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The Counseling Center Field's Relationship with the Mental Health Marketplace

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Title: The Counseling Center Field's Relationship with the Mental Health Marketplace
Language: English
Authors: Benjamin D. Locke, Marcus Hotaling, David Walden
Source: Journal of College Student Mental Health. 2024 38(4):924-943.
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: 20
Publication Date: 2024
Document Type: Journal Articles
Reports - Descriptive
Education Level: Higher Education
Postsecondary Education
Descriptors: College Students, Mental Health, Access to Health Care, Guidance Centers, Agency Cooperation, College Role, School Community Relationship, Barriers, Outsourcing, Legal Responsibility, Trust (Psychology), Cooperative Planning, Health Services, Counseling
DOI: 10.1080/28367138.2024.2400591
ISSN: 8756-8225
1540-4730
Abstract: One of the most significant changes to college mental health is the growing use of telehealth vendors to provide, extend, or augment mental health services provided by college and university counseling centers. In a time of sharply increased demand for services, new investments in the mental health marketplace, and the perception that mental health is a "crisis," the relationships between counseling centers and mental health vendors are increasingly important. This paper provides an overview of these new relationships, briefly reviews relevant history and context, and explores the relationship dynamics shaping this space. In addition, this paper reviews common fears and worries faced by counseling centers when considering vendors, addresses some of the confusion surround vendor/service types, and offers a set of suggestions for the inevitable future relationship in the development of guiding principle and standards.
Abstractor: As Provided
Entry Date: 2024
Accession Number: EJ1443534
Database: ERIC
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  Value: <anid>AN0180231311;[nm80]01oct.24;2024Oct15.04:47;v2.2.500</anid> <title id="AN0180231311-1">The Counseling Center Field's Relationship with the Mental Health Marketplace </title> <p>One of the most significant changes to college mental health is the growing use of telehealth vendors to provide, extend, or augment mental health services provided by college and university counseling centers. In a time of sharply increased demand for services, new investments in the mental health marketplace, and the perception that mental health is a "crisis," the relationships between counseling centers and mental health vendors are increasingly important. This paper provides an overview of these new relationships, briefly reviews relevant history and context, and explores the relationship dynamics shaping this space. In addition, this paper reviews common fears and worries faced by counseling centers when considering vendors, addresses some of the confusion surround vendor/service types, and offers a set of suggestions for the inevitable future relationship in the development of guiding principle and standards.</p> <p>Keywords: Collegiate mental health; counseling centers; institutional decision making; mental health marketplace; mental health strategy; technology</p> <hd id="AN0180231311-2">INTRODUCTION</hd> <p>Over the last decade, one of the most significant changes in the field of college mental health is the growing use of vendors to provide, extend, or enhance mental health services. Our field is one of relationships – between students and their peers, clients and therapists, clinicians and supervisors, directors and upper administration; the role of vendors has introduced a new relationship into the mix. Like any new relationship, this one is ripe with hope and fraught with worry. If we imagine this relationship like a dating relationship (bear with us), some lead to marriage on the first date, some are arranged, and some end before the appetizers arrive. Parallels to the stages and phases of relationships might also apply, such as getting to know each other, exploring values and goals in search of alignment, uncovering differing motivations, as well as sharing unrealistic hopes and concerns.</p> <p>Relationships work best when the parties involved understand each other. The best relationships usually involve individuals who understand their own histories; can share their needs, values, and goals openly; and have a realistic sense of what is and what is not possible in a partnership. These kinds of relationships are marked by open communication, trust, and mutually beneficial goals. Relationships that are not successful tend to be marked by mistrust, lack of openness, misunderstandings, and/or differences in needs, motivations, and goals. The relationships between counseling centers (and more broadly, educational institutions) and vendors in the mental health space share a similar set of dynamics.</p> <p>This paper seeks to provide some useful framing for understanding this new set of relationships in our field by offering an overview of the relevant histories of the parties involved, observing the dynamics that lay beneath, and sharing proposals for areas of mutual exploration. Whether a fast-moving collaboration, a relationship prompted by upper administration, or a partnership that ends quickly to make room for a new resource, relationships with vendors are here to stay; our collective responsibility is to build the healthiest relationships we can on behalf of those for whom we are charged to care.</p> <p>The relationships between mental health vendors and higher education are deeply rooted in the dynamics of increasing demand for mental health services and how that growing demand is conceptualized and responded to by institutions, counseling centers, and the mental health marketplace. Understanding this shared history is critical for successfully navigating the relationships between counseling centers and vendors.</p> <hd id="AN0180231311-3">THE EVER-GROWING DEMAND FOR MENTAL HEALTH SERVICES</hd> <p>Perhaps the best place to start is with the simple fact that "mental health" seems to be on everyone's mind. Billions of dollars have been spent in the last few decades to reduce stigma (Stuart, [<reflink idref="bib24" id="ref1">24</reflink>]), increase help-seeking behavior, and train communities to identify and refer those at risk (DeAngelis, [<reflink idref="bib10" id="ref2">10</reflink>]). These efforts have been pursued by public and private entities, alongside a range of other efforts, such as the fight for mental health parity, prevention, and the integration of mental health with primary care. Mental health care has become more widely utilized, more openly discussed, more widely promoted, and even demanded – not just by providers – but by students, parents, faculty, staff, celebrities, politicians, and social media influencers.</p> <p>As a consequence of so much successful attention and cultural change over the last two decades, we are now facing a level of demand for mental health services that dramatically exceeds available clinical capacity. The Kaiser Family Foundation found that in 2022, 47% of the U.S. population lived in a "mental health workforce shortage area" that would require hundreds of new practitioners to change (Phillips, [<reflink idref="bib22" id="ref3">22</reflink>]). The dramatic growth in demand/lack of capacity has also been widely observed in colleges and universities (e.g., Center for Collegiate Mental Health, [<reflink idref="bib4" id="ref4">4</reflink>]).