Let's talk: getting out of the counseling center to serve hard-to-reach students.
Este articulo describe Let's Talk (Hablemos), un programa de acercamiento a los centros de consejeria. Los consejeros mantienen horas de puertas abiertas sin cita previa en distintos lugares del campus para atraer a estudiantes que de otra forma no buscarian acceso a la consejeria. Las ubicaciones se eligen para alcanzar comunidades con servicios insuficientes. Los consejeros ofrecen consultas informales, una alternativa menos formal a la consejeria tradicional.
College and university counseling centers serve an average of 9% of enrolled students (Gallagher, 2006), yet utilization may not reflect the level of need on campuses. More than 40% of respondents to the 2006 National College Health Assessment reported feeling so depressed in the previous 12 months that it was difficult to function (American College Health Association, 2007). Although feeling depressed does not necessarily warrant a professional intervention, the difference between this figure and the percentage of students counseling centers usually serve is striking. Other data are equally telling. Only 19% of students who reported attempting suicide on the 2000 National College Health Assessment were in treatment (Kisch, Leino, & Silverman, 2005). Eisenberg, Golberstein, and Gollust (2007) studied mental health concerns and service utilization at a midwestern university. Among students who screened positive for depression or anxiety, the proportion who did not seek any services ranged from 37% to 84%, depending on the disorder. Furthermore, international students and racial and ethnic minority students tend to utilize university counseling centers at even lower rates than do other students (Davidson, Yakushko, & Sanford-Martens, 2004; Kearney, Draper, & Baron, 2005; Yakushko, Davidson, & Sanford-Martens, 2008). This disparity reflects a broader trend of mental health service utilization by marginalized groups in the United States (Sue & Sue, 2008; U.S. Department of Health and Human Services, 1999).
This article describes Let's Talk (Boone & Eells, 2008), a counseling center outreach program at Cornell University designed to reach students who are less likely to seek mental health services. Counselors offer precounseling conversations, called informal consultations, in multiple strategic locations across campus. Let's Talk attempts to make the first conversation with a counselor as accessible as possible to engage students who would be otherwise hard to reach.
serving students in alternative ways
The reasons for low utilization are varied, and an exhaustive review is beyond the scope of this article. Some noted causes include a lack of awareness of services (Eisenberg et al., 2007; Hyun, Quinn, Madon, & Lustig, 2007), a perceived lack of need (Eisenberg et al., 2007), stigma (Vogel, Wade, & Hackler, 2007), a lack of culturally appropriate services (e.g., Hyun et al., 2007; Sue & Sue, 2008), and mistrust of predominantly White service providers by ethnic minority students (Nickerson, Helms, & Terrell, 1994). Proposed solutions often involve service provision that is more attuned to the unique characteristics and help-seeking styles of specific populations; traditional counseling styles and formats are de-emphasized in favor of alternative methods of support. Brinson and Kottler (1995) argued that "the conventional model wherein clientele 'seek' counseling services is not going to occur among minority college students without the considerable effort of professionals to make their services more user friendly" (p. 377). They recommended that counselors leave their offices to provide workshops, consult with student organizations, show greater visibility, and make presentations on mental health concerns. Komiya and Eells (2001) recommended alternative approaches such as psychoeducational programs for "individuals from cultures that do not value verbal expression and self disclosure to people outside of their immediate support network" (p. 158). Atkinson, Thompson, and Grant (1993) suggested that counselors adopt a variety of nontraditional roles, including adviser, advocate, and facilitator of indigenous support systems, among others, depending on the client's goals for counseling, degree of acculturation, and problem etiology. Sue and Sue (2008) encouraged culturally competent counselors to use alternative modalities such as "psychoeducational approaches, working outside of the office, and engaging in practices that violate traditional Euro-American standards (advice giving and self disclosure)" (p. 52).
In a university setting, "working outside of the office" usually refers to the methods mentioned here: workshops, presentations, consultation, and other prevention activities targeted to groups of students, faculty and staff, and university offices. It rarely refers to actually providing counseling services. However, some students might benefit from placing counseling services in alternative settings. Mori (2000) reviewed the mental health concerns of international students and noted that some might be likely to avoid the counseling center for fear of running into someone they know. Placing mental health services in the vicinity of other services might make access more comfortable. Yoon and Jepsen (2008) compared the attitudes and expectations of counseling among Asian international and U.S. graduate students. Among other things, they found that Asian international students had a greater preference for a more flexible counseling format, one that provided more variability in time and place. Bonner (1997), noting a similar need among Black male students, recommended bringing counseling to cultural centers and student unions.
