College Counselors' Perceptions of Working With First‐Year Students With Chronic Illnesses

An emerging area of concern for today's college population is the readiness of students with health concerns such as chronic illness (Carroll, Muller, & Pattison, 2016; Eaton et al., 2017). Chronic illness is defined as a disease that is persistent over time (at least 3 months); results in an overall decrease in quality of life; and includes conditions such as asthma, diabetes, and cancer (Centers for Disease Control and Prevention, n.d.). Unlike their peers without such illnesses, first‐year college students with chronic illnesses face a myriad of academic, personal, social, and health issues in the transition from high school to college. College counselors can be a valuable resource for these students in developing and implementing appropriate interventions to assist in addressing these issues.

First‐Year College Student Success and Chronic Illnesses

Despite improvement in the attendance rates of students with chronic health issues, disparities in college readiness and completion persist, with a 16% graduation rate for undergraduate students with chronic illnesses versus a 50% graduation rate for students without such illnesses (Carroll et al., 2016). First‐year students with disabilities such as chronic illnesses are of particular concern because they often deal with personal, social, and academic adjustment problems that may result in lower completion rates and difficulty maintaining career goals (Cholewa & Ramaswami, 2015; Knight, Wessel, & Markle, 2018; Melzer & Grant, 2016). First‐year students with health issues are also at more significant need for assistance in addressing social, physical, and emotional barriers; dealing with stress of self‐managing health tasks and issues; and accessing disability services for appropriate accommodations (Carroll et al., 2016; Eaton et al., 2017; Leonard, 2013).

According to Herts, Wallis, and Maslow (2014), 27% of first‐year college students reported dealing with a chronic illness and expressed concerns related to academic support, stress management, and self‐advocacy (Francis, Duke, Brigham, & Demetro, 2018). The inability to navigate and address these issues related to college success is substantial. Consequences include delayed graduation, lower rates of persistence, loan obligations, fewer job prospects, lifetime of lower earning, difficulty making career decisions, greater anxiety and academic‐related distress, participation in public assistance programs, and lack of help‐seeking behavior (Conduti, Hayes, Locke, & Young, 2016; Hughes, Gibbons, & Mynatt, 2013; Leonard, 2013). Beyond academic and career concerns, students with chronic illnesses have a high prevalence of suicide ideation and attempts, as well as self‐injurious behaviors (Barnes, Eisenberg, & Resnick, 2010; Ferro et al., 2017). Mullins et al. (2017) also found that college students with chronic illnesses tended to display more depressive and anxious symptomatology. Furthermore, Balfe (2007) found that first‐year college students with chronic illnesses engaged in risky alcohol consumption, putting their mental and physical health at increased risk.

With the increased emphasis on college success for all students, it is essential to understand intervention options for students transitioning from high school. According to Leonard (2013), 95% of high school seniors expect to attend college; however, there is still growing concern that high school graduates are not prepared for the academic and social aspects needed for successful college readiness. At‐risk students (e.g., those with chronic illnesses) have even greater difficulty with this transition (Hughes et al., 2013; Lawson, Gould, & Conley, 2016). For example, students with chronic illnesses reported significantly lower college preparation in high school than did their peers without such illnesses (Carroll et al., 2016). Furthermore, unmet personal and social needs often result in poor college outcomes for this population (Lapan, Poynton, Marcotte, Marland, & Milam, 2017).

Despite being well positioned to work with high school students for college and career preparation, many school counselors perceive a lack of training and time due to large student ratios to properly prepare students for college transition (Goodwin, Li, Broda, Johnson, & Schneider, 2016; Morgan, Greenwaldt, & Gosselin, 2014). As a result, the responsibility often falls on college counselors to provide preventive, crisis, outreach, and consultation services to all students (Council for the Advancement of Standards in Higher Education [CAS], 2015). Additionally, the Americans With Disabilities Act (1990) addresses the need for aid to improve attendance and persistence for students with disabilities such as chronic illnesses (Carroll et al., 2016). Furthermore, the American Counseling Association (ACA; 2014) states in the ACA Code of Ethics that all counselors are responsible for assisting clients in promoting mental health and well‐being as well as seeking fairness and equality.

