Aligning Students and Counseling Centers on Student Mental Health Needs & Treatment Resources

Abstract

Objective:

To recognize gaps between students’ expectations of college counseling centers and centers’ current practices and to identify strategies to improve care from both clinicians and students.

Participants:

As part of an ongoing study on mobile technologies for stress management, we gathered data from counseling center clinicians and students at two large Midwestern universities.

Methods:

Clinicians completed online questionnaires on their current practices and interest in digital mental health tools. Students and clinicians completed co-design workshops. In subsequent individual interviews, students identified barriers to care.

Results:

Both students and clinicians recognized a need for stress management and mental health support outside of counseling sessions.

Conclusions:

Students and clinicians recognize barriers to face-to-face therapy and are eager to collaborate to identify opportunities to address barriers to mental health services. We discuss digital mental health tools as a potential opportunity for support and benefits of including students in discussions of treatment resources.

Introduction

College students are increasingly being recognized as a population particularly vulnerable to mental health concerns.^1,2 Many factors contribute to the stress-inducing climate on college campuses, including a rigorous academic environment,³ social and/or familial pressures,⁴ and financial worries.⁵ Furthermore, some have argued that these concerns have been exacerbated by the increasing use of social media, which is believed to contribute to rising rates of loneliness,⁶ as well as the increasing cost of tuition, which places a significant burden on students.⁷ Besides these environmental factors that put college students at risk for developing mental health conditions once they arrive, many students are navigating the difficult developmental period of emerging adulthood⁸ and a large number of students enter college with pre-existing mental health conditions.⁹

Colleges and universities are incentivized to provide services that alleviate mental health concerns, as data show that mental health conditions are predictors of lower GPA and higher risk of dropping out.¹⁰ As a result, many colleges and universities in the US provide on-campus mental health services to their students that are generally paid for through students’ health fees.¹¹ Over the last ten years, college counseling center utilization has increased. According to data from the Healthy Minds Study, in 2007 about 6.6% of students received treatment at a college counseling center. In 2017, this number jumped to 11.8%.¹²

Unfortunately, many counseling centers struggle and are unable to meet this growing demand for services, leaving students concerned. Over the past two years, several articles from student-run publications on college campuses have emerged that demonstrate students’ concerns about structural issues surrounding unmet mental health needs such as long waitlists and shortages of providers (see Table 1). These articles demonstrate that college counseling centers across the US are facing similar issues, and that students are aware of them. Furthermore, the majority of the complaints reported in these articles concern traditional face-to-face counseling; yet, the increased proliferation of efficacious non-traditional methods of support offers a greater array of mental health services that could meet students’ needs.^13,14 For example, a systematic review found that the majority of digital mental health interventions for college students were effective in producing changes in psychological outcome variables such as depression and anxiety.¹⁵ Additionally, mindfulness practices such as yoga and mindfulness-based therapy have been shown to reduce depression and anxiety in college students, and peer-led groups that offer support around mental health concerns have been shown to reduce stigma.^16–19 While these findings suggest that these resources are efficacious, students’ support for them needs investigation.

Table 1:

Campus News Articles Regarding Student Counseling Centers

Article Title	Year	Complaints (summarized)
“CAPS says students decide when their treatment ends — but students disagree”39	2017	Not enough counseling sessions offered
“Student-led Mental Health Task Force Submits Recommendations to Administration”40	2018	Not enough funding, not enough clinicians
“Students demand mental health reform, criticize administration’s prior efforts”41	2018	Not enough funding, not enough clinicians, lack of diversity in clinicians
“Mental Health Town Hall brings together administrators, students”42	2018	Long wait times, not enough funding, not enough clinicians
“MU responds to student complaints and consultant report regarding mental health services”43	2018	Long wait times, not enough counseling sessions offered
“Students criticize mental health services”44	2018	Long wait times
“Despite the university making mental health a priority, students must wait for appointments at campus clinics”45	2019	Long wait times
“Student Mental Health Demonstration calls for CMHS reform”46	2019	Not enough student input, not enough funding, not enough clinicians
“Students start petition to change USF’s walk-in counseling services”47	2019	Limited hours of service, location concerns
“Students protest lack of Counseling Center resources”48	2019	Long wait times, not enough funding

