Implementing a counseling center triage system to meet the needs of diverse urban commuter - PowerPoint Presentation

1. Implementing a counseling center triage system to meet the needs of diverse urban commuter college students

2. Who am I? Megan wilen, LCSWI’ve worked at Lehman College Counseling Center since March 2010.I’ve served on the Board of NASW-NYC.Won Union Square Social Justice Award in 2011 for work with Trinity Place (LGBTQ Youth) Shelter.Worked for 6 years in Community Mental Health in the South Bronx.

3. Lehman collegeAn urban commuter school located in Bronx, NYOne dorm with 20 bedsPart of the City University SystemNearly 12,000 undergraduate students enrolled in fall 2017Hispanic serving institution52.5% Latinx, 30% Black, 2.7% non-resident, alien58% from the Bronx Transfer student serving institution1365 incoming transfers in fall 2016 versus 672 incoming freshmanhttp://www.lehman.edu/institutional-research/interactive-factbook.php

4. Median household income is $35,000Per capita income $18,896Rent on average is $1098 so $13,176 per yr28.6% of residents live in poverty10% of population doesn’t have health insurance58.8% of households speak a language other than English19% of residents hold a bachelor’s degree or higher34.9% of population was born outside of the UShttps://www.census.gov/quickfacts/fact/table/bronxcountybronxboroughnewyork/SEX255216

5. Mental health stigmaAfrican-American and Latinx people cite mistrust of health care professionals, concerns about provider ethnic/racial competence and fear of institutionalization as reasons not to seek mental health treatment.Afro-Caribbean communities have experienced mistreatment and social exclusion by mental health professionals.Both communities are more likely to use family support or go to clergy for mental health problems.Males have more negative attitudes towards treatment.(Gonzalez, J.M., Alegría, M., Prihoda, T.J., Copeland.L.A., & Zeber, J.E., 2009)

6. Stigma cont…African Americans with prior mental health treatment have worse attitudes towards seeking treatment than those with no prior treatment.Many behaviors are over-pathologized if they differ from those of the majority (white) cultureE.g. active or “aggressive” male youth of color being diagnosed with ADHD or ODDLatinx family networks are strong and tightly meshed which discourages people from seeking treatment.It is only if these family support systems are “lacking or become ineffectual in handling a crisis that Latinos may seek professional help.”If Latinos or Non-Hispanic White people perceive their support systems will not judge them and they will not be embarrassed they are more likely to seek specialized mental health care. (Gonzalez, J.M., et al., 2009)

7. Why a triage system Counseling Center has 3 full time therapists and a director to serve 12K students.When allowed walk-ins for a full session there was a large no show rate to follow up appointments, especially when with a different counselor.Therapists were getting burnt out due to high demand.Increased over past 10 yearsHigher severity of needVP (and ethics) didn’t want a large wait-listDidn’t want service limitations due to lack of mental health services in BronxHad to figure out a way to service students when they made a decision to seek treatment due to mental health stigma concerns while giving optimal care by busy therapists.Looked to the literature to see what others were doing and changed it to suit our needs and size. Hardy, J. A., Weatherford, R. D., Locke, B. D., DePalma, N. H., & D’Iuso, N. T. (2011)

8. Our processIn person, right now Complete CCAPS-34CCAPS-62 given at intakeComplete Request for ServiceSDS given at IntakeComplete AUDITDifferentiate between Crisis HR, Crisis and TriageData obtained during paperwork and appointment allows us to make clinical decisions about type of follow up and when to schedule

9. Request for service(Modified from Penn State SDS)Address stigma (SFBT “pre-session change”)Contract around format of session and clarify expectationsScan for relevant informationRace, gender, sexual orientationLook for engagement questions:Who referred you?Relationship status MajorTransfer/ class statusBeen in counseling before?I ask about work

10. Request for serviceSolution Focused questions“What would make you feel like coming to counseling today was worth it?” OR “How would you know you felt better if you woke up feeling good tomorrow?”Miracle questionClarify sources of supportClarify what has helped overcome obstacles in the pastEven maladaptive coping skillsScaling questions for checklistAddress any substance useSummarize at end of session (support self-efficacy)Stress post-score and scaling

11. Solution-focused approachClients come to therapy with some level of hopelessness because their lives aren’t going the way they’d like. When clients believe therapy will work, or believe in a solution, they are more likely to work towards that solution and feel better. So by developing goals, especially early on as change happens rapidly in the first 4 sessions, we are instilling hope in clients.With SFBT, client and therapist work together to construct how therapy will be useful and helpful by co-creating the path towards change. Strengths-based and highlights the client’s inner resourcefulness “A lot of people are depressed and do nothing about it, but you did. That takes a lot of strength.”Reiter, M. D. (2010)

