Postgraduate Psychology Students’ Perceptions of Mental Wellbeing and Mental Health Literacy: A Preliminary Mixed-Method Case Study

Abstract

This preliminary study aimed to explore postgraduate students’ perceptions of mental wellbeing and mental health literacy at a university in the East of England. Due to government widening participation initiatives, more students from minority groups are attending universities, most of which have expanded their wellbeing support offers to students through dedicated Student Wellbeing Services and student success teams. This study employed mixed methods with two stages. The first stage, quantitative data collection, employed an online survey (designed by the first author), analysed by Qualtrics with resulting data used to select themes for the second stage, a focus group discussion, analysed by inductive thematic analysis. Five themes and eight sub-themes were identified: 1. Expectations: The university and students. 2. Judgement: Personal perceptions and mental health stigma. 3. Stress: University disorganisation and how stress feels. 4. International Students: Difficulties with studying and healthcare. 5. The National Health Service. The data shed further light on students’ levels of understanding of mental wellbeing (mental health literacy), providing important information for HE policymaking on students’ expectations of support for mental wellbeing. Participants advocated for more promotion of real student experiences of dealing with mental health issues and clearer signposting of support services to further tackle stigma.

1. Introduction

Mental health is universal and refers to a wide spectrum of experiences. An individual’s mental health can be affected by many factors, from the interpersonal to experiences related to the environment. The World Health Organisation (2022) defines mental health as a state of mental wellbeing that enables people to cope with the stresses of life, realise their abilities, learn well and work well. Good mental health is generally perceived as healthy functioning and is often represented by the absence of obvious mental dysfunction. In contrast, poor mental health is associated with mental illness and distress (De Pury & Dicks, 2021) and is known to impair daily living, ranging from minor occurrences of worry/stress to more serious/long-term conditions such as anxiety/depression (Mind, 2014). The term mental wellbeing used here encompasses mental health and refers to more general, wider experiences and the subjective feelings of satisfaction and fulfilment (Barkham et al., 2019) rather than solely the absence of mental illness or distress.

In the United Kingdom (UK), there has been an increasing level of awareness regarding the prevalence of mental health issues. Indications show the rate of mental health issues among the general population are increasing. There were 1.81 million referrals via the National Health Service (NHS) for talking therapies in 21/22, up 24.5% when compared to the previous two years (NHS Digital, 2022). Factors thought to be driving this increase include the negative impact of the pandemic and the increased use of social media, exposing people to information on mental health in a way not seen before. Recently, the cost-of-living crisis has contributed to the increased likelihood of poor mental health.

One-in-five UK university students experience mental health concerns, a five-fold increase over the past decade (Thorley, 2017). A recent survey found 59% of respondents reported a mental health issue, and, of these, 29% reported a diagnosed mental health issue (Student Minds, 2022). Research commissioned by the Universities and Colleges Admissions Service (UCAS, 2021) suggests that there are risk factors making students particularly vulnerable to mental health issues: age, issues associated with transition, stigma related to disclosure and the diversity of the student body. This list is not exhaustive and does not include societal factors that will apply to students as high consumers of social media. Payne (2022) delineates more detail on the additional risk factors applicable to students. In a review of health approaches to promoting student mental health, mental disorders (anxiety, depression, suicidality) were common among university students across 19 high-income countries, with similar risk factors established as for UK students (Bantjes et al., 2022). A US student survey showed that 80% of students were stressed daily, and one-third of first years reported a mental health condition (Mark in Style, 2021) while another found, in a sample of 1074 college students, that 23.6% reported anxiety, depression (18.4%), and stress (34.5%) (Ramón-Arbués et al., 2020). Auerbach et al. (2018) in a WHO survey of 19 colleges across eight countries found that 35% screened positive for at least one of the common lifetime disorders assessed, and 31% screened positive for at least one 12-month disorder.

The physical and emotional move to university is a massive transition for a young person. Students are expected to adapt to significant changes including a new location, culture, and social network. In addition, having sole responsibility for their own wellbeing and learning, some also cope with disability in this context. These factors are intrinsic to university and can predispose students to mental health difficulties, such as anxiety (NUS, 2021). In addition, the age of onset of many mental health difficulties crosses the teenage and university years 18–25 (De Pury & Dicks, 2021) further complicating this period of life.

Recent years have seen an increase in Higher Education (HE) students disclosing a mental health condition at the application stage. Of UK 2020 applicants, 21,105 shared a mental health condition in their UCAS application. This equates to nearly 1 in 25 and represents a 450% increase in declarations since 2011 (UCAS, 2021). However, as a measure of the impact of mental health-related stigma in the HE environment, UCAS estimates that there were 40,000 students entering HE in 2020 with an existing mental health condition, over half choosing not to declare it. Research commissioned by UCAS suggests that students believe disclosure will impact their chance of an offer. These data indicate that stigma related to mental health affects many students, including international students.

The student body is extremely diverse, encompassing the full spectrum of the UK population and a significant international element. Certain demographics within the student community face additional challenges in relation to mental health. Of the 2.75 million students studying in HE in the UK, 2020/21, 605,130 (22%) were international students (HESA, 2022). Language barriers and cultural differences are additional challenges. It is likely that many arriving in the UK for the first time will have little understanding of the healthcare system and eligibility for NHS treatment. A significant and largely hidden issue relates to how mental health and wellbeing is understood and conceptualised by international students. Research suggests that, although international students are more likely to report concerns for a range of issues including mental wellbeing, they are less likely to self-report a mental health issue: 62% UK students versus 47% international students (Frampton et al., 2022). This suggests a misalignment and highlights that it is important to remember that, for other cultures, mental health issues can be marginalised, stigmatised or, at best, understood differently.

