Introduction

John was an average student in college. Interpersonally anxious, he had difficulty making friends and had limited experience in intimate relationships. Joining a fraternity provided him a social network and allayed some of his social anxiety. In his senior year, he suffered an acute manic psychosis, requiring a medical leave of absence from school. Eager to return to school and his fraternity house, John felt welcomed by his fraternity and used the word “brothers” to convey a deeper meaning than simply the other members of his fraternity. His fraternity brothers had visited him in the hospital, kept in touch during his leave, and enthusiastically welcomed him back. They provided tutoring and study help, monitored his use of alcohol and drugs, assisted with medication adherence, and helped him get to class and appointments. The fraternity played a major role in John’s recovery.

This vignette illustrates how a group of college students with no special mental health training spontaneously formed a caring and therapeutic community that was instrumental in John’s recovery from an acute manic episode. In this paper, we will use the college community to illustrate the range of ways in which students help other students. We will suggest that college campuses offer many advantages for the study of population-based mental health initiatives and that peer-to-peer (student-to-student) interventions offer a widely available and inexpensive resource that could be an effective component of these initiatives.

Psychiatric disorders are disorders of youth. Three quarters of all lifetime cases appear by age 24 [1]. Delays in starting treatment are the rule for persons with mental illness. Persons with new onset schizophrenia suffer psychotic symptoms an average of 1–3 years before diagnosis and treatment but display manifestations of the disease another 2–5 years before that [2, 3]. Delays in treatment for mood and anxiety disorders range from 6 to 8 years and 9 to 23 years, respectively [4]. This combination of early onset and prolonged untreated illness contribute to the high personal and societal burdens of mental illness. These include higher rates of educational discontinuation [5], teenage parenthood [6], and divorce [7]. Identification, engagement, and treatment of youth with early signs of mental illness are critical to reduce the personal suffering and societal costs associated with these conditions.

College campuses provide a rich environment to develop innovative programs. In terms of psychiatric disorders, college students are representative of their age-matched peers. They consume slightly more alcohol, use slightly fewer drugs, and show fewer personality disorders compared with non-college-attending peers. Otherwise, rates of psychiatric disorders among college-attending and non-attending youth are generally equivalent [8]. Suicide is the third leading cause of death among individuals aged 15–24 years [9] and may be the second leading cause of death among college students [10]. Recent research indicates that 6–10 % of college undergraduates reported having “seriously considered suicide in the past 12 months” [11, 12]. Importantly, college students commit suicide at one half the rate of non-college-attending students [13]. Although college appears protective against suicide, suicide risk remains a serious concern.

Excessive alcohol consumption is associated with serious injury or death. In 2005, 1825 college students died due to alcohol-related unintentional injury and many more sustained serious, non-fatal injuries [14]. This same study reported that 97,000 students were victims of alcohol-related sexual assault or date rape and almost 700,000 students had been hit or assaulted by another student who had been drinking.

Why invest in studying mental health services in college students? First, as mentioned above, college students suffer mental illness at the same rates as their non-attending peers. Second, large numbers of youth are concentrated in one place. Third, most colleges offer some form of health and mental health care on campus. Fourth, a broad support and reporting (case finding) network extends into the campus through faculty, residence life, sports organizations, fraternities, student affairs offices, and campus police. Fifth, highly publicized campus tragedies have focused attention on the mental health care of college students. Most notable of these responses has been the Garrett Lee Smith Memorial Act, which allocated federal funding administered through the Substance Abuse and Mental Health Services Administration (SAMHSA) “to support the planning, implementation, and evaluation of organized activities involving statewide youth suicide early intervention and prevention strategies, to authorize grants to institutions of higher education to reduce student mental and behavioral health problems, and for other purposes” [15].

Reports such as the National Survey of College Counseling Center Directors [16•] indicate that college counseling centers are serving increasing numbers of students with serious mental health problems. In the most recent survey, 95 % of counseling center directors reported that their center served increasing numbers of students who experienced severe psychological problems. Counseling center staff served more students in crisis. Almost 90 % of counseling center directors reported a steady rise in the number of students who had been prescribed psychotropic medication prior to requesting services at the college counseling center. The rate of counseling center clients taking psychotropic medication rose from 9 % in 1994 to 25 % in 2013 [16•].