The standards mentioned above especially hold when working with potentially at‐risk students, such as those with chronic illnesses. In particular, first‐year college students with chronic illnesses such as asthma, diabetes, and cancer are in great need of academic, social, and personal assistance when transitioning to college (Cates & Schaefle, 2011; Lapan et al., 2017; Melzer & Grant, 2016). For instance, these students face issues related to caring for their own medical needs in addition to gaining access to health care services on and off campus (Lemly, Lawlor, Scherer, Kelemen, & Weitzman, 2014). Furthermore, first‐year college students with health issues have more significant transition needs (e.g., roommate relationships, medication maintenance) than do their peers without health issues (Carroll et al., 2016). If these needs go unmet, poor college outcomes, as well as potential decreased physical health, could result (Eaton et al., 2017; Hicks & Heastie, 2008; Lapan et al., 2017). Because of such difficulties, students with chronic illnesses reported the need for increased emotional or mental health support (24%) as the most requested service in college (Francis et al., 2018). The impact of interventions is vital considering that counseling serves as a strong predictor of freshman success for underrepresented populations (Cholewa & Ramaswami, 2015; Hughes et al., 2013; Melzer & Grant, 2016). With counseling interactions providing such a potentially positive impact on successful college outcomes for first‐year students with chronic illnesses, there is a necessity for further research into the perceptions and experiences of college counselors to gain knowledge about areas of need and strength in providing college success support, services, and practices.

Method

We explored the experiences and perceptions of college counselors working with first‐year students with chronic illnesses through a phenomenological lens. This qualitative approach to research allows for in‐depth understanding and identification of perceptions, experiences, and insights of the participants, resulting in deeper meaning associated with them (Creswell, 2013). In this type of qualitative inquiry, researchers respect and honor that the college counselors are experts in their own experiences and can relate their perceptions of working with first‐year students with chronic illnesses in a meaningful and relevant manner (Crotty, 2003). Our work was guided by the following research question: What are college counselors' perceptions and experiences of working with first‐year college students with chronic illnesses?

Participants

For this study, we used a purposive sample of 15 professionally credentialed college counselor volunteers who worked at the counseling centers of 4‐year, public universities. We recruited volunteers through the American College Counseling Association's (ACCA) electronic mailing list, which is used by 1,500 college counselors. By reaching out to a national membership, we recruited a diverse sample of participants to contribute to the study. This number of participants meets the qualifications for this type of phenomenological study (Creswell, 2013). We collected the following demographic information from the participants: race/ethnicity, gender, years of experience as a college counselor, and location of practice in the United States. Of the participants, 13 identified as White women, one as an African American man, and one as a White man. Years of experience as a college counselor ranged from 0 to 16, with a mean of 5.76 years. Regarding location of practice, six participants had practices located in the Northeast, four had practices in the Southeast, and five had practices located in the Midwest. All participants met the requirement of being a professional credentialed counselor working at a college counseling center.

Procedure

The principal investigator (the first author) obtained approval from the institutional review board before participant recruitment or data collection. The study met all requirements for the ethical treatment of participants as outlined by the ACA Code of Ethics (ACA, 2014). ACCA granted access to potential participants. ACCA's electronic mailing list was used to send invitations requesting participation in the research study on two occasions. Members were provided a link to the questionnaire, which included an informed consent form that needed to be completed before the questionnaire would commence. Participation in this study was completely voluntary. We provided the participants with a $10 gift card to a national retailer for completion of the data collection process.

An open‐ended questionnaire created by the principal investigator and a qualitative data analysis collaborator was used to gather data from the participants. We created this questionnaire to explore the particular areas pertinent to this research endeavor based on issues found in the relevant literature. The questionnaire consisted of 13 questions and prompts to explore the participants' demographic information (e.g., race/ethnicity, years of experience, location of practice) and perceptions and experiences (e.g., training, interactions, interventions) related to working with incoming freshman students with chronic illnesses. Sample items include “Discuss any counseling interactions you have had with freshmen with a chronic illness condition (i.e., cancer, asthma, diabetes, sickle cell syndrome, etc.),” “Share what type of counseling interventions you have used with freshman students dealing with chronic illnesses,” “Describe the training you received in your counseling program related to working with students with chronic illnesses,” and “What are some recommendations you would suggest for services for students with chronic illnesses?”

