Nineteen-year-old Sophie described her state of mind when asked about what prompted her to seek therapy at her university's on-campus counseling center in the spring semester of her freshman year: “I was feeling really depressed adjusting to college: the alcohol consumption, relationships, living really close to people for the first time after being an only child who was used to a lot of personal space and privacy — basically, the mess of freshman year.”
Sophie, who asked that her last name not be used, had been in therapy before. A lot of it. From age seven through 18 she had seen the same therapist back home in Los Angeles to treat her ongoing anxiety. The transition to college found her, for the first time in a long time, without a therapist to unburden herself and help her cope.
As a seasoned client she carefully unpacked for her campus counselor all the issues afflicting her and asserted a need to have someone to talk with who might really understand her. But, the counselor seemed more interested in cataloguing Sophie's symptoms than truly listening to her painful life predicaments. Sophie’s distress was palpable as she recalled how the counselor responded.
“Being clear about what I needed felt like I was doing something wrong," Sophie said. "The counselor knew what she wanted me to be. She wanted me to be a problem she could fix or put a band-aid on. I believe that therapy is a long-term process and the counselor was not interested in that. I only went to one appointment. It felt like I was with a graduate student getting practice doing therapy.”
After the first session, I was given a date a month later to see a different therapist," she continued. "I’m sure the counselor had some order of immediacy, somebody who posed harm to themselves or others. I felt like I really needed help at that time but I didn’t fit their model. I wasn’t a priority.”
Adding insult to injury was the fact that Sophie had partially chosen her college over other choices because its well-advertised counseling services were a drawing point for her. Without her regular therapist and insurance coverage that would allow her to see a therapist in the nearby city, Sophie was counting on campus-based therapy. “I wish they had been more honest about what people could expect from the service," she said. "I thought there would be more counselors. They really underestimated the number of students who prioritized their mental health.”
Sophie’s story is fairly typical of what all-too-commonly occurs on college campuses nationwide: students with complex mental health problems, and a rather sophisticated understanding of psychotherapy based on previous experience, relying on college counseling centers for quality treatment, dropping out prematurely when they encounter inexperienced clinicians who only offer crisis-intervention or a quick-fix approach.
Let’s start with findings that substantiate the complex mental health needs of the new generation of college students. Trends among college students serviced in college counseling centers tracked in the 2016 Center for Collegiate Mental Health (CCMH) annual report show 33 percent having “seriously considered attempting suicide,” compared with 24 percent in 2010-2011. The majority of the 518 counseling center directors polled in the 2014 National Survey of College Counseling Centers (NSCC) pointed out significant increases in the number of students presenting with anxiety disorders, clinical depression, self-injurious behavior, sexual abuse and eating disorders, over the previous five years. More students are showing up on campus with thornier mental health issues, as well as a prior history of receiving therapy. The 2016 CCMH survey estimates that one in two students seeking services on campus has been in therapy before. So we have a cohort of students who are savvy about therapy and in need of quality interventions.
Zach (not his real name) is one such informed psychotherapy consumer. His susceptibility to panic attacks had become aggravated by the dawning sense that his choice of college — a small liberal arts college in New England — might have been an incorrect one. He badly wanted a therapist to act as an objective sounding board so he could pick apart whether there was merit to his dissatisfaction with this particular college, or whether transitioning to any college would have been distressing. “He wanted to talk about my mental health and I wanted to talk about practical things," said Zach. "But that’s not how therapy works necessarily. It’s like a lot of very practical talk, then you get moments of deeper understanding.”
Other disclosures reflect Zach's finessed understanding of quality psychotherapy and his disappointment over not receiving it. “He asked about childhood trauma very quickly," he said. "In fact, the questions he asked were not in sync with what I was talking about. I’m sure it’s good to understand how somebody thinks and you need to do that eventually. But I was flustered. No one at school seemed to listen and meanwhile he wasn’t listening. That was pretty alienating. I was so done after the first visit.”