As part of a larger study focused on the design and implementation of app-based digital mental health tools, we collected data from college students and counseling center clinicians at two large universities on student mental health needs and desired strategies. Because of the context of the larger study, some of the data collection specifically focused on digital solutions. During data collection, the need to identify opportunities to better align students and clinicians on needs and resources became clear. In this paper, we use qualitative and quantitative data collected as part of the larger study to 1) identify students’ concerns with existing mental health services, 2) identify desired strategies for providing mental health support outside of traditional face-to-face counseling sessions, and 3) explore potential benefits of bringing students and counseling center clinicians together to discuss mental health services. This mixed-methods approach that integrates student and clinician perspectives on designing mental health services has potential to improve and innovate service delivery and utilization on college campuses.

Methods

Participants

Data were collected from clinicians and students (undergraduate and graduate) at two large Midwestern universities. These universities are labelled as “School #1” and “School #2” throughout this paper. Partnerships were formed with these universities as part of an ongoing study on designing mobile technologies for college student mental health.

Procedures

Data collection for this study occurred in three phases: 1) an online questionnaire, 2) co-design workshops, and 3) individual interviews. Students were recruited via print advertisements, email, and student organization contacts. Clinicians were recruited via email and presentations at staff meetings. All study procedures were approved by the authors’ Institutional Review Board before enrolling participants, and all participants provided informed consent.

Online Questionnaires

A total of thirty-one clinicians from both sites completed an online questionnaire assessing their current mental health treatment practices and their interest in digital mental health tools. The questionnaire was adapted from a previously published questionnaire of mental health providers’ interest in using web and mobile-based tools in their practices.²⁰ Questions on interest in digital mental health assessed how often participants use technology for work purposes, their interest in using technology to communicate with clients, and their technology recommendations for clients’ personal use. These questions were structured in various forms, including multiple-choice, Likert scale, and open-ended questions.

Co-Design Workshops

A total of twenty students and ten clinicians from both sites participated in co-design workshops. Procedures for co-design workshops were rooted in human-centered design techniques. This served to bring together a diverse group of participants and engage them in creative thinking and brainstorming activities.²¹ Workshops took place in the counseling centers of both institutions with groups of ten people or less, students and clinicians combined. In these workshops, participants were provided with a summary of a to-be-designed stress management program that read as follows:

“A tool that students can freely access, complete brief mental health assessments, receive feedback, and build upon their own stress management/coping skills by receiving access to a handful of interactive, clinical tools. Students whose assessment scores indicate that they may benefit from in-person evaluation and counseling will also receive information about counseling center services (and potentially other resources on campus).”

Participants were then engaged in multiple design activities, including a brainstorming session on features and advertising strategies for a digital stress management program, an activity in which they put together a “storyboard” depicting a hypothetical student’s journey in using a digital stress management program, and a sketching activity to identify user interfaces and features of a digital stress management program.

Individual Interviews

A total of fifteen students from both sites completed individual interviews in which they identified perceived barriers to mental health care. Students were recruited who indicated at least moderate symptoms of depression or anxiety, as measured by a score of 10 or greater on the Patient Health Questionnaire (PHQ)-9²² or the Generalized Anxiety Disorder (GAD)-7,²³ respectively. These measures were administered via an online screening questionnaire to determine eligibility. Four clinicians also completed individual interviews. Clinicians were recruited through direct emails. Individual interviews took place at the counseling centers of both sites and lasted approximately 45 minutes. They were conducted by the senior author. The interview was conducted in a semi-structured format and focused on questions related to general college student mental health and barriers to care, the responses to which were included in this analysis (example questions include “What barriers do you see for students to access mental health treatment options on campus and/or in the community?” and “What do you think happens to the percentage of students who could benefit but don’t come in?”).

