Before the disruptive and tragic pandemic, college campuses were still in the same throes of a mental health crisis as they have been for the past decade. The pandemic has certainly not relieved college students of mental distress; in many cases, their struggles have been exacerbated.
What's more, when COVID-19 hit, college faculty and administrators across the country abruptly had to create entirely different ways of delivering services to students no longer on the campus -- or even in the same state or country. And because states regulate mental health services and counselors can’t provide those services in states where they’re not licensed, people like me who direct counseling centers didn’t simply scramble to figure out how to deliver services but also faced serious questions about whether we could even provide services to our students. We did our best to navigate through countless hours of reviewing various state licensure boards exceptions and consulting about the legal and ethical issues to see whom we could still serve.
In the midst of this endeavor, it occurred to me that what sets me apart from all my nonclinical campus colleagues is that, even though I participate in a number of national professional organizations specifically related to helping college students, I operate as a health provider while all of my colleagues operate under the broader identity of educators. Among the most notable changes in college mental health over recent decades has been the increasing medicalization of our work and the solid location of our professional identity in the health sphere. On some level, that has provided our profession with the respect and credibility that the health industry enjoys, but the burden of being a health provider in this context reveals how that comes with a cost.
Certainly, many aspects of our work align with the diagnostic and treatment frameworks of the health industry, yet unlike mental health providers in other settings, counseling centers have traditionally owned the role of “supporting the academic mission of the institution.” Unfortunately, however, our identity as health-care providers has so eclipsed this aspect of our role that the closest most of us come is “restoring student functioning” enough for them to engage in the academic mission of the institution.
There is a lesson here that applies as much to our work in pandemics as it does to our continuing struggle to keep up with the demand for services: we need a more intentional and strategic ownership of our roles as educators.
To be clear, psychotherapy and academic coursework are not the same. But counseling and learning share substantial elements. Many standard therapeutic interventions rely on effectively introducing new skills and adding flexibility to the perspective of the client in key dimensions of student development. Once in therapy, collaborations between counselor and client begin as they engage in things like unpacking their experiences and processing their emotions, all of which imply some combination of skill, comprehension and ability to synthesize the various elements related to some subject matter. And while clinicians would certainly include elements of healing, recovery and growth to describe the goals of psychotherapy, the actual outcomes desired from much of counseling center service can be framed as educational: learning new skills and additional ways of understanding one’s self and the world so as to relate to one’s experiences in ways that reduce distress and enhance flourishing.
Yet we remain locked in a struggle to keep up with demand for our clinical services, and to educate campuses on how to refer students to them, without much articulation of the goals and outcomes of those services. Notions of developing coping skills are referenced without specifying what, exactly, those skills are and how they are developed. Students, faculty and staff regularly refer to the counseling center as the place to go where you can learn “how to deal with” problems, with no common framework to assess what “deal with” entails.
Addressing Concerns Through Pedagogy and Curriculum
To be certain, much of what happens in therapy is an organic process that can’t be replicated in a classroom. But the continued outcry about counseling centers being unable to keep up with demand invites us to ask what can be addressed in the classroom toward the goal of preparing students for life after graduation in fulfillment of the mission of most universities.
What if colleges could more effectively address a significant proportion of their students’ mental health concerns through pedagogy and curriculum? What if we include crucial elements of counseling in broader student learning outcomes? In the same way that each academic discipline must take a particular pedagogical approach that suits their subject matter, the expertise and data that exist in college counseling centers can be translated into coursework, with experiential and reflection components included. Given the alarming pervasiveness of certain student struggles, it seems reasonable -- if not urgent -- to consider shifting the paradigm from reacting to a persistent mental health crisis to also addressing a pervasive mental education deficit.
At Oxford College of Emory University, we observed that among the more common responses in student counseling intake data was a strong endorsement of a statement referencing “that no one understands me” -- including for students who did not report isolation or were quite engaged socially. Through consultation and review, it became clear that the theme of stress related to authenticity emerged quite frequently on our campus.
Through an RA training session offered by our counseling staff, this observation was introduced, and student leaders worked with an anthropology professor who created an independent study research project on this issue. This culminated in presentations at the end of the year, followed by a powerful discussion on how both the faculty members and students could relate to the issues being discussed. The next semester, that anthropology professor introduced an entire course on authenticity to prompt students to study and define this phenomenon, on our campus and in the world, in consultation with the campus counseling center.
A single course or independent study does not constitute a clinical intervention. But the significance of such efforts is that a therapy issue is now also viewed as a campus or community issue, with academic relevance and the added perspective that comes from working across academic disciplines. Through such efforts, colleges can expand the narrative around mental health in a way that students become engaged in deeper reflection and, even more important, in discussion with each other about many of the concerns that are usually addressed in confidential therapy hours. While such endeavors do not have the safety of that confidential space, they also do not have the stigma that prevents the very engagement with each other that reduces the isolation and invites more authenticity. Perhaps most significantly, they can add nuance to the way our world understands student struggles.
A Paradigm Shift
Broadly speaking, a shift from mental health to mental education would prioritize teaching students critical thinking skills and self-management abilities in intrapersonal, interpersonal and social domains. We can apply lessons from stepped-care models of counseling center service delivery, which offer a hybrid of didactic instruction, experiential and interactive practice, and goal setting. Such programs may provide an infrastructure to build on mental education as a priority in higher education.
The first step in the early stages of this aim must include broadening the narrative from a mental health frame to a mental education frame that attends to student struggles from a variety of perspectives in the campus community. We can begin to imagine such a shift in how we approach the common practice of screening days or awareness weeks on depression, anxiety, eating disorders or mental illness in general. Beyond restating high-prevalence crises and re-emphasizing institutional resources, a campuswide symposium on how any of these concepts are viewed through the various academic or cultural lenses of the campus can help launch this paradigm shift on a campus.
What does “depression” mean and how is it understood in terms of psychology, sociology, economics, literature, film, evolutionary biology or race and gender studies? Similar inquiries and the discussions they prompt can be applied to anxiety, disordered eating and suicide.
How might a combination of academic perspectives blended with invitations to the community to share myriad personal narratives impact those who struggle or those who know someone who is struggling? Might such a symposium lead to conversations that could reduce stigma, introduce creative ways to address the widespread nature of the problem and offer opportunities for connection among members of the community who find some way to relate to each other?
Colleges and universities can also offer courses with learning outcomes that include navigating emotions, improving distress management and enhancing interpersonal effectiveness. Perhaps they could be in psychology departments, but they could also emerge in applied philosophy, sociology and other fields, limited only by the curiosity that already leads to interdisciplinary studies on many campuses.
If this pandemic has shown us anything, it is that we are capable of shifting how we think about what we offer in higher education. To address the high demand facing campus counseling centers, we can aim to meet more of our goals through learning objectives in the curriculum, potentially amplifying the overall treatment outcomes in the therapy sessions.
Clearly, some topics must remain in the spaces provided in therapy sessions -- such as trauma, deeply personal family issues and other experiences where privacy is a vital ingredient for support. But many students may benefit more from a shared learning experience as they discover how common their varieties of struggles actually are and how integrated that learning, growing and healing actually can be.