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Sound Mind, Sound Student Body

Challenges and strategies for managing the growing mental health crisis on college and university campuses
University Business, April 2013
mental health

Before entering college, Nicole, a junior at a small liberal arts college in New England, had been getting treatment for anorexia for two years. Finding a college with adequate mental health services was one of her biggest concerns, so she was relieved when the director of counseling services at the college she selected promised her a full treatment, complete with a weekly dietician meeting and regular sessions with a psychiatrist and a therapist.

“I entered [college] full of hope, but was immediately disenchanted with the counselors,” she says, noting that the dietician was in such high demand, she could only see her every three weeks. By the second semester of her freshman year, Nicole had relapsed.

“It was clear that there was no system in place,” she says. “The physician did not find my symptoms serious enough, and the psychiatrist had found another job.”

Nicole is now seeing a psychiatrist at school who she feels “makes a great effort to meet the medical needs of students on campus.” Yet, she is still unsatisfied with the counseling services as a whole, specifically with graduate student interns working in the center who she feels are inexperienced and not equipped to diagnose complex disorders, let alone identify symptoms.

Nicole isn’t alone in needing on-campus mental health services. One in four college-aged Americans has a diagnosable mental illness, and severe mental illness is more common among college students than it was a decade ago, according to the American Psychological Association. Meanwhile, state and local funding for higher ed declined by 7 percent, to $81.2 billion, in 2012, and per-student funding dropped to the lowest level in 25 years, according to the State Higher Education Executive Officers Association.

With an increased demand for counseling services paired with budget restraints, experiences like Nicole’s aren’t uncommon.

Why the Increase?

Early intervention and a decreased stigma surrounding mental illness are two reasons campus counseling centers are seeing an increased demand.

After the shootings at Virginia Tech and Northern Illinois University in 2007 and 2008, most institutions began creating behavioral intervention teams—called early intervention teams, care teams, or threat assessment teams, depending on the campus.

“These intervention teams are keeping students from falling through the cracks—which is a good thing—but it increases the demands on counseling centers,” explains Dan L. Jones, president of the Association for University and College Counseling Center Directors.

“It’s kind of like a small town with four-lane highways coming into it. All the traffic is able to get into town, and then there’s nowhere for it to go,” explains Jones, who serves as director of the Counseling & Psychological Services Center at Appalachian State University (N.C.), as well.

A decrease in the stigma surrounding mental illness is also responsible for the increased services demand, as more students visit counseling centers from self-referrals.

“This generation of students seems more willing to seek counseling,” says Jones. “There used to be more stigma to getting counseling, and since the stigma has diminished, that leads to more counseling.”

Difficulty Meeting the Need

A 2012 survey by the American College Counseling Association found that more than one-third (37.4 percent) of college students seeking help have severe psychological problems, up from 16 percent in 2000. Of the 293 counseling centers surveyed, more than three-quarters reported more crises requiring immediate response than in the past five years.

Despite the increased need, tight budgets aren’t allowing for many counseling staff hires to pick up the slack, with the number of counselors increasing only marginally over the past 20 or 30 years, shares Drew Walther, national chapter director for Active Minds, Inc., a mental health advocacy organization with more than 400 campus chapters dedicated to outreach.

Active Minds exists to help remove the stigma and start a larger conversation about the issues surrounding mental health. But it also helps fill a hole in the need for outreach. As counseling centers get busier, counselors who would normally be promoting available campus services wind up spending all their time fulfilling an increased need for therapy sessions, so outreach falls to the wayside.

Even with counselors working full throttle, students are still not able to receive as much help as they need. In non-emergency situations, it’s common for students to have to sit on a waiting list for a month before getting their first therapy session, and about half of institutions use a short-term model, where students are only allowed six to 12 sessions per academic year, shares Jones.

Last February, before hiring a new staff member and taking on additional trainees to help with the client load, Appalachian State referred out 60 percent of the students who came in. Even after referrals, the center still had a waiting list 70 people long, shares Jones.

“Therapy works best in long chunks, and if you’re only getting six sessions, how much progress can you be making?” points out Walther.

The most recent AUCCCD survey shows that more institutions are adding counseling positions, which could signal that administrators recognize the greater need for mental health services. But Jones points out that the trend is coming on the heels of the economic downturn when resources remained static, but demand was steadily growing.

