The University of Edinburgh has a long history of student welfare support. The Student Counselling Service itself has been in existence for over thirty years and is well embedded into the institution. The University Health Service, where the majority of the 20 000 students are registered with general practitioners, also offers a weekly consultant psychiatric outpatient clinic. Referral to this clinic is managed by the GPs and any referral is made through them. However the psychiatrist offers informal consultation directly to advise on any referrals. The other welfare services comprise the Disability Office, the Student’s Association and Nightline, the University Accommodation Service including their Mind’s Eye project. The latter is a specialist service which the Accommodation Service purchase from a specialist housing association. The association provides both training for accommodation staff and also social work support, for students with mental health difficulties, who live in university accommodation. Although the student welfare services operate independently, they share a line manager and are co-ordinated by a welfare consultative committee. This aims to provide coherent policy and service provision for students.

Close working relations are valued by all in the support services, both formally through the committee structure and more informally. We at the counselling service have biannual seminars with the GPs and psychiatrists, liaison meetings with the consultant psychiatrist as well as the chaplain and disability officers and individual meetings with the senior GP. In these we look at particular concerns about our own university, share knowledge, discuss when and where to refer and have confidential case discussions. We have recently started a joint venture with the sports centre promoting exercise as a way to improve mental health.

A case study of Alison, a 20-year-old Psychology student, helps to illustrate the necessity of pre-existing support structures and liaison networks in containing increasing disturbance.

Alison came for counselling under pressure from friends who were concerned about her increasingly withdrawn behaviour. She expressed little emotion, declared doubt about the point of counselling, yet was increasingly agitated in sessions, talking of her disconnected feelings and losing her sense of self. Beyond that she gave very little history other than that she had had a happy childhood. Her parents were both living abroad and suffered from periods of depression. She had an amicable if distant relationship with her siblings, and had had a lot of independence. She had no previous mental health problems, a good academic record, and many friends. There seemed few warning signs of what was to come. Her behaviour became more impulsive and dangerous and Alison was finally persuaded to let the counsellor talk to her GP. Although she expressed no suicidal ideation, the GP and counsellor felt that she was a risk to herself and both of us talked to the consultant psychiatrist. He offered an immediate assessment appointment and Alison was admitted to psychiatric hospital.

What became rapidly clear was that hospitalisation provided relief to the friends and family involved with Alison, but not to her. She was treated for a major depressive disorder but medication relieved only some of the symptoms. Talking helped a little but gave limited containment. Remaining in hospital seemed to increase her self-harming behaviour (cutting, paracetamol overdoses). The effects of Alison’s illness impacted on her carers and friends in a significant way. Her personality changed and her disturbance grew as did her suicidality. Her constant denial of feelings resulted in everyone around her being highly anxious and helpless.

A care plan was agreed between myself, the consultant psychiatrist, GP, and to some extent Alison. The consultant advised that it would be best to keep hospital admissions to a minimum as Alison’s self-harming increased there. We agreed there should be regular GP appointments, weekly counselling appointments and fortnightly psychiatric outpatient’s appointments. As returning to her flat was not possible, the University Accommodation Service provided a room in a small warden supported student house. Alison was put in touch with a social worker through the Mind’s Eye scheme and continued to receive weekly (or more) support from them throughout her illness.

It was obvious that Alison would be unable to complete her year’s study but that the support would be available during her time out from her studies.

Throughout the period of her illness, Alison had four formal carers to support her, Two from the NHS, one from the university and one paid for by the university. This treatment and therapy undoubtedly helped to contain her. This was achieved through structured support but also by the care team understanding and containing the unconscious dynamics.

Alison herself later said, prior to returning to her studies ‘I don’t know if I would be here but for you all’

A course in student support and guidance has been offered once or twice a year for the past five years and is always very well received. It runs for half a day over ten weeks – is open to any member of staff with some responsibility for supporting students. In practice the majority have been academics and all Faculties have been represented.

The first part of the session is given over to consideration of particular issues or practice in developing particular skills. Topics covered include recognising students at risk, how, when and where to refer, the impact of transitions, the responsibilities and limits of the personal tutor role, managing one’s own stress, and the needs of particular categories of students – e.g. international students, those with disabilities. Relevant readings are provided for each session. The majority of the input is from the counselling service but there are invited speakers from other student services, from the Faculties and Student Union so that a picture of a network of care is established. The second half of each session is given over to the presentation by course members of aspects of their own contact with students and to the group’s thinking together about the implications of the situations that are presented.

It is possible to take the course for credit: members who wish to do so write a paper applying their learning from the course to a pastoral care issue in their own Faculties. Many of these – on inter alia student induction, students on hospital placements, needs of disabled students have resulted in improved practice in departments. At the end of the course most participants report increased confidence in their ability to help students, a better grasp of student issues and a clearer sense of what central support services can offer. They tend to become better judges of when students need more specialist help than they can themselves offer and to refer appropriately. Past course members frequently comment on the continuing relevance to their various responsibilities

The Peer Support Programme was set up in Oxford University eleven years ago, initially as a pilot project. This programme provides a thirty-hour training to students in basic counselling skills, after which they make themselves available by offering support and a ‘listening ear’ to other students. It provides a support network within the University for those students who wish to talk about problems they are facing, but are not yet ready, or do not feel they need professional help.

Although mainly basic counselling and support skills are taught on the course, those trained are called peer supporters. In fact, although the peer supporters employ basic counselling skills (listening, support, empathy, clarification, helping a person to come to their own decisions, limit-setting, giving referrals, etc.), what they mainly do is offer support to fellow students. The concept of peer support appears to be acceptable to many students seeking help. Therefore, the Peer Support Programme is designed to complement, not compete with, the University Counselling Service. It is preventive as peer supporters are often the ‘first stop’ for those seeking help, and trained supporters can help a person before a problem becomes too severe.

Panels of students are trained in twenty-one of the undergraduate colleges in the university. The panels are made up of a minimum of four and maximum of twelve students, and consist of undergraduate and post-graduate students, and, sometimes, a member of the Senior Common Room (i.e. academic staff, Chaplain). The training is thirty hours long, and takes place over a ten-week period. It is designed to build on skills as training progresses, as without the earlier group-bonding and skill-building sessions, and the structure they bring to the training, it is difficult for the trainees to grasp the importance of the "issues", especially crisis management, which come in the latter part of training. Individual sessions concentrate on confidentiality, listening, values clarification, decision-making versus advice giving, and getting to know the group. These are followed by two sessions on assertiveness training with the remaining sessions focus on "issues" such as family concerns, crisis intervention and suicide prevention education, limit-setting and referrals. All the work is underpinned by the listening and support skills the peer supporters have learnt throughout.

Following training, fortnightly supervision is provided for the students. Supervision provides continuity for the training group who have moved on to becoming the peer support panel. It is a mandatory and integral part of the existence of such a scheme because through supervision the students’ anxieties are contained and worked with. It is crucial for this type of post-training follow-up in order to hold the boundaries of the sometimes very heavy, upsetting and confusing issues the supporters confront. As they are not trained to be counsellors, it is imperative that this support is provided for the students.