A Shared Responsibility

When college mental health care providers and students talk about campus mental health resources, two very different perspectives emerge.

Students who have experienced mental illnesses themselves see the availability of on-campus services as one of the core responsibilities of the institutions they attend. They believe that if those services aren’t being utilized or are found by students to be inadequate, it’s up to the college to adjust.

College-based mental health providers consider themselves central to student well-being and academic achievement. They want to help as many students as possible but say the need for services well exceeds what their centers are funded to provide.

Where these positions converge and diverge has become the latest challenge for many colleges across the country facing increasing demands and skyrocketing costs for student mental health services.

For example, American University officials recently attempted to call attention to the number of missed appointments at its counseling center due to late cancellations and no-shows. Some students took offense at what they felt was an example of the university blaming students for the center's failures.

Daniel Solomon, a senior at Clemson University who founded ​You’re Not Alone, a peer support group on campus for students who struggle with mental illness or who have family members or friends that do, said he could relate to AU students' frustrations.

Students make sacrifices to go to college and in return expect the institution to take care of them, he said.

“It all has to go back to providing more resources. That in and of itself would solve all the issues,” Solomon said. “If universities are going to bring smart, well-educated students to their campus and provide them with an education and also make us pay for our health bills, then it’s their responsibility to keep us healthy.”

Shivani Nishar, a student at Brown University, is co-coordinator of its chapter of Project LETS, a national organization that works to decrease barriers to mental health resources on campuses.

“The blame or responsibility should never be on the student, especially a mentally ill student,” Nishar said. If a student doesn’t show up to a scheduled counseling appointment, it’s the university’s responsibility to “work out the logistics,” she said.

But counseling center directors believe students should view campus mental health services as a shared resource and a shared responsibility.

“It’s not totally fair to expect in any mental health service that I can be seen as much as I want to be and as quickly as I want to be,” said Peter LeViness, director of counseling and psychological services at the University of Richmond.

Counseling resources are a two-way street, said Ben Locke, executive director of the Center for Collegiate Mental Health at Pennsylvania State University.

“Big picture, it’s important for institutions and the services they provide to have a both-and conversation, where the students are an integral part of that service and making the service successful and being responsible consumers of expensive services,” Locke said.

The average annual operating and salary budgets of counseling centers at institutions with more than 10,000 enrolled students exceeded $1 million, while those with 35,000 students or more reached $4 million from 2017 to 2018, according to the most recent 2018 survey of 571 counseling center directors conducted by the Association for University and College Counseling Center Directors, or AUCCCD. The average total annual budget for counseling centers recorded in the association survey increased by more than $112,000 from 2016 to 2018, rising to $1,059,324.

Yet demand continues to outpace the supply of services universities are struggling to provide, said LeViness, who also coordinates the AUCCCD survey. As a result, center directors are taking a hard look at how resources can be wasted, including by the very students they are meant to help.

When American University sent an email to students listing the hours lost in psychiatric services due to appointment no-shows, some students found the email “hurtful” and felt it blamed them for the gaps in the mental health services provided by the university.

AU has been attempting to improve those gaps in services as part of its strategic plan, said Traci Callandrillo, assistant vice president for campus life. She said the idea to share information with students was well-intentioned.

“When it comes to health-care agencies, being able to be clear that we’re doing the best that we can in how the resources are being utilized is an important part of us being good stewards of resources for the community,” Callandrillo said.

The email listed data from the fall 2019 semester: one-fifth of all counseling center appointments were no-shows or late cancellations, or the equivalent of five no-shows each day. And there were 48 missed appointments with psychiatrists at the student health center. Similarly sized institutions (10,000 to 15,000 total enrollment) had a no-show rate of 9.2 percent for talk therapy appointments from 2017 to 2018, according to the AUCCCD survey.

Students have been complaining about the wait time for initial consultations at the counseling center in forums with administrators, said Jeremy Ward, speaker of the student government’s undergraduate senate. So when students received the email from Fanta Aw, vice president of campus life and inclusive excellence, it caused a “flare-up,” Ward said.

“We do not know why the administration felt the need to express what comes off as complaints about students, and we do not believe that telling students that their behavior is the problem will do anything to improve mental health services on campus,” the student government executive board said in a statement.

