3

Environments to Support Wellbeing for All Students

Definitions of wellbeing vary, but for the purposes of this report, as described in previous chapters, wellbeing is a holistic concept referring to both physical and mental health. Balanced nutrition, exercise, sleep, and proper hygiene, coupled with access to medical care for temporary and chronic conditions, supports physical wellbeing.

Support for student wellbeing does not mean that students will not experience stress or difficult periods. It does not mean that colleges and universities are responsible for ensuring that students avoid all emotional discomfort and that on-campus treatment is available for all needs. What higher education can do, with its focus on academic development and through its actions and policies, is inform lifelong behaviors, both healthy and risky, that can develop during this time. While colleges and universities do not need to have health services that address all possible student needs, they do have an obligation to make students aware of the resources available to them, including academic support, health-related services, and wellbeing programs. In the event there are clinical health services available, students should have access to transparent information about the scope of services, cost and fees, and other community resources when a licensed provider is needed (See Chapter 4 for additional information on clinical services).

Institutions of higher education have increased their attention to student wellbeing over recent decades. This shift aligns with a movement in broader U.S. society beginning in the early 1990s, when the federal government began to increase efforts related to health and wellbeing in the workplace with Healthy People 2000.¹ While higher education’s role in supporting student wellbeing has incrementally

___________________

¹ See: https://spark.adobe.com/page/BmX0QbGmKRJ1d.

increased over the better part of the past century, documentation from the past decade includes the integration of wellbeing into higher education: Considering Wellbeing, and its Connection to Learning and Civic Engagement, as Central to the Mission of Higher Education (2013); the Okanagan Charter (Okanagan Charter: An international charter for health promoting universities and colleges, 2015); and The Council for the Advancement of Standards within Higher Education’s cross-functional framework for advancing health and wellbeing (Travia et al., 2019). These documents can serve as an overarching framework for wellbeing in higher education to span “health, wellbeing, flourishing, and thriving of college students in the context of a healthy community” (Travia et al., 2019).

This chapter covers broad, campus-wide efforts to support overall student wellbeing and success. It also profiles specific populations of students and provides insights into how higher education can support students across all of their identities. These descriptions also include information on populations of students more likely to have been exposed to trauma and harm perpetuated against them. Finally, as students often identify with multiple groups, the profiles make note of the ways that individuals with intersecting identities might benefit from additional support. Recognizing students’ full identities contributes to educational and training environments that support that wellbeing of all students.

SUPPORTING THE GENERAL STUDENT POPULATION THROUGH WELLBEING AND WELLBEING STRATEGIES

Many campuses offer wellbeing resources and programs open to all students. These wellbeing efforts, which are not intended to replace clinical services or grow needed clinical service capacity, do provide education and skill-building aimed at preventing and mitigating less severe instances of stress that can lead to more serious mental health issues. For some students who have not had access to education related to general health, exposure to information on nutrition, physical activity, sleep, and other factors that contribute to wellbeing may be the first step to developing and maintaining healthy habits.

Wellbeing programs on campus employ a variety of approaches, and the availability of services varies considerably depending on existing funding, staff, and type of institution. For example, the National Institute on Alcoholism and Alcohol Abuse (NIAAA)² offers a range of evidence-based strategies and interventions—sorted by level of efficacy and cost—that institutions of higher education can use to develop and deploy wellbeing activities that support efforts to reduce alcohol use among college students. The suggested approaches include skills training, brief motivational interventions, and personalized feedback interventions (NIAAA, 2019). At the campus level, colleges and universities can raise awareness about available services, launch campaigns to reduce stigma related to

___________________

² See: https://www.niaaa.nih.gov.

mental health and associated services, and ensure that policies, including those prohibiting bullying, harassment, and assault, promote mental health and wellbeing. Colleges and universities might also create opportunities for students to build community and peer support and develop healthy connections with faculty and staff. At the individual student level, workshops, seminars, and other events may provide them the opportunity to alleviate stress, develop mechanisms for processing challenges, and learn about other ways to adopt a healthy lifestyle, including exercise, meditation, nutrition, sleep, and other health-related behaviors.

Campus Programs and Activities

Pre-orientation materials, orientation events, and workshops held at the institutional, department, or program level are channels through which colleges and universities can transmit information about wellbeing services. However, for students enrolled at community colleges, graduate programs, and professional schools, the introduction to campus may not include the same volume of events as residential, undergraduate programs. Graduate and professional students may only receive information on their school or department without guidance to the campus as a whole.

As part of orientation, some campuses provide students with mental and emotional health screenings as a way to understand important signals related to overall health and gain a baseline understanding of their existing wellbeing. While these screenings are not diagnostic, may be prone to over-estimating prevalence rates (see Chapter 2), and cannot replace the evaluation of a licensed professional, early screenings can provide students with an understanding of what warning signs for distress look like in themselves as well as others. Screening sessions can also provide students with information about health and wellbeing services on campus and connect them to national resources (SAMHSA, 2018).

Beyond helping students build individual skills, colleges and universities may also support student wellbeing through community and group activities. Student-led groups can take many forms and focus on a range of interests, including academic, athletic, social, religious, and spiritual affiliation, community service, and professional interests, as well as groups based around student traits or identities. Building connections with peers can alleviate loneliness and provide students with a sense of belonging on campus. These groups can also help students with opportunities to reduce stress and to learn new skills, and they can serve as venues to continue activities and hobbies they may have enjoyed prior to enrolling in their program. While student-led groups may provide valuable assistance, and in some cases informal support, the administration may not be aware such services are being offered.

Campus Mental Health Services

In addition to orientation programs and student groups, colleges and universities often employ other strategies to support students and inform them about mental health services. Campaigns that reduce stigma around mental health issues and challenges can normalize help-seeking behavior and encourage students to access services that may suit their needs (e.g., a stress management workshop or in-person counseling). (See Box 3-1 that describes some current national efforts to address stigma against mental health and highlights some examples of efforts under way at individual institutions). Colleges may work with visible and well-known offices on campuses (e.g., student services, financial aid, residential life, and recreational facilities) to host workshops and provide resources on nonacademic skills that can support student mental health. In the event that a campus experiences a student death by suicide, there may be additional support

sought, prevention and awareness services provided, and questions around communication.

Most importantly, institutions offer mental health supports through counseling centers, which have been found to be effective in supporting emotional wellness for students. McAleavey et al. (2017) conducted randomized controlled trials (RCTs) to evaluate the effectiveness of psychotherapy in a large (N =9895) sample of clients in university counseling centers. The authors found that while there are areas for improvement, in general, “across several different problem areas, routine psychotherapy provided substantial benefit, particularly to clients in the most distress.” In its 2017 annual report, CCMH reported that students who came to counseling centers in 2012-2017 with “high levels of initial distress” reported that their distress level decreased from 2.65 to 1.8 on the CCAPS Distress Index after 10 sessions (CCMH, 2018).

Supporting Students Online

Today’s students have had greater exposure to online and virtual environments than previous generations. These “digital natives” not only have greater exposure to tools and programs, but also have experienced more of their life through social media and virtual outlets. As the pressure on mental health services on campus has increased, colleges have sought other technology-enabled methods for supporting students. These include mental health applications and virtual health and wellbeing tools (Kern et al., 2018), not to be confused with telehealth, which are one-on-one services offered directly by a mental health provider through virtual means. These mental health applications have become particularly popular during the COVID pandemic. For example, numerous online programs to support mental health have become popular in the higher education setting, including several that provide digital behavioral health care, specifically online programs to support treatment for depression, anxiety, stress, and resilience for college students.

While colleges and universities may seek virtual health and wellbeing tools (separate from telehealth and distance therapy services), the evidence base regarding their effectiveness remains limited. Estimates suggest that of the 325,000 available emerging digital health technologies, as many as 12,000 focus on mental health (ADAA, 2020).

Although many community colleges were more likely to provide a form of online education prior to COVID-19, there has been little done to understand how they use virtual tools to educate and support students. Additional research on support mechanisms, from general wellbeing to more specific mental health, for primarily virtual students would provide a great service to the community college community, as well as others turning to hybrid and virtual models during the pandemic (Chiauzzi et al., 2011).

