Mental health disorders among students are a growing problem in today’s postsecondary institutions. Counselors in many of these institutions are overwhelmed by the increasing demand for their services. This chapter presents findings from a qualitative study that examined the challenges community college counselors face when working with students experiencing mental health disorders. Ten counselors from seven colleges in the province of Alberta in Canada participated in semi-structured individual and telephone interviews that were analyzed thematically. The counselors dealt with a high proportion of minority and ethnically diverse students who experienced multiple barriers to postsecondary study. Two broad themes with several subthemes emerged from the analysis. The two broad themes were (1) challenges for counselors arising from the mind-set of students about their mental health condition and (2) challenges for counselors arising from lack of resources. Implications of these findings for practice and policy are discussed.
- postsecondary students
- mental health problems
- community college counselors
Mental health disorders are a growing problem among postsecondary students in Canada , the USA [2, 3], United Kingdom , and Australia . A recent Canadian study conducted by the Ontario Reference Group of the National College Health Assessment  2016, in which more than 25,000 students from 20 Ontario postsecondary institutions participated, indicated that postsecondary students in Ontario are generally experiencing a decline in mental health compared to the same survey undertaken in 2013. Specifically, 46.1% of students reported feeling so depressed that it was difficult to function, 65.4% of students reported experiencing overwhelming anxiety, 14.8% of students reported experiencing tremendous stress, 13.7% of students reported having seriously considered suicide, 2.2% of students reported a suicide attempt, and 9.3% of students reported having intentionally cut, burned, bruised, or otherwise injured themselves in the previous year . The comparative figures for 2013 are 40.1, 57.9, 12.7, 10.9, 1.5, and 7.5%, respectively, in 2013 . These figures highlight that the rates of depression, anxiety, stress, suicidal thoughts and attempts, and self-harming behaviors are trending up among the college students. The Ontario college students study reports that students diagnosed or treated by a professional for depression and anxiety increased from 10 and 12.2% in 2013 to 14.7 and 18.4% in 2016, respectively.
With increasing numbers of students experiencing mental health disorders and the growing social acceptance of counseling as an intervention that can be helpful for people struggling with mental health as well as developmental and life issues, college counselors are experiencing a significant upsurge in the number of students who are seeking out campus counseling services [9, 10]. In this context, it is important to understand how campus counselors are responding and the challenges they are facing in providing best practice counseling and support in all aspects of their work.
2. Literature review
2.1. Reasons for the increase in mental health difficulties among postsecondary students
Postsecondary educational qualifications are fast becoming an essential requirement to gain employment in Canada, and an increasing number of students from all socioeconomic backgrounds are enrolling in postsecondary study. However, many students are ill prepared for the challenges involved in postsecondary study. Starting postsecondary study can be stressful for many students. They may face complex needs and experience many intersecting transitional stressors when moving from teenage to early adult developmental stages signified by the beginning of college life. These potential stressors may include but are not limited to identities shifting from teenagers to young adults, transitioning from a more structured high school learning environment to a less structured and often more demanding college learning environment. For some students moving away from home may demand more sophisticated skills and approaches including personal time and financial management, diverse relationship building skills, making long term life goals and career decisions [11, 12]. Stressors may also arise from pressures to succeed academically and the need to undertake employment to meet study costs and manage family responsibilities [3, 11, 13, 14]. Immigrant, indigenous, and international students from diverse cultural backgrounds can face additional pressures arising from limited racial diversity in predominantly white academic environments, discrimination, cultural isolation, acculturative stress, lack of access to same-ethnicity role models, and low educational expectations, all of which increase their risk of experiencing mental health disorders [15, 16]. Students who have come as refugees may have unrecognized preexisting vulnerabilities arising from war and pre-migration traumas, which can interact with environmental factors in postsecondary institutions and impact academic performance .
