Recognize and Refer?

Mental health issues on college campuses are a pertinent concern for college counselors and their constituents (Auerbach et al., 2018). Auerbach et al. (2018) conducted an international investigation of 13,984 college students across 18 colleges in eight countries and found that approximately 35% of students screened positive for at least one mental health disorder. College counselors are responding to the need for mental health support services on college campuses by devoting approximately 41% of their time to providing systems‐level mental health services (Brunner et al., 2014). Peer‐to‐peer mental health support, for example, is a popular systems‐level mental health support strategy (Brunner et al., 2014; Lekka et al., 2015). Peer educators are a common type of peer‐to‐peer mental health support initiative in which college counselors identify and train students to recognize and refer their peers to mental health support services (Golightly et al., 2017), because peers are typically the first point of contact for a student who is in mental distress (Walther et al., 2014).

Peer‐to‐peer mental health support initiatives have grown on college campuses (Golightly et al., 2017). However, the results of a national survey of undergraduate students (N = 51,294) indicated that the majority of students (72%) are not making referrals to mental health support services when encountering a peer in mental distress (Albright & Schwartz, 2017). To this end, Kalkbrenner and Flinn (2020) developed, validated, and cross‐validated scores on the Mental Distress Response Scale (MDRS). The MDRS is a screening tool for appraising two latent variables or dimensions of mental health literacy that compose college students’ potential responses to encountering a peer in mental distress. Specifically, the MDRS consists of two subscales: Approach/Encourage (responses consistent with peer‐to‐peer mental health support) and Diminish/Avoid (inactive or avoidant responses to encountering a peer in mental distress). However, little is known about demographic differences in college students’ propensity for making peer‐to‐peer referrals to the counseling center.

The 21st century has seen substantial increases in young adults’ enrollment in postsecondary academic institutions (Auerbach et al., 2016). This new wave of college students represents an increasingly diverse population with an assortment of mental health needs (Kena et al., 2016), and there are significant demographic differences in college students’ attitudes about mental health and their utilization of mental health support services (Cheng et al., 2018). It is, therefore, essential for college counseling researchers and practitioners to consider cross‐cultural implications (including student demographic differences) as they design, implement, and evaluate peer‐to‐peer mental health support initiatives. In the present study, we sought to explore demographic differences in students’ responses to encountering a peer in mental distress. College counselors and researchers are increasing their allocation of resources to supporting systems‐level interventions in response to the growing and evolving college student population. Peer‐to‐peer mental health support, for example, includes training students to recognize and refer their peers to the college counseling center (Golightly et al., 2017; Wei et al., 2015).

Peer‐to‐Peer Mental Health Support and Mental Health Literacy

Mental health literacy (MHL) is an emergent concept in the college counseling knowledge base that encompasses one's attitudes and behaviors about mental health, including one's utilization of mental health support services, familiarity with warning signs and resources for mental distress, and proclivity for recommending mental health support services to others (Wei et al., 2015). Several past investigators have found positive associations between increases in MHL and college students’ inclination to seek mental health support services (Coles & Coleman, 2010) as well as their propensity to recommend mental health support services to their peers (Kalkbrenner & Hernández, 2017; Servaty‐Seib et al., 2013). However, the literature on peer‐to‐peer mental health support (i.e., recognize and refer) with college students who identify with non‐White ethnic identities is in its infancy. Investigating MHL in a cross‐ethnic context is an important area of inquiry because college students who identify with minority ethnic backgrounds tend to be less likely to seek mental health support services when compared with their counterparts (Cheng et al., 2018; Masuda et al., 2009).

College Student MHL: Correlates With Demographic Characteristics

For decades, past and present investigators have emphasized the importance of considering demographic differences in college student mental health (Cauce et al., 2002; Cheng et al., 2018). Specifically, past investigators have identified differences in college students’ attitudes about seeking mental health support services based on a number of demographic variables, including gender (Eisenberg et al., 2013), ethnicity (Smith et al., 2014), and help‐seeking history (Kim et al., 2015). The synthesized findings from previous researchers suggest that students who identify as female tend to report mental health disorders more frequently when compared with their male counterparts (Eisenberg et al., 2013; Smith et al., 2014). College students who identify as female also report more favorable attitudes about the benefits of attending personal counseling (Pattyn et al., 2015) and are more likely to attend counseling (Pedrelli et al., 2016). Relatedly, female students tend to report higher awareness of warning signs for mental distress and mental health support services (Kalkbrenner et al., 2020). Female college students are also more likely to refer a peer who might be showing signs of mental distress to the counseling center as compared with their male counterparts (Kalkbrenner & Sink, 2018). In addition, Kalkbrenner and Hernández (2017) found that male students were significantly more likely to refer a peer in mental distress to debilitative resources (e.g., taking them drinking) when compared with female students.