</p> <p>Despite the rapid increase in demand for services, funding for mental health services in higher education was comparatively slow to respond. Indeed, funding remained relatively flat or slow-growing (e.g., Rando & Barr, [<reflink idref="bib23" id="ref5">23</reflink>]) until the late 2010s, when most centers were significantly underfunded, requiring massive infusions of new financial resources to even begin catching up. Over the last decade, significant infusions have occurred (LeViness et al., [<reflink idref="bib20" id="ref6">20</reflink>]), along with a broad range of financial ripples and implementation arrangements, including: new buildings, embedding staff across campus, student fees, charging for services, housing staff off-campus, providing on-campus space for private-practitioners, integrated mental health/health services, outsourcing health/mental-health, insourcing after outsourcing, and even the construction of fully integrated wellness centers with healthcare, mental health, and recreation. All these efforts were well intended, but none stopped the growth in demand; indeed, the growth in demand seems to be pervasive and without a clear end.</p> <p>From 2007 to 2019, the percent of enrolled students using counseling centers per year (annual utilization) grew from 7% to 12% according to counseling center directors (LeViness et al., [<reflink idref="bib20" id="ref7">20</reflink>]). However, some institutions resourced counseling operations to serve more than 40% of the student body per year. Pushing the needle even higher, the Healthy Minds Survey reported in their Fall 2020 Data Report that more than 60% of students "screened positive" for a mental health concern (Eisenberg et al., [<reflink idref="bib11" id="ref8">11</reflink>]). In other words, during the last two decades, we have witnessed the need for/utilization of mental health services balloon from a small proportion of the student population to a majority of students on their campuses. Much of this increase was pre-COVID, which simultaneously stressed our global population and completely reshaped our use of technology in the delivery of healthcare and related services.</p> <hd id="AN0180231311-4">How Demand is Understood</hd> <p>This explosion of demand/need for services by college students is often referred to as the "mental health crisis," even though it should arguably be viewed as a crisis of capacity to meet the demand we have collectively fostered through reduced stigma and increased help-seeking across society. This "crisis narrative of mental health" is the dominant cultural narrative in use today to describe our demand/supply problems while also imbuing our conversations with pressure for quick actions and quicker solutions. Once realized, the narrative is pervasive and easy to make use of; it can be seen in research, advocacy, media, social media, industry, nonprofits, language used by both students and marketers, and even the efforts of mental health leaders seeking more resources. Like any crisis narrative, the mental health crisis narrative pulls for greater reactivity and less proactive strategy at all levels of institutions, from students to presidents. Making matters worse, each reactive effort that fails due to a lack of planning or follow through generates more frustration and reactivity, further reinforcing the narrative.</p> <p>A critical source of fodder for both the demand/supply imbalance and the crisis narrative is the ever-broadening definition of "mental health," which is in turn driven by things like concept creep (Haslam, [<reflink idref="bib17" id="ref9">17</reflink>]), diagnostic expansion (i.e., overdiagnosis of various mental health conditions) (Hofmann, [<reflink idref="bib18" id="ref10">18</reflink>]), linguistic appropriation of psychological jargon (i.e., popular use of terms like depersonalization, schizophrenic, etc.), and even pivoting institutional attention toward generalized wellness/wellbeing. Simply put, "mental health" is now being used to describe the entire continuum of life experiences ranging from wellness to normative developmental distress, to severe mental illness. However, because the resources viewed as "legitimate" for supporting mental health concerns have not been equivalently broadened, our communities remain stuck in the view that professional treatment is the only truly acceptable support option for "mental health" concerns, a recipe which effectively further amplifies demand. Collectively, these dynamics have shaped our environment and fostered a clear and present need for effective solutions that are both novel and far-reaching. Of course, this dynamic is not new for counseling centers and student affairs professionals, who have been evolving for decades.</p> <hd id="AN0180231311-5">Higher Education's Response</hd> <p>To illustrate this dynamic, consider that while mental health has become the number one concern of college presidents over the past few years (American Council on Education, [<reflink idref="bib2" id="ref11">2</reflink>]) and research has increasingly highlighted the impact of mental health on general and specific academic outcomes (American College Health Association, [<reflink idref="bib1" id="ref12">1</reflink>]; E. L. Gorman et al., [<reflink idref="bib12" id="ref13">12</reflink>]), student mental health has always been the number one concern of counseling centers and they have been actively evolving for decades to meet that priority. While centers have increasingly added staff over the last decade according to surveys of counseling center directors (K. S. Gorman et al., [<reflink idref="bib14" id="ref14">14</reflink>]), as awareness has grown, counseling centers have been engaged in a never-ending balancing act involving clinical service details, demand, and resources; a challenge that can result in approaches that notably depart from what is known about how treatment works (Center for Collegiate Mental Health, [<reflink idref="bib5" id="ref15">5</reflink>]; K. Gorman et al., [<reflink idref="bib13" id="ref16">13</reflink>]). Counseling centers bring never-ending professional creativity to this challenge.</p> <p>For example, over the last twenty years, counseling centers have explored the full range of service models such as shifting to 30-minute appointments or every other week sessions, adding session limits, adding triage or eliminating intake appointments, implementing urgent care models or stepped-care systems, and mental health services that are fully integrated in a primary care model. Many of the innovations seek to allow more students to "be seen" or to be seen "more quickly," which can inadvertently lead to diluted services and an approach that is sometimes referred to as the "absorption model" (Center for Collegiate Mental Health, [<reflink idref="bib6" id="ref17">6</reflink>]). Some of these efforts have been identified as leading to increased paperwork, less clinical efficiency, and even increased staff burnout (Holly, [<reflink idref="bib19" id="ref18">19</reflink>]; Walden et al., [<reflink idref="bib25" id="ref19">25</reflink>]). In addition, research has consistently found that better treatment outcomes are broadly achieved via lower-caseloads (Center for Collegiate Mental Health, [<reflink idref="bib7" id="ref20">7</reflink>]; Hansen et al., [<reflink idref="bib16" id="ref21">16</reflink>]), which raises concerns about innovations that achieve the opposite.</p> <p>Despite these innovations and efforts over many years, neither counseling centers nor their parent institutions have been able (alone or in partnership) to fix the demand/supply problem. As a result, counseling centers have landed in a difficult place: our "bag of tricks" seems exhausted and demand has continued to increase far beyond the reach of our local adjustments. In addition, we have to acknowledge that the stresses impacting our campus systems are also having a direct and profoundly negative impact on our staff and centers, especially as evidenced by staff turnover (K. Gorman et al., [<reflink idref="bib13" id="ref22">13</reflink>]). In 2021, more than 60% of centers reported turnover (low salaries and working conditions as primary reasons) with 70% of those centers also reporting difficulty filling vacancies. Perhaps most striking, in the 2021–2022 academic year, more than 76% of directors reported five or fewer years of experience as a director (K. S. Gorman et al., [<reflink idref="bib14" id="ref23">14</reflink>]). We have had to admit our limitations, acknowledge that continued "innovation" may just further dilute of the services we offer, and begin to chart a new path forward.