The Complications of Counseling

PHOENIX -- Getting an early glimpse at the results of this year's national survey by the Association for University and College Counseling Center Directors, campus officials celebrated their progress and commiserated over their struggles, both of which are significant at a time when their organizations are going through prolonged and fundamental shifts.

Among the highlights: students' thoughts of suicide are up, staffing continues to be strained, and counselors say their psychiatric services are inadequate, even as many students are on psychotropic medications.

The brand new data -- collected through the association's annual survey in fall 2011 -- represents 416 institutions diverse in size and type. It was presented here Tuesday at the annual meeting of NASPA: Student Affairs Professionals in Higher Education. The complete monograph is slated for completion in the coming days.

"I've got to tell you, diversity [of counselors' challenges] is the issue," said Victor W. Barr, the lead researcher and director of counseling services at the University of Tennessee at Knoxville.

What that diversity means for counseling became apparent during the course of the session. Large institutions struggle to maintain the proper professional-to-student ratio (one clinician for every 1,500 students). Rural ones have few options when they're overloaded with clients and need to refer students off campus. As budgets and staff sizes shrink, some can muster the time and manpower to figure out solutions like merging counseling and health centers, while others struggle to create the infrastructure necessary to gather a few extra dollars from charging fees for visits or certain services.

But there are many problems with which most any center can relate: more students are coming in with severe psychological problems, staff responsibilities are extending far beyond counseling alone, and -- although things are looking ever so slightly less bleak several years after the economy took a dive -- budgets and staff levels are tenuous.

Students who visit counseling centers still struggle with anxiety most often followed by depression; the former overtook the latter in last year's survey, and this year, rates of anxiety rose one percentage point to 41 percent, while depression dropped by the same amount to hit 37 percent. The next most common problem, relationship issues, was reported by 35 percent of students. Twenty-five percent said they use psychotropic medications, and that figure has stayed consistent over the past several years.

The percentage of students who report suicidal thoughts or behaviors, however, has been "gradually creeping up" in the six years AUCCCD has been surveying its member colleges. But this year it saw a considerable jump of about three percentage points, to 16 percent. Also on the rise is the number of students with extensive or significant prior treatment histories (13.2 percent), alcohol abuse or dependence (10.8 percent), and engagement in self-injury (9.2 percent).

"These are growing problems on our campuses," said Elizabeth Gong-Guy, director of student counseling and psychological services at the University of California at Los Angeles.

Counselors have widely attributed the increase of patients and psychological issues at least in part to more open discussions about mental health and the encouragement of students with problems to seek help, triggering a slow erosion of the stigma surrounding psychological issues, but professionals at Tuesday's session shared how campus outreach, which is becoming an increasingly weighty responsibility for counseling centers, is a double-edged sword.

Sixty-three percent of directors said their centers run mental health stigma reduction efforts, which can be particularly helpful in reaching male students (who comprise only 33.7 percent of clients) and special populations, such as minority and LGBT students who are typically less likely to seek out campus resources. While this is obviously a positive, it inevitably adds more pressure to already overbooked centers.

"The severity of issues and what's going on on campuses has changed, and so having more staff would really be of benefit," said Micky Sharma, director of the counseling and consultation service at Ohio State University. The survey showed declines in the number of positions gained and lost this year, with centers in total adding 197 positions and removing 39. The ratio of students to staff at small colleges is holding steady at about 1,250 to 1, but at large institutions it averages about 2,500 to 1.

Of particular note is the recent increase of case managers who form relationships with local hospitals and health service providers. Case managers can dabble in everything from Behavioral Intervention Teams to post-hospitalization support for students. Whereas "very very few" campuses had case managers previously, 23 percent of campuses now employ them, Gong-Guy said.

"We're all seeing clients whose needs exceed what we can provide for these folks," Sharma said. "These case manager positions are really helping with that."

Further, officials have faced more time constraints as they've given more consults to faculty and staff who want to discuss when a student demonstrates alarming behavior. Nine in 10 counseling centers do this, and while counselors have long given these sorts of consultations, their frequency has increased in the aftermath of shootings at Virginia Tech and Northern Illinois University, said Dan Jones, president of AUCCCD and director of the counseling and psychological services center at Appalachian State University.

And faculty aren't the only ones counselors are working with: 79 percent report having targeted education programs for faculty, yes, but also staff such as coaches, clergy and residence hall advisers, training them to recognize and handle a potentially distressed student.

When it came to budgets, directors reported (just barely) good news: just more than half of centers had bigger budgets this year, while 42 percent stayed the same and 7 percent saw theirs decrease.

Half of institutions receive no funding from mandatory student fees, and 24 percent are entirely funded by such fees. Perhaps reflecting strained budgets, while the latter percentage has been steadily declining since 2006, when 59 percent were not funded at all through fees, the former has been on the rise; in 2006, only 14 percent were entirely fee-funded. (The rest of the counseling centers are partially funded through fees.)

Also to deal with budget constraints, some centers have tried charging fees for certain services, though very few have been successful in producing significant revenue. Nonetheless, 16 percent of centers charge for psychiatry services. One in 10 charges for couples counseling; 9 percent charge for every individual counseling session, and 8 percent do so after a given number of sessions.

As the numbers show, few centers charge for services -- yet.

"That is probably a trend that will be changing over the years now, as we move forward," Gong-Guy said. "Counseling centers in general are underfunded, and are looking at how to maintain and expand opportunities. And one of the ways in which we can do that, of course, is by charging for services."

One particularly striking finding emerged when Sharma contrasted two separate results. Despite the fact that 25 percent of students are on psychotropic medications, a full two-thirds of directors say their campus's psychiatric services are inadequate.

Forty-one percent of institutions have psychiatric services housed in their counseling centers, and 16 percent have them in the student health center. Twenty-seven percent, however, have no access to psychiatrists beyond private referrals.

For psychiatry and other services, 77 percent of counseling centers have an off-campus referral network.

"The number of students who come in for treatment goes way beyond the number that we have the ability to treat within our centers, and that's true regardless of the size of the counseling center," Gong-Guy said. (For institutions in rural areas where those networks don't exist, case managers can help fill the gap here.)

Still, 77 percent of directors said their institutions have on-site medical services, and 68 percent have emergency services on campus. Thirty-eight percent have "post-vention services" to follow up with students and make sure their health is stable and they're on track academically after being released from the hospital.

Even as centers are being flooded with students needing treatment, counselors must remember the importance of stepping back and working to prevent problems from happening in the first place, Jones said. Three out of four centers report having suicide prevention programs, and 63 work to reduce mental health stigma (which, again, results in longer waiting lists and difficulty treating everyone). Sixty-one percent have sexual assault prevention programs, and 49 percent have programs for alcohol and drug prevention. Forty-one percent have such programs targeted at violence reduction. Only 1 percent reported no form of campus outreach.