At a university where I interned, all first year students were strongly encouraged to meet for three appointments with a counselor in the university counseling center during their first year. In addition, all of the counselors, in addition to being mental health counselors, were also academic advisors.  As a result of these two practices, students meeting with a counselor became more the norm rather than a rare and potentially stigmatizing occurrence.     

Thank you Mark. These are good suggestions and we will see how can these be used in our setting. Academic advising is generally the role of the faculty here, but encouraging all to meet is definitely a good option. Were these meetings mandatory?

Dear Hadia

I also have faced the same situation in military which is worse than university. Here are few things which worked out well

Conduct common awareness programs. Include them to orientation program what you have now.

Get down a previous service user if possible and ask that person to speak to the crowd about the benefit of counselling

Print nice simple leaflets and banners include a hotline number. Suggest situations they may need someone's help ( include some non stigmatized situation like deciding which module to follow), but include relationship issues, adjustment issues, and other psychological conditions without using technical terms like depression, anxiety etc.. 

Create discussion and dialogues among students with few experts.

Ensure confidentiality.

use case studies with fake names

Good luck

Kanthi

The progress will be slow but steady.

Good luck

 Yes - attending the counseling sessions was mandatory at the state university where I interned.  

Thank you very much Kanthi and Mark for your help and offering great suggestions. 

Kanthi your ideas seem practical and useful. Some are already in place and we will definitely try to incorporate at least some of the others at our place.

Warm regards.

Time is scarce at university level. Students have to feel that being involved in a counselling program is useful for them and that have an instrumental design.

I may suggest that you create small courses or workshops where you preview explore with them practical components of career development (how to elaborate a CV, good sources to find a job, vocational exploration, decision making difficulties, etc).

It may be interesting for them to have similar workshops regarding other themes that are congruent with their current development stage, such as study method at university level, time management, tips to help daily life organization away from home.

These workshops are an excellent way to introduce the message that psychologist may help them in several areas and the they are not only there for treating severely disturbed psychiatric patients.

Hope can you find these tips helpful

Hugs.

Thanks a lot Ana. I love the use of word "instrumental". I totally agree with your idea about conducting workshops that are of practical use to them. We have already offered a workshop on time management and are planning to build upon such sessions according to the needs of the students. Your suggestions will surely be very beneficial in this regard.

Warm regards.

Dear Hadia 

I am a psychotherapist and have been working in a multi faculty university counselling service for over 20 years , primarily with medical students who also belong to a community where any vulnerability can be felt as shameful. Stigma, which is an ongoing issue across all mental health services, becomes reduced over time as students become confident about the confidentiality and professionalism of the service. For this reason it has also been felt to be very important to have a very firm boundary between the counselling service and the academic process. This  is difficult to maintain if clinicians have dual roles. Induction talks in which a counsellor talks in an ordinary approachable way about the reasons students might approach the service can be very important  important  as are outreach workshops such as  exam anxiety etc. If students see the counsellor(s)as someone they might feel safe talking to , or hear this from their friends, they will start coming ,even though this is slow at first. It will happen. we have very large numbers of students requesting counselling. 

best wishes

Diana

Dear Diana,

Thank you very much for the insightful comments. Here we are dealing with medical students, nursing students, and graduate students of education and health related fields. As you mentioned, we have also observed that medical students are the most reluctant ones to seek help. 

At our university we are also very firm about keeping the role of the counsellors distinct from the academic area. We are offering workshops on academic and personal management skills and in individual counseliing, we ensure confidentiality. and professionalism. It is a new service that we have started and I hope that the stigma will eventually reduce.

Warm regards.

Dear Hadia,

Your concern is very much relevant in the context of developing countries, where there is much stigma and apathy about mental health aspects. Psychiatrists are very few in number in these countries, therefore counseling the only option to address the issue of health & wellbeing, such programs must start with school, colleges, Universities ..I am a psychologist & started Guidance & Counseling centre in University at JMi, Delhi. Infact there is lack of awareness about the necessity of understanding the issues affecting positive mental health..students very rarely come forward for personal issues, parents and teachers are also not aware..so we started with common theme weekly workshops for school & University students. Career guidance & counseling was the catching area and then students started seeking appointments in centre..However, still the response not much as they are overburdened by their academic schedule, attendance issues etc.

