It’s the day before Samia Chughtai’s first big exam at the Johns Hopkins University, and the recent transfer from Northern Virginia Community College is “very stressed.” She’s come to the top floor of the library for a study break, and a free massage.
For the next five minutes, Osiris Mancera, a sophomore, will roll, squeeze, and twist the tension from Ms. Chughtai’s muscles. When it’s over, Ms. Chughtai says she feels calmer than before.
“I’ve had back rubs from professionals,” she says, “that were not as nice as this.”
Welcome to Mellow Out Mondays, a weekly event in which trained student volunteers offer seated massages to stressed-out classmates through a program known as Stressbusters. The program, which is paid for by Hopkins, tackles stress head-on, aiming to assuage anxiety before it escalates. It’s a small part of a growing effort to ease the strain on campus counseling centers, which have seen an unrelenting — and unsustainable — rise in demand for mental-health services.
Over the past six years, the number of students seeking appointments has grown by an average of 30 percent, five times the average rate of enrollment growth, according to the Center for Collegiate Mental Health. This growth is due to several factors: More students are arriving on campus with pre-existing diagnoses and psychiatric medications. More faculty members are referring students for treatment, and more students are seeking it, thanks to a reduction in the stigma surrounding mental illness.
In some ways, colleges are a victim of their own successes. Having spent millions of dollars on suicide prevention, threat assessment, and behavioral intervention over the past decade, campuses have improved how they identify and treat troubled students.
This is good news, clearly, but it also means that more students have to wait for treatment, settle for less-frequent appointments, or leave campus for care. The rapid growth has bottom-line consequences for colleges, too. Research shows that students who are left untreated are more likely to drop out of college or become a danger to themselves or others; for colleges, wait lists can mean lower graduation rates and increased liability, if a tragedy occurs.
Recognizing these risks, many colleges have enlarged their counseling staffs and added more group-therapy sessions. They’ve adopted triage models to sift the more serious cases from the more routine ones, and they’ve sent more students to off-campus providers for care.
Now some colleges are turning to telepsychology and mental-health apps to reach more students, more quickly. They’re offering drop-in visits to help students work through specific, short-term problems, and adding workshops to help students cope with stress and anxiety before their problems become severe. And they’re trying to build resilience in their students, so they’re less likely to become overwhelmed in the first place.
Expanding Services
The easiest, but hardly the cheapest, way for colleges to reduce wait times is to add more staff. A 2015 survey by the Association of University and College Counseling Center Directors suggests that many colleges are doing just that, with more than half of respondents adding new positions that year.
In March the University of California announced that it would hire 85 counselors, an unprecedented systemwide increase that is being paid for with a 5-percent annual increase, over five years, in student service fees.
Gary Dunn, director of counseling and psychological services at California’s Santa Cruz campus, said two things spurred the expansion: long wait times on some campuses and the 2014 killing spree in Isla Vista, near the system’s Santa Barbara campus. UC counseling centers have seen a 54-percent increase in students seeking access to services since 2007, and waiting lists on some campus had grown to as long as five weeks by the time the hiring plan was announced.
The new hires will increase the counseling centers’ clinical staff by 43 percent, bringing student-staff ratios in line with recommendations of the profession’s accreditor: one counselor for every 1,000 to 1,500 students. At the Santa Cruz campus, the hiring of seven additional staff members is expected to cut wait times in as much as half during peak periods.
But filling the 85 slots hasn’t always been easy. The cost of living near UC’s campuses can be high, and some of the slots are set aside for therapists with specific backgrounds and skill sets, narrowing the field, Mr. Dunn said. The system missed its goal to complete the hires by September, with one-third of jobs still open.
Another challenge has been finding places to put the new practitioners. At Santa Cruz and several other UC campuses, the counseling centers are at or near capacity.
Most of the big hires are happening at public flagships; regionally oriented public campuses and small private colleges often don’t have the resources to expand their counseling centers.
Instead, some of these clinics are turning to temporary contract therapists — who don’t receive health insurance and other benefits — to get through the peak periods of late fall and spring. Many clinics have also expanded their use of trainees, interns, and postdocs.
And at least one is drawing on faculty from other parts of the college: Augusta University, in Georgia, recently persuaded four of its psychology and counseling-education professors to spend a few hours each week treating students they don’t teach. Mark F. Patishnock, the center’s director, said the arrangement helps meet increased clinical demand while providing faculty with the ability to keep their skills sharp.
Meanwhile, the Jed Foundation, a nonprofit group focused on the emotional well-being of college students, is pushing colleges to integrate their health and counseling centers so primary-care providers can screen and treat students with mild to moderate conditions, said Nance Roy, its clinical director. That practice frees up counselors to treat students with more serious conditions and reduces the chance that the centers will see the students with milder problems down the road.
Even so, most experts agree that colleges can’t hire or job-shift their way out of waiting lists; the demand is simply growing too quickly.
Rationing Resources
For years, college counseling centers have used session limits as a way to offer services to more students. In the latest survey, half of center directors said they limited the number of annual visits.
But a majority of those ceilings were “flexible,” and only 6.7 percent of respondents said they limited students to fewer than 12 visits. Many students never reach the cap, making it a generally ineffective means of rationing care.
That means that many colleges have been forced to spread out visits, seeing students less frequently than once a week.
At Virginia Tech, for example, some students are seen every other week, said Christopher Flynn, the counseling-center director. They can go to group therapy as often as they want, he said, and some choose to remain in a group for all four years.
