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Medicine and Health

Take Note: Ben Locke On College Student Mental Health Trends

Ben Locke
Courtesy of Ben Locke
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On this episode of Take Note, we talk with Ben Locke, the director of Penn State's Counseling and Psycological Services and the director of the Center for Collegiate Mental Health at Penn State. He founded the Center in 2005 and began leading the process of conducting an annual reporter of mental health services for colleges across the U.S. in 2008.

Here is the interview:

Welcome to Take Note. From my home studio, I'm Jade Campos. May is Mental Health Awareness. Over the past 20 years, there's been a dramatic increase in college students seeking out mental health treatment. Today we'll talk with Ben Locke, the senior director of Penn State's Counseling and Psychological Services. Locke started in the position in 2016 after serving as the associate director of Clinical Services for five years. He's the founder and the director of the Center for Collegiate Mental Health at Penn State. Every year, the Center releases an annual report that looks at counseling services at colleges across the United States.

JADE: Ben Locke, thanks for joining us to share your expertise on mental health. 

 

BEN: Happy to be with you, thanks for the invite.

 

JADE: So, over 150 schools took part in the report this past year. So, how does the Center for Collegiate Mental Health conduct its annual reports and where's the data coming from? 

BEN: So, the Center for Collegiate Mental Health actually represents almost 650 institutional members. And of those, a portion of them are able to contribute data each year. And CCMH is called a practice research network, because we bridge practitioners and researchers through this membership organization. So the way that we gather data is really different than how almost all other information about college student mental health is generated. So instead of conducting a survey when we report on data from the centers we're essentially reporting on the measured population as opposed to a sample of the population, and our data is all coming from students actually seeking mental health services.

 

JADE: It has been basically 20 years since you've been conducting the report, so what kinds of changes in trends have you seen since it started?

 

BEN: Yeah, well, a lot. So, the original idea of CCMH was began in 2004, pursued in 2005, building the technology and pilots and all of that led to our first data coming out in 2009. So, the big trend is that nationally we know that the percentage, the number of students seeking mental health services, has grown many many many times that of institutional enrollment. In 2015, it was at least five to six times the rate of institutional enrollment. And what's really interesting is that many of the media reports out there will say that college student mental health is a crisis, everything is getting worse and that's sort of the narrative. What we actually see in this very high quality national data is that most areas of mental health have been fairly flat — there have not been huge increases or spikes. It's just that there's more people seeking the services than ever before and that increases every single year. And then within that increase the one trend that does appear to be the case is that students with characteristics that represent a potential threat to themselves have been going up every single year that we've been measuring the data. And I guess that along with students reporting greater rates of self reported anxiety or depression. So those are those are, I guess, a couple of the big trends that we've been seeing there.

 

JADE: Yeah, I noticed that anxiety has been the most prevalent mental health concern for clients over the past several years, and over 60% of students surveyed this past year said anxiety was one of their primary mental health concerns. Do you think there's a reason for this trend? 

 

BEN: Well, so, a couple of things. Anxiety eclipsed depression for students in the mid ‘90s. So, it used to be the reverse that, in treatment centers depression was primary, anxiety was next. So, there's been a lot of writing and a lot of speculation as to why it is that anxiety has become a predominant concern for today's generation, and certainly pressure to perform, pressure in schools, the ever present level of multi-threaded communications happening all day long — kind of too many demands on the same person — contribute to that. We have been actively encouraging the reduction of stigma — so the worry about being judged negatively for mental health concerns — we've been actively encouraging people to seek help and we've been training communities in the identification referral of mental health concerns. So, I think one of the components that has happened is that people have learned to use mental health language to describe their internal experiences as a culture. And so that today, instead of having butterflies in my stomach before giving a talk, people might say I have anxiety about public speaking, which might be true but anxiety is also normative. So, I think that the rise in anxiety is interesting, it's also leveled off this year. So, if you look at our annual report, that bit of data you mentioned actually, the 60%, comes from clinicians. So after a clinician sits down with a student and evaluates them they indicate why they came in. For the last couple of years we've seen, the rate of anxiety and depression start to level off a little bit, which suggests that the rate at which new students are coming in with those concerns has slowed down some.

 

JADE: Do you think this is because more people have been seeking counseling services? There's been a dramatic increase in recent years, is it just because having mental health concerns and seeking counseling has become more normalized and more okay in society?

