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Research Report

Meeting the Escalating Demand for Mental Health Services

Targeted interventions for key student segments

September 10, 2018

Demand for campus mental health services continues to grow with no signs of slowing. Higher education leaders recognize the high stakes associated with delayed access to mental health support. Students’ mental health concerns and access to treatment also impact key organizational goals, such as academic performance and retention.

Hiring additional staff is not a sustainable, long-term solution. Even well-resourced counseling centers struggle to keep pace with demand. To meet demand, colleges and universities must target interventions to key student segments and maximize existing resources.

In this study, EAB recommends campuses align resources with students’ varying levels of need and risk. Colleges and universities should pursue strategies that make the most of current campus and community resources.

Section 1: Addressing high-need students

High-need students are students with mental health conditions that require intensive, ongoing, or specialized care. These students might have a history of serious mental health conditions or require long-term therapeutic engagements, medication management support, or specialized treatment. These students are an increasingly visible group on many campuses, as they are coming to the campus counseling center looking for support. While there are some outliers, most institutions are not equipped to address the needs of high-need students, especially in high volume.

Practice 1: Scope of care statement

A sustainable scope of care statement outlines the breadth and depth of mental health services offered on campus. Elon University shares a scope of care statement prominently on their counseling services webpage. The statement includes a clear statement about the goals of counseling services and explicit guidelines that feature examples of cases that may require treatment off campus. Widely sharing a scope of care statement is valuable because it helps establish upfront expectations with students, families, and campus stakeholders about the types of services available on campus and what types of concerns might require off-campus support.

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Practice 2: Orientation letter

Baylor University educates parents and families about students’ care options with a letter that all incoming students receive prior to orientation. The letter helps set expectations about the types of care that can and cannot be provided on campus. It also encourages students and families to establish a care plan before transitioning to Baylor. For example, the letter suggests students continue their care with their home provider if possible or seek an off-campus specialist if they require frequent or ongoing therapy sessions. The letter boosts early interactions with the counseling center, as it invites students and families to contact the clinical case manager with questions or to learn more about care options.

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Practice 3: Plan "B" exercise

Kutztown University also uses orientation as an early opportunity to educate families and students about care options. During orientation, Kutztown’s health services and counseling services staff hosts a session about services available to students on campus. The session clarifies the scope of campus services: presenters communicate that students need to explore off-campus alternatives for long-term medical needs or intensive and specialized mental health care. Families and students are encouraged to establish a Plan B to ensure the appropriate level of care and discuss details including available providers, insurance, and transportation options.

Kutztown initiated this orientation session in summer 2017 and noticed an initial uptick in students seeking campus support for connecting with off-campus providers. Kutztown plans to continue this content at future orientation sessions and provide additional support to families and students as they establish their care plans.

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Practice 4: Data-informed referrals

The second step to promoting successful off-campus care is to match local resources with students. EAB recommends that institutions use data to strategically pair community services with students whose needs go beyond the scope of a campus counseling center.

Ryerson University uses a data-informed time audit to identify students whose needs are best suited for offcampus care. Ryerson asks key questions about clinical resource utilization to identify high-need, complex cases that map to targeted community services. Ryerson’s referral strategy demonstrates the potential resource savings of strategically referring a small group of students whose needs are beyond the expertise and services of the university counseling center.

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Practice 5: Expedited local referrals

EAB also recommends that institutions use referral data to identify student groups that are ready for off-campus care. Metropolitan State University of Denver (MSU Denver) identifies specific student populations that commonly seek off-campus referrals and expedites their referral process by empowering campus partners.

An expedited referral process allows students to bypass the counseling center and connect more quickly with community resources. There are many specific student populations that might benefit from an expedited referral process to specialized community resources, such as campus veterans, survivors of domestic abuse, or undocumented students.