As with their non-college-attending peers, many students with psychological problems do not seek counseling for their difficulties. This becomes critical as almost half of students with mental illness who dropped out of college did not access mental health services and supports [17•]. Westefeld and colleagues [18] reported that only 26 % of students were aware of their school’s mental health services. Another study found that 80 % of college students who had committed suicide in the past year had no contact with counseling services [16•].

It is beyond the scope of this paper to discuss all the extra-center initiatives undertaken in college mental health as our aim is to discuss student-to-student interventions. However, when counseling center directors were most recently surveyed about what they were doing to address the increase of students with serious psychological problems, the three top responses involved activities outside of the counseling centers: training faculty and others to respond helpfully to students in trouble and to make appropriate referrals, expanding external referral networks, and serving on interdisciplinary committees aimed at early identification of troubled students [16•]. This reflects a move away from in-center trainings and staff additions towards a population-based orientation. Recognizing that many students who experience psychological problems do not seek services, counseling centers have developed initiatives to improve case identification and facilitate referral by educating parents, faculty, residence hall staff, and other college employees about the characteristics of mental disorders. Many of these programs have been formalized and are easily adaptable (e.g., Question, Persuade, and Refer (QPR), Campus Connect, Mental Health First Aid) [19].

As noted in John’s case above, social support from friends or other students can offer many benefits when students experience psychological difficulties. When queried about where they would turn for help when experiencing suicidal thoughts, 77 % of students said they would turn to friends whereas only 20 % would turn to a school counselor [20]. Students’ inclination to seek support and help from their peers provides a largely untapped option for colleges to expand support and assistance to students beyond the traditional menu of counseling center services.

The present article will describe innovative approaches that capitalize on students’ natural inclination to assist their peers. These approaches have the potential to improve the psychological well-being of the entire campus community. The next section of this paper will provide a broad overview of the range of peer-to-peer programs that can be available on college campuses. Following that, an example of an innovative program developed at Worcester Polytechnic Institute, the Student Support Network, will be described in more detail. The subsequent section will review peer-to-peer programs for students with serious and persistent mental illness.

Broad Overview of Peer-to-Peer Programs

Opportunities for college students to support each other have flourished in the 25 years since Chickering wrote that “a student’s most important teacher is another student” [21]. Peer group culture has been explored for improving outcomes in alcohol abuse, date rape, disordered eating, and other peer-influenced behaviors [22–24].

Students have long helped one another in numerous ways. Table 1 captures the multitude of peer support opportunities found both inside and outside of the classroom. This menu of ways-in-which-students-are-helping-other-students across college campuses has been subdivided into categories of academic and career; crisis-response; health, wellness, and prevention; multicultural and identify-focused; political, leadership, and social justice; and spiritual and religious. Of note, these categories are not mutually exclusive and many groups cut across multiple sub-categories with regard to their mission and purpose. In addition to these structured activities, students support each other spontaneously as designated drivers and drink watchers, in study groups, and as roommates and friends responding to crises and troublesome behaviors such as self-injury, alcohol poisoning, disordered eating, or sexual assault.

Table 1 Menu of students helping students on college campuses
Full size table

Students Helping Students in Hospital- and Community-Based Programs: the McLean Hospital College Mental Health Program

Student peer support opportunities are being integrated into hospital- and community-based mental health programs where college students are seeking treatment [16•]. The Center for Early Detection, Assessment and Response to Risk, a community-based clinic focusing on the early identification and intervention in youth at risk for psychosis, has partnered with local college communities in metropolitan Boston to reduce stigma and increase earlier access to treatment (www.cedarclinic.org). McLean Hospital, a comprehensive psychiatric facility near Boston, Massachusetts, established a hospital-based College Mental Health Program (CMHP) in 2008 to address the needs of its expanding student cohort more effectively [25]. In 2013, nearly 600 students from over 200 colleges and universities accessed services at McLean, giving rise to possibilities for cultivating peer support among students with serious mental illnesses.

