These mental health centers were overloaded even before COVID-19. What happens now as students return to school as budgets are cut?
Abrams, Z. (2020, September). A crunch at college counseling centers. Monitor on Psychology, 51(6). Https://www.fundacionfernandovillalon.com/monitor/2020/09/crunch-college-counseling
Demand for mental health services at college counseling centers in the United States has been on the rise for years. In 2019, nearly 90% of counseling center directors reported an increase in students seeking services, according to the Association for University and College Counseling Center Directors (AUCCCD) Annual Survey.
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In particular, data from more than 200,000 college students at 163 institutions show there’s been a steady uptick in threats to self—including suicidal ideation, suicide attempts, and nonsuicidal self-injury—as well as depression, anxiety, social anxiety, and traumatic experiences (2019 Annual Report, Center for Collegiate Mental Health, Pennsylvania State University).
“Prior to the pandemic, most centers had two- to three-week waitlists for students seeking care,” says Claytie Davis III, PhD, ABPP, chair of the Association of Psychology Postdoctoral and Internship Centers (APPIC) board of directors. “All of us, with just a few exceptions, have been trying to figure out how can we meet student demand when it continues to increase every year.”
The growing need can be attributed in part to more people with mental health issues attending college. Better medications and psychological interventions are enabling students with issues such as depression, schizophrenia, attention-deficit hyperactivity disorder, and more to attend college—but most still require specialized support.
In an effort to meet those needs, about 44% of college counseling centers added staff last year, according to AUCCCD. But that trend is likely to halt or even reverse in the face of COVID-19-related financial deficits tied to lower enrollment in higher education. Experts say subsequent budget cuts could leave student mental health issues unaddressed.
“The pandemic is a real recipe for concern because we’re going to see increased levels of need from students. At the same time, universities are experiencing significant financial downturns,” including hiring freezes and budget cuts, says Catherine Grus, PhD, fundacionfernandovillalon.com’s chief education officer. “I really worry about the ability of universities to adequately provide for the mental health needs of their students.”
Disconnected and lonely
College counselors, like many other mental health-care providers, largely saw a decrease in service utilization at the start of the pandemic as students dealt with immediate concerns, such as retrieving belongings from university housing and readjusting to family life.
“People were shocked, scared, surviving,” says Carmen Cruz, PsyD, president of the Association of Counseling Center Training Agencies. “They were focused on crisis management in their own lives, so seeking psychological services may not have been the top priority.”
As students settled into their new normal, many centers saw an uptick in demand in April, says Cruz, who is also the associate director and director of training at the counseling center at Texas Woman’s University in Denton.
Early data indicate that much of that increase was tied to the pandemic. The Center for Collegiate Mental Health (CCMH) reports that about 47% of students seeking help from Penn State’s Counseling and Psychological Services during the second half of the spring semester did so because of concerns related to the coronavirus. Specifically, reports of academic distress, family distress, and social anxiety have increased there.
“Shelter-at-home orders have definitely led to students feeling disconnected and lonely,” says Davis, who also directs training for counseling and psychological services at the University of California, Berkeley (UC Berkeley). “And those with problematic family situations may also face trauma or challenging dynamics at home, which can exacerbate existing mental health concerns.”
Others have experienced financial and career uncertainty, difficulty adjusting to online learning or the loss of a loved one to COVID-19, says Sharon Mitchell, PhD, president of AUCCCD and the senior director of student wellness at the University at Buffalo. Students also face a high degree of what Mitchell calls “ambiguous loss”—less tangible losses such as missing graduation or the final season on a sports team.
Before COVID-19, the most frequent concerns students reported were anxiety, depression, and relationship issues—which Davis says are likely to hold, just at a higher rate.
Telehealth and training
As college counseling centers work to support students through these challenging times, they’ve faced a crisis of their own: the rapid transition to telehealth.
“In a matter of weeks, nearly every counseling center in the country had to convert from in-person services to exclusively telehealth,” says Ben Locke, PhD, executive director of CCMH. “That was an absolutely unprecedented level of change.”
One to two years of policy, technology and operations work was squeezed into just a few weeks, Locke says. For example, counseling center directors needed new protocols for informed consent, crisis management, training and more.
In particular, training psychology interns and fellows is a key role of many campus counseling centers. “We carry a lot of responsibility for the training of psychologists, and we’re very serious about maintaining high standards,” says Cruz. “But conducting training and supervision remotely is a new challenge.”
For one, trainees need to exhibit proficiency with teletherapy before they can provide services to clients via phone or video. They also need to understand the ethical, legal, and regulatory concerns involved in delivering care remotely.
In light of those difficulties and anticipated budget cuts across academia, some centers are wary of accepting new interns in the fall, but Davis says training new providers is more important than ever.
