I realize that by writing this column, I will sound exactly like that kid in high school who reminds the teacher to assign homework before a long holiday weekend. Regardless, I want to make an unpopular argument. It's unpopular because it involves college counselors' and psychologists' having to work harder with a high-risk group of students. It's unpopular because it requires counseling directors to argue and advocate with their deans, vice presidents, and lawyers for permission to make their jobs more difficult.
But it's the right thing to do. So, here goes: An ideal, successful, well-functioning college counseling center must serve a wide range of clients. I want to push back on the latest trend in the journals, at the professional conferences, and in online discussion groups, in which institutions seek to limit campus counseling to students who are in need of short-term, developmental care, and "refer out" those who are at higher risk or require more specialized treatment.
We've all said or heard comments like this lately:
- "Our center is really dedicated to short-term, solution-focused treatment. We offer students eight sessions before we refer them out."
- "Your problems are beyond our center's treatment mission. We have a list of community providers who can better serve your needs."
- "It would be unethical for our clinicians to continue to treat you, given the severity of your symptoms. Perhaps it is time to take a break from college and seek treatment, get better, and then return to school."
- "We refer out those clients."
- "I mean, really, I don't know why these kids come to college. It seems like they are here just to get therapy. It's a place to learn, not a social-work clinic. There is only so much we can do with the resources we have."
Those students who struggle with diagnosed disorders, who have frequent suicidal thoughts, or who have the unfortunate luck to experience a bipolar or schizophrenic episode around the time that some other troubled student decides to shoot up a college—all of those students are ones that many campus counseling centers are telling to seek help somewhere else.
The trend is a modern-day version of the old not-in-my-backyard movement, which argued against allowing mentally ill individuals to live in residential neighborhoods—except this time, some counselors and psychologists who fought for inclusion are now leading the charge for exclusion.
I'm not without empathy. It's hard to treat students who hear voices. You'll get no argument from me that treating patients with chronic disorders can be difficult and time-consuming. Trying to treat a student with an eating disorder requires additional training and can involve lengthy work with medical staff as well as the student's parents.
It's easier to help a student who is upset about his roommate overusing his snooze alarm or the young lady who is struggling to work through her parents' divorce. It doesn't take as much time to talk with a student overwhelmed with organizing his academic schedule. Most clinical-staff members are well trained to assist a student through the basics of handling her anxiety related to public speaking.
But we can't simply point students to the door when their problems don't happen to coincide with the limited mission of our counseling center or when we arbitrarily draw a line in the sand and say, "We will treat these students, but not those over there."
We shouldn't accept the premise that college counseling should be offered only to students whose problems can be neatly resolved in eight to 10 sessions. We shouldn't tell Sarah, who struggles with chronic suicidal behavior, that we can't treat her, because she has tried to kill herself too many times. We shouldn't tell Mike, who struggles with borderline personality disorder, that we can't treat him, because he can't keep his appointments and frustrates the office staff. That is what they do. That is who they are. That is why they come to us for help.
I had a recent conversation with a student-affairs friend about a frustrating student I'm treating: "He is just mean and grumpy all the time. Would it kill him to smile?" While I understand my friend's impatience, the student's behavior and attitude is part of his disorder. Everyone thinks the student is grumpy and mean. And that's why I'm seeing him. I'm trying to fix that.
Too many campus counseling offices seem to be misusing the term "referral." Most of the time—not all of the time, but most of the time—a referral is an excuse to transfer a difficult, high-risk, annoying, frustrating, scary, time-sapping, complicated student somewhere else. The problem is that referrals rarely result in the student's forming another therapeutic connection. Here's why:
- A student who doesn't have money to buy food or make rent isn't going to spend $25 a week on a co-pay for therapy. Perhaps he should, but it is my experience that he does not.
- A student who falls into the "high-risk, chronic, refer-out" category often doesn't have private insurance, helpful parents, or transportation to get to the outpatient clinic.
- In the rare case that a student does have insurance, she is often worried about her parents' finding out that she is going to therapy when the insurance bills arrive at home. That stops the student from attending off-campus treatment and billing insurance.
- A therapy relationship doesn't transfer easily. How long have you worked with your bank? How about your dry cleaner? How much harder do you think it is for a student who has bared her soul to simply "do it all again" with another treatment provider at the community mental-health center?
- Off-campus therapy options can be seriously limited in terms of access. Students can wait months for a first appointment.
- Outpatient clinicians sometimes lack a solid understanding of the developmental needs of college students.
Some skeptics might counter: "These are problems the student has. The school is not responsible. We can't fix everything. We have limited resources."
But when a college fails to treat a student, the student's problems remain at the college. Many students who are "referred out" do not actually get treatment in the community. Instead they recycle the problems (only now without any therapeutic support) back into the classroom and the dorms. While those students may no longer be the problem of the counseling center, they are still experiencing their symptoms and often causing problems around the campus.
"Scope of practice" limits are another way college-counseling centers and administrators attempt to limit access to care. They say, "We don't treat substance abuse, eating disorders, borderline personality disorder, psychotic disorders, bipolar, ADD/ADHD, (insert your disorder du jour), because we don't have the training and expertise in that area. It is beyond our scope of practice."
Counseling centers need to expand their scope of practice. Counselors, psychologists, and social workers need to obtain additional training if they lack the expertise needed to work with high-risk or difficult students. If a campus counseling center is getting an increase in substance-abuse referrals, it should seek to increase training or hire someone with that expertise. If a center is struggling with an increase of Asperger's students seeking care, it should invest in training or find a way to offer a clinical group to deal with this growing population.
Some may suggest, "What about child molesters? What about chronic heroin addicts? How about students with traumatic brain injury?" I would agree that there are times when a referral to an expert or an off-campus community mental-health treatment center is important. We don't need psychologists and counselors reaching that far beyond their expertise and doing harm to students who need very specialized assistance.
I am concerned, however, that some of us are crafting mission statements and treatment protocols to limit our services. And our reasons sometimes have more to do with time, budgets, and "I don't want to" rather than the more-reasoned arguments related to training and clinical expertise. We shouldn't pick and choose the mental illnesses that we treat in our centers. We can't develop policies and procedures that systematically take one group of students with high-risk mental-health problems and refuse care while focusing on those who respond well to short-term, time-limited treatment.
Investing in more-comprehensive care is not only a question of professional ethics but also financially sound. There have been several lawsuits filed against college counseling centers after a student committed suicide after the center refused care on the basis of short-term-care limits, scope of practice and training, or availability of resources. Most of the suits were settled at a significant cost to the institutions.
We shouldn't take the easy path. We need to treat students who are in danger of being "policy-and-procedured" out of our offices by risk-adverse administrators and overwhelmed clinical staff workers too tired or poorly trained to work with high-risk, difficult students. We need to advocate for those in need. We need to stand against those clinicians and administrators who are concerned only about a student's not committing suicide on their watch. Those students lack the voice or ability to speak for themselves.