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Practice 6: Clinician open house

The third step to promoting successful off-campus care is to create mechanisms that facilitate effective community referrals and help students overcome barriers to access. EAB research revealed that one obstacle to successful off-campus referrals is clinicians’ hesitancy to refer students off campus. Clinicians may be hesitant to refer due to students’ financial circumstances, concern for their wellbeing, or a lack of knowledge about available community services.

The College of Charleston helps overcome these barriers by educating clinicians about available community resources through their annual meet-and-greet event. Each spring, the College of Charleston hosts an open house for campus clinicians and community providers. Attendees network and exchange information about available campus supports and community practices. This low-cost event helps clinicians feel confident about community resources and helps community clinicians better understand the breadth of campus supports available to their student clientele.

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Practice 7: Health services assistant

Southern Methodist University (SMU) established a Health Services Assistant (HSA) to ease students’ transition to off-campus care. SMU’s HSA is an administrative support professional, not a specialized new hire, who wanted to do more direct work with students. When students receive an off-campus referral, they briefly meet with the HSA to review their options and identify next steps. The HSA maintains a suite of tools, such as a list of available providers and community transit schedules, that can make it easier for students to connect.

SMU’s approach is effective because it does not require additional staff or expertise. Guidance from the HSA helps students understand the referral process and facilitates a quicker connection between students and community providers.

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Practice 8: Referral coordination program

The University of North Carolina at Chapel Hill’s (UNC Chapel Hill) Referral Coordination Program streamlines the off-campus referral process for students. When students receive an off-campus referral, they are automatically scheduled for a 30-minute appointment with a referral coordinator. The appointment generally occurs three to seven days after the initial referral. During the appointment, a social worker or trained intern will facilitate a personalized discussion with the student about initiating off-campus care. The discussion might include activities around mapping out a transportation plan, locating a student’s insurance card, or calling a provider to make the first appointment.

One to two weeks after the referral coordination appointment, the coordinator will check in with the student via phone or email to ensure that a successful connection was made and troubleshoot any new challenges or concerns. Students are also asked to complete a short survey about their satisfaction with the program and their new off-campus provider. Using data from this survey, UNC Chapel Hill found that students who participate in the program are 2.5x more likely to connect with their off-campus provider than students who do not participate in referral coordination.

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Section 2: Students with short-term needs

More students are seeking individual therapy appointments at colleges and universities across the United States and Canada. Data shows that from 2009-10 to 2014-15, the number of total counseling center appointments grew seven times faster than institutional enrollment growth. EAB research interviewees report that many students come to campus expecting on-demand access to individual counseling.

The increased demand for individual therapy appointments has contributed to unsustainable service wait times and fewer students being able to access timely support. Data indicates that one-third of institutions maintain a waitlist for individual therapy appointments. Average wait times on campus range from two to three weeks and grow even lengthier during periods of high demand, such as midterms and finals. Counseling centers cannot keep pace with the number of students seeking individual therapy on campus, which can lead to students not having access to timely assistance and support.

Practice 9: Individualized action plans

Creating a goal-oriented experience should begin with students’ first engagement with the counseling center. Rutgers University prioritizes goal-setting with an Individualized Action Plan. The plan is a document created jointly by the student and clinician during the first appointment as a framework for defining individualized treatment goals and success markers.

It serves as a treatment road map and it includes space to define goals, prioritize interventions and resources, and determine measures that will be used to evaluate progress. The action plan is effective because it helps students understand individual therapy as a structured interaction with a clear end point. The action plan is stored in students’ electronic health records and it is revisited and revised at subsequent appointments.

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Practice 10: Appointment checkpoints

Beyond initially setting goals for individual therapy on campus, EAB recommends employing checkpoints to track progress over time. The University at Buffalo regularly assesses student goals during therapy with a structured appointment checkpoint. When students reach their fourth individual therapy appointment, their clinician engages them in an intentional conversation about their evolving goals and progress to date. Together, students and clinicians determine the best next step, whether that’s continuing with individual therapy sessions, exploring alternatives (e.g., group therapy), or ending active treatment at that time.

