped, then, by having students with mental
illness enroll and attend colleges with non-outpatient treatment/program peers (Drake et al.,
2015). If students struggling with mental illness do not get the chance to complete their college
education, let alone participate in college in the first place, it is a disservice to society to
eliminate an entire population of people from having their chance at education. Having better
care during college means that students can build resilience, lessen the chronic nature of mental
illness, and lessen the future health care costs to themselves and insurers (Blanco et al., 2008;
Pedrelli et al., 2015).
As many young people have the goal of attaining education during the timeframe that
mental illness first occurs, it is important to develop supportive environments that are prepared to
deal with the challenges that come with mental illness. Elements of a supportive environment
COLLEGE OUTPATIENT EXPERIENCES 13
might include allowing all students to have a positive experience in college and set students up
for success via the support systems and treatment programs created to address mental health
issues and the challenges outpatient students face while attending college and managing their
mental health. Brackney and Karabenick (1995) noted that mental illness, or “psychopathy” is a
combination of psychological distress accompanied by “limited coping resources” (p. 456), and
is something that college students may experience as a barrier to cognitive functioning in
addition to all of the other challenges college students face. They posit that if students face
challenges with their mental health and cognitive abilities, they will face lower self-efficacy, or
confidence in one’s own abilities to achieve outcomes (Bandura, 1977); but, Brackney and
Karabenick (1995) also deduce that if students can boost this efficacy in at least one area of life,
it may transfer over to other areas of life (e.g., becoming better at solving mental health problems
may lead to becoming better at solving academic problems). I infer that knowing that symptoms
of mental illness may be out of students’ control allows college staff and student peers to have a
level of empathy toward their experiences managing mental health in college. I assert that by
understanding the experiences of students dealing with mental health issues, higher education
settings can provide adequate and appropriate care resources to help enhance student quality of
life and success in academic settings.
Although some students may be first experiencing the onset of mental illness during
college, as much as 75% by the age of 25 (Kessler et al., 2005), other students have already had
experiences with their own mental illness prior to coming to college. Students may have
experiences with inpatient hospital or program settings prior to attending college where treatment
for behavioral, emotional, psychological, or substance use issues occur. These programs are
designed specifically for youth, with some academic components incorporated depending on the
COLLEGE OUTPATIENT EXPERIENCES 14
population served, program setting, and severity of mental health issues that need to be treated
(Christenson & Gutierrez, 2016; Lee, 2008). The less restrictive the setting, the less intensive the
therapeutic aspect and daily regimented schedule will be in the residential setting or outpatient
setting. Outpatient settings are a program type that allow for the most freedom of patients
seeking treatment for mental health issues. For example, intensive outpatient treatment programs
(IOP) or partial-hospitalization programs (PHP) require participants to fulfill a certain amount of
hours over a certain number of days each week to attend group and individual therapy, or other
care that supports mental health management and related symptoms. These settings do not have a
residential aspect, and consist of supportive day or night programs, allowing patients to work, go
to school, and socialize outside of the program setting (Gifford, 2016).
The purpose of this study is to qualitatively examine the mental health experiences of
students enrolled in outpatient treatment while attending college. Currently, there is a wealth of
quantitative studies on mental health and college students, but not many qualitative studies (Byrd
& Mckinney, 2012; Pedrelli et al., 2015; Rosenbaum & Liebert, 2015). Additionally, there is not
much research in the area of outpatient programs for college students in neither quantitative nor
qualitative studies (Kirsch et al., 2014; Russell, 2005). Accordingly, this research will attempt to
fill the gaps of existing literature on college student experiences with mental health, with
particular focus to those students who are currently or have recently been in outpatient treatment
or enrolled in outpatient programs for mental health treatment.
To understand college students’ experiences with mental health issues, it is important to
understand the language used and definitions behind mental health and mental illness. The World
Health Organization (WHO) (2016a) defines mental health as “a state of well-being in which
every individual realizes his or her own potential, can cope with the normal stresses of life, can
COLLEGE OUTPATIENT EXPERIENCES 15
work productively and fruitfully, and is able to make a contribution to her or his community.” To
expand on this definition, one can include in mental health the wellness of “everything that goes
on within an individual’s mind…a wide range of phenomena such as a person’s thoughts,
feelings, affects, emotions, beliefs, expectations, hopes, dreams, judgments, and ideas of who
and how they became that way (history)” (Rosenbaum & Liebert, 2015, p. 181). When these
definitions are taken into consideration, mental health is a personally lived experience, good or
bad, conscious or unconscious, that can be improved or worsened depending on context and
influences (Rosenbaum & Liebert, 2015). For one to be mentally “healthy,” though, these
thoughts, processes, and other phenomena must go on fluidly and without major disruption or
error (Rosenbaum & Leibert, 2015).
In comparison, the WHO (2016b) defines mental disorders as an amalgam of “abnormal
thoughts, emotions, behaviour [sic] and relationships with others.” The emphasis on abnormality
in this definition echoes the concept of thought processes failing to go smoothly and without
mistake. If health is seen from an objective standpoint where disruption to the process is
abnormal compared to whatever a “normal” person may experience, the student dealing with
mental health issues is denied an inherent “context, subjective meaning, ambiguity, or not
knowing” that is a part of the mental health equation (Rosenbaum & Liebert 2015, p. 184). For
the purposes of this paper, mental illness will be defined as a hybrid between these given
definitions, encompassing the complexities and individual experiences of mental health for each
individual affected.
For the purposes of this paper, the experiences students have with their mental health will
not be described as a struggle, but rather as “management” to avoid negative language
associations with mental illness and the college student population. Whether management is
COLLEGE OUTPATIENT EXPERIENCES 16
strong or weak, students may be taking action to take care of their symptoms and lived
experiences with their mental illness at any given time. Understanding the importance of
language is a part of breaking down the stigma in the conversations that surround college
students and mental health, and by framing language into more asset-based thinking we can
begin to reframe the negative, stigmatized, or taboo connotations of discussing mental health
issues in public forums.
The following four chapters in this study will examine the mental health experiences of
college students in outpatient treatment and how they are managing their mental health. Chapter
Two will look at a review of the current literature on mental health, types of treatment programs,
help seeking and support system utilization, and a theoretical framework to view the mental
health experiences of college students. Chapter Three will address the methods used for this
study, including sampling, data collection, and data analysis. Chapter Four will review the
findings of the study, and Chapter Five will include a discussion of these findings with space to
explore the suggestions for future research and implications for practice in the realm of college
students and their mental health experiences.