</p> <p>Given higher education's inability to meet demand, despite all these efforts, and the growing volume and impact of the crisis narrative of student mental health, it was inevitable that the fields of higher education and mental health would both attract outside attention and seek new solutions that would lead us to enter new relationships – this time with the mental health marketplace. Between the mid-90s and early 2000s, this relationship with the marketplace was nascent at best. In the broader physical/mental health care world there was a vibrant and rapidly developing marketplace focused on serving the needs of very large and lucrative markets (e.g., health insurers, employee assistance programs, employers, state & federal programs). The broadening of this marketplace also included the full range of practitioners from solo private-practices to massive multi-state systems of care.</p> <hd id="AN0180231311-6">EVOLVING MENTAL HEALTH MARKETPLACE</hd> <p>Despite its quickly growing presence outside of higher education, the mental health marketplace largely ignored, and was ignored by, the counseling center field because needs and solutions did not initially overlap. One of the most visible indicators of the growing overlap between the needs of higher-education and mental health marketplace offerings can be found in the evolving presence of corporate sponsors and vendors at professional conferences in the collegiate health space. An established presence in physical health-focused higher education conferences, such as the American College Health Association (ACHA), attendees can wander convention centers filled with companies giving away "swag" in exchange for information and interactions. By contrast, the vendors attending counseling center conferences several decades ago were few and offered operational services such as informational pamphlets, employment opportunities, and highly specialized treatment referral options such as high-end hospitalizations or intensive outpatient programs. Beginning in the late 1990s, the number of vendors began to grow and expand to include phone-crisis services, electronic health record systems (EHR), assessment systems, video recording, and a slow trickle of tentative digital mental health solutions. This trend began to accelerate in the mid-2010s and has continuously expanded since. Today, both physical- and mental health-focused conferences are overflowing with vendors offering the full range of mental health services from point solutions to ecosystems of care.</p> <p>In general, the unprecedented level of commercial/industrial attention focused on college student mental health can be seen as a natural byproduct of overlapping needs and solutions. More specifically, however, it seems that the never-ending growth in demand, paired with a crisis narrative that prioritizes large-scale interventions in the context of a mature and investor-driven mental-health marketplace, created near-perfect conditions for a paradigm shift and a new relationship.</p> <hd id="AN0180231311-7">The Relationship: Higher Education, Meet the Mental Health Marketplace</hd> <p>Interest in the higher-education mental health marketplace began to accelerate in serious and impactful ways after 2014 with more and more investors, entrepreneurs, and established vendors recognizing the potential new market. Between 2014 and 2020, many new companies were founded, invested in, or rebranded to focus on the college student mental health market. This focus, in turn, meant that administrators (buyers) increasingly became the target of research, advertising, and marketing efforts.</p> <p>This rapidly growing interest comprised dozens of vendors providing services ranging from off-campus referral services, to EHR vendors, to tele-counseling/psychiatry providers. While interest in these services grew quickly, the pace of early adoption was slowed by the ponderous, bureaucratic, and seasonal pace of procurement in higher education, along with broad resistance toward tele-services. This resistance incorporated many ingredients, including restrictive state and federal laws, privacy and confidentiality concerns, a lack of trust in technology or vendors in general, and student/provider preferences for in-person services. Despite these concerns, large-scale resistance was overcome almost overnight in 2020 after the onset of COVID-19, which heralded a herculean transition from in-person services to virtual services globally. Indeed, the overnight transition to telehealth saved counseling operations during COVID-19 and turbo-charged both the role of tele-services and the marketplace for vendor solutions for the foreseeable future. The context of COVID-19 also resulted in even more new ventures in the mental health marketplace. Indeed, the frenetic financial energy around digital health solutions cannot be understated: in 2021, an estimated $57.2 billion was invested in digital health solutions and an estimated $5.5 billion of that was invested in digital mental health solutions (CB Insights, [<reflink idref="bib3" id="ref24">3</reflink>]). Every one of these new companies began to seek customers.</p> <hd id="AN0180231311-8">The Relationship: It's Complicated</hd> <p>As institutions sought new solutions to a seemingly unsolvable problem and new/growing companies sought new customers, relationships blossomed. As noted above, these relationships were impacted and influenced by historical experiences that drive reactions; explorations of likes and dislikes, priorities, values, and goals; and attempts to establish trust.</p> <p>The historical dynamics surrounding these relationships are as varied as the people, institutions, and vendors participating. For some, history around prior business relationships (or ideas about business relationships in general) and the role of money fuel discomfort and suspicion. For others, previously developed skills around negotiation, contracts, and collaboration lead to eager and successful partnerships. In every one of these relationships, however, we see an exploration of how needs, services, and goals align. There are inevitable tensions at the intersection of profit and service, and tensions between institutions' needs for customization and vendors' needs for standardization.</p> <p>Also complicating these relationships are the people, systems, and institutional structures involved. Administrators may be seeking to check a box or achieve very specific results, corporate executives might be seeking a foothold in a competitive/evolving market, counseling center directors are invariably looking for relief from the pressures of demand, and clinicians are desperately seeking trustworthy and collaborative relationships to help support students in need.</p> <p>One of the factors that has significantly complicated counseling center relationships with vendors is the sudden and rapid expansion of "chefs in the kitchen" - i.e., stakeholders in higher education who make and fund decisions about the purchasing and deployment of services related to mental health. While there have always been concerns about this dynamic (e.g., concerns about outsourcing and managed care companies in the 1990s), 20–30 years ago it would have been unusual for mental-health related contracts/purchases, including campus-wide services, to have been made by a stakeholder other than the counseling center director. Today, mental health procurement decisions are being made by positions across the leadership spectrum from counseling center director to mid-levels (Associate Vice President, Vice President) and even Presidents. As a rule, the more elevated the position/budget within the institution, the greater authority for final purchasing decisions. Consequently, vendors of mental health services often focus their marketing efforts on financial decision makers rather than counseling center directors. This focus, in turn, can lead to sudden, sweeping, and even destabilizing procurement decisions that exclude key mental health leaders ultimately responsible for implementation. Ultimately, this dynamic only exacerbates tensions within institutions and fosters to distrust of vendors and services.