12. SFBT InterventionsPre-session change: “Making the session today was already a positive step you took- what strengths do you have that allowed you to do that?”What’s different question: “Are any of these concerns less than they would have been a month ago? What’s different? How were you able to do that?” Future focused questions: suggests the future is a hopeful place where destiny can be created; what clients want, not how life has been unfulfilling. Therapist: “What are you hoping for coming to therapy today?”Client: “I don’t want to be depressed, I want to be happy.”Therapist follow ups: “What would your life look like if you were happy?” “What would you be doing?” “Who would be in your life?” “What’s a small step you can take today to make that reality happen?”Exception Questions: suggest that there are sometimes when the client has mastery over a certain concern or when the concern doesn’t happen: “Are there any times when you don’t feel lonely? What’s different then? Can you replicate this?”Reiter, M. D. (2010)

13. Use of Motivational interviewingMotivational Interviewing is “a client-centered, directive method for enhancing intrinsic motivation to change.”Collaboration Partnership that honors clients’ perspective while expressing empathyEvocation Resources and motivation for change lies within the client- help them understand what works and their values and goalsOARSAutonomyCounselor affirms capacity for self-direction towards their informed solutionCan make progress in single sessionHelps us assess readiness for change (stage of change)Arkowitz, H., Westra, H. A., Miller, W. R., & Rollnick, S. (Eds.). (2008)

14. Why scaling questionsScaling questionsPart of both Motivational Interviewing and SFBTHelp assess stage of change and elicit change talkHelps understand importance and confidenceE.g. How stressful is this concern on a scale of 1-10, when 1 is hardly stressful and 10 is extremely stressful?How confident are you on a scale of 1-10, when 1 is not confident and 10 is extremely confident, that you will follow through with your solution of/coping skill… Begin to build change talkTherapist: “You say that loneliness is an 8/10, what would it take you to move to a 7?”Client: “If I could talk to someone in class and they give me their number or their Instagram…”Therapist: “How likely is it that you can do that on a scale of 1-10?” “What personal strengths can help you succeed?”OR in SFBT“You say loneliness is an 8, if you woke up and tomorrow it was a 7, what would you notice that was different in your life that would have you choose that number?”Arkowitz, H., Westra, H. A., Miller, W. R., & Rollnick, S. (Eds.). (2008)

15. Practice with each otherTake a look at the example of the Service Request provided to you today.Using this sample client, get into pairs and practice engaging the student. Each person should take turns in a role play being the client and the therapist.One person of the pair should ask a Solution Focused question using the written data.The other person should ask some MI scaling questions around the concerns or around what committed action the student should take.

16. Assessment of urgency of needRatings for concernsOverall level of distressStage of ChangeStrengthsCoping skills: adaptive and maladaptiveAUDIT score and substance useYour own conceptualization/assessment

17. Triage assessmentEmergent, Urgent, RoutineEmergent: Positive Suicidality, homicidality, DVPart of case management systemUrgent: Severe depression or anxiety; coping methods are not available or not utilized or are maladaptiveRoutine: Adjustment issues, mild anxiety, stress. Coping skills are utilized and/or adaptive

18. At the end of the brief sessionReaffirm coping skills and solutions committed to in session.You should have created these using your SFBT and MI based questionsRemind them of what has worked in the past. exception questionsEncourage them to reach out to their supporters. Coping questions, solution buildingGive hope that goals can be met in the timeline the student wants. Create a case management system to follow up, especially with higher risk students.

19. Waitlists… is there ever enough space?We did have waitlists this year due to high demand for servicesAt 125% of utilization as compared to 2016-17Understaffed, counselor position vacant for entire school yearWaitlist entries were also prioritized based on triage assessmentTitanium allows you to do this; can choose a priority and risk levelNo one who is actively suicidal or homicidal was put on the waitlistWaitlisted students were contacted 3 times before being taken off of the listStudents were assigned to a group while they waited for an individual appointment

20. Demographics of our assessment of the Triage process

21. Effectiveness of triage process

22. Why this worksStudents are reminded of their coping resourcesWhat worked in the pastWho are their alliesStudents asked to commit to a coping plan before next sessionNeeds are met right awayalready combated stigma to get through the doormeet the student where (and when) they arecommutes are long; this gives easy accessnot marginalized, same treatment for allstudents feel heard and like their concerns matter

23. How can you implement in your settingDiscussion and questions

24. ReferencesArkowitz, H., Westra, H. A., Miller, W. R., & Rollnick, S. (Eds.). (2008). Motivational interviewing in the treatment of psychological problems. New York: Guilford.Hardy, J. A., Weatherford, R. D., Locke, B. D., DePalma, N. H., & D’Iuso, N. T. (2011). Meeting the demand for college student concerns in college counseling centers: Evaluating a clinical triage system. Journal of College Student Psychotherapy, 25, 220–240. Reiter, M. D. (2010). Hope and expectancy in solution-focused brief therapy. Journal of Family Psychotherapy, 21, 132–148.http://www.lehman.edu/institutional-research/interactive-factbook.phphttps://www.census.gov/quickfacts/fact/table/bronxcountybronxboroughnewyork/SEX255216

25. thanksMuch thanks to Keeauna Jacobs, BS, our research intern for everything.If you have any questions and want to contact me, please do so by emailing megan.wilen@lehman.cuny.edu