When I first joined a university counselling service eight years ago, the work was generally shaped around a neat seven-session contract. Using an almost exclusively one-to-one relational model, I regularly worked through a beginning, a middle and an end with my clients and could usually review their needs and offer more sessions, should they need it. I always had a few students of particular concern, including those who self-harmed, and I would sometimes refer someone on for specialist or GP support.
My clients were negotiating, as young people aged 18 to 25 usually are, transitions into adulthood of varying complexity. But most were able to benefit from short-term counselling for support, heightened awareness and a greater understanding about their life to date and their choices in the moment. The work had a certain rhythm to it – it was usually manageable but busy at the usual peaks of the academic year, around spring term dissertation hand-ins and final projects.
Not so today. The question at assessment now is no longer primarily how many sessions we offer but whether it would be ethical for our service to engage with the person before us and, if so, how. Not having mental health advisers on our team, as some university counselling services do, we regularly refer out immediately. In this scenario, our role becomes one of ongoing case management and therapeutic holding as we support the student to access – and wait for – the NHS, long-term or specialist help they need.
When we do take someone on, it may well not be classic counselling that we suggest. Nowadays my colleague on campus and I use our rare quiet days – for us, in late summer and early autumn – to plan a schedule of other offerings, such as wellbeing initiatives, self-help ideas, relaxation sessions, groups/workshops, staff trainings, management briefings and meetings with NHS and other service providers. We know that a giant wave of demand for one-to-one work will hit us by mid-November and, from then on, the challenge for our service will just be to stay afloat.
Rising tide of demand
These are changing times. In a climate of financial upheaval and spending cuts at UK universities and HE institutions, BACP cites a 2013 survey by the Heads of University Counselling Services (HUCS) which says the number of HE students seeking counselling from their educational establishment rose 16 per cent between 2010 and 2013. In the same period, there was an 85 per cent increase in those seeking online counselling, as services began diversifying what they offered. Average waiting times for first appointments went up to between five days and three weeks, while the number of sessions offered by the majority of HE counselling services remained on average four to five.
Ruth Caleb, Head of Counselling at Brunel University and Chair of the Mental Health and Wellbeing in HE Working Group, says the CORE outcome measures used by many counselling services show that students are presenting with a higher incidence of complex mental and emotional issues, as well as self-harm and risk. ‘Jake’ (above) – whom I saw for seven months in his final year to support him to complete his degree – is typical of these students presenting at high-risk of or with severe mental health difficulties. BACP has not collated robust statistics on severity or suicide risk, but Patti Wallace, its Lead Advisor for University and College Counselling, says it’s clear that more students are now coming to university with pre-existing mental health issues: ‘There is more complexity of need, greater risk and counsellors are having to handle more difficult situations across the board. They are doing this with fewer resources and that puts pressure on the counselling service. Ultimately my concern is that there are services where students aren’t being seen as quickly as they have been in the past. If that happens, it would be a real loss because the timeliness of a service is really important for students.’
She argues that speed of response is particularly important with this client group. Students, because of their age, are less likely than older adults to have faced similar problems in their lives and to have evolved the necessary coping strategies. They are also negotiating the stresses of what she calls a ‘time-sensitive environment’, in which missing deadlines or failing exams can have a significant impact on their life at university and, potentially, their future.
So how, when and why did university counselling services get so stretched and demand from students increase?
Clearly there has been a rise in the number of young people with mental health issues in the general population in recent years. But there is also increasing realisation of the psychological vulnerability of HE students, voiced by the Royal College of Psychiatrists in its 2011 report, The Mental Health of Students in Higher Education. Developmentally, the report pointed out, HE students are already coping with transition – leaving home for the first time, looking after themselves, joining new peer groups and taking on academic demands. They are living in an environment where there is often pressure to misuse drugs and alcohol, at an age (mostly 18 to 25) that is also statistically the peak period of onset for severe and enduring mental health issues like schizophrenia or bipolar disorder. Added to this, it said, is a harsh national economic climate, with increasingly uncertain job prospects and where students often have to earn money while they study, sometimes leaving them less time than they need to meet their deadlines. Also the more democratic policy of widening access to university for students from different backgrounds and profiles means that, while a greater percentage of the population now undertakes HE, the newly expanding student groups – for example, the financially lucrative and growing cohort of international students – bring specific needs for which institutions may not previously have made significant provision.
Then, in September 2012, the Government introduced significant cuts to HE funding. In a radical shake-up of the fee structure, instead of a block grant from government to cover their costs, universities and colleges were now required to generate funds to cover half their budgets themselves, from fees charged to the students they recruited. The drive for some HE institutions to recruit became intense. Many staff across the sector felt less secure as, in an attempt to cope in the new climate, jobs were cut and departments reviewed, reorganised and merged. For students, it was a whole new era – they now had to pay £9,000 a year for their studies and faced the prospect of graduating with an average personal debt of £27,000.
