Embedded Student Counseling Services

Over the past several years, there has been a trend for universities to respond to increasing demands and improve access to student counseling services by developing satellite offices around campus (Golightly et al., 2017) or by creating counselor positions embedded in schools or colleges within the broader university (Adams, 2017). For example, LeViness et al. (2017) reported that approximately 13% of the counseling centers that participated in the Association for University and College Counseling Center Directors survey have counselors embedded in athletic departments, residence halls, colleges within the university, or other locations on campus. Additionally, some universities have developed separate counseling services to serve students in specific graduate and professional programs. Although embedded counseling services are becoming more common, there have been limited discussions in the counseling literature regarding practices and challenges associated with developing and sustaining them. These discourses may be valuable to university counseling professionals who are already working in embedded roles and to university counseling center administrators and other stakeholders involved in developing and supporting these positions.

The purpose of this article is to describe how counselors who are members of the Veterinary Mental Health Practitioners (VMHP) group under the auspices of the Association of American Veterinary Medical Colleges are using innovative embedded counseling models to meet the mental health needs of professional students in colleges of veterinary medicine (CVMs). VMHPs are involved in building wellness and support programs in CVMs, developing best practices in veterinary counseling, and providing counsel and expertise to veterinary leadership (Association of American Veterinary Medical Colleges, n.d.). They provide a useful prototype for discussing applications of embedded counseling models to serve professional student populations, due to the range of services they offer and the robustness of the programming they have developed. In this article, we offer insights and suggestions for establishing embedded counseling services, defining scope of practice, transitioning to embedded counseling practice, maintaining professional boundaries, and navigating ethical challenges. To accomplish these objectives, we solicited descriptive feedback from members of the VMHP group by distributing a Qualtrics survey (https://www.qualtrics.com) via email. Survey responses were collected between June 7 and July 7, 2018. We contacted all 40 current members of the VMHP group, and 24 members responded.

Mental Health Needs Among Veterinary Medical Students

One of the first considerations involved in developing embedded university counseling services is determining the specific needs of the target client population and the feasibility of using embedded models to meet those needs. Research suggests that professional training in veterinary medicine is associated with significant academic and nonacademic stressors, including heavy workloads (Pickles et al., 2012), concerns about academic performance (Sutton, 2007), transitional and relationship stress (Reisbig et al., 2012), and financial concerns (Pickles et al., 2012). Many studies have found that veterinary students are at increased risk for anxiety and depression (Karaffa & Hancock, 2019; Reisbig et al., 2012; Siqueira Drake et al., 2012), suicidal ideation (Cardwell et al., 2013) and nonsuicidal self‐injury (Karaffa & Hancock, 2019). Furthermore, rates of completed suicide among postgraduate veterinarians tend to be several times higher than rates among the general public (Tomasi et al., 2019). Ultimately, mental health concerns may negatively affect veterinary students’ academic performance and impede their ability to provide quality services to their patients (Hafen et al., 2007).

Graduate students, in general, may tend to experience numerous difficulties regarding competing roles and responsibilities (Benshoff et al., 2015), and the issues experienced by veterinary students are very similar to those reported by professional students in other disciplines. For example, literature suggests that both medical students (Dyrbye et al., 2006, 2008; Schwenk et al., 2010) and law students (Bibelhausen et al., 2015; Flynn et al., 2019; Larcombe & Fethers, 2013; Organ et al., 2016) report high rates of anxiety, depression, and suicidality. They may also experience stressors related to heavy workloads, adjustment to the professional school environment, exposure to human suffering, financial concerns, perfectionism, and managing ethical dilemmas, which may affect their mental health (Bibelhausen et al., 2015; Dyrbye et al., 2005; Flynn et al., 2019; Jolly‐Ryan, 2009; Lester et al., 2011).

Access to student counseling services can decrease academic distress (Lockard et al., 2012) and improve retention (Lee et al., 2009), and it may also be an important factor in student recruitment (Bishop, 2010). Pragmatically, there are several potential benefits associated with embedded counseling positions in veterinary medical and other professional training programs. For example, even if counseling services are available through university counseling centers, it may be difficult for professional students to travel to access services during typical business hours because their programs often include internship and practicum responsibilities (Hafen et al., 2017). Having access to an embedded counselor allows students to attend appointments during lunch breaks or between classes, and it offers greater accessibility to services in crisis situations (Drake et al., 2017). Some authors have suggested that embedded counselors are also in a unique position to develop a specialized understanding of the structure and challenges of professional training, which may improve rapport and clinical effectiveness with students (Drake et al., 2017; Kogan et al., 2012). Accordingly, most CVMs in the United States have created fully or partially embedded positions for counselors to provide a variety of services (Hafen et al., 2007), and similar approaches could be applied in other professional training programs.

