Many believe that students are in college just to get a degree, but those more familiar with higher education recognize the complicated “life curriculum” with which students regularly engage in addition to their academic obligations. These developmental milestones go hand in hand with formal learning. The emotional tasks of a college student—whether a traditional-aged undergraduate at a small liberal-arts college, a working parent fitting in community college classes around jobs and childcare, or a star athlete at a large state university— are often as daunting as their classroom tasks, and always have been. But what does this have to do with governance, you might ask? From liability (risk and reputational) to resource management, quite a bit, actually.
Research tells us that a brain that is dealing with stress is compromised in its ability both to learn and to make good judgments.
Research of a different kind tells us that today we are seeing a student population with increasingly greater mental health challenges, including stress. Surveys of college counseling center directors, health center staff members, and students themselves provide evidence that college students are dealing with significant emotional and mental health disorders, including depression and anxiety. A 2015 survey by the Association for University and College Counseling Center Directors (AUCCCD) reports that more than 47 percent of students seeking counseling suffer from anxiety, and 40 percent report suffering from depression. Similar statistics have come from the American College Health Association’s annual National College Health Assessment, which shares results from more than 93,000 students. Almost 60 percent of respondents reported feeling “overwhelming anxiety” at some point within the preceding 12 months. Nine percent reported serious consideration of suicide during the previous year.
The Center for Collegiate Mental Health, which collects data from 140 counseling centers serving 100,000 students, reports similarly worrisome numbers, noting particularly that rates of self-injury and suicidal ideation are on the rise.
College counseling centers are the first line of response to this wave of students in need of support, and the same surveys show the pressure these centers are under. Directors report increasingly frequent use of waitlists to manage volume, and they have begun exploring in earnest the use of technology to supplement in-person counseling, along with group sessions and peer counseling. More than half of directors report an increase in budget and staff compared with the previous year.
Counseling centers used to be places where students could seek guidance and support for the typical challenges of college: homesickness, roommate and romantic difficulties, career indecision, identity development. Today’s counseling centers must have the ability to “treat” as much as counsel, as more and more students arrive with diagnoses of more serious mental health disorders. In addition to caring for these students, counseling centers must respond in times of campus crises, such as highly visible tragedies and crimes, natural disasters, and other situations that may leave students in emotional distress. These same professionals are asked to provide training to campus colleagues, education and outreach to all students, and, in the case of 70 percent of the institutions surveyed by AUCCCD, training programs for graduate students in psychology and social work.
RESPONDING TO INCREASED DEMAND
Higher education institutions have taken several approaches to respond effectively to this growth in demand for mental health services:
- Increase the size of the counseling staff
- Refer students to services offered by community providers, using case managers to oversee this process
- Train paraprofessionals on campus to provide “help” (as opposed to “counseling”) to lessen the demand for counseling center appointments
The benefits and challenges of these approaches are numerous. The most obvious challenge to increasing staff to meet demand is the cost. At a time when higher education budgets are shrinking, demand is increasing, and student debt is overwhelming, institutions may be unable or unwilling to add staff members to a counseling center. Counseling is only one of many areas seeking staff increases: Title IX, disability services, retention efforts, and campus infrastructure are also in need of frequent funding increases. In response to this dilemma, some institutions have chosen to limit counseling sessions or to charge students or third-party providers for certain services.
This latter response is growing in frequency (if not necessarily popularity) among counseling center directors, according to the AUCCCD survey, and the equation that has led to this growth is simple. Most institutions require students to have health insurance. Most coverage includes mental health services. Why not require students to utilize this coverage, for which they are already paying, to support services on campus, much as they would if the student sought counseling off campus?
The subsequent equations are anything but simple. Students come with dozens of different health plans. A counseling center that chooses to go the route of charging for services that are then billed to insurance will require back-of-the-house staff and software as complex as any major health provider. Is it impossible? No, as more institutions are demonstrating each year. But the startup costs are considerable, and the lead time to implementation is not quick. And while students may start their college careers with insurance, some lose it or give it up later on.
