Below is the complete set of answers Dr. I-Ching Grace Hung and Fabrizia Sacerdoti, the leaders of Minerva’s Counseling And Psychological Services (CAPS) team, sent in response to a series of questions from Quest. Find the full article about CAPS at Minerva here.

Note [from Dr. Hung:] we did not answer per city; instead, we are offering general trends from when our team first began operating in 2015, until now. The reason is twofold: first is to offer some level of privacy for students who are currently pursuing services, given that we are a small community (e.g., related to your questions for each city, on how many students have visited our team so far this semester). The second reason is a hope to offer good data — as it is premature to note any trends before the semester or academic year ends. 

Without further ado, here we go: 

1. How many students in each city have visited the mental health team (renamed to Counseling & Psychological Services (CAPS!)) at least once this semester?

Historically, between 45-55% of students in Foundation Year (SF) have engaged with CAPS services (confidential consultations, counseling) at least once by the end of the academic year. 50% as the average has been the magic number.

For upper year students, that number is between 42% to 60% of each cohort at the end of each academic year. So far, Direction Year students have been on the lowest end of the usage spectrum, with Focus Year students, and finally, Synthesis Year students, on an increasingly higher end. 

2 + 3. How many students visit CAPS regularly? What is the average number of sessions a student has with a CAPS staff?

About half of the students who use our services in Foundation Year see us for only 1 time. Overall, the average number of sessions a student attends is between 3-4, with the most common (median) number of sessions being 2-3. The trend for upper year students is comparable.

4 + 5. How many sessions can a student attend with a mental health counselor? Do you ever have to turn students away because of demand?

CAPS does not set a session limit to our services, and we don’t intend to, despite seeing an annual utilization rate that far exceeds the averages for a school our size. We have consistently shared with students that we provide short-term therapy, which is our treatment model, which is also common for US college centers. The main factor that determines the number of sessions is typically the student’s presenting concern(s). Counselors collaborate with students to decide on goals, treatment plans, and timeline. 

Of course, this also occurs within real life constraints: the nature of the global rotation and related implications (e.g., short-term contract hire for cities outside of San Francisco), for example, limits the treatment time to when students are residing in a city. Providing telehealth as a consistent option or having a counselor who travels with students to all cities is currently impossible (in fact, in most cases, illegal!) due to the complicated legalities of licensure laws for different mental health providers, which vary from country to country and state to state (within the US, for example). Other de facto constraints include budget and counselor availability (they do have lives outside of Minerva, after all!). 

Despite these real world constraints, we have made efforts each year to provide a smoother transition for students transferring from counselor to counselor. Examples include using a new electronic healthcare system (EHR) for centralized documentation, having meetings to transfer cases between semesters, doing warm handoffs from city to city, creating new management/reporting lines to better support each city counselor and improve consistency and cross-city communication, etc. This is an ongoing work in progress, as we are dedicated to evolving and improving as a team, in order to better serve Minerva students.

We are also proud that our efforts to prioritize student access has consistently been a huge strength of CAPS. We have never needed a waitlist, nor have we turned students away because of high demand. We typically offer appointments within 3 (or max, 5) business days, although students may not be able to schedule until later, due to conflicts with their schedules. This is in contrast to national US trends (pg. 46), where many (37%) college counseling centers closest to our size have waitlists ranging from 1 week to more than 35 weeks. When we could not offer the same turnaround, our counselors usually increased their availabilities for Minerva. (See question 8 for specifics related to Berlin this year)

A point of clarification is that although we do not turn students away because of high demand, we may refer them to other providers if a counselor, using their professional/clinical judgment, decides that the student can be better served by another professional. This is best practice in the world of mental health; all settings and counselors have their own areas of competency and specialties, and must refer if it is clear that another professional can provide better care.  Examples of this may include psychiatric care, certain specialized disorders or preferences, need for long term care, etc. These circumstances are uncommon, but does and can happen. In the event that we may not be the best match for a student, our priority is to assist the student to engage with a provider that is a better match for their needs.