Aside from the challenges faced by non-UK students, other factors also contribute to an increased risk of poor mental wellbeing in students. Data from UCAS suggest that, whilst women are more likely than men to be diagnosed and come forward for help for a mental health condition, in 2012, women were 1.6 times more likely to declare a mental health condition than men. However, by 2020, they were 2.3 times more likely than men (UCAS, 2020). This suggests that men are being under-diagnosed and under-reporting, therefore not accessing support. A similar picture exists with ethnic minorities, who, broadly, are less likely to declare a mental health condition than their mixed or white student counterparts. Black and Asian applicants are less likely to declare a condition than those of mixed or white ethnicity (UCAS, 2020). Factors thought to be affecting declaration for ethnic minority students are the fear of judgement and cultural differences in the understanding of mental health conditions. Defeyter et al. (2021) asserted that stereotypes and racial discrimination contribute to lower mental wellbeing for non-white students.

Research indicates that those from the LGBTQ+ population are at greater risk of developing mental health disorders (King et al., 2008). A meta-analysis (Semlyen et al., 2016) provides further evidence. Smithies and Byrom (2018) indicates that the LGBTQ+ student population is not homogenous, making it more difficult to identify issues related to mental health and to provide effective support. In addition, the experiences of other marginalised groups such as first in family, commuter, disabled, neurodivergent, lower socio-economic backgrounds and care leaver students cannot be minimised.

The NUS has warned of an emerging mental health crisis amongst UK students, driven by numerous factors: the commercialisation of HE and creating a culture that focuses on rankings and profitability, leading to a lack of focus on the student experience (NUS, 2021) and student mental health and wellbeing. There is also reference to a lack of funding for support services such as counselling within HE. Given the current state of NHS waiting lists for services, it is likely that this situation also exists in educational settings. Further, there is the financial aspect. Benson-Engleton (2019) found a link between mental wellbeing and financial circumstances, as students experiencing financial difficulties had lower levels of mental wellbeing (Benson-Engleton, 2019).

The impact of the COVID-19 pandemic in HE has been considerable with at least three effects: (1) the obvious detrimental impact on student mental health during the lockdowns, (2) the effect on new students who found transitioning to HE harder following disruption to their previous education, and (3) graduates concerned that the pandemic would affect job prospects (Lewis & Bolton, 2023). Furthermore, a survey found 79% of respondents were worried about this issue (Brown, 2020). There is a fair degree of nuance within the above effects if we consider the diverse nature of modern student cohorts, as many work alongside studies and some have caring responsibilities or financial dependents (Stone & O’Shea, 2019). The pandemic created a set of practical issues around learning; for example, the switch to online learning and many students were forced to isolate in their student accommodation or to leave, creating major life disruption (McGivern & Shepherd, 2022). Brown (2020) investigated the impact of the COVID-19 pandemic on UK university students. It was found that, whilst the fear of COVID-19 was low, increased depression, anxiety, stress and worry and a general deterioration in mental health and motivation to study were among its most prominent findings (Brown, 2020). It is reasonable to infer that the pandemic has had a uniquely and considerable negative impact on mental health and quality of life for university students.

The consequences of poor mental wellbeing for students are serious and span from poor academic performance and attainment, withdrawing, to self-harm and suicide at the extreme end (Lewis & Bolton, 2023). Currently, within the UK education system, a duty of care will be introduced, which refers to placing a legal obligation on schools, colleges and universities to ensure the safety and welfare of children/students (Department for Education (DfE), 2024). Recently, the family of a student who died by suicide took the university to court for negligence, arguing that their daughter was a victim of disability discrimination. Although it was a complicated case involving a student with a diagnosed mental health condition, the outcome highlighted the lack of a ‘duty of care’ owed to students by universities. This is important because, in this case, the duty of care was discussed in the context of psychiatric injury and harm. The duty of care issue also casts light on student suicide and how HE supports students at the most serious end of the mental health spectrum. Universities UK (UUK, 2023) reported that, whilst the rate of student suicide is half that of the wider population, one in four young people will, at some time, experience suicidal feelings. Suicide is the biggest cause of death for young adults and men (Maggs, 2021). Despite this, UUK does not advocate for the extension of a legal duty of care to students, arguing that the current framework is proportionate and practical through the adoption of its initiatives, such as Suicide Safer Universities (2018), Whole University Approach and the Stepchange Framework (UUK, 2020). Clearly, the scope of the duty of care issue is an important one to address in HE.

However, universities have taken significant steps to support students with their mental health. Many interventions that were adopted during the pandemic, such as the recording of lectures, have remained. These adjustments support those with specific learning disabilities or students who combine their studies with paid work. In recent years, HE has structured mental health and wellbeing support through dedicated wellbeing services teams. The offer has been expanded to include counselling, one-to-one advice and online tools. Crucially, a diagnosis is no longer needed to access this support. Most universities (99%) have adopted the enhanced suicide-safer guidance provided by UUK (House of Commons, 2023).

