Outsourcing counseling comes at cost to community (opinion)
For years we have been discussing well-documented concerns about the mental health of college students. The Center for Collegiate Mental Health reported a 30 to 40 percent increase in students utilizing services from 2009 to 2015, even as enrollment only went up slightly (5 percent). In 2019, nearly 90 percent of college counseling center directors reported increases in students seeking services.
Administrators have clearly taken note. In February 2021, 73 percent of college presidents surveyed by the American Council on Education listed student mental health as one of their most pressing concerns, making it the most commonly cited concern among presidents. Along with this, more than half of the presidents surveyed stated that they planned to increase their budget for mental health services for the upcoming academic year.
We should not be confident that these budget increases will address students’ needs. College health centers saw cuts to budgets and staff positions, including counseling staff, after the start of the pandemic, and they have historically been forced to do more with less. To cut costs, many counseling centers have made problematic compromises in their essential service of talk therapy, either severely limiting the number and regularity of appointments or eliminating face-to-face treatment altogether. In some instances, counseling centers have had to abandon their time-tested treatment model and recast themselves as a triage or stepped-care service that aims to refer students to off-campus clinicians. As an iteration of this change in mission, some counseling centers now outsource to online third-party vendors, such as Talkspace, to provide the personal and nuanced conversation that talk therapy requires.
The Loss of Community: The Tail Wagging the Dog
We think it fair to assert that in too many institutions the budget has become the essential factor, rather than an important element, in defining the treatment model and mission of the counseling center. The tail is wagging the dog.
While these changes are well intentioned and from a practical point of view understandable, they are problematic for two reasons.
First, these changes for the most part result in services that are inferior to those that counseling centers have traditionally offered. Second, these changes fail to address the underlying and systemic issues that generate the greater student distress that is being reported. Accordingly, we argue that what is needed is considerably more investment in counseling centers themselves, not only so they can return to a place of providing meaningful talk therapy but also so counselors have an affirmed role in contributing to the thoughtful address of larger, institutionwide issues of student well-being.
To refocus our efforts back to the dog wagging the tail rather than vice versa, we should briefly consider the essential roles a college counseling center fills. While counseling centers have historically had numerous roles reflecting the changing landscape of higher education, in recent times their focus has been on providing various forms of therapy (e.g., individual, group, crisis) to students, working as outreach coordinators and consultants to faculty and administrators as they develop and implement programs and policies that require sensitivity to mental health concerns, playing various crucial roles on cross-unit behavioral intervention teams, and offering various mental health support services to the campus community as a whole.
All these roles are sensible, because our institutions herald themselves as educational communities. As institutions, we have evolved toward viewing ourselves as not only providing education but also experiences. These experiences invite students to actively bring in contributions and perspectives that spring from their histories, cultures and intellectual grasp of the issues at hand.
As we promote community and, toward that end, the diversity of our student population, and seek to provide experiences that promote transformation and growth, the lack of investment in college counseling becomes increasingly consequential. Personal and community growth is seldom smooth and easy. The better we become as institutions in providing the educational challenges that we value, the more we must expect accompanying stresses as students struggle to assimilate what they are learning intellectually and to accommodate this perspective within the familial and cultural stories that have defined them.
The community offers numerous supports. For instance, professors support students in meeting intellectual challenges, coaches help athletic development and deans and student affairs professionals see to students’ day-to-day needs. From our perspective, the support for finding meaning and understanding in students’ psychological lives must not be seen as less important. While third-party services promise almost immediate access to therapists and can provide a wide milieu of clinicians from which to choose, these therapists are not necessarily trained in working with college-aged students—and, just as importantly, these therapists are not community members.
From our perspective, there is a stark irony that we must consider if in our educational endeavor we characterize ourselves as community-sensitive but we choose (1) through outsourcing to exile our students with psychological challenges to professionals who are not part of the community and (2) to starkly limit the availability of community mental health resources.
With outsourcing to noncommunity resources, we send students to professionals who have neither stake in the community’s welfare nor appreciation of its complexity and potential participant role in a particular student’s psychological issue. Moreover, we rely upon for-profit telehealth businesses that may not be ethically sound; Talkspace, for example, has faced accusations of relying upon at best questionable therapy practices, failing to protect clinical data and even misleading investors. (See also the recent position paper published by the Psychotherapy Action Network on mental health apps and technology for more guidance as well.)
