CAPS experiences strain under increased demand

Over the past few years, the college has seen a strong upswing in student use of counseling and psychological resources. While the long-term national trend has been for growth in use of these resources, the demand at Swarthmore has picked up in the past few years. As this demand has continued to rise, the resources that CAPS is able to offer have shown strain.

Interest in student mental health sparked last semester after the release of the campus climate survey. Only 64% of students reported feeling “very comfortable” or “comfortable” with the campus climate, compared to a typical rate of around 80% for schools surveyed by the independent contractor hired for the job, Rankin & Associates. 41% of respondents reported having “seriously considered” leaving the college.

Student use of CAPS has risen steadily over the past five years. The 2014-2015 academic year marked a 52% growth in number of students served over the 2009-2010 year. In 2012, during the middle of that growth period, CAPS was expanded from four to eight offices. In 2014-2015, the number of students served was 426, and those students attended 4,296 sessions in total. In recent years, the average number of visits per patient has risen from 6 or 7 to 10.

CAPS use has grown especially rapidly this year, causing a greater strain than usual on resources, earlier in the year than usual. According to Director of CAPS Dr. David Ramirez, in most years, CAPS use steadily increases from the beginning of the fall semester through the spring. The CAPS office houses eight counselors, who can offer around 200 hours of therapy every week. When demand outpaces the service that the full-time employees can provide, CAPS uses a contingency fund to bring on extra counselors part-time. According to Ramirez, CAPS normally uses this money sometime in the Spring semester. This year, a part-time counselor was hired by the end of September.

In general, Ramirez is confident in the college’s funding of the services his department provides. “If I exceed the amount in my budget, the college will cover it… they just get that money from somewhere, ” he said. “I don’t know what it looks like at that level but I’ve never been told, ‘you’ve got to stop doing this, stop hiring extra people.’ I’ve been told, ‘do what you’ve got to do.”

Often, though, funding is not the problem.  “The college is very supportive in terms of providing the monetary resources to hire people, the constraint we operate under is space, basically. We are operating to full capacity,” he said.

As demand increases, students who want to schedule consistent meetings increasingly need to apply at the very beginning of the semester. Of the six students interviewed for the article, all but two reported scheduling their meetings at the very beginning of the semester. As the semester goes on, meetings are more difficult to come by, and a consistent or long-term schedule is especially difficult.

Kat Galvis Rodríguez ’17 described her difficulty setting up appointments even fairly early into the semester: “It was so hard to get an appointment so I wouldn’t use it very often because the appointment times I would get were just really inconvenient for my schedule,” she said. “As an incoming freshman you don’t know how high in demand CAPS is until you try to make an appointment two weeks in or three weeks into the semester and realize that they are all booked.” During her sophomore year, Galvis remained on the waiting list for two months. She noted, though, that the office has recently been open later in the day, which works better for her schedule.

CAPS maintains a scheduling list to handle students waiting for appointments. According to Dr. Ramirez, CAPS only considers the list to be an actual waiting list if it takes more than two weeks to schedule an appointment.

Even more than the normal counseling, CAPS’ psychiatric service faces high demand. Under normal conditions, the school’s psychiatrist Dr. Hewitt is only at school on Tuesdays and Thursdays for about ten hours each week. Like the flexible counselor hire, Dr. Hewitt can and often does work more hours in response to high demand, but only within a limited range due to time constraints.

Like other resources, the psychiatrist has faced a particularly straining demand this year. According to Ramirez, the Psychiatrist will often see between 55 and 60 students in a year. As of last week, he has already seen 88 students this year.

“We’re like the people at the bottom of the roller coaster holding on, like, ‘OK. How is this going to go?’” joked Ramirez, “I have a plan, I’m the director, I’m responsible for seeing all this stuff through. But in our world there’s just a lot of unpredictability.”

On top of his availability, Ramirez explained, there are limits to how late in the semester the psychiatrist can be of help to certain students. For most medications, patients need to be professionally observed during the initial trial period. Towards the end of the semester, starting students on a new medication is often not viable. In the fall, the cut-off point is before Thanksgiving break.

As a result of this high demand, CAPS has encouraged students who need more frequent psychiatric care than the college can provide to seek care off-campus. Students with this kind of need who do not have the resources for a private psychiatrist, though, are usually treated in-house. Ramirez noted that even for those who can afford it, finding a psychiatrist nearby can take a long time.

One student, Henry*, described an experience of considering quitting psychiatry appointments with Dr. Hewitt. As of right now, Henry regularly sees both the psychiatrist and a counselor. Diagnosed with bipolar disorder when he was 15, Henry has been on the same medication regimen for two and a half years. For much of that time, his condition has been stable but . At one point, he felt that his healthcare need was mostly clinical, and pursued the option of quitting his talk therapy appointments since he felt that he did not need them as much as other people. When he mentioned this idea to CAPS, they raised the option of him not seeing Dr. Hewitt either, and returning to clinical care with his nurse practitioner back home. Though he did not feel like anyone was pressuring him towards any one decision, he felt that the suggestion might be related to high demand of services.

“I don’t know that the reason that they suggested I could go off-campus for services was because they were trying to free up room to free up more appointments, because they were experiencing high demand. But I think that that could be a way that they can kind of manage the demand that they have.”

Recently, CAPS has begun requiring that students have already met with a counselor several times before requesting a new appointment with the psychiatrist.