In 2019, the University Mental Health Charter was created (Hughes & Spanner, 2019). Whilst the Charter Improvement Programme is voluntary, it encourages HE to adopt a whole institution approach to student mental health. It provides specific guidance to university staff to share good practice and improve their approach to mental health and wellbeing. Adoption provides a platform through which the training of academic and support staff can be stepped up.

‘The Stepchange Framework: Mentally Healthy Universities’, relaunched by UUK in 2020 and co-developed with the University Mental Health Charter, is a strategic framework advocating for mental health and wellbeing to be seen as central to the student experience. The framework provides guidance around the effects of discrimination, culture and environment, early intervention and prevention with respect to mental health.

Gorczynski et al. (2017) suggested that higher rates of mental health literacy were significantly positively correlated with help-seeking behaviour. Furthermore, in a review of studies measuring factors associated with student mental wellbeing, Campbell et al. (2022) found that low levels of mental health literacy were amongst other behaviours associated with poor mental health. These studies demonstrate the importance and relevance of understanding students’ perceptions of mental wellbeing and the knowledge and understanding (literacy) of mental health.

The research demonstrates that there are a wide range of reasons for the escalating poor mental wellbeing for students in HE. However, little has been established for student mental health literacy in individual universities and none with postgraduate psychology students. A report conducted by Ulster University and Atlantic Technological University suggested that some students may be attracted to psychology due to negative early life experiences. It found that psychology students reported elevated rates of panic disorder and social anxiety (Murray et al., 2022). With reference to postgraduate studies into student mental health, a global study of 2279 postgraduates found that they were six times more likely to experience depression and anxiety than undergraduates (Evans et al., 2018). Students of psychology at postgraduate level may, therefore, be at risk of poor mental wellbeing and mental health literacy.

The current preliminary study presented below fills a gap in mental health wellbeing literacy studies amongst students. Furthermore, it adds to the research on the mental wellbeing of university students. It provides useful preliminary insights into the difficulties that these postgraduate psychology students in this university experience with reference to mental health literacy/wellbeing during their studies.

2. Methodology

2.1. Research Question

What are the experiences of postgraduate psychology students in a university in the South-East of England towards mental wellbeing including mental health literacy?

2.2. Aims

• To explore through a mixed methodology the perceptions of postgraduate psychology students towards mental wellbeing and mental health literacy at one university.
• To make preliminary recommendations for further studies on mental health literacy with postgraduate psychology students.
• To analyse these perceptions and discuss the findings in relation to the literature.
• To understand the limitations of this preliminary study in view of further studies within postgraduate psychology student communities.

2.3. Hypothesis

It is hypothesised that postgraduate psychology students will provide their experiences and understanding of elements of mental wellbeing (including mental health literacy) arising during their studies. It is anticipated that aspects such as limited literacy, stigma, accessibility and acceptability of mental wellbeing services will emerge together with barriers and any enablers to support for mental wellbeing at this university.

2.4. Design

Ethical approval was granted for this study with Protocol Number LMS/PGT/UH/05385. This preliminary case study was undertaken to explore MSc psychology students’ perceptions of mental wellbeing and mental health literacy at an East of England university. This study aimed to explore the support that students expect the university to provide, both in terms of teaching, support from academic staff and university services such as counselling. This study employed a mixed-method approach with two stages. Future research will be required with a larger sample and across other programmes of study.

The first stage was a survey that collected data from 22 students regarding views on aspects of mental wellbeing and mental health literacy. The survey had five sections: an initial section requesting 17 items of demographic data and a further four sections using Likert Scale rated questions. The ratings used were 1 Strongly Agree, 2 Agree, 3 Neutral, 4 Disagree, and 5 Strongly Disagree. The four sections were as follows: (1) Identifying Mental Health Difficulties, (2) Support for Mental Health from Academic Staff, (3) Support Services—Student Wellbeing Services and (4) Ongoing Support for Student Mental Health Needs.

Sample statements follow from four of the sections, respectively, such as ‘I have some knowledge of the risk factors that may cause poor mental health’, ‘I believe it is the academic’s duty to approach me if I am showing signs of concern for mental health’, ‘I would be reluctant to approach Student Wellbeing Services due to poor experiences’, and ‘I am confident to request support for a diagnosed mental health condition’ (please see Supplementary for the survey).

The second stage was a focus group with seven participants. The investigator (second author) asked a series of semi-structured questions based around topics derived from the first stage data collection. For example, how do you think stigma around mental health affects students? The discussion was audio recorded and transcribed verbatim. The completed transcript data were analysed inductively using a six-step qualitative analysis process, known as thematic analysis (Braun & Clarke, 2006). The key themes that arose during the focus group are considered in the findings and Section 4 below.

2.5. Respondents

The survey sample was recruited opportunistically via a call on the psychology programme website, email and social media. The demographics for participants in the survey are shown in

Table 1. To show respondent demographics for the first stage by frequency.

Age 22–29 Years	9
Age 30–49	9
Female	13
Male	3
Non-binary	1
Prefer Not To Say	1
White	8
Asian/Asian/British/Asian Other	3
Black	6
British	0
Mixed	0
Chinese	0
Other	1
Refused/Unknown	0
International Student	10
Home Student	8

and for the focus group in

Table 2. To show respondent demographics second stage by frequency.

