The Rise of Mental Health
The amount of young adults seeking higher education has been growing, and with it the amount of young adults who are ill prepared for higher education (Mowbray et al.,2006). Along with all this growth, colleges and Universities are finding higher and higher rates of mental illness on campus (Mowbray et al.,2006). A variety of studies has shown the rate of mental illness for college students to be somewhere around 12-18% compared to 10 years ago when it was closer to 5% (Mowbray et al.,2006).
It should be noted that while this rate is high it does not even touch the total amount of increase College Counseling Centers are seeing, in that this percentage only reflects the amount of students with a diagnosable mental health issue (Mowbray et al.,2006). In line with this, 68% of College Counseling Centers in a national survey reported that they are seeing a sharp increase in the need for counseling based services (Kitzrow, 2009); Columbia University reported a 40% increase, MIT a 50% increase, and University of Cincinnati reported a 55% increase during a survey of counseling center directors (Kitzrow, 2009).
In addition, more students are seeking psychological services, and the type of needs students report are diverse and growing more complex in nature (Kitzrow, 2009). For example in 1994 only 9% of clients seeking mental health services on college campuses reported psychiatric medication usage where as this rate is now closer to the 20% range (Kitzrow, 2009). But students that have medication issues or whose needs are more complex aren’t all College Counseling Centers must deal with, they also must cope with the fact that around 28% of freshman polled in a natural survey report feeling overwhelmed; with subsets of the students polled developing clinical levels of distress that continued through college (HERI, 2000). This statistic demonstrates that in some respects the growing need of students seeking to utilize college counseling centers are represented by two tiers; tier 1: students needing assistance in “lower-level” needs of anxiety, distress, family of origin issues, and tier 2: students with clinical disorders or high suicide idealization needing intense and often prolonged treatment.
Mental Health: Why Care?
An important question needs to be asked about the mental health services that are offered on college campuses: why should colleges or universities invest? Providing mental health services costs MIT over $838,000 per year, the cost of mental health is not cheap (Healy, 2002).
While the services are not cheap, the benefits that they bring to colleges are not small either. Brackney and Karabenick (1995) found that academic performance finds a significant correlation to high levels of psychological distress. This means that in providing mental health services to students, the likelihood that those students will do better overall at school are significantly strengthened, which brings about a higher chance of that student completing their program. It has been estimated that 4.29 million people in the United States are in a state in which they have been unable to graduate from college due to psychiatric disorders, so the amount of students and therefore the amount of money they could bring to institutions is by no means small (Kitzrow, 2009).
In addition, a six year longitudinal study found that emotional adjustment is one of the most important factors in retention of students, so the amount of impact mental health services provides to colleges is profound (Gerdes & Mallinckrodt, 1994). That impact is operationalized in a study of students that used University of Idaho’s Student Counseling Center, which found that not only did 77% students report that counseling allowed them to stay in school, 90% reported that counseling helped them achieve their overall goals (University of Idaho, 2000). While counseling centers have a great amount of impact on the campuses they service, the coming crisis in terms of higher demand will be something unlike counseling centers were ever designed for or could ever prepare for, as we will see in a review of their history.
Counseling Center History
Counseling has always existed in some way, shape or form within higher education, but was handled by the office of dean of women or the dean of men (Hodges, 2001). Then during the 1930’s and 1940’s, an argument arose in higher education that faculty should be providing counseling, especially the faculty that expressed interesting in the helping profession (Hodges, 2001). Thus some educators fought for faculty to take over the “normal” academic concerns, while other trained professionals handled more of the concerns deemed psychological (Hodges, 2001).
However, there was much confusion over the credentials, duties, and specialization needed in order to be offering psychological services (Hodges, 2001). Then, with the end of World War II, veterans began coming to college in droves, thanks to the financial assistant the Veterans Administration was offering (Hodges, 2001). This movement sparked a change in mindset for higher education because Federal funds were provided to make sure veterans were offered vocational preparations. This eventually set in motion the expanding role of counselors and created Counseling Centers on college campuses (Hodges, 2001).
