Edyta Dembińska, MD-PhD

Faculty of Psychotherapy of the Jagiellonian University Medical College

University study is a period when the risk of occurrence of various mental health difficulties, including the first episodes of mental disorders, increases. This is caused by a number of factors. The major one is related to the typical course of a mental illness. Most of them begin at the end of puberty and in early adulthood (Table 1).

Table 1.The age of onset of the first symptoms of mental disorders
Mental disorders The most typical age of onset of mental disorders
Schizophrenia 20-30
Depression 20-30 (the first peak of incidence)
Bipolar affective disorder 20-30
Anxiety disorder 15-25
Obsessive-compulsive disorder 12-35
Eating disorders: Anorexia 14-18
Eating disorders: Bulimia 18-25
Conversion disorders 20-30
Somatoform disorders 18-30
Personality disorders 17-30 (diagnosed from the age of 18)

Another risk factor is the transition time between puberty and adulthood, which is when young people become students. This period and the developmental changes related to it such as the need to define your own identity, which includes decisions about your future professional career, establishing your role in a peer group and entering into the first stable emotional relationships, cause great emotional pressure, which increases susceptibility to stress factors.

Additionally, when taking up university study, one must often confront a number of serious life changes such as separation from the person’s family, friends and acquaintances he or she has had so far, the need to fit into the new environment, a different way of studying, greater independence with regard to the person’s style of studying and own budget, the ability to find his or her own place in the complex university structure, making new friends and entering into romantic relationships.

This is why a student’s worrisome behaviour, which includes a sudden and violent expression of emotional difficulties or a slow and gradual change of behaviour, may be first recognised among the academic community. Unexpected, risky behaviour demonstrated by students is not always related to the onset of chronic mental health disorders as it may also be caused by psychoactive substances, the student’s difficult personal situation, poor resistance to stress caused by a build-up of difficult situations in a short time.

During an unexpected onset of mental health difficulties, it is extremely important that the student’s environment (university teachers, other students, other university employees) be able to respond to it in a professional way. Further on in this article I will focus on some selected difficult situations that might occur in the academic context and recommend the best response to each of them.

Suicide attempt

The population of students is not characterised by increased incidence of suicide attempts. Suicide thoughts in this group are usually related to mental disorders (depression, a mixed anxiety-depressive disorder, abuse of psychoactive substances, a bipolar affective disorder, personality disorders or schizophrenia). Most people who have suicidal thoughts never act upon them; nevertheless, the mere occurrence of them should be treated as a potential life threat. The factors that increase the risk of suicide are, above all, earlier suicide attempts, having a detailed plan of suicide and suicide attempts and depression among family members. Additionally, but to a lesser extent, they include a negative vision of one’s future, the feeling of hopelessness and helplessness, the feeling of isolation and alienation, seeing death as a way of escaping problems, abuse of psychoactive substances.

Usually, people intending to commit suicide leave tips as regards their plan prior to it. These might include a farewell letter, sudden fascination with the subject of death, talking directly about their plans or making allusions to them in conversations with other people. Sometimes it may be a suicide attempt before the eyes of others or informing them about such an attempt in a text message, letter or e-mail. What to do if you are certain or able to guess that a person you know has suicide thoughts?

How to behave

  • Talk to the student in a private conversation, ask openly about his or her feelings and plans related to suicide. A question about suicide thoughts will not evoke thinking about suicide and persons who have such thoughts respond well to the interest they have been shown.
  • Remember that all suicide threats must be treated as potential life threats.
  • Treat the student’s confession about suicide plans or suicide attempts before your very eyes as a cry for help – call emergency services if it happens and stay with the student until they arrive.
  • Be calm and composed, express your concern about the student and your willingness to help.
  • Make sure that the student receives medical assistance because only a professional may diagnose the student’s current condition and the risk of death.
  • Tell the student where to ask for help in the future (DSS, Crisis Intervention Centre)

What to avoid

  • Do not try to downplay the situation by telling the student that in fact he or she does not want to kill himself or herself.
  • Do not get involved in a discussion about the absurdity of taking one’s life or the moral aspects of suicide.
  • Do not ask other students to take care of their friend.
  • Do not ignore your own limitations related to providing assistance – do not start any “therapeutic conversations” with the student.