There have been several studies of the efficacy of online interventions for reducing stress, depression, and anxiety in students. Farrer et al. (2013) conducted a systematic review of technological interventions targeting certain mental health and related problems in university settings. The authors noted that “technological interventions targeting certain mental health and related problems offer promise for students in university settings. The data suggest that technology-based CBT may be particularly useful in targeting anxiety and, to a lesser extent, depressive symptoms in interventions targeting both depression and anxiety.” Similarly, Davies, Morriss, and Glazebrook (2014) found that computer-delivered and web-based interventions designed to improve depression, anxiety, and psychological well-being of university students can be “effective in improving students’ depression, anxiety, and stress outcomes when compared to inactive controls.” However, the authors cautioned that these interventions need to be “trialed on more heterogeneous student samples and would benefit from user evaluation.”

In another related study of these interventions and applications, Conley et al. (2019) noted that additional research may be needed to assess the effectiveness,

including cost-effectiveness, of the types of interventions and their components; how they are delivered, including through which types of technological devices; and the target populations. Lattie, Lipson, and Eisenberg (2019) noted the need for further research to ascertain the effective elements of digital mental health tools, and Harrer et al. (2019) added that research is also needed to examine the “student subsets for which Internet-based interventions are most effective and to explore ways to increase treatment effectiveness.” Virtual platforms can also provide opportunities outside of the digital classroom for students who attend higher education in hybrid or online models to meet and interact with other students. In fact, virtual environments can provide a place of connection for all students to share stories and form a support network. For example, PhD Balance³ is an online community developed by graduate students to share narratives about mental and emotional health struggles and share resources. Other virtual spaces, notably for students who have not developed connections on campus, can provide other channels to develop relationships and find support based on their interests. #BlackandSTEM, for example, is an online community that uses Twitter to connect a community of Black professionals, students, and teachers across the country (Ireland et al., 2018; Montgomery, 2018).

The online environment has been shown to impact students’ emotional health. Research indicates, for example, that adolescents receiving positive reactions to their social media presence have higher self-esteem and are more satisfied with life (Ahn, 2011). On the other hand, social media that is perceived to be negative, including social rejection and cyberbullying, can negatively affect an individual’s emotional state (Chou and Edge, 2011; NASEM, 2020). Social media may also bias and skew perceptions of normative behavior ranging from body image, substance use, socializing and partying, and other behaviors than can enhance feelings of loneliness, decrease a feeling of belonging or welcome, and limit connection to others (Huang et al., 2014; Zhu, 2017).

Another concern is that students may feel unsure about how to connect with other students who share posts that include distressing information or suggest that the account holder may be experiencing difficulties. The Jed Foundation and the Clinton Foundation created a guide for students with information about identifying warning signs, guidance on how to respond, and national resources for reference (Jed Foundation and Clinton Foundation, 2014).

Online dating apps also have the potential to threaten both psychological and physical health. Individuals who use these apps can avoid vulnerable situations by developing safety protocols that include meeting with individuals in public settings, letting a friend or trusted individual know about the event, and limiting the amount of personal information and/or images shared in advance (Breitschuh and Göretz, 2019; Wong et al., 2020).

Finally, many students do not have a full understanding of the terms of service, data sharing policies, and privacy guidelines to which they agree when they use

___________________

³ Additional information is available at https://www.phdbalance.com (accessed August 17, 2020).

apps and social media. Providing guidance about the impact of social media on emotional health, an understanding of how algorithms operate to promote content, and privacy concerns regarding user data can help students foster safe and productive relationships with the online environment (Brandtzaeg, Pultier, and Moen, 2018; Obar and Oeldorf-Hirsch, 2020; Sarikakis and Winter, 2017).

PROVIDING SUPPORT FOR SPECIFIC STUDENT POPULATIONS

Many institutions of higher education have offices, groups, and/or staff on campus dedicated to working with specific groups of students. While these populations are described in isolation, students can and often do hold multiple overlapping identities, such as a first-generation student who is Black, Indigenous or a Person of Color (BIPOC) and a veteran. While this chapter primarily focuses on population-level programs and wellbeing services, the sections on specific populations below do include some information on ways these groups may exhibit certain characteristics related to mental health and wellbeing, reported rates of mental health issues, differences in access or rates of mental health utilization, and other clinical services covered in greater detail in Chapter 4.

Black, Indigenous, and Students of Color

As noted in Chapter 2, the proportion of students who are Black, African American, Hispanic, Asian, Pacific Islanders, Native American/Alaska Native, and multiple-race non-Hispanic is projected to increase in the coming years. BIPOC students often have intersecting identities, including first-generation status, having a disability, having insecure documentation status, or being a survivor of trauma. BIPOC students are also more likely to be part-time students, work while a student, live with dependents, and come from families with lower annual incomes (Espinosa et al., 2019).

BIPOC students, compared to the student body as a whole, are more likely to have experienced conditions that impact their health, education, and development, such as experiences resulting from systemic racism and oppression (Ingram and Wallace, 2018), limited access to health care and health insurance (including mental health); food insecurity; domestic violence; housing insecurity and eviction; bankruptcy; interruption of education due to relocation; and exposure to environmental health hazards (Jury et al., 2017; Metcalfe and Neubrander, 2016; Sohn, 2017). These additional factors, when present, should not be misinterpreted as implying that BIPOC students do not have potential and responsibilities in terms of academic achievement, leadership capabilities, or contributions to campus. Rather, institutions of higher education, and especially those that are predominantly white institutions, need to recognize that the pervasive effects of systemic racism and sexism, including inequality in K-12 education, can coalesce with college policies and practices in ways that compromise postsecondary

academic resilience (Jack, 2019). As students from these groups continue to enter higher education at higher rates, colleges and universities hoping to support students from admission to graduation may consider investing in programs and services that provide support specific to these students.

One such program, The Husky Promise, was designed to support low-income students in Washington state, as defined by the requirements for Pell Grants or the Washington State Need Grant (Cauce, 2019). Through this program, students could attend any of three University of Washington campuses without paying tuition. Students also received financial aid to help with the cost of attendance as well, such as rent, food, etc. Cauce (2019) notes that original projections were that about 5,000 students a year would attend the University of Washington through the Husky Promise. “Ten years later, almost 40,000 students have availed themselves of the program, which covers students for up to 5 years, and today we have about 10,000 Husky Promise students across our three campuses.”

Similarly, University of North Carolina (UNC), through its Carolina Covenant program, offers students whose family has an adjusted gross income (AGI) that is at or below 200 percent of the poverty guideline financial aid to attend and graduate from UNC-Chapel Hill (UNC, 2020). The program is designed to “communicate a clear, simple message of predictability of financial aid for low-income students, and promises that low-income students can graduate debt-free.” The Covenant program, which has been found to contribute to the academic success of these students, incorporates a campus-wide support network and commitment to student success. A mentoring program is also a central component of the support network (Ort, 2020).

Understanding and recognizing the biases that students from these groups may face is only the first step in establishing programs aimed at fostering wellbeing in these student communities. Faculty and staff recognition of how students who are BIPOC respond to stress and react in ways distinct from the majority-white student body can reduce microaggressions and actions that create hostile environments (Ryu and Thompson, 2018). Institutions of higher education can offer staff, faculty, and all others who interact with students training and focus on developing skills, knowledge, and attitudes to understand ways to identify racist behavior, correct biased policies, and provide all students with support (Ryu and Thompson, 2018).

In addition to providing culturally competent programs and services to students, colleges and universities may consider how they communicate, raise awareness, and reduce stigma around mental health specifically for students who are BIPOC. Research has shown that the presentation of symptoms can differ based on racial and ethnic backgrounds, as can engaging in help-seeking behaviors that differ from those of cisgender, heteronormative white men (Ryu and Thompson, 2018). This can make it difficult for those trained to recognize mental health symptoms based on cisgender, heteronormative white men in students who are BIPOC and make it less likely they will seek treatment (Ryu and Thompson, 2018).