Establishing Embedded Counseling Services

When initially establishing embedded counseling services, it is important to consider factors such as prospective counselors’ credentials, practical considerations regarding office space and equipment, organizational and supervision structures, funding sources, and record‐keeping resources. Among the VMHPs who offered feedback to our survey request, all held graduate degrees in a counseling‐related field and were independently licensed to provide mental health services as psychologists, clinical social workers, or licensed professional counselors. Mental health practitioners with a variety of professional credentials may effectively provide embedded university counseling services; however, stakeholders should strongly consider employing practitioners who are licensed or license eligible, with relevant professional experience in university counseling centers or community and outpatient mental health settings.

In the initial stages of establishing embedded counseling services, stakeholders must also consider embedded counselors’ access to office space and the equipment they will need to complete all functions of their positions. Counselors’ offices should be easily accessible for clients but also as private as possible, given the constraints of the building in which they are located. For example, in CVMs, embedded counselors may not have access to dedicated waiting rooms because they may occupy spaces that were originally designed as faculty offices or research laboratories. In these situations, it is preferable to identify a space that is away from heavily trafficked hallways or administrative offices to protect clients’ privacy. Counselors may wish to consider installing white noise generators outside their offices to muffle sounds from counseling sessions. Counselors can also establish protocols with their clients to reduce the likelihood that they will be identified by their colleagues. For example, the first author asks clients to arrive promptly at their scheduled session time (rather than early) and makes a dedicated effort to end sessions with enough time for clients to exit discretely. Embedded counselors’ offices should be large enough and furnished to comfortably accommodate the services they offer, especially if they provide couples or group counseling. In addition to physical space, embedded counselors will need a secure computer that can run any necessary software, a private printer for printing case notes or other clinical materials, and a locked filing cabinet for storing confidential information. Likewise, it is essential for embedded counselors to have access to a dedicated fax line or another secure alternative for transmitting confidential information regarding client care.

Embedded counselors may be affiliated with one or multiple organizations. Although over half (54.2%) of the VMHPs were affiliated only with the CVM at their respective institutions, several indicated that they were affiliated with a university counseling or student health center, with a full‐time or part‐time appointment in their CVMs. Some also indicated that they had a primary appointment with their CVMs and a secondary appointment with their university counseling centers, or a shared appointment with their CVMs and their university's department of social work. In general, embedded counselors’ supervision structures will likely vary based on their organizational affiliations. Many VMHPs are overseen administratively by more than one supervisor, and they commonly report to the dean of student affairs in their CVMs, the dean of academic affairs in their CVMs, the directors of their university counseling centers, or other academic department heads.

Being solely affiliated with a CVM or another academic college or department may offer some benefits to embedded counselors regarding procedural flexibility, but there may also be strengths to embedded counselors being associated with established university counseling centers. These benefits include access to peer consultation resources and training opportunities, well‐established procedural guidelines, and increased referral options (Adams, 2017). Because of the unique demands associated with providing embedded counseling services to a specialized student population, counseling center administrators involved in creating and supporting embedded positions should contemplate the feasibility of adapting certain forms or protocols if there are compelling clinical or logistical reasons for doing so. For example, allowing embedded counselors to create new appointment codes, streamline the client intake process, or modify attendance policies in some cases may help them meet the needs of their clients more effectively. It should also be noted that policies and procedures may need to be modified over time, particularly as newly embedded counselors are able to draw from their experiences with the target population or organizational context.

Stakeholders must also consider how embedded counseling positions will be sustainably funded. The majority of the VMHPs (87.5%) are funded by their CVM's budget, often through the veterinary teaching hospital, the academic affairs or student affairs offices, or a combination of both. Some are also funded by external entities, such as their university counseling centers or schools of social work. Stakeholders interested in creating embedded positions in specific colleges or professional programs should consider the needs of the target population, how they overlap with other populations on campus, and the possibility of partnering with established organizations with joint interests to share financial and administrative resources.

