I am responding to a letter in the April 7 issue in which Joseph R. Cowen, M.D., raises an issue about a well-publicized case (Williamson v. Liptzin) in which I have been involved. I agree with him that adequate care for any mentally ill person can be adversely affected by setting arbitrary time limits. I decry this practice imposed on therapists by managed care companies and insurance programs. Since I don’t know how informed Dr. Cowen or other Psychiatric News readers are about psychiatry as practiced in student health settings, let me provide some information.

At the University of North Carolina (UNC) Student Health Mental Health Clinic, the primary mission is to provide quality care to any student in need. Of necessity, this must be short term, and the students are informed of this fact prior to and at the time of the initial appointment.

On average, 6 percent to 8 percent of the eligible 24,000 students are seen each year, for about 3.5 to four visits per student, by the seven FTE professionals (composed mostly of part-time psychiatrists, psychologists, and clinical social workers). During the 25 years that I was director of the clinic, there was never a defined six-session visit limit. (This fact, as well as some of the above data, may no longer reflect current practice at UNC.)

With increasing demand for services, and with some data showing that students coming for care are more disturbed, it is a challenge to student health clinics to provide quality care. This must begin with a thorough assessment considering first the factors leading up to the student’s making and keeping the appointment and how these issues are affecting the student’s life. The therapist must establish a therapeutic alliance, and the therapy proceeds as an integral part of the assessment process. Therapy in part entails teasing out and trying to understand with the students the relationship of their presenting issues as an interplay with how well they have mastered their age-appropriate developmental tasks, their history, their psychological strengths and vulnerabilities, and any biological risk factors.

With other students, it is apparent early on that they are going to require additional therapy or, depending on the symptoms and diagnosis, a medication trial. Our task is to go beyond triage—to establish a sufficient relationship for the student to trust our recommendations, to accept a referral, and to follow through.

My care of Wendell Williamson ended after six visits because he had reconstituted and passed his final exams, the spring semester was over, and he left to go home—a considerable distance from the university. He was well enough to do so. He was informed of the need to continue on medication and given options for his follow-up care. Unfortunately, he chose not to follow my recommendations. Neither a nonexistent arbitrary limit of six visits nor my impending retirement impacted on this disposition.

In a different scenario, had his psychotic decompensation occurred earlier in the fall, I would have continued to work with him until his psychosis cleared. Then, once it became apparent that he could sustain this improvement and continue his pursuit of a law degree without disrupting classes, as with any other student, I would have referred him to another psychiatrist in the university or local community. He could then have continued his individual long-term treatment—something that is beyond the capability of any university student health service.

For a more in-depth discussion of providing treatment in student health centers, I recommend two GAP monographs—"Psychotherapy With College Students" (Brunner/Mazel, 1990) and "Helping Student to Adapt to Graduate School—Making the Grade" (Haworth Press, 2000).

Myron Liptzin, M.D.

Chapel Hill, N.C.

As a former college psychiatrist of 12 years, I have followed the controversial verdict against college psychiatrist Myron Liptzin, M.D., with much sympathy and interest (Psychiatric News, June 2). On reflection, I think the expectations that college administrators have of our work on campus significantly shape the nature of our work—we can never be "all things to all students" or a "full-service bank."

I was hired at Louisiana State University (LSU) in the wake of the 1966 tragedy at the University of Texas in which a former marine, Charles Whitman, climbed up an observation tower on campus and shot 46 people, of whom 16 died. At the time of my hiring, LSU had the expectation that one of my key functions would be to triage for dangerousness—"We have a tower at LSU too!" I had excellent support from campus security and the East Baton Rouge Parish coroner and sheriff, so we could easily remove dangerous students from campus or get them hospitalized either privately or at state facilities.

Unfortunately, in recent years another of the results of deinstitutionalization and marginalization of psychiatry by managed care is the severe difficulty we now have in arranging (involuntary) inpatient care for college students, most of whom have no or inadequate insurance. It may also be that Dr. Liptzin’s patient did not "fit" the usual profile in that most psychotic students deteriorate academically and need to take a "medical leave of absence" to avoid failing grades (with the immediate referral of the student off-campus for treatment).

We had a "limit" on the number of individual sessions a student could receive at the student health service (four a year in 1966, decreasing to two a year by the time I left in 1975) since I was the only psychiatrist there. (We did have "psychiatrist extenders," but that’s another story.)

Finally, as was seen in the recent Columbine tragedy and the Kip Kingle case featured on the PBS program "Frontline," it is difficult for many private practitioners working in isolation—as do most college psychiatrists in my experience—to realize that many factors, such as the Internet and easy availability of guns—are leading to an increase in the number of dangerous youths in the (white) middle and upper classes.

John L. Kuehn, M.D.

Rootstown, Ohio