McLean’s “Bridge to Campus (BTC)” sessions place peer support at the center of its programming for college students by integrating student-focused groups into existing treatment approaches. College students in the program who are enrolled or on medical leave from school participate in psychoeducational 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. The BTC group approach varies according to the level of care (inpatient, partial, residential, and outpatient) and diagnostic program, but core topics include readiness to return to school; accessing 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. Although BTC groups are facilitator-led, students actively support each other by modeling successful strategies for self-care on campus, expressing solidarity and hopefulness, applying DBT and CBT skills to specific college situations, critiquing petitions to return to college, and shaping the treatment experience for future students. Students appear to be more effective than treatment providers and parents in reducing peers’ resistance to taking (or extending) medical leaves of absence, easing back into campus life, accepting the need for accommodations through disability services, transferring to more manageable academic environments, and redesigning college goals. The culture of peer support extends beyond the facilitated BTC groups into less-structured peer support experiences. Outpatient and residential BTC groups have spawned study-, college lunch-, and creative writing-support groups. Additionally, BTC alumni have formed a cyber community through which they maintain contact post-discharge, request to visit BTC groups during semester breaks, and send school-related updates and messages of encouragement to continuing group members.

Student Support Network

The high prevalence of mental health issues among college students and data that demonstrate that students turn first and foremost to their friends for help [12, 20] highlight the importance of empowering students to be more responsive and supportive when their friends are experiencing distress. Colleges have expanded the use of “gatekeeper training” models such as QPR or Campus Connect (see Suicide Prevention Resource Center (SPRC) Best Practices Registry) [26, 27] to educate the community more fully about suicide prevention and mental health promotion. Most of these trainings involve basic instruction in how to recognize, respond to, and where appropriate, refer individuals experiencing significant distress to professional resources.

The Student Support Network (SSN) Training is one such gatekeeper training program that was developed on the campus of Worcester Polytechnic Institute (WPI) in Massachusetts. Naturally occurring networks of peer support, formal and informal, develop and evolve on all campuses. This occurs in part due to proximity (e.g., residential living), interest (e.g., clubs and activities), and seeking like-minded others (e.g., Greek life, international students). Students turn to each other for support within these networks but students often feel “in over their heads” in their attempts to support their friends. The SSN program seeks to select and recruit student leaders and perceived helpers from these various networks into a 6-week training program so that they may be better trained and supported in helping their friends. Ultimately, the goal of SSN is enhancing the values of caring and responsiveness within the campus community.

Training groups of 15 to 18 students are formed through student recruitment and by marketing the training to the student population. Any student who is interested in the training is welcomed into the program. Recruitment efforts result in the formation of six training groups per academic year for the 6-week training session. The 50-min training sessions are co-led by counseling center staff with occasional assistance from other professional, non-clinical staff on campus. One group facilitator follows each cohort throughout the 6-week training while the other co-facilitator is a clinical counseling center staff member who rotates into the session to provide leadership on the differing topics. Each training session is broken down into discussion, to enhance knowledge in key areas, and experiential exercises that promote skill development.

The goals of the SSN training program involve (1) enhancing knowledge of mental health conditions, (2) promoting skill development in core helping skills, (3) reducing stigma associated with help seeking, and (4) enhancing connection with key campus resources. Key knowledge areas addressed in the training include (1) understanding elements of “good” mental health; (2) practical understanding of the signs of depression, anxiety, self-harm, suicide, and substance abuse; and (3) awareness of and understanding how to access local helping resources and (4) how to determine level of concern associated with friends who are in distress. Skill development occurs in the context of role-playing activities and experiential exercises designed to enhance empathic responding. These exercises also are intended to develop understanding of resistance to help seeking and how to help people move closer to connecting with professional help when needed.

Since 2007, ongoing training in the SSN model resulted in 100 students per year completing the 6-week training to become part of the Student Support Network. At any given time, there are about 400 students trained on campus, which is over 10 % of the undergraduate student population at WPI. Outcomes of the training include a 500 % increase in the overall number of counseling center consultations about students of concern, an increase in the percentage of students connecting with counseling services annually from 8 to 12 % of undergraduates, and significant increases in participation in traditional peer education programs on campus with goals of mental health promotion, sexual assault prevention, and alcohol/drug abuse prevention.