“It’s not like there’s some huge trend of hiring lots of counseling center people. It’s just better than the past few years,” says Jones. “It’s improving, but it’s far from meeting the demands of university counseling services to see all the students that need to be seen in a timely manner.”

Consequences: Drop Outs, Violence, Litigation

A 2012 National Alliance on Mental Illness survey of 756 college students living with mental health conditions found that 64 percent of those who had stopped attending school within the past five years did so for a mental health-related reason. Half of those students didn’t access mental health services and supports while they were attending.

In other words, at-risk students falling between the cracks and being unable to complete could harm a school’s ability to retain students. In addition, without proper outreach and care, troubled students could harm themselves or others. Suicide is the second leading cause of death among college students (second to accidents), according to the Centers for Disease Control. Each year, 1,100 students die by suicide—figures that have remained steady in recent years.

There is also a risk for litigation. A noted 2002 wrongful-death lawsuit against MIT was a first in the higher education world. It implied that it’s not only medical professionals who legally have a “special relationship” with their patients who could be held responsible for a death or other incident, but schools, administrators, and other employees could, as well.

In 2000, Elizabeth Shin, an MIT student, died from wounds inflicted by a fire in her dorm room. Shin had multiple suicide attempts and hospitalizations for mental illness in the past, although it was never proven whether her death was suicide or an accident.

In 2002, Shin’s parents filed a $27 million wrongful death lawsuit against the institution, as well as administrators, campus police, and mental health employees, claiming their daughter did not receive enough mental health treatment and that the fire was not responded to properly. In 2006, the case was settled out of court for an undisclosed amount.

“It was never clear what the results might have been, but it really shook up the university world,” recalls Jones of AUCCCD.

A more recent example worth considering is the pending litigation over last year’s movie theater shooting in Aurora, Colo. against the University of Colorado, Denver and shooter James Holmes’ psychiatrist Lynne Fenton.

Although Holmes left the institution a month before the tragedy, at least 20 tort claims have been filed saying that Fenton and the university’s threat assessment team should have done more after it was brought to their attention that Holmes could have been dangerous.

Doing More with Less

While increasing resources is the best way to improve services, doing more with less is the option that’s more realistic for many schools in the meantime. Here are some strategies Jones has seen counseling centers across the country adopt to deal with the influx of students seeking services:

  • Increased use of group therapy. “Outcome studies report equivalent results between group and individual therapy,” says Jones. “Advocates for group therapy point out that it is cost-efficient and time-efficient since more people are served.”
  • Using trainees (such as field placement students or graduate assistants) to help serve clients with less severe illnesses, and interns or post-docs to help with the more severe clients. This requires adequate office space, which many centers are lacking, notes Jones. 
  • Increased use of technology and online services, including online and distance telecounseling to help with excessive demands.
  • Hiring part-time temporary contract therapists during peak usage times. Such staff often need advance notice to be available, and institutional administrators would likely need to complete time-consuming background checks before contract therapists can start working, points out Jones.

The Outlook

As with other big issues within higher education and the community at large, reaching agreement on how to improve mental health services won’t come easily.

“There are so many decision makers, getting all of them on the same page and getting them all in line to be supportive of counseling centers—financially and resource wise—is difficult,” Jones says.

But federal efforts could influence everyone, from state legislators to chancellors to boards of trustees.

The Garrett Lee Smith Memorial Reauthorization Act of 2013,  a bill introduced in Congress earlier this year, may be one such step.

The bill would increase grant funding for colleges and universities from $5 million to $7 million for providing counseling services and training mental health providers, according to the office of Senator Jack Reed (D-R.I.), a sponsor of the bill. The original bill, enacted in 2004, provided funding for suicide prevention education and outreach, not for the delivery of services.

The act also funds the Suicide Prevention Resource Center and provides grants to states and tribes to support suicide prevention efforts.

“Over the past 10 years, we’ve been looking at what’s been going on among children and young adults to see where improvements can be made and how schools, colleges, and universities are using their funding,” according to the office of Senator Reed. The conclusion was that education institutions needed the flexibility to expand their use of the funds outside of outreach.

“When you think about kids going off to college and the services that universities offer, mental health is a critical component. If we don’t have an infrastructure that’s capable of providing treatment on those campuses, there are students who will go without.”