Age 22–29 years	4
Age 30–49	3
Female	4
Male	1
Non-binary	1
Prefer Not To Say	1
White	2
Asian/Asian/British/Asian Other	2
Black	3
British	0
Mixed	0
Chinese	0
Other	0
Refused	0
Unknown	0
International Student	3
Home Student	4

. The only requirement to participate was to be a postgraduate (MSc) psychology student. There were 22 respondents, of which 18 respondents’ data were usable.

2.6. Materials

The self-developed survey was delivered online via Qualtrics and was formed of five sections: (1) Demographics (17 items) (2) Identifying Mental Health Difficulties (9 items), (3) Support for Mental Health from Academic Staff (20 items), (4) Support Services—Student Wellbeing Services (12 items), and (5) On-going Support for Student Mental Health Needs (8 items).

The focus group was via Zoom. An interview schedule containing questions derived from the analysis of the survey data was employed (see Supplementary). The focus group discussion was audio recorded using a mobile phone and on Zoom.

2.7. Procedure for Recruitment

For the survey, once a volunteer respondent clicked the link on the email, an instruction would appear requesting that they read the Information Sheet and Informed Consent Form (see Supplementary). Participants were told that the survey would take about 15 min to complete. The first section required participants to select one answer for each of the 17 demographic questions. Following this, the first topic appeared containing a short definition of mental health and wellbeing to provide an informative introduction to the area of this study. There were then four sections of statements relating to different aspects of student mental wellbeing and mental health literacy (detailed above). Participants were asked to select one option on the scale of Strongly Agree to Strongly Disagree and advised not to select more than one answer per row. At the end of the survey, participants were asked if they would like to leave their email to be involved in the focus group discussion, the second stage of this study.

For the focus group, a list of topics was created following analysis of the survey. Key areas of disparity among students’ views were identified from the initial data. Themes for the questions/topics were formulated from these identified areas and care was taken to ensure questions were open-ended and varied. In advance, volunteer participants were provided with an Information Sheet and a Consent Form via email (see Supplementary). Given the sensitive nature of this topic, the investigator spoke to participants at the start of the focus group to ensure that they understood it was confidential, the data anonymised, and they could cease involvement if the discussion made them feel uncomfortable/distressed without consequences. In addition, they could request that their data be omitted without any consequence to them. Participants were provided with a Debrief Sheet, which signposted various sources of mental health support, should it be needed. The focus group lasted for just over one hour.

3. Results

3.1. Survey Data Analysis

The survey contained 49 Likert-type statements for each sub-section/block, as follows:

Block 1: Identifying mental health difficulties: nine statements.

Block 2: Support for mental health from academic staff: 20 statements.

Block 3: Support for mental health from Student Wellbeing Services: 12 statements.

Block 4: On-going support for mental health needs: eight statements.

To identify statements that generated the most varied responses across the respondents, the mean and standard deviation (SD) score was calculated, for each of the statements. Those which generated the most varied responses (indicated by larger SD values) were then considered for the formation of themes that would be further explored in the focus group. The tables below show these data for each statement. The questions highlighted were the ones to be considered for the focus group.

The mean statement scores displayed broadly similar ratings within the blocks with scores ranging between 2 and 3.5. This demonstrates that respondents generally displayed positive agreement with statements about their mental health knowledge, the performance of academics and the relevance and usefulness of Student Wellbeing Services. Where the mean scores were closer to three, this demonstrated a feeling of neutrality amongst respondents and does not indicate general discontent or strong feelings of dissatisfaction. The exception to this was in Block 1, with statement one and nine displaying mean scores closer to 1.5. These statements focused on the knowledge of general risk factors for poor mental health and the knowledge of a specific risk factor and the impact of social media on poor mental health and demonstrated that respondents felt greater mental health knowledge in this area.

To prepare for the focus group to determine areas of greater variability of scores and therefore diversity of viewpoints, individual statement SDs were explored. Standard deviations at 1.00 and above were considered. These statements were reviewed to check for possible aspects for exploration in the focus group.

Table 3. To show statements reviewed for themes with example questions.

Question Block 1–4	Question
Identifying Mental Health Difficulties	The university has given me the tools to enable me to identify a fellow student who might be experiencing mental health problems
Identifying Mental Health Difficulties	I have received some education in mental health and wellbeing at the university to support myself and fellow students
Support for Mental Health from Academic Staff	Academics do not have the skills to support students with mental health concerns
Support for Mental Health from Academic Staff	I do not feel comfortable speaking about my mental health needs with academics
Identifying Mental Health Difficulties	I have had an experience where I believe mental health issues carry stigma
Support for Mental Health from Academic Staff	I have had an experience where I believe the stigma around mental health is an obstacle to academics providing effective support for students with mental health needs
Student Well Being Services	The stigma around mental health prevents students with mental health needs approaching the Student Wellbeing Service
On-going Support for student Mental Health Needs	Mental health awareness should be included in the curriculum for all programmes of study

displays the statements in block order that were perceived to represent an area for exploration. The first four and the last statement relate to various aspects of the university’s mental health support offer to students. The other three statements are linked to experience or the perception of stigma and mental health.

University support for students’ mental health and mental health stigma were chosen as areas to be discussed at the focus group. There were some statements with higher SDs, which were omitted and not considered for discussion. One such example was statement number eight in Block 3, a closed question about knowledge of the student wellbeing pamphlet. These types of statements were not selected because they were not considered likely to generate a quality discussion.