Then as the civil rights movement started, social barriers to higher education were challenged and older students began to enroll, creating even more diversity on campuses (Aubrey, 1977). This drastic influx of students, combined with additional pressures for college personnel, provided counseling the right to move out of the faculty housing into it’s own profession (Hodges, 2001). This move into it’s own profession also created responsibilities for the counseling profession, in the need to develop standard of practice, ethics, and specialized training (Hodges, 2001).
In all of this, the American Psychological Association or APA grew in prestige, and created it’s own accreditation guidelines, training programs, and credentialing, moving what was a “generalist” movement into a highly specialized field (Hodges, 2001). With this specialization comes competition, between a variety of degrees, something that very much continues to this day (Hodges, 2001).
In a sense, College Counseling Centers have come out of a history that has required a defense, in that it is extremely special in nature and that sense of specialty must be preserved. If not, it could easily fall back into the sense of generalized mindset it worked so hard to come out of. As stated before the argument of faculty handling advising, counseling and other services has been around since the 1940’s and is still very much alive to this day (Mowbray et al.,2006). Even still there are those with the attitude that a university’s role was to teach, not to treat the students it served on campus (Mowbray et al.,2006). So, those who provide counseling on college campuses face a battle of being able to offer counseling to a growing diversity of students while maintaining that they provide a service that can’t just be handled by any faculty member (Mowbray et al.,2006).
Colleges obtained a majority of funding via the Federal Government in the form of loans that students take out in order to attend intuitions (McPherson, 2010). Due to this the law, in the sense that the government and therefore funding is directly tied to current law, law is critical in the discussion of College Counseling Centers.
First line in this consideration is the possibility that College Counseling Centers can be sued by the students and community they serve. Lawsuits do happen, not just to larger schools but also to smaller ones (Affsprung, 2010). That said: the larger the campus, the greater likelihood that the College Counseling Center can be sued (Affsprung, 2010). In fact, in an analysis of survey results from 1994-2008 of counseling directors found that once enrollment at a University or College reaches around 7,500 they become 3 ½ times more likely to be the target of a lawsuit or some sort of legal challenge (Affsprung, 2010).
It is important to note that during this same analysis of legal action taken against college counseling centers a variety of reasons for lawsuits were found (Affsprung, 2010). These reasons ranged from malpractice in the form of inappropriate medication being prescribed by the psychiatrist to the most common related to student suicide (Affsprung, 2010). Therefore Counseling Centers find themselves most at risk in relation to suicide idealization of students (Affsprung, 2010).
This brings up the important case of Elizabeth Shin versus MIT, in which the student committed suicide and her parents sued for $27 million. On top of the high monetary amount, legal opinion is Shin’s parents could have won but elected for a settlement of ‘undisclosed amount’ (Hodges, 2001). Shin’s parents were able to sue MIT for their daughter’s suicide because it was ruled that the University had a ‘special relationship’ with Elizabeth and because of this had a higher responsibility to her than just a normal bystander (Massie, 2008). This case, among others, should be noted in higher education in that prior to cases of this nature, Universities had no “duty to rescue.” However, a revision of Torts section 314A revised the student and University or College relationship to be included under “special relations” (Massie, 2008).
This is important within the discussion of the rising mental health issues on college campuses, in that these changes in law will impact the likelihood of Universities winning future cases to the ever growing requirement that colleges take “reasonable steps” to prevent students from harm (Massie, 2008).
In light of this lawsuit, MIT increased its mental health significantly, in order to have an outreach campaign to students seeking counseling as well as to build policy that would provide better counseling systems to students (Kitzrow, 2009). This is critical in that around 41% of counseling directors report that they do have formal follow-up procedure to assist students, which could easily give way to “high-risk” students being lost in the college counseling system (Kitzrow, 2009). However, when it comes to the legal issues, additional outreach is only part of the way to defend against lawsuits.