Having health professionals on campus who recognize, support, and treat students from all backgrounds can help lower some of the barriers for students who are BIPOC. This may include staff at the general or primary health clinic who can recognize signs of mental health issues as well as processes that allow students to move between physical and mental health services. Research has demonstrated that biases in providers, notably along the lines of race and gender, can impact the efficacy of diagnoses and treatment plans for patients (Chapman et al., 2013; Green et al., 2007; IOM, 2003; Obermeyer et al., 2019). Actively and consistently addressing the systemic and institutional biases that exist in policies and in individuals can ameliorate the harm done to students from underrepresented groups and contribute to a more supportive environment.

This section, while it provides insight into the ways that students who are BIPOC could benefit from intentional support, does not provide an in-depth review of how these issues vary across different racial and ethnic groups. While on a statistical basis, students who are BIPOC may more often be first-generation students or less represented on campus, this is not always the case. Building programs and services that are equitable and inclusive means recognizing how higher education at times dictates a one-size-fits-all approach that colleges and universities can now work to undo and create campuses that support all students. Listening to individual students and how they characterize their experience will allow them to bring their full selves and thrive in their whole identity (CookSather, 2018; Cropps and Esters, 2018; García and Henderson, 2014; Lehmann, Davies, and Lauren, 2000; Rasheem et al., 2018; Reddick and Pritchett, 2015; Syed et al., 2011).

Students with Disabilities and Disabled Students⁴

In 2015-2016, 19 percent of undergraduate (3,755,000) and 12 percent of postgraduate (423,000) students reported having a disability (Snyder et al.,

___________________

⁴ The committee would like to acknowledge that the National Center for Disability and Journalism recognizes that different communities prefer the use of person-first (persons with disabilities) and identity-first (disabled persons) terminology. According to the NCDJ:

Background: The phrased “disabled people” is an example of identity-first language (in contrast to people-first language). It is the preferred terminology in Great Britain and by a growing number of U.S. disability activists. Syracuse University’s Disability Cultural Center says, “The basic reason behind members of (some disability) groups’ dislike for the application of people-first language to themselves is that they consider their disabilities to be inseparable parts of who they are.” For example, they prefer to be referred to as “autistic,” “blind,” or “disabled.” Several U.S. disabilities groups have always used identity-first terms, specifically the culturally deaf community and the autistic rights community.

NCDJ Recommendation: Ask the disabled person or disability organizational spokesperson about their preferred terminology. If that is not possible, use people-first language (NCDJ, 2018).

2019),⁵ an increase over the past 20 years from 5.3 percent (892,000) of undergraduates and 3.2 percent (89,000) graduate or first-professional students (NCES, 1999, Table 211). Within this group, there is a higher percentage of undergraduate students who are also veterans (26 percent) than those who have not served in the military (19 percent) and higher percentage of students aged 30 and over (23 percent) than those aged 15-23 (18 percent) (Snyder et al., 2019a).

For students, the disability designation can be for a physical, behavioral, or learning disability.⁶ The 1990 Americans with Disabilities Act (ADA) defines disability in the context of higher education as “a physical or mental impairment that substantially limits one or more major life activities, a person who has a history or record of such an impairment, or a person who is perceived by others as having such an impairment” (DOJ, 1990). ADA recognizes five categories of impairments that require mental health diagnoses: anxiety disorder, depression, bipolar disorder, schizophrenia, and other psychological disorders. In the context of higher education, a mental health disability is defined as “a persistent psychological or psychiatric disorder, emotional or mental illness that adversely affects educational performance.” To comply with ADA, campuses must provide accommodations commensurate with the range of disabilities that students experience. Disabilities may be long-term and chronic, but ADA also covers short-term disability for surgery, trauma, or other medical conditions (including pregnancy). Given that students with disabilities are not a monolith, faculty and staff supporting these students will want to approach mental health and identity issues with sensitivity (Iarovici, 2014).

The percentage of students diagnosed with mental health disabilities is increasing. These students can face challenges in receiving necessary accommodations because their disability is often less visible and poorly understood by the campus community, including by faculty, than physical disabilities (e.g., blindness, deafness) (Condra et al., 2015). According to a report by the National

___________________

⁵ From ED: Students with disabilities are those who reported that they had one or more of the following conditions: blindness or visual impairment that cannot be corrected by wearing glasses; hearing impairment (e.g., deaf or hard of hearing); orthopedic or mobility impairment; speech or language impairment; learning, mental, emotional, or psychiatric condition (e.g., serious learning disability, depression, ADD, or ADHD); or other health impairment or problem.

From the American Community Survey 2017: The American Community Survey (ACS) estimates the overall rate of people with disabilities in the US population in 2016 was 12.8 percent. The percentage of those with a disability in the US civilian population slowly increased from 11.9 percent in 2010 to 12.8 percent in 2016. See: https://disabilitycompendium.org/sites/default/files/user-uploads/2017_AnnualReport_2017_FINAL.pdf.

⁶ According to the Department of Education, students with disabilities are those who reported that they had one or more of the following conditions: blindness or visual impairment that cannot be corrected by wearing glasses; hearing impairment (e.g., deaf or hard of hearing); orthopedic or mobility impairment; speech or language impairment; learning, mental, emotional, or psychiatric condition (e.g., serious learning disability, depression, ADD, or ADHD); or other health impairment or problem See: https://ies.ed.gov/ncser/definition.asp.

Council on Disability (2017, p. 15), “College faculty, staff, and administrators need training to 1) identify and support students with mental health disabilities and 2) responsibly provide disability-related modifications and accommodations as required under federal disability laws.” A survey of 76 practitioner and 148 students, carried out by the National Alliance on Mental Illness (NAMI), identified a range of practices that “colleges can engage in to enhance the inclusion, retention, and graduation of students with mental health disabilities” (NCD, 2017a).” Among those named as promising practices by respondents were:

• Making efforts to reduce stigma associated with mental health disabilities, which may take the form of staff workshops and professional development, faculty outreach, the efforts of student groups and student-led programs (such as those provided by Active Minds and NAMI), campus-wide events or activities, and work with external groups, such as NAMI (see Box 3-1)
• Locating offices for mental health services thoughtfully in order to provide students with confidential access when necessary or desired
• Creating a campus culture that normalizes discussion of mental health as a component of the wellness for the entire campus through the actions and statements of campus leaders
• Hiring case managers to provide resources to students in distress
• Educating faculty in how to identify students in need and refer them to campus support services and resources
• Entering into partnerships with community resources in the larger health care system when on campus resources are limited

Table 3-1 from the 2017 National Council on Disability report shows the percentage of students and practitioners who named certain practices as best practices in mental health services.

Disabled students may also benefit from additional support and programs that intersect with other identities as a means of preventing potential problems with loneliness and isolation (Iarovici, 2014). According to one report, “students with disabilities were also more likely to be from an ethnic minority group than students without disabilities, to identify as biracial or multiracial, and to identify as gay or bisexual” (Iarovici, 2014). This suggests that peer group and community activities that support students in their identities across the lines of race, ethnicity, gender, and sexual gender minorities may benefit from deliberate efforts to reach students with those identities who are also disabled.

Feelings of social isolation and lack of connection experienced by students with disabilities align with other mental health risks, such as developing a substance use disorder. Indeed, research has found that students with disabilities were more likely to engage in risky substance use (Iarovici, 2014), with the

TABLE 3-1 Percentage of Practitioners and Students Who Named Certain Practices as Best Practices in Mental Health Services

Source: NCD, 2017a.

rate of substance misuse among students with a disability ranging from 14 to 65 percent across all disabilities (Casseus et al., 2020). Given the complexity and breadth of the types of disabilities experienced by students, there is a need to understand substance use disorders with greater nuance. Overall, the research on substance use in the population of students with disabilities remains limited, and additional research⁷ would help provide insight into rates of prevalence and appropriate mechanisms to support students with disabilities to completion of their degree program.

First-Generation Students

As enrollment in higher education has continued to rise, there has been growing attention to students who are the first in their family to attend college or whose parent or guardian did not attain a bachelor’s degree. For these students, the important factor regarding mental health is that they often lack the benefits of family members who can provide institutional knowledge on how to navigate the bureaucracy of higher education and its services. First-generation students can benefit from additional support related to the barriers related to finances, academics, and sense of belonging (PNPI, 2020a).

___________________

⁷Chapter 6 discusses open research questions that need to be answered.

