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Embedded Counseling Programs in Post-Secondary Settings

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Title: Embedded Counseling Programs in Post-Secondary Settings
Language: English
Authors: Sandra Yuen, Gaya Arasaratnam, Cheryl Washburn
Source: Journal of College Student Mental Health. 2024 38(3):573-588.
Availability: Routledge. Available from: Taylor & Francis, Ltd. 530 Walnut Street Suite 850, Philadelphia, PA 19106. Tel: 800-354-1420; Tel: 215-625-8900; Fax: 215-207-0050; Web site: http://www.tandf.co.uk/journals
Peer Reviewed: Y
Page Count: 16
Publication Date: 2024
Document Type: Journal Articles
Reports - Research
Tests/Questionnaires
Education Level: Higher Education
Postsecondary Education
Descriptors: College Students, School Counseling, Mental Health, Guidance Centers, Foreign Countries, Program Content, Institutional Characteristics, Access to Health Care, Social Attitudes, Counseling Services, Barriers
Geographic Terms: Canada
DOI: 10.1080/87568225.2023.2203875
ISSN: 8756-8225
1540-4730
Abstract: This paper examines embedded counseling programs across ten Post-Secondary Canadian counseling centers. We highlight common drivers for developing embedded counseling programs, commonalities and differences across programs, successes and challenges in implementation, and recommend a common set of metrics. Our overview demonstrates variability in program structure that reflects the host faculty or department and the culture, expectations, and realities they each face. Based on lessons learned, we highlight emerging and promising practices for university counseling centers.
Abstractor: As Provided
Entry Date: 2024
Accession Number: EJ1432480
Database: ERIC
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  Value: <anid>AN0178559270;[nm80]01jul.24;2024Jul24.05:35;v2.2.500</anid> <title id="AN0178559270-1">Embedded Counseling Programs in Post-Secondary Settings </title> <p>This paper examines embedded counseling programs across ten Post-Secondary Canadian counseling centers. We highlight common drivers for developing embedded counseling programs, commonalities and differences across programs, successes and challenges in implementation, and recommend a common set of metrics. Our overview demonstrates variability in program structure that reflects the host faculty or department and the culture, expectations, and realities they each face. Based on lessons learned, we highlight emerging and promising practices for university counseling centers.</p> <p>Keywords: Counseling college students; embedded counseling; program evaluation; student mental health; university counseling centers</p> <hd id="AN0178559270-2">Introduction</hd> <p>According to the Association for University and College Counseling Center Directors (AUCCCD) 2014–15 annual survey, 6.8% of respondents reported an embedded counseling program on campus (Reetz et al., [<reflink idref="bib15" id="ref1">15</reflink>]). By 2019–20, this percentage roughly tripled to 19.7% (Gorman et al., [<reflink idref="bib6" id="ref2">6</reflink>]). Despite this growing trend, relatively few published articles have been written on the subject of embedded counseling programs within post-secondary settings (e.g., Adams, [<reflink idref="bib1" id="ref3">1</reflink>]; Davis et al., [<reflink idref="bib5" id="ref4">5</reflink>]; Orchowski et al., [<reflink idref="bib13" id="ref5">13</reflink>]; Rawls et al., [<reflink idref="bib14" id="ref6">14</reflink>]), with limited literature on the design, development, and implementation of embedded counseling programs.</p> <p>Embedded programs highlight a "localized knowledge – centrally managed" approach where counseling staff report or co-report to a counseling center but hold offices in host faculties and departments (B. Schreier et al., [<reflink idref="bib17" id="ref7">17</reflink>]). According to the AUCCCD, embedded sites are primarily located in athletic departments (49.3%), followed by schools or colleges (37.3%), student services departments that serve under-represented groups (24%), health services (24%), and residence halls (22.7%) (Gorman et al., [<reflink idref="bib6" id="ref8">6</reflink>]).</p> <p>One specific approach to embedded counseling is the Counselors-in-Residence program where doctoral-level clinical psychology or counseling education trainees live in residence and provide direct services to students, consultation for residence life staff, and for some, counseling for staff (e.g., Davis et al., [<reflink idref="bib5" id="ref9">5</reflink>]; Orchowski et al., [<reflink idref="bib13" id="ref10">13</reflink>]). This approach provides the opportunity for a greater understanding of residence life and the challenges that students experience and provides after-hours services (e.g., Davis et al., [<reflink idref="bib5" id="ref11">5</reflink>]; Orchowski et al., [<reflink idref="bib13" id="ref12">13</reflink>]). Counselors-in-Residence programs provide students with individual counseling, follow-up sessions, and referrals to central services. They also provide walk-in appointments, crisis support, "house calls," outreach activities, and workshops to support the work of residence life staff. In one instance, consultation services were provided to residence life staff as the primary "client," rather than individual counseling for students (Rawls et al., [<reflink idref="bib14" id="ref13">14</reflink>]).</p> <p>Mackay et al. ([<reflink idref="bib11" id="ref14">11</reflink>]) investigated the benefits and challenges from the student, faculty, and counseling center perspectives at two Canadian counseling centers. For students, benefits included improved access, advocacy, knowledge of localized student challenges, convenience, and credibility (Mackay et al., [<reflink idref="bib11" id="ref15">11</reflink>]). For faculty, benefits included tailored programming, understanding of faculty culture, staff and faculty consultation, and being a trusted partner (Mackay et al., [<reflink idref="bib11" id="ref16">11</reflink>]). For counseling centers, benefits included positive faculty relationships, improved communication with faculty partners, and enhanced awareness and visibility of mental health services (Mackay et al., [<reflink idref="bib11" id="ref17">11</reflink>]). Identified challenges included balancing the supply and demand of services, logistics (space requirements, booking systems), lack of crisis support, counselor isolation, and funding to support services. More recently, B. A. Schreier et al. ([<reflink idref="bib16" id="ref18">16</reflink>]) examined survey data from 39 college and university counseling center directors who provided information on 105 embedded counselors and found that embedded programs differed regarding who they served, where they were housed, the source of funding, and various other system-level factors. Identifying the benefits, challenges and system level factors associated with embedded counseling programs can provide a foundation for evaluating and improving these programs to better meet the needs of students.