To ensure that proper questions and prompts were used, we created the questionnaire in collaboration with a qualitative data analysis collaborator. The questionnaire was also shared with college counselors from our campuses for feedback and edits. We administered the questionnaire through SurveyMonkey, a standard tool used to administer surveys and questionnaires. The site meets requirements for appropriate confidentiality and storage of private materials. The questionnaire and results were available only to the principal investigator and were password protected on a computer that is password protected.

The questionnaire took approximately 30 to 45 minutes to complete. We used a web‐based questionnaire because most individuals are familiar with email, electronic mailing lists, and the internet. Additionally, internet‐based questionnaires are more cost‐efficient, tend to generate higher response rates and faster response time, minimize interviewer error, and allow for greater flexibility with the formatting of information (Berry, 2005). As mentioned above, an informed consent document was included and had to be reviewed and completed before the questionnaire would commence, thus ensuring that all aspects of the research process, including potential risks, benefits, confidentiality, and voluntary participation, were covered. Participants could withdraw from the research process at any point in the data collection process. Participants were assigned pseudonyms to maintain confidentiality.

Data Analysis

We used a thematic analysis. This approach is a flexible process that identifies, analyzes, and reports patterns or themes within the data to organize and comprehend the perceptions, experiences, and potential needs of the participants (Attride‐Stirling, 2001; Braun & Clarke, 2006). Thematic analysis is guided by Braun and Clarke's (2006) six steps for analyzing data: (a) becoming familiar with the data, (b) generating initial codes, (c) searching for themes, (d) reviewing the themes, (e) defining and naming the themes, and (f) producing a report of the results.

The principal investigator reviewed all the questionnaire responses before the coding process began. In qualitative research, researchers completely immerse themselves in the data by continually reviewing the materials, making notes as themes begin to emerge (Braun & Clarke, 2006; Potrata, 2010). An open coding procedure was used to examine the questionnaires for distinct segments and sort them into categories (Grbich, 2007; LaRossa, 2005). Throughout this process, we dissected the data into recurring words and phrases that could create the basis of repeated patterns or themes. Subsequently, the principal investigator consulted with the qualitative research collaborator to discuss coding of the data and to organize the categories and subcategories that described common themes that emerged from the process. We then grouped the data into new combinations by identifying relationships between the categories. Finally, the coding process linked the categories together into a specific set of categories to address the research question. The principal investigator and collaborator reviewed and refined the final results to ensure that there was complete consensus on the thematic content and phrasing of the results.

Research Team

The research team consisted of the principal investigator with 10 years of qualitative research experience and an assistant professor (the second author) with 10 years of experience as a professor and mental health practitioner. We compensated the collaborator through a grant for her work on the research project. The principal investigator developed the methodology and instrument and conducted the majority of the data analysis. The collaborator reviewed and provided feedback on the development of the data collection instrument in addition to providing feedback on the data analysis process in consensus coding.

Trustworthiness

Throughout the data analysis process, several trustworthiness strategies were used to establish credibility and rigor. For instance, the principal investigator and collaborator met to discuss any inherent assumptions and biases that could exist and influence the data collection and analysis processes. We identified assumptions based on personal experiences as counselors and counselor educators. For example, the principal investigator discussed his previous counseling work with high school students with chronic illnesses and college preparation as well as current work in counselor education with counselors‐in‐training to work with this population.

Additionally, the collaborator disclosed and processed her previous interactions working with children with chronic illnesses as a resident counselor and therapeutic support person at a summer camp for 2 years. In this role, the collaborator provided services in the event of emotional or behavioral crisis experienced by the children or the staff. The principal investigator and collaborator explored the impact of their experiences, beliefs, and potential biases to ensure that they did not affect the study. Identifications and acknowledgment of these assumptions imply that the researchers' beliefs have less chance of affecting the perceptions of the participants in the results (Creswell, 2013; Patton, 2015).

We also used member checking in this study as a measure of the accuracy and trustworthiness of the data analysis (Patten, 2007). Participants were contacted by email and provided findings of the data analysis to review and offer any additional feedback, information, or questions. The participants reported agreement with the findings in terms of the accuracy of the ideas and comments. Peer debriefing was also used to enhance trustworthiness (Patton, 2015). This process involved a review by two colleagues with significant college counseling and chronic illness experiences; they reviewed and discussed the data analysis process and results of the study. Final efforts that were used to enhance the study's trustworthiness included reflective journaling for transparency, an audit trail of the data analysis process, and a constant comparison method during the data analysis to represent a rich and full immersion into the data (Patten, 2007).