Bizarre behaviour, incomprehensible for the environment

The onset of many mental health disorders that include psychotic symptoms leading to losing touch with reality occurs at the time when young people take up university study. Psychotic symptoms include delusions, hallucinations and complete disorganisation of one’s behaviour. Delusions are false convictions that fail to be adjusted despite the evidence to the contrary. Hallucinations are false sensations, such as hearing voices.

The background of psychotic disorders experienced by students may vary. They may occur after taking psychoactive substances, especially the ones with hallucinogenic properties or a sudden withdrawal of the psychoactive substances taken for a long time. Also, they may accompany schizophrenia, depression, an affective bipolar disorder (the period of mania or depression) or brain infections. Characteristic symptoms include incomprehensible, illogical way of speaking, inability to participate in a logical conversation, extremely bizarre behaviour, emotional reactions which are completely ill-fitted for the situation or no reactions at all, strange behaviour indicating hallucinations (talking to the person that no one can see, covering your ears with hands), strange convictions that lead to serious distortions in perceiving reality (delusions), withdrawal from social contacts, excessive and entirely unjustified suspiciousness.

What to do when, suddenly, a student in class starts to behave in a way that is incomprehensible for his or her environment, makes bizarre declarations or shouts statements which are ill-fitted for the situation?

How to behave

  • If the student’s behaviour is very much disorganised or you fear for his or her health or the health of other people – call an ambulance.
  • In other situations, contact DSS in order to determine later steps.
  • Be direct and specific when you talk to the student, focus on the current situation.
  • Express your fears related to the student’s behaviour and your concern that he or she needs help.
  • Ask for explanation if you cannot understand what the student is saying.
  • Pay attention to the student’s feelings and concerns but without confirming false convictions.
  • Reduce stimulation of senses (turn off the radio, silence other students, if you feel safe, invite the student to another room but remember that your own safety comes first).
  • Remember that in this kind of a situation the student may represent a potential danger for himself or herself because his or her behaviour is based on irrational premises and his or her perception of reality is totally distorted.

What to avoid

  • Do not enter the student’s intimate zone, do not touch him or her and prevent other people from surrounding the student – all this behaviour may cause his or her fear and trigger an aggressive reaction in defence.
  • Do not assume that despite the symptoms the student is able to take care of himself or herself.
  • Do not deluge the student with questions about the causes of his/her bizarre/different behaviour.
  • Do not get involved in a discussion with the student’s delusional thoughts.
  • Do not assume that the student will understand what you are saying.
  • Be flexible in your approach to the student – there is more than one way of behaviour.
  • Do not chase the student who decided to escape – report the incident to the police or the security service at the university.
  • Do not ask other students to take care of their friend.

Bouts of anxiety

Anxiety disorders are the most common mental disorders that affect about 30% of the population. These statistics are also true for students. Because of apparently mild symptoms, they tend to be overlooked. Sometimes, professional medical assistance is provided a few years after the first anxiety episode.

Anxiety may occur in many different situations or be constrained to one specific situation (e.g. public speaking, being in a group, travelling by bus, crossing a bridge, contact with spiders or rats). It may occur as recurrent bouts or chronic symptoms (on-going tension, restlessness, inability to relax). Feelings that usually accompany anxiety include: the inability to relax, excessive fear, problems with sleep, accelerated heart rate, shortness of breath, tremor of hands or the entire body, excessive sweating, vertigo, nausea, the feeling of fright and the fear of the loss of control. How to behave if a student in your class has a bout of anxiety?

How to behave

  • Talk to the student one-to-one.
  • Allow the student to tell you about his or her feelings related to fear as it often helps him or her to relieve symptoms and reduce tension.
  • Provide the student with a quiet and calm place until his or her symptoms go away.
  • Remain calm, speak in a clear way.
  • Assure the student that heor she needs professional help as regards treating anxiety symptoms.
  • Indicate DSS as a place that provides information on treatment options.

What to avoid

  • Do not question the student’s irrational fears (e.g. fear of rodents or spiders).
  • Do not downplay the symptoms of anxiety experienced by the student.
  • Do not convince the student that symptoms do not require a therapeutic intervention.
  • Do not overwhelm the student with a surfeit of ideas on how to solve his/her situation.

Aggressive arguments in class

Students may express their anger verbally, which is a way of responding to difficult situations, especially the ones they are unable to deal with. Often, they pass on their anger on persons who are not the direct cause of their frustration. It should be remembered that, in fact, the student may not be angry directly with you – you just happened to be around when he or she needed to vent his or her anger. Mild symptoms of verbal aggression might be demonstrated when arguing about a grade, in arguments with other students and by excessive involvement in discussions concerning controversial topics. What to do when we are dealing with an argumentative student?