Earlier this year, Galvis encountered this rule for the first time. Galvis decided to schedule an appointment with Dr. Hewitt one night after seeing her talk therapist, but she had not talked with her therapist about making that appointment. As a result, she needed to wait the whole week to schedule her appointment. The next week, she had a bad mental health episode, and ended up in the hospital, where she received medication. After the hospitalization, she had an emergency appointment with Dr. Hewitt to check-in. Though it is not clear that knowing about the rule change would have allowed her to get an earlier appointment, Galvis said that she experience wished there were more resources

“It cost a lot of money, even with school insurance, but I had no other option at that point…” she said. “That’s a situation that could have been prevented if there were more resources at CAPS.” Like the extra counselor hire, Ramirez has funds to hire a short-term employee who is authorized to write prescriptions. This January, CAPS started to use this option.

Galvis emphasized, though, her overwhelming positive experience with Dr. Hewitt. Unlike counselors, who often change, he has been a consistent familiar face at CAPS.

“Even with all of that… he’s really responsive by email, so if I have questions about my medication I can always e-mail him, which hasn’t been the case for other psychiatrists,” said Galvis. But I also just feel like he has a lot of students doing that all the time. He’s amazing, he’s the best psychiatrist I’ve ever had. I just don’t know how he’s the only one who handles — I don’t even know how many students go through him.”

Ramirez pointed to several trends that have encouraged the high level of recent resource use besides declining student mental health. He mentioned the overall increase in the student body, the increase in the number of incoming students who have already received mental health care of some kind, and a perceived decrease in the stigma of using CAPS as contributing factors.

“We used to have this goal, 10-15 years ago to reduce the stigma of going to CAPS, to lower the barriers, to try to make it easier if people didn’t want to come, if they had to be talked into it,” he explained. “That’s kind of totally gone away. CAPS just seems way more approachable now. So that’s a success, in terms of a cultural phenomenon.”

With the recent addition of administrators in the OSE, the Title IX office, and the Health Center who interact with students on a regular basis, Ramirez also said that more students are being directed to CAPS.

“There’s a lot of feeding that’s going into CAPS. It’s a very good system. It’s stimulated a lot more utilization,” he said.

Additionally, the college offers CAPS patients more leniency than some other undergraduate institutions. Unlike many peers, the college does not place a limit on how many meetings a student can schedule in a semester. The college also does not charge students for missed appointments, which occurs at other institutions. Missed appointments, according to Ramirez, are a universally frequent event at undergraduate institutions. In 2014-2015, CAPS scheduled 5,650 appointments, but only 4,296 were used.

Several students interviewed for the article reported feeling guilty about missing appointments and about taking up space in general, but missing appointments can also be dangerous. Henry relies fairly heavily on reliably having his medication. Most students who get their medication at Worth have their prescriptions delivered from Rite-Aid. Henry expressed frustration with this process, and specifically Rite-Aid.

“[Rite-Aid] just takes an unreasonable amount of time to fill and deliver prescriptions. It has taken over a week before for me to have my prescription after I drop it off at Worth.” Henry described instances where he had to rent a Zipcar and drive to Rite-Aid to get his prescription on time.

With delays from Rite-Aid, Henry has on occasion had difficulty filling his prescription after missing appointments. Each time, though, he said that CAPS has worked around and resolved the issue.

Galvis described her own experience feeling guilt about the use of CAPS resources. “One of the reasons I stopped using CAPS at one point was because, miraculously, I was okay at Swat. I wasn’t going through anything traumatic, my disorder wasn’t extremely bad. And so I remember thinking, ‘I shouldn’t be using CAPS right now because there are so many people on this campus who need it, and aren’t getting it because I have the appointment slot. If I’m okay, then I should just give up this appointment slot so that somebody else could have it,” she said. By this reasoning, she quit her sessions at the time.

“Lo and behold I found myself four weeks later in crisis. Because that’s not how counseling works. You can’t just go as needed. You need to go consistently for it to work,” she said.

Besides limiting access to resources, higher demand can also change the quality of the resources themselves. Student demand may affect, for instance, how consistently a given student can see the same therapist from semester to semester, especially if certain therapists are particularly popular. Continuity can be very important for therapy, and switching therapists is often difficult. Galvis expressed the difficulty she faced when she found out at the end of her Freshman year that the counselor she had been seeing was going away.

“It’s such a long term process of trying to get to know someone and open up to someone and have them hear your story, and kind of build that trust and have that relationship with someone,” she said. “To spend a whole year trying to do that, and to find out you have to try someone else and you have to do that process again… that takes up at least the first four sessions.”

Mark*, a student who has seen the same counselor for almost two years, expressed that this continuity was very important to him.

“There are sort of two things that are lost, at least in my experience. One is the ability of the person to have an intuition for what’s going, or to see a pattern in the things you’re worried about,” he said. “The second thing that’s lost, which is maybe a certain type of therapy, is the sort of therapy where you really dig into familial stuff or more deep-seeded things. I don’t think generally people feel comfortable talking about that sort of thing in any real way with a stranger.”

These more subtle, qualitative changes occur on the administrative end as well. Describing the limitations of the flexible hire system, Ramirez emphasized the importance of team-work among CAPS counselors.

“The downside to having to hire another person is that our model of clinical work is collaboration. We rely a lot on being able to communicate. Staff with supervisors, I supervise everybody, there’s another layer of supervision that supervises the more junior people. We all interact with Dr. Hewitt,” he said. “That’s already 10 clinicians. I am very reluctant to add another person. It’s not like we’re digging a ditch: ‘ok, you. Go dig over there.’ It’s not that easy. There’s a lot of coordination that has to go on. So we’re ready, if we need to add another human being to the system. But I try to keep it to a limit.”

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