Editor’s Note: This story contains references to suicide and mental illness that may be troubling to some readers. Additionally, to distinguish between multiple anonymous sources, the names of some students in this article have been changed. These students are identified by first-name pseudonyms, Sophie and James.

On Instagram, Francis Aguisanda’s life looked perfect.

The Ph.D. student posted glowingly about his research on stem cell biology at Stanford, his Bay Area adventures with his girlfriend and the San Francisco March for Science they both attended.

But, beneath the social media facade — the personal brand he had built around being strong — Aguisanda felt like he was drowning.

Suffering from what he would later identify as depression, Aguisanda had to leave the lab and walk to Main Quad every hour to escape. He began to have panic attacks, and his professors’ words “felt like water,” he said, spreading his fingers wide to describe the sensation of knowledge slipping through his consciousness. It was a frightening feeling for a bright, successful student whose academic prowess had always depended on his quick comprehension.

Struggling at the very university he had held up as his dream and trapped between feeling that he could not continue with his Ph.D. program but that he also could not stop, Aguisanda’s thoughts began to spiral.

“I was on the train to a particular destination,” he said. “I didn’t know where I was going, but I was moving too fast to jump.”

On April 24, 2018, Aguisanda stayed home from lab. He had decided that he would kill himself that evening, and he spent the day preparing to end his life. That afternoon, though, he spoke to his girlfriend over the phone, and he confessed to her that he was having dark thoughts. She dropped everything to come to his side, and called Stanford’s Counseling and Psychiatric Services (CAPS).

Aguisanda would spend the next six days in Stanford Hospital’s psychiatric ward. From his window, he could see the lab building where he had spent so many hours.

“My friends are working right outside this window, and I’m in here,” he remembered thinking. “It was the worst moment of my life.”

A mental health crisis

After leaving the hospital, Aguisanda spent three months going to therapy for 20 hours a week, and he began taking antidepressants. Now, he regularly speaks out about his experiences, advocating for better mental health treatment at Stanford and posting candidly about his recovery on Instagram.

But not all stories have Aguisanda’s happy ending.

Nearly a year after Aguisanda entered Stanford Hospital, Stanford is grappling with the aftermath of two suicides in the School of Engineering. One fifth-year materials science and engineering Ph.D. student died by suicide just over a month ago in the Paul G. Allen building. Kelly Catlin, a former world-champion cyclist and computational and mathematical engineering master’s student, died last Thursday in her on-campus residence.

However, the “mental health crisis” — a phrase used by multiple interviewees — among Stanford graduate students reaches far beyond these two students. It extends into the ways counseling and psychological services are provided at the University and into the intrinsic nature of graduate education. In interviews with The Daily, current and former Ph.D. students described insufficient mental health services and a culture of overwork, further worsened by toxic advisor relationships and a learned reluctance to discuss mental health. Many students were granted anonymity to prevent them from being blacklisted within the small, specialized fields that make up the upper echelons of academia.

Despite the stigma, this year alone, such issues have been publicly aired at Stanford in a variety of different forums.

In a survey of 1,180 graduate students conducted by the Graduate Student Council (GSC), one-third of respondents reported that they were either neutral or dissatisfied with their mental health — numbers Aguisanda and others believe to be even higher in reality due to the taboo surrounding the issue.

At a GSC town hall discussion last October with representatives from CAPS and Student Affairs, graduate students identified similar themes, raising grievances over the financial and logistical difficulties of seeking off-campus psychological care and the difficulties of working with advisors “who don’t understand the importance of work-life balance or mental health.”

On Feb. 21, more than one hundred students protesting Stanford’s “inhumane and deficient” leave of absence policies, currently the subject of a class action lawsuit, took to the steps of White Plaza. Amid a lineup of mostly undergraduates, geological sciences Ph.D. student Sandra Schachat stepped forward.

“A number of years ago, there was a wave of graduate student suicides,” she told the crowd. “The University’s response was to create a program where students who live off campus could get boba or hamburgers together. We don’t need more boba. We need humane policies that treat [students with mental health issues] with respect.”

Therapy, on campus and off

In 2015, Sophie — a recent graduate of the School of Earth’s Ph.D. program who wished to remain anonymous in order to preserve her relationship with her advisor — and five others in her Ph.D. cohort took a prospective Ph.D. candidate out to dinner.

Sitting at a restaurant on University Avenue, the prospective candidate mentioned that she was in therapy. One by one, the current students at the table said that they were, too, but none of them had ever discussed it with each other.

