Therapy Without Limits

Given his background in clinical psychology, it’s no surprise that Oglethorpe University president Nick Ladany has made student mental health a priority throughout his 30-year career in higher education. He often jokes that he uses his therapy skills as much as a college administrator as he ever has in any other job.

But his experience came in especially handy at the start of the COVID-19 pandemic in 2020—soon after he assumed the presidency—when student mental health tanked amid illness and the isolation of virtual schooling.

It prompted Ladany to launch a revamp of the university’s counseling center, in the hopes of helping students recover both mentally and academically from the impact of the pandemic.

The cornerstone of the revamp was the decision to eliminate caps on the number of counseling sessions students could attend each semester. Many institutions allow students only a set number of free counseling sessions before they have to pay for the service or get a referral to an outside therapist. But at Oglethorpe—a private institution in the suburbs of Atlanta serving just under 1,500 students—students can see a therapist an unlimited number of times.

Ladany said short-term counseling models can be effective—but also limiting.

“If you have a career concern or a mild relationship concern, it may only take three to six sessions,” he said. “But if someone’s been sexually assaulted or experienced trauma, six sessions is inadequate.”

Outside referrals aren’t always effective in those situations, either, he noted. Therapy can be prohibitively expensive; some students don’t have insurance, or, if they rely on their parents for insurance, they might not feel comfortable divulging they are in therapy. Students may not have access to transportation to get to their appointments or have a private space in which to do virtual appointments—especially if they live with a roommate, Ladany said.

Oglethorpe isn’t the only institution that operates without session limits; according to research conducted in 2021 by Penn State University’s Center for College Mental Health, which surveyed the 661 counseling centers that are CCMH members, 65.5 percent do not have session limits. That figure was roughly the same—64.2 percent—in CCMH’s 2019 pre-pandemic survey, showing that despite increased concern about student mental health, most colleges that cap counseling center visits haven’t made the switch post-pandemic.

According to Brett Scofield, executive director of the CCMH, most institutions that limit sessions do so because they wouldn’t be able to handle the demand otherwise.

“Institutions typically implement session limits as a ‘demand management strategy,’ which is one of many strategies centers commonly use to respond to the challenge of increased demand for counseling services with limited supply of treatment,” he wrote in an email.

Marcus Hotaling, president of the Association for University and College Counseling Center Directors, noted that many colleges do not use hard limits—allowing students, say, only 12 counseling center appointments each year. Instead, they rely on clinical judgment to regulate how often a student can utilize their mental health services. A student with mild anxiety may only be seen a handful of times, for example, while a student at greater risk may come in weekly, he said. A 2021 survey of AUCCCD’s members showed that approximately 44 percent of centers offer weekly appointments to some students.

“Ultimately, the goal is to meet the needs of the school,” said Hotaling, who is also the director of the counseling center at Union College in Schenectady, N.Y.

To accommodate the unlimited sessions, Oglethorpe added a new full-time counselor to the college’s counseling staff and is looking at potentially adding more. The ratio of counselors to students is currently just above one to 375 (although one counselor role is still filled by a part-time contractor). That’s much better than the ratio recommended by the International Accreditation of Counseling Services, which ranges from one to 1,000 to one to 1,500.

Many colleges and universities are nervous about the cost of adding new counseling staff, Ladany said, but he believes those costs are likely to be offset by the number of students who end up remaining in school rather than dropping out because of mental health struggles. He wants to study the relationship between increased mental health services and retention as Oglethorpe continues with this new model, which officially launched in fall 2021 and has led to an increase in students utilizing the university’s counseling services.

“Universities have to prioritize. A university might choose to build a rock-climbing wall or build something on campus, [like] a fountain. They have to ask themselves, ‘How much does it cost to hire two therapists?’” he said. “Flowers on campus are lovely—where are the therapists? To me, it’s part of the fundamental infrastructure of a university.”

While Oglethorpe officials did not specify the costs of providing mental health services, a spokesperson said in an email that "spending on counseling services is prioritized in our operating budget proportionally with other students support services."

Other Initiatives

Removing limits on counseling center sessions is not the only change Oglethorpe has made since Ladany became president. The counseling center also updated its website to make it easier for students to schedule appointments. The site explains what clients should expect at their first session—which the center’s director, Michelle K. Lyn, said encourages students to show up for the initial visit.

Going forward, Lyn also hopes to implement a feedback survey for students who utilize the counseling center and to expand the college’s counseling training program, which allows graduate students and postgraduates in clinical psychology to intern at Oglethorpe’s counseling center. Such programs are win-wins, she said, because they help prepare future counselors in the greater Atlanta area while also increasing the number of counselors available to current students.

“That’s definitely part of the vision,” she said.

Other goals are more ambitious. Ladany said he dreams of making the counseling center available not only to students but also to their families; since students can be negatively affected by stress at home, allowing their families to get counseling at Oglethorpe could help lessen that impact.

“Sometimes, what’s happening in the family could be incredibly disruptive” to students’ lives, he said. “We’re not there yet, but I could envision us offering mental health services to the families of our students.”

He is currently considering applying for grants to fund such an initiative.

The initiative would not be the first of its kind; the Yale University medical system offers mental health services to students’ spouses and domestic partners. But Hotaling is skeptical that similar programs could be adopted at smaller institutions with fewer resources.

“I would be very hard-pressed to find many campuses that would be willing to do this, for two reasons,” he said. “It’s more of a liability. We’re liable for the students on our campus, the students that are enrolled, and I think the attorneys for the schools would be like, ‘Why are we taking this risk?’ Two, we’re already maxed out in terms of resources.”

Other future mental health programs and reforms will likely be guided by data that Ladany hopes to soon begin collecting regarding the number of students seeking counseling, the issues they present with and the effectiveness of their treatment.