Very practical suggestions are given by Mark, Ana & Regina..we may develop a culture specific (I mean academic program & other cultural aspects) model & may assess its impact..

Best wishes,

Waheeda

Dear Regina,

Thank you so much for sharing such wonderful strategies. I feel we are doing most of what you suggested in points 1,2 and 4 but will definitely look into what else can be done. I am specially excited about the third point, i.e arranging outdoor activities on preventive topics. It seems to be such a promising idea. We were already thinking of arranging one such event to celebrate wellness on campus, but the various suggestions that you have given have certainly broadened my perspective.

Warm regards,

Hadia. 

Thank you Waheeda for your understanding and support. Finding culture-efficient strategies would definitely be the way to go.

Warm regards,

Hadia.

Currently, we are investigation the use of support services in our University with a group of students - perhaps it is useful to think of counselling as "support" in terms of guidance and referral than treatment and intervention - as social stigma is always and will associated with symptomologies and treatment therein - we perhaps can educate and reduce this but this also needs to be challenged with the context of diagnosis and prognosis  

I agree with you Dr. J-F. If student problems are generally conceptualized as "diagnoses" then stigma free services cannot be designed. We are trying not to adopt a medical model that will give the impression of student problems as manifestations of mental illness. More important are the out-of-clinic interactions with students that help them understand that these services are meant for everyone to increase personal effectiveness (guidance approach). Another important step would be to help them understand that even when they come for counselling, it does not mean that they are seeking treatment.

Warm regards,

Hadia. 

I think again you need to clarify what you mean by counselling within an education context - remember welfare and education are two different paradigms and you must ensure that you clearly have a good grasp of both - further how are you going to study the use of services be it support, therapeutic, counselling, referral etc....in other words what is the basis of setting up counselling within an educational context -

Hi Hadia,

This is a large issue in higher education, but perhaps less so in education where I spend most of my time. This is because one of the underpinnings of education is catering for the needs of learners. If we are to be preparing our pre-service teachers to be authentic teachers catering for diverse learners, then this implies that our pre-service teachers should also be treated with respect and their own individual learning needs catered for. In this environment, pre-service teachers should feel that the course offers a safe space for them to seek help.

Regards, Kevin

This begs the question of what is the role of a pre-service teachers within the context of education in terms of are we or do we train our teachers and further how well do we support our pre-service teachers in catering for their needs - and again 'needs' have to be conceptualized within the role of higher education - fundamentally education and welfare are two different paradigms and some how they are intermixed to make it that one is necessary or subject to the other 

Dear Dr. J-F. Thank you for your thought-provoking comments. I think I am not very clear about the use of "welfare" as you put it. For me counselling and/or guidance fulfills some aspects of the holistic development that should be the goal of any educational institution and thus both counselling and other aspects of education complement each other. i think I would be clearer if you could please briefly share your conceptualization of the education and welfare paradigm and how does it relate to counselling services..

i wanted to support you Hadia ,in your assertion that Student Counselling is a skilled and specialised discipline undertaken by well trained mental health practitioners. It is holistic in the sense that it takes into account the late adolescent developmental stage of most students as well as the transitional space that the educational process ideally offers between childhood and adulthood. Diagnosis is not generally helpful at this stage as it forecloses the understanding that this stage of life can be full of intense, disturbing and turbulent experiences both internally and externally . Students become aware that there are many different ways to think and live and this can challenge their ideas and emerging selves. Unresolved issues from childhood emerge at this stage of development, but students who have highly developed intellectual defences (Winnicott's "false self ) which are reinforced by a "performance" culture, will often only present for help when they can no longer function academically, even though they have been suffering for some time. A good relationship with tutors can help this process. It is a vital time to offer good psychological help, as preventative work at this stage can change the course of young people's lives. Risk has to be assessed carefully and occasionally consultation and referral may be necessary, but a containing therapeutic alliance with someone familiar with but not in the educational process is very important. We see both home and international students from a diverse range of cultures. I am presently researching the interaction of students' background cultures with the culture of the institution and the impact of this on students' mental health and wellbeing. 