‘The £9,000 is a huge debt on their shoulders,’ says Ruth Caleb. ‘On top of this they have to pay for their food, their rent, their books and their lives so, in order to cope, many students are now working a number of hours that are impinging on their course. They’re finding that they’re getting behind or they haven’t got the time to do their assignments properly. It’s a major problem for many of them.’
A shared responsibility
Charlotte Halvorsen, Head of Student Counselling and Mental Health at City University, agrees. Students are not only taking out loans and working more to make ends meet during their studies; as a result, she says, they feel under greater pressure to get a good degree in order to find a well enough paid job at the end of it. They may even at some level assume they are entitled to a degree, whatever their academic outcome, because they’ve paid so much for it. And, when pressures and problems do hit during their studies, they feel less able to take the time out that they might need or even to consider leaving if their course or the HE path is not right for them. In a 2012 survey, BACP found that 81 per cent of students who responded felt counselling had helped them stay at university or college.1 However, alongside the general push to recruit and retain students, Charlotte Halvorsen says there needs to be a level of understanding in institutional leadership that ‘sometimes we encounter a student who is failing in the system and the best outcome may be to support their exit sooner rather than later’.
As institutions recruit more students who are themselves under greater pressure and of whom more declare extra needs, she calls for more ‘joined-up thinking’ between different departments. Academic departments have a duty to support the students they recruit – not just to hand them over to the counselling service. ‘There should be more consideration given to and consultation with the students recruited,’ she says. ‘Students who declare any special needs prior to arrival should be assured that their academic department is aware and appropriate support has been put in place.’ In the current climate she believes some institutions are compromising on investment in the necessary support structures in order to survive. ‘It’s almost turning into a customer-driven service, a private sector business,’ she says. ‘The business need is to maximise student fees and that’s done by collating numbers rather than by appreciating individuals’ needs for support.’
Ruth Caleb shares her concerns: ‘Counselling services are not the owners of responsibility for mental health in an institution,’ she says. ‘That has to be owned by everybody, from the vice chancellor down, including academic schools and departments. It is up to the university to offer the appropriate form of support for its students, so if you expand the number of overseas students, for example, you need to be aware that those students will have particular stresses… they may be doing their study in their second, third or fourth language, they may be leaving family behind, they may be struggling financially, they may know no one in this country and they may experience culture shock.’ Likewise, she argues, students recruited into HE from, for example, BTEC courses that offer more course work assessments, one-to-one support and less exam-based work, may need more practical help with the transition.
So are institutions letting down students in their drive to recruit large numbers? Sir Bob Burgess, Vice Chancellor of the University of Leicester, acknowledges the financial pressure across the sector. ‘I think this year has been the most challenging I can remember,’ he says. ‘And it’s inevitable that, when the Government announces cuts, that’s going to trickle down to staff and to students.’ He accepts that, for some students, the pressures of the new fee structure will contribute to their difficulties but argues that, as greater numbers – some 50 per cent – of young people now enter HE, it’s natural that the level of demand for support will increase. He believes there is a need for more personal tutors offering pastoral care, more funding for counselling and for staff training in mental health.
‘It would be good if we could increase funds for these forms of support,’ he says, ‘but in the current climate that is challenging to deliver.’ Another useful support for students who are assessed as having a mental health problem has been the Disabled Student Allowance (DSA), although this is currently ‘under review’ by the Government. This allowance enables students who are assessed as eligible to have a mentor to help them with a range of supports, including stress management and confidence building.
Meanwhile the pressure on counselling services, usually working to frozen budgets, continues to build. In terms of practice, Ruth Caleb says this means that, in many cases, counsellors are often unable to see a student for as long as they might need. Time is taken up by the sheer numbers of requests, including supporting those whose complex needs may require regular check-ins for the whole of their course. Waiting lists are long – both in university counselling services and in the NHS. In many services, she says, particularly those with lone counsellors for whom there is little or no extra cover at busy periods, practitioners become overwhelmed and burned out. They have little time for CPD or peer support or time to plan the crucial input they can offer an institution to academic practice and student wellbeing: ‘The more pressure we are under from the people coming to see us, the less we are able to do preventative work – staff training, student groups and other strategic activities. Counselling services tend to be the boats in the water with the fishing nets fishing people out. We need to see why they are jumping in.’