Counselor-in-residence (CIR) programs (Davis, Kocet, & Zozone, 2001; Halstead & Derbort, 1988; Harris, 1994; Rawls, Johnson, & Bartels, 2004) have been used to take counseling into students' communities. Davis et al. (2001) described a program "designed as a model to provide counseling for students who otherwise might not take advantage of the services from a traditional university counseling center" (p. 190). The counselors are doctoral students in the university's Counselor Education program who live on campus, provide 24-hour on-call crisis response, and offer appointments during office hours and other scheduled times. According to the authors,
the CIR program is unique in that the staff make "house calls." Whereas traditional university counseling centers primarily see students in their offices, the CIR program provides access for students in their own living environment. Students who may be hesitant in going to [the university's counseling center] can seek help in the relative privacy of their "home" from a CIR assigned to his or her residence hall. (Davis et al., 2001, p. 191)
Meeting with a CIR breaks down the barriers of seeking help in an unfamiliar setting and opening up to a professional who is not connected to one's community.
However, merely changing the location of counseling might not be sufficient to reach some students; it might require also letting go of familiar characteristics such as scheduled appointments, fixed length meetings, and formal assessment processes. Citing research indicating that minority clients might be better served by less structured and more informal methods, Brinson and Kottler (1995) recommended developing drop-in centers and flexible alternatives to the "50-minute hour." Pedersen (1991) observed that some international students are best served not just by different settings but also by methods that might not be readily recognizable to professionals as "counseling." He noted,
Counseling international students frequently occurs in an informal setting, such as a hallway, home, or street corner, and frequently depends on an informal method such as a presentation, discussion, or daily encounter, which might not be perceived as counseling according to standardized models. It is important for counselors working with international students to broaden their understanding of counseling beyond narrowly defined methods and contexts. (Pedersen, 1991, pp. 28-29)
Most useful for some international students and, it could be argued, for other students who might be reluctant to seek counseling are direct encounters that are different from traditional counseling.
Mier, Boone, and Shropshire (2008) described an especially flexible and informal helping format, one that provides first contact with a counselor anywhere the student would be more comfortable, whether that is an adviser's office, a dorm room, or the student union. More important, they described an alternative role for professional counselors, called student support, which focuses on problem solving, accessing resources, and advocacy. The student support role is distinct from the role of a traditional counselor in that it involves acting on the student's environment with the intention of relieving stressors that may lead to depression or academic problems. Although students are aware that they are meeting with a professional counselor, many are more likely to engage because they are not agreeing to undergo "counseling." After an initial intervention, students are more likely to be open to traditional counseling if it is warranted. However, many students are assisted without formal counseling of any kind. For those who might never access mental health services, this may be the optimal intervention.
the historical context of let's talk
Let's Talk was born out of an awareness among counselors, student service professionals, and faculty at Cornell that many students would not access the counseling center despite robust health promotion and outreach efforts to make services more visible and user-friendly. Student service professionals frequently sought advice for dealing with students who were struggling emotionally or academically but who would not accept a referral to the counseling center. Many of these students were international students, ethnic and racial minority students, and others who could be described broadly as nontraditional students (Bundy & Smith, 2004), including first-generation students and students from lower socioeconomic backgrounds. Moreover, counseling center data had consistently indicated that international students and Asian American students had accessed services at lower rates than had other demographic groups. In the fall of 2002, an Asian and Asian American Campus Climate Task Force made up of faculty, students, student service professionals, and counseling center staff was created to address a number of concerns regarding Asian and Asian American students. These concerns included overrepresentation in completed suicides at the university, bias-related incidents, underrepresentation among staff and faculty, low satisfaction with the university experience, and a perception of a lack of appropriate services. The task force's report, released in October 2004, observed that faculty and staff had difficulty encouraging Asian and Asian American students to utilize counseling services. One of its recommendations was for the university to "provide support services by mental health professionals ... in more natural community settings" (Cornell University Asian and Asian American Campus Climate Task Force, 2004, p. 28), such as student centers, colleges, residences, and the international students office.