</p> <p>Although much of the literature indicates the benefits associated with embedded counseling programs, there is little discussion of their challenges, promising practices for successful implementation, or consideration of how to evaluate them. The purpose of this article is to provide an overview of embedded counseling programs across ten Canadian universities. The article reveals a diversity of approaches that counseling center Directors took to develop embedded counseling programs that suited their institutional needs and contexts. The article also discusses common strengths and challenges of embedded programs (regardless of a Director's localized approach), and offers promising practices and considerations for institutions that might be interested in introducing embedded programs into their setting.</p> <hd id="AN0178559270-3">Methods</hd> <p>Using a "snowball" sampling method, Directors from ten post-secondary universities who oversee Counseling or Health & Wellness Centers came together to evaluate their respective embedded counseling programs. There was representation from Central Canada (<reflink idref="bib6" id="ref19">6</reflink>), the Prairie Provinces (<reflink idref="bib1" id="ref20">1</reflink>), the West Coast (<reflink idref="bib1" id="ref21">1</reflink>), and the Atlantic Provinces (<reflink idref="bib2" id="ref22">2</reflink>). Eight institutions were located in larger urban areas and two were located in urban areas with populations of less than 200,000. Seven institutions were considered large and three were medium sized (Conway et al. [<reflink idref="bib4" id="ref23">4</reflink>]). This process resulted in a purposive sample of institutions.</p> <p>Each Director was invited to complete a survey inquiring about their embedded counseling model and its structure (see Appendix A). Upon completion of the survey, Directors were invited to participate in a one-hour semi-structured interview in order to provide additional clarity on their embedded counseling models, lessons learned, and recommendations for a successful service model. An analysis of the survey and semi-structured interview data was conducted via triangulation of the data sources and pattern matching and thematic review were employed.</p> <hd id="AN0178559270-4">Findings</hd> <p>Dialogues with the Directors from the ten institutions revealed that some institutions have firmly established embedded counseling programs while others are at the development stage. Common themes identified through the analysis include common drivers prompting the development of the embedded counseling program, program structure, challenges, and lessons learned across the ten institutions.</p> <hd id="AN0178559270-5">Common drivers</hd> <p>All ten institutions identified four key drivers that prompted their development of an embedded counseling program: (a) promote access, (b) reduce stigma, (c) promote awareness, and (d) provide tailored services. For the Directors, the first three drivers sought to enhance help-seeking behaviors in students, while the fourth driver helped augment their service delivery models by aligning them more closely with the needs of students in any given faculty or other embedded site.</p> <p>Director interviews revealed that embedded counseling programs promoted help-seeking by increasing access to services for students, particularly in faculties that are geographically distant from the main counseling center. Embedded programs were found to be especially helpful for students who have little unstructured time outside of their academic-related requirements and students who tend to spend the majority of their time in well-resourced faculty buildings (i.e., buildings with classrooms, eateries, and computer labs; Wu et al., [<reflink idref="bib18" id="ref24">18</reflink>]). Director anecdotes suggest that the better resourced a faculty building is, the less likely a student is to leave it, and the higher the affinity that a student has with their faculty. This appears to be supported by existing literature about the physical design of buildings (Wu et al., [<reflink idref="bib18" id="ref25">18</reflink>]). Embedding counseling services makes it convenient for students to seek help when needed by increasing the number of access points to mental health support. This, in turn, can reduce some of the demand and wait times for central services, which increases access to mental health support for all students.</p> <p>While all ten institutions support early intervention efforts, four centers have taken intentional steps to build early intervention into the design of their operational structures. Here, embedded sites can act as first points of contact and provide low-barrier access to low-intensity interventions for students with mild to moderate concerns.</p> <p>Embedded counseling programs also appeared to increase help-seeking by making it more comfortable for students with a stigmatized view of mental health to access services outside of an ostensible health setting. Discussions with counseling directors revealed that embedded counseling offices often do not have visible name boards identifying them as mental health services; this provides a less stigmatized access point for students concerned about privacy and confidentiality. However, it was also pointed out by some institutions that the reverse can also be true – some students in small faculties may find more anonymity in leaving their faculty buildings and utilizing central services.