 

BEN: Well, there's lots and lots of good conversations happening about that question and books being written and all kinds of things. It seems very clear that there's multiple factors. So, many people point to the rise of technology — social media as a major contributor to the rise in anxiety and mental health concerns. Other people point to the demands and competition that students and others experienced in terms of going to college, and other people would point to two decades of intervention focused at helping people bring concerns forward. I think I would tend to believe all of those things as playing a role, but I am a particular advocate for acknowledging that we have spent two decades trying to convince people to seek help and giving them the language to label their experiences as a mental health concern. And the one concern that I have there is that anxiety is a normative human experience. In fact, If you don't have anxiety, we might be worried about you in a different way because anxiety is your body's way of kind of communicating with you that you've approached a boundary or an edge or there's too much happening. It allows you to respond appropriately. And even the experience of depression is a normative human experience over the lifetime — mild maybe even semi-moderate. And so, I think one of the things that may have happened is that, in addition to being successful and encouraging people to bring their concerns forward when they have legitimate mental health concerns, is that we may have inadvertently kind of convinced a generation of people and their parents to label normative experiences as a mental health problem instead of a life challenge that is about transitions and loss and all difficult things, but things that have historically also been managed through natural support systems and natural helping networks. And that's a very tricky thing to disentangle — what requires professional help versus what can be managed through all the normative channels, but I think there's been this repetitive drumbeat of a message driving people into professional help and that may be part of what we're seeing, certainly not the only thing but part of it.

 

JADE: Yeah, there's definitely a lot more of an acceptance of it on college campuses. Being a college student myself, I know a lot of students feel a lot more comfortable being more open with their peers about mental health concerns. Do you think there's something that students themselves can be doing to combat these normative experiences, especially if they don't necessarily need professional services?

BEN: Yeah, great question. So absolutely, and I think what we're labeling these days is called “wellness” or “well being,” maybe “holistic well being." You know, when I used to do a lot of counseling and I was working with people with anxiety, one of the kind of messages I would give people that was somewhat surprising was this idea of embracing the anxiety. You're experiencing anxiety for a reason. Let's not run away from it, because that actually will make it worse. How do you turn and sort of face the difficulty you're experiencing? It's not so much I think students need to combat normative experiences but that I would say as institutions begin to pivot from ‘if you experience distress, seek professional help’ toward ‘if you experience distress, what are you doing in your life to help yourself be well?’ That that's kind of the messaging we want to give to students very early, on as early as possible, K-12 and college. Here are all of the things you can be doing in your life to be happy and well. And when you have the guaranteed periods of being upset, being down, being sad, feeling worried, here are the ways you can navigate those as a person that lots of other people use successfully. And I think one of the challenges about being well at a holistic level is that you kind of have to do it in advance. Right, you can't wait until you have a crisis to be well you have to be taking the steps every day, intentionally and planfully. So, that's I think probably the most important message there.

JADE: If you're just joing us, we're talking with Ben Locke, the senior director of Penn State's Counseling and Psychological Services. He's also the director of the Center for Collegiate Mental Health, which surveys U.S. colleges about their counseling services.

JADE: The report measures colleges and universities by their clinical load index, so schools that have a higher clinical load index have a higher average annual caseload per counseling staff member and the highest was 310. So that's one counselor seeing 310 students over a year?

BEN: That's right. So, the clinical load index is something that CCMH has been developing over the last couple of years to create a new metric that colleges and universities can utilize to understand the level of mental health services they provide on their campus. And you can think of a CLI score as being equivalent to the annual caseload of a standardized counselor. So yeah, a score of 310 would translate to being responsible for 310 clients in a year whereas other schools might have a 45 so you're responsible for just 45 clients in a year. And one of the things that research in mental health treatment, and actually almost any kind of human service finds is that case loads matter. When you have a really high caseload, you have to ration what you're able to provide each person. When you have a lower caseload, you can give each person more of whatever it is you're responsible for handing out. And in mental health treatment, we know that people get better in the course of treatment, just in counseling centers nationally, very, very effective. But if you don't have enough of it, you may not benefit fully. And at a school with a CLI of 250, 260, you know, even over 200 really, there's not going to be a lot of what we think of as treatment going on. There will be quick evaluations, maybe follow ups, referrals to community providers, but it'll be probably hard to get ongoing individual treatment. 

JADE: So, fewer in shorter appointments for students then. 

BEN: Yep, so if you're at a school with a high CLI, you're going to have fewer appointments and they're going to be spaced farther apart.

JADE: So where does Penn State fall on the caseload per counselor index then? 