“Unless it’s your really good friends, you don’t talk about it,” Sophie said. “It’s still stigmatized, and it’s still seen as a sign of weakness. It took someone to be honest … [and then] everyone else opened up.”

According to statistics provided by CAPS director Bina Patel, CAPS counselors saw 22 percent of the graduate student community over the 2017-2018 academic year, for an average of 4.5 visits per student. Graduate students make up 59 percent of the students CAPS serves, which Patel said is consistent with peer institutions.

Sophie’s experiences with CAPS began in 2013, while she was going through a period of depression leading up to her Ph.D. program’s qualifying exam. Though she started on-campus treatment through CAPS, she quickly realized she would need longer-term care, which CAPS typically does not provide. Moving off-campus to accommodate this need required a month of looking for a long-term provider. Once she found one, her Cardinal Care plan charged a $25 co-pay per session, which she says added up quickly on her graduate student’s salary.

Although she described her experience as largely positive, her reservations about the challenges of receiving off-campus care are common among graduate students, many of whom reported positive experiences with CAPS’ emergency care but found the provider’s long-term care options lacking.

Some highlighted the difficulties of arranging transportation to off-campus providers, an additional hassle and extra cost for students who lack their own cars, and may not even know where their next meal is coming from. This, of course, assumes that students can find an off-campus provider, something they say grows increasingly difficult as a high cost of living forces therapists out of the Bay Area.

As a result, students — during the mental health rally and in the town hall as well as in interviews with The Daily — have called for increased long-term care at CAPS. While CAPS does not have a specific limit on the number of therapy sessions an individual student can have before being referred off-campus, Patel told The Daily, students reported that they were able to have between six and eight sessions before being told they would need to find another provider.

According to Patel, rising Bay Area salaries are making it difficult for CAPS to hire and retain therapists. At the October town hall, Vaden director Jim Jacobs added that CAPS has open positions that it has not been able to fill, although he also implied that CAPS, as part of a larger “ecosystem” of mental health care that includes the psychiatry department at the School of Medicine and off-campus providers, is not the only destination for students seeking mental health care.

For students who do end up off-campus, Patel said that the financial aid office, the Opportunity Fund and the Grant-in-Aid Fund for graduate students are all resources to mitigate the costs of long-term care, which she acknowledged was “a hardship for many students.”

One student — who was granted anonymity in order to preserve the confidentiality of sensitive medical details — found a way to continue receiving care at CAPS for five years, well beyond the typical timeframe: because she takes medication to manage her anxiety, her monthly sessions that she says function mostly as talk therapy officially fall under the auspices of medication check-ups.

It is a system that she describes as expensive — her appointments cost $25 per visit, and medication is $15 a month — but invaluable. When she started feeling worse symptoms just last week, she was able to move up her regular appointment to be seen the next day. Had she not maintained her therapy at CAPS, she believes she would have had to wait far longer to be seen. This convenience of care has led her to stay on her medication even though she believes that she no longer needs it, she said.

For students not in her situation, wait times for traditional appointments can extend beyond three weeks, according to Patel, who wrote that CAPS is struggling to keep up with requests for new appointments that are 25 percent higher than they were three years ago. However, she stressed that students with same-day needs can walk in to CAPS during business hours and be seen by on-call staff, and that counselors are always available over the phone — emergency services also praised by students interviewed by The Daily, including Aguisanda.

However, before he ended up at Stanford Hospital, Aguisanda said that he struggled with feeling like his problems were significant enough to warrant therapy, telling himself that grad school was just tough. Though he visited CAPS once, he did not have continuing care, and he had difficulties admitting the depth of his troubles to others.

“A big reason it got to that point was because I felt like I couldn’t say anything until I got to the hospital,” Aguisanda said. “Only once I was hospitalized were my feelings valid.”

For Sophie and her fellow Ph.D. students, the stigma surrounding therapy persisted even after their University Avenue dinner. When she told a faculty member in her department about the incident, he told her, “‘Well, this is Stanford,’” she said. “‘We are just going to attract a higher number of people who are like that.’”

“That shouldn’t be normal,” Sophie said in her interview. “Let’s say, even if it is, if Stanford has a way of attracting people who struggle mentally, which I don’t believe — even if it’s true, you should still be doing something about it.”

The advisor-student relationship

In 1998, Jason Altom, a Ph.D. candidate in Harvard’s chemistry department, died by suicide. By all accounts, Altom was exceptionally gifted, with a position in one of the university’s most prestigious labs. He left behind three suicide notes: one to his parents, one to his department and one to his advisor, all calling for changes to Harvard’s chemistry department that Altom wrote could have prevented his death.