Previous researchers have identified demographic differences in college students’ MHL by ethnic identity. Students who identify with minority ethnic backgrounds tend to report higher levels of mental distress, including depression, loneliness, suicide attempts, and binge drinking, and indicate poorer mental health functioning (Pérez Benítez et al., 2010; Smith et al., 2014). Similarly, Kim et al. (2016) found that students who identified as White reported higher rates of attendance in personal counseling and were more likely to complete counseling when compared with students who identified as Asian, Indian, Chinese, Korean, and Vietnamese. There are, however, some inconsistencies in the literature because Rosenthal and Wilson (2008) reported no significant associations between gender or ethnicity and college students’ utilization of mental health services. The complex intersectionality between gender and ethnicity, and differences in expression of mental health disorders (i.e., somatically vs. psychologically), might explain these inconsistent findings (Boyraz et al., 2015).

Boyraz et al. (2015) extended the literature on demographic correlates with college student mental health by investigating the interaction between gender, ethnicity, depression, social support, and posttraumatic stress disorder (PTSD). Results revealed that perceived social support was significantly affected by both PTSD and depressive symptoms for students who identified as White and male when compared with those who identified as female or as Black and male. However, students who identified as Black and male did not report significantly lower perceived social support when experiencing PTSD‐related avoidant symptoms (Boyraz et al., 2015). Hefner and Eisenberg (2009) also demonstrated the importance of social support in the relationship between gender, ethnicity, and mental health. Hefner and Eisenberg discovered that ethnic minority and male students were less likely to have high‐quality social support; these findings are important to note because such support is correlated with lower levels of depression, anxiety, suicidality, eating disorders, and self‐harm.

One's help‐seeking history or past attendance in counseling is another demographic variable associated with MHL. Kalkbrenner and Neukrug (2018) collected data from a national random sample (stratified by age, ethnicity, and gender) of adults living in the United States and found significant demographic differences in participants’ sensitivity to barriers to counseling by help‐seeking history. In particular, participants with a help‐seeking history (sought at least one session of personal counseling) reported more positive attitudes about seeking counseling when compared with participants who had not sought counseling in the past. Similarly, Kim et al. (2015) found that college students with a history of counseling‐seeking behavior reported higher MHL (more likely to recognize depressive symptoms in a vignette) when compared with students who had not sought counseling in the past. Cheng et al. (2018) extended this line of research by identifying demographic profiles of students (e.g., male, Asian American, no help‐seeking history) who reported the least positive attitudes toward utilizing mental health support services.

The Present Study

College counselors implement peer‐to‐peer mental health support (e.g., recognize and refer) strategies to promote college student mental health (Golightly et al., 2017). However, little is known about demographic differences in college students’ proclivity to refer a peer in mental distress to support services. We sought to begin addressing the gap in the literature regarding demographic differences in college students’ frequency of peer referrals to the counseling center, one of the most common goals of peer‐to‐peer mental health support interventions. Making a peer‐to‐peer referral to the counseling center, however, is only one possible response a student might have when encountering a peer in mental distress. To this end, we also sought to investigate demographic differences in undergraduate students’ Approach/Encourage and Diminish/Avoid responses to encountering a peer in mental distress. College counselors can potentially use these results to inform the structure and curriculum of peer‐to‐peer mental health support initiatives.

Specifically, the following research questions were posed:

Research Question 1: To what extent are there demographic differences in the number of peer‐to‐peer referrals students make to the counseling center?

Research Question 2: Are there demographic differences between college students’ Approach/Encourage and Diminish/Avoid responses to encountering a peer or student in mental distress?