Even though first-generation students come from all backgrounds, they are more likely to be BIPOC or have an identity that has been historically excluded from higher education. In 2012, 41 percent of Black and 61 percent of Latinx students identified as first-generation, in contrast to 25 percent of white and Asian-American students (PNPI, 2020a). First-generation students can differ from continuing-generation students, who have at least one parent with a postsecondary degree, in other distinct demographic and socioeconomic characteristics, too (see Table 3-2).

Developing specific communication strategies for first-generation students to raise awareness about the availability, cost, location, and purpose of programs and services available through campus wellbeing, general health, and mental health offerings can promote wellbeing and college completion (Wang and Joshi, 2018). Many first-generation students may benefit from programs and services embedded in places they are likely to visit in their daily interactions, such as academic buildings or community centers, or might visit for other health reasons, such as a general health clinic or women’s health clinics. Extended hours later in the evening or on the weekends and available day care might also help first-generation students with dependents and those who work full time (Wang and Joshi, 2018).

Mentoring programs may also be useful in supporting the social, emotional, and academic needs of first-generation students (Plaskett et al., 2018). As an example, Cornell University’s College of Agriculture and Life Sciences (CALS) peer mentoring program, for example, is designed for incoming first-generation students and was developed “to help students feel more closely connected to the campus environment and to help them bridge gaps in academic success and psychological well-being.” The program, which pairs upperclassmen with incoming students based on majors and general demographic information, was found to be successful in improving academic performance and supporting psychological wellbeing. The 60 first-year students who fully engaged with the mentoring programs earned grade point averages that averaged 0.61 higher than those who did not. As evaluators of

TABLE 3-2 Comparison of Characteristics between First-Generation and Continuing-Generation Students in 2015-2016

Source: PNPI, 2020a.

the program noted, “part of a student’s academic success is making sure they are having a good psychological experience on campus.…Providing academic guidance as well as social support helps students to navigate the often difficult, but important, journey of collegiate life” (Cornell University, 2020).

International Students and Students without Documentation

In 2017, 1,000,722 students were classified as non-resident aliens, accounting for 5.1 percent of total enrolled student population, 0.3 percent of the undergraduate population, and 14.2 percent at the postbaccalaureate level (NCES, 2017). While this group of students is often categorized with the blanket term “international students,” the label does not provide the nuance to all the nationalities and backgrounds present at U.S. colleges and universities. While this grouping does not disaggregate between the many different cultures present, there are some common trends for institutions of higher education to acknowledge in the support of international students.

The relocation and life change that international students experience may contribute to culture shock upon arrival on campus (Iarovici, 2014). While many colleges and universities have offices and or staff dedicated to supporting international students, assistance beyond logistical and administrative support can ease the transition for those students navigating a new country. Support groups that provide a sense of community and a welcoming environment to those from their country of origin can provide international students with opportunities to develop social connections and a sense of belonging on campus and learn the nuances of life on a U.S. campus. These groups may include other international students who can share stories about their experience and normalize challenges or they may provide international students the opportunity to build connections to students with U.S. citizenship.

There are important considerations for colleges and universities to attend to while providing support for international students. The concepts of wellbeing and mental health, for example, may differ considerably depending on the students’ country of origin, and international students utilize counseling services at lower rates and are less likely to return after an intake appointment (Alexander and Iarovici, 2018). Colleges may consider offering sessions on an as-needed basis or in groups settings that convene outside of the counseling center to create settings that feel more familiar and comfortable to students who feel less comfortable with the U.S. presentation of mental health and wellbeing services (Alexander and Iarovici, 2018). Providers and staff may also consider adapting counseling styles and programming to fit the expectations and the interests of international students (Iarovici, 2014).

In addition to international students, there is a population of undocumented students attending U.S. colleges and universities. Some 47 percent of undocumented students came to the United States before age 12, and 39 percent came

between the ages of 13 to 21 (Feldblum et al., 2020). In 2018, the American Community Survey estimated there were approximate 450,000 students without documentation enrolled in higher education, accounting for about 2 percent of all students (Feldblum et al., 2020). Of students without documentation, a subset of 216,000 students (1 percent of all students) are eligible for Deferred Action for Childhood Arrivals (DACA) status. Conducting research and collecting data on undocumented individuals is difficult given that they may not wish to participate in any activity that could reveal their citizenship status and jeopardize themselves or their family. In terms of supporting students without documentation, there are a number of barriers to consider. Students may avoid academic, financial, health, and other campus services in fear of exposing themselves or family’s undocumented status. Students without documentation may also have less familial financial stability, as their relatives may not have labor protections if they are also undocumented or live in another country. The students themselves also may not qualify or be willing to pursue the process to receive financial aid (including work study funding), scholarships, or employment. Students without documentation may also be first-generation students, who may be less likely to understand how tuition and fees may grant them access to free or low-cost health care options (Perez et al., 2009; Suárez-Orozco et al., 2015).

Beyond providing support that aligns with the needs of international students and students without documentation, there are also unique stressors that can affect their lives and mental health, as well as their ability to pursue their studies. Government regulations related to immigration, travel restrictions, and visas can create urgent situations for international and undocumented students. In the event of potential or pending policy changes, colleges and universities can rely on student services, immigration support staff, and centers for international students to provide updates and resources to students. These regulations may also impact their ability to pursue permanent and stable employment in the United States, creating uncertainty about their financial stability and general life prospects. Some federal policies may not have clear guidance directed at colleges and universities and may require additional deliberation to identify the impact on students. Counseling services, resources, and legal assistance can reassure students and mitigate the negative impact caused by rapidly changing policies and regulations that remain uncertain in terms of their duration and continuation.

Student-Athletes

Approximately 460,000 student-athletes are enrolled in U.S. colleges and universities (NCAA, 2020). Overall, student-athletes demonstrate excellence in academics with 8 out of 10 student-athletes earning a bachelor’s degree (NCAA, 2020). The daily life of the student-athlete is distinct from the other students given the specific time demands of their training and competition program. Student-athletes must balance their time between academics and

athletics, and they may have limited availability to build social connections beyond the athletic program as a result of their tightly packed schedule. As colleges and universities seek to support student-athletes, they may consider providing support services and wellbeing programs located on the athletic campus or closer to training facilities. For general wellbeing, ensuring that other student services such as cafeterias, student services, and other central services can help student-athletes have the same ability to access nutrition and logistical support as other students.

In reviews of student-athletes, the literature suggests distinct benefits related to mental health. Athletic participation is associated with lower rates of depression and correlates with higher levels of self-esteem and connection with others (Bornheimer and Gangwisch, 2009; Pluhar et al., 2019). The team environment, which can be positive and supportive, can also create negative stressors if the presence of group conflict, peer pressure, and bullying (Post and Kelley, 2018). Additionally, if the broader campus environment does not have a positive culture toward students from historically marginalized groups, student-athletes from those backgrounds may experience additional discrimination and harassment given their higher visibility on campus resulting from their role as an athlete (Post and Kelley, 2018).

Student-athletes may also face unique stressors related to athletic performance. Perfectionism is a trait common to high-performing individuals, including musicians and researchers, and student-athletes can encounter lowered mood or self-esteem after a relative change in position on the team or a poor competitive performance (Post and Kelley, 2018). In the event of injury or leaving the team, student-athletes may experience isolation from social networks, the loss of their identity, and having access withdrawn to special academic, health, and financial support. Wellbeing programs tailored for the needs of student-athletes can help build additional coping mechanisms, provide an environment to share challenges outside of the team dynamic, and offer students who are temporarily or permanently on leave from athletics support to develop an identity outside athletics. During COVID-19, the athletic seasons for many student-athletes have been suspended without certainty of return and, for some athletes, reduced or zero access to training facilities. While research specific to the wellbeing of student-athletes remains limited, the University of Michigan’s Athletes Connected research aims to increase awareness of mental health issues, reduce the stigma of help-seeking, and promote positive coping skills among student-athletes overall and during the COVID-19 pandemic (Kern et al., 2016).⁸ For example, in one pilot study, an educational intervention for varsity athletes that featured presentations that provided an “overview of mental health, two videos highlighting former student-athletes’ struggles with mental illnesses, and a discussion at the end with the

___________________

⁸ Additional information is available at https://athletesconnected.umich.edu (accessed September 29, 2020).

former athletes portrayed in the videos” found, through surveys of 626 student athletes, “significant increases in knowledge and positive attitudes toward mental health and help-seeking” (Kern et al., 2016).

