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Scope of practice and refusal to provide treatment in college counseling centers

Discussion in 'Psychology [Psy.D. / Ph.D.]' started by futureapppsy2, 02.21.12.

  1. futureapppsy2

    futureapppsy2 Ed Psych PhD student Moderator Gold Donor

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    Interesting opinion-ish article from the Chronicle of Higher Ed. It argues that the refusal/referring out of students with more severe/chronic mental health problems (e.g., BPD, chronic suicidality, bipolar, schizophrenia,PTSD, etc) is ill-advised because most students who are refered out don't end up getting treatment in the community because of cost, time, lack of insurance, etc. It also suggests that the brief therapy model employed by most university counseling centers is at the root of some of these problems.

    http://chronicle.com/article/Giving-Troubled-Students-the/130838/

    What do you think? I haven't worked in college counseling center, so I don' t really feel qualified to have a strong opinion one way or another.
  2. Ollie123

    Ollie123

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    I'm at one now.

    Outside referrals are definitely a problem and I hold no doubt that most people don't follow through on them. However, I would have the same question in most other settings - I don't think its limited to UCCs by any stretch of the imagination. As hard as it may be to accept, I do think we have to draw a line at some point where its "Not our responsibility anymore". We can't make people seek treatment. Do we take on clients we can't competently treat, just because they won't put in the effort going elsewhere? Is inadequate care better than no care? Can the system be changed to provide adequate care in that setting, or is that just not realistic? I don't know, but its an important question.

    Personally, before we leap to opening up inpatient units in UCCs I think its important to look at system-level variables first. Most colleges require students to have insurance - do their plans not cover mental health tx? If not, maybe we should be looking at changing that first. Similarly, what is the referral system? Do you say "Here's a number to call" and leave it at that, or is their follow-up? Are their social workers on staff to help connect students with community resources? Again, I think there are a number of other factors and other possible solutions.

    All that said....yes, the short-term model is a problem. We have a 10 session limit. Even as someone who is trained exclusively in short-term, problem-focused therapy, that is tight. Even standard short-term CBTwas designed for more like 12-16 sessions. Unfortunately, the 10 session limit is largely there because we are busy. Extend that to 20 sessions, and that means you can only see half as many people.

    To me, I think some middle ground is needed. We have the view that anyone who comes in the door is entitled to therapy. Admittedly they don't route the severe cases to the prac students, but I've had several clients who simply had no reason to be in therapy. Yes, yes, you have a little troubles managing your time. Your boyfriend/girlfriend broke up with you and now you want to "process" it (i.e. complain to someone now that your friends are sick of hearing about it). You are worried about finding a job after graduation and wonder what that will be like. Now sometimes, these are the presenting problems but true pathology is discovered - but many times not. Certainly some more minor (but still critical) issues should be addressed there (e.g. test anxiety). I mostly just object to providing therapy that seems to have no clear purpose when people in need aren't getting services. That's coming from someone with a clinical background so this may be a difference in tradition, but if I had to say which service would be more useful/valuable for a university to provide...that's not even a question in my eyes. Why see people who are doing perfectly fine when in many cases there is precisely zero evidence we can actually do anything to help - and yet have to tell the genuinely depressed individual that they can't be seen anymore because they hit their 10 session limit and now its time for us to spend 10 sessions convincing someone to buy a calendar and planner, or someone who came in because they just finished psych 101 and thought it would be interesting to "explore their psyche"?

    So basically, I would argue that we should shift towards referring out the MOST severe (SPMI, certain substance use & ED cases, etc.) AND the least severe. Right now its all of the former and none of the latter (at least here). I have no problems with someone wanting to "explore". That's fine, though I do question whether there's any reason to believe that needs to involve psychologists. However, when people need treatment...that should take precedence. If they want to "explore" go pay someone to do it - UCCs should be a part of campus healthcare, not recreation.
    Last edited: 02.21.12
  3. nika751

    nika751

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    I think it is tragic that some colleges refer students out and they fail to follow through. I think what is even more tragic are the people I have seen who are treated by someone unskilled to treat them. While it is difficult and expensive for college students to be able to get treatment outside of the university setting, the reality is that I have never been in a university setting that was equipped to handle long-term therapy for the bipolar, dissociative, suicidal, or schizophrenic patient. It can seem almost unethical to not treat them knowing that they may fail to follow through, but I think I third option needs to be considered.

