Students Need More Counseling—and More Than Counseling

The need is great, but the takers are few. While the mental health challenges facing college students are well documented, many students aren’t seeking out counseling and other support services available to them on campus.

In the latest Student Voice survey, only 34 percent of students who say they have personally struggled with any item from a list of mental health challenges during college—which included anxiety, disordered eating, significant mood swings, suicidal ideation, substance abuse and other challenges—had used in-person counseling or telecounseling, gotten grief counseling, or been referred to an off-campus therapist for support during the pandemic.

And lest anyone think such mental health concerns are uncommon, note this: students selecting one or more of seven challenges listed total 1,794 of the survey’s 2,000-student sample. The survey was conducted March 16 to 22 by Inside Higher Ed and College Pulse, with support from Kaplan.

“I was just talking to a student who said that some students will just never utilize counseling services, and even students with a severe mental health condition like suicidal ideation may not see one-to-one counseling as an appropriate step for them,” says Kevin Thomas, a licensed psychologist and associate director for student wellness and counseling and psychological services at California State University, Fullerton. Clinical staff and trainees there represent a range of individual and social identities and experiences, and include licensed psychologists, marriage and family therapists, professional clinical counselors, and clinical social workers, as well as a life coach, a psychiatrist and a psychiatric nurse practitioner. Recently the department added two new positions to coordinate preventative education, plus access to the YOU at College personalized wellness platform.

“I tell students all the time that I’ve never met someone in my life who has done everything on their own,” says Thomas. “Everybody has a mentor, a therapist or someone else who has helped out.”

He cautions, however, about the pressure that mental health first aid programs, while valuable in guiding students toward help, can place on their peers. “We’ll hear from roommates [of students who may be suicidal], ‘I feel like I have to watch them every moment. How can I go to class if I’m supposed to babysit them?’ We have to balance getting more people help while not burdening people at the same time,” he says.

Lingering stigma around mental health is likely at play in students not seeking help. In a Healthy Minds Network survey of 707 Montgomery County Community College students, 49 percent agreed that “most people would think less of someone who has received mental health treatment.” Yet only 9 percent agreed that “I would think less of someone who has received mental health treatment.”

Ashley Slaff, a licensed marriage and family therapist who manages the community college’s new wellness center, sums up the disconnect this way: “Most support others getting mental health care, but they don’t realize they support each other.”

Other findings from the Student Voice survey—which revealed specific mental health and wellness concerns among undergraduate students, asked them to grade their institution’s mental health services, and sought opinion on where colleges should direct future investments in mental health and wellness—include:

• Students were most likely to give their college a grade of B for mental health services, with 26 percent of the full sample, and 38 percent of those who felt comfortable assigning a grade (30 percent did not have an opinion), giving that letter.
• Among students who got referred to an off-campus therapist or provider for a mental health issue, they were most likely to have gotten that referral after completing multiple sessions with a campus therapist (32 percent).
• Asked to select up to three priorities for further investment in campus mental health services, students selected expansion of on-campus counseling staff (37 percent), the addition of a psychiatrist (32 percent) and a 24-hour emergency mental health hotline (25 percent) the most.

Mental Health Services Report Card

Although nearly one-third of the Student Voice respondents didn’t know enough about their college’s mental health services to assign them a grade, B’s and C’s are the most common response. Still, it appears from the survey’s open-response question about what’s working well and what needs more attention, those grading lower are most passionate about their stance. As a Midwestern public university student wrote, “I don’t think any of it is working ‘well.’” The student, who called for both more counselors and psychiatrists and “better counselors and psychiatrists,” also takes issue with the service model that seems to exclude anyone “struggling with real mental illnesses.”

More generally, students who believe their institution’s mental health services are lacking may just have the wrong perception about the purpose of counseling. “There’s this unrealistic expectation that counseling fixes everything,” says Jenny Ortiz, associate director of wellness and health promotions at St. Olaf College. “You can’t go to counseling and expect life is going to be better after the first time you go.”

Liadan Solomon, who works part-time as a research data and report analyst for the Healthy Minds Network as she pursues at dual master’s in social work and public health at Boston University, has noticed a lot of frustration from students, who wonder how institutions charging so much to attend don’t have enough funding to provide them with needed mental health care. Of course, Solomon says, “The solution is so much more nuanced. It’s not just about allocating money but making sure it’s going to the right things.” Adequate staffing is about both quantity and quality, she adds.

Among students who identify as having specific mental health struggles, those with substance abuse issues are most likely to give their institution a D or an F—35 percent compared to 18 percent (with results filtered to only include respondents who assigned a grade).

Jonathan Mitchell, a licensed psychologist at the University of South Florida at St. Petersburg, a 2022 Active Minds Healthy Campus Award recipient, believes this group might have a clouded perception of resources and options to engage with them. “I can’t say that active drug use will alter perception of our day-to-day lives, but that could factor in to whether someone feels confidence that mental health resources are going to help.”