Data Analyses

Quantitative data from the clinician survey were characterized using descriptive statistics. Means, standard deviations, and percentages are listed in the results. While this study employed a sequential mixed methods design, such that quantitative survey data were collected prior to the majority of the qualitative data, the quantitative and qualitative data were embedded and examined collectively to inform the findings of this study. The co-design workshops and individual interviews were audio-recorded and then transcribed. The transcriptions served as the primary qualitative data source, and the transcripts were coded and analyzed by the authors using a qualitative description approach.²⁴ Co-design workshop transcripts and individual interview transcripts were first coded separately, and then in tandem due to a high level of thematic overlap between responses. The approach used allowed the coders to become familiar with the data as they organized codes into the broader topic areas that are presented in the results. Two members of the study team read each transcript, and preliminary codes were discussed. Study team members created a codebook and coding was completed on all transcripts using NVivo software. The coders met regularly throughout the analytic process to discuss the codes and ensure validity. Due to the nature of the recordings and transcripts, individuals in the co-design workshops could not be uniquely identified, and thus these participants are not linked with specific quotations in the results below.

Results

Participant Characteristics

Participants in the clinician survey sample included 16 participants from School #1 and 15 participants from School #2. The sample was predominantly female (74.2%) and predominantly white (77.4%). Clinicians had been in practice for a wide range of less than 1 year to 32 years. The mean length of time in practice was 10.5 years (SD = 9.3).

Participants in the co-design workshop sample included 20 students and 10 counseling center clinicians. Participants were predominantly female (83%) and were ethnically and racially diverse (including 4 participants who identified as Hispanic or Latino, 8 participants as African American, and 5 participants as Asian).

Participants in the individual interview sample included 15 students and 4 counseling center clinicians. Participants were predominantly female (89%) and were ethnically and racially diverse (including 4 participants who identified as Hispanic or Latino, 4 participants as African American, 2 participants as Asian, and 5 participants as more than one race). Student participants in the individual interview sample had elevated scores on the PHQ-9 or GAD-7. Twelve participants had an elevated score on the PHQ-9 and 13 had an elevated score on the GAD-7. The mean PHQ-9 score was 12.5 and the mean GAD-7 score was 13.2.

Students’ concerns with mental health services

Throughout the co-design workshops and individual interviews, students voiced concerns about the mental health services that were available on their campus. These concerns were primarily disclosed through the identification of barriers to receiving services, which were grouped into themes of “structural” and “psychological” barriers.

Structural barriers

First, we describe the structural barriers that emerged surrounding unmet mental health needs. One structural barrier was the counseling centers’ appointment hours, as these can be misaligned with students’ schedules. As one student noted,

“The [Counseling Center] is usually pretty … busy. So sometimes they don’t have opening for students or if they … want to do like group counseling, it doesn’t fit in their school schedule.” -Participant #2.

Further, while many students recognized that the counseling center was somewhere they could go in the event of a mental health crisis, the appointment hours did not consistently match the hours that students perceived themselves as needing support. One participant highlighted this mismatch by describing:

“They can’t like go see counseling services at like midnight or something if they’re having a panic attack or something.” – Participant #24.

Another structural barrier was the intermittent presence of a waitlist, which prevented students from receiving or seeking services. Specifically, some students experienced the waitlist directly after they had undergone the intake procedures and then were placed on the waitlist, and others described hearing about the waitlist from peers.

Lastly, the counseling center’s location on campus served as a barrier. Some students noted that many of their peers did not know where the counseling center was located, and students said travel time to the center was problematic. In fact, travel time was a barrier regardless of whether the school was located in an urban or rural setting. Students at school #1, located in an urban setting, often live throughout the city and surrounding suburbs. Consequently, they did not necessarily treat campus as a home base, indicating the commute was a barrier. As one participant noted,

“Maybe if you like live across the city and you know don’t wanna like commute if you have really far to get to your appointment especially if it’s only like an hour” -Participant #31.