What about referring students to community providers who then bear the burden of billing insurance claims? This is often a necessity for smaller colleges where counseling centers do not employ full-time medication providers (primarily psychiatrists and specially trained nurses). Utilizing community providers offers students a wider range of services than a campus-based counseling center might provide, such as specialists in particular diagnoses like eating disorders, substance abuse, or medical conditions with a mental health dimension.
But there are two significant challenges to outside referrals: One is location, the other is communication. Students at rural campuses are particularly challenged when trying to find a provider nearby. They may not have a car, public transportation may be limited or nonexistent, and the time it takes to get to and from an appointment may add considerably to a student’s already busy schedule. This is assuming a local provider has an opening for a new client—a challenge in some underserved communities.
Communication with those outside providers is also complex. As is the case for all mental health providers (including those in a college counseling center), these outside providers must guarantee confidentiality as an expectation of their licensure. Without permission from a client, a licensed counselor may not even confirm that a student is participating in treatment.
An additional concern is that students may be reluctant to go off campus for services they believe they have already paid for through student fees.
A third option to manage a counseling center’s workload is the enlistment of other staff and faculty, and even some students, to serve as “first responders” who help students with non-emergency matters. In addition to the growing number of students presenting with serious mental health challenges such as anxiety disorders and depression, many students are in need of only a caring and nonjudgmental person to talk about homesickness, relationship problems, and career anxiousness. But the increase in the number of students presenting with serious mental health issues has made this common engagement more fraught. Many faculty and staff members are concerned about becoming involved in a situation where they feel overmatched by a student’s needs and worry about the risks they are assuming in working with students in such a personal way. Nonetheless, some willingly accept the training offered by the counseling center to at least recognize signs indicating the need for more significant help and to know how to refer those students to that help.
LIABILITY AND RISK
How does this impact governance and the responsibilities of governing boards?
Institutions are facing a growing wave of need and demand for mental health services. Counseling centers are admirably stacking sandbags against that rising water, but as those responsible for an institution’s fiscal health, trustees know that there must be a limit to those sandbags.
One answer, to extend the metaphor, is to go “upstream” to the earliest interactions with prospective students and share with them the limitations of mental health services on campus. Rather than offering the blanket statements that are often made in admissions presentations—“free, unlimited counseling services” or “a psychiatrist on staff” when in reality, it’s an eight-hour-per- week contracted employee—colleges and universities need to talk honestly about service limitations—for example, that a center is only open from 8 a.m. to 6 p.m., and after-hours services are provided by a local agency or hospital emergency room.
Such honest conversations may result in families thinking more carefully about their students’ mental health needs. They may talk with their current providers about continuing care via Skype or phone, for example. They may request that pediatricians who have been prescribing medication for years continue to do so, even if students cannot be seen in the office as frequently. They may look outside the campus community for an appropriate provider and research ways for their students to receive treatment from that person.
The topics of liability and risk are critical in understanding how a college counseling center must structure its staff and response protocols. Counselors and psychiatrists at college counseling centers have found themselves the targets of litigation by students or their families who believed that a counselor provided inadequate treatment and, because of that treatment, harm occurred. A student’s suicide is often at the center of such litigation, although lawsuits resulting from harm caused to others by a mentally ill student are also becoming more commonplace. The 2007 Virginia Tech shooting may be the best-known example. Emerging case law is providing some guidance around the obligations of a counselor’s (and counseling center’s) treatment of a student, but, as is the case with all litigation-based instruction, it is happening slowly. In the meantime, thousands of students are seeking mental health services on their campuses.
Licensed counseling professionals generally have malpractice insurance adequate to support their defense in such a lawsuit, and, of course, colleges and universities carry their own liability insurance to cover such situations. But what may be overlooked in the legal wrangling is the cost of personnel hours and morale when a college counselor is named in a suit. Every hour a counselor must spend attending depositions, assembling records, strategizing with attorneys, or sitting through a trial is an hour that person is not available to work with a student in need. And the stress of being brought before a licensure board is as daunting as a lawsuit.