3.2. Outcomes

The completed transcript data were analysed inductively using thematic analysis (Braun & Clarke, 2006), a six-step qualitative analysis process. The data were transcribed verbatim directly from the audio recording and coded by marking comments in the margin for each data item. Codes were grouped according to their similarity under broad headings. Themes within the data were then identified in relation to their relevance to the topics posed at the focus group. There were five themes and eight sub-themes. During this process, the investigator remained aware of the importance of always focusing on the participants’ experience as expressed in the data, to ensure as bias-free an analysis as possible.

The findings from the thematic analysis are reported below in

Table 4. To show summary of thematic analysis findings.

Themes	Sub Themes
1—Student Expectations	1.1—Expectations of the university 1.2—Expectations of students
2—Judgement	2.1—Personal perceptions of judgement 2.2—Addressing mental health stigma
3—Stress for Students	3.1—University disorganisation 3.2—How stress feels for students
4—International Students	4.1—Difficulties with studying 4.2—Healthcare
5—The National Health Service

.

3.2.1. Theme 1: Student Expectations

Expectations of the University

This theme relates to that which students expect from the university in relation to mental health and wellbeing. There were many strong statements related to actions that participants thought the university should be undertaking. Although different reasons were cited, there was agreement amongst all but one for a clear responsibility on the part of the university in relation to supporting students with their mental health and wellbeing. The majority of participants thought the university had a clear responsibility to students, even stating it as a ‘duty of care’: “100% there should be a duty of care… I think that it should almost be like a kind of requirement of universities to provide at least some kind of basic mental wellbeing support” (Participant 5, line 63, 52–55).

Most participants were positive about the mental wellbeing service that the university offers:

I think we are really lucky where we are that these services are available if you want to use them……sometimes you just need someone to talk to, you need strategies to put in place to help you cope, you know, with what’s going on and I think we are fortunate that the university does that side of things.

(Participant 1, lines 31–32, 45–47)

Participants saw the university as having a strong role in looking after students, not just providing mental wellbeing services or delivering lectures but being there and present, checking on students:

By holding sessions, by initiating contact with them if there is something.

wrong… so checking up on students would make the students feel like okay,

they are being heard, they are being cared for.

(Participant 4, lines 11–15)

Apart from suggesting a strong, almost pastoral presence on the part of the university, one participant linked this obligation to fees: “we pay a lot for university to have some kind of basic wellbeing support, I don’t think it is too much to ask” (Participant 5, lines 58–59). Another pointed out the accessibility of wellbeing services, suggesting that this is also an important responsibility: “their duty of care around wellbeing and mental health is to make sure that’s accessible” (Participant 2, lines 20–21). Participants are clear that the university’s role here is an obligation and crucial to the success and wellbeing of students. Only one participant felt that there should not be a defined responsibility for universities: “I think it’s good that they offer wellbeing services…. but they are not obligated to do that, they’re not a healthcare service, they aren’t your family, they’re not your friends, they’re not your carer” (Participant 2, lines 24–26).

Expectations of Students

Having clearly defined the role of the university in relation to its obligations to students’ mental health, it is important to mention that there was also discussion around student’s responsibilities: for example, “it is like a personal responsibility to make sure one’s mental health is 100% if possible” (Participant 6, line 240).

There were comments around communicating personal difficulties and how students, as adults, must do this: “number one it’s on my end how I explain my situation and number two is like, how I receive that kind of help” (Participant 4, lines 148–149).

Participants acknowledged that students also have responsibility in communicating about their mental health and how they receive and accept treatment/help.

3.2.2. Theme 2: Judgement

At various times during the discussion, there were some strong personal contributions relating to the fear of judgement. Participants reported fearing judgement in relation to academic ability, personal ability to cope and being judged for who they were.

Personal Perceptions of Judgement

There were two participants who identified themselves as mature students, and they reported fearing judgement around their academic abilities:

you know we all get imposter syndrome at some time in our life… am I going to be like the one that asks the stupid questions or do I just sit back and like just struggle”.

(Participant 1, line 438, lines 449–450)

On the other hand, another, who suggested that they were amongst the youngest students on the course, feared judgement from older staff members in relation to their mental health:

If I had a problem, I’d find it more difficult to speak to, like an older lecturer, to try and reach out to someone that was quite older than me, because I just feel like in the generation above me mental health is so trivialised.

(Participant 5 lines 331–334)

Another experience related to feeling like they just had to cope and get on with it for fear of seeming incapable:

if you say too much about the problem, we tend to say, you know your problem is not special, everybody is facing the same so because of statements like this we tend to suck it up.

(Participant 4, lines 305–306)

Overall, there were varied representations of how students feared being judged. Being judged appeared to inhibit these students from coming forward for support, and this has a detrimental effect on mental health and wellbeing in this sample’s perception.

Addressing Mental Health Stigma

Participants focused largely on ways that they perceive it is possible to address the stigma related to mental health. There was agreement that stigma exists but that things are improving in this area. There was also a high degree of pragmatism, with an acknowledgement that the university can only do so much to address stigma:

The university can only tackle stigma to a certain extent… they’ve ended stigma for mental illness at the university, as soon as you left, you’d still be exposed to everything that contradicts that.

(Participant 5, line 587, lines 589–590)

There was a strong sense among participants that stigma can be broken down within the university by improving the visibility of mental health service provision, for example:

one way I think they can break down the stigma, is the sign postage for help, is visible everywhere. I do know there are areas where students congregate and there’s nothing, there’s no sign postage there.