“APPIC can be a voice and champion to make sure that our interns and fellows are being supported,” he says. “We’re working with training directors and administrators to ensure that sites are abiding by their match agreements and meeting their obligations to trainees.”
Schools with large out-of-state student populations have also faced regulatory challenges around treating clients across state lines. Temporary suspensions of licensing requirements have allowed some practitioners to deliver teletherapy to students in other states, but many of those orders have already expired or will soon. As institutions launch plans for extended distance learning through the fall semester, campus counseling centers are looking for creative ways to meet student need.
Many counseling center directors have used the summer recess to refine their telehealth protocols and prepare for another surge in demand when the fall semester begins.
“It looks like COVID is here to stay until there’s a vaccine, so from an operational perspective, psychological services in higher education will need to be extremely flexible,” Locke says. “We will probably exist in a new space moving forward: a hybrid teleservice and in-person model.”
Psychologists are recognizing both the power of teletherapy to continue serving students while minimizing the risk of coronavirus transmission—as well as its limitations. Early data from several counseling centers, including those at Penn State and UC Berkeley, indicate that students generally prefer in-person care over telehealth.
“If you already knew your therapist in the room, the transition tends to be smoother,” says Cruz. “But a lot of people who are newer to therapy aren’t sure what to expect from telehealth.”
One problem is that many students, whether based at home or on campus, lack a private space from which to engage in phone or video sessions, says Brett Scofield, PhD, CCMH’s associate director. Universities are working to address that by designating private spaces for students on campus or finding ways to safely deliver in-person care.
Crisis care, for instance emergency services for an individual experiencing suicidal ideation, may need to be delivered in person, Davis says. That will require therapists and students to wear personal protective equipment and maintain six feet of distance, which may also feel strange at first.
“Most of us question how effective therapy is going to be if we’re both wearing masks,” says Davis.
Both AUCCCD and the Council of Chairs of Training Councils have released guidelines for resuming such in-person services, including comprehensive cleaning protocols, COVID-19 symptom management, and suggestions for prioritizing which patients should receive in-person care—such as those with severe or clinically complex conditions or disabilities that make it hard to access teletherapy.
For cases where remote care is deemed the safest option, directors are finding creative ways to keep sessions engaging for both parties. After observing “Zoom fatigue” among therapists conducting back-to-back video sessions with clients, Davis’ team at UC Berkeley is shortening some sessions from 45 to 30 minutes in length. They’ve also launched a series of virtual drop-in groups—covering themes such as self-compassion, grief, anxiety, depression, and academic stress—to enhance feelings of connectedness between students.
Davis says campus counseling centers are increasingly moving toward a stepped-care model, where students can access a menu of service options—a single one-on-one session, weekly therapy, support groups, mindfulness classes, and more. In 2019, about 37% of the centers surveyed by AUCCCD were using a stepped-care model.
Schools are also attuned to the needs of students from racial- and ethnic-minority groups, who may be facing outsize effects from the COVID-19 pandemic and simultaneous nationwide protests against police brutality and racial injustice. UC Berkeley recently added virtual drop-in groups for African American, Asian American, and Indigenous students, as well as a support group aimed at healing racial trauma.
“Individually, psychologists have a lot of power in our own spaces,” says Cruz. “We can use our voices to share our knowledge at our institutions about the intersections of race, trauma, and COVID—and the importance of supporting students of color who are disproportionately affected by all three.”
Preparing to treat trauma
As they gear up for students’ return to campus, psychologists across the country are embracing a trauma-informed approach to care.
“Data on community-wide catastrophes—mass shootings and natural disasters, for instance—tells us that the first year following an event can be pretty traumatic for people, once they’ve gotten their basic needs met,” Mitchell says.
On-campus providers should prepare to treat trauma, grief and loss, depression, general anxiety, and the loss of motivation and focus, she says.
They should also expect the college experience to look very different from the way it did before. Many students may remain off campus, and even those who return won’t be able to experience athletics, clubs, or social gatherings in a traditional sense.
“College will just feel different—so we expect to be hearing a lot about that from students throughout the school year,” Davis says.
He also warns of “anticipatory anxiety” around a resurgence of COVID-19. Like many Americans, students may struggle to get comfortable for fear of increased coronavirus transmission or the return of shelter-in-place orders.
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To manage all this, experts agree that schools should beef up counseling center resources—or at least avoid making cuts where mental health is concerned. CCMH data indicate that when providers at college counseling centers are overloaded with patients, student outcomes—including symptoms of depression, anxiety, and general distress—suffer.
“In a way, we’re facing a perfect storm,” says Locke. “Higher-education institutions are in a financial crisis, and at the same time we’re anticipating a surge in demand from students. I worry that we’re in for some difficult times in terms of service provision.”