    While this third option would take more time, effort, and may be close to impossible in some areas, why could universities not employ or at least work with one psychologist and psychiatrist? That way if a student did come in presenting with major issues they could be taken care of, but with someone more able to do long-term therapy. I know university counseling centers use a lot of graduate students doing practicum for counseling. While these cases are good experience for us, I think it is also hard for the patient to have to change counselors once the semester practicum is up. I think with these patients there needs to be some level of commitment that lasts longer than a semester or year. While we need exposure to these types of cases, I think there needs to be a balance and some time of continuity for the client.

    Also, no one is obligated to treat anyone. I think the ethical and responsible thing to do when presented with a case that you feel unable to treat is to refer it. While psychologists and counselors should care about what happens to the patient once they leave the room, trying to treat those you can not handle is like tying a swing to tree branch that is to small. Eventually it is going to swing to hard and to fast and break.
  4. futureapppsy2

    futureapppsy2 Ed Psych PhD student Moderator Gold Donor

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    How do you really effectively triage, though? Our program clinic (a CMHC, not a UCC) does prelim phone intakes and even in then in just one semester I've had clients whose phone intake seemed to point to serious problems and yet they turned out to be more mild/moderate and clients who seemed to have more mild/moderate problems based on their phone intake but who were actually in crisis-level situations. Similarly, how do you effectively triage someone who wants to "process" a break-up versus someone who's having, say, suicidal ideation over a break up, given that the latter may not mention it over, say, a triage phone interview? I think that might be where the "see all comers" attitude originates--fear of missing the more severe, immediate issues that seem benign on first blush. Otoh, this can lead to long waiting lists that may keep the people who need treatment the most "backlogged." I agree with you re: UCCs as health care v. reacreation, but putting it into practice could be tricky. Plus, I think a lot of UCC's emphasize the "all comers" aspect as a way to reduce stigma--and maybe as a function the role they have traditionally filled...?
  5. Ollie123

    Ollie123

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    Oh its definitely a tricky issue, but its also certainly possible to be a bit more rigid about it than the CC I'm at is (and I suspect many others are as well). No triage system will be perfect - let's just acknowledge that up front. There are pluses and minuses to doing this, but if we have systems in place that we trust to rule out the most severe (and rule-outs aren't limited to people presenting with florid psychosis at intake - there is subtlety on that end as well), I'm confident we can come up with something to rule out the folks looking for "recreational therapy" (to continue with that term).

    I see it happening at several levels. Certainly, I think SOME in-person contact is critical. We have social workers who do initial intakes, I think a setup like that is a great first step. Maybe I just have a trustworthy face, but I've had very few clients that won't open up SOMEWHAT if pressed. If by the end of an hour interview they are functioning well by all objective indicators (GPA, work, etc.), they aren't reporting any particular problems beyond existential issues, there is no safety concern, etc. - I'm okay with telling those people "It sounds like things are going well for you right now - we have a lot of people we need to help, so here is a private practitioner (or other appropriate referral) you can call to discuss those issues if you want. You're welcome to come back if you feel like you need us".

    I also think some of it is not just a matter of triage, but a matter of being willing to take more control and terminate early if its clear there is nothing there. We tend to let the clients "have control" here - which can have benefits in some clinical scenarios, but also allows things to drag out longer than they should with the "worried well". I've seen more of a shift towards speeding things along even in the 6-7 months I've been there, and I imagine that trend will continue - I've heard it was VERY different even just a couple years ago. Lots of places deal with these issues - in the vast majority of clinical settings you can't walk in and say you just want to "Explore your thoughts about x" and expect 10 (or even 2) sessions of therapy. I don't see any reason CCs couldn't find some way to handle this. Again - this may mean we lose some people who truly needed help. Its an empirical question, but I think we lose more with the current system than we would from a shift.