2.2. Experiences and challenges of campus counselors
Campus counselors are responsible for providing a range of services to students. These can include long- and short-term counseling, consultation with faculty and staff, providing academic support and career counseling, and working with interns in the crisis and emergency services [17, 18, 19, 20]. The type and scope of services they provide depend on factors like the structure of the student affairs division of the institution, the type of institution (e.g., 2-year, 4-year), budget and resources, and staff size and training [18, 20]. Counselors at community and technical colleges generally have very broad responsibilities that may include admissions, academic advising and registration, testing, teaching, consultation with faculty, career coaching and counseling, crisis and intervention, psychoeducational programming, mental health evaluation, referrals for long-term services, and individual counseling [20, 21, 22]. By contrast, counselors at 4-year institutions can provide services that are more congruent with traditional mental health counseling. These can include counseling, consultation services to faculty and staff, workshops focused on prevention and remediation, and specialist services like couples counseling . Research shows that students who receive counseling services are more likely to persist and graduate within 6 years than those who do not [24, 25, 26, 27, 28].
A review of research on the experiences of campus counselors shows that they are currently facing several challenges. First, there has been a significant increase in the number of students with mental health disorders seeking counseling services. Second, counselors are experiencing an increase in the severity of symptoms manifested by students [21, 29, 30]. Third, many campus counselors are feeling the pressure of a rapidly changing, culturally diverse, and nontraditional student population that includes older, part-time, and full-time working evening students and ethnic minorities. Traditional counseling models may not work well with these diverse student groups. Lastly, despite a significant increase in their workload, there has been no appreciable increase in the support services available from campus counseling centers , and counselors have “do more with less,” a dynamic that can create significant challenges . The situation is worse in community colleges . As highlighted by Much et al., “over the years campus counseling services have become stretched because of diminishing financial resources, shifting accountabilities, and intensifying scrutiny on the part of governing boards, policy makers, and the public” .
2.3. The current study
Given the enormous challenges that campus counselors are facing, the aim of this study is to examine how they are dealing with these and the kinds of support they need. This study specifically focuses on the challenges faced by community college counselors. This is because community colleges are vastly underrepresented in much of the study on college student mental health [33, 34, 35]. Further, compared to universities, community colleges receive far less funding to provide counseling support services [22, 36, 37], despite evidence that community colleges have a greater proportion of students from lower socioeconomic and ethnic minority backgrounds [38, 39] who would benefit from having access to more psychological support services.
This study used a qualitative exploratory research design to examine the research question. A qualitative approach is ideal for this study because it allows the researchers to explore detailed accounts of problematic experiences of the counselors and the webs of social relationship that join persons to one another . Qualitative methods are widely advocated for investigative inquiry into issues and topics that have not received considerable attention and to promote participatory research .
Ethics approval for conducting this study was obtained in 2010 from the University of Calgary Research Ethics Committee. The study was conducted during 2010–2013. Counselors from six publicly funded community colleges in the province of Alberta were contacted by a student research assistant to gain first-hand understanding of the student groups they serve, the kinds of student problems they encounter, the services they offer, and the difficulties they face in meeting the needs of students and managing their own workload. Based on the information provided by the counselors, a semi-structured interview schedule was developed which was then used for subsequent in-depth interviews with college counselors. Following this, counselors from 12 (including six that were previously contacted) publicly funded community colleges in the province were contacted by telephone, to tell them about the study and request them to participate in a one hour face-to-face or telephone interview. Private colleges were excluded from the study as their student cohorts and support services are different. Ten counselors from seven community colleges from across the province agreed to participate. They had between 3 and 20 years of experience as counselors. Four interviews were conducted face to face while the remaining six interviews were conducted via the telephone. Chance of misinformation by the interviewer was minimized by audiotaping the interviews with the counselor’s prior permission and transcribing them verbatim.
The method of constant comparison was used for identifying codes, categories, and themes that helped to make meaning of the raw data and to transform it into a coherent depiction of the counselors’ experiences . Each transcript was read several times independently by two researchers to obtain an overall understanding of the experiences and challenges faced by the counselors. An initial coding framework was established based on the first few interviews. The researchers then conducted independent coding, and their codes were compared to ensure interrater reliability. The coders also wrote ongoing self-reflective memos documenting their personal reactions and thoughts on each counselor’s narratives about their experiences, challenges, and needs. These memos helped in developing specific questions to target during later interviews, and these were included in the data analysis. An audit trail was maintained for the whole research process. Other measures that were taken to increase the rigor of the results included checking the comments of each participant counselor against those of others, debriefing after the interview, and including several direct quotes while discussing the results of the study.