Pre/post testing of student trainees demonstrated that SSN training improves student confidence and perceived skill in recognizing warning signs for suicide, asking directly about suicidal ideation, convincing someone to seek professional support, and awareness of helping resources. Additionally, trainees experience significant improvement in crisis-responding skills as measured by the SIRI-II [28] and significant decreases on two measures of mental health help-seeking stigma [29]. SSN training also significantly improves trainee mental health functioning as measured by the AAQ-II [30], a measure of “psychological flexibility.”

SSN training is listed as a “best practice” by the Suicide Prevention Resource Center. A detailed manual outlining all aspects of the training model has been freely distributed to well over 250 campuses nationally upon their request (sdcc@wpi.edu) and the model has been successfully implemented on several other campuses nationally. The SSN model has also been used for training faculty and staff as well as a way to connect with “hard to reach” populations, such as international students. Implementing the SSN model can be done with a very low cost, but requires moderate time commitment. Campus counseling centers that embrace the model appreciate the importance of investing time in preventive/community development work as part of their mission and often re-evaluate their clinical delivery models with an eye towards improving effectiveness.

Peer-to-Peer Programs for Students With Mental Illness: Review of the Literature

There is a long tradition of mutual aid and self-help groups in the USA. Perhaps, the most widespread self-help group is Alcoholic Anonymous, which dates back to the 1930s [31]. In recent years, mutual aid groups in the form of “support groups” have emerged for dealing with many of life’s stressors. Examples of common support groups are those for individuals who are recently divorced or women who have recently given birth. The benefits of support groups have been demonstrated in recent research showing that women who had been diagnosed with breast cancer had greater survival rates and quality of life when they participated in support groups [32].

Peer support has emerged as an important component of treatment for individuals with mental health conditions. It was identified as one of the 10 core components of the recovery paradigm defined by SAMHSA and has been an important tenet of the adult mental health consumer movement [33]. Peer support for individuals with mental illness has taken many forms. Examples are consumer-operated self-help groups [34] and inclusion of peers as members of mental health treatment teams [35]. Social learning theory [36, 37] highlights the impact that modeling has on the behavior change process. In the context of peer support programs, peers can play a key role by modeling more effective behaviors for dealing with health care providers, adaptive coping strategies, and other skills essential for personal empowerment.

Research on peer support programs for mental health conditions suggests that individuals who receive peer counseling demonstrate better social functioning and more problem-focused coping strategies [38]. A recent review of mutual support groups, peer support services, and peer-delivered mental health services found some evidence “that peer support was associated with positive effects of hope, recovery and empowerment at and beyond the end of the intervention” [39]. Another review found that when peers delivered specific curricula or when peers were added to traditional mental health services, consumers showed better engagement with care, higher levels of hopefulness for recovery, and improved relationships with providers [40]. Other research, however, found little or no evidence that peer support “was associated with positive effects on hospitalization, overall symptoms or satisfaction with services” [39, 41, 42].

There is a small body of research pertaining to the age group of typical college students that examined the impact of same or near-age peers to other youth and young adults. Although the number of studies that examined this issue is small, this research has found positive gains for some outcomes [43]. For instance, the quality of the peer mentor relationship, specifically closeness and trust, has been found to be related to youth social and academic functioning [44]. However, despite some research that examined the benefits of using peer mentors, this research is still in its infancy. Presently, at best, one can surmise that the benefits found for peer support among the adults who have mental illness will apply to young adults with these conditions.

Conclusion

This article focused on a relatively untapped resource to extend the reach of mental health services – students themselves. The personal and societal advantages of prosocial, altruistic behaviors are well known and students have the potential to instigate changes in attitudes of stigma and discrimination. Even more important, students can be agents to create a culture of caring and protection on college campuses.

As discussed earlier, students will turn to each other for help long before they will turn to professionals [12, 20]. Peer-to-peer interventions seek to capitalize on this natural inclination to help others in distress. As an example, the SSN program at WPI, which works to capitalize on students’ wish to help other students, has destigmatized mental illness and effected change on campus. The SSN program accomplished this, in part, by stating explicitly there are no “us (healthy) and them (mentally ill)” students. Rather, the message emphasizes a sense of caring and community. A reflection of the impact of this program is that approximately 10 % of students on the WPI campus have been trained and participate in this program.

