Having issues with administration at a college counseling center - advice appreciated.

Groupthink

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I'm a licensed clinical psychologist and I work at a large university counseling center on the east coast. My organization is housed within the student healthcare building, but we are two separate organizations.

Unfortunately, the physicians in Student Health don't think so, nor does the university administration. This has created a whole host of problems and a lot of stress on my staff, and I'm looking for recommendations and advice on how to handle this situation.

As any ethical therapist should have, we have treatment guidelines. We are a small staff and, in line with most university counseling centers, our caseloads are bursting at the seams. As such, we limit the scope of our practice to specific mental health diagnoses. Though we are happy to conduct assessments, we are unable to provide appropriate treatment services for SPMI (schizophrenia, bipolar, etc), history of suicide attempts and non-suicidal self-injury, and other diagnoses that would require a higher level of care.

Unfortunately, the students have established a narrative that our counseling center "turns students in need away". This could not be further from the truth. It is our policy, again per the ethics code's statements on abandonment, to work with a student by providing appropriate referrals and doing our best to ensure transfer of care.

The physicians and university administrators perpetuate the student body's chant that we turn students away. I've had clients regularly tell me that the doctors say not to use our services, or "if you get assigned this therapist ask for someone else". There is pressure from the higher ed admins to treat everyone who wants help.

Myself and my directors have repeatedly tried to explain why this is inappropriate and unethical. We do not offer 24/7 crisis care. We are able to see students on a bimonthly basis due to clinician availability. We do not offer the resources for sufficient care.

I even tried to use their own logic against them. "Do you treat cancer here?" They said no, of course not. I said, "Why? If you are saying we are expected to treat all students then you should be following your own principles as well."

Their response, word for word, was "Well, medicine is different than Psychology."

Yes thank you, Dr. Schmuck, for telling me how to do my job.

I have no idea how to resolve this. I keep telling my organization admins that we need our own building to create a physical boundary from the other organization. But even then, it seems like our reputation on campus is tarnished and we are being expected to do the unethical.

Frankly, it's having a negative impact on the morale of my staff. We work very hard to meet the demands of students, but it's never enough and we're always being told what we're doing wrong.

What can be done about this?
 
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LadyHalcyon

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You are only able to see students once per month? For therapy?
I'm a licensed clinical psychologist and I work at a large university counseling center on the east coast. My organization is housed within the student healthcare building, but we are two separate organizations.

Unfortunately, the physicians in Student Health don't think so, nor does the university administration. This has created a whole host of problems and a lot of stress on my staff, and I'm looking for recommendations and advice on how to handle this situation.

As any ethical therapist should have, we have treatment guidelines. We are a small staff and, in line with most university counseling centers, our caseloads are bursting at the seams. As such, we limit the scope of our practice to specific mental health diagnoses. Though we are happy to conduct assessments, we are unable to provide appropriate treatment services for SPMI (schizophrenia, bipolar, etc), history of suicide attempts and non-suicidal self-injury, and other diagnoses that would require a higher level of care.

Unfortunately, the students have established a narrative that our counseling center "turns students in need away". This could not be further from the truth. It is our policy, again per the ethics code's statements on abandonment, to work with a student by providing appropriate referrals and doing our best to ensure transfer of care.

The physicians and university administrators perpetuate the student body's chant that we turn students away. I've had clients regularly tell me that the doctors say not to use our services, or "if you get assigned this therapist ask for someone else". There is pressure from the higher ed admins to treat everyone who wants help.

Myself and my directors have repeatedly tried to explain why this is inappropriate and unethical. We do not offer 24/7 crisis care. We are able to see students on a monthly basis due to clinician availability. We do not offer the resources for sufficient care.

I even tried to use their own logic against them. "Do you treat cancer here?" They said no, of course not. I said, "Why? If you are saying we are expected to treat all students then you should be following your own principles as well."

Their response, word for word, was "Well, medicine is different than Psychology."

Yes thank you, Dr. Schmuck, for telling me how to do my job.

I have no idea how to resolve this. I keep telling my organization admins that we need our own building to create a physical boundary from the other organization. But even then, it seems like our reputation on campus is tarnished and we are being expected to do the unethical.