4.1. Population served
Among the seven community colleges that are represented in this study, only one is in a major capital city. This college was better resourced than the others in terms of the counseling supports that were available for students. Two of the colleges primarily served First Nations (indigenous) students and as highlighted by one of the counselors in this college: “…probably fifty percent of my clientele would be Aboriginals and that’s because of the nature of some of the programming that we offer here. They are funded by the Saskatchewan government for Aboriginals …and lots of times they (students) are coming with lots of issues…”. All the seven colleges offered upgrading programs, diplomas, and English as second language (ESL) programs. Two counselors were mainly engaged in providing academic and career support services for students. These included helping students to navigate through the process of accessing services, providing workshops on general issues like time management, and working with other departments to help students access various kinds of support that they were eligible for. The others performed multiple roles, like providing one-to-one counseling services, coordinating with external sources of support like mental health services, referring students to mental health and other specialist services in the community, monitoring general student issues, providing follow-up care for students who had ongoing difficulties related to mental health and academic study, and negotiating with faculty for accommodations for the students. Some counselors also provided training to faculty and college staff, on how to identify mental health issues in students and provide appropriate support.
A large proportion of the caseload of the counselors comprised first-generation migrant and refugee students from the Middle East and Africa (particularly Sudan, Ghana, and Liberia), who had experienced persecution, trauma, and death of loved ones. Many of these students were in ESL and upgrading programs, and according to one counselor, about 50–60% of these students experienced more mental health difficulties than those in the direct career stream.
Depression and anxiety were by far the most common mental health disorders experienced by 70–75% of the students who sought counseling. The symptoms that students often presented with, in the words of a counselor, were, “they’re having trouble focusing in class, they are not sleeping very well and not eating very well, they’re really stressed out and you’ll see a lot of symptoms of distress, like tearfulness and sadness.” Counselors reported that about 25–30% of their students were on antidepressant or antianxiety medications. The counselors were uncertain if these prescriptions were provided by a general practitioner and whether the students really needed these medications. After depression and anxiety, the most common mental health conditions that students experienced were attention deficit hyperactivity disorder (ADHD), bipolar illness, and posttraumatic stress disorder (PTSD). As explained by one counselor:
A lot of times you don’t necessarily know that it’s PTSD…what you see first is the depression or anxiety stuff and then you start to collect stuff, you know, the bits and pieces that tell you it’s probably PTSD… it’s only after you… do a little bit of digging to find out…to be able to start attaching that (their symptoms) to past trauma and the students don’t always even tell you…We have lots of survivors of all sorts of trauma, whether that’s domestic trauma or war trauma-----
Counselors reported that some of the students had multiple disabilities, “they may suffer from depression but also have a brain injury or a chronic medical, ADHD, learning disabilities.” The counselors regularly dealt with students who were battling with grief and loss issues, domestic violence, trauma of rape and sexual abuse, and chaotic family relationships.
4.2. Counseling approach
The counseling approach used by most counselors was a brief solution-focused counseling. Although counselors saw students with a wide range of diagnosed and undiagnosed conditions, ranging from anxiety and depression to bipolar disorders and schizophrenia, many said that they were averse to mental health labels because of the stigma attached to them and the impact these can have on students. They were reluctant to classify conditions like ADHD under mental disorders and preferred to describe these problems as learning disabilities. In the words of one of the counselors:
…when I look at mental health issues, I’m looking at bi-polar, borderline personality, dissociative type stuff and yeah, --I’m having difficulty with the term “mental health” because to me, mental health means they have been diagnosed with some kind of mental health issue such as schizophrenia or something like that, ---we have students with ADHD, we have students with dyslexia but we don’t define those with mental health issues…and dyslexia is not a mental illness problem…We define them as they’re having learning disabilities, let’s help them out.--- I am really, really careful about diagnosing students because they carry that diagnosis the rest of their lives…And I suppose that that’s their choice if they want to do that, I just…I won’t do that because I respect our students too much to give them a mental illness label.
The perspectives of campus counselors on the challenges they face in meeting the needs of students can be classified into two broad themes, each with several subthemes: (1) challenges arising from the students’ mind-set about their mental health condition and (2) challenges arising from lack of resources. Each theme and its subthemes are discussed subsequently.