Conversations about wait times and appointment availability at American’s counseling center were “certainly” happening when she was a student, said Kelly Davis, a 2015 AU graduate and director of peer advocacy supports and services for Mental Health America. Davis leads the Collegiate Mental Health Innovation Council, an elected group of students who lead mental health initiatives on their campuses and identify trends and best practices. She said the email was “tone-deaf” and “discounts the fact that no-shows are pretty common across all health concerns.”

“If you’re offering a service that people are not utilizing, most businesses would not blame the customer,” Davis said. “There’s a whole lot of reasons that someone wouldn’t show up for an appointment, and that can be like a kick while you’re down. Not only are you not showing up, you’re preventing others from getting help.”

But when a student does not show up for an appointment or cancels too late for the appointment time slot to be given to someone else, that’s time that another student could have been seen, Aw said in her email. Wait times at counseling centers increase when there are more no-shows, LeViness said.

“It’s an unfortunate loss of resources in any case, and if you want to think of it in terms of cost, it’s even more costly for psychiatric appointments, in terms of the units and time that person is being paid,” LeViness said.

Seventy-two percent of 400 university presidents reported in a 2019 American Council on Education survey that they were spending more funds now on mental health initiatives than three years ago. ​

Psychiatric appointments, which are usually with medical doctors, are typically two to three times more expensive per hour than meeting with a counselor or therapist, who are not medical doctors, and they’re also more coveted, because of how limited they are at any given center, Locke said. More than half of the institutions in the 2018 AUCCCD survey had no psychiatric provider, a licensed medical doctor or nurse practitioner who could diagnose and care for students with psychological disorders. American has both a full-time psychiatrist and a nurse practitioner, said Lisa Stark, assistant vice president for communications.

“In the world of health care and mental health care, big picture, that’s in some ways a cost of doing business,” Locke said. “But if a large percentage of appointments are just simply no-shows or late cancellations, and they can't be reused for other students … that represents a financial investment that's unused.”

University medical centers are looking for ways to reshape their structure to mitigate no-shows, such as relying more on a walk-in appointment model and sending students reminders about scheduled appointments, Locke said.

When there are no-shows at the University of South Florida’s counseling center, the counselor is put “on call” so if a student walks in, they can be seen, said Scott Strader, director of the center. South Florida was recognized as a leading university for its quality of and investment in mental health care in 2018 by the nonprofit Active Minds, a youth mental health research and advocacy organization. Having clinicians available for initial consultations on a same-day basis allows students to show up when they are feeling most motivated to seek help, Strader said.

“As we look at the demand for services, maximizing the clinical availability of time is very important, and a lot of us are focused on how our providers’ time is maximized,” Strader said. “That is a way to kind of offset the no-show issue. Students can get an immediate touch point with a provider. They might not need a follow-up, and if they do, we put them in that initial provider queue and wait a couple of weeks.”

The South Florida center’s no-show rate is between 7 and 8 percent for scheduled appointments, Strader said, lower than the national average for talk therapy appointments, according to the AUCCCD survey. The South Florida center also saw a significant decline in no-shows when it increased its fee for missed appointments from $10 to $15 in 2017, Strader said.

The University of Oregon, which also won Active Minds’ Healthy Campus Award in 2018, charges a $25 fee for no-shows, said Alisia Caban, the associate director of the Oregon center. Oregon informs students about the fee up front and explains to them that the center is an important, utilized resource, Caban said.

American does not want to charge students for missing counseling appointments because it can be a barrier for people who can’t afford the fee, but it does charge a $20 no-show fee for psychiatric appointments, said Callandrillo, the campus life official. She said the university will continue to receive feedback from its wellness council and campus as a whole about “how we as an institution are meeting those needs and understanding the expectations.”

Despite her criticism of American’s data-sharing email, Davis, the alumna, praised the university's willingness to engage in dialogue about the no-show problem.

“There is an inherent power imbalance between those who use the services and those who provide it,” Davis said. “There’s a shortage of resources, there’s a lack of investment in campus mental health, and from their perspective, if they’re putting in resources they don't’ think people are utilizing, that’s frustrating … The answer isn’t to blame the consumer of the service. It’s to try and be creative in how you get better outcomes.”