COLLEGE OUTPATIENT EXPERIENCES 17
Chapter Two: Literature Review
The existing literature on experiences of mental health among college students is limited
and focuses mainly on quantitative studies (e.g., Byrd & Mckinny, 2012; Eisenberg et al., 2009;
Hefner & Eisenberg, 2009; Kim, Saw, & Zane, 2015). Very little to no research has been
conducted on the experiences of students with mental health issues in college who have come
from therapeutic programs or inpatient settings during high school or prior to first enrollment in
college. There is a lack of literature on the topic of college students attending school and
inpatient or outpatient treatment services. In addition to the information provided by current
research studies, national health data sites and surveys also provide information related to college
students and mental health (e.g., National Institute of Mental Health, National Survey of
Counseling Center Directors, Substance Abuse and Mental Health Services Administration, U.S.
Department of Health and Human Services).
The existing literature provides some data insights to the college students’ mental health
experiences but does not build a holistic picture of student experiences with mental health. The
remainder of this chapter will cover a brief overview of mental health risk factors and
definitions, different types of treatment programs, post-program care, help seeking, and an
ecological theory application to help build a framework to answer the questions, what are the
experiences of mental health for college students in outpatient treatment, and how are they
managing their mental health while in college?
Mental Health
Individual factors that must be considered alongside mental health problems are the
adjustment to academics in college, and the demands of an increased workload, motivational
needs, requirements, and efficacy (Byrd & Mckinny, 2012). Accordingly, these individual
COLLEGE OUTPATIENT EXPERIENCES 18
factors also have an influence on different psychological disorders and can affect student health
habits and/or exacerbate existing mental health conditions (Byrd & Mckinny, 2012). According
to the Americans with Disabilities Act (ADA) of 1990 and the following ADA Amendments Act
in 2008, discrimination against students with mental health issues is protected if the students has
a disability that “substantially limits one or more major life activities” when it is actively
presenting (p. 7). According to national data, “people with disabilities, as a group, occupy an
inferior status in our society, and are severely disadvantaged socially, vocationally,
economically, and educationally” (ADA, 1990, p. 5), yet the ADA was one of the first legal
protections put in order to ensure there is legal order to rectify any discrimination against
individuals with disabilities. Accordingly, Section 504 of the Rehabilitation Act of 1973 asserts
that this also includes admission and reasonable accommodations for students in college (U.S.
Department of Education, 2015). Accommodations can include leave of absence, modified work
load, extended time to complete assignments or a degree, and testing environment changes in
order to best serve the student’s needs (ADA, 1990). College students with mental health issues
may be entitled to protection by legislature, yet the cost of offering protection such as
accommodations are left of the institutions themselves. This can lead to a gap in care, no matter
how well-intentioned the institution, if providing comprehensive accommodations is an
excessive or unjustifiable financial burden to the institution. Thus, this source of protection may
not always match available funding.
College students are at an age where the first onset of mental health issues may occur,
making them a large portion of the population that are at risk for developing mental illness
(Eisenberg et al., 2009). Mental health issues that college students manage are most typically
anxiety disorders (including social phobia, panic disorder, generalized anxiety disorder,
COLLEGE OUTPATIENT EXPERIENCES 19
obsessive-compulsive disorder, and post-traumatic stress disorders), depression, suicidal
ideation, eating disorders or disordered eating, attention-deficit/hyperactivity disorder,
schizophrenia, and autism spectrum disorders (Pedrelli et al., 2015). Of these mental health
issues, anxiety disorders and depression were the most common among college students (Pedrelli
et al., 2015).
In Zivin et al.’s (2008) research on persistence of college student mental health problems,
findings showed that over one third of students who initially had mental health issues during
screenings at the start of their study still had mental health problems two years later, and that
some of these students also ended up having predictable problems of a different nature at the
follow up (Zivin et al., 2008). Zivin et al. (2008) deduced that the mental health issues that
college students were experiencing were not just “transient issues related to adjustments other
than temporary factors,” such as the general life adjustment all college students make when they
first attend college (p. 184). Byrd and Mckinny (2012) found that differences in student mental
health can be explained by both social and psychological factors, consistent with the findings
from current literature (e.g., Zivin et al., 2008).
Stress and Emotional Intelligence
For college students, skills to cope with stress and mental health may not be as robust as
those of an adult, making them more susceptible to negative symptoms of mental illness (Blanco
et al., 2008). In Byrd and Mckinny’s (2012) research, findings lead strong support that student
with good coping skills or the perception of good coping skills were better able to handle stress
and had better mental health in general. The value in fostering good coping skills for such an at-
risk and vulnerable population, such as students with mental health issues in college, is of utmost
importance to encourage student success and a better quality of life. In addition to stress,
COLLEGE OUTPATIENT EXPERIENCES 20
emotional intelligence (EI) is another factor in the mental health of college students (Jayalakshmi
& Magdalin, 2015). Having the ability to use emotional intelligence allows students to inform
the way they think and act (Esmaeili & Baloui Jamkhaneh, 2013). Esmaeili and Baloui
Jamkhaneh (2013) provide a list of the five basic components of emotional intelligence:
intrapersonal (self-awareness and self-expression), interpersonal (social awareness and
interaction), stress management (emotional management and control), adaptability (change
management), and general mood (self-motivation). They found that students in an international
study exhibited a significant relationship between these five components and their mental health,
supporting the notion that when a student has a stronger EI, they are more likely to be able to
handle the challenges of transitioning and functioning in college (Esmaeili & Baloui Jamkhaneh,
2013). These findings have significance for U.S. college student populations as well by helping
to inform the way we think about U.S. students and their stress and EI. When stress becomes
another added layer on top of emotional intelligence, students may struggle to maintain a healthy
emotional state, whether or not they are managing any mental illness, which can interfere with
healthy student development (Papalia, 2014). In this time, students may also become reluctant to
try any help seeking or counseling support services because these have not previously been a part
of their support system (Papalia, 2014).
Considering the manifestations of mental health that can be seen or experienced
externally, there is a more biological level of mental health that affects students beyond their
own intervention or control. Research has shown that students with depression, for example,
have structural brain abnormalities, a lack of short-term memory functioning and information
processing abilities, cognitive abilities, executive functioning impairment, and episodic memory
deficiencies (Austin et al., 2001; Brackney & Karabenick, 1995; Steingard et al., 2002). Whether
COLLEGE OUTPATIENT EXPERIENCES 21
or not students have previous experience treating their mental health problems in a professional
setting, the support systems offered by counseling services and outpatient treatment should be
seen as a primary care system, and not something that a student seeks out as a last-ditch effort
(Papalia, 2014). The Substance Abuse and Mental Health Services Administration (SAMHSA)
(2015) mentions the importance of “illness management” as a form of treatment for people with
mental health issues (Center for Behavioral Health Statistics and Quality, 2015). Once students
understand their illness and become more informed about their status, the warning signs of
imminent relapse that may come early on, and ultimately have the ability to make better
informed decisions about their treatment and care (Center for Behavioral Health Statistics and
Quality, 2015).
Treatment Programs
Many different treatment options exist for students with mental health issues. Mental
health treatment programs extend beyond basic understandings of residential rehabilitation (for
example, substance use, eating disorders, or self-harm) and can extend to many non-residential
settings that allow social, vocational, and educational training to help students assimilate into
college communities and society as a whole (Center for Behavioral Health Statistics and Quality,
2015). These programs exist on a spectrum, ranging from restrictive, live-in facilities to more
flexible day programs. Programs have some shared similarity in structure and treatment, but
should be understood to be differentiated settings depending on patient needs and existing
structural systems, as well as target population, length of stay, and level of restrictiveness (Lee,
2008). The following information will include a historical background of treatment and
residential care for mental illness, as well as highlight residential treatment and outpatient
treatment centers available to both adolescents and young adults. This study considers the history
COLLEGE OUTPATIENT EXPERIENCES 22
of treatment and types of programs available to students managing mental health as important
parts of the ecosystem and affect experiences students face within different settings.
Historical Background
The general history of treatment options for young adults with mental illness begins in
the 18th and 19th century in the form of public facilities designated for the poor or
physically/mentally ill, such as orphanages, hospitals, and asylums (Leichtman, 2006). In this
time, people who were mentally ill were overwhelmingly given rigorous, lengthy, and crude
physical treatments to rectify their physically “disordered brains” (Rogers & Pilgrim, 2014, p.
125; Leichtman, 2006). By the early 20th century, World War I produced a plethora of higher-
ranked individuals mentally scarred from the war (Rogers & Pilgrim, 2014). Considering the
historic stigma of mental illness, the need to battle against the “crisis of legitimacy for the
dominant,” or to protect those in power who were perceived to now be in weakened states due to
mental distress, opened up the possibilities of some new forms of psychological treatment
(Rogers & Pilgrim, 2014, p. 125). At the same time, the hospitals, asylums, and orphanages of
the earlier centuries began to shift into institutions for residential treatment of adolescents who
were neglected, abused, or with severe mental health issues, although I assert that it is subjective
as to what is considered a mental health issue that was profound at any given time (Christenson
& Gutierrez, 2016; Leichtman, 2006).
By the 1940s, the “residential treatment” of individuals popped up in multiple programs
that differed in their counseling/service approach and targeted population to serve, which was the
foundation for residential settings for adolescents today (Leichtman, 2006). The creation of the
American Association of Children’s Residential Centers (AACRC) by the American
Orthopsychiatric Association in 1954 tried to bring some order and regulation to practice
COLLEGE OUTPATIENT EXPERIENCES 23
standards and guidelines for residential care for adolescents (Leichtman, 2006). Throughout the
rest of the century, the original conception of long-term residential treatment shifted to more
short-term stays for adolescents, and the creation of new pharmacological interventions and
outpatient therapies have helped alleviate the dependence on residential programs alone
(Leichtman, 2006). The advent of outpatient therapy is something to be noted, as well. By the
end of the 20th century, there were many critics of residential programs, due to the costs of such
programs, as well as abuse, maltreatment, and other scandals associated with residential care
(Leichtman, 2006; U.S. Government Accountability Office, 2008). Developing outpatient care as
a more holistic approach and an option to help individuals who have been treated in inpatient,
residential settings allow individuals to continue care at home and with a safe outlet to try out
new strategies and coping mechanisms, such as through “homework” assignments outside of the
structure of therapeutic appointments and groups (Leichtman, 2006, p. 289).
Residential Treatment Centers (RTCs)
Christenson and Gutierrez (2016) describe five main categories of current residential
treatment settings for adolescents: therapeutic boarding schools, residential treatment centers
(RTCs) that are both client-funded and government-funded, short term programs, and lockdown
facilities. Patient populations at these setting vary by race, ethnicity, class, gender,
socioeconomic status, and severity of mental illness or psychological distress, and according to
Behrens and Satterfield (2006), with private facilities generally housing patients that are more
typically White, coming from a higher socioeconomic status, and are placed in care by family
members who pay for treatment, versus public RTCs that more commonly house patients of
lower socioeconomic status and minority races, which is referred by other public institutions and
money. Traditionally, private residential treatment settings can have comprehensive individual,
COLLEGE OUTPATIENT EXPERIENCES 24
family, and group counseling aspects worked into the highly regimented daily schedules that
patients are expected to follow (Behrens & Satterfield, 2006). Residential programs may include
different levels or phases that students must work through to progress out of the program. These
transitional markers are comprised of allowing the students an increase in responsibility and
privilege according to their growth in the program structure and curriculum, such as allowing for
personal items, family visits, excursions off site, leadership positions, etc. (Behrens &
Satterfield, 2006). College students coming from these settings may already be familiar with the
style particular to therapeutic treatment programs, such as what may be seen in an outpatient
program, and may find their experience from previous programs transferable or applicable to
navigating new treatment settings.
Post-Program Care
Lyons (2015) highlighted the subjective nature of understanding students in their
environment and in context to their problems, which applies to students with mental health issues
as well. Students who enter into inpatient programs may still need continued care after they
graduate out of the program or leave voluntarily/involuntarily, and the duration of continued care
and support is crucial to success (Sallis et al., 2008). Although some students may graduate from
programs having accomplished all the necessary phases and markers of progress, other students
may discharge from programs early, before all phases of treatment have been completed and
against the advice of program staff and clinicians, which may be due to an apparent “cure” to
problems after seeing positive results in a brief amount of time in treatment (Behrens &
Satterfield, 2006). After-care, for the purposes of this paper defined as any care that occurs after
initial hospitalization or other intensive treatment options such as inpatient, intense outpatient
programs (IOP), etc., is one way that continued care can be managed. Students in this transition
COLLEGE OUTPATIENT EXPERIENCES 25
may have achieved many gains toward more positive mental health and management of
symptoms and/or episodes, but these students may also be lacking the internalized vision
necessary to put their new skills into action in a consistent way (Bolt, 2016; Russell, 2005).
Students who are enrolled at or attending college benefit from having coordinated care between
current mental health service providers and the after care providers they transition to, with
careful consideration of how to continue care during school vacations and other breaks within the
academic year (Pedrelli et al., 2015). Although campuses may provide their own psychological
support for students, such as addressing common mental health issues in the student population
through awareness campaigns and increasing visibility of mental health resources, the support a
student needs may go beyond what the college is able to offer (Perron, Grahovac, Uppal,
Granillo, Shutter, & Porter, 2011). Outpatient care is one option for after-care that allows
students to receive treatment but also integrate into the college community, allowing students to
attend classes and still enjoy an active and involved role on campus.
Outpatient
One example of a successful college student outpatient program was studied in Kirsch et
al.’s (2014) research on McLean Hospital in Boston, MA. McLean created a College Mental
Health Program, which included the Bridge to Campus Program (BTC). According to Kirsch et
al. (2014), the BTC exists for college students “enrolled or on medical leave from school [to]
participate in psychoeducational [sic] support groups that teach cognitive-behavior therapy
(CBT) and dialectical behavior therapy (DBT) skills for co-managing their mental health and the
stressors of campus life” (p. 525). The program has various levels of care from inpatient to
outpatient (most restrictive to least restrictive), and allows students the opportunities to talk
about their mental health issues framed in topics such as “readiness to return to school; accessing
COLLEGE OUTPATIENT EXPERIENCES 26
accommodations and self-advocacy; developing an effective leave of absence; building a campus
support team; navigating campus relationships; managing procrastination and perfectionism; and
regulating diet, exercise, and sleep” (Kirsch et al., 2014, p. 525). The “community-campus
partnership” that BTC exhibits is a good way to broach the need for “environmental management
strategies” when considering the ecological context of students with mental health issues on
college campuses (Perron et al., 2011, p. 9). The existence of such a program is not novel; it is a
powerful example of adaptable and appropriate care for college students managing mental
illness.
While institutionalization in a residential treatment setting may offer a consistent
schedule and routine that is necessary for students who need the most restrictive environments,
there is merit in the outpatient setting for after-care purposes. Residential programs are
somewhat impractical in the sense that students may not be able to continue their routinized
schedules and reliance on others (staff, administration, counselors, etc.) at the same level that
they experience in residential settings. Therefore, different variations of outpatient treatment
(when a student is ready for this transition) allows for students with mental health issues to have
the opportunities to fail in a controlled and safe setting. College students seeking independence
may first struggle with the concept of autonomy while attending outpatient treatment or
outpatient treatment programs, as they “strive to individuate from their parents and families,”
and the grip of any previous inpatient or RTC program, and students may feel that their mental
health issues get in the way of their ability to feel independent and in control of their mental
health (bolt, Gjesfjeld, & Greeno, 2013, p. 23). The safety net that outpatient provides allows
students the opportunity to use the new support systems they have built to get the feedback and
COLLEGE OUTPATIENT EXPERIENCES 27
guidance needed while they learn to adapt to the college setting and have potential reoccurrence
of major symptoms (Bolt, 2016).
Miller and Rollnick (2002) state that relapse is often essential to the process of change,
and although relapse may be seen as failure in some perspectives, it can also be interpreted as
opportunity in the right setting. To have the opportunity to use settings, personnel, and peers
within programs to their fullest potential is to learn new skills and also to practice these new
skills and behaviors, such as emotional resilience “with minimal risk of harm as a result of those
mistakes” (Bolt, 2016, p. 64). If students are not able to practice skills of adapting to social
environments, such as the college campus and community, then it can consequently lead to
“unhealthy emotional reactivity, which manifests as social, physical, or emotional symptoms.”
(Bolt, 2016, p. 65). The positive outcomes of allowing students to transition into the general
college community with an appropriate support system and feedback from trained professionals
and peers who also manage their own mental health problems are worth the effort on the student
and community’s part.
Help Seeking and Support
Eisenberg et al. (2009) describe help seeking for students with mental health issues as a
process, which requires students to “experience a mental health problem, perceive a need for
professional help, evaluate the costs and benefits of receiving treatment (within the context of
social norms regarding seeking help), and take action to receive care” (p. 523). Since college
students account for a portion of the population who experience a higher rate of mental illness, it
is important to manage illness to prevent problems from persisting beyond college years (Pedrelli
et al., 2015). Because of the effects that a lag in treatment can have in student success, it is
important to acknowledge the importance of early identification of mental health issues, and the
COLLEGE OUTPATIENT EXPERIENCES 28
“timely and effective treatment [that] may offer substantial long-term benefits” (Eisenberg et al.,
2009, p. 523; Pedrelli et al., 2015).
According to the 2014 National Survey on Drug Use and Health, 62.9% of adults over
the age of 18 received treatment for serious mental illness (NAMI, n. d. a). Despite this,
researchers have found low rates of treatment for mental illness among college students (Blanco
et al., 2008). Particularly, Pedrelli et al. (2015) found that the low number of students who seek
and adhere to treatment may be due to the inherent “nature of psychopathology” (Pedrelli et al.,
2015, p. 509). Accordingly, in Zivin et al.’s (2008) research, of the students who were found to
have mental health disorders, many of them were not utilizing services to receive support, but
interestingly, students who screened negative for mental health disorders were accessing mental
health services available to the student population (Zivin et al., 2008). This finding may point to
the inference that choice to seek help may be outside of a student’s control or that there may be
something that compels them not to go, such as stigma of mental illness or seeking help in
general, or student experiences in outpatient programs and the effect that has for them on
campus.
Students seeking out care may follow the typical pattern of seeking out mental health
services, where treatment desired is the least restrictive environment possible, with sequential
transitions to less restricted care as students are able to manage their mental illness better,
eventually until support services are minimal or no longer necessary (Evashwick, 1989). Bolt
(2016) draws a parallel between mental health after care treatment and the after-care treatment
received from patients who return home from hospital care. These life adjustments that must be
met include “treatment, monitoring, rehabilitation, and lifestyle changes,” which also encompass
“triggers” that may exacerbate mental health conditions negatively (Bolt, 2016, p. 63).
COLLEGE OUTPATIENT EXPERIENCES 29
Stigma
The terms “mental health problems” or “mental illness” may in themselves conjure up
feelings of stigma. Rosenbaum and Liebert’s (2015) research focused on the impact language has
as far as the meanings we apply to the term “mental health” and what subliminal (whether
intended or not) messages the term brings with it. On the note of stigma, Eisenberg et al. (2009)
studied college students and mental health stigma, finding that perceived stigma, personal
stigma, and self-stigma were central to a student pursuing treatment for mental health issues.
They found that the fear of being criticized or discriminated against for utilizing mental health
services deterred them from actually seeking out help. If this public perception of mental health
is one that immediately is pushed to a more objective yet less worthy problem to only be
eradicated and solved, there is a level of stigma that prevents students from seeing their own
experiences with mental health as worthwhile or important, and leans more toward a deficit
approach (Rosenbaum & Leibert, 2015).
Additionally, personal stigma and health stigma were of concern to students considering
seeking help, because for a student to actually seek out services “implies acknowledgement of
one’s own mental health problems” (Eisenberg et al., 2009, p. 524). This potential absence of
acknowledgement or identifying mental health problems further complicates the path for help
seeking and possible duration of experiencing mental health issues (Pedrelli et al., 2015). When
good health is the goal, Rosenbaum and Leibert (2015) posit that any “deviation from ‘health’ is
considered problematic” and therefore makes a student more visible in the community, and
where “standing out is seen as not healthy,” this can have great impact on perceived public
stigma as well as self-stigma (p. 190). Furthermore, one’s own negative views on mental health
COLLEGE OUTPATIENT EXPERIENCES 30
may also prevent help seeking, feelings toward self and identity, and willingness to actually
disclose the true level of stigma or mental illness (Eisenberg et al., 2009).
Ecological Frameworks
Bronfenbrenner’s (1979) ecological model of human development will be used for the
theoretical framework of this research. Ecology is generally associated with biology, referring to
how organisms react and contribute within their environment (Sallis, Owen, & Fisher, 2008). In
a social sense, the ecological model positions people in their environments, and in the realm of
mental health, how symptoms and outcomes are the result of many layers of different
contributing factors across many different levels within an ecosystem, from the micro to macro
scale (Sallis et al., 2008; Byrd & Mckinney, 2012).
The ecological model can be seen as a system with levels situated in an inverted
triangle, starting with society at the top (most macro level), then narrowing down to community,
institution, interpersonal, and finally individual at the most micro level (Centre for Addictions
Research of BC, 2011). These level are similar to Bronfenbrenner’s (1979) systems theory,
which looks at the influences of different levels of environment as they are a “nested
arrangement of concentric structures, each contained within the next” (p. 22): microsystems
(individual), mesosystems (interpersonal), and exosystems (institutional), and macrosystems
(cultural/ideologies) have on student development. The individual, interpersonal, and
institutional are of particular importance to mental health issues of college students, with each
level having a multitude of influences over mental health symptoms and behaviors (Sallis et al.,
2008).
Individual level factors include interactions with other people that are in smaller groups
and close to the individual within a setting of “particular physical and material characteristics”
COLLEGE OUTPATIENT EXPERIENCES 31
(Bronfenbrenner, 1979, p. 22). These factors include the academic adjustment students face in
college, including coping with increased rigor, demand on the person from the environment, and
need for self-efficacy in meeting new challenges (Byrd & Mckinney, 2012). Interpersonal level
refers to the physical settings and social environments, the interrelation between multiple
settings, and how well students assimilate into their role(s) and involvement on campus with
others (Bronfenbrenner, 1979; Byrd & Mckinney, 2012). Institutional levels are the exo- and
macro-level systems that include actual institutional setting policies, climate, quality of life, and
formal requirements of students, faculty, and staff in the educational setting (Bronfenbrenner,
1979; Byrd & Mckinney, 2012; Zubrick & Kovess-Masfety, 2005). While microsystems and
mesosystems involve the student as an active participant, the exosystem and macrosystem
typically do not involve this level of agency (Bronfenbrenner, 1979).
Within the microsystem are the roles of students. There is a reciprocal nature to roles
in the ecosystem, where a role is both the relationships and activities of the individual students,
as well as the other individuals in relation to the student (Bronfenbrenner, 1979). According to
Bronfenbrenner (1979), when a student goes into a new environment, such as college, there is a
“setting transition” that affects the students’ ability to understand roles and act with agency, as
well as use or form abilities to cope with the transition. To cope, the student has to have a
worldview that draws from previous settings that the student was an active participant in, as well
as the relationship of these previous settings to the current one (Bronfenbrenner, 1979).
Depending on the student’s level of engagement and action in previous situations, it will also
affect the capacity to utilize effective strategies to cope (Bronfenbrenner, 1979).
This course of coping and action is outlined in the Process-Person-Context-Time
(PPCT) model (Bronfenbrenner & Morris, 2006). Development relies on people engaging in
COLLEGE OUTPATIENT EXPERIENCES 32
activities within their environment, which includes dispositions in a setting, resources to
effectively function in the setting, and demand within the setting (Bronfenbrenner & Morris,
2006). Engaging in a setting has to take place in a continuous manner (microtime) with fairly
regular frequency and over an extended period of time (mesotime), going as far as throughout
one’s life span (macrotime) for students to develop and foster complexity in their activities,
where “participation in such interactive processes over time generates the ability, motivation,
knowledge, and skill to engage in such activities both with others and on your own” leading to
students to become “agents of their own development” (Bronfenbrenner & Morris, 2006, p. 797).
Bronfenbrenner and Morris (2006) referred to this process in one’s immediate environment as
“proximal processes,” which includes activities such as problem solving, making plans, and
gaining new knowledge and skills, such as those necessary to be successful in college.
Effectiveness of development is reliant on actual meaningful change, not just going through the
motions of activities and interactions. Additionally, there needs to be reciprocity in the process,
not just a unidirectional influence on either the student or the others in the setting. Lastly,
interactions do not just happen with people, they happen with objects and symbols within
settings. All of the PPCT model encompasses what affects and what students have an effect on in
the college environment.
When it comes to mental health, across all of these levels, influences on mental health
interact, compliment, and interfere with each other, and coping abilities are varied yet
interrelated in and between each level (Sallis et al., 2008; Byrd & Mckinney, 2012). Students
progress and grow in a dynamic manner as they occupy and restructure each environment in the
ecosystem (Bronfenbrenner, 1979). The specific impact each level’s setting has on mental health
is something that should not be ignored or taken out of consideration (Lahtinen, Joubert,
COLLEGE OUTPATIENT EXPERIENCES 33
Raeburn, & Jenkins, 2005). Individuals with mental illness are not isolated from the other
aspects of life that occur in levels outside of the individual, and there is a “multidirectional
complexity and dynamic interplay among factors operating within and across respective levels”
(Centre for Addictions Research of BC, 2011, p. 2; Bronfenbrenner, 1979).
The external environment cannot be ignored in mental health symptoms and severity, and
there is a need to recognize the outside influences on individuals to shift away from “victim
blaming” or putting sole responsibility on biological and individual factors of mental illness
(Sallis et al., 2008). The social and physical environment dictates interactions. Depending on the
environment, individuals will have different access to and experiences with support, skills, and
coping mechanisms, policy, physical structures, media/cultural images and messages, and
interpersonal interactions as they relate to mental health (Byrd & Mckinney, 2012; Cohen et al.,
2000; Fisher et al., 2005). If environments are not safe and “capable of meeting (at a minimum)
the basic needs of individuals” (Zubrick & Kovess-Masfety, 2005, p. 153), then students with
mental health issues may not be supported in having a smooth transition which would best
facilitate their success in college. And, since the levels in an ecosystem are interrelated, the
barriers and catalysts students face to managing their mental health will be encroaching them
from multiple levels at any given time.
Summary
In this chapter the existing literature related to college students and mental health has
been reviewed. Relevant points of focus included an overview of college student mental health
with attention to stress and emotional intelligence, the treatment programs available to students
including the history of programs and specific types of programs (RTCs, post-program care
options, and outpatient services), help seeking and support systems with attention to stigma
COLLEGE OUTPATIENT EXPERIENCES 34
influences, and finally an ecological theoretical framework. The following chapter will outline
the methods that will be used in this study.