As demand for services has increased, many colleges have enhanced their group-counseling programs. Group counseling is “cost-efficient, time-efficient, and research shows outcomes to be basically equal” to individual therapy, says Dan L. Jones, the counseling-center director at East Tennessee State University.
But group counseling is not without its challenges, says Victor Schwartz, medical director of the Jed Foundation and a former medical director of New York University’s counseling center. Groups can be time-consuming to create, and it can be hard to work around every student’s schedule, particularly as the semesters change.
One alternative is short-term groups. The University of California at Santa Cruz recently created a three-session seminar called “Embrace Your Life” that aims to help students pinpoint what they want to change in their lives and how to do it. The university also offers a student-run stress-reduction group and a drop-in program where students can talk to a counselor for 15 minutes about concrete, subclinical problems, such as roommate conflict or exam-related stress. In some cases, students will continue on to traditional therapy; in others, they decide they don’t need it after all.
Drexel University offers walk-in sessions, too, although it has found that many appointments are taken up by students who are already in counseling and can’t wait the week to see their therapist. This year Drexel is trying a new approach: offering a three-session workshop called “ACT One” that teaches students the introductory skills of therapy, such as mindfulness and openness. It aims to both prepare students for individual therapy and to make them more comfortable sharing in a group, as a way of funneling more students into the groups Drexel already has.
Sorting Students
As the number of college students seeking treatment increases, colleges need a way to sort them, quickly. Many are turning to triage, a practice that dates back to World War I but was unheard of in college counseling until 20 years ago, when the University of Massachusetts at Amherst and Cornell University began experimenting with it.
Today many colleges use some form of triage, steering the less-severe cases to group therapy, workshops, and online therapy — or asking them to wait.
Taking that approach to the next level is the Memorial University of Newfoundland, which assigns students to one of nine tiers of care using a “stepped care” model common in Australia and Britain. Under stepped care, students with less-severe conditions might get online self-help, while those with more serious conditions might get intensive care. Students can move up the spectrum, but more than 80 percent of them are initially assigned to a Step 5 (online therapy) or below, according to Peter Cornish, director of the university’s wellness and counseling center.
Colleges, he says, are sending “way too many people to intensive treatment.”
The college hasn’t yet compared outcomes under the old model and the new, but Mr. Cornish says student-satisfaction scores haven’t changed, and more clients are showing up for their appointments.
Meanwhile, many colleges are looking for ways to help students develop better coping skills so they’re less likely to show up in the counseling center in the first place. Workshops on managing stress and anxiety have proliferated, as have relaxation centers, with features like biofeedback stations and seasonal-affective-disorder lamps.
Stressbusters, which started at Hopkins, is now being used at 15 colleges nationwide, with institutions paying $5,000 or more for the program.
Other institutions are teaching students how to bounce back from failure. In January, the University of Virginia tapped Timothy Davis, the head of its counseling center, for a new role: executive director of student resilience and leadership development. So far he’s focusing on student leaders in high-profile, high-pressure positions, trying to cultivate in them a mind-set that sees failure as a learning opportunity rather than a catastrophe.
Drexel has begun one-on-one coaching with its physician-assistant students, using sports psychology to help them deal with personal and academic stressors, said Paul C. Furtaw, associate director of counseling services. If it works, the college hopes to expand the model to undergraduates.
Mr. Furtaw is quick to stress that “coaching isn’t psychotherapy,” at least in the traditional sense. Still, he says it can help struggling students get back on track, and give them the skills to cope going forward.
“You’re seeing campus counseling centers redefine what therapy is,” he said. “We’re talking to students about how to be amazing, as opposed to saying, Come to us when you’ve derailed.”
Increasing Referrals
Meanwhile, many campuses are increasing referrals to community providers, particularly for students with chronic conditions, such as bipolar disorder, and those seeking longer-term treatment.
But off-campus care brings its own set of challenges. Some students can’t afford the co-pays; others refuse to use insurance because they don’t want their parents to know they’re seeking help. Getting to the appointments can be a challenge, too, particularly in rural areas.
Some colleges are trying to reduce barriers to off-campus care, negotiating discounts with clinicians who are just starting out and persuading groups of therapists to see some students pro bono. Some universities have worked out deals with their teaching hospitals to see students who need longer-term or specialized care — such as help with an eating disorder — at reduced rates. Other colleges are offering to help students with co-pays and out-of-network fees.
Still, not many colleges track outcomes for off-campus care, so it’s hard to know how many students are attending their appointments and whether they’re doing as well as those who are treated on campus.
As more students seek treatment, college counseling centers must communicate their mission clearly to students and parents and manage expectations. The messaging is difficult to get right, and even some college that have eliminated wait lists feel pressed to do more.
James Troha, president of Juniata College, in Pennsylvania, said many families choose Juniata because of its reputation as a place that takes care of its students. He thinks families are satisfied with the current level of support the college provides, but he says he can’t be sure.
“I think the expectations, the pressures, continue to rise,” he said. “It’s just, Where is the end point?”
Kelly Field is a senior reporter covering federal higher-education policy. Contact her at kelly.field@chronicle.com. Or follow her on Twitter @kfieldCHE.
Correction (11/8/2016, 1:50 p.m.): This article originally misstated the job title of Victor Schwartz. He is a former medical director of New York University’s counseling center, not its former director. The article has been updated accordingly.