Method

Participants and Procedure

We used G*Power (Version 3.1; Faul et al., 2007) to conduct an a priori power analysis, which revealed that a minimum sample size of 152 would provide a 95% power estimate, with an alpha level of .05 and a moderate effect size (f2) of 0.06. Data were collected from 813 undergraduate students from two different universities. These universities are located in different geographic regions of the United States, and both institutions are nationally ranked for ethnically diverse student populations. The first institution is located in the southwestern United States, and the second is located in the Mid‐Atlantic region of the United States. According to the Carnegie Classification System of Institutions of Higher Education (2018), both institutions are large, public, primarily nonresidential, research‐intensive universities. The data were collected using an identical convenience sampling procedure at both institutions. Specifically, the lead researcher (first author) and two research assistants reserved a table in the student union, and participants were recruited as they entered the building. Five recruitment sessions took place at each institution between approximately 11 a.m. and 2 p.m. Participants were asked for their informed consent and to confirm that they met the inclusion criteria for the study, including (a) enrollment in at least one college course and (b) age of at least 18 years old at the time of data collection. Participants completed the instrumentation (described below) at the table in the student union.

The demographic profile of the sample (N = 813) is as follows. For gender, 59.5% (n = 484) of the participants identified as female, 39.5% (n = 321) as male, 0.7% (n = 6) as nonbinary or third gender, and 0.2% (n = 2) did not specify their gender identity. For ethnicity, 32.3% (n = 263) identified as White, 30.3% (n = 246) as Latinx, 22.3% (n = 181) as Black, 10.0% (n = 81) multiethnic, 2.3% (n = 19) as Asian, 0.9% (n = 7) as American Indian/Alaska Native, 0.9% (n = 7) as Native Hawaiian or Pacific Islander, 0.4% (n = 3) as Arabic, 0.2% (n = 2) as Middle Eastern, and 0.5% (n = 4) did not specify their ethnic identity. Student participants ranged in age from 18 to 70 (M = 21.9, SD = 5.90). For help‐seeking history (n = 808), 38.6% (n = 312) had attended at least one session of personal counseling in the past, and among participants who responded to the question about making a peer referral (n = 810), 37.2% (n = 301) had made at least one peer‐to‐peer referral to the counseling center. (Percentages in this section may not total 100 because of rounding.)

Instruments

Demographic questionnaire. Participants completed a demographic questionnaire and specified their gender identity, age, and ethnic identity. Respondents then indicated their help‐seeking history (i.e., whether they had attended at least one session of personal counseling in the past). Finally, participants reported the number of peers, if any, they had referred to the college counseling center.

MDRS. The MDRS (Kalkbrenner & Flinn, 2020) is an MHL‐based screening tool designed to measure college students’ responses to encountering a peer in mental distress. The MDRS is composed of two subscales: Approach/Encourage and Diminish/Avoid. The items that compose the Approach/Encourage subscale consist of peer‐to‐peer mental health support responses of college students to encountering a peer in distress that are likely to help the person get connected with support services (e.g., “suggest that they go to the health center on campus”). The items that compose the Diminish/Avoid subscale consist of responses that are avoidant or passive (e.g., “I would stay away from this person”). Kalkbrenner and Flinn (2020) validated scores on the MDRS among two separate samples of undergraduate students and found sufficient evidence of internal consistency reliability in both samples for the Approach/Encourage (αs = .70 and .78, respectively) and Diminish/Avoid (αs = .84 and .76, respectively) subscales. Findings of exploratory and confirmatory factor analyses provided support for the construct validity of the MDRS. Furthermore, Kalkbrenner (2020a) demonstrated the utility of the MDRS for use with faculty members, and Kalkbrenner (2020b) found support for the factorial invariance of the MDRS with community college students. Finally, Kalkbrenner and Goodman‐Scott (in press) validated scores on the MDRS with a national sample of high school students.

Data Analysis

Research Question 1. A factorial univariate analysis of variance (ANOVA) was computed to examine demographic differences in students’ frequency of peer referrals to the counseling center (Research Question 1). The independent variables (IVs) were selected from the previously reviewed extant literature (e.g., Eisenberg et al., 2013; Kim et al., 2015; Smith et al., 2014) on common demographic correlates with MHL in college students. The first IV, gender, had two levels (1, male; or 2, female). The second IV, help‐seeking history, also comprised two levels (1, previous attendance in counseling; or 2, no previous attendance in counseling). The third IV, ethnicity, included four levels (1, White; 2, Black; 3, Latinx; or 4, other ethnicity). On the basis of the recommendations of Kaneshiro et al. (2011), the fourth level of the ethnicity variable (i.e., other ethnicity) was aggregated from participants who did not identify as Black, White, or Latinx (15%, n = 124) to ensure that sample sizes were sufficient for inferential statistical analyses. Similarly, the gender variable was coded into two levels (male or female) to ensure acceptable sample sizes for statistical analyses. The dependent variable (DV) consisted of the number of peer‐to‐peer referrals students made to the college counseling center. Tests of simple effects were used as the follow‐up analysis for significant interaction effects on the basis of recommendations of Field (2018).