</p> <p>Student help-seeking is also enhanced by increasing student, faculty, and staff awareness of mental health concerns, mental health literacy, and resources (Beks et al., [<reflink idref="bib2" id="ref26">2</reflink>]). Embedded programs were seen to help increase awareness of mental health services by offering consultations for faculty and staff. These consultation services can often result in greater awareness of, and sensitivity to, mental health concerns and more effective referrals to counseling and other student services.</p> <p>Finally, Directors believed that their counseling services benefited from an enhanced understanding of the unique "culture" impacting students' experiences at any given site or faculty. This enables counselors to provide more tailored and informed support for students and consultation to staff and faculty that more closely align with their unique needs.</p> <hd id="AN0178559270-6">Structure of embedded counseling programs</hd> <p>All of the counseling centers adopted a "hub and spoke" model where the "hubs" are fully-resourced counseling or health and wellness centers, and the "spokes" are single-person offices in faculties, residence halls, and other student services departments. However, centers vary according to their target clientele, access points, services, and staffing. Early adopters of the embedded counseling model tended to create embedded sites that closely mimicked their hub's services. However, later-stage adopters tended to offer embedded multidisciplinary teams that integrate a range of student support services in one space and serve multiple faculties and students. In one instance, an early adopter naturally evolved into a multidisciplinary site over time.</p> <hd id="AN0178559270-7">Target clientele</hd> <p>Eight centers adopted an "exclusive" approach, where only students enrolled in the host faculty or department are able to access services onsite. Here, embedded staff are assigned to a single faculty or department and faculties tend to provide space, equipment, and full or partial funding for salaries. This approach can have positive effects on capacity building, partnerships between health professionals and faculty and staff, and opportunities for collaboration over time (Adams, [<reflink idref="bib1" id="ref27">1</reflink>]).</p> <p>In contrast, two centers identified adopting a "neighborhood" model where students enrolled in the faculty are prioritized, however, in order to improve overall access, students enrolled at other faculties can be seen at any location provided they are appropriate for the embedded services (e.g., early intervention, brief counseling, anonymous drop-in conversations). At one of these centers, an office site was identified in close proximity to neighboring faculties so that it could serve the local "neighborhood," as well as students who are accessing central services.</p> <hd id="AN0178559270-8">Access to services</hd> <p>Embedded counseling services were conceived to "meet students where they are" and to serve as low-barrier access points for students (Boone et al., [<reflink idref="bib3" id="ref28">3</reflink>]; Davis et al., [<reflink idref="bib5" id="ref29">5</reflink>]). As such, embedded services within faculties and departments can reduce geographical, pragmatic, and psychological barriers. At five centers, embedded sites function as the first point of contact for students, offering some combination of triage, single session or walk-in counseling, or anonymous drop-in sessions. The other five centers conduct their triage in central services, with students being referred to embedded sites as appropriate. For three institutions, triage occurs at both central and embedded sites.</p> <hd id="AN0178559270-9">Services</hd> <p>Six centers offer many of the same services and programs offered through their central services, including individual and group counseling, wellness programming, psychoeducational workshops, consultations, and crisis support, customized to fit the needs of the local faculty or department. At two centers, career-counseling is embedded within off-site student service units.</p> <p>Four centers serve students with primarily low to moderate clinical severity at embedded sites. These institutions focus on early intervention efforts or low to moderate intensity interventions including anonymous drop-in conversations, psychoeducational workshops, consultations, single sessions (walk-in, by appointment), and brief counseling. Two of these centers invested significant time in building faculty and staff awareness of appropriate referrals so that higher intensity cases are directed to central services. From the perspectives of the Directors, this approach provides early intervention services and reduces clinic wait times for low-intensity services. Students with more complex needs can be seen centrally where additional health and mental health supports (e.g., psychological or psychiatric care, crisis management) are proximal. At one site, nurses, social workers, counselors, and trainees constitute a "mid-level rapid access" layer of support between faculty and staff trained to provide low-level well-being advising, low-to-mid intensity interventions (e.g., walk-in single sessions), and system navigation to help students, peer helpers, staff, and faculty identify the right level of support.</p> <p>For these four institutions, the enhanced early intervention model provides a holistic, upstream approach to support student mental health. Directors underscored the importance of clarifying the nature and scope of this type of model in order to avoid misalignment of expectations for faculty, staff, and students and to ensure that faculty and staff in the host faculty or department have effective mechanisms to refer higher intensity cases to their central services. Directors shared that within this approach, embedded counselors voiced feeling professionally "restricted" by their scope of practice by providing only low-moderate intensity services. It is therefore important to be clear on expectations and scope of practice at the hiring stage.