</p> <p>Success in these relationships, as with all relationships, is impacted by both structural and relational elements. There are structural matches and mismatches around goals that can impact success, such as the specific goals of an institution and the services offered by a specific vendor, but equally as important are the relational dynamics that are part of any new collaboration. The degree to which both parties engage in effective/clear communication, are open to collaborating, seek to understand each other, and strive to work toward shared goals, all determine whether the partnership will be successful.</p> <p>In a field defined by relationships, it is also worth noting that the expansion of the mental health marketplace, paired with a shortage of experienced providers, means that mental health professionals are now moving between higher education and vendors, working in both spaces. One year someone can attend a conference as a member and the very next as a vendor. This new reality has challenged relationships and assumptions and has even led to changes in the bylaws of associations. The fact that mental health professionals can now seamlessly work in both settings will surely continue and require ongoing adjustment.</p> <hd id="AN0180231311-9">The Relationship: Fears and Worries</hd> <p>A primary block to the success of any relationship is fear. The fears impacting this space are many and are worth a brief review. The following outline is intended to articulate some of the worries the field is navigating with the hope of encouraging intentionality and reducing reactivity.</p> <hd id="AN0180231311-10">Outsourcing</hd> <p>One of the fundamental fears felt within the landscape of increased vendor presence in higher education is the fear of outsourcing, and for good reason given past history. Much like fears in the 1990s related to managed care organizations, who promised to easy fixes and reduced costs, today's counseling center directors continue to worry that vendors could intentionally or unintentionally convince institutional leadership that on-campus counseling centers cannot do what is needed for the institution. As colleges face tightening budgets and an upcoming enrollment cliff, the shiny, but vague, promise of providing support for every enrolled student may appear enticing to a fiscal manager looking to quickly solve a complex problem with a single check. Center directors worry that these motivations, in the absence of understanding the complex realities of mental health services delivery and student needs, will lead to bad outcomes for students and college/university counseling centers.</p> <p>This worry is triggered in part because some vendors market themselves as a way to solve the mental health crisis and meet demand with a single contract. While an enticing promise, the reality is that every institution is different in its mental health needs, resources, preferences for services, and goals. In addition, each student seeking mental health services will vary in what they need, and those needs may or may not align with institutional resources. For example, some centers/institutions refer cases requiring long-term care out to the community. Telehealth vendors cannot meet this need, which might best be met through community partnerships and local capacity to receive complex/long-term referrals. Additionally, mental health services delivered via phone/video are simply not appropriate for all needs, and many vendors provide extremely limited levels of care (e.g., 30 minutes every other week). Indeed, one study found that more than 60% of students treated in counseling centers could meet exclusion criteria for tele-services depending on risk-tolerance (Center for Collegiate Mental Health, [<reflink idref="bib8" id="ref25">8</reflink>]).</p> <p>There are many positive aspects to treatment delivered via tele-means (e.g., access, a potentially more diverse selection of clinicians) and research has found that outcomes are similar between in-person therapy and telehealth (Center for Collegiate Mental Health, [<reflink idref="bib9" id="ref26">9</reflink>]). On the other hand, research has also found that many students hold mental models of treatment that lead them to prefer in-person contact and that many students using telehealth struggle with the lack of connection to a provider, lack of a space for privacy, and lack of school-specific knowledge (Hadler et al., [<reflink idref="bib15" id="ref27">15</reflink>]).</p> <hd id="AN0180231311-11">The Profit Motive</hd> <p>Another common fear is the for-profit nature of the mental health marketplace and the investors that participate. Healthcare, including behavioral health, has traditionally been offered by both not-for-profit and for-profit businesses (including private practices). While it is common to expect an individual licensed practitioner to treat their clients ethically at a small scale, the influence of investor-driven dynamics on a company's policies and service models holds the potential for substantial conflict of interest. Counseling center staff worry that a company driven by quarterly-profit margins may not prioritize treatment quality, collaboration, or outcomes – and therefore create risk for students, counseling centers, and institutions. This concern is closely tied to outsourcing concerns, discussed above, and become especially salient when marketing materials promise services that just seem too good to be true (i.e., support every student in need) without providing detail about the supports (e.g., capacity, frequency, length, limit of counseling sessions, etc.). On the other hand, it's important to recognize that counseling centers, however well intended, operate within massive financial entities (colleges and universities) that are absolutely competing for market share and often making promises they cannot always meet. When considered through a relationship perspective, it's helpful to remember that there will always be risk in a new relationship, but such risk can be minimized through intentionality, critical thinking, and ongoing evaluation. The truth remains that sustainable business models, along with an alignment of values and goals, are needed for both vendors <emph>and</emph> counseling centers to make these relationships viable in the long term.</p> <hd id="AN0180231311-12">Long-term Stability</hd> <p>An additional fear of using a vendor is instability/change in a relatively young, rapidly emerging, and investor-driven marketplace. As has been seen with past areas of educational-tech offerings, such as online prevention and education modules, the marketplace can be unpredictable. Many institutions have experienced the pain of carefully choosing one vendor that was subsequently acquired by different company, bringing changes to values, services, costs, and operations that complicate existing services. With the newness of the mental health marketplace, it is reasonable to worry about the consistency and stability of vendors, especially when considering the potential costs of reeducation if services are changed, renamed, or removed. At the same time, it's helpful to take a longer-term perspective, be reminded that change is constant, and recognize that we are active participants helping to shape the early stages of a rapidly developing marketplace.</p> <hd id="AN0180231311-13">Liability</hd> <p>Liability is a core operational concern in counseling centers and should absolutely be examined in relationships with vendors. Regardless of who is providing care, both the institution and the counseling center are likely to be named in a resulting lawsuit. What might go wrong when a vendor is responsible for managing mental health concerns involving risk? What role and responsibility do the vendors have in maintaining a safe campus environment? What liability do the vendors have if something bad happens? Do clinical records exist? Who holds them (institution, vendor, contracted provider, etc.)