6. If you have worked at Minerva before, how have you seen mental health services change over time?

Within Minerva, our clinical trends have not changed much over the years. We have an unusually large number of students accessing CAPS services, compared to US national trends. We credit this, in a large part, to students’ openness in trying different ways of learning and accessing resources, as well as Minerva-wide efforts to reduce stigma toward using our services. For US colleges that are most comparable to Minerva in size (pg. 26), the average number of students served by counseling services is 21.6%. In contrast, we serve approximately 50% of our student body each year, and by the end of the 4 years, only a small number of students have never accessed CAPS. This is particularly notable given that the majority of our students are “international” by US categorization. For other US college counseling centers, the number of international students accessing CAPS is typically even lower.

Related to change and improvements within CAPS, see question 5 and 12 for some examples. 

7. Are you, the mental health counselors in each city, full time or part-time?

As mentioned earlier and on The Hub, all of our counselors outside of San Francisco are part-time, usually by semester. We also hired a part-time counselor in San Francisco this year, in addition to our existing full time staff.

8. For Berlin: Since you are some of our first counselors to not be employed by Minerva, how much of the above factors are determined by Minerva vs. GeoBlue vs. Linden?

For Berlin, all factors remain the same in terms of determining session limits (e.g., clinical need/presenting concern as primary factor in determining treatment plan and number of sessions), with one addition: the use of insurance (GeoBlue). ASM contacted Dean Lyda recently and inquired about Berlin CAPS specifically. What was shared may be helpful here as well: 

“Students are eligible for up to 30 sessions under Geo Blue. Students use their Geo Blue to access counseling through Linden, and as a result they should have no out of pocket costs in doing so because Linden is an “in-network” provider and can directly bill Geo Blue; no need to pay up front and be reimbursed and also no need for a co-payment. Geo Blue does require authorization for additional sessions (up to 30), after 5 sessions. This process is handled by the Linden counselor (“counselor of record”) who must use their clinical judgment and submit paperwork to request approval for additional sessions to be covered. It does not mean a student needs to have a severe condition to be approved, but processing can take some time. Use of the term diagnosis is misleading in this situation because every interaction one has with a mental health or medical professional has a “diagnostic code” based on either the ICD-10 or DSM 5. This is standard practice for U.S. based insurance regarding mental/behavioral health, and is what you would likely face if you use private (or in the U.S., employer provided) insurance for counseling or psychotherapy.

With this new system, there were growing pains that were unexpected, and we are thankful for students in Berlin this year for testing it out with us, as well as for Linden counselors and admins, for creatively troubleshooting with us. We are glad to clear up any confusions and miscommunications the changes have caused. 

To Kroner, your question regarding why M21’s have external counselors (I assume you are referring to Linden): We have partnered with Linden since Fall 2018, that is not new this year. What is new this year is the way we are partnering with Linden. Our hope for the new model was for students to have even more options for counseling: Linden is able to provide two counselors dedicated to Minerva students, and potentially more, if there were more demand. In fact, they recently added a third counselor to the list. Moreover, students have the option of continuing to use Linden remotely after leaving Berlin, until their insurance ends. This would be decided by the counselor and the student, and within the 30 sessions of GeoBlue, all at no additional cost to students. From past clinical data, we know that 30 sessions is significantly more than what students typically attend with CAPS, and having the option of continuing therapy past a semester seemed to be a big pro, which has not been available to students in the past. We know from past feedback, that this was something that students have expressed the desire for. 

An additional (although not main) benefit to this system is for students to develop more skills and experience in navigating mental health systems outside of the relatively more contained college counseling environment. After the graduation of our first alumnis, we realized that CAPS can do a better job of preparing students for the realities of navigating these systems, including using insurance, searching for a counselor match, etc. I will speak more about this in question 12. Ideally, of course, we’d like to do this in a scaffolded way that is not overwhelming and still relatively smooth. We are certainly learning from this process and plan to improve upon it. 