Research Question 2. A factorial multivariate analysis of variance (MANOVA) was computed to examine multivariate demographic differences in students’ Approach/Encourage and Diminish/Avoid responses to encountering a peer in mental distress. The IVs included gender, ethnicity, and help‐seeking history. The DVs consisted of participants’ composite scores on the Approach/Encourage and Diminish/Avoid subscales. We investigated both main effects and interaction effects. Bonferroni adjustments were applied to control for the family‐wise error rate. A discriminant analysis was computed as the post hoc test for significant findings in the MANOVA on the basis of the recommendations of Warne (2014). Effect size is reported as partial eta squared for ANOVA on the basis of the guidelines provided by Sink and Mvududu (2010).

Results

Demographic Differences in Frequency of Peer‐to‐Peer Referrals to the Counseling Center

A factorial 2 (gender) × 2 (help‐seeking history) × 4 (ethnicity) ANOVA (see Table 1) was computed to investigate demographic differences in college students’ frequency of peer‐to‐peer referrals to the counseling center (Research Question 1). A significant main effect emerged for ethnicity, F(3, 704) = 5.81, p = .001, partial η2 = .02. Students who identified as White (M = 2.09) made significantly more peer referrals to the counseling center when compared with participants who identified as Black (M = 0.69). A significant main effect also emerged for help‐seeking history, F(1, 704) = 35.76, p < .001, partial η2 = .05. Students who had sought counseling in the past (M = 2.15) made significantly more peer referrals to the counseling center when compared with students who had not sought counseling in the past (M = 0.50). A significant Ethnicity × Help‐Seeking History interaction effect emerged, F(3, 704) = 4.24, p = .006, partial η2 = .02. Tests of simple effects showed that among students who had sought counseling in the past, those who identified as White (M = 3.91) made significantly more peer referrals to the counseling center as compared with students who identified as Black (M = 0.81), Latinx (M = 2.31), and other ethnicity (M = 1.93), F(3, 719) = 13.93, p < .001, partial η2 = .06.

Table 1

Demographic Differences in Frequency of Peer-to-Peer Counseling Referrals: 2 (Gender) × 2 (Help-Seeking History) × 4 (Ethnicity) Analysis of Variance Results

Note. The dependent variable was frequency of peer‐to‐peer referrals to the counseling center. Error df = 704.

*p < .01, two‐tailed. **p < .001, two‐tailed.

Demographic Differences in Approach/Encourage and Diminish/Avoid Responses

A factorial 2 (gender) × 2 (help‐seeking history) × 4 (ethnicity) MANOVA revealed a significant main effect for ethnicity on the combined DVs, F(15, 783) = 16.32, p < .001, Wilks's Λ = .89, partial η2 = .06. The MANOVA was followed up with a post hoc discriminant analysis. Two discriminant functions emerged. The first function significantly discriminated between groups, Wilks's Λ = .82, χ2(6) = 162.68, Rc = .42, p < .001. The second function also significantly discriminated between groups, Wilks's Λ = .99, χ2(2) = 8.07, Rc = .10, p = .018. The first function accounted for 95.5% of the variance, and the second function accounted for only 4.5% of the variance. The first function was interpreted because it accounted for the majority of the variance. The correlations between the latent factors and discriminant functions showed that Diminish/Avoid loaded more strongly on the first function (r = .88) than on the second function (r = .49), suggesting that Diminish/Avoid contributed the most to group separation by ethnicity. The following mean discriminant scores emerged on the first function: for participants who identified as Black, –0.72; as other ethnicity, –0.09; as White, 0.01; and as Latinx, 0.56.