COLLEGE OUTPATIENT EXPERIENCES 35
Chapter Three: Methods
This study was conducted as a qualitative case study of undergraduate college students’
experiences with mental health. The purpose of this research was to examine the experiences of
undergraduate college students, particularly in outpatient treatment programs or outpatient care
while attending college. There is a lack of existing literature on this population, especially using
qualitative research approaches (Kirsch et al., 2014; Kitzrow 2009). This study will give voice to
students who wish to share their experiences with mental health from their own daily lives.
Through this research, we can learn how students managing mental health in college make
meaning of their experiences and how they view their own “subjective mental worlds,” including
more context and room for the unknown than quantitative measures can provide (Rosenbaum &
Liebert, 2015, p. 183). For this research, a qualitative study was conducted using a social
constructionist lens. The use of a grounded theory through an ecological approach, examining
the way students are influenced by their environments in addition to how they feel, act toward
other people and things, and ultimately make meaning within their environments, enhances the
decoding of student narratives of their experiences as they navigate college and tend to their
mental health issues (Esterberg, 2002). Because of the vast model of ecological framework, only
what the participants and researcher deem the most salient elements of this model based on their
responses are used in the findings. This chapter includes a consideration of sampling, data
collection, and data analysis strategies most appropriate for the nature of this study and the
student population studied.
Sampling
The sampling technique for this study was non-proportional, purposeful selection. The
purpose for choosing this sampling technique was to ensure that the study involved the most
COLLEGE OUTPATIENT EXPERIENCES 36
appropriate participants from the student population of interest. This study sought to explore the
experiences with mental health for four individuals across the country within outpatient
treatment and outpatient treatment centers/programs.
Students were recruited in two ways. First, students were recruited on or nearby a four-
year private university on the West Coast using flyers posted in outpatient counseling centers off
campus, counseling centers on campus, and disability services centers on campus. Additional
students were recruited through personal contacts/connections at treatment centers on the West
Coast and within higher education. Second, students were recruited via snowball sampling.
Students described the study to their friends and gave contact information for the researcher
without necessarily disclosing that they were participating in the study as well. Although the
original population sample was intended to come from IOP or PHP programs exclusively,
securing participants exclusively from these types of programs became challenging. As other
professionals in higher education and former participants in such outpatient programs began to
learn about the study, further participants were recruited through snowball sampling. For
instance, a faculty member at a college who had previously worked with an eligible student, and
a former inpatient participant (who the researcher decided not to include for ethical reasons) was
able to reach out to two friends in outpatient care who were interested in this study and met
eligibility requirements for this study. All participants chose to be a part of this study voluntarily
and were willing to accept and share their experiences.
To ensure students were most appropriate for the study, an initial pre-interview screening
was conducted among prospective participants via email, phone, and/or text. Each student had
already received or seen one of the recruitment flyers before pre-screening occurred. This
screening asked the questions: 1. “Are you currently or have you been in outpatient treatment
COLLEGE OUTPATIENT EXPERIENCES 37
within the past year while enrolled in college courses?”, 2. “Are you between the ages of 18-
25?”, and 3. “Are you available to do an interview?” (within a given timeframe).
Students were initially identified for this study if they self-identified as having sought
any treatment for mental health, and if they were currently participating in and/or previously
attended an inpatient and/or outpatient treatment service or program within the past three months
from date of contact with the researcher, but this timeframe was later expanded to outpatient
treatment within the past year from the time of this study in order to include more eligible
participants (see Figure 1 in Chapter Four for participant descriptions).
Procedures
Data collection occurred over the course of one month during the spring academic term
of 2017. The researcher relied on her own training in counseling and disability services, as well
as consulted with a trained professional, a lead staff member from a behavioral crisis
interventional team on a college campus in Southern California, to review identifying
psychological red flags, safety for participants’ well-being, and other concerns that may have
risen to avoid harm to participants. Data was initially collected through in-depth, semi-structured
interviews conducted in-person or via Skype and Facetime. These interviews were facilitated
with an interview guide created by the researcher and implemented in an established protocol
(see Appendix B), and all interviews were audio-recorded with permission from participants for
later transcription. Interview questions were developed prior to interviews, with room to allow
participants to elaborate on certain prompts as needed or necessary and for clarifying questions
to be asked by the researcher. After each interview, student participants received general
information sheets with a list of supplemental resources local to their college and surrounding
COLLEGE OUTPATIENT EXPERIENCES 38
area (see Appendix D), as well as an incentive for their participation in the form of a $15 gift
card to Starbucks.
Interviews. Before interviews were conducted with students, the researcher had contact
information for local counseling resources available if something was triggered during the
interview process. Interview settings were chosen by the participants based on their location,
preference, and comfort in a particular environment of their choosing. Using a semi-structured
interview guide was an effective way to collect data and to understand the mental health
experiences of students in higher education in their own words and meaning. Due to the focus of
this study, the resource sheets provided for participants included appropriate care professionals
and departments on campus to stay connected to through treatment (i.e., counseling department,
lead contact, campus security, community support centers, disability services, etc.) to also
protect the participants from unintended harm (see Appendix D). Due to the sensitive nature of
some of the questions, only the researcher, trained in counseling, conducted interviews. Before
interviewing started, students were given consent forms that clearly described the nature of
interviews (see Appendix C). The researcher also took supplemental notes during interviews
with participants, and all interviews were audio recorded for later transcription.
Data Analysis
The raw data of students’ self-reported experiences with mental health while attending
college and outpatient care was collected and analyzed using a thematic coding system of the
interviews conducted. Data was hand coded, to ensure confidentiality. Themes and patterns that
arose were grouped using a codebook. Data was sorted and stored based on interrelating themes
and descriptions as outlined in the codebook. Any field notes, voice recordings, and observations
COLLEGE OUTPATIENT EXPERIENCES 39
made during the interview stage of the study were collected and stored within each students’
protected file (identified by a pseudonym), making sure to label the date and time of creation.
Validation of information occurred after all the information was collected, organized, and
prepared for analysis; validation methods included rich, thick description, triangulation, and
clarifying bias (Creswell, 2014). Interrelating themes and descriptions were assigned and
interpreted after all interviews were completed. Interpretation of data findings included the
meanings gathered from comparing prior information from existing literature reviews to the
current findings of this study, and noted any confirmations or contradictions of past literature. If
new questions were raised by the data during the analysis portion, they were reflected in any
agenda or call to action that the researcher included in the findings.
Trustworthiness of Data
Bias. Controlling for and being mindful of potential researcher bias was an important
aspect of this study. The researcher has experiences with inpatient, outpatient, and residential
programs, and was able to understand the nuanced complexities that would not be recognized by
an individual without this unique knowledge. Along those lines, the researcher was able to ask
informed follow-up questions during the interview. Finally, the researcher was able to develop a
more immediate understanding of study participants which may be a particular challenge for
students in this study. All of the above considerations to control for bias were kept in mind
during the data collection and analysis process for this study.
Limitations. Due to the small nature of the participant pool, it is not possible to
generalize results to all students experiencing mental health and outpatient treatment while
enrolled in college. Although students were recruited from the Northeast, Midwest, Southwest,
and West Coast of the United States, the nature of recruitment via one campus and
COLLEGE OUTPATIENT EXPERIENCES 40
personal/professional connections does not mean the findings will be generalizable to all college
students in outpatient programs in the United States.
Sample generalizability is a concern due to the focus on emotional stress and mental
health issues focused on one population, which may be challenging to apply findings from one
study to the whole population of college students with mental health issues (Gerdes &
Mallinckrodt, 1994). Similarly, a critique of ecological models in general is the “lack of
specificity about the most important hypothesized influences,” (Sallis, Owen, & Fisher, 2008, p.
480) which makes the possibility of an ecological fallacy, or trying to generalize data analysis
from one level to another level in the student’s ecosystem, more probable (Whiteford, Cullen, &
Baingana, 2005).
Additionally, given the varied range of treatment philosophies and styles of counseling,
the findings from one outpatient setting may not be transferrable to another type of program
(Christenson & Gutierrez, 2016). The study may benefit from replicating the current study
among a larger sample of students, and possibly broadening to a non-convenience sample.
Furthermore, the participant pool was fairly homogenous as far as race, class, and sexual
orientation, telling only a very narrow narrative of students who may be in outpatient care. Also
considering the narrow population, this study originally sought out to interview participants
currently enrolled in outpatient treatment as defined by intensive outpatient treatment programs
(IOP) or partial hospitalization programs (PHP), but eventually expanded the definition of
outpatient treatment to include consistent individual counseling and/or other therapeutic and
medical-psychological services (such as seeing a psychiatrist or case worker). This more
inclusive definition was essential for telling a more well-rounded narrative of student
experiences.
COLLEGE OUTPATIENT EXPERIENCES 41
Lastly, time was a limitation since this study is only a snapshot of a much larger, chronic
problem for students in higher education. Incorporating a longitudinal qualitative approach to
further investigate students with mental illness may give more insight of the college experience
for students, and expanding the participant pool to students who are not currently seeking care
but are experiencing mental health management while in college can provide more insight on this
issue.
Threats to Validity and Bias. Some threats to validity are lack of trustworthiness and
credibility. Students may have been reluctant to share their experiences of mental illness due to
stigma and not wanting to be labeled or discriminated against. Being that this qualitative research
focused its main findings on interviews that cover some difficult topics, this may have cause the
interviewees to be triggered and have difficulty answering the questions.
The interview process may have posed a bias response based on the interviewer's
presence where the student may have felt forced to answer based on what they thought the
interviewer wanted to hear (Creswell, 2014). Furthermore, misinterpretation of participant
responses during transcription of interviews may be a factor in threatening the validity of this
study. To combat this limitation, the researcher used clarifying questions during interviews and
followed up with participants if there was any further clarification needed during the analysis
process.
Minimizing Threats and Limitations. Ways to minimize threats and limitations
described in this paper are to overall be transparent in the study and when interacting with
participants. The researcher informed participants of their rights by giving them an informed
consent form, and letting the participants know that they could choose to leave the study at any
time during the process. The priority in this study was to ensure that the experience for the
COLLEGE OUTPATIENT EXPERIENCES 42
participants was as comfortable as possible by being present, attentive, and ensuring that
confidentiality was upheld between the participants and researcher. An additional layer of
checking errors is to initiate peer debriefing to enhance the accuracy of this study. The researcher
worked with the thesis committee to review the findings and ensure the study was
understandable by future readers, which also ensures validity (Creswell, 2014). If students
decided the process was too difficult and chose to quit the study, with the consent of the
participant, the researcher would choose to use the existing data that is still meaningful to the
study. If participants chose to withdraw entirely from the research, a meeting with the researcher
and participant would occur, with the option available to the participant to choose to withdraw
their data from use in this study. This process was explained to participants via the informed
consent form and screening practices. The researcher intended to ethically report this anticipated
situation and include such situations in the study, but did not encounter such situations at the
time of submission for defense.
COLLEGE OUTPATIENT EXPERIENCES 43
Chapter Four: Findings
In this chapter, the personal narratives of each of the four participants are shared to
explore the experiences they have had with mental health while in college and seeking outpatient
care. Common themes within these narratives are: shame, acknowledgement/ “it’s not real,”
relapse, and help seeking.
Introduction to Narratives
Each interview was transcribed to make sure each participant’s narrative would be told as
accurately as possible. These narratives may include information of gaps in time from school, or
instances of mental health issues prior to treatment and college because they were based on each
individual’s recollection of their own experience. Participant pseudonyms were personally
chosen by some participants, while others had no preference. Majors, programs, places of origin,
and schools of the participants are not clearly identified as noted in Institutional Review Board
(IRB) (see Figure 1 for narrative demographic information overview). After each narrative has
been presented, there is a summary of common themes found in the narratives as it relates to
college student experiences with mental health while in outpatient care.