The threat of litigation becomes a more dire issue with each passing year as the number of students with serious pre-existing mental health conditions arriving on campus increases. While working with students who are struggling with the major life transitions endemic to this phase of life is the reason college counseling centers were developed in the first place, our campuses are seeing more and more students with not just serious mood and anxiety disorders but severe eating disorders and longstanding substance abuse issues, as well. In fact, the number of students coming to college in recovery from a serious drug or alcohol addiction is growing rapidly enough that “recovery housing” is becoming common on larger campuses. The state of New Jersey recently passed legislation requiring that state schools provide students with a sober housing option—an admirable idea, but one that brings with it more liability concerns.
The support provided by sober housing is intuitively recognized by anyone who has worked with students in any kind of support groups. Living with, and interacting with, students who share one’s challenges can be helpful. It is not hard, then, to imagine demands for housing that supports students with other mental and emotional health conditions. Clinically, this is an intriguing idea. From a resource perspective (primarily staffing), it is challenging. And from a risk perspective, it raises the question of an institution’s liability for admitting and promising support to a student with a known history of mental illness.
This should not be interpreted as a suggestion that colleges and universities deny acceptance to students with diagnoses of mental illness. Such students enjoy the protection of the Americans with Disabilities Act (ADA) and should be free from such discrimination. There’s also the more prosaic issue of some students developing mental or emotional disorders while in college. Late adolescence is, for example, a common period in life for the onset of bipolar disorder and schizophrenia. Substance abuse disorders often begin in college, as well.
QUESTIONS FOR THE BOARD
- If your board is struggling with how best to respond to the needs and concerns of the millennial generation—particularly the mental health challenges they present—the following list of questions is a good place to start assessing where your knowledge gaps might lie. The board should also consider periodically inviting the director of the institution’s counseling center to meetings to provide updates on the center’s functioning and to “take the temperature” of the student body.
- Is your board familiar with the requirements of the Family Educational Rights and Privacy Act (FERPA) and the Americans with Disabilities Act (ADA) and confident that the institution is in compliance with them?
- Is your board knowledgeable about the budgetary and staffing needs of the campus counseling center?
- Does your institution have a crisis communications plan in place in the event of an emergency caused by a student suffering from mental health issues?
- Is the director of the institution’s counseling center a licensed professional actively involved in his or her professional association(s) and current on emerging case law and evolving best practices?
- Are there memoranda of understanding in place for relationships with local emergency rooms, crisis centers, and counseling practices that make clear how information will (or will not) be shared?
- Are service limitations (session limits, after-hours access, medication provider availability) clearly indicated on the institution’s website where a prospective student and family can easily find them?
- Are admissions staff knowledgeable about services (and limitations), and aware of relevant staff and how to refer families to them?
- If the institution provides access to a tuition insurance plan, is mental health covered in the event a student needs to leave mid-semester? Does the health insurance plan recommended by the institution also cover mental health conditions adequately?
- Is the institution employing a range of harm-reduction approaches, including peer education, to address issues such as binge drinking, suicide, and illicit and prescription drug use/abuse?
- Are measures for academic and social performance included in the institution’s metrics for identifying and assisting students most at risk of dropping out or needing additional services? This should be part of the institution’s retention efforts for at-risk students.
Ultimately, the discussion that needs to occur at the highest levels of institutional governance is about the place of mental health care—extensive, intensive, costly and, in many cases, risk-laden—within an institution of higher education. The answer to the question, “Does this kind of service belong here?” is not a yes or no. Students come with all sorts of challenges that institutions must find ways to address if the goal is retention and completion. Each institution must look in both directions: upstream and downstream. Upstream are the complicated conversations with prospective students and families that make clear the opportunities and limitations of campus-based mental health care. Downstream is the impact those services can make on the life of a student. Standing on the banks, looking both ways, and considering the issues in the greater context of the institution’s resources, trustees should continue to ask thoughtful questions of their institution’s mental health professionals and support them in this increasingly difficult work.