Dear Hadia,

I am working as a psychologist/counsellor in center for counselling and career advisory NUST. I totally agree that in our country seeking counselling or going to a psychologist is a taboo. Despite having free facility students hesitate to visit the center or if they visit they don't tell anyone about it. Our counselling center is running since 2008 and now it has established to the point where we have a team of 5-psychologist and during new semester all the psychologist s have a busy schedule and at times we even get 4-5 students a day. The activities at our center includes orientation sessions about the center and the importance of counselling support with all the schools in the start of the semester, we also conduct orientation sessions with parents. We conduct workshops on topic like stress management, time management, anger management, peer pressure, presentation skills, communication skills etc. we also arrange workshops fr faculty on different topics including suicide prevention (as this is one of the issue among youngsters). It took us a long time to develop a rapport and a trust worthy environment where  students can come and discuss there problems. peer sharing also helped in flourishing our center, once a students visits a center and he/she is satisfied with the counselling services they motivate their friends to visit the center if they are having any problem. I am sure you will be doing all these activities in the center give yourself some time. develop some brochures, handouts etc. We also set up counselling camp every year in which we not only provide counselling at the spot but we also offer certain tests like personality test, aptitude test, EQ test, dream analysis, signature analysis etc. such things attract students   and it also helps in promoting the center. 

Regards

Ayesha Mujeeb

Psychologist

Dear Ayesha,

Thank you for your support and useful suggestions. Setting up a counselling camp was one of the things that we were considering. Please let me know, do you conduct these assessments online or use hard copies. At present we are two people who provide counselling/psychotherapy and catering to a large number of students is one of our concerns.

Warm regards,

Hadia.

I think there is distortion in how one makes conceptualization around three aspects:

1.      Welfare

2.      Counselling

3.      The role of education institutions with regard to assisting (i.e., I use word assist carefully and with reservation, so as to not to include and/or interpret it to be other things).

As a premise, we must begin with the question and carefully conceptualize “welfare” – in other words within a clinical paradigm has to do with “welfare of a person – in terms of socially, emotionally, cognitively and physically”.

To a great extent most individuals are able to do and/or some might be fairing well (i.e.,  functioning normally, remembering that each individual might a certain concern/problem at some level with regard to something) in one of the lifespan domains and/or in one particular domain. But welfare here is a concern if and when a certain experience/disorder – either limits/minimizes and/or effects their everyday normal functioning – and this requires proper diagnosis, prognosis and interventions – the question is - here could be - is there room for counselling? If so what warrants it? This never clearly conceptualized?

It is important to note that welfare needs to have baseline data to show both the divergence from and convergence toward pattern of behaviour - to warrant counselling (again not sure what counselling is - but we will come to it in the next section). In this educational institutions have not fully conceptualized “welfare” – and have misunderstood and/or misjudged to be “well-being”. Critiques might argue that this is more a debate about semantics but then they miss the real conversation and challenges that both these paradigms present.

Individuals involvement is higher education only ONE part of their life and is temporal and perhpas time-phased, further if one were to follow age-based paradigm young adults are at risk of several and a number of problems and disorders just because that is the age they are in – in other words, this is when they are likely to be at most risk - and they also happen to have certain problems present or absent at the time of their study. So let us not put the cart before horses.