A significant Gender × Ethnicity interaction effect on the Diminish/Avoid subscale emerged, F(3, 793) = 6.69, p < .001, partial η2 = .03. Tests of simple effects showed that students who identified as female and Latinx (M = 3.03) scored significantly higher on the Diminish/Avoid subscale as compared with those identifying as White (M = 2.58), Black (M = 1.75), and other ethnicity (M = 2.46). Also, among female participants, those who identified as White (M = 2.58) scored significantly higher on the Diminish/Avoid subscale when compared with those who identified as Black (M = 1.75). Among male participants, those who identified as Latinx (M = 3.02) scored higher on the Diminish/Avoid subscale as compared with those who identified as White (M = 2.40) and Black (M = 2.37). Finally, among participants who identified as Black, men (M = 2.37) scored higher on the Diminish/Avoid subscale when compared with women (M = 1.75), F(3, 799) = 46.64, p < .001, partial η2 = .15. In addition, a significant main effect also emerged for ethnicity on the Approach/Encourage subscale, F(3, 784) = 6.91, p < .001, partial η2 = .03. Students who identified as Black (M = 3.23) scored higher than students who identified as White (M = 2.91) and Latinx (M = 2.84).

Discussion

In line with the findings by Albright and Schwartz (2017), the majority of college students in our sample (63%, n = 509) had not made a peer referral to the counseling center. It is possible that differences in college students’ MHL (i.e., the ability to recognize warning signs for mental distress) are associated with their propensity to refer a peer in mental distress to the counseling center. Our results indicated that help‐seeking history was associated with increases in college students’ MHL. Similarly, Kim et al. (2015) found that students with a help‐seeking history were more likely to recognize warning signs of depression as compared with students without a help‐seeking history. Extending Kim et al.'s (2015) findings, the significant Ethnicity × Help‐Seeking History interaction effect that emerged in the present study demonstrated that students who identified as White with a help‐seeking history reported a higher frequency of peer‐to‐peer referrals to the counseling center (a form of MHL) when compared with students with a help‐seeking history who identified as Black or Latinx. The effect size (practical significance) of this finding was in the moderate range on the basis of the guidelines provided by Sink and Mvududu (2010). Moderate effect size values indicate that there is potential value in interpreting possible explanations for the findings because a noteworthy amount of shared variance exists between variables.

Macrolevel systemic factors might explain the Ethnicity × Help‐Seeking History findings in the present study in that we collected data from students enrolled in 4‐year universities in the United States where the mental health care system is embedded in individualistic and Westernized cultural worldviews (Bedi, 2018). The cultural worldviews of non‐White students might not be aligned with a Westernized conceptualization of mental health services (Cheng et al., 2018). Thus, it is possible that for college students with a help‐seeking history, the Western‐based mental health system in the United States affected or contributed to reticence among Black or Latinx students with respect to referring their peers to the college counseling center. Moreover, the identity of counseling centers’ counselors in the United States tends to be based on predominantly White worldviews (MacLeod, 2014; Meyer & Zane, 2013). Meyer and Zane (2013) also found that ethnicity considerations in counseling were more strongly related to client satisfaction and treatment outcomes for non‐White clients when compared with White clients. Thus, it is possible in the present study that students who identified with ethnic identities other than White might have been less likely to utilize and refer their peers to counseling services because of an incongruity between their cultural worldviews and the culture or system of mental health support on campus.

Although our results indicated that students who identified as White were significantly more likely to make a peer‐to‐peer referral to the counseling center as compared with students who identified as Black, results also revealed that students who identified as Black scored higher on the Approach/Encourage subscale when compared with those who identified as White. In other words, White students were more likely than Black students to make a peer‐to‐peer referral to the counseling center. However, Black students were more likely than White students to report Approach/Encourage responses (which are not limited to making a referral to the counseling center) to encountering a peer in mental distress. The effect size of both of these findings was in the small‐to‐moderate range (see Sink & Mvududu, 2010). These similar effect sizes suggest there were notable but not substantial differences between White and Black students’ self‐reported responses to encountering a peer in mental distress. These findings support the notion that a Westernized conceptualization of mental health services might not align with the worldviews of students who identify with ethnic identities other than White. As mentioned above, this incongruity might contribute to non‐White students’ reticence to refer a peer to the counseling center. For example, Murry et al. (2011) found that participants who identified as Black tended to encounter barriers to seeking mental health support services (e.g., community stigma) as well rely on support from family, schools, or churches. Students who identified as Black in the present study might have been reticent to make a peer‐to‐peer referral to the counseling center because of a stigma toward seeking mental health support.