Another important initial consideration pertains to how embedded counselors will maintain their clinical records. Over half (62.5%) of the VMHPs informed us that they maintain their clinical records electronically using software such as Titanium Schedule, Point and Click Electronic Health Records, SimplePractice Electronic Health Records, Medicat Electronic Health Records, or StringSoft. However, some maintain paper charts and track client data using an office software suite. VMHPs who are unaffiliated with their university counseling centers are more likely to maintain paper records, possibly due to the costs associated with electronic record‐keeping systems for one or a few individuals. Stakeholders must budget for initial and recurring software and technical support costs regarding record keeping. In addition, university counseling centers who are already employing electronic record‐keeping systems should consider how embedded counselors will access secure data if their offices are located offsite. In many cases, this may involve collaborating with campus information technology professionals who are familiar with protected health information and data security practices.

Embedded counselors should also consider whether they will use standardized symptom or outcome measures to monitor counseling effectiveness, and whether they have the resources needed to do so. Two thirds (66.7%) of VMHPs who offered feedback indicated that they do not use standardized measures with their clients, which is consistent with figures among counselors in general (Castonguay et al., 2015). Nonetheless, as embedded counseling services become more common, outcome data may be useful in demonstrating their effectiveness and informing policy and funding decisions (Hunt et al., 2012). Although many measures are suitable for this task, the Counseling Center Assessment of Psychological Symptoms (Locke et al., 2011) is the most commonly used instrument among VMHPs.

Defining Scope of Practice

The next major consideration for developing embedded counseling services involves determining the overall scope of counselors’ practices. This includes identifying the types of services they will offer, the target population, and the service provision model they will use. Whether embedded counselors offer services on a part‐time or full‐time basis will likely depend on the demand for services, the roles counselors maintain within their organizations, and the financial and logistical resources available to support these positions. Most VMHPs (75.0%) provide services in their CVMs full‐time (i.e., 40 hours per week), but this may range from 10 to 40 hours per week, depending on whether they have shared appointments outside their CVMs.

Embedded counselors may provide clinical services that are consistent with the typical roles of other university counseling professionals (Prince, 2015), but some services may also be specific to their target population. As shown in Table 1, the most common clinical services that VMHPs provide include individual counseling; consultation with veterinary students, interns, or residents; crisis counseling; and consultation with faculty or staff affiliated with their CVMs. Some VMHPs provide services specific to the veterinary mental health role, such as consultation or grief counseling for pet owners and veterinary teaching hospital clients.

Table 1

Characteristics of Services Provided by Veterinary Mental Health Practitioners

Note. N = 24.

VMHPs are also involved in outreach programming, which is an integral component of contemporary counseling center practice and serves an important educative and primary prevention function (Golightly et al., 2017). The outreach topics VMHPs present (as shown in Table 2) are consistent with the needs of veterinary medical students as reflected in the literature (Sutton, 2007). Embedded counselors working with other professional student populations should be cognizant of tailoring outreach efforts to the specific target group. This may involve modifying preexisting outreach programming or creating new programming after reviewing relevant literature. Doing so may be a time‐consuming endeavor, particularly for newly embedded counselors. Therefore, it is important to factor in time for program development when initially establishing clinical case limits and contracting other professional responsibilities.

Table 2

Outreach and Psychoeducational Seminar Topics Provided by Veterinary Mental Health Practitioners

Note. N = 24.

Depending on the needs of their target population and organization, embedded counselors may also be involved in teaching, which is an uncommon role among counseling center practitioners (LeViness et al., 2017). Slightly more than half (54.2%) of the VMHPs informed us that they teach didactic or clinical courses in some capacity within their CVMs on several topics, such as the Healer's Art (Meyer‐Parsons et al., 2017), communication skills, human‐animal bond, grief and loss, mental health, and ethics. One VMHP clarified that they are only involved in providing guest lectures, with no involvement in course coordination or oversight, because of the potential for multiple relationships in light of their other clinical responsibilities. This highlights an important point: Although embedded counselors may bring a unique skillset that can contribute to the educative missions of their organizations, they must remain conscious of and adhere to ethical best practices that may not be fully understood by the organizations they serve.

Although research productivity is not typically emphasized by university counseling centers, Bingham (2015) explained how counselors working in these settings may help advance the profession through research endeavors, including authoring publications and presenting on topics related to their practice. Some VMHPs (33.3%) conduct research on topics related to mental health and veterinary medicine, including well‐being initiatives within CVMs, mental health stigma, the human‐animal bond, and moral distress. Considering the dearth of scholarship on embedded counseling models in general, it may be valuable for embedded counselors with appropriate interests and training to consider conducting research or presenting at professional conferences regarding aspects of their professional practice and for their supervisors to support them in these efforts.