Altom’s death was covered extensively in The New York Times, and it sparked a wave of changes in his former department, including the adoption of a three-member committee to monitor graduate students’ progress and free, confidential access to a therapist.

Two decades later, though, pieces of Altom’s last words still rang true for James, who recently earned his Ph.D. from Stanford’s School of Humanities and Sciences and who was granted anonymity to protect his future prospects in academia. James read the article every couple months, seeing himself in Altom’s experiences — in the demanding nature of working in a lab, in the pleas for improvement Altom spent his last words fighting for — and feeling comforted to know he was not alone.

Nearing the end of his Ph.D. program, James felt encroaching pressures that may have besieged Altom as well, 20 years earlier. In the last week of the program, as he was working 17-hour days, James began to wonder how long it would take for a body to reach terminal velocity if it were to go over the side of a tall building. Getting coffee on the third floor of the Clark Center, he hurried down to ground level, worried that if he lingered, he would jump.

In conversation with The Daily, James raised concerns about aspects of life as a Ph.D. student that echoed Altom’s experiences — factors that stretch beyond grievances with a single mental health services provider or even a single university to speak to the fundamental structure of graduate students’ education. James, as well as every other student interviewed for this article, stressed how easily relationships with advisors can turn toxic, as well as how readily some advisors, labs and even students perpetuate a culture of overwork.

Unlike in undergraduate education, where students take a variety of classes and interact regularly with multiple professors, as Ph.D. students writing a dissertation or thesis, students are dependent on a single faculty advisor, who is tasked with acting as both mentor and boss and who students say has the power to make or break not only their educational career but their professional prospects post-graduation.

“It is not only the stress of having only one advisor telling you about your research, but you depend on this person financially as well,” said GSC member and aeronautics and astronautics Ph.D. candidate Ana Tarano.

Advisors fund students’ work in their research group, a dynamic Sophie said can lead to advisors telling students that they simply won’t pay for ideas the advisor doesn’t support. According to James, graduate students’ low salaries for research work also mean that advisors may see them as a source of easily exploitable cheap labor, especially when students’ research is funded by lucrative contracts of which the students see only a fraction.

After James asked his advisor for feedback on a paper James gave him more than a year ago, concerned that the advisor wasn’t respecting his work, his advisor told him he “hadn’t been getting a return on [his] investment for the past year,” James said.

“It felt as if I was telling him he didn’t respect me, and he essentially said, you’re right,” he recalled.

Furthermore, because advisors are the ones who will write their students’ recommendation letters, students — including those quoted anonymously in this article — are terrified to speak against them, for fear that a negative letter will ruin their prospects in the relatively insular world of specialized academia.

Even when students do want to speak up, at Stanford, there is no formal mechanism through which to do so.

“Students who feel trapped by the situation feel like they have to advocate for themselves,” said Katerina Gonzales, a Ph.D. student in earth system science. “And it’s hard to advocate for yourself during a crisis.”

Students end up afraid to speak to their advisors and even to other professors, said Aguisanda; even if students were to speak to another member of the department, there’s no guarantee the complaint wouldn’t find their advisor regardless.

Such behavior is something that Paula Welandar, an earth system science professor who now advises students of her own, has not experienced in her own advisor-student relationships but has seen at multiple institutions.

“It’s difficult for students to come forward,” she said, “and they feel like they’re the only one in this toxic relationship.”

Ideally, Welandar said, advisors — who she termed students’ “first line of defense” — should work with students not only on their experiments but on their next career moves and on their mental health. However, she said she recognizes that the “power differential” inherent in the relationship, as well as the gradual nature of academic progress, means this is not always the case. A lack of mental health-specific training for advisors does not simplify the problem.

“Change is hard,” she said, admitting it moved at a “glacial pace — it’s never fast enough.”

At least in her department, she does see improvements: when she was going through school, “people were treated a certain way in academia.”

“You went through that, and because you did, your students have to as well,” she added. “Among my colleagues, I feel like that’s not the mentality we have. That’s not the way to do good science.”

In other departments, however, historical patterns of overwork and strained advisor-student relationships do seem to persist. Both James and GSC co-chair and cancer biology Ph.D. candidate Amy Tarangelo pointed to a “publish or perish” culture in which advisors push students as hard as possible to produce research, although Tarangelo noted that her own advisor did not fit into this mold.