With experience from earlier in the semester, Linden and CAPS have been able to iron out many of the factors that led to counseling services being disrupted or delayed by insurance processes. We are also committed to delivering no-cost-counseling to students who opted out of GeoBlue this semester. We will be gathering student feedback, and at the end of the academic year, we will be re-evaluating this model to determine whether it’s fruitful to continue with this model.

9 + 10. For Taipei: How many counselors will be present in Taipei for the class of 2020? Do you know who those counselors will be already, or are you still in the hiring process?

We will have 1 counselor in Taipei this coming spring. Her name is TienAn Lin! We hope to have her bio up on the Taipei Hub page early December.

11. How do you anticipate demand for counseling services to change, and what are you planning to accommodate that change?

Given that this is our first year in Taipei, we can only anticipate what the clinical demand may be, given trends for M20’s in the current semester (Fall 2019), as well as trends in M19’s last semester. Also, we’re aware that Capstone will be due mid-semester, and that some students may be leaving Taipei earlier than the end of April, both of which would likely affect the use of services. Our counselor’s availabilities in Taipei was contracted according to these factors, and more hours may be added if needed. We are also looking into referral options in Taipei, in order to provide students with additional choices.

To Kroner’s question about why M20’s have only 1 counselor — we have had only 1 counselor in London each year so far, due to M19’s and M20’s having less students than other cohorts (e.g., this year, ~100 M20’s, versus ~150-165 students in other cohorts). We determine the number of counselors and hours contracted based on anticipated demand. For next year, we will likely need to hire an additional counselor to meet the demands. Recently, Sonia also increased her hours due to higher demand in London. We are grateful for our counselors, who love working with Minerva students, and manage to find some flexibility in meeting our needs.

12. What else do you want students and the broader Minerva community to know?

To better understand Minerva CAPS, the data, and our model, it’s helpful to turn to some context. Here’s an article that talks about the “mental health crisis” on US college campuses, from the interesting angle of college presidents. If you are academically inclined, here’s a good summary article, and if you are data inclined, here’s the most up to date national data on colleges

As we know from past Wellness Surveys, our data tends to be comparable with these national trends, although we have the unusual opportunity to address these concerning trends in fresh ways. In addition to offering counseling, a big part of CAPS is also collaborating with other Minerva staff and faculty. Our approach and philosophy is introduced in our page on The Hub, and most recently, in an updated article by Dr. Gary Glass. While counseling supports students one on one, this additional community-level approach seeks to reduce/prevent distress, and build support networks that students can use in their daily lives, not just in the counseling room. Some of this effort can be seen through Oxygen programming, although much is behind the scenes, through collaborating and offering our perspective on student wellness and creating optimal learning environments in policies and overall Student Life programming.

Regarding counseling services specifically: As I mentioned earlier in a previous question, CAPS continually seeks to improve, and one thing we hope to work on next is to better prepare students on navigating counseling services outside of college. With great diversity in licensure laws in each country, state, and differences in each provider’s professional training (are you a psychologist, social worker, counselor, life coach, or psychiatrist?) and counseling approaches (CBT, DBT, ACT, psychodynamic, Rogerian, _insert other industry lingos_), we’d like to begin by increasing efforts to help students mold their own counseling experience, such as by selecting a counselor that matches their needs. We plan to start implementing this by better highlighting the different strengths, styles, and trainings of our own counselors across cities and cultures, while also building additional connections with other providers to bolster options for counseling, and offering support to students seeking services outside of Minerva (e.g., in summer months).

While we aim to maintain a level of fundamental consistency across all cities for our services (e.g., confidentiality, no additional costs, short-term therapy model, friendly counselor faces, etc.), we are realizing that students can also benefit from learning to navigate the differences / complexities of the counseling world. This is aligned with Minerva’s principle of “teaching to fish,” and we are excited about the prospect of Minerva students becoming savvy users of counseling by the time they graduate, wherever they end up in the world. Of course, we also hope to do this in a scaffolded manner across the four years, and as usual, look forward to hearing student feedback on our efforts.