</p> <hd id="AN0178559270-10">Staffing</hd> <p>Nine centers have a single counselor at each embedded site, while only one center has two counselors at two sites. Two centers have implemented embedded multidisciplinary teams at their academic sites. One of which has intentionally designed a multidisciplinary approach from the onset, embedding health teams that include health promotion nurses, counselors, art therapists, peer supporters, chaplains, and accessibility advisors who conduct drop-in hours and are organized by a central coordinator. At this site, a coordinator works with local community agencies to provide a roster of community-based events (e.g., yoga, therapy dogs) in the embedded sites. At the other center, the multidisciplinary approach evolved over time. Originally, student life professionals worked in isolation from their embedded staff peers, but over the past five years, the division intentionally created localized teams, organized by a local coordinator. The coordinator is responsible for team meetings with student life professionals and academic staff and coordinates a combined annual report. At both institutions, regular meetings with staff or faculty and all the front-line providers help with efforts to coordinate tailored services for the faculty.</p> <p>Directors shared that the multidisciplinary team provides increased comfort with help-seeking as students can choose from a variety of providers and peer supporters, increasing wellness options. For example, some students might feel more comfortable speaking to a chaplain instead of a counselor, while others might prefer to speak with a health promotion nurse. A multidisciplinary service facilitates informed referrals between providers and integrated programming opportunities (e.g., co-facilitated workshops by a learning strategist and wellness counselor). However, this approach necessitates significant coordination, such as organizing a schedule of events in every embedded site and securing space in faculties for more than one embedded professional.</p> <hd id="AN0178559270-11">Common successes</hd> <p>Despite the differences in institutional approaches to embedded counseling, every institution saw similar successes for students, faculties and departments, and the Health & Wellness or Counseling Center.</p> <p>Embedded counseling services, in addition to central services, provide increased access and tailored mental health supports to students. Embedded services are in close proximity to where students study and live and reduce barriers to help-seeking associated with stigma (e.g., increased comfort accessing services in locations that are not labeled as "counseling/mental health"). There is an opportunity for system navigation and "warm" transfers between central and embedded services, as reflected by the following example, "This [embedded program] makes for a 'warmer hand-off' and leaves the student with the feeling that we care and have helped them make a critical connection."</p> <p>Embedded counselors have a greater understanding and appreciation for the students' needs, contexts, and challenges that are unique to their faculty (e.g., academic challenges, socio-cultural environment) and can therefore tailor programming for the student demographic and enhance student satisfaction with services.</p> <p>Embedded services provide on-site staff and faculty support through consultation, training, and education (e.g., health literacy, referral pathways) and therefore, enhanced mental health literacy and knowledge of campus mental health supports. Embedded services provide increased opportunities for collaboration with the academic site, including class presentations and program-specific problem-solving. Overall, embedded services appeared to enhance professional relationships between faculty and counseling centers in all ten institutions and improve staff and faculty satisfaction with counseling services.</p> <p>From a pragmatic perspective, embedded counseling programs provide an opportunity for increased financial resources for mental health support with faculties or departments covering all or part of counselor salaries and non-salary expenses and potentially providing office supplies and equipment. Embedded services can improve service efficiencies by providing low-intensity services at embedded sites and higher intensity care at central services, improve capacity for student mental health supports, and reduce wait times for counseling. There is an ability to provide more holistic health and wellbeing support delivered through multidisciplinary approaches or by embedding counseling services within specialty services that serve specific demographics (e.g., international students, Indigenous students, faith-based issues). Finally, embedded services enhance relationships and opportunities for collaboration with staff and faculty and improve mental health literacy and awareness of campus mental health support at partner sites (e.g., residence life wellbeing initiatives).</p> <hd id="AN0178559270-12">Common challenges</hd> <p>While all centers agree that their embedded services were valued by students, staff, and faculty, all identify some ongoing challenges. For students, limited services, hours, and/or less anonymity in small faculties and departments can be challenging. Additionally, some sites require initial registration through central services which can be perceived as an added barrier to help-seeking. A lack of understanding of counselor roles and responsibilities can be a challenge for faculty and departments. Some faculties or departments may desire increased hours of service, may have difficulties meeting space requirements, and may lack funding to adequately support embedded services.</p> <p>Counseling centers can encounter a number of challenges to the successful implementation of embedded counseling services. Finding appropriate available office space can be difficult given the space limitations that often exist on campuses and offices can be less than ideal in terms of location, size, and soundproofing. Consideration of counselor safety in isolated locations and student privacy and confidentiality is necessary. There is often little office reception and administrative support from faculties, and if appointments are not managed by central services, embedded counseling staff have to function both as "receptionist" and counselor. Administrative support at local sites also necessitates appropriate consent procedures and arrangements for handling personal health information. It can be challenging to manage unscheduled student and/or faculty requests for support. Students requesting support or faculty seeking support for students in crisis may "drop by" a counselor's office and expect immediate help and can get frustrated when this is not available upon arrival, particularly if the faculty is paying for the embedded service. Faculty can also sometimes "drop by" requesting a consultation to address their own mental health issues. Staff turnover at all levels (i.e., central services, embedded sites, faculties, and departments) necessitates ongoing relationship management, program monitoring, implementation protocols, and quality improvement practices. Confidence in, and utilization of, embedded services can be negatively impacted when faculty or departmental leadership do not champion and/or promote embedded services to instructors, staff, and students. Leadership changes can also impact support and funding, leaving these programs vulnerable.