School #2 was located in a more rural area, and the majority of students live on campus or in apartments on the periphery of the campus. Due to the sprawling nature of the campus, in which it can easily take 20 minutes or more to walk across campus, travel time also served as a barrier:

“So you definitely have that, that sense of like ‘Oh well it’s a little bit too far’ so like you know like ‘I don’t wanna kinda do that.’” –Participant #42.

Taken together, structural barriers such as travel time, waitlists, and appointment hours may hinder students from seeking help as they can both limit students’ ability to access services and contribute to a negative representation of the counseling center as unapproachable.

Psychological barriers

Students reported barriers to treatment in the form of psychological barriers. One such barrier was mental health stigma, as one student participant observed and suggested:

“But maybe changing even just something as simple as changing what they call the department …Because I think that the word ‘Counseling’ has always, just for so long been a ‘Oh you’re messed up’ like type of connotation with it.... for a student to […] accept to go there they like really have to […] feel like there’s something wrong with them to the point where like, ‘I need like professional help.’” -Participant #3.

This participant, along with others, appeared to believe that counseling could be helpful for a wide variety of students, but observed that their peers typically viewed counseling as an option to pursue only in more dire situations or as a last resort.

A second barrier was the discomfort of opening up to a new therapist. As one student noted:

“What was difficult was like trying to open up about like everything […] I would had been ashamed about or like felt weird about. […] When you start over with a new therapist it’s always like harder, but […] when you even start with your first one, it’s like okay so ‘Here’s my whole life story.’” – Participant #24.

This participant’s discomfort may be a result of the expectation for college counseling to be short-term (i.e. the student may only access services until they graduate and may only have a limited number of sessions with a clinician). Thus, it is possible that one barrier for students is the difficulty of forming a relationship with a clinician while knowing the therapeutic relationship may end before the student feels ready to end it.

A third barrier was loss of motivation that can occur at many stages of the process for seeking services (e.g. prior to contacting the counseling center, after initial intake, and after getting connected with a clinician for ongoing sessions). For example, one student highlighted that it was useful that they could take mental health screenings online at any time, but found it problematic that they were not able to make an appointment immediately after completing the screening, when they identified their own personal need for services, resulting in decreased motivation.

“At the point that I took the survey, the hours for me to call and set up an appointment were not in the time that I could do that … So, maybe if they had like a 24, maybe not 24-hours but like a late shift where you can call and make appointments at least … because I didn’t follow-up the next day or two days later to make that appointment.” – Participant #15

Another student felt demotivated when referred elsewhere due to a waiting list at the counseling center:

“I made an appointment and I came in. And, they said they were … really full at the time so they were like if you want, we can give you other like places to go to counseling, because I just basically wanted just somebody to talk to … I was just like really stressed out, I had a lot to do, felt like I was wasting a lot of time just driving and commuting so I wasn’t like getting caught up on my work … But I ended up never following through with it just because it was like, “Oh now I have to go somewhere else.” And I was like “Yeah, I already came here”.” – Participant #27.

To better facilitate connection to services, these transition points appear to be crucial times for delivering motivational support to students in need, but do not necessarily align with how and when services are traditionally delivered.

A final barrier was issues of fit that can cause students to terminate treatment early. As Participant #34 noted,

“I think for a lot of students who eventually get through the process of actually getting to a counselor of some sort, if they don’t like the person, like don’t match with them, then they might be like disenchanted, or like you know persuaded not to continue pursuing.” – Participant #34.

Thus, even for students who do make it in for an initial appointment and then get set up with a clinician, problems with fit pose a barrier to remaining in care.

In summary, students had a number of concerns, both structural and psychological, that served as barriers to seeking and receiving mental health care from their campus counseling center. To meet the mental health needs of students, additional forms of mental health support appear to be desired.

Strategies for providing mental health support outside of traditional face-to-face counseling sessions

Both students and clinicians offered a number of suggestions for ways to provide mental health support to students outside of traditional face-to-face counseling sessions, which can address students’ perceived barriers to accessing traditional services (See Table 2). Suggested strategies ranged from appreciation of existing campus programs (e.g. having therapy dogs around finals time), to ideas on better integrating information about existing programs, to the brainstorming of new programs and services that could be offered. Additionally, there were two overarching recommendations, namely, offering resource lists with a variety of existing services and offering on-demand resources. These recommendations are described below.