Frankly, it's having a negative impact on the morale of my staff. We work very hard to meet the demands of students, but it's never enough and we're always being told what we're doing wrong.

What can be done about this?
 

WisNeuro

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This sounds toxic to the top of the heap. I hate to sound so pessimistic, but in this case, voting with your feet may be the only way to get change to happen. If they have a high degree of staff turnover, they may finally get some insight into the problem, but I also doubt that.

Lots of organizations/clinics/hospitals in healthcare suck. Usually due to management issues. So, if you want to change it, you engage in a Sisyphean/Herculean task, and try to change it within the system, or you can leave for a position that actually works well. It's up to you and your sanity. I choose myself first. A happy and well-compensated me does the best work for my patients.
 
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...We do not offer 24/7 crisis care. We are able to see students on a monthly basis due to clinician availability. We do not offer the resources for sufficient care...
Are you stating this as a matter of fact regarding your clinic, or is this what the physicians and admin are saying about your clinic? If you are saying this, then that’s where I’d start. If you can’t meet the needs of many of the students referred to you, then you really aren’t going to be seen as a valid referral source. Whenever you have a policy of not treating the significant needs of the population you purport to serve- regardless of reasons- you will be seen as a lesser option than those who don’t.

In summary, the best way to keep people from talking down about you often starts with you being better. Reputations are usually earned. The other option- there is a large and baseless conspiracy against your clinic- seems a little far fetched.
 

erg923

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I'm a licensed clinical psychologist and I work at a large university counseling center on the east coast. My organization is housed within the student healthcare building, but we are two separate organizations.

Unfortunately, the physicians in Student Health don't think so, nor does the university administration. This has created a whole host of problems and a lot of stress on my staff, and I'm looking for recommendations and advice on how to handle this situation.

As any ethical therapist should have, we have treatment guidelines. We are a small staff and, in line with most university counseling centers, our caseloads are bursting at the seams. As such, we limit the scope of our practice to specific mental health diagnoses. Though we are happy to conduct assessments, we are unable to provide appropriate treatment services for SPMI (schizophrenia, bipolar, etc), history of suicide attempts and non-suicidal self-injury, and other diagnoses that would require a higher level of care.

Unfortunately, the students have established a narrative that our counseling center "turns students in need away". This could not be further from the truth. It is our policy, again per the ethics code's statements on abandonment, to work with a student by providing appropriate referrals and doing our best to ensure transfer of care.

The physicians and university administrators perpetuate the student body's chant that we turn students away. I've had clients regularly tell me that the doctors say not to use our services, or "if you get assigned this therapist ask for someone else". There is pressure from the higher ed admins to treat everyone who wants help.

Myself and my directors have repeatedly tried to explain why this is inappropriate and unethical. We do not offer 24/7 crisis care. We are able to see students on a monthly basis due to clinician availability. We do not offer the resources for sufficient care.

I even tried to use their own logic against them. "Do you treat cancer here?" They said no, of course not. I said, "Why? If you are saying we are expected to treat all students then you should be following your own principles as well."

Their response, word for word, was "Well, medicine is different than Psychology."

Yes thank you, Dr. Schmuck, for telling me how to do my job.

I have no idea how to resolve this. I keep telling my organization admins that we need our own building to create a physical boundary from the other organization. But even then, it seems like our reputation on campus is tarnished and we are being expected to do the unethical.

Frankly, it's having a negative impact on the morale of my staff. We work very hard to meet the demands of students, but it's never enough and we're always being told what we're doing wrong.

What can be done about this?
If monthly treatment is all you can offer, you probably aren't really "treating" anything. Sounds like maintenance at best. You aren't within the standard of care or empirically supported treatment guideline for most disorders, and you can (and very much SHOULD) use this fact with administation to petition for more resources and staff.

Its a shame your clinic directors let this get to Defcon 2. Its bad for the patients and for your clinics reputation. I wouldn't talk-up or encourage patients to utilize a clinic that does "not offer the resources for sufficient care" either. Would you???
 
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PSYDR

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If you're arguing with anyone other than administrators about anything other than getting more resources, you're doing it wrong.
 