Sadly, Zach's final remark reflects an alarming trend in the delivery of care on college campuses — premature drop out. Various studies conducted by University of North Texas professor of psychology Jennifer Callahan reveal that premature termination of psychotherapy in college counseling centers approaches 80 percent, while similar rates in private practice and community clinics fall between 40 and 60 percent. Cognizant of this alarming trend, the authors of the 2016 CCMH report assert that “the management of client drop-out should receive greater attention during treatment and clinician training.”
Is it possible that the inordinately high therapy drop-out rates at campus clinics reflects inexperience on the part of many practitioners and the quality of care offered? We know from the latest annual survey of the Association for University and College Counseling Center Directors, spearheaded by David Reetz, the director of counseling and psychological services at Rochester Institute of Technology, that there is about a one in four chance that a student walking into a college counseling center for services will be treated by an unlicensed trainee mental health professional. However, this data set may underestimate the actual chances a student ends up receiving therapy from a trainee. Several years ago, sleuth work by staff at The Flat Hat, the College of William and Mary student newspaper, discovered that students who sought services at the campus counseling center had a 58 percent chance of being treated by an unlicensed or trainee mental health professional. Depending on where you turn for information, there is probably a one in two to one in four chance that students’ therapy needs are met by trainees on college campuses.
In fairness to trainees, they are often left to "learn as they go," because supervisors' time is spread thin and decisions have to be made between reviewing trainees' work with clients during supervision time and attending to trainees' professional development and conduct. A study led by Chris Brown at the University of Missouri-Kansas City found that a majority of training directors at college counseling centers were ethically troubled by their struggle to find time to adequately focus on the quality of treatment trainees were providing to clients on the one hand, and addressing issues of professional development and conduct (e.g., discussing child abuse reporting laws, covering laws and ethics pertaining to treatment notes, dressing appropriately, treating other staff members as colleagues/coworkers rather than friends), on the other.
Trainees often aren't afforded the opportunity to observe their supervisors perform psychotherapy, nor get observed doing psychotherapy themselves. A recent investigation of over 1200 trainee psychologists overseen by Gerardo Rodriguez-Menendez, former dean of the College of Psychology at John F. Kennedy University in Florida, found that 62 percent of trainees had never been observed by a supervisor performing psychotherapy during their internships. Beginning therapists are often left to somehow transpose what they have learned from textbooks and scientific studies into actions that are therapeutically useful.
Matthew Liebman, a psychologist in training at the Montefiore Medical Center in the Bronx, captures the dilemma no-doubt shared by his counterparts in college counseling centers.
"In graduate school it is easy to forget that everything you learn has to do with people," said Liebman. "None of the theory is any good unless it can be applied to helping people in need. And when that person is sitting in a chair across from you, looking at you with a bizarre mix of depression and hope as if the next thing out of your mouth could potentially have the power to make it all better, the pressure may be enough to shake loose every bit of information you've learned in the past several years all at once, creating a flood in your psyche. Alternatively, everything you've learned thus far may simply disappear."
Not only is there a high chance of being treated by a relatively inexperienced trainee when students seek campus-based services, the therapy offered is likely to be of the short-term, solution-focused, crisis-management variety, with sessions spaced weeks apart. On the Health and Counseling Services website at Northeastern University in Boston, students are quickly schooled on the type of therapy offered:
. . . we focus on identifying issues or major concerns, problem-solving, and we provide support to help you develop strategies to address your personal goals. Some problems can be addressed in one or two sessions, while others need a number of sessions spaced over a period of time. We do not automatically see students on a weekly basis.
The emphasis is often on risk-assessment and risk-management, rather than giving clients ample time and space to talk at length about their angst-ridden concerns and delve deeply into the sources of their anxiety and depression. Along these lines, Ben Locke, who directs counseling services at Pennsylvania State University, recently told a STAT news reporter, “You’re making sure people are safe in the moment. But you’re not treating the depression or the panic attacks or the eating disorders.”