    RE: Stigma...I don't buy it. Well, I buy that this may contribute to why these policies exist, I just don't think its a good one. This is colored by my personal view on PC culture, but this seems like another attempt at a "cosmetic" fix to the issue. If we want to eliminate stigma that seems a really half-arsed way to go about it. Campaign, encourage celebrities to come clean about their issues publicly, get these out in public, etc. Make it "okay" to have depression just like its "okay" to have the flu. If we're gong to eliminate stigma its going to be through activities like that, not from a CC pretending someone downing a liter of vodka a day and experiencing command hallucinations is no different from someone coming in to "understand themselves better" because we're all just people. This is similar to how we get so caught up in the terminology used to describe disabilities/disorders that seems to miss the bigger picture that changing the label only results in a new word becoming associated with stigma, it does absolutely nothing to fix the actual problem.
    Last edited: 02.21.12
  6. cara susanna

    cara susanna Predoctoral Intern

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    I'm at a counseling center right now and I think it's important for therapists to know their limits. I'd rather they refer out than handle a case that they don't have any competence in.
  7. DynamicDidactic

    DynamicDidactic Unestablished Non-member

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    Really? With all 3 colleges I attended this was not the case. Similarly, none of my friends went to colleges where this was the case. Actually, my experience is that the cost of UCCs is covered in tuition and services are very cheap, which does not necessitate the need for insurance. In my view, this is actually a benefit to the UCC set up.
  8. nononora

    nononora Dis Member Moderator Emeritus

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    When did you go to college? In the last few years, there has been a strong push towards mandatory health insurance in many colleges. UCCs are typically free but community referrals will require insurance coverage.
  9. zensouth

    zensouth

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    I briefly did an M.Ed counseling internship at a university counseling center, so I have some limited experience in that area. I tend to agree with some of the comments in the original article which point to expectations about what a UCC should be. Just as any university health center would refer out for serious cases (i.e. cancer) so too should a UCC. I don't think the mission of a UCC should be to handle the more extreme/difficult mental health issues but rather more normative college stress/transition related issues. However, given that a UCC is sometimes the first any only contact point a student may have for mental health care I do think that any type of referral system should be very robust in order to help transition into a higher level of care.
  10. KillerDiller

    KillerDiller

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    Sure, no UCC I've heard of actually bills insurance. The services are free to students and the salaries of the staff are paid by the university. However, all schools I've attended/worked at still require students to carry health insurance. Students can either provide proof that they have an outside provider (e.g. are covered under their parents' plan) or they are automatically billed for a plan through the university. Usually this is included with the tuition bill. This is done so that if something happens that is beyond the scope of health services to treat, the university can be relatively sure that the student is covered.

    Maybe there are universities that don't do this at all? I don't know.
    Last edited: 02.22.12
  11. KillerDiller

    KillerDiller

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    I think the vast majority of UCCs do employ at least one psychologist. Actually, I've read that UCCs are one of the venues that have held out against the swing to hire mostly masters-level therapists. Many also employ a psychiatrist at least part-time, though I'm not sure of the percentage that do. Still, just having a psychologist and a psychiatrist does not mean the facility is equipped to deal with SMI. Some cases will require intensive outpatient, or even inpatient tx.
    Last edited: 02.22.12
  12. KillerDiller

    KillerDiller

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    If counseling centers are reluctant to let these students go entirely, perhaps another solution is to refer them to groups instead. Granted, I'd hate to see UCCs transition to a primarily group-based format, but getting a few process groups going each semester for the worried well could maximize resources.
  13. cara susanna

    cara susanna Predoctoral Intern

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    The one I'm at doesn't require insurance. It also has a lot of groups that it refers students to.
  14. Ollie123

    Ollie123

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    Well, I was definitely under the impression most schools (at least nowadays) require insurance and many will offer fairly minimal plans through the university if no other insurance plan is available to the student. That point was unrelated to the UCC though - these generally provide services for free to students. I was simply indicating that students without any insurance plan are FAR less likely to pursue or find quality services from outside providers so this is important for referrals. Maybe I'm wrong or this hasn't caught on to the extent that I thought it had, but it sounds like some other posters have had similar experiences. Of course, just because someone has insurance doesn't mean the plan is good - I imagine $50 co-pays, a huge deductible, etc. with an obscure carrier that few providers actually take is not going to provide a great deal of encouragement for students to seek services.