Table 2:

Identified strategies for support outside of face-to-face counseling sessions

Support Strategies
On-demand tools	• Guided meditation podcasts
	• Mobile apps featuring self-help tools and educational resources on stress management
	• Mobile apps for distractions (e.g. games, coloring)
	• Interactive resource list and/or map of existing campus/community mental health-relevant resources
	• Mobile biofeedback technology
	• Prompts to connect with relevant campus groups
	• Chatrooms or secure messaging with clinical providers
	• Chatroom support groups with peers
Elevated programming	• Therapy dogs during finals
	• Yoga classes
	• Mindfulness programming

Throughout the co-design workshops, there were requests for high-level messaging around a broad spectrum of things students can do to improve their mental health, for which counseling services could be framed as one of several options. One co-design workshop participant described her ideas for an interactive resource list that provides:

“So many options of seeking for help that she [a hypothetical student] had the choice of either going to a friend or a professional. I mean, if she chose to go see a counselor, I think that kind of says something about the level of stress and need that she has, so I think that’s also a nice way to self-assess her own needs and how severe the situation is for her.” ”- Co-design participant.

As indicated by this student, resources could include implementing peer support methods if they do not already exist on the campus.

There were abundant desires for on-demand tools to help manage distress in the moment. Students and clinicians spoke of the utility of mobile phone apps that could be used as helpful distractions or provide relaxation techniques and skills-based psychoeducational prompts. As illustrated below, one participant envisioned a dynamic system in which a user would get a brief relaxation exercise to complete, and then assess mood after each exercise to receive more tailored instructions on things to try next. It was described as being prompted with:

“Five minutes of calm based on what their interests are is available, because if they’re in a hectic situation and it can be like, here are things that – because I know that sometimes when you’re in a really dire situation, you might not be able to think of anything that you enjoy. So, if you have that thing that’s like, you said you enjoy these things, pick one. I’ll time it for five minutes. After, are you feeling better? No, let’s do another, sort of thing, and after a few, if you’re not feeling better, here’s other things that you could do, here’s somebody you could call or whatever, and then ways to deescalate the situation based on different situations”- Co-design participant.

There was recognition that mental health management strategies could be individually introduced to triage people in need to the lowest level of services required to meet their need. As evidenced by the student above, students are not rejecting traditional services, but rather, want to be connected with alternative, lower-burden methods of managing their moods when appropriate.

In line with students’ interests for mobile app delivered strategies, the clinician survey revealed that a sizeable number of clinicians recommended the use of mobile apps to their clients. Of the 16 clinicians surveyed at School #1, 7 respondents indicated they recommend internet sites to their patients and 9 respondents indicated they recommend mobile apps to their patients. Of the 15 clinicians surveyed at School #2, 14 respondents indicated they recommend internet sites to their patients and 13 respondents indicated they recommend mobile apps to their patients. Thus, many clinicians were already comfortable with incorporating technology into their practice. However, at the time of this study, neither campus had any initiatives to broadly disseminate digital mental health tools to their student bodies outside of the counseling session. So, while students were interested and clinicians were supportive of digital services, the main entry point to digital mental health care was interfacing with traditional mental health services that came with a number of barriers, as evidenced in the prior section.

Bringing together students and clinicians

In this last section, we describe the value of bringing together students and clinicians in co-design workshops to collaboratively identify strategies to improve mental health resource delivery on campus. In particular, the co-design workshops allowed for students and clinicians to discover and build on their mutually held ideas, as well as to learn from one another. This was particularly beneficial for instances in which students and clinicians discovered they were not aligned in their understanding of resources on campus.