Our findings revealed that students who identified as Black and male were significantly more likely to report a Diminish/Avoid response when compared with Black female students. The effect size of this finding was in the strong range (Sink & Mvududu, 2010), indicating that Black male students were substantially more likely to report a Diminish/Avoid response when compared with Black female students. Relatedly, among Latinx students, those who identified as male were significantly more likely to report a Diminish/Avoid response when compared with male students who identified as White. The effect size of this finding was in the moderate‐to‐strong range (Sink & Mvududu, 2010). Similar Gender × Ethnicity results emerged for students who identified as female. Latinx female students were more likely to report a Diminish/Avoid response compared with female students who identified as White. Collectively, these findings are consistent with past investigations of non–college student populations (Jang et al., 2011; Murry et al., 2011; Neukrug et al., 2013) regarding demographic correlates of negative attitudes toward seeking mental health support services. In particular, individuals who identify as male, Black, or Latinx tend to report more negative attitudes and mistrust toward making use of mental health support services when compared with those who identify as White. This mistrust and more negative attitudes might be due to incongruities between the culture of mental health services and the worldviews of students who identify as Black, Latinx, and/or male (Jang et al., 2011; Murry et al., 2011; Neukrug et al., 2013). Extending these findings, our results suggest that college students who identify as male, Black, or Latinx might be more likely to have a Diminish/Avoid response to encountering a peer in mental distress when compared with their counterparts. Collectively, the effect size values suggest that this might be especially true for college students who identify as Black and male.

Limitations and Directions for Future Research

The methodological limitations of the present study should be acknowledged before considering the implications for practice. Self‐report and response bias, for example, are limitations of cross‐sectional designs. The large (N = 813) and diverse sample allowed us to examine group differences in DVs across four levels of ethnicity (i.e., Latinx, Black, White, and other ethnicity); however, our findings might not be generalizable to other populations of college students. Relatedly, the procedure that was used to aggregate participants into the other‐ethnicity group might have limited the discovery of demographic differences between participants who did not identify as Latinx, Black, or White. Future researchers can extend the line of research on peer‐to‐peer mental health support with more ethnically diverse samples. As just one example, college counselors can facilitate semistructured focus groups with non‐White students to begin understanding their worldviews about peer‐to‐peer mental health support. Moreover, the present investigation did not consider the potential impact of participants’ previous experience with systems‐level recognize‐and‐refer interventions. Future investigators can extend this line of inquiry by examining differences in MHL between students who had engaged in a training or workshop regarding how to recognize and refer.

There is also a need for future lines of inquiry on the utility of peer‐to‐peer mental health support with populations of college students who might be particularly susceptible to mental distress, including first‐generation college students (Stebleton et al., 2014), international students (Akanwa, 2015), nontraditional students (Trenz et al., 2015), and students who are making the transition from high school to college (Young & Calloway, 2015). In addition, future researchers might investigate the efficacy of peer‐to‐peer mental health support among high school students. Consistent with previous researchers (e.g., Kim et al., 2015), in the present investigation, we measured help‐seeking history on a categorical‐level scale (i.e., previous attendance in counseling or no previous attendance in counseling). Future researchers can extend this line of inquiry by measuring help‐seeking history on a continuous‐level scale (i.e., the number of counseling sessions one has attended) and investigating the extent to which the number of counseling sessions a college student attends might predict their MDRS responses.

Implications for College Counseling

Systems‐level interventions, such as peer‐to‐peer mental health support through outreach and education, are a critical component in the practice of college counseling (Golightly et al., 2017), especially when considering the sizable proportion of college students who do not make use of mental health support services (Eisenberg et al., 2011). Several implications for enhancing college counselors’ outreach and education work have emerged from the findings of the present study in that we found numerous demographic differences in college students’ responses to encountering a peer in mental distress. Students with a help‐seeking history who identified as White made significantly more peer‐to‐peer referrals to the counseling center as compared with students with a help‐seeking history who identified as Black. However, students who identified as Black scored higher on the Approach/Encourage subscale when compared with White students. Approach/Encourage responses include, but are not limited to, making a peer‐to‐peer referral to the counseling center. Training college students to make peer‐to‐peer referrals to the counseling center is embedded in a Westernized philosophy of mental health support services in which individualistic cultural worldviews are dominant (Bedi, 2018; Kalkbrenner, 2020b). However, college counseling practitioners must think beyond Westernized values to deliver mental health support services that meet the unique needs of the diverse clients who receive their services (Hinkle, 2014). Making a peer‐to‐peer referral to the counseling center emerged as a feasible Approach/Encourage response for White students; however, our findings suggest that training students to recognize and refer their peers to the counseling center is not a one‐size‐fits‐all method of peer‐to‐peer mental health support. To this end, college counselors can use the MDRS as a tool to begin understanding the culture or climate of peer‐to‐peer mental health support on their campus. In addition, the Substance Abuse and Mental Health Services Administration (SAMHSA, 2014) has offered a comprehensive protocol for enhancing the cultural competence of mental health services. Specifically, college counselors might find SAMHSA's recommendations for endorsing collaborative treatment (Step 3) approaches as well as obtaining and integrating culturally relevant information and themes (Step 4) particularly useful for connecting with and understanding non‐White students’ views on mental health and peer‐to‐peer support.