COLLEGE OUTPATIENT EXPERIENCES 44
Figure 1. Narrative Demographic Information

NARRATIVES
MAY
AGE: 2 3
LOCATION: WEST COAST
RACE/ET HNICITY: WHITE
REL IGION: ATHIEST
GENDER: FEMALE
SEXUAL ORIENT ATION:
HETEROSEXUAL
SCHOOL EXPERIENCES: EAST
COAST, WEST COAST; FOUR-YEAR;
IN-PERSON
TREATMENT EXPEREINCES:
OUTPATIENT, IOP
TREATED FOR: DEPRESSION,
ANXIETY, EATING DISORDER, AND
CHEMICAL DEPENDENCY

ST EPH
AGE: 25
LOCATION: MIDWEST U.S.
RACE/ET HNICITY: WHITE
REL IGION: CHRISTIAN
GENDER: FEMALE
SEXUAL ORIENT ATION:
HETEROSEXUAL
SCHOOL EXPERIENCES:
MIDWEST; FOUR-YEAR AND TWO-
YEAR; IN-PERSON AND ONLINE
TREATMENT EXPEREINCES:
OUTPATIENT, PHP, IOP, INPATIENT,
HOSPITALIZATION
TREATED FOR: EATING
DISORDER, OBSESSIVE
COMPULSIVE DISORDER, ANXIETY,
AND DEPRESSION

JILL
AGE: 21
LOCATION: SOUTHWEST U.S.
RACE/ET HNICITY: WHITE
REL IGION: NON-DENOMINATIONAL
CHRISTIAN
GENDER: FEMALE
SEXUAL ORIENT ATION:
HETEROSEXUAL
SCHOOL EXPERIENCES: TWO-
YEAR; IN-PERSON AND ONLINE
TREATMENT EXPEREINCES:
OUTPATIENT, INPATIENT
TREATED FOR: DEPRESSION,
SELF-INJURY, ANGER
MANAGEMENT, DRINKING,
PROMISCUITY, AND SUICIDAL
THOUGHTS

BOPO
AGE: 19
LOCATION: WEST COAST BY WAY
OF NORTHEAST U.S.
RACE/ET HNICITY: ASIAN
AMERICAN, CHINESE
REL IGION: BUDDHIST
GENDER: MALE
SEXUAL ORIENT ATION: QUEER
SCHOOL EXPERIENCES: FOUR-
YEAR; IN-PERSON
TREATMENT EXPEREINCES:
INPATIENT, PHP, IOP, OUTPATIENT
(ON CAMPUS)
TREATED FOR: EATING
DISORDER, DEPRESSION, AND
ANXIETY

COLLEGE OUTPATIENT EXPERIENCES 45
May
May was a 23-year-old white female from a middle class background. She identified as
atheist and heterosexual. Having attended another university at the start of college, she was a
transfer student and current junior studying in the STEM field at a private four-year university on
the West Coast. During our interview, May was very lighthearted and jovial. She was actively
participating in an intensive outpatient treatment program (IOP) to address her mental health
concerns regarding depression, anxiety, eating disorder, and chemical dependency.
When asked what mental health meant to her, May stated, “I think it can be kind of your
current mental state in terms of like, whether you’re thinking healthily about yourself and the
world, but also I think it is about whether you have kind of imbalances in your [points to head].”
Growing up, May had heard negative stereotypes about mental health. Such examples she gave
were that people with depression are lazy or oversensitive, that it is not a “real problem,” and
that mental health issues were not “as big of a deal” as physical issues. When asked to reflect
back on how she felt toward these stereotypes as she first began experiencing problems with
mental health, she responded that she first began experiencing mild depression around age 14 or
15. Although her parents were supportive, she felt that it was difficult for her because her sister
had depression and weight issues, so she and her family “just kind of like invalidated my mental
health issues because hers were worse.”
May had previously sought out support for her mental health issues prior to coming to
college. She first began treatment by seeing a therapist in junior high school, and then different
psychiatrists and therapists during high school and college. She had taken time off from her
former university to enroll in an IOP for an eating disorder, and then transferred to her current
COLLEGE OUTPATIENT EXPERIENCES 46
campus. After one year, she took time off again to attend another IOP for chemical dependency
and had recently returned to campus and enrolled in another IOP that works with her campus.
While in college and prior to her current IOP, all individual counseling and the IOP
programs she had utilized were off-campus programs. When asked how she felt about using
these services, she stated:
Well, (sigh) um, at this point I am more used to like, dealing with the fact that I
have problems, you know? Like when I first went into like an IOP program for
the alcoholism it was like, really hard to deal with that kind of reality, so it’s
easier this time around um, but it is difficult because I was sober last semester so I
do feel like…it’s hard just because I kind of didn’t meet my own expectations in
sobriety.
Of the mental health services she had thought about using but had not yet tried, May
showed an interest in specific therapy groups for different mental health concerns, but that she
was unable to attend them due to a combination of the amount of work she perceived it would
take to research the groups and reach out to them, but also scheduling conflicts. She mentioned
that she did reach out to counseling services on campus at her current campus, but that “they
were basically like ‘you’re a long term case, so, can’t help you’… They didn’t even give me
details they were just like, ‘NOPE.’ I mean, but in a nice way, they were really nice about it.”
She followed up by saying that she had tried some of the on-campus chemical dependency
groups, although without much continued interest due to her own personal issues with the
Alcoholics Anonymous program structure, but that the IOP center she was currently using was
the first on-campus service she had truly utilized. She also identified that she felt like this
COLLEGE OUTPATIENT EXPERIENCES 47
program was such a good fit for her, that “I don’t see myself leaving until I graduate, if they’ll
have me.”
May experienced a variety of symptoms from her mental health issues, including
struggling with self-care, apathy, and addictive behaviors. When asked how she felt about
managing her mental health moving forward with this academic term, May identified a negative
behavior pattern that was starting to improve since being in treatment. She stated that:
I feel like every other time that my mental health issues reach a peak of
challenging, I, like, take a break. But right now I relapsed at the beginning of this
semester and my depression has been, has been pretty crippling just in terms of
like, normal everyday things. Like: get up, shower, eat, go to the grocery store,
laundry, do homework. None of that has been easy and um, so it’s made it really
hard.
Despite what challenges May felt she was managing daily, she did mention that she had a
very supportive department and professors on campus. When asked to then identify how she
manages mental health during breaks from school, such as spring break, she stated that she had a
very supportive family that she was going home to visit during break, and that their constant
presence would help her stay on track and be a “safe place.” She mentioned a plan to attend
group meetings in her hometown and get an appointment with a local psychiatrist.
In regards to help-seeking, May declared that she was admittedly struggling to seek out
help. When asked how she knows when she needs help with something, not necessarily mental
health, she responded that she hated asking for help. She continued,
The past couple months I feel like I’ve asked for more help than I have in like, the
past few years, you know? Like, um, and I think again it’s because I am in this
COLLEGE OUTPATIENT EXPERIENCES 48
situation where I’m in school but I’m really struggling with my mental health and
…generally, I can focus on one and then the other (laughs), and right now I’m
trying to focus on both and so it’s been like, extra difficult, um, and so I’ve been
reaching out a lot more than I normally would and I think it’s because…I feel like
I’m a pretty self-aware person so I can recognize when I’m getting to like, the
edge of a cliff and I like, need someone to hold me back from jumping, you
know?
May provided an example of how her mental health issues interfere with her ability to ask
for help, such as from a professor. She had recently received an unsatisfactory grade; she wanted
to visit office hours and she was having trouble bringing herself to talk to the professor. Because
she had not been attending class regularly due to her mental health, she stated that,
I projected that he was going to have like, negative words for me, you know, and
so I ended up asking a friend to walk me to his office um, and help calm me down
because I was like in tears, it was like, you know just normal things like that I
normally would never ask someone for [help] like you know? But um, so I’m
trying, I’m really trying to like, kind of recognize that.
By seeking help from a friend, May was able to successfully go to her professor’s office and
resolve the grade issue with a positive outcome.
When May described how she knew she needed help with mental health concerns, she
stated again that she generally did not like asking for help, clarifying, “I know I can’t do this on
my own but I don’t want to go ask for help. Or like I convince myself that I’ll eventually be able
to do it myself.” She continued to explain that she felt it was more difficult to ask for help with
COLLEGE OUTPATIENT EXPERIENCES 49
mental health concerns versus an academic one because, “you need to be like, intimate with this
person, you need to like, be close to them to ask for help, that’s kind of the big difference there.”
Although May identified that on occasion her parents were the ones to help her realize
when she needed help, she confidently stated that she is usually the one to recognize when she
needs help with something. She mentioned that she was good at hiding her problems until she
got to “the edge of the cliff,” and recognized that she would need to do something about it, which
was why she might be the person to recognize this need for help before others.
It is not that May had a negative attitude toward help seeking, though. In fact, she
mentioned that if the significant others in her life, such as family and friends, wanted to
seek help for mental health concerns that she would be very supportive and empathetic
because she understood how difficult it can be to seek help, and even felt that she would
be “honored” if her friends chose to tell her that they were seeking treatment.
When asked how she identified her current mental health status, she stated that in
addition to therapeutic treatment, she was taking prescribed medications for some of her
diagnoses, and that she was making steps to “push through” symptoms and feelings on a daily
basis. She mentioned that, although now sober, she felt like she was starting to have “kind of bad
habits with my eating and kind of leaning into eating disordered behaviors because I’m not
drinking, so that kind of sucks.” She did continue, though, to say that she accepted her mental
health status for what it was, and that she felt she was “old enough at this point to realize like,
I’m not without my problems and I can’t just pretend they’re not there.” Overall, May was happy
with the support of her department on campus and in her current treatment setting, and was
making progress in her recovery and mental health management.