The Way Forward
As stated before, “reasonable steps” are a key point when considering the outcomes to lawsuits in College Counseling Centers. While outreach is a key component of “reasonable steps,” MIT, in the steps taken after Shin’s suicide, found that the importance of additional staff could not be left out (Hodges, 2001). These findings have been generalized, in the increasing literature looking at students who have entered or are currently in college, their demands as well as their parent’s demands of timely mental health service (Brunner et al., 2014). In fact, in review of the coming generation, Howe and Strauss (2007) provide the advice that counseling centers must “staff up” if they will keep even close to the pace of demands for services.
This insight is directly opposite of where most counseling centers stand today, in that most counseling center director’s report that they have waiting lists for counseling services (Brunner et al., 2014). In fact, estimates are even as high as to state that one third of college centers are unable to meet the demands for counseling service (Brunner et al., 2014).
The importance of additional staff is critical, but where is this staff to come from? Central Michigan University decided to address this issue with the design and implementation of Counselor-in-Residence program (Orchowski et al., 2011). The Director of Residence Life and the director of the counseling center came together to promote increased collaboration between the two departments (Orchowski et al., 2011). Counselors-in-Residence or “CR’s” worked in conjunction with the Residence Advisors, or “RA’s”, in that RA’s would refer students to the CR’s at provided student-friendly counseling times of 5 pm to 10 pm, which is after the normal counseling center business hours (Orchowski et al., 2011). The program at Central Michigan University was staffed with licensed Master-level Professionals Counselors and Social Workers (Orchowski et al., 2011). The University reported that such extension of the college counseling center provided a cost-effective solution to the increased demands for college counseling on their campus (Orchowski et al., 2011).
While a wonderful example of what departments can do when they work together, programs of said nature also carry certain risks with them. Blacklock (2003) caution against multiple locations for students to seek counseling, in that this may force students to drift from office to office until they locate the correct entry point. In addition, it is important to consider how the CRs must be balanced between dorms, in that certain dorms could command more robust attention than others.
That being said, the Counselor-In-Resident program was wonderful in that it brought an additional option to the professionals that currently serve students on college campuses: that of master’s level counselors (Orchowski et al., 2011). A survey of counseling center directors report that around 94% of counseling center staff either have their doctorate in counseling or clinical psychology (Kitzrow, 2009). While the amount of masters-level clinicians working within counseling centers is small, the importance of said clinicians is growing (Kitzrow, 2009). In talking in-depth with counseling directors, one study, which sought to focus on the challenges college counseling centers face, reported that graduate interns and peer counselors are extremely important in allowing their centers to serve additional students (Kitzrow, 2009).
So why aren’t masters-level clinicians being better utilized to serve students on college campuses? The answer is rather complex and once again comes with an important historical context of how masters-level practitioners are viewed. As stated before, the competition for professional opportunities within college counseling centers is competitive and the APA holds a lot of support (Jackson & Scheel, 2013). The APA’s attitude for more than 60 years has been the predominant stance that master’s-level counselors should practice under supervision of doctoral level psychologists (Jackson & Scheel, 2013).
In fact, in 1947 the APA even recommended the discontinuation of masters degrees for “lower level” psychology work, only shifting their stance in 1955 as master’s level curriculum was promoted to support the need for psychological services following World War II (Jackson & Scheel, 2013). While the APA’s history has been one that has sought to fight the independent licensing of masters-level counselors, it finds itself arguing a moot point on this issue, as all 50 states currently allow for master-level counselor to practice via state license (Jackson & Scheel, 2013). Yet the stance of higher education seems stuck within APA’s viewpoint of the 1940’s and 50’s. Masters-level counselors are allowed to practice in all 50 states, are used in social services programs, and allowed to be placed on medical insurance boards (Jackson & Scheel, 2013). It seems the state, social services, and even the general medical community has accepted the use of master’s level counselors, so why not higher education? Even the APA has changed it’s stance in some regards, as a 2006-2010 study by a board created within the organization came to the stance of not opposing independent practice by master’s-level counselors or promotion of supervisors of said counselors by doctoral-level psychologists (Jackson & Scheel, 2013).