First, there were many points of agreement and shared ideas. Both students and clinicians recognized a need for stress management tools and mental health support outside of traditional counseling sessions. Ideas included tools for relaxation and distraction, motivational quotes and prompts to help people feel supported and understood, and psychoeducational information that could be applied to oneself or could be used to help others. Additionally, students and clinicians built off of each others’ ideas. For example, students shared multiple ideas about how to connect distressed students with peers as a primary source of support and stress management strategy. Given potential problems of delivering strategies that exclusively focused on social connections, clinicians made recommendations about also including strategies for students who preferred solitary experiences or may not have access to peers at the times they need to enact a stress management strategy.

Second, students and clinicians learned from each other during these sessions. For example, clinicians shared some evidence-based practices that the student participants were largely unaware of, such as strategies based in dialectical behavior therapy (DBT) and biofeedback, and offered these practices as useful stress management tools. Students in turn spoke of the value of co-designing strategies with clinicians. At one point in a co-design workshop, a student asked participants seated in one section of the room:

“Are you guys all mental health professionals?” and when answered in the affirmative, the student continued with “I figured. So, I was like – well, not in a bad way, but I was like, however this design is developed, having a wide variety of mental health professionals involved in it, so that way it’s reflective of therapeutic things.” - Co-design participant.

Here, we observed that students wanted to have their ideas reflected in stress management tools that would be deployed on campus, but they were appreciative of the clinical expertise that the clinicians were bringing to the table.

Third, through the co-design sessions, we learned that students and clinicians were frequently not aligned on the opportunities and resources available on campus. As clinicians and students shared their ideas for directing students to resources on campus, differences emerged in their recommendations.

Students and clinicians both believed that engaging student organizations was valuable, but had different conceptualizations of the organizations that would be particularly useful. Students brought a number of ideas to getting the word out about mental health resources that were not identified by the clinicians, including relatively low resource strategies such as posting information in bathroom stalls and elevators, and having resources included in the syllabi for classes. Students also acknowledged that, although information about resources is commonly disseminated via email, a number of mass emails go unread. Instead, they said that they are most likely to learn about programs and initiatives when announcements come from personally relevant and trusted sources (like their home department, or a club/organization to which they belong).

Clinicians brought up other support services available on campus, and it was clear that the students were not aware of these resources or where to find them. As one student noted to a clinician in co-design workshop,

“I thought of something else when you were mentioning all the campus services. I’m like, that’s great. I don’t know what half of those are. So, for [a resource or tool] to say what exactly those places would offer you I think is really important.” - Co-design participant.

This highlights that there is often a knowledge gap between clinicians and students, and providing education around existing on-campus resources would be valuable to students. Similarly, another student in a co-design workshop noted that resource lists should come along:

“With a campus map so they know specifically what building they can get their certain resources, because I know I’ve been here a couple years and I still haven’t been to every single building on campus.”- Co-design participant.

These ideas are helpful for combatting the location-based barriers that many students identified.

Due to differences in practices at college counseling centers, there is a clear value in aligning the students’ and clinicians’ understanding of the services that are offered so that students are better informed about what is entailed when they present to the counseling center. As one of the clinicians noted,

“Well, I remember once at a previous place I – a university I worked, they were kinda framing the counseling center as a place – if you’re ever sad or anything and you just wanna talk, come in. When it’s a little bit different than just that, especially here you have to – you go to intake, and you meet with somebody, and talk about everything going on. So, sometimes students don’t always realize that that’s what it is versus something more informal where you just meet with somebody quickly.”- Co-design participant.

The students in this workshop appeared to find this information helpful, suggesting there would be utility for counseling centers to provide targeted information about how and why students should make an appointment there. Further, campuses that offer additional resources outside of the counseling center could give more detailed information about the services and procedures, which may help alleviate students’ frustrations and changes in motivation when they present for care.