</p> <p>From a staffing perspective, without meaningful support and connection to central services, embedded counselors can feel isolated and left to create stand-alone operations that may produce gaps in care. However, to some degree, this feeling of isolation may have been assuaged during COVID-19 when many campus counselors were working from their homes and reporting to work at "virtual offices." More research is needed to verify this in a post-COVID context. Some faculties want health and wellness staff to report solely to the faculty; this presents challenges in providing clinical oversight, caseload management for counselors, and providing consistency of care with the counseling center.</p> <p>On the other hand, faculty and staff may not feel that their needs are met if counselors are not connected enough with the faculty or department. Embedded counselors can feel vulnerable to pressure or obliged to honor requests from the faculty that may fall outside of their scope of practice or can feel caught between two "bosses" with conflicting sets of expectations if the reporting structure, roles, and responsibilities are unclear, especially when salaries are paid in whole or part by the faculty. Additionally, embedded counselors require ongoing education and consultation provided by the counseling center. Larger embedded programs may experience challenges with organizing multiple embedded sites and managing a large number of counselors.</p> <hd id="AN0178559270-13">Promising practices</hd> <p>A number of lessons learned, or "promising practices" emerged from our review of embedded counseling programs. These practices are based on the cumulative experiences of the institutions, regardless of the specific approach adopted.</p> <hd id="AN0178559270-14">Program expectations</hd> <p>Establishing clear expectations regarding the nature of the embedded service and the role of the embedded counselor is essential for all parties. A clear message that "a person is not a clinic" can assist in defining the limits of an embedded service and the counselor's role. Communicating clear rationales for procedures that protect the privacy and confidentiality of personal health information, student safety, and occupational health and safety, helps mitigate against requests for services that fall outside the scope of the embedded services (e.g., requests for after-hour services without appropriate back-up). It is essential to provide faculty and staff with information on the nature of services and programs, how students can access services, referral procedures, key contacts, and protocols for responding to students at-risk. Establishing a memorandum of understanding identifying roles and responsibilities and clarifying such things as scope of services, accountability, and reporting lines is recommended (B. A. Schreier et al., [<reflink idref="bib16" id="ref30">16</reflink>]). The intentional design and development of embedded programs for local context and culture create more buy-in from all stakeholders and allow for long-term sustainability.</p> <p>Marketing the service to students to increase their awareness of service options is important. Mixed media approaches (including print and social media) and multiple avenues such as faculty or department-led communications, centralized messaging from the institution or central services, as well as counselor participation at student orientations, events, student leadership trainings, and staff and faculty meetings are worth considering. To manage demand at embedded sites, it is important to enhance students' awareness of the mental health resources that are available on and off-campus. Providing students with an understanding of how mental health resources are organized, including the importance of being able to step care "up" or "down," is important in managing student expectations within the institution.</p> <p>In training an embedded counselor, it is important to address possible implications of having "two families" (i.e., faculty or department and the counseling center), including competing expectations and feeling pressure to "please" both parties. In addition, students may perceive some counselor activities that are directly involving staff or faculty as potential breaches of their confidentiality (B. A. Schreier et al., [<reflink idref="bib16" id="ref31">16</reflink>]). It is important to be mindful of potential misunderstandings when a counselor wears multiple "hats" that influence the way they interact with students and the types of conversations they can have in each setting (e.g., the counselor as a therapist (clinician), a workshop presenter (educator), and attendee at student events (supporter)). Students may perceive counselor activities that directly involve staff or faculty as potential threats to their confidentiality. A needs assessment or gap analysis can assist in defining the scope of services provided on-site, rather than have this be defined solely by stakeholders' perceived needs.</p> <hd id="AN0178559270-15">Relationship management</hd> <p>It is important to build a collaborative partnership with the faculty or department including co-designing the embedded programs to the degree possible, co-defining success metrics, and seeking input in all stages of implementation (e.g., involve faculty partners in recruitment, onboarding), and providing informal "check-in" meetings. The counseling center should provide education, training, and tools for the faculty or department partner in order to facilitate an effective communication strategy for faculty, staff, and students. This could involve meetings with faculty and administrative staff who are likely to refer students, mental health literacy training, informational resources (e.g., brochures, FAQs, referral guidelines), and support from other clinical team members (e.g., crisis contacts, health promotion staff, administrative lead). A community coordinator can help faculties promote self-care, coordinate wellness events, and offer workshops to promote connections. Regular meetings to report on service usage and outcomes provide opportunities for mutual feedback and trouble-shooting to strengthen collaboration and build trust.