In addition to the APA’s changes in regards to masters-level counselors, another important factor in their inclusion is the requirements promoted by the International Association of Counseling Services or IACS, which is important for counseling centers at a university or four year level in order to maintain their accreditation (Danger et al.). IACS standard indicates that professionals with a master’s degree from counseling disciplines can provide psychological services to students and even allow for trainees, provided that they are supervised by qualified staff (Danger et al.).
With all of these changes, it seems higher education has been left behind in its mindset of hiring mainly doctoral-level counselors, as seen by the statistic of 94% of centers having doctoral-based staff (Kitzrow, 2009). Perhaps the perspective is that because doctoral-level staff are allowed to prescribe medication, they are in a sense a better deal for the University than masters-level clinicians who currently don’t have that ability (Kitzrow, 2009). However, as stated before, the coming crisis in mental health isn’t just about the increased diversity in students’ mental health needs, but also about the increased demand (Mowbray et al.,2006). Simply having Universities or Colleges focus on the greatest diversity of services clinicians are able to provide will not stop lawsuits that focus on the American with Disabilities act or the ever increasing need to provide “reasonable steps” in preventing student suicide (Massie, 2008).
So the future of mental health must accommodate two-levels of service: in-depth need, as such is the case with medication, and quality need, as will be the case with the increase in anxiety and depression based disorders (HERI, 2000).
While other members on college campuses can provide some support, the important need of confidentiality and division of mental health services from academic based services must be noted (Mowbray et al., 2006). Students must feel that they are able to present their mental health needs without fear of these needs creating some sort of division on campus (Mowbray et al., 2006). An important part of meeting this need of confidentiality must come from those who are licensed to enforce it, both from a client-centered perspective and from the legal perspective (Mowbray et al., 2006).
The increased usage of masters-level clinicians is a natural solution to this issue of confidentiality and meeting of needs, as they are currently utilized within a variety of other sectors within society. In following with the model of Central Michigan University, these masters-level clinicians could be used in order to fill the extensive need of students, assigning “lower risk” students to them. This would follow the model that most mental health providers use in their coordination, in that students would receive an intake and off of said intake they would be set up with doctoral-level or masters-level clinicians (Schulberg et al., 2002). Masters-level clinicians would receive the students that do not currently need medication support or adjustment, and whose needs are more in line with general anxiety or depression based disorders. Once again, this follows the model of most mental health services and has been shown to be effective in managing cost and providing quality services (Schulberg et al., 2002).
As the masters-level clinicians or practicum students are working with termed “lower-risk” students, doctoral-level clinicians would be assigned “higher-risk” students. These students would be needing more extensive mental health issues or could be needing assistance with management of medication. The use of said system, along with the coordination of support groups and the use of peer counselors, could provide the quality and quantity needed to meet mental health services on campus. This model has been found to work in social services, as well as hospital and private services, showing to be both cost-effective and able to handle the diverse needs associated with providing mental health to a community (Schulberg et al., 2002).
The upcoming crisis on college campuses in terms of mental health has been growing for years and currently does not show signs of slowing down (Brunner et al., 2014). Instead of reverting to the faculty centered model of the 1940’s or simply continuing as planned could easily result in disaster or even worse: more lawsuits. Other solutions must be explored. Yet the cost must be handled in such a way that the already rising cost of tuition does not take another huge climb, as mental health services are expensive to any institution (Kitzrow, 2009).
The recommendation of more inclusion of masters-level clinicians must be explored, as current society has already adjusted to allow for their inclusion (Schulberg et al., 2002). There is already extensive research on how higher education interacts with general society, and how the two are correlated (Komives & Woodard, 2003). This correlation must not be dismissed when it comes to mental health, as higher education has fallen behind in this regard, and must consider a diverse range of opportunities that above all else does not focus on the spaded history of the past. Instead, the focus needs to be on the coming college student’s mental health needs and how to best meet those needs.
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