COLLEGE OUTPATIENT EXPERIENCES 50
Steph
Steph was a 25-year-old self-described white female from the Midwest and a middle
class background. Having previously attended a college campus three hours north of her home,
as well as a local community college in person and online, at the time of the interview she was a
current sophomore taking online college courses through an out-of-state university. Steph
identified as Christian and was pursuing a communications degree with the goal of helping
others. Steph had a happy demeanor and was confident in all of her responses to interview
prompts. Steph was currently seeking outpatient treatment for eating disorder, obsessive
compulsive disorder, anxiety, and depression.
When asked about her own definition of mental health, Steph identified it as “the
emotional side of things. And just kind of what’s going on, on the inside.” She grew up hearing
negative stereotypes about mental health, and was under the impression that mental health was
not something that should be addressed. When she first started experiencing problems with
mental health, she stated that she “tried to kind of protect myself from them…I tried not to
address them.” Prior to college, Steph had never utilized services for mental health, declaring
that “in college is kind of when my downfall started,” and that she realized she needed to utilize
services at that point in time.
Before seeking counseling or inpatient care, Steph used to visit the nurse on campus or an
academic advisor to manage her mental health concerns. Because she did not talk to people about
her mental health experiences, she felt like it was hard to tell people when she was going to the
nurse for these concerns; she emphasized that although it was convenient to be able to be within
walking distance to see someone on campus for help, she still had qualms with the level of
confidentiality on campus, such as running into people she knew in waiting rooms or the student
COLLEGE OUTPATIENT EXPERIENCES 51
workers in the offices. On this campus, she did not utilize the counseling services, but recognized
in hindsight that being able to talk to someone then may have helped her at the time. She spoke
about the barriers preventing her from seeking help:
I just think my own fear probably was keeping me from using them…I know that
I had heard about [counseling services] but I didn’t really know exactly where it
was so I was just, I didn’t go seek it out either because I didn’t want to do it by
myself. Yeah…probably my own fear.
Steph then described what initially led to her seeking out help for her mental health:
Growing up my, like I didn’t ever really recognize mental health until I was
honestly diagnosed with it and kind of had to face it. Um, and I don’t know if that
was just how I grew up or if that’s like how a lot of kids are… I didn’t really
understand what was going on and no one really brought it up to me either so I
just kind of stayed kind of, suppressed, as much as I could and then it got bad and
I had to go away to treatment.
This treatment that Steph spoke of occurred during her freshman year of college. Steph’s parents
had seen a decline in her mental health and came to pick her up from campus one day to take her
to treatment:
I was either going to be court ordered or could decide myself to go to the hospital
that night, and I did. I decided myself because I didn’t want to be court-
ordered…I guess it was more-so their decision but, um, I went along with it. And
then I think for like the rest of my treatment time, like, I would get
recommendations from treatment teams. And I knew that I needed help, but I
didn’t ever really want to say that I needed help…I went when people told me to
COLLEGE OUTPATIENT EXPERIENCES 52
go, um, and I really didn’t want to go, also. I don’t know (laughs) it’s kind of like
back and forth…
The mixed feelings toward receiving treatment for mental health was a shared theme across all
four participants. In Steph’s case, she clarified that even if the decision to go to treatment was
not entirely her own, she did find agency in other ways:
I think the only decision that I probably made was actually like, staying there [in
treatment] and doing the work. Um, but I think getting there was probably, I
probably needed the help of other people.
After her initial hospitalization and taking an official leave from college, Steph
eventually went away to treatment in a free-of-cost private, Christian, out-of-state inpatient
facility, where she felt like she was finally able to start seeing a positive improvement in her
mental health concerns. When asked about her feelings toward the situation that brought her to
the inpatient center, she was happy that something good, meaning this journey through receiving
help, was able to come from what she had been experiencing.
While in inpatient treatment, Steph attempted to continue college classes. Steph described
the particular elements of her experience attempting to be in treatment and attend school at the
same time:
Well I actually tried to do college while I was in treatment… and that was pretty
difficult, because it’s hard to like, focus on that and also have to focus on myself
and get myself better. And it was also something that I wanted to, like I just
wanted to avoid getting myself better as well so I did school. Um, and that didn’t
really work out.
COLLEGE OUTPATIENT EXPERIENCES 53
Steph had tried to stay a college student via online education while in treatment multiple
times and within multiple treatment settings, including inpatient, partial hospitalization (PHP),
IOP, and outpatient. This balance of school and treatment was something that ultimately led
Steph to stop taking classes and just focus on her treatment in one of her last inpatient programs.
Once she graduated the program, she was able to seek out outpatient care by regularly seeing a
therapist at home, and suggested that it was more manageable to attend school this way because:
“I am definitely in a better place than I was before treatment, and so it’s easier to handle things
and to not have to like, I don’t know I’m just in a different mindset.” She continued to describe
the experience of attending college prior to and during inpatient and IOP treatment, but her
current, more flexible outpatient structure:
I did have to take a break but before, I didn’t want to take a break from school and
I um, forced myself to do it… it just didn’t really work out to be in IOP and also
to be in class on opposite days; it just became a lot and um, I couldn’t really focus
on one or the other and so I didn’t really do well in either. Um, and then, right
now I, when I came home from treatment this time I took a couple months off
before I went back to school to make sure that I was on my feet and could kind of
do that, and then I was able to add in school little by little and so that’s where I
am now.
Some of the symptoms of her mental health are easily identifiable as influences on the ability to
be a college student successfully by traditional norms. She listed some of the mental, emotional,
and physical symptoms she experienced that can interfere with her education, life, and progress
in treatment: “I get very irritable. Um, I just want to sleep, I isolate myself, I don’t, I just get
really like, agitated easily. Um, I don’t really concentrate very well…Just physical, like, things.
COLLEGE OUTPATIENT EXPERIENCES 54
Headaches, um, things like that.” These symptoms end up lasting for a couple of days at a time
every four to six months, to her best guess. She did clarify that this is progress, stating that
before finding treatment that worked for her, these symptoms used to present on a weekly basis.
As far as the most concerning parts of her mental health, Steph identified the suicidal
thoughts that come with depression, as well as the avoidant behaviors that come from anxiety.
Additionally, she expressed concern over the physical impact of her eating disorder on her
weight and health. Although she has these concerns, she mentioned that she does not think about
them often, because “it does take a toll on me to where I like, don’t really do things I guess I
deep down want to.” Overall, though, Steph identified that her mental health symptoms and
behaviors changed in a positive way during her treatment, and that “I feel like I have a lot of
control over [my mental health] honestly um, I need to actually make the decision to…take care
of myself.” This decision to take care of herself was a concept Steph was still learning to
navigate at the time of this study.
Bopo
Bopo (an acronym for “body positivity”) was a 19-year-old male originally from a
Northeastern state. He was a self-described queer, Asian American of Chinese decent, born to
Buddhist parents from a middle to lower class background. He came to the West Coast to attend
a private, four-year college, and was a current sophomore earning a degree in media. During my
interview with Bopo, he came across as very wise beyond his years, and passionate about
advocating for students. He had been in and out of different treatment over the past year for an
eating disorder, depression, and anxiety.
Because he recognized the many aspects that interplay with mental health, Bopo had a
challenging time defining what mental health meant to him. These definitions included, “the
COLLEGE OUTPATIENT EXPERIENCES 55
ability to take care of yourself in ways that like others can’t. Kind of like… how like the world
revolves around you” and that mental health “[is] like a way to get out of yourself, but also come
back home to yourself.” He identified that to have good mental health was “being mindful and
present and that’s like truly living I think. Because you can’t like, live for real if you don’t have
good mental health.”
Coming from a verbally and emotionally abusive household, Bopo grew up in an
environment where mental health issues were not spoken about. When it came to his own mental
health issues, he recalled, “I didn’t really notice it. Like I knew…I had mental health problems
like probably since I was a kid, like I never really…notice it or diagnose it.” He continued,
I kind of brushed it off because I was like, ‘oh maybe like, it’s like not real’, you
know? Because like, because people are saying it’s not real, so it’s probably not
real; like all made up in my head.
Once in college, Bopo went through a variety of treatment programs at a private center
for eating disorders. This included inpatient therapy, partial hospitalization (PHP), IOP, and
currently individual therapy and support groups, when possible (time and cost were extremely
limiting factors for him). He had first been admitted as inpatient for two weeks during his first
semester freshman year, and then after a relapse, returned again the following summer. At the
center, Bopo had access to a full treatment team, including a psychiatrist, psychologist, doctor,
nurse, nutritionist, and chef. Bopo stated that using the services at the treatment center made him
feel good, because he knew that he otherwise couldn’t afford mental health services, and
although the center waived some of the fees due to his financial situation and need for care, he
was still currently trying to pay some of the outstanding bills for his treatment there.
COLLEGE OUTPATIENT EXPERIENCES 56
Now seeing a counselor on campus, Bopo liked the convenience of having someone
located so close by, but found this experience limiting and missed having a full support team like
he had at the center. Additionally, Bopo felt like being on campus for treatment put him in an
environment that triggered him to be anxious, including the concern that what was being said in
session would potentially be relayed to others. Despite this, Bopo declared that he was trying to
keep himself accountable by reaching out to others and utilizing whatever resources he could on
campus, such as professors who could help him with nutrition advice. One of the other
drawbacks of only seeing a counselor on campus was that Bopo wouldn’t have access to care
during breaks, and stated that he didn’t know how he would manage his mental health during
these times.
Bopo expressed that his general experience on campus was lonely, at times. A very
popular student, he was having trouble connecting to others and finding close friends. He
recounted his life experience with mental health as it related to these feelings of isolation and
sadness:
Growing up I was, I was always very moody and I think that, that manifested a lot
in my…depression and my anxiety… My mental health suffered a lot because my
parents always told me like, I was worthless and like they did a lot of
‘gaslighting,’ …Like, ‘gaslighting’ is when..they like abuse you, but then they’re
like, ‘oh no we do it because we love you.’ …It happened a lot in my life, so
[after therapy] I realized that like, literally like all my friendships that I’m making
is like a manifestation of how my parents treated me. So like, they treated me like
shit so like, I’m gonna unconsciously seek out people who treat me like shit, and
it’ll reinforce that negative like, idea that like, I’m worthless. Or like, that
COLLEGE OUTPATIENT EXPERIENCES 57
negative core belief that like, I am not able to be loved and stuff, you know? And
it’s like, it’s a shitty cycle but like it happens sometimes still and like, I hate it, but
like, it’s something that I still have to work on… Like I’ve always felt my whole
life like I was worthless, or that everyone around me hates me, and like, which is
like not true. But like I can’t tell myself that on bad days, you know? I’m just like,
‘oh everyone doesn’t like me; I’m so alone.’
Bopo recalled his experiences with his family as an ongoing source of his anxiety, fear, and
depression. These mental health issues manifested in symptoms such as becoming agitated,
isolating himself, and lacking motivation, and they manifested in his eating disorder with
subsequent symptoms such as:
I have like a lot of tunnel vision. Inability to focus…These are a lot of the effects
[from] malnourishment, too. So like, I felt really cold all the time, I had like night
sweats, um, really, really, really low heart rate, and like dry skin, my hair was
falling out.
Although he took time off from school during his inpatient treatment, Bopo was now in school
and outpatient care managing these symptoms while trying to still be like a typical college
student, going to classes and participating in organizations on campus. He described the stigma
of his eating disorder, specifically how it is brushed off by others, and the toll it takes on him:
I think it’s really stigmatized. And that people think like... ‘oh you’re just shallow
and you just like, you want to like, look perfect,’ and all that. But like, people
don’t see it as like a sense of control. And that the fact like, what you’ve gone
through is like, it’s like something in your life that you can control because you
feel so out of control. And that’s when you have people like, like when my life is
COLLEGE OUTPATIENT EXPERIENCES 58
really out of control… I like sought to like bulimia because that was like, stuffing
all my feelings in and then like, purging it all out; which is the same as like
emotional purging. And then like, when I was a kid I struggled with like, binge
eating, and that was like, because my parents kept on yelling at me and like,
telling me I was worthless so I didn’t want to feel that way and that helped. Kind
of, food kind of soothed me. And then, um, anorexia came when like I wanted to
just like, be in, really controlling and, of my body because that was the only thing
I could control.
Bopo did include that one of the most concerning aspects of his mental health issues was the fact
that it could kill him. He was very cognizant that his behaviors of isolation and starvation cause
him to “just sit in my bad mental health,” and that he knows he has to pull himself out of these
states, otherwise he would be risking potential death.
Considering all that Bopo was managing, in IOP he made his health a priority over
school. He would schedule his classes around the times that he needed to be in treatment for
appointments or other obligations. When it came to challenges in school, Bopo had a different
approach than the other participants. He emphasized his use of plans and schedules to help keep
him accountable, but had a more laissez faire approach to school:
People are so caught up in like ‘GPA is forever,’ I’m like, ‘no…your health is
forever’ You know? So like, I’m not going to like, stress out, not sleep for like 24
hours, and drink like, ten cold-brews [coffee] and die, you know? Like, I’m gonna
just, like chill out and sleep…I just take a step back, you know? From like,
school…When it’s more like, personal [challenges] I think it’s harder, when it’s
like more school things it’s like, ‘whatever.’
COLLEGE OUTPATIENT EXPERIENCES 59
Overall, when Bopo was able to overcome these challenges, he felt “awesome, I feel like
I’m closer to myself and like, those around me.” He also identified that now his mental health
was in an in-between phase of stable and unstable, but that he did feel that he had more control
over his mental health now than in the past. He attributed the change he has seen to treatment,
and to “realizing like, what was the factors behind it… The problems were not me, it was like,
sometimes other people too.” Bopo was passionate about this revelation that other people can
affect an individual’s mental health, sometimes exasperating existing conditions or contributing
to their formation in the first place. His emphasis on nurture and environment was not unique
across all narratives.
Jill
Jill was a 21-year-old recent graduate from a two-year college. Jill had begun her college
experience as a high school student, doing dual-enrollment at a local college. She self-identified
as a while, non-denominational Christian female from a working class background. Born and
raised in a Southwestern state, she had studied English in school and worked multiple part-time
jobs during her education. Jill was lively during her interview, willing to go into great detail on
her experiences. Jill was currently in outpatient treatment for depression, self-injury, anger
management, drinking, promiscuity, and suicidal thoughts.
Jill identified mental health to mean “psychological well-being; how [people] process
through things, how they can handle life.” Growing up, Jill had very negative connotations with
mental health, stating that this concept brought to mind people with “mental issues” and that she
associated counseling with psychiatric hospitals. When she began experiencing mental health
issues of her own, she declared that the negative perception that she had of mental health
growing up did not change much, continuing to say “[this] is part of the reason why I had so
COLLEGE OUTPATIENT EXPERIENCES 60
many issues, because I thought so negatively of myself for having mental health problems.” As a
survivor of years of sexual abuse, Jill had mastered suppressing her feelings. After a related
interaction with Child Protective Services, Jill became scared to talk to anyone else about her
problems. She recalled,
I just kind of didn’t talk to anybody else about it or anything, so I was depressed
and going through a lot, and trying to figure everything out on my own so that led
to very, very, very poor life decisions.
Jill had taken a break from college and her senior year of high school to attend the same
free-of-cost, private, Christian, out-of-state inpatient facility as Steph. This was her first
experience with counseling; although she had been asking to go to counseling for years. Her
family had encouraged her to just talk to them about her issues instead of seeking counseling
when she asked for it, which she proclaimed made her not to talk to anyone about her issues at
all. What would normally be a six-month stay in the program ended up being almost a full year
for Jill. When she reflected on the length of her stay, she commented that it was “kind of
embarrassing” for her. During this time, Jill saw progress and did not attend school. Explaining:
I wasn’t working or going to school, I was just processing through things. I did
start that process and by the end of [my stay at the program]; I thought that I was
like, really strong and that I could like, handle life and came back into doing work
and school and still trying to process things, and that’s when shit hit the fan.
Jill described that after her intensive inpatient treatment and beginning to return to work
and school, she relapsed and began using drugs and alcohol, used to suppress her feelings. She
admitted the access to alcohol and drugs in college is what made it easy for her to get a hold of
these substances.
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Jill was seeing a counselor off-campus. On-campus, Jill did not utilize counseling
services unless it was to report incidents of sexual assault and harassment from classmates. She
liked the convenience of having a counselor close by on campus, but had worries about the
“repercussions” of seeing one. She preferred seeing an off-campus counselor to process through
her mental health issues, stating that on-campus counselors have bias and boundaries about what
they hear in sessions, such as, “what they can and should do in a situation. Or what I can and
should do in a situation,” citing their legal requirements as a driving force. Jill felt like the
counselors on-campus had a very large case load, the entire campus, so that she felt better seeing
a counselor outside of campus with a smaller case load. Overall, Jill liked that her off-campus
counseling sessions allowed her to talk about anyone and anything freely, without worry of what
may happen to someone she may mention in sessions.
During vacation and breaks from school, Jill was able to continue care with her counselor
via phone sessions. Breaks were hard for Jill, stating that even though it felt like a weight was
being lifted off of her each time she would have a break from classes, she knew she would be
dealing with the prospect of having to go back to classes and return to her busy work and school
schedule eventually.
Although Jill had decided to start processing through her mental health issues during
college, she stated that “I think I should have either taken a break from college or work and
processed through it instead of trying to do all three at once…Um, I think that really caused a lot
of stress and feelings of being overwhelmed which led to further depression instead of alieving
it.” After returning to school, Jill had a rough year; she was suffering from severe depression and
suicidal ideation, reaching the precipice of having a plan. She described what led to her first
episode in the spring of last year:
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I was working like, 25 hours [a week] and taking five classes, one of them being
an honors course for the study abroad that I was going to do that May, and I just
felt extremely overwhelmed…I was just exhausted as well because I was just
doing so much, um, and on my way to work one morning I just decided that I was
going to crash my car [to kill myself].
Jill was able to reach out to her counselor before following through with her plan,
I pulled off to the side of the road and we talked for about 45 minutes…she talked
me down from it, and then I went to work.
Jill continued to manage depression and suicidal ideation off and on throughout the year.
Jill described an episode during Thanksgiving break of her last semester in school, where she had
reached another major breaking point and felt she was unable to balance her mental health, work,
and school obligations any longer. During this time, she recalled that she had been suicidal for a
matter of hours in previous episodes, but that this time it was for weeks on end. She continued to
describe the situation:
I decided to take five more classes last fall so that I could graduate in December
instead of having to take another semester, while working part time. And instead
of just working part time with [her place of business], I decided to also work part
time as a professor’s aide…I was just really trying to distract myself, like
basically every moment of my life was taken up with something, so I didn’t go
with any of the sadness of being broken up with or um, not having things to look
forward to. And in November during the Thanksgiving break, um, I didn’t have
any homework or any work to do, because both of my jobs were related to
school….I had already done all of my homework and so, I literally just had a
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complete mental breakdown and that’s whenever I got suicidal for those three
solid weeks…. [I] basically had to be babysat by a family member at all times and
so that was really embarrassing, but it was necessary and it’s probably the reason
why I’m still here. So, um, yeah I’ve had suicidal thoughts off and on since then,
but I haven’t had the plan or intent to carry them out.
At that time of her suicide watch, Jill asserted that she had a lack of motivation to live
and hatred toward herself, stating that she felt like a failure, but then acknowledging that this
wasn’t objectively true. She spoke about how she was able to graduate, had a 3.9 GPA, got a
promotion at work, and had professors willing to write her references, reflecting to say “so
obviously I was not failing at life,” but also that, “I was just so caught up in myself and my
issues that I wasn’t able to see anything good that I was doing.”
During this time on homebound suicide watch, Jill’s professors worked with her to make
sure she could still finish the semester. They would email her assignments and allow her to miss
classes, only coming in to present speeches or projects as required for the course. She described
their support as flexible to her needs. Jill recalled one final anecdote from earlier in the semester,
though one of her professors had not been as flexible or understanding about her behavior prior
to the homebound suicide watch:
One of my professors was really hard on me. Like, the entire semester like, she
literally locked me out of the classroom because I was like two or three minutes
late or something. And it was like, I had had a counseling session, an on-the-
phone counseling session [the night before]. And I balled my eyes out, and then I
finally went to sleep and I woke up like, 30 minutes late, and I like, basically did
not even change out of my pajamas and like, ran out the door. And I’m locked out
COLLEGE OUTPATIENT EXPERIENCES 64
[of the classroom]. And I took notes for 45 minutes outside her classroom before
one of my other classmates like, got up to use the restroom and I went in [the
class] and like sat down and like continued taking notes inside of the classroom.
But like, the look she gave me…it made me feel like I was a really shitty person,
and I was only a few minutes late. Literally two minutes late.
She continued,
If I hadn’t gone through [the homebound suicide watch], I think that she would
have continued being hard on me because I don’t tell everyone, ‘hey you know, I
was sexually abused for eight years and I’m still trying to process through and
work through everything because I was like, a raging alcoholic for a while, and I
don’t really want to cut anymore. So crying and doing all sorts of overwhelming
things is my life right now, so I’m sorry that my homework doesn’t have the date
on it, or um, I forgot to staple it or I showed up to class two minutes late.’
Jill’s experience with her professors honed in on the invisible nature of the mental health
management that each participant had experienced. Without revealing their status to others, they
were able to feel safer, but also left themselves vulnerable to professors, peers, or other staff
treating them in ways that were less compassionate or understanding of the full circumstances
surrounding these slips in performing the role of a college student.
Common Themes
The main research question for this study was “what are the experiences of mental health
for college students in outpatient treatment, and how are they managing their mental health while
in college?” Each narrative is a unique reflection of the experiences with mental health that
college students in outpatient care go through. Although no two participants were alike, there
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were some common themes shared across their experiences. The themes of shame,
acknowledgement, relapse, and help seeking (see Figure 2) will be explored briefly in the next
section, as they relate to college student experiences with mental health while in outpatient
treatment.
Figure 2. Common Themes