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Psycycle

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Are you stating this as a matter of fact regarding your clinic, or is this what the physicians and admin are saying about your clinic? If you are saying this, then that’s where I’d start. If you can’t meet the needs of many of the students referred to you, then you really aren’t going to be seen as a valid referral source. Whenever you have a policy of not treating the significant needs of the population you purport to serve- regardless of reasons- you will be seen as a lesser option than those who don’t.

In summary, the best way to keep people from talking down about you often starts with you being better. Reputations are usually earned. The other option- there is a large and baseless conspiracy against your clinic- seems a little far fetched.
Are you my former boss? Because he liked to tell me to be better without giving me the resources to be better. I agree that the needs aren't being met, but at the same time if you don't have the staff, you don't have the staff and you do the best you can. Expecting a college counseling center to handle SPMI is a tall order.

As far as the conspiracy goes, it doesn't sound like there's some deliberate thing going on: "Let's bash the ccc." Rather, it sounds instead like people who don't understand mental health treatment, clinic pressures, mental health diagnoses, and so on have started voicing their opinions and reinforcing each other. Groupthink and all that.

If I were in that situation and fortunate enough to be able, I'd vote with my feet.
 

Sanman

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If you're arguing with anyone other than administrators about anything other than getting more resources, you're doing it wrong.

Agreed, I don't know why the clinic directors are allowing themselves to take the heat for this. You want us to treat all the students who walk in? These are the number referrals we get, in order to treat them appropriately based on clinical guidelines, we need this many therapists, this much office space, etc. You want crisis care? This is the cost for the school to start a crisis line and staff it. Can we have our $10 million dollars for more resources? If the administration says no then it is on them.

Why are you seeing people only monthly vs seeing them in a time limited (say 8 week) fashion with a waitlist? To me that makes more sense for a this type of clinic.
 
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erg923

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Are you my former boss? Because he liked to tell me to be better without giving me the resources to be better. I agree that the needs aren't being met, but at the same time if you don't have the staff, you don't have the staff and you do the best you can.
If you don't have the resources to provide adequate care, you SHOULD be turning people away (sans an acute SI/HI situation).

How does it help to continue to "do the best you can" when that is substandard care? It doesn't help patients. Delaying treatment (via referring out) is preferable to subpar treatment. Also, continuing to "do the best you can and keep moving the meat doesn't give incentive to the administration to get more staff for the clinic.
 
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Groupthink

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You are only able to see students once per month? For therapy?
Ugh, this was a typo. We see students bimonthly, as in once every two weeks. We cannot offer weekly services, and students requesting weekly services are those we refer out as well. I have edited the OP. My apologies for the error.
 
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Groupthink

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Are you stating this as a matter of fact regarding your clinic, or is this what the physicians and admin are saying about your clinic? If you are saying this, then that’s where I’d start. If you can’t meet the needs of many of the students referred to you, then you really aren’t going to be seen as a valid referral source. Whenever you have a policy of not treating the significant needs of the population you purport to serve- regardless of reasons- you will be seen as a lesser option than those who don’t.

In summary, the best way to keep people from talking down about you often starts with you being better. Reputations are usually earned. The other option- there is a large and baseless conspiracy against your clinic- seems a little far fetched.
This is a matter of fact about our clinic. But in my opinion, we are meeting the needs of the vast majority of students. We treat slightly over 97% of individuals who seek our services, and refer out the less than 3% who do not meet our treatment criteria.

Given that Anxiety and Depression are the "significant needs" of the population we serve, yes, we do treat the significant needs of this population, and refer out for specialist treatment.

Being so black-and-white to label this a "conspiracy" is needlessly hyperbolic.

Upper administration wants us to provide treatment for populations for which we are not prepared to treat, and upper administration will not give us the funding to acquire resources to conduct this treatment. Additionally it would require an entire restructuring of our organization and change of our mission. Are we really expected to treat schizophrenia that requires inpatient hospitalization? Would a family care physician be expected to diagnose a major sleep disorder that requires specialist testing when there is a sleep clinic a mile down the road? Where do you draw the line?
 