 

BEN: So, we land in the 140 to 150 range, and we would be about average among peers of our size so other Big Ten institutions, other large public institutions. And one of the interesting things about Penn State is that that number applies to University Park and many of our commonwealth campuses may actually have much lower case loads, because they're smaller campuses. And so one of the things I think that we, as a field of higher education, need to begin thinking about is, you know, what is it that a student needs when they go to college, what's the overall experience? And if you're a student who goes to college thinking, and your family, 'We really want to be able to have, you know, ongoing kind of mental health care right available on campus all the way through,' a really, really big, large public institution may not be the best choice whereas a smaller, more intimate hands on school may be a better choice. So we're hoping that as the CLI starts to develop that it can be used to help in decision making — both for students and parents but also for institutions that are evaluating how much of what services are providing. 

 

JADE: Since Penn State is pretty average on its caseload, what does that mean for the students attending Penn State right now?

BEN: Penn State Counseling and Psychological Services at University Park, like many schools of our size, operates what's called a short term model — so we don't tend to provide long term individual treatment. We tend to provide short term support and short term counseling, short term psychiatry. And then if students are in need of long term care, we'll typically work to help them find a referral in the community. The other thing that it would mean is that if you were attending a school with a very low CLI, it might be possible for you to begin individual counseling when you start at that campus and stay in counseling all the way through until you graduate. At Penn State, we will have to limit that, because we just don't have the resources and so that means that there will be some limits on the amount of care, how long you can be in care, and at certain times of the year, there may be a wait for some kinds of services. So, that's what a score in that range typically means. One of the reasons for creating the score was to help bring kind of transparency to understanding why limits exist in mental health services. Sometimes people get very frustrated — ‘I don't want to be on a waiting list, why is the wait long,’ you know now, or whatever. Those limits exist because of the case loads. So, it's not that the counseling, you know Penn State or any other counseling center, doesn't want to be helpers — everybody who works in the counseling center spent their entire professional career becoming a helper. The limits exist because of the number of folks available to serve. And so we're just trying to bring really transparency to that experience, and hopefully to bring alignment to the stakeholders — the parents and students and faculty and staff and university leadership. 

JADE: So the 2019-2020 report went through June 30, 2020. So, it does include the first few months of the pandemic. Did you see this affect the report in any way?

 

BEN: When, in the spring of 2020, when most colleges and universities went remote, one of the consequences of that is that there was a big drop off in the number of students being served in counseling centers. And we did complete a five part blog series that's on the CCMH website as well where we did a very deep dive into kind of the intersection of COVID and mental health. And so, in the 2020 annual report, it did reflect that drop off in students being served in the spring. And then what we observed in the fall nationally, there was a drop in the average number of students seeking mental health services nationally. And my sense of that is that it was really tied to residential living — in other words if students were living at home, if they were remote, they were probably tending to seek services where they lived as opposed to a campus far away. 

JADE: Yeah. And does that include telehealth services? There were 67% of institutions that were involved in the report that reported that they were offering telehealth services for their clients.

BEN: Yeah, and when we updated that with fall data we found like 99% of campuses converted to telehealth and that included Penn State. Yeah, so that did include telehealth services. 

 

JADE: Is telehealth a good alternative to in person services? How much is lost compared to attending a session in person?

BEN: Yeah, what a great question. So, prior to COVID, telehealth was an amazing innovation that was kind of slowly moving along and where it was most useful was in the case of specialties that couldn't be accessed locally and in the case of just being unable to provide a local provider. The onset of COVID forced everybody into remote services, and it was wonderful in the sense that CAPS was still able to serve students all the way through the COVID experience, but there were real limitations there. So, for example, it's not allowed for mental health providers to treat students in other states, because you have to be licensed in the state where the student lives so that definitely got in the way. But that kind of limitation aside, my sense is that both students and mental health providers generally prefer in-person care but that when in person care is not available or the specific kind of in-person expertise you need isn't available, that telehealth was an amazing option, which really saved us all during the pandemic because without that people would not have been able to seek care in the same way. And we are very much looking forward to holding on to some of the silver linings with telehealth as we move back onto campus and figuring out what worked really well and what do we want to keep and what was really something we did because we had no choice. 

 

JADE: What are some of the things that you feel like worked really well for this past year? 