According to a trusted source who has been on staff at a variety of top-tier university counseling centers in Southern California, "I'm listening for risk more than listening for things that would result in me making a real connection with a client. I'm listening for any words that I need to jump on because they indicate a suicidal potential. Then I go into overdrive getting consent forms signed, alerting resident assistants, parents, anybody who can keep an eye on the client. My clinical decisions are so governed by fear and anxiety, rather than what the client really needs, which is a connection to a trained professional to talk about distressing problems."
This source also informed me that at one site he was required to have his laptop open at all intake sessions with clients asking numerous symptom-oriented questions and clicking off boxes accordingly.
This medical-model, symptom-governed, solution-focused, crisis management approach to psychotherapy might quell the anxiety of beginning clinicians, making them feel they are being productive and safety-conscious. It may also satisfy the aspirations of college administrators worried about any added liability associated with increased numbers of students on campus admitting to suicidal ideation. However, paradoxically, a therapy approach where the practitioner functions more like a medical provider and dictates the agenda in terms of symptoms, goals and solutions, can undercut clients being genuinely engaged, encountered and listened to in their moments of dire need. In fact, suicide-prevention experts, like David Jobes at Catholic University of America in Washington, D.C., would proffer that any effective suicide-prevention counseling is predicated on hearing in great detail suicidal clients’ agonizing reasons for having reached such emotional lows in their life; really settling in to thoroughly understanding their existential struggles; really entering the painful narrative they tell and struggling with them to restore hope and meaning in their life.
And, to effectively treat the depression that accounts for clients’ suicidality, short-term therapy comes up short. In one of the most well-regarded studies of its kind, Jeffrey Vittengl, psychology department chair at Truman State University, along with several colleagues, found that crisis intervention, symptom-reduction, solution-focused therapy is insufficient to treat many clients’ depression. Within a year, almost 30 percent of clients offered this approach relapse, as do 54 percent within two years.
If college counseling centers are to accomplish their mission of maximizing the mental health of struggling students to enable them to be “ready to learn,” they need to heed this message from Louise Douce, former assistant vice president of student life at Ohio State University, in the influential publication A Strategic Primer of College Student Mental Health:
Fundamentally, we need a web of caring services that makes it more likely that students who experience symptoms or consequences of a behavior or mental health problem, whether those symptoms are personal, social, or academic in nature — will “stick” somewhere and find their way to one of the entry points for mental and behavioral health care.
Presumably, "stick” means not just improving access to needed psychotherapy, but ensuring it is of quality — relationship based, humanistically-informed and of adequate duration. That way any emotionally troubled student will have a reasonable shot at having contact with the same, well-trained, caring psychotherapist over time. A system heavily staffed by trainees who typically have a year-long stay counteracts the continuity of care from the same trusted provider a recurringly depressed student may intermittently need throughout the four or more years it takes him or her to graduate.
When more than 240 experienced psychotherapists were asked in a 2003 study by the Emory University psychology professor Drew Westen about the number of psychotherapy sessions the average anxious and depressed client needed to achieve meaningful and lasting change the number ranged from 50 to 75. That falls far short of the 4.66 average number of attended therapy sessions per student at campus counseling centers cited in the 2016 CCMH study.
Effectively engaging and keeping college students in the therapy they need to enduringly overcome the psychological problems interfering with their readiness to learn will require a more relationship-based, humanistic type of therapy. College administrators may need to turn back the clock and get reacquainted with the original client-centered philosophy of treatment fostered at the flagship counseling center at the University of Chicago, founded in 1945 by one of the pioneers of humanistic psychology, Carl Rogers: Sustained active listening and empathic understanding, nonjudgmental acceptance and recognition of clients' feelings, and genuine regard for and dedication to students as they struggle to acquire personal agency, meaning and purpose in their lives.
“I want to know that the person is listening and considering what I am saying in the context of me, not from their own context," said Zach, the New England college student. "Somebody with an air of experience and calmness.”