Shame
Shame was an explicit phrase that was used by each of the participants in relation to
mental health. May mentioned shame as one of the symptoms of her mental health as well as
shame toward her feelings about telling others about her mental health, especially those who do
not previously know that part of her life. Jill also acknowledged her shame and embarrassment
toward utilizing services for mental health, fearing that people may judge her because of her
COLLEGE OUTPATIENT EXPERIENCES 66
mental health problems. Both May and Jill used the tactic of saying they had a generic
appointment or had to see a general doctor as code for seeing one of their mental health care
providers around people who they had not disclosed their mental health status to at that point in
time. They both emphasized that by doing so, people wouldn’t question these appointments any
further and would allow May and Jill to feel more comfortable with their help-seeking.
In an exemplary scenario, Steph felt shameful not only about her other family members’
experiences with mental health, but also felt shame toward her first experience and some
subsequent experiences of her own mental health problems. She explained that she felt shameful
about herself around others who were not in treatment, elaborating to say she feels shame “when
I get around people who aren’t in, like aren’t getting help for anything and don’t need help for
anything. And I’m like, ‘well, maybe I’m like lacking somewhere’ type of thing.” She explained
an instance that happened over winter break, where she was under pressure from external and
internal sources:
When I was like super overwhelmed like around Christmas time, um when I was
needing to shop, and finish classes, and do exams, um, and I also was working,
and there were also a lot of like Christmas events going on that I wanted to
participate in and so there was just a lot going on…I ended up just kind of like,
getting super overwhelmed. Um, and I just got really irritable and just kind of,
um, I didn’t like necessarily like isolate myself this time, um, but I didn’t really
talk to many people. [I] avoided a lot of things. Uh, and, that went on for probably
like, a month...like, the whole month of December where I didn’t really like, talk
to many people and just kind of like, avoided a lot of stuff like that, so, [I felt]
definitely a lot of anxiety. Um, and just, I think that there was some also like,
COLLEGE OUTPATIENT EXPERIENCES 67
sadness that um, that, just that I, I couldn’t, I think, I think I wanted to please
people too and do everything that I could, and I didn’t feel like I was able to do
that so I think that I was really like, upset with myself because of that. Um, and,
yeah. I don’t know. I think a lot of like, guilt and shame because of that too.
After Steph shared her recent experience with her mental health symptoms and the shame she
felt, she elaborated further by describing the emotions and feelings that she associated with that
particular situation when she reflected on it currently:
I do still feel a little like, shameful about it. Uh, just because I feel like there’s all
this stuff I could have done or things that I could have like, said to people, or um,
time that I could have made to kind of like, take care of myself. But uh, I guess
also like I’ve learned that I need to kind of make a schedule during that time
especially when things are kind of chaotic. Yeah. And do something different next
time. So.
These feelings of shame can be caused by the widespread perceived stigma toward mental health
issues in society. The way that the participants experience and assign meaning to their mental
health issues can be heavily influenced by this shame towards diagnoses, help seeking, and the
ability to be what is perceived as normal and functioning (Rosenbaum & Liebert, 2015).
“It’s Not Real”
One of the common themes in each narrative was the negative stereotypes around mental
health and the culture of keeping quiet about mental health issues. Each participant recalled a
personal experience with suppressing feelings or feeling like what they were experiencing were
not legitimate problems. For May, it was that the severity of her mental health issues did not
seem “enough” to be valid to herself and others. For Steph, she was taught that mental health
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issues should not be addressed, so she suppressed her feelings until she had to be hospitalized.
For Jill, when she wanted to first seek professional help, her family told her to only talk with
them about it, which made her suppress her mental health issues and feelings, and struggle to
express herself in a healthy way. In Jill’s case, she even went about her day as if nothing was
wrong after a near suicide attempt, with few people at her work or school knowing what had
almost just happened to her. Bopo was also taught not to acknowledge his mental health issues,
and to just “cheer up” instead of really process through his mental health concerns.
Just as Jill stated that her professor was hard on her until the professor knew what Jill was
going through, Bopo also shed light on the issue of ignoring negative mental health symptoms
and warning signs, recalling the recent suicide of a student on his college campus:
People don’t realize these things [mental health issues], but like a lot of people
just realized like after the fact like, ‘awe, they were such a good person…’ I was
like, ‘No!’ Like, ‘shut the fuck up,’ like literally…because you brushed off that
they were sad that day, maybe that was like the reason why they did that, you
know? So like…don’t ignore people… realize that like, your actions [in college]
will have an a consequence on people, like, even if they don’t have mental health
issues, because it could lead to like really great mental health issues if people feel
like they’re neglected or like, ignored.
Relapse
Relapse was also a common theme among participants. Although all participants were
currently in some form of outpatient treatment at the time of this study, it was not uncommon for
participants to take multiple leaves from school to seek treatment. May had taken multiple breaks
from attending school, recounting: “I went to [east coast college] two years, took a year off, went
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to IOP for eating disorder, transferred to [California school], did a year of [California school],
took a year off, did IOP for chemical dependency, and then came back last semester.” May had
recently relapsed only a couple of months before the time of our interview, and had sought out
her current IOP after this most recent relapse.
Steph had a similar experience; she had started college her freshman year but then had to
take time off, just before completing the semester, for treatment as well. In fact, Steph had
switched treatment programs/plan around a total of 21 times between seven different treatment
centers and outpatient care settings, and transitioned in and out of school at least four times
between three different colleges--all of this over the course of almost five years. Her incredible
resilience to adapt and readapt is a testament to her ability to navigate her complex roles as
student and patient over and again during periods of relapse and growth. At the time of
interview, she was finding success with exclusively taking online courses and going to outpatient
treatment, lessening her load compared to previous attempts at balancing both school and
treatment. Interestingly, both May and Steph were unable to clearly articulate what year in
school they were on based on these inconsistencies in attendance. Jill took time off after starting
college, although she had started taking college classes through concurrent enrollment in high
school. She had moved from intense inpatient treatment and into individual therapy outpatient
treatment feeling confident, but relapsed after arriving home and returning to work and school.
Bopo also went into treatment at the beginning of his college career, and then relapsed at the end
of his first academic year, returning to inpatient treatment at that time.
Recovery and treatment are a process for these participants, with certain adjustments
made to help ensure the success of their recovery. Three of the four participants explicitly stated
that balancing school and treatment was challenging, and made it hard to focus on one area or the
COLLEGE OUTPATIENT EXPERIENCES 70
other. All participants had varying levels of involvement with school during their different
treatment programs as well.
Help Seeking
Across the board, all participants stated that they did not like seeking help. Whether or
not they knew that they needed to seek help was not the question, in fact, all participants said that
they were able to recognize that they needed help to varying degrees. They had roommates, close
friends, some family members, and treatment teams to help them realize this too. As Bopo put it,
though, “you can only be helped as much as you want to be helped.” Previous research on
emotional intelligence (EI) has shown that if a support system or treatment program has not been
a part of their previous coping strategies, they may be reluctant to seek it out (Papalia, 2014). Jill
stated that she was still trying to break from the previous negative connotations she had about
counseling and mental health in general, as did May. May stated that she was self-aware, and
that she wished she could just get through treatment without having her family notified, but that
family therapy sessions were a requirement at some of her programs, making that individual
journey impossible. Steph mentioned that she knew overall that she needed help, but that she did
not like knowing that she had to seek it when others did not. She only eventually sought help
when she felt “so sick of being sick and I kind of saw hope in a different way,” crediting finding
God as a part of her own recovery journey. Lastly, Bopo stated that he felt he subconsciously
knew that he needed help with his eating disorder for years, associating his attending school
across the country as a cry for help to get away from the negative environment of his home life
and mental health issues developing there. But, by the time he was going to seek out treatment,
“I was crying because I knew like I had to go to treatment soon. And I was like, I was very
scared of being like, alone in it.”
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Although each participant may have been hesitant to seek treatment, all of them were
adamant about the significant others in their life seeking treatment for themselves, if they wanted
to. May had mentioned in her narrative being happy for those significant others, as did Jill; Steph
stated that she would be proud of the people in her life if they sought help, and thought it was a
good thing when people even had just a desire to get help. Bopo said that he would feel good if
the people close to him sought help, and just wanted them to try small steps at a time.
Additionally, almost all of the participants stated that they hoped some of their friends and loved
ones would go to some sort of counseling or treatment, because they can see them suffering
alone and without treatment. Each participant was able to see the severity of mental health issues
and the affect they can have on people, with three out of the four participants claiming the
outcome of death as one of the major concerns of their mental health issues. Each participant was
able to acknowledge that they were seeing positive progress overall in their recovery and
treatment due to different forms of inpatient and outpatient treatment over time. Furthermore,
most participants were able to identify some faculty and staff on campus, outside of counseling
or health services, who made their college experience easier by offering flexible hours,
additional assistance on assignments, and open doors for them to come talk.