How to behave

  • Prevent the build-up of the student’s anger and frustration.
  • Emphasise that you can see his or her emotions: anger, fury and frustration.
  • Limit the stimulation of senses – if you feel safe, talk to the student one-to-one in calm surroundings.
  • Allow the student to tell you what made him or her lose his or her temper and listen to him without interrupting.
  • Put up boundaries – tell himor her that you cannot accept the behaviour when he or she is shouting at you, tell him or her to move away if they are trespassing upon your intimate zone at the same time showing that what you do not accept is his or her behaviour, not the student himself or herself.
  • If the student’s anger prevents a peaceful conversation, arrange with him or her that you will talk again when he or she calms down.
  • If, instead of calming down, the student’s behaviour escalates, do not hesitate to call the university security service or the police.

What to avoid

  • Do not get involved in an argument; do not raise your voice.
  • Do not act in anger (do not shout, do not try to embarrass or ridicule the student).
  • Do not make the student explain the reasons for aggressive behaviour if he or she does not want to do it.
  • Do not touch the student as it may increase aggression.

Bouts of verbal or physical abuse

Other types of aggressive behaviour include a number of symptoms ranging from intimidation and verbal threats to physical aggression directed at items or people. Aggression can also be expressed by e-mails, phone calls and letters with threats. Although it is very difficult to predict a bout of aggression before it occurs, some factors increase the likelihood of its occurrence. These are: earlier tendencies towards aggressive behaviour, excessive suspiciousness, a paranoid attitude, unstable studying history (changes of university or the programme of study, dropping out of university, conflicts with university teachers or other students), abuse of psychoactive substances, fascination with weapons, cruelty against animals and problems with controlling one’s emotions. It should be emphasised that bouts of increased verbal or physical aggression are not common among students. Only some personality disorders (e.g. borderline personality, dissocial personality) increase proclivity to aggressive reactions. As for other mental health difficulties, various forms of aggression occur as often as in the general human population.

How to respond to the students’ aggressive behaviour such as breaking objects in class, pushing or beating other people, insulting them or threatening with weapons?

How to behave

  • Take care of your own safety – if you feel in danger, call the police or the university security service (indications for calling the police include, e.g., direct verbal threats, threats with weapons, direct physical danger from other people, breaking objects, destroying property).
  • Take care of other students’ safety – tell them to leave the classroom or other room where there is an aggressive person.
  • If you think you should stay with the student until the security service arrives, remain in open space with access to a way out (remain closer to the door, do not allow the student to block your escape route).
  • Make sure that you are assisted by at least one more person from the university staff.
  • Remain calm – there is a greater chance that your calmness will have a positive impact on the student.
  • Indicate to the student in a non-aggressive way what behaviour is unacceptable for you.
  • Use simple language, express yourself clearly and precisely.
  • Promise the student that you will talk to him or her again when he or she calms down.

What to avoid

  • Do not remain in the situation where you are being threatened.
  • Do not talk to the student alone.
  • Do not respond with anger, fury or aggression because it increases the student’s aggressive behaviour.
  • Do not criticise the student.
  • Do not ignore the signals indicating that the student’s fury is increasing.
  • Do not touch the student; do not enter his or her intimate zone.
  • Do not ignore your feeling of danger.
  • Do not make sudden movements.

 

The above-mentioned emergency situations are not the only ones that may be encountered by university teachers. The ones described are the most difficult situations that may come as a shock and arouse fear. In this kind of moments, it is important that the teacher does not panic and remembers about the fundamental rules of behaviour in emergency situations: taking care of your own safety and remaining calm so that you can control the situation all along. You should also remember that the recommendations presented here are general guidelines of behaviour. There is no one effective way of responding and flexibility is advised in each situation.

References

  1. Bilikiewicz A., Pużyński S., Rybakowski J., Wciórka J., Psychiatria, t.1-3 [Psychiatry, Vol.1-3], Urban & Partner, Wrocław 2002
  2. Golec S., Kokoszka A., Postępowanie w nagłych zaburzeniach psychicznych [What to Do in Sudden Onsets of Mental Disorders], Medycyna Praktyczna, Krakow, 2002
  3. “Mental Health of Students in Higher Education”, collective work, Royal College of Psychiatrist, London, 2003