Results

We determined four primary themes that described how college counselors perceived their experiences working with first‐year college students with chronic illnesses: (a) chronic illness counseling preparation, (b) chronic illness interactions, (c) counseling interventions, and (d) needs of students with chronic illnesses. Each theme is discussed below, with relevant quotes that illustrate the college counselors' experiences and perceptions.

Chronic Illness Counseling Preparation

In discussing how their counseling programs helped prepare them to work with populations with chronic illnesses, including first‐year college students, the participants indicated a significant lack of training. Of the 15 participants, 10 reported that they received minimal training and education while in their counselor preparation programs regarding how to appropriately counsel individuals with chronic illnesses. These participants' experiences included no “specific training,” “none,” “very little” training, or training that was “very minimal.” Only one participant, Mari, specifically mentioned any training provided during a master's‐level curriculum, with chronic illness being covered in her “diversity course.”

As a result, several participants acquired training in this area beyond the traditional master's‐level counselor preparation program. For example, Ray noted that he “took classes in counseling students with chronic illness,” but this came during his “doctoral program in counseling psychology.” Peter also discussed his “training at two externship sites” in which he received “training in MI [motivational interviewing] techniques” and “family therapy for building support for the identified patient.” Similarly, Natasha shared her “limited exposure to the impact of diseases on mental health” during her practicum but that this experience helped her learn that “chronic illness conditions can be central to the mental and social well‐being of humans.” In Laura's case, she gained her chronic illness knowledge as the “disability services coordinator” at her counseling center, with this training coming “through the Association on Higher Education and Disability.”

In contrast, Barbara stated that although she had “no formal training,” her experience as a “Type 1 diabetic” assisted her with “personal knowledge to work with chronic illness.” Kara also commented on the importance of being “aware of their medical needs and the impact on their daily living” as well as being “aware of my own biases related to their condition.” Thus, the college counselors noted a significant lack in the amount of training and education that allowed them to prepare to work with students with chronic illnesses in effective and knowledgeable means.

Chronic Illness Interactions

The majority of the participants (n = 11) indicated having at least one experience working with a first‐year student with a chronic illness. The chronic illnesses directly experienced by these participants included diabetes (n = 7), asthma (n = 4), cancer (n = 3), epilepsy/seizures (n = 2), mood disorders (n = 2), arthritis (n = 1), lupus (n = 1), sickle cell (n = 1), traumatic brain injury (n = 1), and other (n = 4).

The college counselors indicated a wide variety of experiences resulting from their interactions with students with chronic illnesses. For instance, Diana noted that although she worked with students who had “asthma and diabetes,” it “was not the presenting concern when [they] came to our counseling center.” Conversely, Jean discussed that her students with “asthma and diabetes” came to the counseling center for “their mental health, not physical health needs. If students register with disability services, they get help with their physical disability with them.” Janet added a specific experience with her comment that “student athletes make use of counseling services when chronic illnesses impact their performance or ability to play.”

Peter discussed his difficulty in his interactions with this population, noting that “freshmen tend to not respond well to counseling unless they have had previous counseling and are returning to counseling” and that they “tend to experience denial of their condition or do not take it seriously.” Barbara shared her experience with students who “struggle with managing their diabetes independently.” Similarly, Laura noted the importance of working with students to “understand how their illness contributes to their college and career decisions.” Finally, Natasha shared the positive experiences of working with this population in her understanding the importance of “working on respecting the body and accepting the body's gifts, depathologizing the self, [and] making repairs to the damage done to students' self‐respect.”

Chronic Illness Counseling Interventions

Whereas three participants noted no counseling interventions needed or used, the remaining 12 participants discussed a variety of approaches for providing services to students with chronic illnesses. Most notable, eight of the participants shared specific theoretical approaches that they used in providing counseling services to this population. These counseling theories included cognitive behavior therapy (CBT; n = 7), solution‐focused therapy (n = 2), dialectical behavior therapy (n = 1), existentialism (n = 1), person‐centered therapy/motivational interviewing (n = 1), and eclectic models (n = 1).