During this period of heightened concern, counseling center staff created Let's Talk with the support of student services staff and faculty. The program began as a handful of unrelated walk-in counseling sites, which were staffed by psychologists and social workers from the counseling center, targeted to particular communities, and situated within students' environments. Eventually, it evolved into a comprehensive program made up of nine sites offered throughout the week and open to the entire community of approximately 20,000 students. The goal of Let's Talk was to make conversations with counselors as accessible as possible. To this end, a new service called informal consultation, much like Mier et al.'s (2008) student support, was created. Informal consultation shares many features with traditional counseling but sheds the formal characteristics that can make counseling less palatable to some students.
The informal consultation format was inspired by our experience that many reluctant students made first contact with counselors by showing up at traditional outreach activities and initiating personal conversations in private with counselors afterward. This informal, precounseling conversation often made making a referral to the counseling center much easier. Once contact had been made in this way, having a second conversation seemed far less scary. Informal consultation was devised to facilitate these conversations without having to offer outreach presentations that were often poorly attended and required hours of preparation.
Informal consultation has fewer potential roadblocks to initial engagement: There is no paperwork; no appointment to make; no initial telephone triage (Rockland-Miller & Eells, 2006); no need to be seen walking into the counseling center; and, if the student prefers, no need to give one's name. In addition, there is no formal intake; students are encouraged to start with whatever they feel like talking about and are not routinely asked diagnostic questions about mood and anxiety or alcohol and drug use. The focus of the meeting is on whatever the student presents in the moment, whether a need for problem solving, information about resources around campus, or simply a skilled listener. Meetings can last anywhere from 10 minutes to an hour depending on the student's needs and the number of other students waiting. Students are informed about the unique characteristics of Let's Talk by a website that describes it as "a drop-in service where students can have an informal consultation with a counselor from time to time" and states that it is "not formal counseling" (Cornell University, Gannett Health Services, n.d., para. 3). It goes on to state that
"Let's Talk" is the best fit for the following people: students who are not sure about counseling and wonder what it's like to talk with a counselor; students who are not interested in ongoing counseling but would like the perspective of a counselor; students who have a specific problem and would like someone with whom to talk it through; students who have a concern about a friend and want some thoughts about what to do. (Cornell University, Gannett Health Services, n.d., para. 4)
Furthermore, informal consultations are not limited to conversations, and problems are not assumed to reside solely within the student. Let's Talk counselors are especially attuned to the role of environmental stressors in the lives of students and are not reluctant to advocate when necessary. For example, with the student's permission, a counselor might act as a case manager and call financial aid to help access needed resources, communicate with the academic advising office to help secure academic support, or facilitate a referral to the international students office for a student with visa concerns. This kind of intervention can often help prevent a problem from escalating into a crisis.
Let's Talk sites are chosen with four considerations in mind. First is proximity to communities that traditionally underutilize counseling services in the United States. For example, there are sites in close proximity to the offices of the Latino Studies and Asian American Studies programs.
A second consideration is proximity to groups that have historically used fewer mental health resources at Cornell. These include freshmen, international students, and Asian American students. Consequently, there are sites at a freshman community center; the International Students and Scholars Office; and the College of Engineering, which enrolls approximately one third of Cornell's undergraduate international students and Asian American students.
Third, sites are chosen to be close to communities that might benefit from easier access to conversations with a counselor for other reasons. For example, there is a site in the Learning Strategies Center, where students who are struggling with academics or English proficiency might go for support. There are also sites at the Law School and School of Veterinary Medicine, where busy academic schedules may prohibit students from seeking help elsewhere on campus.
Finally, and perhaps most important, sites are chosen with the intention of offering the most complete access to the entire community. Thus, all sites are open to all students regardless of where the site is located. This broad accessibility is intended to allow students to choose sites based on any factor that would most likely engage them, such as alignment with academic schedules, preference for a particular counselor, proximity to familiar communities or areas of campus, or remoteness from familiar communities or areas of campus. It is assumed that for some students, seeking support "close to home" may be important; for others, the possibility of being seen accessing help within their communities may lead them to go elsewhere. (Originally, a site was held at an African American program house. However, utilization data indicated that the location was rarely used and that African American students accessed other sites frequently. It may have been that the site, which was located in close proximity to a community area within a dormitory, was too public and therefore did not provide enough anonymity for students reluctant to be seen accessing help.)