4.3.1. Challenges for counselors arising from the students’ mind-set about the disorder
18.104.22.168. Students fail to recognize mental health condition
Many counselors said that students often fail to understand that they have a mental health condition, despite their symptoms and behaviors being obvious and a nuisance to others in the campus. This posed a challenge for the counselors as they had to help students who lack insight to recognize their problems and seek treatment. As expressed by a counselor:
We had a student from China who was later diagnosed with bi-polar disorder and we knew something was wrong because her behavior was becoming increasingly inappropriate or louder and then she got into photocopying room …our library staff had to put limits on her …Usually a person, where you say, “That’s too much photocopying”, they might be grumpy with you but they live with it but she totally escalated out of control with yelling and all that stuff so it’s pretty obvious that there’s something seriously wrong.
22.214.171.124. Students do not disclose their mental health condition
Another challenge arose because some students deliberately hid their mental health diagnoses from the college faculty and counselors. When the student does not disclose, counselors are unable to provide timely assistance and appropriate interventions, and this can hinder the students’ academic performance. One of the counselors described her experience as follows:
I remember working with a student a couple of years back who had been diagnosed with schizophrenia before she started her career program. It was a very difficult career program and she had a heavy- duty exam coming up, none of us knew that she had been diagnosed. She told no one and what happened is she had stopped taking her medications a couple of days before the exam because it affected her memory and she took the chance that she would write the exam before she started having symptoms and guess what, she didn’t quite make it. So the morning of the exam, she started hearing voices like crazy-- she was so overwhelmed----- so the teacher called us up ----first we called emergency …it was pretty frantic right-- Finally, just after the EMT (emergency mental health team) got here, she was able to say that she had medication in her purse but that stuff doesn’t kick in right away --and anyway, bottom line was she didn’t go with the EMT and she absolutely refused to let us discuss any of it with her---.
126.96.36.199. Students with mental health issues refuse to seek help
Counselors expressed that they do not have the right to force students experiencing mental health issues to seek help on campus, especially when they have not caused any danger to self or others. Counselors felt that some students are not comfortable seeking help, especially when the campus is small and there is a risk that others will come to know about their illness. In these instances, counselors would explain to the student that seeking help would reduce the risk of decline in functioning, refer the student to external resources, or as stated by a counselor: “I don’t hesitate to give the students my referral list and let them choose whomever they would feel more comfortable with and then leave it to the student to follow through.” Another counselor highlighted the consequences of not following through: “If they refuse then we can't force them, you can't help someone who doesn't want any help so if they weren't being successful in school, chances are they will be terminated at the end of the semester or whatever, like they'll be withdrawn from their course.” Counselors also expressed their concerns about other likely consequences for students if they did not follow through with timely treatment: “what they'll tend to do is they'll abuse alcohol and marijuana rather than kind of find, you know, go and get diagnosed.”
188.8.131.52. Students lack understanding about the impact of mental disorder on learning
Another concern that counselors expressed was the lack of understanding among many students of how their mental health condition can affect academic performance and the motivation to seek help:
Students also often underestimated the time required to manage their mental health condition and requested quick fixes to address their academic issues. Some students also declined counseling follow-up, and counselors had to respect their choice. They did not want to be intrusive unless there was a concern that the student may be at risk of harming self or others.
184.108.40.206. Students’ resistance to medications
College counselors noted a general reluctance on the part of students to take psychotropic medications due to stigma, worries about their side effects, and lack of understanding of the pathways through which these drugs could work on them. As stated by a counselor, “…there’s only so much we can do in the therapy and we recommend that anti-anxiety meds be considered, or an anti-depressant and we get resistance. It seems to be a bit of a trend sometimes that students are reluctant to take any type of medication.” Another counselor highlighted her experience with students who had ADHD, “people with ADHD resist medication, that seems to be a bit of a trend too and part of it is because they don’t want to change personalities right, they like who they are and so there’s sort of this stigma to the medication part of it.” Counselors felt that in some cases, the reluctance to take medication could be part of the illness, where the student blamed everyone else for their problem and did not recognize “that it’s within their own interests to seek help.” Fear of the side effects was another driving force behind the reluctance to take medication. As expressed by a counselor, “I think people are fearful about what those kinds of medication might do to them, there’s side effects right? So that’s part of it. They’ve heard, you know, you gain weight, you’re not yourself, whatever the case may be.” In some cases, however, counselors were successful in convincing students about the benefits of taking a medication.