    I do like the idea of groups, and think they are underutilized at many places. Some things obviously need to be individualized, but other things seem to be equally or more effective in group formats. One thing I haven't seen done frequently but that I'd like to do some research on is a hybrid model (i.e. group format for psychoed, coping skills training, and other more "didactic" components of therapy, with an individualized component for homework review, etc.). Many settings use both group and individual but they don't always seem well-connected, and research on it is minimal. This format could make it easier to have biweekly therapy, shorter sessions, etc. without as many negative consequences.

    In sum, it won't be easy, but I think there is a lot of system-level work that can be done to at least help alleviate the problem. It seems one of efficiency more than scope since we certainly do see (some) more severe cases here, but there's just only so much that can be done in that environment with a 10 session limit, etc.
  15. KillerDiller

    KillerDiller

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    This sounds like a fantastic idea! Now that I think about it, I'm surprised more places don't go for this type of approach.
  16. Markro311

    Markro311

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    I'm completing my pre-doctoral internship at a UCC on a large campus. We have a somewhat large staff, utilize a bi-weekly model for individual therapy, and have a very robust groups/workshops program. Our groups include about a dozen themed groups (LGBTQ, grief, substance use, grad student, dissertation, etc.), 4 general process groups, and 6-7 different psychoeducational/experiential workshops (mindfulness meditation, social skills, coping with anxiety (multiple throughout semester), coping with depression (multiple throughout semester), etc.). We also refer out many clients at triage or intake when appropriate (we also have a case manager to help with the process when needed). In spite of all that, we still have 1-2 week waits for triages, and 2-3 week waits in between therapy sessions.

    Needless to say, UCC's are absolutely more utilized and busier than ever. The increase in client hours has been exponential each of the past 5-10 years. No way could we exist without referring out many clients, especially given the fact that adding more staff is so difficult in this economy.

    EDIT: Most (but not all) students have some type of insurance. However, having out-of-network providers can be a pain still. Plus, there's often initial wait times to get seen off campus as well. So depending on the client, I will keep on a client until I know they are connected. Sometimes this requires cutting into my lunch or note hours. It can be a hectic setting, depending on the student population to staff ratio.
  17. PsychPhDStudent

    PsychPhDStudent

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    FWIW, insurance has been required for students at both my old undergrad and now in grad. However, that doesn't mean the MH coverage on plans have to be good, and frequently they're not.

    Our counseling center sounds similar to a lot of the ones described on here - 10 free sessions (though more can be available through insurance). They are not really equipped to treat serious mental illness, even if they occasionally do. Luckily, we have (separate) in-house training clinics in our graduate program where we see students at a very, very affordable rate. They can receive ESTs here, and the counseling center refers out to us a lot. Since we're a walking distance away and low cost, it's a good option for students with MDD/panic/BPD/etc.
    Last edited: 02.22.12
  18. Ollie123

    Ollie123

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    Hah, thanks. The evidence-based practitioner in me would like to think its because there is so little work that has been done on it, but I know better then to think that would stop people:laugh:

    Obviously grad school is not an optimal time to be running my own large-scale tx study, but this is one of those questions I've been toying with for awhile. Might make for a good R34 submission on post-doc depending on where I'm at. So remember...you heard it here first!
    Last edited: 02.22.12
  19. Duck Duck Goose

    Duck Duck Goose Senior Lurker

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    Just wondering if you're talking about a DBT kind of approach, with the groups and individual tx really interwoven?
  20. Ollie123

    Ollie123

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    Sort of! I'm admittedly not overly familiar with DBT, but from what I do know of it that is similar to what I had in mind. Though with the obvious differences that the content would not necessarily need to bear any relationship to DBT, nor would this necessarily need to be team-based. Mostly just as an implementation style that might improve efficiency without have an adverse impact on outcomes. I think a lot of programs are designed with the "idea" that it would work this way but again - from what I have seen it usually doesn't. Different people running groups and doing individual therapy, they don't know what the other person is doing, little connection, etc.
    Last edited: 02.22.12
  21. Duck Duck Goose

    Duck Duck Goose Senior Lurker

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    I'd include the DBT model in your lit review because there's a lot of empirical support there. :D (Sorry for the tangent, back to CCs.)

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