We also described the McLean Hospital College Mental Health Program, an innovative hospital-based program. In McLean Hospital’s Bridge to Campus (BTC) program, peer support is a core component of the intervention. In the BTC program, students demonstrate a capacity to help one another. These supportive relationships develop and endure under the trying conditions of recovering from an acute episode of mental illness. Findings from this program indicate that students continue these attachments, maintaining a support network consistent with the principles of recovery. The literature on peer-to-peer interventions was reviewed. Peer support is one of the 10 core components of the recovery paradigm defined by SAMHSA and has been an important tenet of the adult mental health consumer movement [45]. Scientific investigation into this area is in its infancy, but preliminary findings suggest “that peer support was associated with positive effects of hope, recovery and empowerment at and beyond the end of the intervention” [39].

The mental health needs of college students are the same as their non-college-attending peers. There are, however, significant differences that can influence the delivery of mental health services for college students compared with the general society. For example, college campuses are safer. There is less violence and less access to firearms. Moreover, college students are less likely to suffer poverty and are less likely to experience food or housing insecurity. College students also have better access to health services as most colleges provide some form of on-campus health care including mental health counseling.

College campuses offer opportunities to develop and evaluate mental health interventions that could be disseminated to the general population. For any particular college, the population of students is clearly defined and geographically contained. There are numerous stakeholders supporting change and there is a broad safety net of supportive individuals and services. Moreover, many colleges have a powerful incentive to develop and invest in effective mental health programs because many students who drop out of college experience some type of mental illness [17•].

On many college campuses, the counseling center offers a variety of mental health services. However, the traditional college counseling center was designed to care for a proportionally small number of students. As increasing numbers of students, including more with serious mental health conditions seek care, this model has been seriously challenged. Even with reports that increasing numbers of students have been seeking services at college counseling centers [16•], a large number of mentally ill students do not receive any mental health services or support because delays in seeking help are the rule for mental illnesses [4].

Faced with increasing clinical pressures, fiscal limitations, and deeply invested stakeholders (e.g., parents, faculty), more institutions are recognizing the advantages of a population-based model to serve the mental health needs of the entire student community. Others [46] discuss the advantages of applying a population-based or public health address mental health problems on college campuses. The effectiveness of many interventions with the college student population, including student-to-student support programs has not been rigorously evaluated. Many reports of these support programs have offered descriptions of a specific program, with only anecdotal impressions of their benefits. Empirical evaluations of student-to-student support programs have been limited to a single college or university. Although informative, it should not be assumed that similar outcomes would be obtained at other institutions that differ in size, mission, or make-up of the student body.

To overcome these limitations, it is important to develop broad practice-research networks that bring practitioners and researchers together to collaborate on efforts to develop and evaluate programs like student-to-student support programs [47]. This will facilitate informed data collection, analysis, development, and dissemination of empirically derived and tested practices. College administrators are concerned about the economic impact of programs and evidence that interventions including student-to-student support programs improve the mental health of students and save money will spur the dissemination of effective programs. In addition to experimental designs often employed in randomized controlled trials, investigators may want to consider quasi-experimental designs [48], which can be used in settings like college campuses.

A full analysis of the state of college mental health is beyond the scope of this paper. Although the list of stakeholders is long, the field suffers from lack of a unifying national body. Leaders in the field argue for practice standards, harmony of clinical practice and research, and development of empirically based interventions [49]. Initiatives moving in this direction are underway across the country; the Center for Collegiate Mental Health at Penn State [50], the National Research Consortium of Counseling Centers in Higher Education [51] at the University of Texas, Austin, the Healthy Minds/Healthy Bodies program at the University of Michigan [52], and the JED Foundation [53] to name a few. We are hopeful these opinion leaders will continue to work collaboratively to build broader, richer networks. We strongly encourage this trend to continue.

Enhancing students’ altruistic, prosocial behavior is consistent with a mission of higher education—to develop better citizens and leaders for society. As we have shown, there is a small, generally positive body of research regarding college student peer-to-peer interventions for mental illness. We encourage future development and evaluation of these promising interventions. We strongly encourage the development of practice-research networks to evaluate the effectiveness of interventions designed to improve the mental health of college students.