? What happens to records if contracts change? As institutions engage in new marketplace relationships, the questions of liability must be explored up front, and a shared sense of trust, based on a shared understanding of good practice, must eventually become part of the relationship.</p> <hd id="AN0180231311-14">Trust</hd> <p>The role of trust is central to the success of any new relationship between an institution and mental health vendor. Moreover, the role of trust threads through all relationship levels and stakeholder perspectives from the individual student (collaborative care for one student at risk) to the contractual language that prefaces the start of the relationship (level of insurance carried by the vendor). In many ways, however, trust will boil down to whether advance public promises match the services and outcomes delivered.</p> <p>For example, a vendor might claim to be offer counseling services to every enrolled student, for the right price. This offer is attractive and creates a sense of hope and resolution for a complex problem. The problem is, most students do not need mental health treatment, many will not be willing to use a telehealth vendor, and many mental health concerns are a poor match for external tele-services due to risk, chronicity, and other factors. Additionally, vendors are often pulled to seek the largest contracts possible at the lowest competitive cost, which will lead to calculated choices about projected levels of cost/utilization. For some types of service delivery, this dynamic can mean that a vendor will be motivated to keep adoption and other service-costs low to maximize margins/profits. This strategy will erode trust among students, counseling centers and administrators. Additionally, trust questions can come up regarding the vendor's reports of services used. For example, vendors might calculate utilization by reporting the number of students who have registered an account, even if they have never used the service, or report a total number of sessions that includes cancellations and no shows. These metrics are not accurate or useful to the institution and convey an intent to mislead, which can be frustrating and threaten trust. Establishing a trusting relationship requires that both parties communicate openly about strengths, weaknesses, and areas of need/improvement. As with any relationship, once trust is broken it can be hard to heal and may impact future relationships.</p> <hd id="AN0180231311-15">Clinical Decision Making and Collaboration</hd> <p>Counseling center staff, and particularly those in leadership positions, are the resident mental health experts on campus. In many cases, they have spent decades honing specialized skills, knowledge, and institutional relationships that they use to quickly support students in need A key worry for these professionals are the potential consequences arising from external vendors using distributed networks of unaffiliated providers who don't hold detailed knowledge of the institution (e.g., class and professor dynamics, policy issues that create stress on particular campuses, housing issues and solutions, pass/fail deadlines, etc.) and may therefore provide care that is less effective with long-term consequences.</p> <p>Another common concern is the handling of risk(s) to a campus community, and the potential disconnects that are likely to occur between an outside provider unfamiliar with policies, procedures, and resources. This concern is especially salient for the significant individual and community risks that often present in more acute cases. Some vendors address this concern by ensuring that their services are coordinated with and/or integrated into existing institutional services (e.g., sharing notes, collaboration portals, case management coordination, etc.), whereas other vendors simply hand off students to contracted providers who cannot coordinate. Vendors will vary in their approach, service model, level of collaboration, and boundaries of care in the years ahead as knowledge evolves; solutions will need to be flexible enough to meet a range of needs.</p> <p>Because clinical judgment about individual cases can create risk for individual students, the community, and the institution, it is imperative that procurement decisions directly involve the mental health leader(s) responsible for day-to-day care, which at most campuses will either be or include the counseling center director.</p> <hd id="AN0180231311-16">The Relationship: Types of Vendors & Services</hd> <p>Just as there are many different people who can enter into relationships, who bring different skill sets, histories, and future aspirations, there are a wide variety of vendors offering different kinds of services. Understanding the differences between them is important. As discussed above, the field is rapidly evolving and there exists substantial conceptual confusion, which can lead to disappointment and disillusionment for institutions, counseling centers, and students. In general, and at this early stage of the marketplace for higher education, vendors tend to fall into the following types or categories:</p> <p></p> <ulist> <item> Crisis services: Providing 24/7 support pathways, typically using either phone or text. These services can be entirely independent of the institution or tightly coordinated with the counseling center or other mental health services. They can range from local county-based services to national/international operations. These services grew in popularity due to freeing clinical staff from being on-call during nights and weekends;</item> <p></p> <item> Prevention/Educational/Wellbeing: Providing information, resources, training, and skill building to the community to educate and prevent problems or catch them early. Typically self-paced without one-to-one interaction, they can be very broad in nature (e.g., overall wellness and health promotion), focused on a specific demographic (e.g., faculty), or focused on identification and referral of those at risk (e.g., gatekeeper trainings, mental health first aid);</item> <p></p> <item> Therapeutic population supports: These services offer support to entire populations through therapeutic mechanisms other than one-to-one treatment. These services provide support through known mechanisms (e.g., peer support, self-help apps, etc.) that are then scaled through technology. These systems typically are moderated/overseen by clinical staff but vary dramatically in their clinical philosophy, staffing, rigor, and risk management;</item> <p></p> <item> Referral services: Providing case management or referral avenues (i.e., providing access to clinicians through the students' insurance or fee for service);</item> <p></p> <item> Treatment/Training supports: A wide variety of vendors/services exist to support either/both treatment and training processes. These services can include documentation facilitation services, video-recording/analysis, and more; and</item> <p></p> <item> Treatment/Intervention/Capacity expansion/Ecosystem: Providing direct clinical services via telehealth as a supplement to counseling center resources. While much variability exists in services offered, all share the ability to expand the capacity to treat students in need. These services can range from providing a specific number of additional licensed clinicians to providing population-wide triage, self-help, crisis support, and stepped care, including traditional counseling, psychiatry, and even intensive outpatient (IOP) or group services. Vendors that seek to provide the full range of services (from prevention to crisis) may refer to providing an "ecosystem" of care.