(Participant 3, lines 577–580)

Many comments suggested that, if the university’s promotional materials, videos etc, featured real students who have experienced mental health difficulties during their studies this would help to normalise the issue and encourage dialogue. The visibility of marginalised groups was also key:

I think like, visibility is very important in addressing stigma, so like, there have been lots of sort of pushes within groups to raise awareness, of men maybe dealing with mental health issues, so like having some sort of programme maybe where you have people being open about their mental health.

(Participant 2, lines 508–511)

Participants saw practical and achievable ways for the university to improve how it addresses mental health stigma.

3.2.3. Theme 3: Stress for Students

Many issues were seen as needless causes of stress. Participants related how they experienced stress on their student journey. Stress is reported in this theme in terms of university disorganisation and how it feels for students.

University Disorganisation

There was overall quite a negative view of the way that the university is run, relating mostly to a perceived lack of structure and disorganisation. All participants commented at some point about disorganisation, perceived as frustrating, for example, “the university just lacks general structure and organisation” (Participant 5, lines 165–166).

This point was developed further by an example of how processes can be elongated or unclear, “we need to speak to this person, or we need to actually get this from this person before we can do this for you” (Participant 5, lines 176–177).

There were other examples, and the point of illustrating them is to represent how much stress and frustration participants felt it caused over and above a stressful Masters’ degree.

In relation to mental health and wellbeing services, participants repeatedly reported being unclear about who was responsible for what. This had to do with signposting and the designation of responsibility rather than the actual experience of the service and more about visibility and clarity within the university:

I would struggle to tell you who was responsible for my mental health and wellbeing at university… is it someone that’s like across the university, is it someone specifically on your course who’s responsible for your mental health?.

(Participant 2, lines 201–205)

This demonstrates the evident lack of clarity that exists around mental health support designation for example, “the variety of options I perceive the university to have, I don’t think it is particularly clear where to go”.

(Participant 3, lines 262–263)

Another participant spoke of not even knowing what some of the services were (in relation to mental health):

I would say there are some facilities that are out there for us to use that we don’t even know are there. So, getting the right information can really point us to places we need to go when we need that mental support.

(Participant 6, lines 251–253)

Consequently, services do not appear to be accessed as widely as might be hoped if there is a lack of understanding about where they are located or who is responsible for mental health and wellbeing.

How Stress Feels for Students

Some participants talked about how they felt during times of mental distress or how they believe students feel when they are experiencing poor mental health or wellbeing such as, “When a student goes through mental health a student can feel lonely and helpless” (Participant 4, lines 6–7). This represents the reality of suffering poor mental health. In addition, the same participant related a personal experience of the mental health impact of struggling with studies, for example, “if we don’t feel successful in understanding a particular concept, that adds a lot of misery and self-loathing” (Participant 4, lines 132–133).

It is important to consider the impact of these feelings.

Another important issue was, whilst suffering difficult feelings, some students struggle to help themselves, such as, “for some of us we know we can reach out, we can talk to people and we can ask for help and support, but I know that’s not the case for everybody” (Participant 1, lines 470–471).

These comments hint at how crucial it is for universities to recognise that not all students are able to deal with difficult feelings and some feel isolated. These are the situations that can lead to the most serious mental health consequences.

3.2.4. Theme 4: International Students

There were some international students participating in the focus group, and aspects of their experience in relation to mental health and wellbeing were raised. These aspects point to additional challenges faced by international students from their perspective.

Difficulties with Studying

There was some discussion from the international students about how they experience and understand the curriculum differently and therefore find studying more difficult. One specific example of difficulties related to the curriculum was that one participant had not previously read papers:

Sometimes international students from different countries have studied a particular subject in a different way….in my undergrad I have never read papers… I guess sometimes that is not discussed. The only thing that’s discussed is the curriculum.

(Participant 4, lines 117–118, lines 124–125)

Another suggested that international students worry about how well they are doing in the course, which can cause mental health challenges that need to be considered:

I would say one of the major causes of mental health, especially from the international students, is maybe academic performances… maybe a particular module giving problems, maybe the school should see it as a source of mental health and they should try to see what they can do about it.

(Participant 6, lines 75–76, 82–82)

It was suggested that academic staff could be more involved in helping international students with their understanding related to the curriculum, for example, “lecturers can help bridge the gap by you know adding some things that might help the people from other spheres” (Participant 4, lines 132–133).

There was also a reference to being able to access the right information and that this was not always straightforward. One participant felt this was harder for international students and therefore made the university experience less straightforward:

I would say one of the most important things especially for international students is getting the right information… getting the right information can really point us to places where we need to go when we need that mental support.

(Participant 6, lines 242–243, 252–253)

The comments generated in this theme demonstrate that international students face challenges beyond the obvious language and cultural barriers. These additional difficulties can impact on mental health and general wellbeing, and additional support would be helpful to bridge the perceived gap.

Healthcare

An important issue pointing to a further challenge for international students was in relation to healthcare. International students are often ineligible to use the NHS. Home student participants had a clear understanding of the purpose and accessibility of the services provided and that international students may be facing a gap, for example,

… you have foreign students or people who are in the country for the first time, … who are not actually eligible for NHS funded services, so they need to be able to access something if they need it quite quickly.