</p> <hd id="AN0178559270-16">Staff Support</hd> <p>Embedded counselors will inevitably feel some disconnection from central services (B. A. Schreier et al., [<reflink idref="bib16" id="ref32">16</reflink>]). It is important to provide counselors with regular clinical consultation and opportunities for team building. Counseling centers may consider a team lead, professional practice lead, or a manager/director to provide clinical consultation on a regular basis, depending on the embedded counselor's stage of professional development. Alternatively, team-based case consultation can support both clinical and team outcomes. It is helpful to augment this support with other clinical team members who can provide additional support around acute urgent situations. Regular team meetings for all counselors in central and embedded services can enhance a sense of connection. Shared roles might be considered where counselors' time is split between central services and embedded sites. Communicating feedback from faculty, staff, and students on the impact that embedded counselors have can reinforce the value of their unique roles. Feedback from counselors on themes emerging from students' experiences in their programs can facilitate changes and key messaging around academic curriculum and programs.</p> <p>In the absence of on-site administrative support, an embedded counselor is required to function as a self-contained, one-person clinic. It is important to clarify office set-up requirements (e.g., soundproofing, furniture, equipment) and procedures for personal safety (e.g., office location). It is important to provide counselors with tools to support their work, including a policies and procedures manual and orientation to the unique culture and context of the faculty or department to understand the local student experience and program needs. The integration of paperwork with electronic record software shared with central services can support seamless care.</p> <hd id="AN0178559270-17">Program evaluation</hd> <p>It is essential to support program sustainability and budget requests through evaluation and continuous improvement and to report outputs and outcomes to faculty partners. Program logic models that chart the desired relationships between inputs, activities, outputs, and impacts, as well as quality improvement activities such as Plan-Do-Check-Act cycles help inform program development and changes. Among the ten institutions, usage rates are the most common metrics collected, followed by student satisfaction. Based on the institutions' evaluation and reporting needs, four broad categories of metrics are recommended, including: (a) embedded program usage, (b) student characteristics and treatment outcomes, (c) perceived value, and (d) staff experience.</p> <p>For program usage, Directors believed that collecting the following outputs would be helpful: the number of embedded sites, the number of counselors (full-time equivalency) at each embedded site and in total, the number of students eligible for services at each embedded site, referral sources, the type of other student services staff at each site, the number of students who received services, the number of visits provided at each site and visits per student (average, variability, range), the number of canceled and missed appointments, and comparative data of site service usage to central services.</p> <p>Data on student and clinician reports of students' presenting issues also assists in tailoring programming to the local site. Student demographic information may be collected, including, age, gender, faculty, program, year of study, and student status (i.e., local, out-of-province, or international student).</p> <p>To assess program effectiveness, it is important to measure student learning outcomes, student pre- and post-treatment outcomes, as well as student's and academic staff's perceived value of the program through satisfaction surveys. The Counseling Center Assessment of Psychological Symptoms (CCAPS) (Locke et al., [<reflink idref="bib10" id="ref33">10</reflink>]) is the most commonly used measure of clinical outcomes among the centers. The Outcome Questionnaire-45 (OQ-45) (Lambert et al., [<reflink idref="bib9" id="ref34">9</reflink>]), Behavioral Health Measure (BHM) (Kopta & Lowry, [<reflink idref="bib7" id="ref35">7</reflink>]), Outcome Rating Scale (ORS) and Session Rating Scale (SRS) (Miller & Duncan, [<reflink idref="bib12" id="ref36">12</reflink>]), and the Patient Health Questionnaire (PHQ-9) (Kroenke et al., [<reflink idref="bib8" id="ref37">8</reflink>]) are utilized by a few centers.</p> <p>For quality improvement or process variables, it is recommended that centers evaluate stakeholder perceived value of embedded services, by including ratings from students, academic partners, and embedded counselors. With respect to the latter, it is important to evaluate staff perceptions and experiences of the degree of support from the faculty or department at the embedded site, and the degree of "mission creep" experienced.</p> <hd id="AN0178559270-18">Limitations and conclusion</hd> <p>This review is limited to ten Canadian institutions and may not be representative of the full range of embedded counseling programs across Canadian campuses, including general and vocational colleges, technical institutes, or smaller campuses, and therefore, it is unclear if embedded counseling programs are useful in these settings. It is also unclear how the Canadian experience might translate to other countries such as the United States, given fundamental differences such as culture and public health policies. However, our findings into promising practices and challenges would be useful to any institution in any country as they consider introducing embedded counseling into their localized context.