Clearly identifying the service population is another necessary consideration when establishing embedded counseling services. VMHPs are most likely to provide counseling services to Doctor of Veterinary Medicine (DVM) students, but many also provide services to client populations that are not typically served by university counseling centers, such as postgraduate interns, residents, faculty or staff, and teaching hospital clients. If stakeholders are involved in creating embedded counseling models in which counselors are providing services to nonstudent clients, it is vital to review university liability policies and consult with legal counsel before establishing these practices. Embedded counselors and their supervisors should also delineate specific protocols to help maintain appropriate boundaries in these situations, because they may increase the likelihood of multiple relationships.

The service models used by embedded counselors, including session limits, attendance policies, and costs for services, should also be considered thoughtfully on the basis of organizational needs and clinical demands. Almost half (45.8%) of the VMHPs informed us that they do not impose session limits for the counseling services they provide, although they tend to work from brief counseling models. Most (87.5%) also indicated that their clients do not incur any additional costs for services because the services are covered through student fees or other funding sources. This is in line with practices among general university counseling centers (Center for Collegiate Mental Health, 2018).

The Center for Collegiate Mental Health (2018) reported that there tends to be a positive relationship between length of treatment and symptom reduction, and some clients may require more sessions to achieve the same magnitude of improvement as other clients. These findings highlight the importance of approaching brief counseling models flexibly, considering the needs of the client population. This is especially salient when working with professional students, since their training schedules and financial resources may preclude them from accessing counseling services off campus if they are referred to community providers. At the same time, embedded counselors, like other university counseling professionals, must balance the tension between ensuring that their clients can access services in a timely manner, while also ensuring that the services they provide are sufficient to effectively address their clients’ presenting concerns.

Over half (58.3%) of the VMHPs provide counseling services outside of typical business hours because many of their clients are in class or completing clinical training during the day. This is somewhat higher than the percentages reported in general university counseling centers (e.g., 39.7%; LeViness et al., 2017). VMHPs may accomplish this by shifting their regular hours (e.g., working from 10 a.m. to 7 p.m.) each day or by working later on certain days of the week. While maintaining flexible hours is one way of improving access for clients, it is essential for embedded counselors to develop a schedule that works with their routine and other life demands to help reduce burnout. Furthermore, counselors should consider after‐hours support protocols for situations in which they have to facilitate a client hospitalization or respond to other risks. Drawing on existing university counseling center services and protocols can be helpful for embedded counselors who offer after‐hours crisis support.

Transitioning to Embedded Counseling Practice

I felt isolated and overwhelmed with the mental health needs of the students. I was not sure where to find resources or the best way to set up systems for meeting the needs of the students. I had very little training on the job and learned as I went.

Another described feeling lonely at first: “I was used to being part of a department of multiple people who speak my language and understand the process mental health professionals use to do our work.”

I was fortunate that I had a DVM faculty member who was able to get me connected with other VMHPs. [This faculty member] also introduced me to faculty and staff in the college. This was very beneficial, because it helped me learn about the curriculum, students, and environment.

Another stated, “I have found that having a formal relationship with the university counseling center has been very helpful—easier access to psychiatry, after‐hours crisis services, and peer supervision/support.” Regardless of whether they are administratively associated with their university counseling centers, embedded counselors may benefit from establishing relationships with other mental health practitioners on campus for professional consultation, collaboration, and to share existing resources. Stakeholders may encourage these partnerships by providing protected time for embedded counselors to consult or attend meetings with other mental health practitioners.

VMHPs also shared insights regarding the importance of flexibility and adapting their practice styles to the characteristics of their clients. For example, a VMHP stated, “I became aware that framing whatever psychoeducation I wanted to share within a science or neuroscience framework worked best.” Others acknowledged how traditional counseling models may be difficult to fully implement within certain situations. One VMHP said, “The time demands of [veterinary] students’ schedules can make it hard for them to commit to getting the type of treatment they need.” Another echoed these sentiments by explaining, “It is difficult to utilize traditional methods of [counseling], as the [veterinary] students need to be able to get back to class, studying, [and] performing. What we want to do and what we can do are often in conflict.” Another responded, “The environment is so stressful that it [can be] hard for students to make progress, [and] students struggle with making time for self‐care.”