Graduate Students

While many student services on university campuses are open to both undergraduates and graduate students, the needs of graduate students differ in terms of their socioemotional development, life expectations, professional demands, and academic stressors. As noted in the National Academies’ Graduate STEM Education for the 21st Century, “High-pressure environments, cloudy career prospects, an imbalance of work and life, and leadership style of one’s advisor also contribute to health problems or unhealthy mental status of graduate students.”(NASEM, 2018a, p. 83). The ongoing efforts of the Council of Graduate Schools’ Graduate Student Mental Health and Well-being Initiative⁹ pays increased attention to the needs of graduate students. Launched in August 2019 in partnership with the Jed Foundation, the two-year initiative will examine the barriers related to care for graduate students and review the evidence-base for practices (Hazelrigg and Woodworth, 2019). The COVID pandemic and accompanying economic crisis have exacerbated pressures on graduate students as job prospects have become even more ambiguous than they were before since so many institutions are cutting back on staffing and the like.

Undergraduate students typically have general education requirements mandating a broad exploration of campus, extracurricular activities, and residential life. As a result, undergraduates often traverse a larger area on campus than master’s and doctoral students, who may be enrolled in a specific program located in a handful of buildings, spend more time off campus, and may be located in another location for field research. Programs and services may be in buildings that primarily serve undergraduates or in areas of the campus that are unknown to graduate students. For graduate students who also have teaching assistantships, location of services can matter in that a graduate student may not want to seek support in the same location where they may encounter their undergraduate students or mentees. For students who have relocated for field research or to complete their dissertation in another city, virtual programs, and services, including telehealth or other distance health options, can provide alternatives to in-person sessions.

Educational demands and professional development may cause stress to graduate students, notably if the existing academic, career, and wellbeing resources on campus feel geared to an undergraduate audience. As academic research funding and tenure-track faculty positions have become more difficult to secure, graduate

___________________

⁹ Dr. Daniel Eisenberg served on the National Academies committee on mental health, substance use, and wellbeing and the Council of Graduate Schools Graduate Student Mental Health and Wellbeing Initiative. Dr. Susanna Harris, a consultant for the National Academies, served on the CGS Initiative.

students who have invested significant time in their life pursuing that career may experience a loss of identity that is distinct for students at that stage of their careers. As a result, they may require help both seeking a job in a nonacademic setting and dealing with the disappointment of not achieving what for many graduate students is a life-time goal (Iarovici and Alexander, 2018).

Students experiencing these stressors can benefit from career advisors and wellbeing services that acknowledge this critical shift in identity and have knowledge of the job market for graduate students. While many of these stressors may align with the normative growth and development issues common to young adults, graduate programs may benefit from providing specialized support services that allow students to build stress management and coping mechanisms that will benefit them throughout their studies and into future roles.

Loneliness, isolation, and competition can also have a noted presence in the life of a graduate student (Ray et al., 2019). Unlike undergraduate students, graduate students often do not participate in introduction to campus programs and do not learn about various supports available to them, and they often have fewer opportunities to join extracurricular activities and build support networks. Graduate programs may be small and isolated from other departments, which can limit the development of friendships and social relationships that can help students create a sense of belonging. In departments and programs where competition for grants, papers, or general status is the norm, the environment can turn students away from each other. Without bridges to a broader community, students may experience isolation, loneliness, and lack a social system that can help individuals cope with their struggles.

For students who have strong social networks at home, leaving an established social structure can also create separation as families and friends may not understand the nature of graduate work. Additionally, graduate students may also experience financial stress if they compare their stipends to peers who work full time and receive salaries (Iarovici and Alexander, 2018). As mentioned previously, students who are completing research or field assignments may also lack the social infrastructure of both their home environment and program, and, depending on the location, may not have reliable means of communicating with those to whom they are close and from whom they can get support.

As with student-athletes, graduate students often demand perfection from themselves and internalize high expectations (Iarovici and Alexander, 2018). One phenomenon common to graduate students in high-pressure, competitive programs is imposter syndrome. The term was coined to describe a trend observed in women in which they believe they are not as competent and skilled as everyone thinks they are despite outstanding academic and professional accomplishments (Clance and Imes, 1978). This phenomenon is also not uncommon in graduate students, many of whom may discount their hard-earned achievements such as admissions, publishing a paper, or getting accepted into a conference while they attribute any setbacks to personal failings (NASEM, 2020). Graduate students

who belong to groups that have been historically excluded in their discipline and program or who are in programs that have not created an inclusive environment can feel additional scrutiny (NASEM, 2018a). Given the siloed nature of graduate programs, wellbeing programs and community services that help link students to others who share similar backgrounds, transdisciplinary research interests, extracurricular activities, or interest in issues on campus can give students who may not feel belonging in their program the chance to create a social system with peers.

Graduate students may be exposed to social and professional arenas as they begin to attend conferences and build relationships outside of their program or institution with an eye toward their future careers. Events such as conferences, workshops, and seminars may include a level of professional decorum and protocol to which they have not been exposed previously. Learning how to navigate these settings can cause additional stress, uncertainty, and lack of belonging. These issues may be particularly felt by students who are BIPOC and or hold other historically excluded identities and who experience feelings of isolation in their program and even their field in the event there are limited students and faculty with similar identities.

Graduate students may also feel a lack of control and agency related to their relationship with a research advisor. While the apprenticeship model that often exists between the researcher and the student may go well, the dyadic structure and its inherent power differential pose risks in the event conflict occurs (NASEM, 2018a). There have been efforts to diffuse the power differential by offering graduate students the ability to have multiple mentors and providing networking events to expand a students’ pool of mentors and advocates. Lab rotations to test research interests (in applicable fields) and policies to mediate and ease conflict between students and their advisors can also help reduce the adverse effects of a power differential. For some disciplines, the stigma around pursuing careers outside of academia remain, and students may feel pressure to conform to the tenure-track career path. Providing students with other ways to explore careers through seminars, internships, workshops, alumni networks, and graduate-specific professional advisors can help alleviate the burden on research advisors and provide students a place to learn without stigma.

In 2019, the National Academies released a study with evidence-based findings and recommendations related to the science of mentorship in science, technology, engineering, mathematics, and medicine. While this report, The Science of Effective Mentorship in STEMM, did not focus on mental health specifically, the report does note how mentoring can impact student development and wellbeing and the importance of identity in mentoring relationships. The report notes the benefits of a positive mentoring relationship for undergraduate and graduate students and discusses some of the negative consequences of a poor relationship. Undergraduate students who participate in mentored research experiences are more likely to stay in STEMM, and students who perceive their mentors as

effective are more likely to pursue doctoral programs in related fields. Graduate students who perceive their mentors as effective are more likely to persist in academic decisions and publish research than students who are not mentored (NASEM, 2019b). For all students, the report references the need to build cross-cultural competencies in mentors to avoid causing harm related to a mentee’s identity. Mentor relationships that do not include respect for mentee identity correlate with depression, reduced psychological wellbeing, and lower academic or professional performance (NASEM, 2019b).

While undergraduate students benefit from positive mentorship interactions, graduate students and postdoctoral researchers often have multiple mentors, each serving a different function, such as research advisor, or career advisor. Graduate students and postdoctoral researchers may often feel dependent on a primary research advisor for feedback on their research, funding, and connections to the field.

Overall, the research on wellbeing and mental health for graduate students remains limited in comparison to undergraduate students. As is true with the other groups discussed in this chapter, graduate students are not a monolithic group, and their identities also intersect with others in this chapter. Effective support for graduate students would benefit from increased research and program evaluation. See Chapter 6 on the Research Agenda for details on recommended research.