</p> <p>While there were more commonalities than differences in the development of embedded counseling programs, some institutions emphasize different aspects. Early adopters of the embedded counseling model tended to create embedded sites that mimicked central services, while other institutions chose to provide more specialized early intervention and/or resource navigation services. More recent emerging trends include the creation of embedded multidisciplinary teams that integrate a range of student support services on-site and community-based embedded sites that serve multiple faculties and students at one site. While most institutions adopted a proactive lens, each university offered early intervention services in different ways. Some universities focused on strengths and skills-based counseling and triage services, while others focused on health education and system navigation. Funding models across campuses also varied, with some supported centrally, by faculties, within their own departmental budgets, or a combination. Despite this variation, reporting lines tended to fall within the scope of the counseling center. Nine of the ten institutions adopted a staffing model where counselors were assigned to specific locations full-time or part-time, while one institution chose to schedule staff off-site in short blocks of time throughout the day.</p> <p>Overall, the ten case studies suggest that students, faculties or departments, and counseling centers receive approximately the same number of benefits. However, counseling centers appear to face disproportionately more challenges in implementing this method of service delivery than the stakeholders who receive it. Our lessons learned offer promising methods to address or mitigate these challenges. Counseling centers are therefore encouraged to weigh their interest in delivering embedded counseling with their capacity to address the challenges identified by the ten Canadian centers included in this review.</p> <hd id="AN0178559270-19">Acknowledgements</hd> <p>With significant gratitude, the authors would like to acknowledge the leadership of Dr. Mohsan Beg (University of Windsor), Debbie Bruckner (University of Calgary), Dr. Peter Cornish (Memorial University), Jan Crook (University of Calgary), Dr. Rina Gupta (Queen's University), Allan MacDonald (Ryerson University), Howard Magonet (Concordia University), Dr. Walter Mittelstaedt (University of Waterloo), Maura O'Keefe (Ryerson University), Dr. David Pilon (Dalhousie University), and Dr. Tom Ruttan (University of Waterloo). Without your time and spirit for innovation, this paper would not have been possible.</p> <p>Thank you for leading embedded counselling programs in Canadian universities. Your work helps inform the development of promising practices in Canadian post-secondary institutions.</p> <hd id="AN0178559270-20">Disclosure statement</hd> <p>No potential conflict of interest was reported by the author(s).</p> <hd id="AN0178559270-21">Appendix A: Interview Question and Survey</hd> <p>Interview Questions</p> <p></p> <ulist> <item> When did your embedded counseling service start?</item> <p></p> <item> What is funding model of the embedded service? Has it changed over time and why?</item> <p></p> <item> What are the reporting lines of the embedded staff (e.g., centrally to clinic and/or faculty)? Are Memorandum of Understandings in place?</item> <p></p> <item> How many hours per week are provided at embedded sites (can be a range)?</item> <p></p> <item> Are embedded staff "live in"?</item> <p></p> <item> What is the range of full-time equivalents for embedded staff?</item> <p></p> <item> How many sites does an embedded staff serve? Are counselors' sites fixed or can they be moved to other sites?</item> <p></p> <item> Are embedded staff full-year or term/sessional?</item> <p></p> <item> How many faculty/departments are currently being served? Please list each.</item> <p></p> <item> Are students enrolled with the embedded site the only students who can access that site? Or can any student access any site?</item> <p></p> <item> What are the business hours of embedded counseling services (days, hours)?</item> <p></p> <item> How were academic sites selected for embedded counseling services?</item> <p></p> <item> Which academic sites work well with an embedded model? Which sites did not work well with this model? Can you provide any insights as to why it went well or did not go well?</item> <p></p> <item> Are faculty/staff perceptions of their students consistent with the experience of the embedded staff? Are there different needs and a unique/local culture at different faculties?</item> <p></p> <item> What "services" do the embedded staff provide to the academic staff/faculty?</item> <p></p> <item> Services Checklist: Directors indicated if the specific service was provided as part of the embedded service (i.e., yes/no) and they were welcome to provide additional details.</item> </ulist> <p>Services Checklist:</p> <p></p> <p> <ephtml> <table><thead><tr><td>Services</td><td>Yes</td><td>No</td><td>Comments</td></tr></thead><tbody><tr><td>Triage</td></tr><tr><td>Individual Counselling (indicate brief, short and/or long-term)</td></tr><tr><td>Single-Session Counselling</td></tr><tr><td>Drop-In</td></tr><tr><td>After hours (specify evenings and/or weekends)</td></tr><tr><td>Health Ed/prevention</td></tr><tr><td>Wellness events</td></tr><tr><td>Psychoed Workshops</td></tr><tr><td>Group Therapy</td></tr><tr><td>Crisis management</td></tr><tr><td>ER/on-call services</td></tr><tr><td>Faculty/Staff Consultation (elaborate below)</td></tr><tr><td>Live-in?</td></tr><tr><td>How are appointments booked?</td></tr><tr><td>Add in Other Services as needed:</td></tr><tr><td>Student orientations</td></tr><tr><td>Meet & greets with staff</td></tr><tr><td>Invited to faculty/staff meetings occasionally</td></tr><tr><td>Biannual and annual meetings with staff to review embedded services provided</td></tr><tr><td>Meetings with student groups as invited</td></tr></tbody></table> </ephtml> </p> <ref id="AN0178559270-22"> <title> References </title> <blist> <bibl id="bib1" idref="ref3" type="bt">1</bibl> <bibtext> Adams, D. F. (2017). The embedded counseling model: An application to dental students. Journal of Dental Education, 81 (1), 29 – 35. https://doi.org/10.1002/j.0022-0337.2017.81.1.tb06244.x</bibtext> </blist> <blist> <bibl id="bib2" idref="ref22" type="bt">2</bibl> <bibtext> Beks, T. A., Cairns, S. L., Smygwaty, S. L., Miranda Osorio, O. A. L., & Hill, S. J. (2018). Counselor-in-residence: Evaluation of a residence-based initiative to promote student mental health. The Canadian Journal of Higher Education, 48 (2), 55 – 73. https://doi.org/10.47678/cjhe.v48i2.187978</bibtext> </blist> <blist> <bibl id="bib3" idref="ref28" type="bt">3</bibl> <bibtext> Boone, M. S., Edwards, G. R., Haltom, M., Hill, J. S., Liang, Y., Mier, S. R., Shropshire, S. Y., Belizaire, L. S., Conklin Kamp, L., Murthi, M., Wong, W., & Yau, T. Y. (2011). Let's talk: Getting out of the counseling center to serve hard-to-reach students. Journal of Multicultural Counseling and Development, 39 (4), 194 – 206. https://doi.org/10.1002/j.2161-1912.2011.tb00634.x</bibtext> </blist> <blist> <bibl id="bib4" idref="ref23" type="bt">4</bibl> <bibtext> Conway, C., Zhao, H., & Montgomery, S. (2011). The NSSE National data project report. Higher Education Quality Council of Ontario.