BEN: Well, one of the things that feels really important is that for some students with very difficult schedules or who are living remotely or at a distance, telehealth is the option and being able to deliver that service is just a wonderful solution. There are all kinds of scenarios that come up in the provision of mental health care where having a session or two remotely would be much preferred rather than not having treatment. And one of the things that we're really constantly innovating on is how do we strike the right balance between giving students quick access to brief clinical consultations versus starting long-term care, and the tele-environment just seems like an ideal way for students to quickly and efficiently meet with a provider without having to kind of walk across campus or sit down in an office and all of those kinds of things. And so we'll definitely be exploring what we can hold on to there.

 

JADE: So, how do you think that the pandemic, since the next report will be the first report that covers a full pandemic year, how is it going to affect the report? Are we going to be seeing some of these things that students themselves are reporting and talking about?

 

BEN: It's a great question and one of the fun things about CCMH is that our data is always in the rearview mirror. And so it's like after the year has passed we look back and say 'Well what did we learn?' So, what we already know is that many areas of mental health, somewhat surprising in comparison to expectations, have remained fairly consistent — average levels of distress and those kinds of things during the pandemic. I think one of my concerns is that the pandemic has forced people to sort of back into their homes and into their apartments and created this social isolation, and there are certain kinds of mental health concerns that really thrive in isolation. So, for example, if you're a person with social anxiety, you're thrilled to not have to go out in the world and it is so much easier not to have to go out and interact with people. But when the world comes back online, that expectation is going to come back online, that's going to be really hard for folks. People who struggle with eating disorders, those symptoms tend to thrive in isolation without feedback and engagement and so we may see folks struggling with those coming forward. And so I think in general, one of the concerns I have as we move into the fall, is that there will be probably a large number of people coming forward who experienced real changes — grief, loss and very real mental health concerns — that were never fully attended to during the pandemic. When that happens, when those folks come forward, my concern is will we have the capacity to see them all?

 

JADE: Lifetime trauma experiences, like physical or sexual abuse have actually increased over the past several years. Do you think the pandemic will ultimately be seen as a traumatic experience for students? 

 

BEN: That's a great question. So, the trauma item — the number that you're referring to — is again provided by a clinician. That still remains a fairly small percentage, but it has been consistently going up year after year. I do think that from a grief and loss perspective in particular, there has been trauma for students. And I'm aware that some one of the other things that can happen is that if you're living in an abusive environment and you can't leave that environment that that can also create the opportunity for trauma, so I do think that is something that we may see more of as people start to come back out into the world. 

 

JADE: You've been a part of the Center for Collegiate Mental Health since 2008. What are the biggest takeaways that you've seen from the reports and what are the main changes universities should be adopting to improve their services?

BEN: Well actually, I founded the Center for Collegiate Mental Health back in 2005 and the first report actually came out in 2008 and it was this crazy event where we weren't quite sure we were going to be able to pull off this idea. I think what CCMH has really contributed in terms of data is a very accurate picture of what students are actually seeking services for and the rates at which they're seeking those services. So, CCMH really was the first to clearly document the rate at which the increase was occurring — the fact that not all areas of mental health are getting worse, that there are specific kinds of concerns that were increasing. And I think, perhaps, the other two things I would mention is that our research and reporting has made it very, very clear that treatment provided by counseling centers is just as effective as the best treatment provided out there if there's enough of it. The clinical load index, CLI, the focus of the most recent report, was created to help institutions and their stakeholders begin to grapple with the trade offs that come with different kinds of resourcing decisions for mental health services. Institutions face many, many competing needs and interests, they have to strike a balance and when they strike that balance, we just all want to be on the same page about what that means for students who are seeking the services. So, for me, to be able to create that tool over time with the CCMH staff and all of the members of CCMH has been a wonderful outcome. But the other part I would speak to is that the data that CCMH generates, which is used for advocacy and policy and funding decisions, is really the voice of students and it is the voice of the clinicians who treat those students, and so it feels like a real honor to be able to, you know, almost 20 years ago, say, ‘What if we did this, would we be able to accomplish that?’ And then today to look back and say, 'Hey we have created a channel really to give voice to students and their providers in helping to drive the future of mental health and higher ed.'

JADE: Ben Locke, thanks for talking with us.

BEN: Thank you for having me, Jade, my pleasure. JADE: Ben Locke is the senior director of Penn State's Counseling and Psychological Services. He's also the director of the Center for Collegiate Mental Health, which surveys U.S. colleges about their mental health services. You can find this and other Take Note interviews on our website at wpsu.org/TakeNote. I'm WPSU intern Jade Campos.

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