The checkpoint structure is effective because it ensures that individual therapy is a goal-oriented experience. Regular checkpoint conversations encourage students to think ahead about their treatment needs and goals. Moreover, these conversations promote the responsible stewardship of limited clinical resources on campus.

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Practice 11: Truncated appointments

Some institutions are restructuring the mechanics of individual therapy appointments as a way to increase efficiency. The “50-minute hour” has long been the standard length of individual therapy appointments. EAB research found that a growing number of institutions are experimenting with truncated appointments, or shorter 15 to 30 minute sessions, as a way to efficiently supplement other interventions with individualized attention.

EAB interviewees expressed that truncated appointments are ideal supplements to other interventions, such as group therapy or online modules, because the flexible structure allows students to check-in about newly learned techniques or troubleshoot concerns as they arise. These abbreviated appointments fit into students’ busy schedules and can also free up clinicians’ time, as students and clinicians can keep in touch without holding an entire appointment block.

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Practice 12: Reeducate clinicians

EAB’s first recommendation is to reeducate or remind campus clinicians about the efficiency and clinical effectiveness of group therapy. EAB research interviewees identified clinician resistance as one of the top reasons why students do not utilize groups. In response to this trend, Duke University developed a strategy to grow staff buy-in and confidence in group therapy. Key elements of Duke’s approach include group champions to manage the program, research-based trainings and experiential learning opportunities, and equipping clinicians with scripting that they can use to push past students’ skepticism of groups.

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Practice 13: Rebrand groups for students

Second, EAB recommends that institutions rebrand group programming to overcome students’ dated understanding of group therapy. Pomona College’s “Life Hacks” miniseries of psycho-educational workshops uses accessible language and compelling titling to attract student interest. The workshops simulate a group therapy experience and help students become comfortable sharing with peers and building actionable therapeutic skills in a group setting. The Life Hacks series is an effective example of how to reintroduce students to group therapy through compelling branding.

Life Hacks workshops include:

  • Self Care 101
  • The Happiness Trap
  • Coping with Distress
  • Stress Management
  • Counting Sheep to Getting Sleep
  • Living Mindfully
  • Overcoming Perfectionism
  • Overcoming Test Anxiety
  • Procrastinators Anonymous

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Practice 14: Deploy data-informed groups

Third, EAB recommends institutions leverage data to tailor group offerings to student needs. The University of Oregon conducts an annual review of key data to reassess the group therapy programs’ logistics and content. This data-driven approach allows Oregon to adapt to changing student needs and make the most of limited clinical resources.

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Practice 15: Accountability Mechanisms

Fourth, EAB recommends that institutions establish mechanisms to track students’ progress and follow-through in group therapy sessions. Institutions must hold students and clinicians accountable for groups. Hardwire accountability for both students and clinicians, ensuring that both parties recognize the value of group therapy in treating students’ mental health concerns.

Restructuring individual appointments and reinvigorating group therapy programs can increase the capacity of the counseling center, but institutions should also pursue dynamic staffing models in order to make more significant gains. EAB recommends that institutions explore progressive staffing models in order to maximize resources and serve more students on campus.

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Practice 16: Outsourced after-hours care

Wesleyan University contracts with a third-party vendor, ProtoCall, to offer after-hours support. ProtoCall’s services are integrated with Wesleyan’s counseling center, which allows for a seamless care transition for students and the institution. Outsourcing after-hours care also alleviates the burden on overworked staff and can free up time for clinicians to spend with students.

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Practice 17: Seasonally contracted staff

The University of Maryland’s seasonal contracting model uses a data-informed approach to maximizing clinical resources across the year. Each year, Maryland’s counseling center analyzes data to isolate peak periods of demand and identifies local clinicians available to work part-time on campus for short-term engagements. Through this model, Maryland has been able to increase the capacity of the counseling center during high-demand periods.