Embedded counselors in CVMs and other professional programs may also need to adjust to how local cultures can either facilitate or pose challenges for providing effective services. For example, VMHPs mentioned how norms regarding working long hours without taking breaks, perfectionism, unhealthy organizational dynamics, and conservatism with regard to implementing educational reforms make their work more difficult. One person explained how they perceive a “lack of understanding [within their CVM] as to how the culture impacts the well‐being of folks in the college.” Current and prospective embedded counselors may benefit from carefully studying the history and culture of the organizations they work within to identify potential challenges and opportunities for advocacy and change. We have found that approaching this task from a systems perspective is particularly helpful, as is consulting with other mental health professionals when needed.

Maintaining Professional Boundaries and Navigating Ethical Challenges

I wish I would have had the forethought to pick one or two areas of focus as opposed to doing a little—or a lot—of everything. I often feel ineffective as I don't have enough time to devote to one area. I often wonder if the students, clients of the hospital, [and] myself miss out, due to my lack of availability. I do recognize that I cannot do it all.

Embedded counselors should work with their colleagues and administrators to determine what is feasible and what is not to reduce burnout and ensure that they are able to consistently maintain high quality of care for their clients. Newly embedded counselors may navigate this process with some trial and error at first and may benefit greatly from regular mentorship or peer supervision.

In many cases, it is not feasible to refer a client out if they have some sort of relationship with another current or former client. However, in situations in which my objectivity could be impaired (e.g., seeing an ex‐partner of a client), I try to consider all possible referral options, and if [a referral] is not possible, I regularly consult with other psychologists at the university counseling center to help manage countertransference issues.

Regarding confidentiality, VMHPs described the “need to be diligent about educating faculty, staff, and students about confidentiality” including reiterating it “as often as necessary.” Some VMHPs mentioned how there are times in which it may be appropriate to discuss clinical issues with veterinary educators and administrators, and one noted how “[they complete] a release of information in these instances to consult with other stakeholders to ensure students’ academic support/success.” In other situations, embedded counselors may have to clarify what kinds of services they are able to provide in the context of their professional roles. For example, a few VMHPs described instances in which they were asked to evaluate students’ fitness for being readmitted into the DVM program, and they explained how making this determination would be unethical because of their other simultaneous roles. Embedded counselors can minimize some of these issues by developing clearly articulated practice protocols, ideally when their positions are initially being developed, although policies may also need to be modified as counselors encounter new, complex scenarios that they may not have been exposed to in their training.

As mentioned previously, some embedded counselors may be involved in teaching didactic or clinical courses within their respective organizations. In the case of VMHPs, while this speaks to their broad contributions in promoting essential nonbiomedical skills in veterinary medicine (Hafen et al., 2007), it also stresses the importance of careful boundary setting and thoughtful planning to avoid professional ethical dilemmas that may arise. For example, if counselors offer clinical services and are also tasked with providing formal or informal instruction to current or potential clients, it is prudent for them to avoid assuming any sort of evaluative role that may exploit power differentials, impair objectivity, or interfere with their counseling relationships. Once again, embedded counselors should work with stakeholders to anticipate challenges and develop thoughtful protocols so that their practices are consistent with professional ethics codes and in the best interest of their clients.

Conclusion

VMHPs provide a variety of clinical and nonclinical mental health services, some of which are unique to their work settings, and many of which are similar to those traditionally provided by university counseling centers. This article makes an important contribution to the college counseling literature by describing the professional practices of a group of embedded counselors. It may also be the first to elucidate considerations associated with initially establishing embedded counseling services, defining counselors’ scope of practice, transitioning to embedded counseling practice, maintaining professional boundaries, and navigating ethical challenges. This is especially timely considering the recent increase in embedded counseling positions around the country (LeViness et al., 2017). Embedded counseling models are one way of improving access to mental health services for specific student populations, but they are not without demands. Stakeholders involved in developing and supporting embedded counseling positions should weigh the potential benefits against realistic logistical, organizational, and ethical challenges. It is difficult to generalize our recommendations to all current and future embedded counselors working in veterinary medicine and other areas because of variations in program structures and professional responsibilities; however, we hope that this article provides useful insights and considerations for continued dialogue, in order to best support counselors and improve counseling practices.