4.4. Challenges arising from lack of resources
4.4.1. Inability to provide the level of care needed
Counselors expressed that time constraints, heavy workloads, and lack of staff limited their capacity to provide the level of support that their students needed. Consequently, many counselors used short-term solution-focused approaches, even though they knew that these may have a minimal value in addressing the students’ complex issues. Many students had experienced various kinds of trauma. Although counselors provided supportive counseling using brief solution-focused approaches, many felt this was inadequate or “superficial” as these students needed more in-depth long-term therapy. While some counselors felt that time constraints restricted their ability to provide the level of support needed, others expressed that they did not have the specialist knowledge/skills to provide the kinds of intervention that these students needed. Due to these reasons, counselors tended to avoid delving into the students’ trauma issues and referred them to external community services, if these were available. Sometimes, when the trauma was accidently identified during the counseling sessions, counselors struggled with the dilemma of whether to address the trauma or just provide the usual short-term solution-focused counseling. As reported by a counselor:
The level of support that counselors can provide very much depends on the resources that their college has. As expressed by a counselor from a college that was poorly resourced: “I know that some post-secondary’s have really been able to do kind of more therapy oriented approach and we have not been able to do that…that’s not a complaint, -- what seems to work better for us, I guess –is solution focused--a, step in, step out and at some point…”.
However, this did not mean that counselors limited student visits to just a few sessions. They allowed emergency visits, drop-ins, and in some cases also provided specialized support. As highlighted by the following excerpt:
Despite all that the counselors are willing and able to do for the students, the bottom line is that if there is resource scarcity in a campus, waiting times for seeing a counselor could be “as long as three weeks or more.” This could negatively impact students with mental health disorders who need timely interventions. Unfortunately, as reported by the counselors, during times of economic downturn or if the college is going through a financial crisis, one of the first services to be slashed is the campus counseling service.
4.4.2. Juggling multiple roles
The role of a counselor in small campuses can be very demanding. One counselor from a small campus described her role as follows:
4.4.3. Conflicts arising from “mandated and non-mandated” responsibilities
Some colleges were able to split the role of the counselor into two positions with one looking after student accommodations and related issues, and the other responsible for mainly counseling and associated functions. In less-resourced colleges, however, this division of responsibility was not feasible. Some colleges, despite being small, had designated accommodation specialists but often, because of their counseling/mental health background, these specialists had to take on counseling-related functions. One registered psychologist with a mental health background who had been appointed as an Accommodations Coordinator and Director of Student Development in a small college explained her situation as follows:
This psychologist, despite not being mandated to address counseling issues, would be consulted on counseling and related issues. She highlighted her ethical dilemma arising from her multiple roles in the following excerpt:
4.4.4. Use of contracted counseling services and experiences with external providers
In some small campuses, there were no designated counseling departments. Sometimes, teachers or instructors, without formal training, were forced to take on a counseling role. Students with mental health problems would be referred to contracted mental health workers for counseling and support. Some campuses did have counselors, but if their responsibility was toward students with learning disabilities, they would not see students with mental disorders unless they also had learning disabilities. Counselors generally did not perceive contracting out services as the best option for students, and some viewed this as a cost-saving strategy used by colleges. They also expressed concerns about the quality of service provided by some contracted workers.
Many counselors also expressed frustration because some of their students with mental health problems had to wait for at least a month before they could see a psychiatrist, and during this waiting period, their condition would worsen. Another challenge that counselors faced was misdiagnosis of the students’ mental health condition by general practitioners. In this context, a counselor said, “one of my students has been diagnosed with about five different things, and she's been put on all these meds and she's getting worse instead of better.” Counselors also expressed concerns about the ease with which students were able to get prescriptions for antidepressants from general practitioners. They were aware that many of their students were on antidepressant medication without having consulted a mental health practitioner even once.