Participants also discussed using an array of techniques and strategies in their counseling interventions. Jessica shared her experiences in aiding these students by helping “them accept their illness and finding coping strategies to manage symptoms both physical and psychological.” Similarly, Laura used “coping strategies that best serve them,” with an emphasis on a “collaborative exchange using solution‐focused interventions where strength‐based successes from the past are used to inform what works in the present.” Janet also noted that “students I've worked with seem to benefit from external interventions that try to find meaning in their experiences.” Jean discussed focusing on grief because “they are dealing with grieving their life before the illness or anxieties surrounding it, so we talk about that.”

Felicia's perspective on serving the students was that “they just need someone who doesn't judge them for their differing abilities or health status” and allowing “them to talk about it along with all of the other challenges they are facing.” She also added the importance of assisting students with developing skills to “ask for accommodations through disability services and how to talk to their professors about it.” Kara used “role playing” to help students increase their natural supports and to “communicate health concerns with an RA [resident assistant] or roommate.” She also assisted students in “identifying a safety plan in case of a medical emergency and creating a list of emergency phone numbers to contact their parents or guardians in case of an emergency.” Natasha shared that “we take a strengths‐based perspective” to help “students understand if and how their condition may be impacting them emotionally” and to help them “think about their living setting with a mind towards their care plan.” Finally, Peter noted the importance of “basic case management” skills to balance all of the students' needs.

Needs of Students With Chronic Illnesses

The final theme that emerged from the college counselors' responses related to the needs of the students with chronic illnesses. Although participants discussed a variety of needs, campus resources were the most common, with eight of the college counselors mentioning this need. For example, Jean stated that students needed to be able to find “appropriate services on campus in different areas, including counseling, disability services, and academic advising” because having “those supports in place very early sets them up for the best success and they will feel supported.” Natasha emphasized that students must become aware of “what health care is available on campus, what the costs are, and where the offices are located,” as well as basics such as “bringing medical records, securing a primary care provider near the school, and having their medical supplies on campus.” Helena also discussed the importance of using the “campus wellness center to meet nurses, counselors, and campus accessibility specialists.” For Diana, it was ultimately about helping students find “different places to receive treatment if needed and how to go about this, what the college health center can and cannot do, and resources in the community.”

The college counselors discussed other areas of need they noted for the first‐year students with whom they worked. Support systems were of importance for several of the counselors. Barbara's suggestion was to help develop or connect with a “student‐run group or join a club if the school has one for additional support on campus.” Working with students to ensure that they were adequately prepared for self‐management of their illnesses was also imperative for some of the college counselors. Jessica noted that her students needed “preparation to handle the illness on their own if they have not done so.” This included helping them with being aware of “doctors they will be seeing, making sure Rxs [prescriptions] are filled and accessible,” and being aware of “disability accommodations, residence life, and medical center/counseling.”

Another need addressed by Peter related to ensuring that students dealing with a chronic illness are “educated about the benefits of involving parents in the transition to college,” as well as “educating them about registration with the office of disability accommodations and establishing a relationship with a counselor early.” Conversely, Janet believed that students with chronic illnesses needed help “managing their health needs without parental involvement” to “take responsibility for things like setting up appointments, knowing how insurance works,” and “having a personal plan that looks at things like self‐care and how they recognize when physical health concerns are becoming an issue.”

Discussion

The results of this study corroborate the specific counseling and support needs for first‐year college students with chronic illnesses. Participants indicated a varying degree of training ranging from no training at all, to some training beyond graduate school preparation, to personal experience with a chronic illness. Because of this overall lack of formal training, we noted an inconsistency with the levels of perceived comfort and skill to work with this population. According to CAS (2015), college counselors have the responsibility to provide preventive and crisis services to students of varying backgrounds. This responsibility is paramount considering that students with disabilities such as chronic illnesses face more significant academic, personal, and emotional needs than do their peers without disabilities (Carroll et al., 2016; Eaton et al., 2017; Lawson et al., 2016). Nevertheless, students with chronic illnesses seek less help from counseling centers, even though counseling has been shown to serve as a strong predictor of academic and social success with this population (Cholewa & Ramaswami, 2015; Melzer & Grant, 2016). Therefore, consistent and thorough training is needed so that college counselors are prepared to serve this population in terms of college transition needs, medical and health services, and academic and personal guidance (Cates & Schaefle, 2011; Lapan et al., 2017). Without adequate training, college counselors may not provide these services effectively and efficiently. Counselor preparation programs can enhance the experiences of college counselors‐in‐training through collaboration with the medical community (e.g., nursing training programs, local high school nurses, pediatricians) to develop increased knowledge of chronic illness issues and interventions.