(Participant 3, lines 68–70)

The same UK-based participant suggested that the university should bridge the gap for international students with this issue. The lack of eligibility to healthcare and/or lack of understanding around eligibility could have serious consequences for international students in relation to their mental health.

3.2.5. Theme 5: The National Health Service

Participants made references to the NHS at various points during the discussion. Early on, reference was made to the unreliability of the NHS in terms of waiting times for mental health treatment, such as, “their waiting lists for counselling, or any form of support is absolutely, unfortunately, ridiculous at this time” (Participant 1, lines 43–44).

This was supported by comments from participants who felt that the waiting time for treatment was too long to make the service a viable option for students in need. This was seen as even more of a reason for the university to offer mental health services to students, for example, “waiting lists are really long so I do think that it falls on like, universities to pick up some of that responsibility” (Participant 5, lines 57–58).

Like most educational settings, a diagnosis is necessary to receive specific learning support or adjustments. The issue of NHS waiting lists was further commented on in relation to students seeking diagnosis for specific learning difficulties, for example, “the NHS has a very long waiting list, and I ended up going private in order to get a diagnosis to get support. I had to pay quite a lot of money to do that, and it wasn’t easy” (Participant 2, lines 374–375). Overall, the NHS was not viewed as a viable option for mental health treatment, and this was widely agreed upon and understood.

4. Discussion

The aims of this study were to explore and analyse postgraduate psychology students’ perceptions around mental health literacy and mental wellbeing, to make preliminary recommendations for further studies around mental health literacy and wellbeing in relation to postgraduate students, and to understand the limitations of this preliminary study. The themes identified were as follows: (1) Student Expectations, (2) Judgement, (3) Stress for Students, (4) International Students, and (5) The NHS. The themes relating to student expectations and an aspect of stress for students, university disorganisation, were areas on which all participants commented. The key insights from the students’ views will now be discussed.

Expectations was a strong theme that drew many comments, suggesting that most participants saw the university as having a clear responsibility to provide mental wellbeing services. Reasons for these expectations were wide ranging, including the belief that the provision of services should be a requirement, a duty of care, and there should be a pastoral focus for the duration of their studies due to students paying a considerable amount for university tuition via a student loan. Participants’ expectations were clearly in tune with national developments here, as an education-wide duty of care for students will be introduced. Student suicide campaign groups advocate that universities should have a legal duty of care to students as they do to their staff. In addition, the NUS argues that mental health provision is a fundamental requirement and suggests universities should focus on both service provision and preventative measures in mental health, advocating for mental health support ratings to be placed on university rankings (NUS, 2022). Participants demonstrated high expectations for the provision of mental health support and were in tune with the ambitions of student groups. They displayed a high degree of mental health literacy, likely explaining their high levels of expectation and value placed on the importance of mental health support at university. This may be because the cohort were psychology students; however, other subject domains may contain students with little or no mental health literacy.

In conjunction with expectations, all participants commented on a perceived lack of organisation within the university. This related to how mental health and wellbeing services are signposted and how, from their perspective, students understand who is responsible for their mental health and wellbeing. It is important to note the strength of feeling demonstrated here: if students are unable to easily access support services, they are far less likely to engage with them. Interestingly, apart from some references to support from certain lecturers and a specific experience related to a student with a diagnosis, at no time did any participant relate an experience of an actual engagement with the Student Wellbeing Service. It seems that a lack of clarity over wellbeing services may well be affecting engagement.

There were strong personal representations about the fear of judgement. Participants talked about how they felt in relation to their academic ability, their age, their mental health and their perceived ability to cope. These personal stories are of interest because they come from three students with completely different backgrounds and relate three different scenarios, all demonstrating a fear of how negatively that others, or the university, may view them. This suggests that a fear of judgement can affect everybody, regardless of their journey to becoming a student. It also links to UCAS research, previously cited, which suggests that over half of students entering HE in 2020 chose not to declare an existing mental health condition because of the impact of mental health stigma. A fear of judgement creates additional stresses for many, especially for ethnic minorities/international students.

Linked to judgement is stigma. Participants were pragmatic in their views towards this. Despite many relating insecurities and a fear of judgement, there was agreement that mental health-related stigma is improving in the university environment. They also agreed that the university should tackle stigma through greater visibility of ‘real’ personal experiences. University promotional material was thought to be a useful arena to relate how students cope with mental health difficulties whilst studying. These suggestions again are in line with current research from the student-facing organisations such as Students Minds, who advocate for the visibility of mental health issues as a means of addressing stigma (Student Minds, 2022).

The experience of international students was raised by students present at the discussion. It was suggested that they may have studied subjects differently previously and therefore conceptualise areas of the curriculum differently. An example of this is that one participant had not previously read academic papers and explained that the focus was only on the curriculum and not how to study. The way that this participant had studied was different, and this put the student at a disadvantage and created stress. This example demonstrates a parallel with the issue of how mental health can be otherwise conceptualised across cultures. This is well recognised by groups such as the NUS and UUK monitoring issues related to challenges faced by international students. Conceptualising the way to study something differently does not point to inferior intelligence or learning but can, as in this case, lead to the student finding the subject that they are studying inaccessible. Cultural barriers were also indicated when referring to international students’ mental health literacy (Bork & Mondisa, 2022).