</item> </ulist> <p>As is evident from this quick overview of services, there are many benefits institutions can gain by partnering with a vendor. One is the sheer variety of offerings available that cannot be provided by a single institution alone. Some institutions do not have the critical mass or resources to develop a homegrown peer support program, for example, or to provide 24/7 crisis coverage. Turning to outside providers can ease that burden. Vendors can also offer capacity expansion without the additional overhead (e.g., supervision time, physical space needs) required for an on-campus clinician, in addition to expanded hours, specific areas of expertise, and demographic diversity that can be hard to find in local resources. The variety of offerings outside vendors can provide is a clear advantage, but it also brings with it some challenges that are exacerbated by the novelty of this space. Primary among these challenges is conceptual confusion around the distinctions between different vendor offerings.</p> <p>Conceptual confusion around the differences between these categories is a primary driver of dissatisfaction with the marketplace. Institutions and buyers are sometimes confused about what a particular resource is <emph>actually</emph> offering, and unintended miscommunications can lead to disappointment on both sides of the relationship. For example, sometimes confusion exists between referral services and capacity expansion. The marketing language for both often refers to students needing "more pathways to care" and "providing additional capacity," but they provide very different things. A referral service offers a well-designed way to find providers, however, students need to use their health insurance to access that care. Capacity expansion can take many forms, but always includes a specified amount of additional one-to-one treatment capacity. Importantly, buyers should pay careful attention to the definitions used for terms such as treatment, counseling, and support.</p> <p>Conceptual confusion is further amplified when the purchaser is not the implementer of the resource, and especially when the purchaser is unfamiliar with mental health services. This case is particularly true when language around referral services leads to the expectation that purchasing access to that platform will ease demand on the Counseling Center. When students do not use the referral platform (often because of cost), the disappointment is very real and leads to continued frustrations and feelings of helplessness. This situation is also true for population model services that use marketing language around providing a certain number of sessions per student per year, but that rely on either low uptake or diluted care (a limited number of brief sessions spread out over time) to make that model financially viable for the vendor and attractive to investors. When demand on the counseling center does not change, all may be frustrated.</p> <p>Differences between purchaser and implementer are just one of the tensions inherent in these new relationships. Some of these tensions are structural. Take, for example, different models of care between an institution's counseling center and a capacity expansion vendor. Like any business that serves multiple customers and larger populations, vendors need to standardize practices and procedures- and that may not always be a match for the customization that institutions like and need to do around their mental health services. This tension extends into documentation practices, and concerns around risk management and liability. There are also related questions about who "owns" clients seen by a vendor when the institution is paying for the services. Related to this, institutions often have concerns about confidentiality and how it will be handled by providers not directly under the supervision of the counseling center as the questions of HIPAA and FERPA privacy guidelines are already challenging for many.</p> <hd id="AN0180231311-17">THE FUTURE</hd> <p>It is important to recognize that the mental health marketplace is not new – it has been evolving for decades nationally and internationally – but colleges and universities have not been widely involved until recently. What is new is that colleges, universities, and counseling centers are now part of this marketplace whether we want it or not. We are part of that marketplace as consumers for certain, but we are also partners in clinical care, implementation, collaborative research, and as employed mental health professionals who will increasingly move between professional settings. Our participation in the marketplace is inextricably linked to money (accessing, spending, raising, etc.) and this will be a new and powerful dynamic for the field in the years ahead.</p> <p>Navigating this new space successfully calls for attending to our ethics, intentionality, thoughtfulness, and alignment of strategies and goals. It also requires realizing the shared problems that institutions and vendors face. No matter how much is promised, or how optimistic the projections, the realities of providing mental health services within higher educational settings will eventually show themselves. No institution or vendor can escape the shared systemic challenges of supply and demand in mental healthcare.</p> <hd id="AN0180231311-18">Strategic Thinking</hd> <p>One of the challenging dynamics in college student mental health is breathtaking diversity and heterogeneity of colleges, universities, counseling centers, and mental health strategies. There is no single problem and there is no single solution; instead, each institution's approach will be rooted in and defined by their unique resources, opportunities, expectations, and limitations. This reality is illustrated by the Clinical Load Index by CCMH (Locke et al., [<reflink idref="bib21" id="ref28">21</reflink>]), which makes clear that there is no single answer but rather a range of resourcing strategies that create a range of service-seeking experiences. Moreover, the very phrase "mental health" has no true beginning or end – and so each institution will need to define those approaches as part of its strategic plan, which must also include the careful selection of vendors to accomplish a specific set of strategic goals.</p> <p>Vendors today range from narrowly defined point-solutions (e.g., a referral platform) to comprehensive solutions that claim to meet all needs of all community members from self-help to long-term care (e.g., an ecosystem). Thus, decision makers need to be decisive, but also long-term strategic planners. Regardless of the actual outcome, participants in this process should be committed to short/mid/long-term strategic planning based on internal alignment regarding the institution's problems and goals. With such alignment achieved, each institution can then examine specific vendors (tools/options) it believes can achieve its goals.</p> <p>At one end of the continuum, a chronically underfunded large community college system might develop a strategy of offering only a crisis line and therapeutic population support to all students, recognizing that they cannot afford to provide treatment or ecosystem services. This recognition would then lead them to narrow their vendor search to meet their predefined criteria. On the other hand, a small, well-funded private institution might develop a strategy that seeks to make the counseling center concept instantly accessible to every student on campus, every hour of every day. This strategy would immediately narrow the search. Similarly, another campus might identify a set of very specific services they do not want to provide internally (e.g., 24/7 crisis line and self-help focused on well-being) and then search only for vendors that meet that need. The key here is to recognize that your carefully crafted strategic plan provides the roadmap for navigating vendor conversations and relationships rather than the reverse.