Further, counselling, needs to be conceptualized – one of the primary questions – why would anyone want to get counselling (i.e., however how might want to define this) needs to be qualified within any setting, in other words – given the age-based paradigm – where social identity forms a fundamental premise for an individual to function – what warrants one to go and get counselling – to put another way, how often do you seek counselling yourself and for what purpose and from whom – and close knit community, family and peer support – far exceed and provide great counselling for individual – than the so called counselling service – further if counselling is defined to be process and giving opportunity for one to explore what they are going through – anyone is can suffice this – as long as trust worthy relationship exists.

Stigma, will always exist – especially more so in countries such as yours – given the cultural and religious and social values you place on material and symbolic values (e.g., social standing …etc). The issue in clinical terms is not one of stigma but the viability of treatment there-in – in other words, if the treatment and/or intervention is evidence based – stigma will take a back chair – even though it exists – so perhaps one of the psycho-educational aspect is to work through this  

Educational Institutes are simply that education institutes – that provide knowledge and skills towards a goal and purpose.

Counselling services in educational institutes are ill defined and not properly operationalized – for many reasons. A Psychologist within an educational instituted can use psychometrics to assess or validated a criteria – and provide screening and services – but needs to be clearly clarified what it looks like:

1.      Is it a clinical service –

2.      Is it is a support service –

3.      Is it a referral service –

The next big question, is why would anyone go to seek clinical services within educational institutes, when are other private clinics, hospital and treatment centres that are available to them.

The role of counselling services/clinical services are not well defined from what I can gather and I am of the opinion that the primary role of educational institutions should be education and if you want to add “Support” service -  you must be clear in what you provide, how you provide it – as you read literature “counselling services” around the higher-educational institutes are not fully utilized for this very purpose – that is back home in the USA we have General Hospitals in UT and other places have a place on campus – so that we provide a holistic welfare service beyond counselling –

Let me also make mention, there is room for “counselling” service in an educational institute – as they are many models of it – career counselling being one of them – but when it comes to looking after the overall “welfare” – higher education have not understood what comes first – they are many assumptions that are made with regard to this and hence they are value poor.

If you understand “welfare” concept properly you will make room for it in all aspects of education and institutional practice – but this does not happen and cannot happen due to economic and social costs.

Dear Dr. J-F,

Thank you for your detailed answer. I believe my perspective about welfare and education is slightly different from what you explained. I will try to respond in line with your answer so that it is easier to compare.

First, I do not equate welfare with clinical paradigm in educational institutions. In educational settings many times students need help specific to a particular issue and thus diagnosis, prognosis and “treatment” is not required. I would also not use the word “normal” because majority of the students are normal – they are just trying to achieve their developmental tasks in most cases (as you have yourself mentioned). When you provide counseling/psychotherapeutic support for them it is not to make their functioning normal, but optimal.

I agree with your point about baseline data, but I would definitely go with the term well-being as this is what any educational or other service should aim for at cognitive, emotional and behavioural levels. That is why when we set learning objectives during teaching, they are about knowledge, skills and attitude. The same holds true for counseling/psychotherapy.

Another thing that is worth mentioning here is that students these days are not young adults only. In some of our departments students are required to have relevant job experience, so majority of them are older mature students who are not at a high risk stage in terms of “disorders” - again a term that is applicable only in some cases.  Even if students are high-risk due to any reason outside their educational institution, they will be more likely to reach their academic goals if they are able to handle their feelings and behaviours in various situations, and this is how counseling support promotes the educational objectives.

I also agree with you that community, family and peer support might be more beneficial in many instances, but counseling cannot be defined only as a “process and giving opportunity to explore”. It is much more with theory driven interventions and specialized techniques which help them to become more self-aware, overcome their internal conflicts, defense mechanisms, cognitive errors and dysfunctional behaviours. So I completely disagree with the assertion that anyone can suffice this.

I am in total agreement with your conceptualization of stigma.

As far as we are concerned, counseling service is all that you mentioned – clinical, support and referral, as well as skill-development through workshops, etc. What is done varies from case to case. Since it is much more than clinical, students need not go to hospitals or treatment centers (unless they are severely disturbed) just like those who want to develop their body or perform better in sports will go the gym rather than to a physician, but will need some clinical intervention once they get injured or fall ill. In educational institutions, the repertoire of problems dealt with in counselling services is along a broad spectrum, with clinical disorders at the most extreme end, forming a small but important component of the issues that are dealt with.