Medical Students

The medical profession has come under scrutiny for a work culture that is exceedingly demanding and can push practitioners beyond their tolerance limits and lead to “burnout” and a range of mental health issues. While this section highlights the mental health issues of medical students, it is important to note that other health professionals face similar challenges, and thus, the discussion likely applies more broadly to these professions and the students studying in these fields. Professional societies from the Association of American Medical Colleges (AAMC), the National Academy of Medicine, and the American Medical Association have conducted research on the toll burnout can take on the medical profession where approximately half of physicians report burnout symptoms: “Burnout is a syndrome characterized by a high degree of emotional exhaustion and depersonalization (i.e., cynicism), and a low sense of personal accomplishment at work” (NASEM, 2019c). As a result of inconsistent definitions, the overall body of research on burnout in academic medicine should be reviewed with caution.

Medical students and other health professionals have a distinct educational trajectory and encounter significant stressors throughout their training. An international meta-analysis found that the prevalence of self-reported depression in medical students to be 27.2 percent, but only 15.7 percent of students with positive screens for depression went on to seek mental health treatment (Iarovici

and Alexander, 2018). Substance use by medical students and trainees has also been documented at higher rates; data showed that 91.3 percent and 26.2 percent of medical students consumed alcohol and used marijuana, respectively, and that additional studies on patterns of substance use are needed to prevent substance use disorders among medical students (Ayala et al., 2017). The gap between positive screens and the decision to pursue treatment has deeper implications—an alarming increase in suicidal thoughts. One large meta-analysis found that over 10 percent of medical students have had suicidal thinking over the past 12 months (Iarovici and Alexander, 2018). Other studies have examined the prevalence of mental health disorders among medical students (Guille et al., 2010; Rotenstein et al., 2016; Sen et al., 2010).

As with student-athletes and graduate students, students in most health care professions operate in a highly competitive environment with demanding expectations on performance and hours dedicated to developing practice. The long hours can lead to reduced sleep, limited physical activity, separation from important relationships, strain on nutrition, and isolation from interaction outside of the cohort and the training environment. The demands and expectations of medical school and other health care training programs may leave students feeling that they do not have time in their schedules to seek additional services. As mentioned previously, the drive for perfectionism can push students to internalize stress and feel that revealing mental health challenges would make them less qualified for medical practice. Providing wellbeing programs that help individuals retain healthy life habits, workshops that focus on reducing stigma around seeking mental health services, and policies that protect students from overwork can provide students with multiple levels to seek assistance. Additionally, there is some research to support the idea that changes to curriculum and grading practices in medical school may reduce stress (Bloodgood et al., 2009; Slavin et al., 2014; Slavin and Chibnall, 2016; Slavin et al., 2014), for example, noted that “efficient changes to course content, contact hours, scheduling, grading, electives, learning communities, and required resilience/mindfulness experiences were associated with significantly lower levels of depression symptoms, anxiety symptoms, and stress, and significantly higher levels of community cohesion, in medical students.”

Students in health care professions often operate in an environment separate from the rest of a university’s main campus, so the health affairs campus has an important leadership role in shaping education and work settings. The medical education system particularly has strong roots in the apprenticeship model and has been identified as more hierarchical. This can be characterized as a system where trainees feel more responsible for following direction from their supervisors than other disciplines, and the culture is less supportive of questions or pushing back against figures of authority (Martinez et al., 2014). To understand the challenges that clinicians in health care face, the National Academy of Medicine has created a conceptual framework of factors that impact clinician wellbeing and resilience across all health professions, specialties, settings, and career stages (see Figure 3-1).

The full tool¹⁰ provides lists of components for each of the external and internal factors (the yellow and blue units on the outside of the model). Given that the medical training environment has a history of hierarchy and dominance from leadership, schools and departments that review and address wellbeing can help shift the climate for medical students and trainees as well.

Neurodiverse Students

While some students with developmental disorders, such as autism spectrum disorder (ASD) or cognitive and learning disabilities, may identify as students with disability, there has been a movement toward thinking about these students under the concept of neurodiversity. In the early 1990s, researchers coined the term as part of a civil rights movement for individuals with neurologically based disabilities (Armstrong, 2017). These investigators worked to shift the paradigm

___________________

¹⁰ The full tool is available online at https://nam.edu/clinicianwellbeing/resources/factors-affecting-clinician-well-being-and-resilience-conceptual-model.

from a deficit-oriented model, which frames these individuals as operating with an impaired sense of cognitive and emotional properties, to a strength-based model where “neurological differences are to be recognized and respected as any other human variation” (Masataka, 2018). While the movement originated with ASD activism, the umbrella for neurodiversity has expanded to include learning disabilities, ADD/ADHD, intellectual disability, and social and emotional disorders (Armstrong, 2017).

Developments in screening, treatment, and support for neurodiverse individuals in their childhood and adolescence has increased their ability to prepare for the academic and psychosocial demands of higher education. Some campuses have developed specific programs designed to support neurodiverse students, including the College of William and Mary’s Neurodiversity Initiative and the London School of Economics’ Dyslexia and Neurodiversity program (Armstrong, 2017). For other colleges and universities, accommodations for students with learning disabilities must comply with ADA (see Chapter 4 and the section on Federal Regulations for Higher Education for more information on the Americans with Disabilities Act). Additional research on neurodiverse students in higher education is needed to determine the efficacy of policies and practices intended to support their wellbeing and academic achievement (see Chapter 6 on the Research Agenda).

Post-Traditional or Non-Traditional Students

Colleges and universities were originally designed to educate white men whose families could afford to support additional years of education in a residential setting. The legacy of these early undergraduates has persisted, living on in the stereotype of a college student in their late teens to early twenties, often living on or near campus. As noted in Chapter 2, there has been a growing number of students who enroll in higher education as older adults or who return to campus to seek additional credentials. The National Center for Education Statistics projected that 38 percent of the almost 20 million students enrolled in institutions of higher education would be 25 years and older—so-called post-traditional learners—in 2018 (Bruce-Sanford and Soares, 2019).

For colleges and universities, many post-traditional students have a different set of issues than first-time, full-time residential college student attending out of the K-12 system. These individuals are more likely to have long-term partners or spouses and other dependents, be employed full time, and be veterans (Iarovici, 2014). With these different life circumstances, post-traditional students are more likely to have other responsibilities and seek support in other ways, such as needing to find childcare and have flexible scheduling (Iarovici, 2014; McBride, 2019). Post-traditional students may have schedules that limit their ability to attend on-site wellbeing programs or to make appointments with counseling services.

For some students, asynchronous resources or virtual services they can access from home, might be more accessible, notably for students enrolled in online or hybrid programs who do not regularly come to the physical campus. Providing extended hours in evenings and weekends, additional locations, and connections to community providers who may be closer to the student’s residence or employer can help students with access as well. While not all post-traditional students attend community college, it is more likely that community college students have challenges accessing basic life needs such as housing, food, transportation, and stable access to technology often considered essential to higher education, such as computers and wi-fi. For students who are caregivers, these needs can compound as they may serve as a primary provider. While these issues may be concentrated at community colleges, they are not limited to them. Colleges and universities that support students’ basic needs can mitigate some life stressors, and enhance wellbeing for those students, and these services have been shown to correlate to higher academic outcomes such as retention and completion.

Access to additional services and extended hours can make programs and support more accessible to post-traditional students, but the research on the mental health and wellbeing of these students remains limited (Cadigan et al., 2020; Iarovici, 2014). Some research has focused on understanding the motivations for post-traditional students, which can help staff and faculty set expectations and work with students toward their goals. As many post-traditional students seek education to advance their careers, their efforts and performance may look different than traditional students. Research has shown that older students may be adversely affected by the emphasis on grades or other extrinsic factors. Better outcomes for older students can be achieved by validating their academic performance and autonomy and treating them as active partners in learning (Iarovici, 2014).

For post-traditional students in academic programs with mostly traditional students, there may be other ways to help students feel a sense of belonging. Post-traditional students, who are more likely to have additional demands with work and family, may not be able to attend office hours, group meetings, or access programs and services. They may feel isolated from the other students because of differences in life stage and have a reduced ability to develop bonds through extracurricular and social activities. Given the additional demands associated with the lives of post-traditional students and their presence in community college, centralized student counseling centers can provide greater ease of access to students and can improve academic outcomes such as retention, transfer, and graduation (Van Brunt and ACCA PAPA Committee, 2010). As noted in previous sections, loneliness and isolation can make students of any age and life situation feel less welcome, which can adversely affect an individual’s wellbeing (Iarovici, 2014).