RAISING AWARENESS OF SERVICES
Students find out about Let's Talk through announcements on electronic mailing lists, posters distributed throughout campus, referrals from faculty and staff, advertisements in orientation literature, announcements by counselors at traditional outreach events, and the Let's Talk website. All advertising directs students to this website, which includes a schedule of times and locations, frequently asked questions about Let's Talk, and pictures and profiles of the counselors. Profiles include a detailed, sometimes humorous, description of the counselor's background, education, and personal and professional interests in order to make the counselors more accessible and the process of counseling less mysterious. In addition, they give students the agency to choose the counselor with whom they feel they would most easily connect.
INFORMED CONSENT AND CONFIDENTIALITY
The website acts as the first stage of informed consent. Here, students are introduced to the distinction between Let's Talk and formal counseling and the scope and limits of confidentiality. The website notes the existence of a written record and the necessary exceptions to confidentiality. Because it cannot be guaranteed that students will access the website before coming, counselors can also provide students with a pamphlet that includes all the information on the website.
REFERRALS FOR TRADITIONAL COUNSELING
Let's Talk visits customarily end with a discussion about next steps. Counselors inform students that they can return to Let's Talk at any time and remind them that traditional counseling is available for ongoing problems. Counselors regularly make referrals to counseling for students who are dealing with diagnosable mental health concerns and, especially, suicidal ideation. Counselors have access to the counseling center's scheduling system through laptops with secure connections, and an intake at the counseling center can be scheduled directly from the visit.
Let's Talk visits do not customarily include a formal safety assessment; however, counselors always explore issues of risk and safety when students report depression symptoms or anything that indicates overwhelming stress or hopelessness. For support in crisis situations, counselors have immediate access by phone to colleagues at the health center as well as campus police. On two occasions in the history of the program, suicidal students have been hospitalized during Let's Talk visits.
Given that Let's Talk is not a formal clinical service, keeping clinical notes of encounters with students would be contrary to the program's mission. However, ethical practice and common sense require keeping some sort of record. Let's Talk visits are documented by making a "nonclinical" note available in the counseling center's electronic health record system. (All students have a preexisting health record that is started when they submit a medical history form upon entering the university.) As a way to mark the distinction between these notes and clinical notes, a Let's Talk note is prefaced with a disclaimer stating that it is a record of an informal consultation and not a document of a counseling appointment. Furthermore, all Let's Talk notes are considered "nonreleasable" should health records be requested. This makes the notes more like the records kept by academic advisers and residence life staff (i.e., other professionals who meet informally with students to discuss concerns), which are not available to students upon request.
Despite assurances of confidentiality, it is assumed that the existence of a written record can be a barrier to accessing counseling. To prevent this, the program allows students to meet anonymously if they need to. A small number of students, composing approximately 5% of visits, request anonymity each semester. Notes from visits with all anonymous students are kept in a single record so that counselors can keep track of their contacts. Most students give their names at subsequent visits once they have developed trust in the counselor, and the notes are transferred to their nonclinical record.
legal and ethical considerations
Let's Talk presents questions rarely encountered by university and college counseling centers. If psychologists and social workers provide a service that is neither a clinical service nor a traditional outreach activity, what are the expectations for confidentiality, informed consent, record keeping, and handling threats of harm to self or others? Consultation with the university counsel's office has been helpful in answering some of these questions. For example, when it was unclear whether a written record should even be kept, university counsel advised that doing so would ensure both that counselors were working within the law and that they were fulfilling the expectations of them as agents of the university. Counsel's office has supported the program--with all of its unique legal and ethical considerations--under the assumption that it serves not only the needs of students but also the university's goal of minimizing the risk of the most distressed students to themselves and to the campus community. The real, but relatively unlikely, risks of conducting a program like Let's Talk--for example, the worst case scenario of a student revealing a suicide plan and leaving the visit without giving his or her name (which has never happened in the program's history)--are well worth the benefit of reaching students who might not otherwise seek help.
In 2009-2010, 296 people utilized the program for a total of 454 visits. The average number of visits per visitor was 1.5; the majority of visitors came once. Forty-two percent were referred to the counseling center for traditional counseling. By matching identifying information students provided at Let's Talk with demographic data students provided upon entering the university, we determined that Let's Talk served the following percentages of students from different populations: 1.02% (n = 91) of White students, 1.80% (n = 17) of Black students, 1.54% (n = 44) of Asian/Pacific Islander students, 1.51% (n = 16) of Hispanic students, 2.63% (n = 2) of American Indian/Alaska Native students, 2.10% (n = 72) of international students, 1.59% (n = 10) of multiracial or biracial students, and 1.05% (n = 29) of students who did not identify their ethnicity and were not international students. The remaining 15 visitors were recently graduated students and faculty and staff who mistakenly accessed the service. On the basis of these data, it seems that 57% of students who accessed Let's Talk were international students or students of color, compared with 32% of the counseling center's 2011 students. This figure is similar to figures from most years in which data were collected: 58% compared with 34% in 2006-2007, 52% compared with 34% in 2007-2008, and 42% compared with 35% in 2008-2009. (The 2009-2010 academic year was the first year in which the multiracial or biracial category was available. In previous years, that small number of students was combined with students whose ethnicity was unknown.)