LGBTQIA+ students are another group with more negative opinions of campus services. Nineteen percent gave a grade of D or F, compared to 11 percent of straight-identifying students.

“Prior research shows that trans students end up feeling they’re having to train or educate a mental health counselor about their gender identity,” says Sarah Ketchen Lipson, a principal investigator for the Healthy Minds Network, which conducts surveys of college students and staff, as well as an assistant professor in the department of health law policy and management at Boston University. These students might spend their entire first session just explaining their identity, and then they may find the counselor ties every issue back to that identity.

Students who got referred to off-campus therapy providers were also feeling less generous about grading, with 32 percent assigning a D or an F. Mitchell will sometimes hear from students who saw a psychologist weekly in high school who want to continue that frequency of care on campus. “We could do that; it’s a matter of making sure this person wouldn’t have to bounce around too much,” he says, adding that brief interventions better match the center’s scope of care. Those most likely to get referred out are students in active psychosis, those with unmanaged treatment, with schizophrenia or active hallucinations, those with uncontrolled and highly disruptive drug use, or who are chronically suicidal.

The way the University of Virginia’s Nicole Ruzek, who is director of counseling and psychological services, explains it, “we try to refer out students who will need care throughout their four years.” Her department serves about 25,000 students with 3.5 full-time-equivalent psychiatric providers and about 20 counselors, depending on the season. Accommodations for receiving services on campus may be made with a student’s family situation, finances, comfort in accessing care and transportation, plus availability of outside providers, in mind.

When referring out, counseling centers should consider what the referral process looks like for those students and for the providers, how students are being supported in making the connection, what happens if an appointment isn’t available right away, and what the follow-up is like, says Amy Gatto, director of research and evaluation at Active Minds, which supports mental health awareness and education for young adults. For students who have just made an initial contact with the center, “there isn’t necessarily that feedback loop,” she adds.

At Montgomery County Community College, Slaff says wait lists in the community for services can be up to a month. “As a wellness team, we can be a bridge, maybe texting with people as they’re on a waiting list.” (Texting is also how some students receiving support prefer to communicate with her.)

At USF St. Petersburg, Mitchell says, the initial on-campus appointment wait time, excluding weekends, is 3.5 days. That is what his team of 3.5 counselors for about 4,500 students can typically accommodate. “What’s interesting about the warm hand-off [to an off-campus provider] is we need to send two messages at the same time—that we’re a full-service clinic where students can come and address things concerning to them, and when we can’t really meet someone’s particular needs, we’re going to get you to where you need to be.”

That involves “doing some of the legwork on behalf of this person we’re treating,” he says. One option is the team’s licensed clinical social worker making the calls to set up a smooth transition. Another is working through care managers on the behavioral intervention team at the student outreach and support office.

More intense off-campus programs may be needed for some students, and that may require greater levels of support. “We’ve had conversation around that issue,” says Ruzek, noting eating concerns and suicidal ideation that isn’t getting better as examples of instances where students may need inpatient care. “Of course they want to be with their friends and doing all the normal things they envision themselves doing during college, so it can be very challenging to think about taking a year or a semester off.”

Substance abuse is another area that may require intense treatment, although UVA and some other institutions are ramping up specialized on-campus assistance in this area. UVA has a substance use counselor on staff, and Ruzek notes that it’s important to engage with students “quickly when they have that motivation [to seek help] so they don’t end up in a place of crisis.” Her institution also offers students access to certified health coaches trained in addressing a variety of areas, including substance use (which may involve co-occurring diagnoses).

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While inpatient treatment is necessary for some students, colleges can work toward “giving students a supportive community so that they can remain in school while getting the help they need,” says Kristina Canfield of the Association of Recovery in Higher Education. Interim executive director and member/program manager for the organization, Canfield first heard about collegiate recovery programs while in grad school and launched one at her alma mater, drawing on her own experience of being “a young person in recovery, in college, at a party school.”

For many students, she says, having that community on campus to help them through the situation may be enough. Recovery programs “serve as a safe place” for students at any point of the spectrum: still using, thinking about stopping using or already in recovery, Canfield adds.

To institutional officials who might worry that such a program would give them a reputation as a campus with a drug problem, she says, “Substance use is part of human behavior. It’s not a reflection on the school—it’s a reflection that you have human beings on campus.”

Perspective on Priorities

When supporting students, one general assumption applies: students have individualized needs. So when looking to improve mental health and wellness services and supports, leaders would do well to think broadly and get a pulse for what students are saying, both nationally and on campus.

That involves listening to students, elevating their voices and including them in conversations and decisions, says Gatto from Active Minds. “It’s not a Band-Aid, one-size-fits-all approach.”