Even when advertised as extensions of counseling centers and designed in as well-intentioned ways as possible, the simple reality is that the counselors associated with telehealth providers are not employees of the university. Instead, they are employees of a third party that dictates treatment students receive. Accordingly, we wonder how many third parties also inform students of the potential conflict of interest that structurally must exist in this situation and define their relationship to the educational communities that they claim to serve.
Devaluing Our Community
In outsourcing, we not only lose our ability to exercise quality control with respect to clinical practice but we even more problematically devalue our own community. We do so by not protecting and investing in the expertise and experiences of college counselors who are uniquely suited to taking care of all our students (and perhaps especially our most troubled). By not providing the resources for them to care for these students, such that they either need to refer them out or offer them less comprehensive care, we send the message that we do not value clinicians who have devoted their careers to studying and learning about the uniqueness of college students.
Working with college-aged students is its own specialty, requiring an understanding of the unique developmental processes these students undergo and an awareness of the culture and context of the higher ed institution. Shifts in models to every-other-week therapy or primarily those of triage and referral entail a loss of therapeutic efficacy—or can even create situations where students get lost in the referral process. In this thrust toward delimiting and referring away we lose the potential for a student to talk with a therapist who knows not only about the special developmental challenges of late adolescence and young adulthood but also a therapist who knows about the unique complexities of the community milieu in which the student is confronting these challenges.
For example, we eviscerate the possibility that a student can talk to a therapist who knows about the typical stresses students often contend with during their orientation week. We implicitly dismiss the importance of talking to a therapist who knows about the insults to self-confidence that many students face when they take certain very demanding courses. We eliminate the opportunity for a given professor and a therapist in concert with a student to figure out how to meet the demands of a given course while also being respectful of the student’s emergent psychological crisis.
Moreover, counseling center work extends far beyond individual sessions with students. Counseling centers engage in outreach across the campus. This not only educates the community about the counseling center but also helps create an environment where various community members can see themselves as playing an important role in the co-construction of environments that value wellness not only for students but also for themselves. Community outreach helps share the expertise honed within the counseling center about college student development and apply it at different levels of abstraction to challenge narratives that therapists are the only ones responsible for student well-being.
Practically speaking, we have begun to see the effects of this devaluation on the counseling center’s ability to hire skilled clinicians. As college counseling work loses prestige and value and shifts away from models of therapeutic care towards referral, triage and crisis management, it becomes harder to hire counselors. One reason for this is that they want a chance to use their particular skill sets in therapeutic ways, which the current situation makes harder and harder. This in turn pushes centers toward greater reliance on third-party systems.
Beyond all the problems we have described another issue here is that contracts with third-party telehealth providers are at best Band-Aids. They have no vested interested in figuring out the systemic, social and cultural reasons students are struggling so much. Indeed, they benefit financially from our students’ suffering.
So, What Can We Do About It?
Institutions of higher education have not prioritized mental health in adequate ways (even as they say they are doing so). What is needed is the type of significant investment that is often made in other services, such as athletics, new buildings or new academic programs. This investment would not only enable counseling centers to hire and adequately compensate therapists to provide direct clinical services but more importantly would provide breathing room for counseling centers to consider broader systematic issues. Investments would not only be in offering wide range of impactful therapy but also in developing innovative and creative outreach programs with the community to address the systematic issues driving the mental health crisis. As each community is different, we suspect that each campus will need to figure out its own way. However, regardless of the intervention, it can only be developed by individuals who themselves are invested and caring community members—and not third-party, for-profit vendors.
We see investment in counseling centers as investment in outreach to other parts of the system such that we can begin thinking of programs and different ways of addressing the mental health needs of the student body from the top down. For example, we are increasingly convinced that part of the reason that counseling centers are so busy is that students simply like and perhaps crave talking to people who are dedicated to understanding and thinking about their experiences with them. Notably, we do not think that this is necessarily the sole province of the counseling centers. We think that many other stakeholders on campus could help provide this service. However, in the current environment there is so much anxiety associated with mental health issues that more and more stakeholders are worried about engaging in meaningful talks with students.
With enough investment, we might begin to think of the various relationships that students experience (e.g., with professors, coaches or administrators) and how to help make these more fulfilling for both sets of parties, such that students can have meaningful relationships with multiple individuals. Students are embedded within networks of relationships, and attending to their mental health needs must mean attending to the needs of the system. This can only be done with considerable investment in those parts of the system capable and interested in such exploration. When outsourced or divested from for whatever reason, the opposite message is sent—namely, that the psychological well-being of the system should be the responsibility of parties with no direct investment in that system.