Some tentative conclusions may be drawn from these data. First, students have made use of the program in fairly large numbers, and Let's Talk is capable of serving a diverse population in a variety of settings. Second, the majority of students who visit Let's Talk are served by only a few meetings. Let's Talk presumably serves the needs of students in a relatively short time without making them wait for an appointment, requiring that they engage in formal counseling, or unnecessarily using valuable intake appointments at the counseling center, resources that can be reserved for students seeking ongoing counseling. Third, Let's Talk acts as a convenient conduit to the counseling center for many students. Fourth, the consistently high percentage of international students and students of color among those who access Let's Talk suggests that the program may serve the needs of previously underserved populations in ways that counseling does not. It may be that by offering more flexibility with hours, location, and format, Let's Talk accommodates differing help-seeking styles and needs, reducing barriers that traditional counseling may present.
Anecdotally, we are aware of many students who have found coming to Let's Talk much easier than going to the counseling center. We have also encountered students who have stated that they might never have sought help at all without Let's Talk. However, any conclusions about the efficacy of Let's Talk must be tentative and should be tempered by the knowledge that despite the success of the program, Cornell's counseling center continues to see far more students overall, including more international students and students of color. Future research could demonstrate whether Let's Talk is truly more successful at serving the most hard-to-reach students. The purpose of this discussion has been necessarily limited to describing the program's history, rationale, and operation.
Inspired by the program's preliminary success at Cornell, 17 other colleges and universities have implemented Let's Talk. All have started with fewer sites (as Cornell did), and some have had enough demand to justify adding sites. This suggests that Let's Talk is not just suited to Cornell but to other settings as well.
Let's Talk is a novel method of serving students driven by the needs of a specific campus and influenced by the literature on cultural competence, counseling center outreach, and help seeking. Where appropriate, it can be added to the repertoire of outreach interventions counseling centers have at their disposal. Let's Talk was born out of an awareness that some students, no matter how robust the outreach efforts of energetic counseling center staff, will not walk through the door of the counseling center. By meeting students first--or exclusively--in an informal way within their communities, Let's Talk attempts to serve them "where they are" in every sense.
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Matthew S. Boone, Maurice Haltom, Sharon R. Mier Sonya Y. Shropshire, Wai-Kwong Wong and Tow Yee Yau, Gannett Health Services, Cornell University; Gene R. Edwards, Counseling Center University of North Carolina at Charlotte; fill S. Hill, Department of Counseling and Clinical Psychology, Teachers College, Columbia University; Ya-Shu Liang, Counseling and Psychological Services, California State University; Lonette S. Belizaire, Office of Health and Counseling, Pratt Institute; Laure Conklin Kamp, private practice, Ithaca, New York; Meera Murthi, University Counseling Center, University of Rochester. Sharon R. Mier is now in private practice, Ithaca, New York. Sonya Y. Shropshire is now at Counseling Center, University of New Hampshire. Meera Murthi is now at Counseling Center University of Cincinnati. The authors would like to thank Sigrid Pechenik, Velma Williams, John Wright, Mahnaz Mousavi, and Gregory T. Eells for their contributions to the development of Let's Talk. The authors also thank their community partners at Cornell University for enthusiastically providing space and support. Finally, the authors thank Toni Wall Jaudon for her feedback on multiple drafts of this article. Gene R. Edwards, Maurice Haltom, Jill S. Hill, Ya-Shu Liang, Sharon R. Mier, and Sonya Y. Shropshire are co-second authors of this article. Lonette S. Belizaire, Laure Conklin Kamp, Meera Murthi, Wai-Kwong Wong, and Tow Yee Yau are co-third authors. Correspondence concerning this article should be addressed to Matthew S. Boone, Gannett Health Services, Cornell University, 110 Ho Plaza, Ithaca, NY 14853-3101 (e-mail: email@example.com).