Inconsistency was also a noted theme in the college counselors' experiences of providing interventions to first‐year students with chronic illnesses. Although the majority of the participants discussed working with students with various chronic illnesses, there was no consensus on the counseling strategies, theories, or interventions that they used. With 23 different interventions (e.g., coping strategies, CBT, person‐centered therapy, collaboration, eclectic models) mentioned by the participants in our study, it is evident that no specific guidelines exist for providing counseling services to students with chronic illnesses at the college level. This lack of a best practice approach to counseling students with chronic illnesses mirrors the inconsistency of the college counselors' training experiences regarding this population. As a result, it can be challenging for college counselors to select a proper path when such a diverse array of interventions has surfaced for working with first‐year students with chronic illnesses.

Researchers have suggested a variety of strategies as valid means for working with students with chronic illnesses and who are facing academic, personal, social, or medical struggles (Hicks & Heastie, 2008; Leonard, 2013; Melzer & Grant, 2016). For example, research has found that the application of cognitive and behavioral interventions has positive effects on college outcomes (e.g., persistence, completion, satisfaction; Haemmelmann & McClain, 2013). Ultimately, counselors must develop methods suited to each student's needs to provide comprehensive interventions in which all aspects of the student's understanding of the illness are addressed (ACA, 2014; Wiginton, 1997). Without consistent knowledge and information regarding the most effective and efficient means for working with chronic illnesses in the college setting, counselors will continue to use inconsistent interventions to provide counseling services to this specific population.

Another area that arose for the college counselors was the impact of students' needs for myriad support and advocacy components in addressing medical and health needs. Participants discussed a wide range of needs for first‐year students with chronic illnesses, such as academic and emotional support, access to health and pharmacy resources, assistance with self‐management of illnesses, and connection to community‐based resources. These needs align with the literature. First‐year students transitioning from high school face the difficult challenge of leaving an environment of familiarity with support systems (Herts et al., 2014; Knight et al., 2018). These freshmen report a desire for a sense of community and inclusion (e.g., mentoring) to assist them in transitioning to the college setting (Francis et al., 2018; Melzer & Grant, 2016). In making this transition, students with chronic illnesses face the additional responsibility of managing their health care needs by finding doctors, maintaining appointments, and handling symptoms, while simultaneously meeting academic and social responsibilities (Eaton et al., 2017).

Fortunately, research supports the capability and resiliency of students with chronic illnesses to manage their issues based on their experiences, family support, and personal strengths (Cantrell & Conte, 2016; Reed‐Knight, Blount, & Gilleland, 2014). Nevertheless, many students with chronic illnesses still require assistance in adapting to specific aspects related to transitioning to the college environment. For instance, Hicks and Heastie (2008) found that students with chronic illnesses have significant difficulties in adjusting to roommate relationships and housing conditions and are more likely than their peers without such illnesses to engage in self‐injurious behaviors and prescription medication abuse. College counselors are in a critical position to assist with these various issues.

Implications for College Counselors

Our findings have direct and consequential implications for the college counseling profession for providing the most current and appropriate counseling services to first‐year students who are managing a chronic illness as they adapt to college life. During their training, college counseling students can communicate with faculty members to request inclusion of information related to chronic illness and proper skills and interventions into the course curriculum (e.g., counseling skills, theories, multicultural counseling). This content can include current articles for review and discussion, role plays, and case conceptualizations dealing with chronic illness issues. In particular, counselor educators must introduce appropriate research‐based, best practice interventions, including cognitive mapping (Wiginton, 1997), CBT (Haemmelmann & McClain, 2013), systemic approaches (Carroll et al., 2016), or narrative therapy (Hughes et al., 2013), to ensure that counselors are working for the good of the client by promoting mental health and well‐being (ACA, 2014). College counseling students and professionals must also be more active in seeking out, attending, and sharing professional development experiences related to chronic illnesses and practical interventions (e.g., coping skills, advocacy) to enhance the opportunities for gaining knowledge and skills required to serve this specific population. This knowledge is paramount considering that healthy behaviors and self‐efficacy gained during the college years can result in improved academic and career outcomes for students (Cantrell & Conte, 2016).