Keeping virtual options even as campuses continue the transition to in-person activities is a key consideration. As Montgomery County Community College’s wellness center continues its launch, “we’re trying to meet students exactly where they are,” says Director Nichole Kang. “If that means Zoom, or all over email or texting or phone calls, or meeting in person, we really give [students] options.”

When asked to select up to three areas they would want additional mental health funding to go toward, Student Voice respondents would most prioritize expansion of on-campus counseling. “We know the demand for counseling services has been [high] over the past several decades, and it’s been outpacing the supply of treatment available, which has led to increased caseloads for therapists,” says Brett E. Scofield, executive director of the Center for Collegiate Mental Health and co-interim senior director of the Center for Counseling and Psychological Services at Penn State University.

In exploring the relationship between clinical load index and treatment dosage for students with critical needs, CCMH research documents how centers with higher counselor caseloads struggle to offer needed care to students with safety concerns and high-intensity needs, such as suicidality, those who are sexual assault survivors or those with a registered disability.

Fifty-five percent of Student Voice respondents who have used on-campus counseling, 51 percent who have been referred to an off-campus therapist and 50 percent of those who have used telecounseling want hiring more counseling staff to be a top priority, compared to 37 percent of the full sample.

One public university student in Colorado expressed frustration at the institution’s promise to bring on 20 new providers and 10 existing ones being let go instead. “When I reached my lowest low, I asked for therapy twice a week instead of once and they discontinued my care entirely because of the request,” the student shared.

Campuses, of course, aren’t the only place in need of more counselors, especially now. So meeting demand both in numbers and in diversity has been difficult. “We’ve tried to adjust some of our advertising for job postings, advertising in publications and on websites specifically geared toward clinicians of color,” says Ruzek. The university’s central Virginia location, requiring relocation in many cases, can be a barrier to ensuring a diverse staff.

Even with UVA’s center being well staffed compared to other institutions, Ruzek would like to see clinician schedules freed up to address longer-term issues. Since the recent addition of TimelyMD’s TimelyCare app, “we’re starting to feel a little bit of pressure shift,” away from the counseling center, she says.

The hope is to provide on-campus services in a more robust way, such as services specific to substance abuse, eating disorders, students on the autism spectrum and the LGBTQIA+ population.

Solomon, from Healthy Minds Network, worked closely with the counseling services office at University of Michigan, from which she graduated in 2021. “The hours were really high, and the burden of supporting that many students, just from a compassion perspective, is really tough,” she says.

Providing access to psychiatrists and psychiatric nurse practitioners isn’t easy for colleges, either. “We’re seeing more students coming in who have already been prescribed medication, and when they arrive, they need to continue those services,” says Ruzek. And psychiatrists out in the community tend to either not take insurance or have long waits for care. Psychiatrists generally prefer to have a collaboration with therapists, and that’s much easier if an institution can manage to get someone to prescribe meds who is on staff. After a screening to make sure it’s appropriate, some UVA students who don’t need psychotherapy at the same time can access a psychiatrist through TimelyCare.

St. Olaf, which also now contracts out for psychiatry services, used to share a psychiatrist with a nearby college, until that provider retired. Yet, says Ortiz, the number of services needed is exceeding what the provider can offer students for free as part of the partnership.

A round-the-clock emergency mental health hotline is the third top response for what Student Voice survey respondents want prioritized. “Some campuses use national hotlines, some use counseling center staff and some contract with a third party,” says Scofield.

While at Michigan, Solomon found herself needing to call the 24-hour help line the university had outsourced. “It was difficult because it wasn’t embedded in the university,” she says. “Call back during business hours” was a typical kind of response to the problem, which results in students who “don’t get what they are looking for when they call.”

Since some students may not even be aware their institution offers access to a help hotline, students involved in Active Minds have been advocating to include crisis numbers right on student ID cards.

Slaff, who has worked on a suicide-prevention line, explains that help seekers are leery about who will actually answer the phone. “It feels like calling a stranger,” she says, adding that offering to call with a student can “make it a little less weird.”

Since some students may not even be aware their institution offers access to a help hotline, students involved in Active Minds have been advocating to include crisis numbers right on student ID cards, explains Gatto. She also suggests that campus leaders promote the number heavily, “getting information to students in a way that works for them.”

Awareness efforts should include the fact that 24-hour help lines are not only for emergencies or for middle-of-the-night issues. According to TimelyMD, nearly one in five of its 24-hour TalkNow service visits is identified as suicide risk, and only about half come in after regular business hours.

“It’s not a crisis line. They can handle crises, but someone with test anxiety can contact them,” says Ruzek.

While more group counseling wasn’t a top priority to the Student Voice respondents, campus counseling professionals speak of its value in reaching students who would not pursue individual counseling, in getting more students assistance and in working with particular groups, such as students who have considered suicide. “How normalizing it can be to just hear other people are dealing with the same things you are,” says Slaff. “A professional can say that, but it’s very different from seeing and experiencing it.”

Read more from the Student Voice survey on the current state of student mental health.