</bibtext> </blist> <blist> <bibl id="bib5" idref="ref4" type="bt">5</bibl> <bibtext> Davis, H., Jr., Kocet, M. M., & Zozone, M. S. (2001). Counselor-in-residence: A counseling service model for residential college students. Journal of College Counseling, 4 (2), 190 – 192. https://doi.org/10.1002/j.2161-1882.2001.tb00200.x</bibtext> </blist> <blist> <bibl id="bib6" idref="ref2" type="bt">6</bibl> <bibtext> Gorman, K. S., Bruns, C., Chin, C., Fitzpatrick, N. Y., Koenig, L., LeViness, P., & Sokolowski, K. (2020). The association for university and college counseling center directors annual survey. Association for University and College Counseling.</bibtext> </blist> <blist> <bibl id="bib7" idref="ref35" type="bt">7</bibl> <bibtext> Kopta, S. M., & Lowry, J. L. (2010). Psychometric evaluation of the behavioral health questionnaire-20: A brief instrument for assessing global mental health and the three phases of psychotherapy outcome. Psychotherapy Research, 12 (4), 416 – 426. https://doi.org/10.1093/ptr/12.4.413</bibtext> </blist> <blist> <bibl id="bib8" idref="ref37" type="bt">8</bibl> <bibtext> Kroenke, K., Spitzer, R. L., & William, J. B. (2001). The PHQ-9: Validity of a brief depression severity measure. Journal of Internal General Medicine, 16 (9), 606 – 613. https://doi.org/10.1046/j.1525-1497.2001.016009606.x</bibtext> </blist> <blist> <bibl id="bib9" idref="ref34" type="bt">9</bibl> <bibtext> Lambert, M. J., Hansen, N. B., Umphress, V., Lunnen, K., Okiishi, J., Burlingame, G., & Reisinger, C. W. (1996). Administration and scoring manual for the Outcome Questionnaire (OQ 45.2). American Professional Credentialing Services.</bibtext> </blist> <blist> <bibtext> Locke, B. D., Buzolitz, J. S., Lei, P. W., Boswell, J. F., McAleavey, A. A., Sevig, T. D., Dowis, J. D., & Hayes, J. A. (2011). Development of the counseling center assessment of psychological symptoms-62 (CCAPS-62). Journal of Counseling Psychology, 58 (1), 97 – 109. https://doi.org/10.1037/a0021282</bibtext> </blist> <blist> <bibtext> Mackay, L., Tauer Martin, C., & Beg, M. (2015). Meeting the needs of the whole student: A dynamic delivery model for counseling services [Conference session]. 2015 Annual Canadian Association of Colleges and University Student Services Conference, Vancouver, BC, Canada.</bibtext> </blist> <blist> <bibtext> Miller, S. D., & Duncan, B. L. (2004). The outcome and session rating scales: Administration and scoring manual. Institute for the Study of Therapeutic Change.</bibtext> </blist> <blist> <bibtext> Orchowski, L. M., Castelino, P., Ng, H. M., Cosio, D., & Heaton, J. A. (2011). The design and implementation of a counselor-in-residence program. Journal of College Student Psychotherapy, 25 (3), 214 – 258. https://doi.org/10.1080/87568225.2011.556968</bibtext> </blist> <blist> <bibtext> Rawls, D. T., Johnson, D., & Bartels, E. (2004). The counselor-in-residence program: Reconfiguring support services for a new millennium. Journal of College Counseling, 7 (2), 162 – 169. https://doi.org/10.1002/j.2161-1882.2004.tb00247.x</bibtext> </blist> <blist> <bibtext> Reetz, D. R., Krylowicz, B., Bershad, C., Lawrence, J. M., & Mistler, B. (2015). The association for university and college counseling center directors annual survey. Association for University and College Counseling Center Directors.</bibtext> </blist> <blist> <bibtext> Schreier, B. A., Anderson, C. L., Galligan, P. K., Greenbaum, B., Corkery, J., Schnelle, T., Gates, C., Hong, J. E., & Kivlighan, D. M., III. (2021). Embedded therapists: Who do they serve? How are they funded? And where are they housed? A foundational survey of emerging models. Journal of College Student Psychotherapy, 1 – 11. https://doi.org/10.1080/87568225.2021.1913686</bibtext> </blist> <blist> <bibtext> Schreier, B., Sevig, T., Dunkle, J., & Sharma, M. (2016, October 23). Extending the footprint: "Embedded" counseling center staffing models [Conference session]. 2016 Annual Association for University and College Counseling Center Directors Conference, Columbus, OH, United States.</bibtext> </blist> <blist> <bibtext> Wu, X., Kou, Z., Oldfield, P., Heath, T., & Borsi, K. (2021). Informal learning spaces in higher education: Student preferences and activities. Buildings, 11 (6), 252. https://doi.org/10.3390/buildings11060252</bibtext> </blist> </ref> <aug> <p>By Sandra Yuen; Gaya Arasaratnam and Cheryl Washburn</p> <p>Reported by Author; Author; Author</p> </aug> <nolink nlid="nl1" bibid="bib15" firstref="ref1"></nolink> <nolink nlid="nl2" bibid="bib13" firstref="ref5"></nolink> <nolink nlid="nl3" bibid="bib14" firstref="ref6"></nolink> <nolink nlid="nl4" bibid="bib17" firstref="ref7"></nolink> <nolink nlid="nl5" bibid="bib11" firstref="ref14"></nolink> <nolink nlid="nl6" bibid="bib16" firstref="ref18"></nolink> <nolink nlid="nl7" bibid="bib18" firstref="ref24"></nolink> <nolink nlid="nl8" bibid="bib10" firstref="ref33"></nolink> <nolink nlid="nl9" bibid="bib12" firstref="ref36"></nolink>
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  Data: This paper examines embedded counseling programs across ten Post-Secondary Canadian counseling centers. We highlight common drivers for developing embedded counseling programs, commonalities and differences across programs, successes and challenges in implementation, and recommend a common set of metrics. Our overview demonstrates variability in program structure that reflects the host faculty or department and the culture, expectations, and realities they each face. Based on lessons learned, we highlight emerging and promising practices for university counseling centers.
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