Sexual and Gender Minorities

Sexual and gender minority (SGM) is a term that has developed to encompass the full range of identities related to sexual orientation and gender. The National Institute of Health’s Sexual and Gender and Minority Research Office defines SGM populations as including, but not limited to,

For the purposes of this report, SGM also encompasses identities that have been considered under LGBTQIAP+, which include individuals who are questioning, pansexual, or polyamorous. In the 2019 ACHA-NCHA fall survey, 17.9 percent of undergraduate and graduate students described their sexual orientation in categories other than straight/heterosexual.¹¹ For gender identity, 1.2 percent of students identified outside of the binary woman/female and man/male categories, and 1.8 percent responded as transgendered. As with other populations, students in this category are not monolithic and their identities may shift during their time on campus. For some identities that may comprise a small proportion of the total, recognition of their sexual and gender identities is critical to recognize the full humanity of these students and combat stigma associated with SGM identities.

___________________

¹¹ The other options available for students includes asexual (0.7 percent); bisexual (8.8 percent); gay (2.0 percent); lesbian (1.3 percent); pansexual (1.6 percent); queer (1.2 percent); questioning (1.9 percent); and identity not listed above (0.4 percent). The total will not amount to 100 percent, as there were also invalid responses and non-responses.

Note from the ACHA-NCHA survey on the use of sex and gender: Survey responses are reported by sex based on the responses to questions 67A, 67B, and 67C. For the purpose of the ACHA-NCHA report documents, respondents are reported as male or female only when their responses to these three questions are consistent with one another. If gender identity is consistent with sex at birth AND “no” is selected for transgender, then respondents are designated as either male or female. If respondents select “yes” for transgender OR their sex at birth is not consistent with their gender identity, then they are designated as non-binary. A respondent that selects “intersex” for sex at birth, “no” for transgender, and man or woman for gender identity are designated as male or female. A respondent that selects “intersex” for sex at birth, “yes” for transgender, or selects a gender identity other than man or woman are designated as non-binary. A respondent that skips any of the three questions is designated as unknown. Only three of the four categories are displayed in this report. Respondents categorized as non-binary are included in the Total column but are not presented in a separate column. When the total of any given row is higher than the sum of the male, female, and unknown respondents, the difference can be attributed to non-binary respondents that selected the response option presented in that row.

For many individuals, their time on campus may parallel a developmental and life stage where they explore sexual and gender identity. Some students may not have felt comfortable working through this aspect of their selves if they lived in a hostile community, while other students may not have developed or recognized a desire to investigate until they arrive at their college or university. Peer support groups that focus on SGM issues can help students who are in the process of exploring their identity, experiencing challenges in close relationships, or validating their identity. Other efforts through residential life and student services that recognize SGM students, provide guidance and training for friends and allies, and offer informal ways to seek help for students in distress or facing harassment based on their SGM identity can help reduce bias and make students feel more welcome.

Wellbeing and mental health support for SGM students should incorporate inclusive methods that recognize the legacy of harm embedded in the history of U.S. laws, medicine, and society. For SGM individuals who choose to enter therapy, other fears may arise such as a concern about information being discovered outside of the sessions, hospitalization, limited resources for those with a SGM identity, and lack of health professionals with experience in working with issues common in the SGM community (Shah, Eshel, and McGlynn, 2018). For colleges and universities seeking to support students, having health professionals who practice inclusive approaches that make strong efforts to normalize minority gender identities and sexualities and who become well versed in the nuances of the SGM culture and vernacular can limit the impact of anti-SGM stigma on mental health (Shah, Eshel, and McGlynn, 2018).

Currently, there is limited research regarding approaches that are effective in supporting SGM students.¹² As the research base continues to grow, there are ways that health professionals, as well as staff, faculty, students, and others on campus, can develop inclusive practices. One example is the use of gender expansive language that goes beyond the gender binary of she/hers and he/his to include the singular they/their or the use of the honorific to “Mx.” Affirming students’ gender through pronouns without qualification (e.g., “preferred pronouns”) is described by the Human Rights Campaign as a way to support others (HRCF, 2018). Introductions in settings across campus, notably those led by individuals in a position of authority (e.g., faculty, staff, administrators, and student leaders) that include the option to include pronouns can normalize non-binary pronoun

___________________

¹² The Committee on Population of the National Academies of Sciences, Engineering, and Medicine will undertake a consensus study that will review the available data and future research needs on persons of diverse sexualities and genders (e.g., Lesbian, Gay, Bisexual, Transgender, Queer/Questioning, Plus/LGBTQ+ and Men who have Sex with Men/MSM). It will also include persons with differences in sex development (sometimes known as intersex), along multiple intersecting dimensions across the life course. The report is due for release in late 2020 or early 2021.

use and allow students to share that identity with others.¹³ This may be repeated over time with new individuals and to allow students to express updated pronouns if they have changes.

Within the student population with SGM identities, colleges and universities may seek additional guidance related to appropriate treatment of transgender individuals. In comparison to cisgender peers, transgender youth aged 12-18 years report higher rates of experiences associated with negative health outcomes including “violence, victimization, substance use, and suicide risk, and, although more likely to report some sexual risk behaviors, were also more likely to be tested for human immunodeficiency virus (HIV) infection” (Johns et al., 2019). Wellbeing services and counselors can develop an awareness of these issues as a context for the fears transgender and transitioning students may express. Mental health services can also support transgender and students in transition by having a working knowledge of the campus resources and even administrative processes such as the ability to change names and pronouns in university systems and serve as a “guide [in the] gender exploration process or to obtain a support letter for therapy with hormones or surgery; or for reasons completely unrelated to gender, such as relationship issues or anxiety” (Khan and Hansen, 2018).

Transgender students and students who do not identify along the female/male binary face harm when forced to reply to government surveys, school paperwork, and other indices that do not list their identity as an option. Additionally, transgender students who have transitioned and have chosen a new name face the risk of being “deadnamed,” the use of their birth or given name, in medical or administrative settings if they have not had a legal name change. The Human Rights Campaign 2018 Youth Report describes better outcomes for students, such as decreased instances of anxiety and depression, when they feel supported by their environment (HRCF, 2018). For example, providing administrative options to allow students to list their names and pronouns, even if a legal name and sex assigned at birth are also required, can affirm student identities, provide faculty and staff with accurate information about the student, and reduce harm.

Student Survivors of Trauma

Consistent with national data in the general population, the student body of most every college and university is likely to include individuals who arrive to campus with a history of trauma (Arnekrans et al., 2018; Davidson, 2017). One important metric of trauma and adversity is the landmark public health study on Adverse Childhood Experiences (ACE), which includes experiences of individuals from birth to 18 years old of abuse and neglect of all kinds as well as parental mental illness, substance use, divorce, incarceration, and domestic violence,

___________________

¹³ The option to share pronouns gives students the opportunity to opt-out if they do not feel comfortable sharing. Mandatory sharing can cause students who are exploring gender pronoun use distress.

showing lifelong impacts on physical development, mental health, and risk taking (Felitti et al., 1998).¹⁴ In 2016, 34 million children under 18, or nearly 50 percent of all U.S. children, experienced one ACE and greater than 20 percent had experienced two or more (CAMHI, 2018). While there is more research on trauma-informed educational approaches for children under 18 and for the K-12 system, there has been increasing attention to understanding trauma’s impact on postsecondary learners and creating strategies for the higher education setting (Plimb, Bush, and Kersevich, 2016). Because of cognitive, self-regulatory, and interpersonal challenges that often result from histories of trauma, research increasingly indicates a correlation between ACE or trauma and lowered educational attainment (Metzler et al., 2017). Existing research regarding the link between developmental trauma and academic resilience, persistence, and completion in college students indicates that the dynamics between trauma and academic outcomes are complex, not well understood, and in need of further research (Anders, Frasier, and Shallcross, 2012; Arnekrans et al., 2018; Baker et al., 2016; Duncan, 2000; Hardner, Wolf, and Rinfrette, 2018; Hinojosa et al., 2019; Metzler et al., 2017; Read et al., 2012).

