To Counsel or Not to Counsel?

Hannah Nunez’s job at Northern Arizona University requires her to be a few different things at once: an advocate, a compassionate ear, a repository of information about campus resources. As a behavioral health coordinator, part of her role includes screening potential counseling patients. During a roughly 20-minute appointment—either in person or virtually, depending on client preference—students describe the problem they’re facing, and she helps them decide the best course of action, which, she says, isn’t always counseling.

“They might mention they’re struggling academically, and that might be a flag for: we’re going to talk to them about tutoring,” she said.

Some students seem to be looking for someone to talk to, and those are the students Nunez typically refers to counseling. But before she does, she tries to figure out if they have a problem that can be solved instead by accessing any of the other extensive on-campus resources at NAU.

“It can feel really validating for folks to come in with what might be an overwhelming, scary, daunting feel, like there’s not really any hope … and then to walk away with very tangible steps—‘I can join this club, I have an intake appointment,’” she said.

Triaging Students

The principle behind such screening processes is much the same as triage in a hospital emergency room, where medical professionals assess the nature and urgency of a patient’s needs.

Though different institutions have different names for the process—triage, screening or “Path to Care,” as Northern Arizona calls it—they all work in a similar manner. Rather than sit through a traditional hourlong intake appointment, each new client who approaches the counseling center is scheduled for a short appointment, which varies in length according to the institution but is typically less than half an hour. (Some universities precede these appointments by asking students to fill out online questionnaires such as a depression screening, for example.)

During the appointment, which is often held over the phone, students provide the triage counselor with the same kind of information they might provide during a full-length intake appointment: demographic details, their reasons for seeking help, their history of mental health treatment, risk factors and more.

The counselors then use that information to determine whether, when and from whom the student should receive counseling, as well as whether they should be directed to any other campus resources—say, a tutoring center if their main source of stress is an upcoming organic chemistry exam. The appointment can also be used to give students additional details about what counseling will entail; at Northern Arizona, that includes information about the cost of an appointment ($25 for an individual session) and how many sessions they are allowed per semester.

Colleges and universities that utilize triage say the goal is to assess students thoroughly, but in less time. One of the challenges of implementing these systems is training counseling center staff in how to complete short, fast-paced evaluations.

“It took a little bit of comfort-building for our staff to realize they could gather all of that information in that short amount of time,” said Natalie Hernandez DePalma, the senior director of counseling and psychological services at Pennsylvania State University, which has included some version of triage in its counseling services since 2009.

Nunez said it can also be challenging to teach new employees about all the campus’s resources, which she mainly knows from working at NAU for about 10 years.

Eliminating Waits

But some institutions that have implemented such triage systems have greatly improved the quality and reach of their mental health care. The counseling center at NAU, a large university with more than 20,000 students on its main campus, introduced a triage process about two years ago and is currently operating with no wait list for the first time in at least 10 years, according to Carl Dindo, director of NAU’s counseling services.

As requests for mental health services have skyrocketed on campuses, triage systems have become a popular tool for managing demand. In 2020, the Center for Collegiate Mental Health’s annual report, which included data from 567 counseling centers, showed that 42 percent utilized some sort of brief screening appointment as their first clinical contact with patients.

Requiring students to undergo a quick assessment before they can sit down with a counselor allows more students to get care—and the right kind of care—more quickly. Additionally, triage appointments sometimes direct students toward resources that the counselors believe will help more than therapy, meaning that students who won’t necessarily benefit from counseling don’t need multiple hourlong sessions to figure that out.

Some college mental health experts say college counseling centers have long promoted themselves as a catch-all resource, overburdening their staffs by drawing students who might be better served elsewhere on campus.

Similarly, Nunez said, students have historically been funneled into counseling because it didn’t occur to staff to direct them elsewhere.

Now screenings make that a fundamental part of the process.

However, centers that use screenings are quick to note that the goal is not to push students away from counseling.

“Most of the students who come that request counseling and want counseling, we connect them just by virtue of the fact that they want it,” said Dindo. “When you have somebody who just got to school and maybe they’re not familiar with what resources exist … I think you have a lot of people sort of telling them maybe what they need or what they think they should access. I think we’ve had a lot of experiences of students coming in saying, ‘My professor told me I should come talk to somebody’ or ‘My mom is concerned about me and she told me I should check out counseling.’ In those instances—both at the Path to Care screening appointment, but also even in counseling—we’ll have really intentional, meaningful conversations around, ‘Well, what do you think you need?’”

Some experts also express concerns about the additional burden that triaging duty places on often-overworked counseling center employees. At both Northern Arizona and Penn State, screening appointments are spread among many staff members; each employee at NAU is required to do about five hours a week of triaging, while each Penn State employee does about two and a half hours. (Triaging at Penn State is completed by counselors, while at NAU it is performed by both counseling services staff and behavioral health team members, who primarily work on the health side of the university's integrated health and mental health system.)

Additional Benefits

Advocates for mental health triage systems say they also help counselors figure out which patients to prioritize: who would benefit from having a counseling appointment tomorrow and who can wait until next week.

“I’m a student and I call up and I say, ‘I need an appointment,’ and they say, ‘OK, the first available intake or the first time is two weeks down the road.’ Well, if I’m suicidal, if I’m having homicidal thoughts, waiting two weeks is not a good idea at all,” said Marcus Hotaling, director of Union College’s counseling center and president of the Association for University and College Counseling Center Directors. “So that’s why a lot of centers now, including our own, have moved to a same-day appointment or same-day triage, so that we can at least get eyes on you.”

Nunez said there are unintended benefits of a shorter screening, as well. Students who are new to therapy often struggle or feel awkward talking about themselves for an hour at a time. Shorter screenings let those nervous students “test the waters a little bit,” hopefully making for a better counseling experience all around.