I concur completely with your last point that the welfare  of student should be inculcated in all aspects of education and institutional practice. 

Hence here again the lack understanding as to what the role of educational purposes are. I think you have not fully grasped the conversation - the terms clinical, welfare and counseling were used as descriptions of the complexity around them - they are not definitions and this is the very reason it is confusing - you have not fully explored or justified the reason for a service within a context or what description and definitions and operational criteria there in - hence the lack of accurate match between needs and audiences and what support is suitable and/or appropriate - irrespective of age or maturity or occupation 

You may be right in your claim. I don't want to argue about it because my focus is on understanding the ways to reduce stigma about counselling services than to debate about the complexities surrounding various paradigms.  I would be grateful if you could share your ideas about some practical strategies for this purpose which can be utilized to promote educational purposes as you perceive them.

Please engage with a in depth literature review with regard to what stigma is and counseling is within the context of education. - If an evidence based argument is not made - then one could open counseling in a hairdresser saloon or a car yard ir even in a takeout place like Wendys - I sincerely think you are dealing with an important topic - so engage with literature from within your cultural prospective and you will make valuable contribution - I just looked up some of what is available in your context and country - there are a lot of gaps and your work can make sensible and practical  contribution if informed by scholarship - otherwise it will be just another thing you want to chat about 

I see this conversation as an information gathering forum with colleagues who are engaged in similar psychological work with students in different institutions across different cultural contexts.  I understand Hadia's question to be concerned with the different methods that colleagues have found helpful, in building up trusting relationships with staff and students in educational institutions whatever their theoretical background might be. This is about the difficult task of creating a therapeutic space in which students feel safe in coming forward with their concerns. This forum should ideally reflect this respectful, inclusive, non-denigratory approach.

Thank you Diana for your understanding and support. I have received several excellent suggestions and I am sure that our work will benefit from it.

Dear All, did not mean to offend or bring disrespect to any of the conversations - as mentioned this topic is very important and necessary to work through - did not approach the topic with anyone level of denigrating ideas towards the topic or personnel - but sincerely appreciated contributions and shared with anyone - without bias or prejudice - didn't mean to upset anyone 

No hard feelings Dr. J-F. I am sure your comments were well-intentioned.

Hi Haida,

I would rather share my experience, than to give any advice.

I am from India, and situations in our countries is similar regarding the way people think about counseling or other psychological interventions. When I started working with a university,initially, I remember just meeting 1/2 student in a day. But gradually the students themselves started recommending meeting me to their friends, juniors etc. Of course, this took a lot of time. Meanwhile I also started conducting small workshop to the new students regarding adjustment to the new environment, handling work related stress (I work with Design Institute, so it's more of work rather than study) and understanding addictions and handling difficult situation etc. This gives the students an opportunity to know the counselor and understand what exactly counseling is , build the rapport which is useful when they really want to see me for some of their issues.

I am NOT claiming, the stigma has gone, but I can see the gradual positive change in the culture of getting psychological help in the students.

Of course there is still a lot to do, a ,long way to go

Thanks Vibha for your encouraging comments.  I am sure the momentum will rise after some time. 

Warm regards,

Hadia.

Dear Hadia,

I know it is hard to do, but I speak to the student personally and encourage the person to seek someone who can help ask questions.  I remind the person that seeking an objective outsider (trained in counseling) is a mature and significant choice and a sign of growth.  It is like adding a resource and perspective for one to consider..

Thanks Susan. I agree that stigma will automatically reduce once people start taking it as a resource rather than as a treatment centre. I see it happening even now to a little extent but a "culture" change happens over a course of time. Just wanted to ask, how do we talk to a student unless we are giving an orientation or the student approaches us? Do you have any other mechanism of contact with them?