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Groupthink

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If you don’t treat suicidality or NSSI at a UCC, you are turning away a lot of your clinical student population.
This is a grey area. It's not like we say, "Oh, you cut yourself once a week, we aren't going to see you." But if an assessment shows that they have been self-harming since age 12, have multiple suicide attempts, past trauma, and unstable relationships, it is likely that specialist trauma treatment or a DBT program is clinically indicated. We do not offer that here.

Are you my former boss? Because he liked to tell me to be better without giving me the resources to be better. I agree that the needs aren't being met, but at the same time if you don't have the staff, you don't have the staff and you do the best you can. Expecting a college counseling center to handle SPMI is a tall order.

As far as the conspiracy goes, it doesn't sound like there's some deliberate thing going on: "Let's bash the ccc." Rather, it sounds instead like people who don't understand mental health treatment, clinic pressures, mental health diagnoses, and so on have started voicing their opinions and reinforcing each other. Groupthink and all that.

If I were in that situation and fortunate enough to be able, I'd vote with my feet.
I agree very much with this post. Students go "Let's bash the counseling center" and then upper administration bends over backwards for the students without considering, or the understanding of, the details of mental health treatment.

Clever use of my username. :)
 
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Groupthink

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If you don't have the resources to provide adequate care, you SHOULD be turning people away (sans an acute SI/HI situation).

How does it help to continue to "do the best you can" when that is substandard care? It doesn't help patients. Delaying treatment (via referring out) is preferable to subpar treatment. Also, continuing to "do the best you can and keep moving the meat doesn't give incentive to the administration to get more staff for the clinic.
I think the user was saying doing the best we can with the resources we are given, since much of that is out of our directors' hands. Referring out is a form of "doing the best we can", because it is the most ethical step towards the client's benefit. "Treatment as usual" is great when conducting an experimental study, but has the potential to be deleterious in urgent, specialist cases.
 

LadyHalcyon

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Are you using a triage system? Some other thoughts: Prevention measures such as campus health fairs, going into classes and doing some psychoeducation, having lots of group therapy options, having a fairly strict attendance policy since there is such a shortage of providers. Sounds like you need more money to hire more clinicians!
Ugh, this was a typo. We see students bimonthly, as in once every two weeks. We cannot offer weekly services, and students requesting weekly services are those we refer out as well. I have edited the OP. My apologies for the error.
 
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Being so black-and-white to label this a "conspiracy" is needlessly hyperbolic.
Yeah - you’re probably right about that. Sorry. Sounds like you’re working hard in a difficult situation. Working for places that don’t have adequate resources to meet the mission is a major drag.

End of the day, you are still describing what sounds like and under-funded, understaffed clinic, and that is contributing to the reputation amongst referring physicians. It’s also probably contributes to the perpetuating cycle of admin not giving you resources because of your reputation, while your reputation is the result of admin not giving you resources.

Is there some misunderstanding of the mission of your clinic? What is your (the clinic) role on campus? If you don’t serve certain populations, why would people be referring them to you?

I’m still trying to jibe together you saying that you meet the needs of 97% of people who come to you with you also saying you do not have the resources to offer sufficient care. Do you see where that would be confusing?
 
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Are you my former boss? Because he liked to tell me to be better without giving me the resources to be better. I agree that the needs aren't being met, but at the same time if you don't have the staff, you don't have the staff and you do the best you can. Expecting a college counseling center to handle SPMI is a tall order.

As far as the conspiracy goes, it doesn't sound like there's some deliberate thing going on: "Let's bash the ccc." Rather, it sounds instead like people who don't understand mental health treatment, clinic pressures, mental health diagnoses, and so on have started voicing their opinions and reinforcing each other. Groupthink and all that.

If I were in that situation and fortunate enough to be able, I'd vote with my feet.
Yeah- my post comes across a little harsh. Let me rephrase it: If you can’t be better, you can’t expect others to think you are better. If you don’t have and can’t get the resources to meet your mission, then you might need to walk. However, if you are meeting your actual mission but not the mission others believe you have (or should have), continue to do good work and focus on better educating the referring sources and admin regarding the work you do.
 