In such a climate, the spectre of outsourcing university counselling lurks in the shadows. It’s already happened in Northern Ireland where all HE and further education (FE) counselling is now contracted out. Patti Wallace argues that outsourcing is not the answer in an age of growing psychological demand, as properly funded, embedded counsellors can offer much more. Located within the educational environment and with relationships across departments, staff counsellors not only see students one-to-one but can run groups and workshops, support and train staff and input to management in a crisis. Nowadays, she says, the remit of on-site counsellors has widened so much that BACP is currently developing a new competency framework for the kinds of skills required to work in both FE and HE: ‘Today we look for people who have knowledge across mental health issues; experienced people who have worked in a range of settings, who are good at assessing and deciding what’s going to be the most useful intervention for this client in this context; people who are able to see someone bringing three or four different issues and work out how they can help them get to the point where they can function again adequately within this context rather than trying to help them resolve every issue in their lives.’
For Alan Percy, Head of Counselling at the University of Oxford, this new era challenges HE counsellors to reflect on what we do and why. ‘The key thing for all counselling services is not to be pulled away from the key performance indicators,’ he says. ‘The measure of the effectiveness of the service is the effectiveness of the clinical interventions. It is important to evidence the real changes – in terms of feeling, symptoms and functioning – the service has made to the students who use it.’
He agrees with Patti Wallace that speed of access to counselling is very important, but argues that the perceived need for an immediate response – by the student seeking help and perhaps by the institution – must be tempered by this understanding about effectiveness. Our priority, he says, is to select the most appropriate intervention for each student from a repertoire of self-help, groups, workshops and one-to-one counselling. As for how many sessions are offered, he argues it’s better to give most people one or two and protect the possibility of a limited amount of medium and long-term work for some than to make a more average offering to all. ‘I think that puts a lot of emphasis and responsibility onto the individual doing the assessment,’ he says. ‘But if you’ve got highly skilled qualified counsellors, that’s where they should be deploying their skills.’
The key, he argues, is to resist the pull to offer one-to-one work: to balance demand and expectation against the reality of what a service is able to do. In his service, much of the longer-term work is done by (trainee) associate counsellors, who may need long-term experience as part of their course learning; higher risk work is managed by core counsellors linked into other support services.
Like Charlotte Halvorsen, Ruth Caleb and Patti Wallace, Alan Percy believes a staff counselling service can be a proactive holistic force within an institution, contributing widely to student wellbeing and increased understanding among staff about mental health and the difference they can make to this. However, he argues that greater general understanding about mental health also has a downside. For him it’s one of the drivers for the rising demand for counselling that, in his view, are independent of the new financial realities of higher education. They include an over-medicalisation of student distress: ‘If every difficulty or upset is symptomised as a mental health illness,’ he says, ‘it makes it a lot harder to deal with both for the student and for those trying to help, rather than understanding it as a difficulty which is very distressing but is a normal consequence of the person’s developmental process. If that is seen as an illness, it becomes a way of objectifying the person, making them feel passive, undermining their self agency and expecting someone – a doctor or a counsellor – to sort it all out.’
Instead of creating a new form of dependency, Alan Percy argues, counselling is more helpful if it allows a young person to individuate, so developing their own internal resilience. He theorises that a general societal shift to more ‘child-centred parenting’ has been partly responsible for raising some young people who, while apparently more mature and confident, are in fact more emotionally dependent on their parents and come to university with a greater expectation of being looked after. ‘The risk is that institutions parallel over-protective parenting by trying to satisfy impossible demands and expectations,’ he says.
Setting this alongside a point made by many academics that the new fee structure has spawned a climate of ‘consumerisation’, that increasing numbers of complaints are made by today’s HE students who see their £9,000 a year ‘buying’ them the right to a whole range of services, including counselling, the potential dangers become evident. Our responsibility as HE clinicians, argues Alan Percy, is to be clear in the face of others’ expectations and to spell it out that change involves hard work and engagement on the part of the person seeking help: ‘If you’re not honest right at the beginning, giving a coherent message about what you can and can’t do, you are inevitably going to be setting up disappointment and dissatisfaction,’ he says.
So have our students – and sometimes as importantly their parents – morphed from clients to customers since I started my work in HE? To some extent I would say yes. Then how does that play out in the power dynamic of the therapeutic relationship? I believe, with Alan Percy, that it is crucial for us to be assertive about what we can and can’t offer. For, unlike those in most other university departments, our job may not always be to offer the customer what s/he wants. At the same time I am probably – consciously and unconsciously – more aware of potential comeback when I make a clinical decision not to take someone on for counselling. I certainly make sure my reasons are logged in my client notes. Knowing the importance of standing my ground – with students and with managers – is crucial. But in a climate of high institutional anxiety and uncertain job security, the challenge as in-house student counsellors is sometimes to be brave enough to do it.
Clare Pointon is a psychotherapist, writer and former BBC journalist who has worked as a university counsellor for the past eight years. She runs psychological training courses for staff and students, as well as relaxation classes.
1. Wallace P. The impact of counselling on academic outcomes: the student perspective. AUCC Journal 2012; November: 6–11.