College counseling practitioners can administer the MDRS to students and use the results as one way to identify and promote a number of potential Approach/Encourage responses among students on their campus. For example, college counselors can administer the MDRS to college students using a variety of platforms to reach a large and diverse group of students. The MDRS was subjected to rigorous psychometric testing (Kalkbrenner, 2020a, 2020b; Kalkbrenner & Flinn, 2020) and allows for time‐efficient administration because of the brevity (10 questions) of the measure. The MDRS is also suitable for both electronic (laptop, smartphone, or tablet) and paper copy administration. College counseling practitioners and their constituents can reach newly admitted students during orientations and by attending introductory 101 classes held in large lecture halls, administer the MDRS, and engage students in a brief conversation about college student mental health and the utility of peer‐to‐peer mental health support. The MDRS can also be administered to students electronically via email. College counselors might consider encouraging student participation by offering small incentives (e.g., a raffle for a gift card). Results of the MDRS might aid in college counselors’ understanding of the peer‐to‐peer mental health support climate on their campus. College counselors and their constituents can use these results to structure peer‐to‐peer mental health support interventions that are more closely aligned with the worldviews of their students and aim to enhance peer‐to‐peer mental health support by promoting Approach/Encourage and reducing Diminish/Avoid responses. The nature of these interventions could be based, in part, on the MRDS results. College counselors, for example, can reach out to particular group(s) of students (e.g., freshman, first‐generation) on campus who score low on the Approach/Encourage subscale to learn about how they can make mental health support services more inviting.

The significant Gender × Ethnicity interaction effect that emerged in the present study also has implications for informing the practice of college counselors. Among female participants, those who identified as Latinx scored higher on the Diminish/Avoid subscale when compared with those who identified as White, Black, and other ethnicity. Similarly, among male participants, those who identified as Latinx scored higher on the Diminish/Avoid subscale when compared with those who identified as White or Black. College counselors should strive to understand how and in what ways Latinx students perceive peer‐to‐peer mental health support. College counselors and their constituents might consider facilitating a series of semistructured focus groups geared toward understanding the worldviews around peer‐to‐peer mental health support among Latinx students and students who identify with other non‐White ethnicities. College counseling affiliates can invite non‐White students to participate in focus groups by collaborating with representatives from residence life and multicultural centers on campus. Semistructured interview questions will allow students of color to share their attitudes and values surrounding peer‐to‐peer mental health support. Emergent themes from focus groups might provide college counselors with valuable information regarding how to promote inclusive peer‐to‐peer mental health support programming for non‐White students on their particular campus.

College counselors should take a multifaceted approach to understanding the peer‐to‐peer mental health support climate on their campus by using both quantitative (e.g., administering the MDRS frequently and widely to as many students on campus as possible) and qualitative (e.g., conducting focus groups with non‐White students) approaches. College counselors might consider collaborating with counselor education faculty and graduate students for assistance with data collection and analyses. Results of the MDRS coupled with the findings from focus groups are likely to yield a more comprehensive understanding of peer‐to‐peer support, which college counselors can use to direct outreach initiatives for taking an inclusive approach to supporting college student mental health.

Conclusion

Taken together, the findings of the present investigation are promising and suggest that college counselors should consider potential demographic differences in college students’ responses to encountering a peer in mental distress. The MDRS might aid college counselors and their constituents in identifying possible responses of their students to encountering a peer in mental distress. College counseling practitioners can potentially use these results as one way to better understand non‐White students’ attitudes about peer mental health support and possibly enhance the inclusiveness of peer‐to‐peer mental health support initiatives on campus.