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Chapter Five: Discussion
The purpose of this study was to qualitatively examine the mental health experiences of
undergraduate college students utilizing outpatient treatment while attending college. The goal
was to use student narratives to highlight the experiences of these students with mental health
and their management of mental health treatment, while giving them a voice to contribute to this
area of research. Additionally, by presenting this research as a case study, the goal of this study
was to also provide an introduction to this particular subset of the general college student
population and some of their shared experiences. The research questions “what are the
experiences of mental health for college students in outpatient treatment, and how are they
managing their mental health while in college?” began to be answered in this study. In this
analysis of findings, Bronfenbrenner’s (1979) ecological model will serve as theoretical
foundation. Although the Process-Person-Context-Time (PPCT) (Bronfenbrenner & Morris,
2006) was also an important influence to consider, only overarching elements of the ecological
model are used for analysis.
Ecological Model Analysis
An ecological approach was chosen as the theoretical foundation for this study due to the
affect that different layers within an ecosystem (individual, interpersonal, institutional, and
cultural/ideological) have on symptoms and outcomes of mental health in a supportive or
detrimental manner (Sallis et al., 2008; Byrd & Mckinney, 2012). The ecological model provides
a more holistic picture of how growth occurs for students as they navigate treatment and college.
By analyzing themes using Bronfenbrenner’s (1979) human ecology theory, the individual,
interpersonal, institutional, and cultural/ideological influences on this sample of college students
seeking outpatient treatment for their mental health can be further understood. Each of the
COLLEGE OUTPATIENT EXPERIENCES 73
common themes from the findings find their place within multiple levels of the ecosystem, and
they cannot be isolated from one another. Common themes will be discussed throughout each
level of the ecosystem as deemed appropriate for this analysis.
Individual
The individual level of the ecological model includes the interactions participants would
have with other people and small groups, for instance close friends or family members
(Bronfenbrenner, 1979). Findings of this study confirm previous literature regarding what
affected participants at the individual level, including adjusting to the academic and social life in
college, and the way that participants coped with or believed that they could cope with these
elements (Byrd & Mckinney, 2012). At the individual level, each student had made an initial
transition to college at some point in time, but this transition was often repeated or coupled with
transitions in and out of treatment programs and settings as well. Because the students were in a
process of relapse and change throughout their college experience, they were constantly
readjusting to their environments, and therefore being constantly activated at this individual
level. Coping mechanisms varied for the students, accompanied by the presence of appropriate
support systems or inadequate support systems of professional or informal nature.
The individual level also includes the core beliefs, feelings, interpretations, and
internalization of experiences that the participants faced. Not to exclude biological and genetic
factors, participants also expressed a lot of feelings toward themselves as individuals and their
mental health. Knowing that mental illness is not just a product of one’s environment, it should
be noted that there are chemical, biological, and internal thoughts that are a part of the scope of
mental health in addition to environmental factors, and that participants were aware of this.
COLLEGE OUTPATIENT EXPERIENCES 74
Considering that there are symptoms and manifestations of mental health that can exist
externally, some of the symptoms the participants in this study experienced were beyond their
control, such as the decline in executive functioning skills accompanying depression (i.e.
sleeping constantly and inability to do basic tasks) as well as physical symptoms (i.e. hair falling
out). For each student, help seeking was a major theme on the individual level. Whether help
seeking was voluntary, involuntary, or somewhere in-between, participants’ choice to seek help
was sometimes out of their control. Findings from this literature confirmed previous studies that
have pointed to the reasons that compel a student to seek or not to seek help, such as perceived
stigma on multiple levels, or previous experiences with help seeking that were either positive or
negative (e.g., Eisenberg et al., 2009). None of the participants had only enrolled in one type of
treatment program, whether outpatient or otherwise. In fact, the number of programs or services
utilized by each participant ranged from four to six, sometimes returning to previous programs or
centers anywhere from one to six times. Seeking help repeatedly was common, but not always an
easy decision for the participants.
Additionally, the help that was initially sought by each participant was more tertiary than
primary care, but that later on, some participants were able to recognize that they were in need of
help again before symptoms and behaviors progressed; this finding supports previous research
that points to utilizing outpatient care and counseling services as a primary care support system,
and not only for emergencies. The participants of this study were able to at some point in their
experiences, albeit not always consistently, identify and treat declining mental health status to set
themselves up for more successful management of their mental health and other life obligations,
such as college.

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Interpersonal
In the outpatient settings each participant was enrolled in during college, their treatment
life was not isolated from their school life, not their personal, work, or other lives that they fulfill
a role in. According to Bronfenbrenner (1979), each time a student enters a new environment,
they are constantly transitioning and trying to find their roles and sense of agency, as well as
ways to cope within their environment. These different life environments include both individual
interaction as well as interaction with other factors that occur in environments out of their
control. The different environments that students may find themselves in allows them to be
involved in different experiences and have access to different levels or types of support to help
them cope with mental health issues (Bronfenbrenner & Morris, 2006).
From weekly therapy appointments to IOP care, students were working to process
through their mental health issues and build coping skills to help them through college and life
otherwise (Byrd & Mckinney, 2012). These outpatient environments provided students with safe
spaces that allowed them to have adequate support to transition through their college journey.
Although it may not have happened immediately, if at any time one setting was not working for a
participant, they switched to another either more or less intensive option to continue care.
In general, the participants worked to prevent intersetting knowledge, or knowledge in or
about one setting shared to another, to be dispersed from treatment settings to campus settings
(Bronfenbrenner, 1979). All of the participants stated that they did not necessarily like sharing
their mental health status and treatment regimen with peers on campus. It can be deduced that
students practiced this barring of intersetting knowledge as a means to protect themselves from
possible negative consequences of sharing their mental health experiences, as such increasing
their abilities to assimilate into their role as college students (Byrd & Mckinney, 2012).
COLLEGE OUTPATIENT EXPERIENCES 76
Along these lines, the findings showed that all students had sought off-campus care, and
only one was currently utilizing a counselor on campus. Where others, such as May, tried to seek
out service on-campus, she was turned down due to the long-term nature of her needs. Although
all of the campuses the participants attended had counseling services and other mental health
support offerings to the general student population, these services do not always fit the needs of
students with mental health issues (Perron et al., 2011). As seen in the findings, this inadequate
fit could be because of severity of symptoms and diagnoses, but also because of student fears of
confidentiality breaches. The participant college campuses just may not have been able to offer
the type of full support that students need, which is why participants sought off campus help.
Institutional
Within the institutional setting of the ecological system, participants are not actively
participating in this level; it’s the overarching setting of the individual settings a participant
exists in (Bronfenbrenner, 1979). This includes the boards or committees in control of
counseling center policies and practices on campus or in treatment centers, and can reach as far
as state or federal legislature. At this level, it is more about decisions or events that affect the
setting that the participants exist in on a daily basis (Bronfenbrenner, 1979). Such affects can
also include impact on student quality of life, and the requirements in educational or therapeutic
settings that are placed on students, faculty, and staff (Byrd & Mckinney, 2012; Zubrick &
Kovess-Masfety, 2005).
With the participants of this study, sometimes the combination of being an individual in
treatment and being a student made their role execution subversive to these requirements in
either setting. As seen in the narratives, if students are late to class or unable to perform to
standards because they are managing mental health symptoms that interfere with their
COLLEGE OUTPATIENT EXPERIENCES 77
performance, they are not meeting the role of students. If the individual is missing treatment
appointments or group therapy sessions because they are taking classes at that time or trying to
prepare for an exam, they may be seen as not fulfilling the role of patient in treatment. For the
participants of this study, these two worlds of college student and individual in treatment do not
exist exclusively and the intersection of roles caused conflict in either education or treatment at
one point or another in time.
Cultural/Ideologies
On the most macro level, both physical institutions and ideological concepts existed that
impacted participants and their experiences with mental health while in college.
Physical. Colleges exist for the same general purpose across the country, one of the most
important being to provide further education for students. Additionally, treatment centers and
programs also exist for the same general purpose in our society, mainly to support patients as
they seek help for their mental health issues. Although each institution that the participants of
this study attended may have varied in specific mission and practices, they are all cut from the
same familiar blueprint, allowing them to be “an analogous difference in form…with consistent
patterns of differentiation” (Bronfenbrenner, 1979). Student narratives shared some similarities
in their experiences in programs and in college because of this familiarity.
Ideological. The two strongest examples of the ideological climate of the most macro
level of the ecological model were stigma and acknowledgement of mental health concerns.
Below they are discussed as they relate to the findings.
Stigma. As a society, we have an overarching negative shared beliefs about mental health
and mental illness, and negative attitudes toward acknowledging these problems in society
(Eisenberg et al., 2009; Rosenbaum & Leibert, 2015). This mass groupthink is a major
COLLEGE OUTPATIENT EXPERIENCES 78
contributing factor to the stigma and shame that is surrounding mental health and seeking
treatment. Additionally, these negative beliefs also lead to the greater issue that mental health
issues are not real or should not be acknowledge. The findings show that all of the participants
identified times in their life where they themselves, as well as the others around them, did not
acknowledge their mental health problems as being valid, worthy of attention, or of concern for
professional help. The participants of this study also identified that the stigma and shame they
felt were not just attached to the diagnoses they had received, but also the help they received and
the symptoms that accompany diagnoses, whether physical, emotional, and/or behavioral.
Studies have shown that stigma is an important factor in seeking treatment and understanding
students with mental health issues (Eisenberg et al., 2009; Rosenbaum & Leibert, 2015).
Acknowledgement. Framing what it is to be mentally healthy, Rosenbaum and Leibert
(2015) articulated that there must be a fluid and uninterrupted occurrence of thoughts, processes,
and events that a person experiences, all without error. Naturally, as life unfolds, this is a high
expectation that not even those without mental illness would be able to achieve. Considering this
definition, and the tendency and apparent ease of applying a deficit lens to mental health in our
society, it is clear that there needs to be a societal shift in our perception of mental health. The
findings confirm that it is not helping these students to ignore them and their mental health
symptoms; it is not helping them to ignore their diagnoses and experiences with mental health. It
is up to the student to share with whomever they choose information about themselves and their
experiences with mental health, but it is important to realize that this societal, ideological stigma
and taboo nature of mental health issues affected the participants on multiple levels across the
ecosystem. Each participant was able to identify that they were still conflicted over seeking help,
even when they were able to see and acknowledge the merits of it and their own personal growth
COLLEGE OUTPATIENT EXPERIENCES 79
because of treatment interventions. These broader, cultural ideas about mental health are being
internalized by individuals, becoming a part of their identity formation and potentially delaying
or completely avoiding seeking treatment, which can further contribute to their mental health
issues and negatively affect their quality of life (Blanco et al., 2008; Brackney & Karabenick,
1995; Gruttadaro & Crudo, 2012; NAMI, n. d. a.).
Future Research
Suggestions for future research include a focus on a different population composition.
Three out of four of the participants identified as Caucasian females, and two of the four
identified as middle class SES. Only one participant was of a non-white decent and non-
heterosexual. Having a larger sample size and a less homogenous group of participants can
potentially garner data that is more generalizable to the greater population of college students in
outpatient care. Additionally, focusing on a larger population may also allow more data to be
collected on gender differences, race differences, class differences, etc. Also for consideration,
this study was open to all college students within the age frame of 18-25, but only undergraduate
students responded. It would be of interest to specifically study graduate students, considering
the increased pressure and rigor of graduate studies.
Additionally, the definition of outpatient treatment was broad for the purposes of this
study, including intensive, structured programs as well as individual counseling. Future studies
could focus specifically on one particular outpatient treatment type to learn more about student
experiences within that type of treatment structure, or to compare types against each other for
evaluation and usefulness for college students.
While analyzing the data, the researcher realized that she did not ask students about their
familiarity with or use of disability services on campus, nor did students mention this resource in
COLLEGE OUTPATIENT EXPERIENCES 80
interviews. Incorporating this resource and utilization of disability services and accommodations
on campus by students with mental health issues can be further explored in future research.
Furthermore, this study was solely focused on using qualitative methods to collect data, a
contrast to the vast majority of quantitative research on similar student populations. By
incorporating mixed methods into a study with a similar population, it may be possible to gain
more information and insight than just one method or the other exclusively.
Lastly, this study was conducted as a single snapshot in time. By continuing this research
into a longitudinal study, there can be more insight as to outcomes and effectiveness of different
types of outpatient treatment, as well as degree progress, student success, or general quality of
life as students move through their college and treatment journey.
Recommendations from Participants
Each participant was asked to give any suggestions or recommendations to college
students wanting to seek help for mental health issues, as well as suggestions for the
professionals who may want to support them. Although not all the answers to these prompts had
common themes, the author felt it was important to share participant views on this topic.
To Practitioners. May suggested that practitioners need to be able to work around
college students’ schedules, and be more inclusive in the types of insurance they can take. She
also advocated for a combination of both group and individual therapy to be offered to students
in treatment programs and/or on campus. May was adamant that being able to be around other
students experiencing similar mental health concerns and symptoms to oneself helps students
most, because it gives students from a potentially isolated experience the ability to be around
“people who have the same problems and you know they’re not going to judge you, and
probably feel the same feelings as you.” Similar to May, Jill noted that flexibility was also
COLLEGE OUTPATIENT EXPERIENCES 81
needed for students, and that practitioners should have “a lot of grace” working with students.
She also like that she had the option to contact her own counselor via phone and text, and that
other practitioners should create a way for patients to know they have the freedom to contact
their practitioner. Steph simply wanted for practitioners to not force treatment on students, and to
just be more supportive in general, stating, “just…letting somebody who is in that state make as
many decisions as they’re mentally able to.” Lastly, Bopo said that practitioners can work to
make treatment not seem scary, and instead more encouraging. Reflecting on his own
experience, he stated “when I was like told, ‘oh you’re gonna be in a center and they’re just
going to like force-feed you,’ I was like, ‘okay, like now I don’t want to go.’” Having a more
open, accessible, encouraging, and supportive environment seemed to be the overall theme of
what participants wanted to see from practitioners.
To Students. Unanimously all participants agreed that students with mental health issues
who wanted to seek support should reach out. As May emphasized, “Tell someone, at least one
person, because you get stuck in your own head, you twist your thoughts, you over-exaggerate
them, and you live kind of in this world where everything is exaggerated and, um, that’s not
reality and you don’t know that until you tell someone. And then you say the words and you
realize, or they help you realize, that, um, that reality is better.” Jill also advocated for students to
reach out to a counselor, declaring, “it never hurts to see a counselor… what’s the harm in
trying? Because obviously what you’re doing isn’t working, so it’s time to implement some
changes.” Telling someone did not have to necessarily mean a counselor, as Steph stated, “talk to
other people if you don’t feel comfortable going to counselors or something, to talk to friends.”
Lastly, Bopo advocated for students to just take small steps like the previously stated ones,
because “they can go a long way.”
COLLEGE OUTPATIENT EXPERIENCES 82
Practice and Policy Implications
What this study has indicated is that some students seeking outpatient care during college
are seeing positive effects of their participation in treatment. For a variety of reasons, services
that students are utilizing are majority off campus. Two suggestions stem from this phenomenon.
First, colleges should take greater responsibility to have more comprehensive mental health
services and treatment options available for students via student healthcare plans or outside
healthcare plans (for example, increasing the number of appointments available to students,
offering a wide variety of group therapy options to students at many different times of day, free
or reduced cost programs, etc.).
Additionally, improving or including appropriate training to recognize the symptoms of
mental health crises and for healthcare providers as well as faculty and staff on campus to
understand the needs of this student population, including connecting students to resources on
and off campus, such as getting accommodations at disability services and programs on campus.
By promoting the wide array of accommodations that are available for learning, physical, and
psychological disabilities (i.e. extended time for assignments, different testing environments,
flexibility for off-site assignments, etc.) students managing treatment in college can have access
to another resource to make their experience more manageable.
Furthermore, taking breaks was a common occurrence for the participants in this study.
These interruptions may be voluntary or involuntary, and the students may have positive or
negative feelings toward breaks. By providing faculty and staff with more information and
training on how to approach breaks or leaves of absence from school, there can be a clearer
understanding of institutional accountability and how these leaves of absence are handled
structurally. This consideration and training needs to account for what interruptions mean for
COLLEGE OUTPATIENT EXPERIENCES 83
students, requirements, penalties, financial aid effects, etc. For some students, these breaks may
not be much of a break at all, as they may be managing treatment during the gap from school (as
seen with all participants) and therefore adjusting and readjusting to environments. Students may
feel negatively toward taking more time to complete their degree and may internalize the
breaking of social norms regarding traditional education timelines. There should be more
emphasis on understanding breaks and on normalizing the potentially longer graduation rates for
students with psychological disabilities or otherwise.
After data collection, the researcher found that there was a clear need for more
understanding of this population and all that they experience and manage on a daily basis as well
as long term. There needs to me more effort on the different institutions’ end to be more
accommodating and to actually promote such accommodations and support for students. There
also needs to be more solidified and dedicated funding for outpatient treatment programs on
campus that can be more in-depth with their support options and less limited to just a few
sessions with counseling services before referring a student to an outside service that may or may
not be affordable or practical for their needs. Ultimately, the researcher feels that college
students managing their mental health issues may not ever speak out about what they are going
through, and that as participants or professionals in higher education (faculty, staff, students,
etc.), there needs to be an understanding that this is a vulnerable student population that exists,
and that these students are out there seeking treatment, facing relapses, and just generally trying
to get their lives together all while attending school; these students also have various degrees of
success based on the support and coping skills that they have access to internally and externally.