James, who described a “pressure-cooker environment” in which students dealt with feelings of imposter syndrome by never taking a break, made it his New Year’s resolution to take at least one day off a week. Before, he said, he would often work two half-days or even one-and-a-half days on weekends, as was the norm.

“In some labs, it’s a toxic culture of overwork,” Gonzales said.

Still, students emphasized that problems inherent to graduate school were not the only factors contributing to the cocktail of mental health issues at Stanford. Tarangelo stressed that such issues hit underrepresented minorities harder. James cited the financial pressures of living in the Bay Area on a graduate student’s salary as another exacerbating aspect: Stanford graduate students often contend with food insecurity and rent and healthcare costs too high to be covered by their stipends, a recent Daily report revealed.

“I know lots of people who come out of undergrad and work 60 hours a week,” said James, referring to his friends in finance and other industries, “but they’re making so much more.”

Facing forward

On Tuesday afternoon, four days after Catlin was found dead in her dorm room, Vice Provost for Student Affairs Susie Brubaker-Cole, Senior Vice Provost for Education Harry Elam and Vice President for Graduate Education and Postdoctoral Affairs Patricia Gumport released a Notes from the Quad post affirming the University’s commitment to mental health and wellbeing.

In the post, they mentioned a variety of initiatives, including expanding CAPS, providing new trainings for academic advisors and implementing “a new university policy that clearly places responsibility on faculty in departments to articulate advising expectations that support students’ degree progress.” The Affordability Task Force is also taking “a fresh look” at graduate students’ financial needs, according to the post.

“The loss of these community members underscores the importance of our work to support student mental health and well-being,” the post reads.

The GSC is calling for change, too, as it has for some time. The Council’s focus groups on mental health and wellness are working to identify key asks, which currently include increasing student services access at CAPS and improving advisor training to “have reasonable expectations, promote mental well-being, and provide resources to students at risk.” As always, the GSC continues to fund events and programming to build a sense of community and belonging, especially for international students.

“But in terms of the GSC’s ability to implement institutional changes within the university, we have relatively little power,” Tarangelo wrote in an email to The Daily. “As advocates for grad student life, the co-chairs work with admins at all levels of the University to discuss the major issues facing graduate students. We can request changes and improvements, but the GSC itself has no power to implement these changes directly.”

On the University side, CAPS is spearheading a program called CAPS Connect, which are one-time consultation and support sessions located in specific communities. In the School of Humanities and Sciences, graduate students part of the Wellness Information Network for Graduate Students provide other students with information about wellness resources, as well as connect students to those resources. Earth Wellness Liaisons serve similar roles in the School of Earth, Environment and Energy Engineering.

Additionally, the Graduate Life Office (GLO) told The Daily that “mental health and well-being and community are themes and goals in everything we do.” New Graduate Student Orientation, along with programs such as “Grad 201” and Graduate Student Programming Board events, are designed to provide students with information about resources and with community.

GLO director Ken Hsu also identified community associates as “local helpful resources to their residents and as community-builders through the events they organize for their residents.”

Joel Schneider, a community associate and chemical engineering Ph.D. student, called himself “the first line of defense” when it comes to his residents’ mental health problems. His residents come to him with anything from a friend committing suicide to instances of sexual harassment to a roommate who plays music too loudly, Schneider said. However, he also emphasized that he and other community associates are not therapists, and that they are trained to connect students to other resources, rather than to solve their problems themselves.

“As a community associate, I want to be able to support community members, but there are so many other parts of Stanford that should be able to able to advocate for students,” Schneider said. “It seems oftentimes that those are ineffective, and students feel like they don’t have anyone else to turn to.”

After the two recent suicides, Gonzales said, the graduate student community is in “crisis mode.”

“We don’t have time to wait decades for the culture to change,” Gonzales said. “We need to act now.”

For Tarano, there is reason for hope.

“[Mental health] is something that unites all of us grad students,” she said. “We know what it’s like to struggle with us and our friends, and we want something to be done about it. It’s a rallying point for all of us.”

This article has been updated to include information about the Wellness Information Network for Graduate Students and the Earth Wellness Liaisons program.

If you have thoughts of suicide or are concerned about the well-being of another, contact the National Suicide Prevention Lifeline at 1-800-273-8255 or Stanford’s Counseling and Psychological Services (CAPS) at (650) 498-2336.

Contact Erin Woo at erinkwoo ‘at’ stanford.edu.

Editor’s note: The name of the Ph.D. student who committed suicide just over a month ago in the Paul G. Allen building has been removed from this article out of respect for the privacy of the individual’s family.