Discussion

The barriers that college students face and the disconnect between students’ expectations and counseling center practices place college students at greater risk for persistent mental health concerns. To address these problems, we employed a mixed-methods approach to identify barriers to care and to align students and counseling center clinicians in strategies for offering mental health resources on campus. Few studies have described the results and benefits of joining students and counseling center clinicians together to address mental health service delivery, and this paper adds to this emerging literature.^25,26

First, students were assessed to identify barriers to mental health care. We found that the traditional face-to-face counseling offered on many college campuses comes with barriers that limit student interest. Long waitlists, limited hours of service, and inconvenient or unknown locations are not only structural barriers that keep students from accessing services, they can often lead to loss of motivation after students have decided to seek services. These barriers reinforce previously cited barriers in the literature and that have been reported by students.²⁷ Our findings support the suggestion that other strategies are necessary to ensure that college students receive the care they need as soon as possible.^1,28 Additionally, we found that psychological barriers such as stigma persist around college counseling. Students reflected that “going to counseling” has negative perceptions, as it indicates a level of distress considered to be extreme or abnormal. Lastly, students noted a lack of resources available for problems that they perceived to be of lower concern than would warrant intervention at a counseling center.

To address these barriers, we brought students and counseling center clinicians together to identify non-traditional resources for delivering mental health services on campus. One potential strategy that we focused on was the use of digital mental health tools. The potential benefits of using digital mental health tools to supplement the care received in college counseling centers have been documented in previous studies.^29,30 College students spend much of their time using technology, meaning they are already comfortable and familiar with it. Mobile mental health tools allow students to access services at any time or place, meaning long wait times, limited hours of service, and issues regarding location could be avoided. Additionally, the negative stigma surrounding counseling services could be decreased by framing digital mental health tools as methods to manage day-to-day stress and low-level anxiety and depression. Our results support the literature that demonstrates students’ eagerness to be connected with alternative methods of managing mental health concerns.^31–33 In co-design workshops, students suggested methods which would provide brief, on-demand, interactive support. We also found that many clinicians were already recommending digital mental health tools as part of their practice, indicating that they are open and willing to integrate technology into collegiate mental healthcare systems.

Additionally, our results support the importance of involving students in the process of developing new services, whether it is a digital mental health tool or another form of support.^25,34 We found in co-design workshops that students were eager to engage in planning and willing to work with counseling center clinicians to generate ideas. The collaborative discussions also generated a more expansive list of ideas than what students and clinicians identified or were aware of on their own. We suggest that college health professionals looking to develop new services or campus initiatives around mental health engage in collaborative approaches with students, such as by employing community-based participatory research (CBPR) strategies. The emphasis in CBPR in engaging the targeted community in research and development stages is believed to lead to more sustained engagement in and adherence to interventions.³⁵ One potential method to engage students is forming a student advisory board, which could help to elevate students’ voices and engage them in collaborative decision making. The key takeaway is to use student-generated ideas and involve them in implementing those ideas.

Limitations and Future Directions

While results are consistent with past research on college student mental health services, results may be limited by the fact that data for this study were collected at two universities within the same state. It is possible that students from these schools shared opinions and ideas not held by students in other areas of the US. In the future, researchers should strive to collect data from colleges and universities across various regions of the US to account for any cultural differences among regions. Another limitation is the possibility of selection bias within students who agreed to participate in co-design workshops and individual interviews. These students may be more interested in mental health or more socially engaged. Future research should strive to target students who may be socially isolated or demonstrate low mental health literacy, given that these students may benefit most from support.^36,37 Third, the clinicians taking part in the online survey portion of this study were predominantly female and predominantly white. Future investigations should ensure an accurate representation of the population by actively and directly recruiting a more diverse sample. Lastly, the present study did not assess the usage rates of non-traditional resources and strategies such as those indicated in Table 2. Future research could investigate the degree and duration to which students use these resources and strategies.

Conclusion

College students are at a key point in their life when mental health concerns are common,¹ and addressing those concerns is pivotal to their sustained wellbeing.³⁸ With the increasing number of students utilizing college counseling centers and needing services,¹² it is imperative that researchers and clinicians identify strategies that will improve services and reach the large number of students in need. Our results indicate that students recognize barriers to face-to-face therapy and are eager to engage both in the development and utilization of novel methods of support. We suggest that colleges and universities across the US continue to support students’ wellbeing by investigating programs for low-level emotional support and involving students in program development.