Certain student groups have a greater likelihood of exposure to trauma, including women, individuals from the SGM community, students with disabilities, and students who are BIPOC (Anders, Frasier, and Shallcross, 2012; Austin, Herrick, and Proescholdbell, 2015; Edman, Watson, and Patron, 2016; Read et al., 2011; Slopen et al., 2016). In addition, whether they have experienced previous trauma or not, students may encounter traumatic events during their time as a student. Research on exposure to a potentially traumatizing event (PTE) during higher education remains limited. There are also time periods that correlate with higher rates of PTE exposure, with up to 50 percent of college students reporting a PTE in their first year (Davidson, 2017).

Sexual harassment and assault constitute a specific form of trauma that has received increased attention in past years. The 2018 National Academies report Sexual Harassment of Women: Climate, Culture, and Consequences in Academic Sciences, Engineering, and Medicine (NASEM, 2018b) states the prevalence of sexual harassment as a key finding.¹⁵ Not only is sexual harassment a common event, it is also one that those who have been sexually harassed tend to experience

___________________

¹⁴ The National Survey of Children’s Health ACE’s 2016 assessed exposure to the following nine experiences: (1) Somewhat often/very often hard to get by on income; (2) Parent/guardian divorced or separated; (3) Parent/guardian died; (4) Parent/guardian served time in jail; (5) Saw or heard violence in the home; (6) Victim/witness of neighborhood violence; (7) Lived with anyone mentally ill, suicidal, or depressed; (8) Lived with anyone with alcohol or drug problem; and (9) Often treated or judged unfairly due to race/ethnicity (CAMHI, 2018). See: https://www.cahmi.org/wp-content/uploads/2018/05/aces_fact_sheet.pdf.

¹⁵ While sexual harassment is experienced by people of all genders, the scope of this report focused on the sexual harassment of women specifically. While this report focused primarily on sciences, engineering, and medicine, it referenced data and research from other areas. Unlike this report, Sexual Harassment of Women looked at women at all roles in academia, not students specifically.

more than once. In a 2016 study of female graduate students that self-reported experiencing sexually harassing behavior, only one-third reported that they experienced a single incident. For women who are BIPOC and SGM women, the report notes that issues of sexual- and gender-based harassment intersect with other biases that stem from their race, ethnicity, and other identities and that sexual harassment is experienced differently (NASEM, 2018b). While the report does not specify research on the experience of SGM students, a study of employees in higher education found that SGM individuals of all genders reported higher rates of gender harassment (73 percent) and sexual harassment (40 percent) compared to heterosexual peers (30 percent and 15.5 percent, respectively) (NASEM, 2018b).

The report also includes data on the perpetrators of sexual harassment, which can provide additional information to guide prevention, as well as information of the impact of sexual harassment on the broader community. The report notes that while people of all genders experience sexual harassment, the predominant harassers are male, with 86 percent of female graduate students who experience sexual harassment from faculty or staff reporting that the harasser was male. Men are also more likely to be the perpetrators of sexually harassing behavior of other men (NASEM, 2018b). Sexual harassment does not only harm those who are targeted, as workplace research indicates that indirect exposure or the perceived level of sexual harassment in a workgroup also leads to similar negative issues as those suffered by individuals with direct experience. The presence of sexual harassment can cause trauma, create an environment that does not support wellbeing, and make individuals feel unwelcomed and more likely to leave that environment. As colleges and universities think about ways to ensure safety and wellbeing, the prevention of sexual harassment and the creation of an accountable, transparent system for addressing harassment cases can aid in those efforts.

Traumatic experiences, regardless of when they occurred, can have lifelong impacts on students. ACHA (2016) states that trauma-informed approaches “emphasize physical, psychological, and emotional safety for both providers and victims/survivors, which allows victims/survivors to rebuild a sense of safety, control, and empowerment.” As campuses build trauma-informed services or adopt trauma-informed practices, it is important to remember how students might encounter different kinds of trauma. In addition to the groups previously mentioned as having a higher likelihood of trauma exposure, international students, students without documentation, and veterans may have exposure to distinct types of trauma based on their background. Colleges and universities can expand the use of a trauma-informed lens beyond programs and services for students, with trauma-informed approaches involving vigilance in anticipating and avoiding institutional practices and processes that are likely to re-traumatize individuals. Trauma-informed approaches allow services to be delivered in a way that facilitates the victim’s/survivor’s participation (ACHA, 2016).

The Department of Health and Human Services (2014) identified trauma-informed principles, including safety; trustworthiness and transparency; peer

support; collaboration and mutuality; empowerment; and cultural, historical, and gender issues.

Student Military Service Members and Veterans

Since World War II, many veterans of the U.S. armed forces have pursued higher education after the conclusion of their service. According to the Student Veteran Association, over a million veterans have returned home since 2008 to pursue a postsecondary degree or certificate using Veterans Affairs education benefits (SVA, 2020). The student veteran population is distinct from the general population: those who served in the armed services tend to be predominately male, entered the military after high school, and are more likely to be from rural communities or the southern United States (Lauff, Chen, and Morgan, 2018). In terms of race and ethnicity, the representation of white and Black groups approximates their presence in the general population, while Asians are underrepresented, and Native Hawaiian and Pacific Islanders are overrepresented (Lauff, Chen, and Morgan, 2018). The distinctions for student service members and veterans (SSM/V) goes beyond demographic information as well in that they are adult learners who often have social, cognitive, physical, and psychological readjustment challenges when transitioning to college environments. In addition, SSM/V students can encounter unique informational and bureaucratic hurdles related to reenrolling and supporting their postsecondary education (Aikins et al., 2015).

SSM/Vs, who are likely to attend postsecondary education after service, experience many of the challenges that post-traditional and non-traditional students experience. They may feel more isolation and distance from the other students, who are likely younger, and SSM/Vs may find a challenge in adjusting to the relatively loose schedule on campus compared to the structured life in the military (Aikins et al., 2015). While many colleges and universities provide specific resources for veterans to navigate the academic, financial, and health and wellbeing services on campus, the support provided varies considerably from campus to campus. One survey found that 57 percent of 723 institutions of higher education provide programs and services specifically designed for service members, with a greater percentage of public four- and two-year colleges having veteran-specific programs than private institutions (Aikins et al., 2015). As SSM/Vs have a number of identities and may seek support through a number of campus services, online directories and resources that inform students, as well as faculty and staff who may be asked for guidance, of which services are available and where can help students navigate the full range of available support.

In addition to the challenges many veterans face in navigating higher education, there are also specific health issues, such as auditory problems, post-traumatic stress disorder (PTSD), and traumatic brain injury (TBI), that have a higher occurrence in veterans and can affect their ability to learn. These conditions,

particularly when co-occurring with mental health problems, can seriously impair social and occupational functioning, including academic performance (Kuhn and McCaslin, 2018).

The impact on cognitive function and the development of learning disabilities can make SSM/Vs eligible for additional accommodations under ADA. These issues may also arise related to concussions and TBI. Of groups in higher education, SSM/Vs and student-athletes have the greatest likelihood of experiencing a TBI, most frequently a mild TBI in the form of a concussion. While there are the immediate cognitive effects of a concussion, there are also associations with repetitive injury—slower recovery and chronically-elevated post-concussive symptoms—and there are concerns that repetitive head injuries “may be associated with an increased risk of chronic neurologic, neuropsychiatric, and neurobehavioral problems, including the possibility of chronic traumatic encephalopathy” (Broglio et al., 2017). General population research has also yielded preliminary connections between repetitive injury and the development of mental health issues, including PTSD (Howlett and Stein, 2016).

More research specific to SSM/Vs (and college athletes) would provide additional guidance to colleges and universities regarding prevention, recognition, treatment, and long-term rehabilitations. Governing bodies, such as the branches of the military and the NCAA, can also use available evidence and research to shift policies to protect SSM/Vs and student-athletes. As individuals and their physicians assess cognitive capacity after a head injury, guidance about accommodations for cognitive impairment and learning disabilities can give students the additional support needed to complete coursework as well as additional mental health treatment and counseling to help with recovery. Offices that provide specific support to veterans and athletes may create resources specifically for students recovering from head injuries and those continuing to manage cognitive symptoms.