</p> <hd id="AN0180231311-19">Guiding Standards & Principles</hd> <p>The importance of thoughtful strategic planning highlights the need for shared guiding lights. As the mental health marketplace, our relationships with it, and related laws evolve, the need for useful guiding principles and standards will only grow. Guiding principles are those general guidelines grounded in a shared set of values around which practices may vary from situation to situation. Standards are operationalized and concretized boundaries from which practices should not normally deviate. These principles and standards must be developed collaboratively between representatives from higher education and from the vendor marketplace. These relationships are bidirectional, and for them to be successful, more voices are needed.</p> <p>As a starting point, we propose the following areas as ready for exploration and consideration:</p> <p></p> <ulist> <item> <bold> Strategy & Alignment </bold> : The success or failure of any initiative in higher education has much to do with the thought and intention behind it. The importance of thinking strategically is critical along with striving to align the choice of a vendor with the objectives of the institution <emph>and</emph> the specific services provided by the vendor.</item> <p></p> <item> <bold> Specific Goals </bold> : Success is hard to measure without specific objectives. The articulation of specific goals on both sides of institution-vendor relationships will make it possible to gather the data to evaluate whether institutional, strategic, and or service goals are ultimately met.</item> <p></p> <item> <bold> Buying & Implementation </bold> : A common source of misaligned objectives and failure in these relationships occurs when different people or departments are responsible for procurement and implementation. This misalignment happens most often when a President, Vice President, or Associate/Assistant Vice President purchases services that the counseling center director has not evaluated but is required to implement. The field should consider a standard that encourages open communication and collaboration.</item> <p></p> <item> <bold> Data Sharing & Reporting </bold> : A source of confusion can be the lack of clarity that surrounds data reporting. For example, when a vendor reports utilization, it is often not clear what a given number represents. This lack of clarity is an opportunity for both guiding principles around the importance of transparent data sharing and standards for data reporting.</item> <p></p> <item> <bold> Data security and consent </bold> : While entire offices exist to vet external vendors for information security, it is worth mentioning that guidelines and standards here are critical. Many are already defined via HIPAA and FERPA, but new standards and guidelines will be needed. In particular, the handling of student data by a vendor and their potential subcontractors or services (e.g., artificial intelligence) will become increasingly tricky in the years ahead. Decision making will be bolstered by guidelines and standards.</item> <p></p> <item> <bold> Clinical Quality </bold> : Given the integrative nature of many vendor services, the quality of the clinical providers is deeply critical to the partnership's success. The field should consider guiding principles regarding the importance of measuring and reporting clinical quality, standards regarding what measures are used, how often that data is reported, and how providers are selected, trained, and evaluated. Similarly, it would be useful to explore standardized definitions for phrases like "clinically moderated" or "clinically led" when referring to non-treatment services to avoid confusion.</item> <p></p> <item> <bold> Outcomes </bold> : Similar to clinical quality, outcome measures are critically important to ensure that the services provided by a vendor are making a positive impact on the community served. Guiding principles and standards around outcome measures and reporting should be considered, along with an expanded awareness for different types of outcomes/impacts. Partnerships between institutions and vendors will be important here.</item> <p></p> <item> <bold> Institutional Commitment </bold> : Finally, while the guidelines and standards mentioned so far are primarily framed in terms of supporting institutions/counseling centers, it is worth noting that vendors hold related concerns. Whereas a counseling center is responsible for their campus, a vendor may be responsible for hundreds of campuses and related protocols. Institutional instability (budgets, turnover, changes in leadership, internal marketing, lack of engagement) directly impact the ability of vendors to care for students, deliver successful services, manage budgets, and successfully collaborate with the institution on specific cases. As these relationships develop over time, the marketplace will also benefit from guidelines/standards that help to ensure institutional commitment and follow through.</item> </ulist> <p>It is likely that standards and principles like these will organically develop over time, whether they are informal or formalized. The authors of this article urge associations and vendors, however, to bring intentionality and purpose to these discussions so that the result is shaped by forethought rather than a collection of disparate practices over time.</p> <hd id="AN0180231311-20">CONCLUSION</hd> <p>The new relational space between counseling centers and vendors in the mental health marketplace is complicated. Our strategic planning, choices, expectations, institutional dynamics, and engagement with vendors have the potential to dramatically improve our pool of resources and/or deeply complicate our lives at a critical juncture. Decades of near-constant iteration, creativity, and heroic efforts by counseling centers have not solved the demand/supply – indeed, they may have unintentionally contributed to increased feelings of burnout and dissatisfaction among our staff. Institutions have been forced to be more flexible, increase budgets, adapt to new realities, and more squarely face the myriad challenges that counseling centers have been managing.</p> <p>The mental health marketplace holds the promise of making it possible for institutions and leaders to meet student demand for a wide range of mental health services in new and scalable ways that work hand-in-hand with existing counseling center services. Whether this space will be a sustainable addition to an increased pool of resources that is thoughtfully and strategically utilized or whether this space will be fraught with skepticism and mistrust is up to us. If we can embrace this new relationship as one deserving of attention, clear communication, intentionality, and aligned goals, it stands to be a mutually beneficial part of our professional futures. Working toward that future, however, will require vulnerability, openness to change, a sense of purpose, and a focus on the fundamentals of our work – which is to say, a focus on what we already know about the initiation, establishment, and maintenance of healthy long-term relationships.</p> <hd id="AN0180231311-21">DISCLOSURE STATEMENT</hd> <p>No potential conflict of interest was reported by the author(s).</p> <ref id="AN0180231311-22"> <title> REFERENCES </title> <blist> <bibl id="bib1" idref="ref12" type="bt">1</bibl> <bibtext> American College Health Association. (2023). American college health association. 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  Data: The Counseling Center Field's Relationship with the Mental Health Marketplace
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  Data: <searchLink fieldCode="AR" term="%22Benjamin+D%2E+Locke%22">Benjamin D. Locke</searchLink><br /><searchLink fieldCode="AR" term="%22Marcus+Hotaling%22">Marcus Hotaling</searchLink><br /><searchLink fieldCode="AR" term="%22David+Walden%22">David Walden</searchLink>
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  Data: <searchLink fieldCode="SO" term="%22Journal+of+College+Student+Mental+Health%22"><i>Journal of College Student Mental Health</i></searchLink>. 2024 38(4):924-943.