This study examined the challenges experienced by community college counselors in addressing the needs of students who experienced mental health disorders. Though the findings are based on a small sample of counselors from seven colleges in one province in Canada, they are nevertheless significant. The results are in keeping with the previous research which suggests that community college students comprise a large proportion of indigenous and ethnically diverse first-generation migrant students who experience multiple barriers [33, 39]. The findings also confirm that community colleges, despite serving a highly vulnerable student population, that experiences severe mental health problems and complex life issues, are struggling for resources to meet the psychological and mental health needs of the students [15, 36, 37]. In keeping with other research [17, 43], many counselors in this study resorted to either placing students on waitlists for services or referring students to outside providers, despite apprehensions about the quality of outsourced services. Some studies show that 42% of students referred for services outside of the counseling center are unsuccessful in connecting with a mental health provider and that students of color have lower rates (43%) of successful referrals than Caucasian students (58%) . Current findings also highlight that even in cases of direct service delivery, counselors were able to provide only a minimal level of service, because of time constraints, the need to balance multiple roles due to lack of staff, and lack of knowledge/skills in specialized areas of practice.
Stigma was the other significant factor that prevented students from accessing services. Several studies show that stigma is associated with denial of the illness, failure to disclose, and follow through with treatment [45, 46]. The combined effect of stigma and the lack of timely and appropriate services for students experiencing mental health disorders can adversely affect their educational achievement, increase the risk of school dropout, lead to lower occupational attainment, workforce failure, and poor community integration.
5.1. Implications for practice and policy
The findings of this study have several implications for practice and policy. They suggest that community colleges are in urgent need for more comprehensive mental health resources to meet the needs of their diverse student body. Toward this, the counselors who were interviewed provided several recommendations. The first was to increase the number of part-time counselors especially during critical periods like mid-term and before the finals, as these are associated with an increase in the students’ stress levels. Counselors who were providing the whole range of student support services including counseling suggested appointing people who could take on the academic and career-advising roles so that the counselors’ time could be utilized for providing psychological services.
Counselors also proposed training some students within the campus to act as peer support for those experiencing mental health difficulties. The study on student support networks  suggests that students willing to take on peer support roles can be provided training in areas like (1) enhancing knowledge of mental health conditions, (2) promoting skill development in core-helping skills, (3) reducing stigma associated with help seeking, and (4) enhancing connection with key campus resources. Some research suggests that “peer support is associated with positive effects of hope, recovery and empowerment at and beyond the end of intervention” . Because of fiscal limitations and pressures on counseling staff, an increasing number of postsecondary institutions are recognizing the advantages of this population-based model to serve the mental health needs of the student community . However, training students to provide peer support will need additional resources like time commitment from counselors, at least initially.
Another population-based approach that was suggested is educating the campus community and other stakeholders, like parents about mental illness and the adverse impact of stigma. Some campus counselors were already engaged in this to some extent. This approach involves conducting workshops for faculty and college staff to respond helpfully to students in trouble, making referrals to college counselors, expanding external referral networks, and serving on college interdisciplinary committees to help in proactively identifying students who are troubled. Counselors also recommended that general practitioners, who see students on a regular basis and prescribe medications, must work more closely with mental health practitioners and refer students with mental health problems to these practitioners.
In addition to the above programs and recommendations, community college counselors can benefit from increased supervision and opportunities for specialized clinical training in areas like trauma-informed practice and suicide prevention. Since community colleges serve a significant number of ethnically diverse and marginalized students, community college counselors must also focus on developing multicultural counseling skills so that these students do not feel disenfranchised in the system. Finally, community college counselors must engage in building reliable partnerships and referral systems with off-campus service providers who can attend to students whose treatment needs exceed campus resources . They must ensure that students referred for services outside of the counseling center are successful in connecting with mental health providers .
Community college counselors’ caseloads comprise a significant proportion of students from ethnically diverse and minority backgrounds. Many of these students experience complex life issues and severe mental health conditions. In the face of rising demand for counseling services and decreasing resources, the counselors face several challenges in addressing the needs of these students. These findings make a strong argument for increasing resources for community colleges so that they can meet the needs of the students and support counselors in their role. They also suggest the need for a comprehensive provincial strategy that can address the rising incidence of mental disorders among marginalized students who aspire to gain postsecondary qualifications and join the workforce. Despite the significance of the findings, this study has limitations. The findings are based on a small sample of 10 counselors from seven community colleges across one province in Canada. Hence, the results cannot be generalized to other regions and student populations. Future studies must include a larger sample of counselors across more provinces in Canada. Future research can examine the perspectives of community college students on the counseling support they need and currently receive to address the challenges they face during their study program.