Poor access to information was raised. One participant cited this as crucial, being able to understand how to access services, and support was especially important for international students who are not in their home environment. The experience of discrimination based on race/culture is often cited as a cause of poor mental health for international students, although not raised by our respondents. The focus was firmly on practical issues. There was a discussion about healthcare eligibility for international students, and this is touched upon in the theme regarding the NHS.

At different stages of the discussion, comments regarding the NHS were made. Participants agreed NHS waiting lists for mental health treatment, particularly for counselling and learning-related diagnoses, were so long as to render the service pointless. One participant had to seek a costly private diagnosis instead. Eligibility for healthcare in relation to international students was seen as a significant barrier, commented upon interestingly, by mainly UK-based students. Overall, the NHS was not seen as a viable option for mental health support, with the eligibility issue adding another layer of complexity for some. This is noteworthy in the context of the mental health support that participants expected the university to provide. One comment directly linked the two, suggesting that the University should bridge this gap in healthcare left by the NHS. It is possible that expectations of mental health and wellbeing support that the university should provide have been raised because of the current situation with the NHS. Seen in this context, universities are left with a level of student expectation that may be hard to meet. The Stepchange Mentally Healthy Universities framework led by UUK recognises this gap and is working with the NHS as part of the NHS Long-Term Plan to improve student General Practitioner (GP) access, build university capacity and capability in mental health and improve the student population access to NHS mental health services (NHS, 2019). Given the sentiments expressed in this study, there is still a long way to go to ensure students have confidence in accessing NHS mental health services.

5. Limitations

In terms of the design, the mixed methods allowed themes for the focus group to be generated by the survey, and this was robust. However, analysing mean response scores did not allow the responses with more extreme scores to be drawn out. It is arguable, with a topic such as mental wellbeing, that it may be more useful to explore further the more detailed, individual or maybe even difficult experiences that generate more ‘extreme’ scores. This may result in more usable data for HE, particularly around how to improve the quality of mental wellbeing services.

Although this survey had been tested with a student body before, it has not been validated with large numbers, which is a limitation. This study was with psychology students on an MSc programme, and the sample was limited to the number who volunteered to participate. An incentive to participate in any future study might help recruitment. For example, an award or points towards one of the university student awards.

Another limitation would be a comment on the sample. There were at least two biases. Firstly, the participants were all students of psychology, which would strongly suggest a sample with enhanced awareness around the topic. This could lead to higher expectations of services. Secondly, the sample represented international and home students well, i.e., ten home students and eight international for the survey, and four home and three international for the focus group. The balance of the gender split, however, was heavily female-biased at both stages; thirteen female/three male for the survey and five female/one male for the focus group. Therefore, overall, this research was heavily biased towards the female viewpoint. This is undesirable given mental wellbeing services are accessed and needed by both genders.

6. Further Research

In terms of further research, dedicated engagement with male students is suggested. This study identified male representation as an issue, and this is borne out of wider research, suggesting that women are more likely to disclose and seek help for a mental health condition (UCAS, 2020; NUS, 2022). To redress this imbalance, male perspectives in relation to mental health must be heard. If universities wish to encourage male students to disclose a mental health issue and to access help when problems arise, it will be important to understand what inhibits male students from being open about their mental health and wellbeing and ultimately learn how to engage them in services. This could be most usefully investigated using a qualitative approach through male-only confidential focus groups. As such, Student Minds have undertaken a three-year project, working with male students: ‘Well Lad’ (Maggs, 2021). Using various media, including podcasts and informal groups, an online support resource has been created. These kinds of approaches need to be adopted by universities to begin to address the current under-representation of males.

Further work could be conducted exploring ways to improve mental health literacy within the postgraduate (and wider) student population. Poor mental health literacy is consistently associated with poor mental health (Bantjes et al., 2022). Given that the NUS advocates that UK universities take a role in preventative measures (NUS, 2022), explicit mental health literacy education could be an important aspect of this. Digital interventions and information delivered during the ‘freshers’ period or alongside the curriculum could be considered.

In conclusion, research on psychology undergraduate students’ mental health is limited. Mental health links directly to students’ wellbeing and success. It is recommended that researchers study students’ experiences, share findings, and communicate best practises for all stakeholders.

7. Conclusions

Overall, participants demonstrated a high level of mental health literacy and pragmatism in their views on tackling stigma. There was agreement that the university should provide mental health support, but it was viewed as disorganised in the way it provided information related to services. Whilst being generally positive about what was perceived to be on offer, there was only one report of engaging with university mental health services. This could be related to confusion over access but also could be a reluctance to relate private experiences given the earlier reported levels of fear of judgement.

It can be cautiously speculated that the lack of clarity over access to wellbeing services could be affecting this university’s ability to effectively tackle mental health-related stigma. It seems clear that participants want mental health success stories to be promoted both as a means of tackling stigma and reducing the fear of judgement. The university could usefully adopt these suggestions as part of the progress towards a more mentally healthy university.

These findings suggest that, whilst students may have high expectations of what the university should provide to them in relation to mental health, they may simultaneously feel stigmatised in relation to their abilities, fearful of mental health stigma and be unclear about where to access support. Furthermore, this exists in a climate where the NHS is not seen as a viable support option. The likelihood of negative impact to studies and personal life is clear. It is suggested that, beyond the UK university involved in this preliminary study, the HE sector must reflect on how their mental health services are signposted and organised, how they promote real student mental health stories to continue to tackle stigma and how they consider promoting positive mental health literacy amongst students and staff.