College counselors can also advocate for college‐ and university‐level changes for training, support, and collaboration. Including community resources from the medical and mental health professions could provide increased knowledge, insight, and interventions. Community and campus contacts can be accessed and organized to provide guest speakers, resources, and training opportunities for students, professors, and counselors. College counselors can also work with other college personnel and students to develop and maintain a response plan and team to address the needs of students diagnosed with a chronic illness. The college counselor should be the leader of the team, along with members who have expertise in medicine and academics (e.g., campus health staff, administrators, student health). The critical tasks of this team would include developing a plan with appropriate staff and college personnel to address a student's chronic illness diagnosis, providing information and access to counseling services, and providing training in communication skills for college faculty and staff to work with this specific population.

Additionally, college counselors should seek out collaborative relationships when working with students with chronic illnesses. A significant strength of this population is that they tend to enter college with coping and management abilities from years of experience with their diagnoses (Cantrell & Conte, 2016; Eaton et al., 2017). Therefore, it is essential for college counselors to collaborate with students regarding skills and abilities already in place and address areas of need. Collaboration with high school counselors is also needed to ensure that knowledge and skills related to management of the chronic illnesses, availability of accommodations, and necessary college readiness skills are in place. This collaboration and preparedness could significantly enhance positive results of transitioning to college (Goodwin et al., 2016; Leonard, 2013).

Finally, college counselors must be willing to advocate for changes in the current status of students with chronic illnesses and how they engage with the college environment. Given that less than 50% of students with disabilities such as a chronic illnesses do not even disclose their diagnosis or utilize existing services, a stigma still exists regarding this population (Carroll et al., 2016; Couzens et al., 2015; Herts et al., 2014). In addition, only 58% of colleges reported a system that was able to identify youth with chronic medical conditions (Lemly et al., 2014). Without this identification, students could be missing out on much‐needed medical, academic, and counseling services. All college personnel must become aware of the needs of and available resources for students with chronic illnesses to combat the difficulties this population may endure at the college level (Hughes et al., 2013; Knight et al., 2018). Furthermore, Cantrell and Conte (2016) recommended that college counselors engage students with chronic illnesses through health education, campus fairs, and empowerment activities to enhance self‐efficacy and healthy life choices while raising awareness of this population.

Limitations and Directions for Future Research

This study has some limitations. First, the qualitative methodology used in the study does not seek to provide generalizable results. Instead, the goal is to provide an in‐depth exploration of the perceptions and experiences of the participants. Our findings may also be limited in that data were collected only from a self‐selected set of volunteer college counselors.

Additionally, participants were predominately White (n = 14) and female (n = 13). College counselors from differing racial/ethnic backgrounds or genders might have had unique lived experiences related to working with college freshmen with chronic illnesses that were not captured in this study. It would also be beneficial to expand the participant populations to include counselors at a variety of institutions (e.g., community colleges, private universities) to explore diverse settings. Exploring perceptions and experiences of first‐year students with chronic illnesses related to high school and college counseling may also help to expand the research in this area. The inclusion of culturally diverse students, parents, and college personnel in the data collection process could also enhance the perceptions and experiences related to chronic illness in the college environment. Finally, although we abided by a thorough thematic data analysis process, it is possible that a preconceived bias could have affected the analysis. These limitations are meant to serve as a starting point for addressing future research. For instance, future studies might include in‐person interviews in conjunction with online questionnaires for a potentially more robust data set.

Conclusion

The goal of this research was to understand college counselors' experiences and interactions with first‐year students with chronic illnesses. Our findings indicated a need for additional training, collaboration, and resources to support both students with chronic illnesses and college counselors. Counselors can use this resulting knowledge in developing more inclusive and supportive college environments for students with chronic illnesses, college counselors, and college personnel.