“Who are your customers, and how well have you served them?” The question, newly introduced into our annual performance review, knotted my stomach.


As a psychiatrist in an American university counselling centre, I provide clinical care to college, graduate and professional school students who come to me for difficulties such as mood swings, anxiety, and relationship problem. I consider them patients, people, students.

Dark thoughts: why mental illness is on the rise in academia

My non-MD colleagues (those who don’t hold the doctor of medicine degree) refer to them as clients – a term I avoid – but which I understand was introduced specifically to free those we help from the potentially pejorative perspective that they are sick or broken.

But “customer”, with its attendant focus on “service”, feels not only antithetical to what we do, but also potentially dangerous, especially in the setting of higher education.

We shouldn’t treat students as customers when it comes to mental health care because, though all health care ultimately seeks to bring satisfaction in the form of alleviated suffering, good mental health care sometimes takes a circuitous route. Treatments take time and may even cause side-effects before they deliver benefits.

Building a relationship is an essential part of healing emotional wounds. The potential benefits of campus counselling centres are diluted by the directive to deliver customer satisfaction, with its attendant emphasis on immediate access, and its framing of the healing relationship in marketplace terms.

Rapid access to care is indeed important, especially in urgent situations, but it’s not the only measure of quality, and for non-urgent problems it can come at the expense of continuity of care. We can’t keep our schedules open enough to see every walk-in – while at the same time running a full programme of regular sessions to make sure we deal with problems until they are resolved. Customer service increasingly translates into a “recognise and refer” model of care, where students are shuffled from one clinician to another.

Overworked and isolated – work pressure fuels mental illness in academia

Mental health problems often affect judgment and insight. The young woman who requests treatment for her depression, but insists her skeletal weight is not an issue, will not be satisfied when I explain that antidepressant medications and therapy will have little to no effect while her body and brain are malnourished. She may balk at seeing a nutritionist, or having a full medical exam, and be annoyed if I insist.

She will be particularly dissatisfied if I tell her that the severity of her anorexia requires she enters a residential program where she will be nourished until her body can respond to treatment for depression. But because everything I’ve learned during my professional training suggests she will not improve, and may even die, without these recommendations, I must make them.

The pre-medical student who thinks he has attention deficit disorder (ADD) because using his roommate’s stimulant drug helped him study will not be satisfied when, because my assessment suggests an underlying anxiety issue rather than ADD, I decline to write a prescription for stimulants.

The student who slept through her appointment on Monday and walks in on Wednesday, when my schedule is completely full, may not feel satisfied when told she has to wait until Thursday.

College students are intelligent and eager to understand: given the opportunity, they can see how a relationship with a psychiatrist or therapist differs from marketplace interactions.