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Groupthink

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Yeah - you’re probably right about that. Sorry. Sounds like you’re working hard in a difficult situation. Working for places that don’t have adequate resources to meet the mission is a major drag.

End of the day, you are still describing what sounds like and under-funded, understaffed clinic, and that is contributing to the reputation amongst referring physicians. It’s also probably contributes to the perpetuating cycle of admin not giving you resources because of your reputation, while your reputation is the result of admin not giving you resources.

Is there some misunderstanding of the mission of your clinic? What is your (the clinic) role on campus? If you don’t serve certain populations, why would people be referring them to you?

I’m still trying to jibe together you saying that you meet the needs of 97% of people who come to you with you also saying you do not have the resources to offer sufficient care. Do you see where that would be confusing?
Agreed -- that is exactly the cycle that occurs. The clinic's mission statement is along the lines of assisting students with their mental health to maintain their enrollment status at the university.

We receive referrals because of misinformation. For instance, our state law has specific requirements for substance use treatment that fulfills court mandated therapy, which is something we do not offer. Regardless of the number of times we have told the court about this, we continue to have students show up seeking services to fulfill their legal requirement. They leave feeling frustrated that they were given misinformation.

With regard to SPMI, the physicians think we should be treating everything under the sun, so they walk them to our clinic since we are in the same building and say "handle this" and then get angry with us when we refer them to an external clinic. Otherwise, we have students show up seeking services, and after an intake evaluation we determine they need a higher level of care, and explain this, they get frustrated that we cannot treat them ("Your clinic is free, I don't want to go to another clinic!") and then feel angry with us. Unfortunately, given some of the personality organization of clients who we refer out, this has resulted in some dramatic behaviors.

I see the confusion in my statement. To clarify, let's define the resources we lack: therapists trained in specific treatment modalities (e.g., DBT), structured intensive outpatient treatment, with the availability of 24/7 crisis and hospitalization services, case management, and psychiatry services.

With this definition of resources, we do not have the resources for sufficient care of students with SPMI and a history high-risk self-harm behaviors. We have the resources (i.e., clinicians trained in evidence-based treatments for depression, anxiety, mild to moderate eating disorders, relational issues, and career coaching) to support 97% of the students who come to see us, who do not require the higher level of care defined above.

The physicians and students expect us to be able to treat the ~3%. To do this with the resources we have would be unethical, ineffective, and, in some cases, countertherapeutic. It would require an entire restructuring of our organization, at minimum doubling our meager 8 staff supporting a university of over 30,000 students.
 
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Groupthink

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Are you using a triage system? Some other thoughts: Prevention measures such as campus health fairs, going into classes and doing some psychoeducation, having lots of group therapy options, having a fairly strict attendance policy since there is such a shortage of providers. Sounds like you need more money to hire more clinicians!
Yes! We take new clients solely on a triage basis. Students can just walk into our clinic and they will be seen during all business hours, at which point we determine a treatment plan of bringing them into our time-limited therapy protocols, or referring them to specialist providers. We have multiple groups going as well, and the program is well utilized.

It often feels like students are saying "you aren't seeing these 3% of people and therefore you are discriminating against them". It's very frustrating because we are seeing them for intake evaluations.

Again, the medical comparison is apt: if your family doctor takes your bloods and determines you have cancer, but then chooses to treat you instead of referring you to an oncologist, that is unethical. The requests we are receiving is like asking every campus student health center to have an oncologist on staff and restructure all their medical equipment to be able to treat cancer.
 

cara susanna

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If you don't have the resources to provide adequate care, you SHOULD be turning people away (sans an acute SI/HI situation).

How does it help to continue to "do the best you can" when that is substandard care? It doesn't help patients. Delaying treatment (via referring out) is preferable to subpar treatment.
Can you tell this to VA administrators?
 
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futureapppsy2

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This is a grey area. It's not like we say, "Oh, you cut yourself once a week, we aren't going to see you." But if an assessment shows that they have been self-harming since age 12, have multiple suicide attempts, past trauma, and unstable relationships, it is likely that specialist trauma treatment or a DBT program is clinically indicated. We do not offer that here.
That makes much more sense—thanks for clarifying.