COLLEGE OUTPATIENT EXPERIENCES 84
Concluding Thoughts
The purpose of this study was to explore the mental health experiences of college
students in outpatient treatment. The main findings were expressed through a combination of
individual narratives as well as core common themes of shame, acknowledgement, relapse, and
help seeking in regards to mental health. Overall findings from this study suggest that college
students who seek treatment for their mental health concerns may appear to lead successful lives
that may mask some of the deeper mental health issues they are battling while trying to balance
school, treatment, and other life obligations. This study provides readers with one glance at some
of the experiences these students face, with hopes to bring a call to action for more research and
support for this vulnerable student population.

COLLEGE OUTPATIENT EXPERIENCES 85
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Zubrick, S. R. & Kovess-Masfety, V. (2005). Indicators of mental health. In H. Herman, S.
Saxena, R. Moodie (Eds.), Promoting mental health: Concepts, emerging evidence,
practice (148-168). Geneva: World Health Organization. Retrieved from
http://www.who.int/mental_health/evidence/MH_Promotion_Book.pdf

COLLEGE OUTPATIENT EXPERIENCES 95
Appendix A
Recruitment Flyer
1

1
Template Design ©Ivy Sabado via Canva.com
COLLEGE OUTPATIENT EXPERIENCES 96
Appendix B
Interview Protocol
Interviewer: Interviewee:
Location: Date:

Instructions: MAKE SURE PARTICIPANT RECEIVES A COPY OF THE CONSENT FORM
AND CONTACT/RESOURCES SHEET, allow room for any clarifying questions the
participant may have, make sure participant signs the form before proceeding with
interview. Remind the participant that the interview will be recorded and that they can stop
the interview at any time.

Questions Notes
1. (Ice breaker) Thank you for being
part of this study, I value your time
and participation, so tell me a little
bit about yourself?
• Where are you from?
• What are your hobbies?
• What is your major?
• How did you choose it?

COLLEGE OUTPATIENT EXPERIENCES 97
• What year in college are
you?
• How old are you today?
• How do you self-identity in
regards to:
o Race?
o Ethnicity?
o Religion?
o Socioeconomic
status/class
o Gender?
o Sexual orientation?
2. (Interviewer answers with words
of affirmation then states the
purpose of the study)
Have you ever been part of a
research study? If so, briefly
describe what your experience was
like
Interviewer then asks participant if
they have any questions about this
study

COLLEGE OUTPATIENT EXPERIENCES 98
3. Given that I am exploring
experiences of college students with
mental health, what does “mental
health” mean to you?

4. What are some of the stereotypes
you have heard about mental health
while growing up?

4a. When you started experiencing
problems with mental health, how
did you feel toward these
stereotypes?

5. Have you have ever sought out
services prior to coming to college?
If yes, what services did you utilize?

COLLEGE OUTPATIENT EXPERIENCES 99

5a. If you have ever sought out
services during college, what
services did you or do you currently
utilize?

5b. On campus?

5c. Off campus?

6. How did it make you feel to use
these services? If there is a
difference between off campus and
on campus, please specify

7. What have you found to be the
pros and cons about on-campus
mental health services?

COLLEGE OUTPATIENT EXPERIENCES 100

7a. What have you found to be the
pros and cons about off-campus
mental health services?

8. What kind of connection do you
feel like you have to your campus?
If there is no connection, what is that
experience like for you?

9. If you have thought about using
services but have not yet tried them,
then which services have you
thought about using but have not
used yet?

10. If study participant has not used
services:
What has kept you from using these
services?

11. How do you feel about
managing your mental health

COLLEGE OUTPATIENT EXPERIENCES 101
moving forward in this academic
term?
12. How do you manage care during
school breaks/ vacations?

13. In general, how do you know
when you need help?

14. How do you know when you
need help with your mental health (if
different than previous question)?

15. Who, if anyone, helps you
realize you need help?

16. How do you deal with
challenges in school?

17. What does it feel like when you
are unable to achieve the outcome
you want when challenges come up?

18. What does it feel like when you
are able to achieve the outcome you
want when challenges come up?

COLLEGE OUTPATIENT EXPERIENCES 102
19. How do you identify your
current mental health status?

19a. How do you feel about your
current mental health status?

20. Please tell me a little bit about
your experiences with mental health
during your lifetime

20a. What have been your feelings
during these experiences? (As is
applies to the mental health
experiences described in question 6)

21. What has been your experience
with mental health while in college?

22. What are your feelings toward
COLLEGE OUTPATIENT EXPERIENCES 103
significant others such as friends,
family, and peers seeking out help
for mental health issues?
23. What mental health issues have
you sought help for?

24. What are your feelings toward
seeking out help for mental health
issues?

25. What are some of the symptoms
you have experienced when your
mental health issues are present?

25a. How often do these symptoms
occur?

25b. How long do the symptoms last
for each time?

26. Please think of a time when
these symptoms were present during
the past year. Please describe the
situation.

COLLEGE OUTPATIENT EXPERIENCES 104
26a. (After describing) What
emotions or feelings do you
remember feeling during the time of
the situation?

26b. What emotions or feelings do
you associate with this situation
when you think back on it now?

27. What do you consider some of
the most concerning aspects of your
mental health issues? (e.g., if it
interferes with life, worried it will
last forever, etc.)

28. Have you ever been hospitalized
or placed in treatment for your
mental health disorder, including the
care of a psychiatrist or
psychologist? If so, please describe
the experience(s), if the
experience(s) were
voluntary/involuntary/something in
between, and duration of

COLLEGE OUTPATIENT EXPERIENCES 105
treatment/care.
29. If treatment interventions stated
in the previous question happened
while you were in college, how did
you or do you currently incorporate
school obligations? (Including if you
did not incorporate them)

30. How much control do you feel
you have over your mental health?

31. How have your mental health
symptoms and/or behavior changed
during treatment?

31a. What led to this change?
32. What advice would you give to
college students who feel that they
are having mental health issues?

32a. What advice would you give to
mental health care providers who
wish to support college students in
need of outpatient care?

COLLEGE OUTPATIENT EXPERIENCES 106
33. If there were any questions that
you previously skipped and would
like to return to, please let me know
and we can review those questions
now.

34. This will conclude the interview
portion of our study. Thank you
again for your time and
participation. Is there anything else
you would like to tell me or any
questions you may have about the
study moving forward?

COLLEGE OUTPATIENT EXPERIENCES 107
Appendix C
Informed Consent Form

COLLEGE OUTPATIENT EXPERIENCES 108

COLLEGE OUTPATIENT EXPERIENCES 109

COLLEGE OUTPATIENT EXPERIENCES 110

COLLEGE OUTPATIENT EXPERIENCES 111
Appendix D
Student Resources Information Sheet Categories
• Student Health Center (On Campus)
• Counseling Services (On Campus)
• Medical Services (On Campus)
• Sexual Violence Prevention Services/Victim’s Rights Services (On Campus)
• Disability Services (On Campus)
• Campus Police (On Campus)
• Local Police/Sherriff (Off Campus)
• Diversity Center(s)/ Cultural Center(s) (On Campus)
• Religious Services (On Campus)
• Gym/Recreation Center (On Campus)
• Wellness Programs (On Campus)
• Student Life/Campus Activities (On Campus)
• Department of Mental Health (Off Campus)
• National Suicide Prevention Hotline (Off Campus)
• Free Recreational Activities (Off Campus)

Abstract (if available)

Abstract The rise in mental health issues for college students is something that cannot be ignored. In 2014, the number of adults in the U.S. with any mental illness (meeting DSM-IV criteria and occurring at least within the past year) was 43.6 million and of this population, traditionally college-aged adults (18-25 years old) account for 20.1% (Center for Behavioral Health Statistics and Quality, 2015). Although some quantitative literature exists on undergraduate college student mental health and treatments, there is a lack in literature on qualitative studies and studies of college students specifically in outpatient care. This research presents a qualitative study of college student experiences with mental health issues who are enrolled in outpatient treatment programs. By using an ecological model to investigate the effects that different settings and interactions in students’ lives have on their management of their own mental health, a deeper understanding of student experiences can be constructed for consideration by higher education professionals and counseling professionals who work with and treat this student population.

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Asset Metadata

Creator Hickey, Erin E. (author)

Core Title Mental health experiences of undergraduate college students in outpatient treatment

School Rossier School of Education

Degree Master of Education

Degree Program Education Counseling

Publication Date 04/24/2017

Defense Date 03/20/2017

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag college,ecological model,IOP,Mental Health,OAI-PMH Harvest,outpatient

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Venegas, Kristan M. (committee chair), Nack, Adina (committee member), Schafrik, Janice (committee member)

Creator Email eehickey@usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c40-366066

Unique identifier UC11255809

Identifier etd-HickeyErin-5270.pdf (filename),usctheses-c40-366066 (legacy record id)

Legacy Identifier etd-HickeyErin-5270.pdf

Dmrecord 366066

Document Type Thesis

Rights Hickey, Erin E.

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA