Among those contemporary college students who seek counseling—and despite their heterogeneity along lines of class, culture, race, gender identity, and sexual orientation—most share similar experiences of discomfort, distress, and a desire for relief. Something’s not right in their life, and it’s taking a toll: interfering with simple pleasures; undermining productivity; compromising functioning; obstructing relationships; causing, in some cases, thoughts of suicide and/or self-destructive behaviors like heavy alcohol- or drug-use and cutting. Moreover, many of them tend to perseverate on certain existential questions: What am I doing? Why am I here? Whose life am I leading? How do I know what I really want?
Clinical symptoms and the life-stories in which they’re embedded are often enmeshed with traumatic experiences, whether recently occurring or carried from the student’s earliest years. Other commonly observed factors include students’ experiences of poverty, racism, parental divorce, failed relationships, illness, and loss. Presenting symptoms and the conditions that give rise to them pose many challenges for the recognition, naming, and treatment of each student-client’s particular disorders. Formal psychiatric diagnoses are crucial to the process of assessment and necessarily serve as the currency of communication for such challenges as anxiety, depression, and PTSD. However, these diagnostic labels can also obscure or discount both the full nature of the student-client’s suffering and the conditions that generated and perpetuate it.
Psychodynamic Therapy Works
In the U.S., college counseling centers have traditionally provided “talk therapy” as a primary modality that has been shown to be effective in addressing student-clients’ needs. Clinical practitioners of talk therapy must have specific listening and organizing skills, which are acquired through different forms of didactic and experiential education (e.g., practica, internships, and residencies) and grounded in the theories and techniques of recent and contemporary psychoanalytic psychology.
Therapists trained to provide talk therapy commit themselves, above all, to listening in an intentional way, both to the student-client’s words and to the emotional timbre of their speech, including any absence of emotional resonance. As psychologist Earl Koile puts it, “our sense of identity and part of our nature as human beings hinge on our ways of talking and listening to” one another (21). While listening to their student-clients, analytically oriented therapists also listen to themselves, both at the cognitive level (What are the therapist’s thoughts?) and at the visceral level (What’s happening in the therapist’s body?).
The therapist’s experiences facilitate their understanding of the student-client’s experiences. This “two-person” (or “interpersonal”) model makes psychodynamically oriented therapy distinct. Other modes of talk therapy often don’t consider the therapist’s experience as an important source of data about the client and the progress of therapy, which can have the effect of compromising the potential power of the therapeutic alliance. Students are quite attuned to the quality of their experience with their therapist, able to assess both the trustworthiness of the process and of the therapist. The quality of this dynamic collaboration can make the difference between wholehearted participation and reluctant engagement.
Therapists in college counseling centers are in a unique position to offer students something unavailable to them anywhere else on campus: the opportunity to speak openly and honestly about what’s troubling them with an attentive, non-judgmental interlocutor in a confidential, therapeutic space that’s free of the demands and pressures to perform that characterize classrooms, labs, and playing-fields. Time spent with the psychotherapist is devoted to sustained appraisal of the distress presented by the student, as well as to the impact of the questions posed and the reactions offered by the therapist. At its best, the process is fluid, iterative, and adaptive to the needs of the student.
But This Takes Time
Before the dramatic increase in demand for student Counseling and Psychological Services (CAPS) in the 2000s, psychotherapists could greet students with the simple question “So, what brings you to CAPS?” and know that they would be able to work with the student on a weekly basis—the only restrictions being those of the academic calendar. Working this way allowed for the emergence of critical concerns at whatever pace best suited the student and also gave the student the time they needed to take the measure of their therapist and to build a trust-based relationship.
Prior to the early 2000s, usage statistics were reliably stable: the most frequent number of visits per student was one, meaning that these students’ needs were met in just one visit. Half of all students utilized 5-6 visits, while the overall average of 8-9 visits encompassed the full range, from a single session to as many as 35 sessions in an academic year. And, up until about ten years ago, counseling centers typically served roughly 25% of enrolled students. Over the past decade, however, utilization patterns remained relatively constant, while the percentage of students served swelled to more than 40% of enrolled students—a dramatic increase that helped precipitate the urgent situation counseling centers find themselves in today.
Although many counseling centers still tried to offer a holding environment for students for as long as needed, the availability of this paradigm for therapy was dramatically reduced—notwithstanding the fact that the efficacy of the talk-therapy model is clearly supported by psychologist Martin Seligman’s 1995 study of the so-called dosage/response effect. Seligman’s study found that talk therapy worked as well as medication for many symptoms and that more talk therapy worked better than less. Because Seligman is an academic psychologist not usually associated with psychoanalytic psychology, his study’s empirical confirmation of the dosage/response effect stands out as a particularly unbiased affirmation of core tenets of psychodynamic psychotherapy. Fifteen years later, Jonathan Shedler re-affirmed Seligman’s findings in his own study of the efficacy of psychodynamic psychotherapy.
And Time Costs Money
As the number of students requesting help from campus counseling centers has grown exponentially, institutions’ commitment of financial resources has failed to keep pace. Over the past decade, a few wealthy colleges and universities responded tentatively by adding some new staff—but never in sufficient numbers. A more common response to the exponential increase in demand was a shift away from psychoanalytic or psychodynamic psychotherapy—which emphasizes development of insight in service of problem resolution—to treatment modes that prioritize targeted symptom alleviation and minimize or ignore causation.
Symptom relief is vital—especially for students in crisis. But targeting symptom relief in the absence of talk therapy yields, at best, temporary fixes and leaves underlying disorders and conflicts untreated. It takes time for the student-client’s story to unfold in dialogue with the therapist so that, together, they can better understand the place and meaning of the symptoms in the student’s experience, which holds out the best hope of managing and even overcoming the root causes of their most profound forms of pain and suffering.
Short-term therapies can be quite helpful in situations of well-defined difficulty and an absence of co-morbid mental-health and situational compromises. But they fail to take into account the specific—often critical—needs of their student-clients in relation to aspects of their life-experience that require time and patience to explore and understand and that span the full range of psycho-social factors, from early-childhood trauma to poverty, racism, homophobia, misogyny, and—quite often—a sense of betrayal by the very institutions charged with protecting and nurturing them, including hospitals, police, courts, banks, and even the colleges and universities they pay to attend.
Even elite colleges and universities—including, for example, the University of Pennsylvania, Swarthmore, Bryn Mawr, Haverford, St. Joseph’s, Amherst, Williams, Brown, and Princeton—appear hard pressed to reconcile tensions between students’ need for readily available psychotherapy and the high cost of providing it. Funding priorities would have to be substantially reordered to make available to today’s students the kind of therapy that was the “industry standard”—at least at these elite institutions—in the 1990s. Indeed, there seems to be an increasingly deeply entrenched mindset within the upper administrative echelons that the kinds of resources made available for teaching and research simply cannot be made available for the psychological, emotional, and developmental needs of their complex, multicultural, heterogeneous student bodies.
Funding priorities and the philosophical principles they reflect ultimately emanate from distant and frequently ill-informed governing bodies such as Boards of Directors and state legislatures. On the ground, the overworked and underfunded leaders of counseling centers are left without the resources or the public support to meet distressed students’ overwhelming need for resource-intensive talk therapy to recover the full use of their minds and spirits. Anecdotal reports of a significant increase in the number of counseling center directors resigning and retiring may reflect a widespread sense of futility regarding this inability to provide students with quality professional care.
From the vantage point of a psychologist who has worked at UPenn, Haverford, and Swarthmore, the situation is growing evermore dire. All readers of this post—students, clinicians, faculty, and administrators—are encouraged to respond with stories from the frontlines and suggestions for restoring essential services. Current undergraduates, especially, are warmly invited to chime in and to share stories and information about the situation at their own institutions. Reader, your thoughts about the mental healthcare crisis in U.S. higher education?
Works cited
Koile, Earl. 1977. Listening as a Way of Becoming. Waco: Regency Books.
Seligman, Martin E. P. 1995. “The Effectiveness of Psychotherapy: The Consumer Reports Study.” American Psychologist 50.12: 965–974.
Shedler, Jonathan. 2010. “The Efficacy of Psychodynamic Psychotherapy.” American Psychologist 65.2: 98-109.
This excellent article shines a light on an under-recognized problem on many U.S. college campuses. A meaningful, trusting relationship between clinician and client is a significant factor in preventing a host of negative outcomes including suicide. Effective therapy takes time, but the investment is well worth it.
Very well articulated and insightful. If academic institutions are going to achieve a level of excellence that attracts quality professors, students, and staff, mental health needs must be prioritized. Perhaps a percentage of all funds raised by an institution (for academic and athletic programs) should be designated for mental health services, and a donor fund specifically dedicated to this purpose would draw attention to this critical need.