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Practice 18: Hybrid staffing model

Facing stagnant staffing, limited flexibility, and increasing levels of student dissatisfaction, Georgia State University developed an innovative hybrid staffing model. This model dramatically changed Georgia State’s approach to staffing, increasing the institution’s capacity to see students and serve their evolving needs.

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Section 3: Low-risk students

Years of outreach and destigmatization efforts in higher education have encouraged students to come forward and ask for mental health support early-before they reach the point of crisis. As a result, today’s low-risk students are often more likely to seek help on campus. EAB research interviews confirmed that many counseling centers are experiencing an increase of students coming forward with low-risk concerns, such as developmentally appropriate challenges, general anxiety or stress, and loneliness or social isolation. Low-risk students are not at risk of hurting or harming themselves or others. As a result, low-risk students may not require clinical interventions.

Even though institutions have augmented their self-serve resources, utilization challenges persist. EAB research revealed three utilization challenges. First, these resources often do not align with students’ expectations for individual therapy. Self-serve resources might not “look” like mental health supports. Second, these resources can feel generic and impersonal. Finally, self-serve resources often lack structure and accountability. When students do not have guidance on identifying and using self-serve resources, it can be challenging for them to explore and follow through with next steps. EAB recommends that institutions pursue strategies to overcome these utilization barriers and help students make better use of self-serve resources.

Practice 19: Rebranded supports

Increasing the utilization of self-serve resources requires institutions to expand students’ perceptions of what constitutes mental health support. As part of their stepped care model, Calvin College advertises the broad array of mental health resources available to students.

Each step features supports of varying intensity that students can access on campus and in the community. For example, step two showcases campus supports such as health services, student success, and group fitness. Step four includes self-help practice and psychoeducation resources such as apps and websites.

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Practice 20: Behavioral prescriptions

EAB recommends personalizing recommendations to drive students’ utilization of self-serve resources. George Washington University developed a Behavioral Prescription, or Bx, to help students recognize the broad spectrum of mental health supports.

The Bx is a written form that is jointly completed by the student and clinician. It maps students’ concerns to specific treatment options, including self-serve and campus resources. The Bx ensures that students have a clear understanding of the spectrum of their treatment options and their personalized recommendations for next steps.

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Practice 21: Guided instruction

Using self-serve resources can be challenging for students because of the lack of structure and accountability. EAB recommends institutions add structure to self-serve resources to make it easier for students to follow through. The University of Florida’s Mind and Body Center provides a dedicated physical space in the counseling center to support students as they participate in mindfulness experiences, online modules, and meditation practices. Launched in spring 2017, the goal of the center is to incentivize students to take advantage of services that might reduce or replace the need for individual therapy appointments.

UF’s dedicated physical space encourages students to take advantage of these resources. The space allows students to walk in to access resources with minimal distraction or make an appointment for a specific service. Students can also connect with graduate assistants and center staff who provide coaching or answer questions.

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Practice 22: Peer listening platform

Student peers can extend the reach of campus mental health services by providing valuable nonclinical support. Many counseling centers already work with student organizations on outreach and education efforts. Calvin College is extending the reach of peer support with their active listening platform. Through a partnership with 7 Cups of Tea, a third-party organization with an online, chat-based platform, Calvin College students can connect with peer listeners who provide anonymous nonclinical support.

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Practice 23: Wellness coaching

Peer coaching is another method of providing targeted, nonclinical support to students. The Ohio State University’s Wellness Coaching Program provides a structured series of one-on-one interactions between students and a trained peer coach. The program helps students explore their character strengths, set and achieve wellness goals, and build skills necessary to succeed on campus. Coaching sessions are goal-oriented and individualized for each student.

During the 2016-17 academic year, 210 students participated in 935 individual wellness coaching sessions. Most students were either self-referred to the program or referred by the counseling center or academic advising. Common themes across wellness coaching sessions include self-acceptance and happiness, self-confidence, navigating transitions, improving social relationships, and stress management. Program assessment data indicates that wellness coaching improves students’ personal wellbeing, academic determination, and social connectedness.

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