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  Data: 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
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  Data: <searchLink fieldCode="DE" term="%22College+Students%22">College Students</searchLink><br /><searchLink fieldCode="DE" term="%22Mental+Health%22">Mental Health</searchLink><br /><searchLink fieldCode="DE" term="%22Access+to+Health+Care%22">Access to Health Care</searchLink><br /><searchLink fieldCode="DE" term="%22Guidance+Centers%22">Guidance Centers</searchLink><br /><searchLink fieldCode="DE" term="%22Agency+Cooperation%22">Agency Cooperation</searchLink><br /><searchLink fieldCode="DE" term="%22College+Role%22">College Role</searchLink><br /><searchLink fieldCode="DE" term="%22School+Community+Relationship%22">School Community Relationship</searchLink><br /><searchLink fieldCode="DE" term="%22Barriers%22">Barriers</searchLink><br /><searchLink fieldCode="DE" term="%22Outsourcing%22">Outsourcing</searchLink><br /><searchLink fieldCode="DE" term="%22Legal+Responsibility%22">Legal Responsibility</searchLink><br /><searchLink fieldCode="DE" term="%22Trust+%28Psychology%29%22">Trust (Psychology)</searchLink><br /><searchLink fieldCode="DE" term="%22Cooperative+Planning%22">Cooperative Planning</searchLink><br /><searchLink fieldCode="DE" term="%22Health+Services%22">Health Services</searchLink><br /><searchLink fieldCode="DE" term="%22Counseling%22">Counseling</searchLink>
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  Data: 10.1080/28367138.2024.2400591
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  Data: 8756-8225<br />1540-4730
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  Group: Ab
  Data: One of the most significant changes to college mental health is the growing use of telehealth vendors to provide, extend, or augment mental health services provided by college and university counseling centers. In a time of sharply increased demand for services, new investments in the mental health marketplace, and the perception that mental health is a "crisis," the relationships between counseling centers and mental health vendors are increasingly important. This paper provides an overview of these new relationships, briefly reviews relevant history and context, and explores the relationship dynamics shaping this space. In addition, this paper reviews common fears and worries faced by counseling centers when considering vendors, addresses some of the confusion surround vendor/service types, and offers a set of suggestions for the inevitable future relationship in the development of guiding principle and standards.
– Name: AbstractInfo
  Label: Abstractor
  Group: Ab
  Data: As Provided
– Name: DateEntry
  Label: Entry Date
  Group: Date
  Data: 2024
– Name: AN
  Label: Accession Number
  Group: ID
  Data: EJ1443534
PLink https://search.ebscohost.com/login.aspx?direct=true&site=eds-live&db=eric&AN=EJ1443534
RecordInfo BibRecord:
  BibEntity:
    Identifiers:
      – Type: doi
        Value: 10.1080/28367138.2024.2400591
    Languages:
      – Text: English
    PhysicalDescription:
      Pagination:
        PageCount: 20
        StartPage: 924
    Subjects:
      – SubjectFull: College Students
        Type: general
      – SubjectFull: Mental Health
        Type: general
      – SubjectFull: Access to Health Care
        Type: general
      – SubjectFull: Guidance Centers
        Type: general
      – SubjectFull: Agency Cooperation
        Type: general
      – SubjectFull: College Role
        Type: general
      – SubjectFull: School Community Relationship
        Type: general
      – SubjectFull: Barriers
        Type: general
      – SubjectFull: Outsourcing
        Type: general
      – SubjectFull: Legal Responsibility
        Type: general
      – SubjectFull: Trust (Psychology)
        Type: general
      – SubjectFull: Cooperative Planning
        Type: general
      – SubjectFull: Health Services
        Type: general
      – SubjectFull: Counseling
        Type: general
    Titles:
      – TitleFull: The Counseling Center Field's Relationship with the Mental Health Marketplace
        Type: main
  BibRelationships:
    HasContributorRelationships:
      – PersonEntity:
          Name:
            NameFull: Benjamin D. Locke
      – PersonEntity:
          Name:
            NameFull: Marcus Hotaling
      – PersonEntity:
          Name:
            NameFull: David Walden
    IsPartOfRelationships:
      – BibEntity:
          Dates:
            – D: 01
              M: 01
              Type: published
              Y: 2024
          Identifiers:
            – Type: issn-print
              Value: 8756-8225
            – Type: issn-electronic
              Value: 1540-4730
          Numbering:
            – Type: volume
              Value: 38
            – Type: issue
              Value: 4
          Titles:
            – TitleFull: Journal of College Student Mental Health
              Type: main
ResultId 1