Every day, he thought about death. But the image of his own — always on his mind — terrified him. More than death, senior Michael Ajeto feared himself.
Ajeto, at his lowest, could never be certain just how far the depression might drive him, he said. He never attempted suicide, but the possibility always lingered on the heels of a bad day.
“I would have a bad day and think, ‘Man, I just want to check out’ or ‘Today, I sucked. I wish I could just escape things,’” Ajeto said. “It was the lowest I’ve ever been.”
One thought kept all the others from driving him to suicide: his mother.
Today, Ajeto describes his time away from counseling as his “Dark Days.”
Ajeto’s story demonstrates what can happen when students can’t access mental health counseling at their lowest points. For other students, the impact might not take the form of suicidal thoughts, but rather slipping grades, fractured relationships or elevated stress.
Some students choose to stop attending counseling sessions on their own. Other students, like Ajeto, don’t have a choice. He stopped because he couldn’t afford to see an off-campus provider without insurance.
The number of clients at Western’s Counseling Center doubled between 2011 and 2016, according to public data the university reported to the National College Health Assessment Survey.
This rise, coupled with a shortage of resources, increases the likelihood that a student will be referred off-campus. But a referral does not assure a student will continue to receive counseling.
Counseling Center Director Shari Robinson describes college counseling as a “primer” to long-term, off-campus counseling. In an average 3.5 sessions per student, Western counselors may be able to diagnose a lifelong mental illness, recommend coping and life skills, devise a life stress plan when appropriate and refer students to a community provider based on their insurance and presenting issues, Robinson said.
But students may never attend off-campus counseling for a host of reasons: among them, cost, insurance, consistency or distance. Sometimes, it’s a combination of factors.
“Our demand is outgrowing our current supply,” Robinson said.
The center does not meet the recommended International Association of Counseling Services student-to-clinical staff ratio. For an institution the size of Western, the counseling center should have one clinical staff member for every 1,000 to 1,500 students.
Western’s ratio stands at one for every 1,700 students.
With nine full-time clinical staff members, Western would need to hire at least four more to meet IACS standards.
This disparity has rendered a situation only conducive to a short-term counseling model.
While the counseling center does not formally limit counseling sessions, it lacks the office space, funding and counselors needed to provide long-term care. And that’s emblematic of college counseling centers across the United States, Robinson said.
“The day and age of counseling centers offering indefinite or unlimited individual counseling services — that’s just over,” she said. “That time is gone.”
If the center allowed students to continue counseling indefinitely, the counseling staff would only be able to serve 2 to 3 percent of the total student population, she said. If students are concerned about off-campus referrals now, an indefinite counseling model would frustrate everyone, Robinson said.
“If there were concerns now,” she said, “There would be outrage [if that were the case].”
The counseling center is working toward embedding counselors in residence halls and other offices while also working to increase the number of group counseling sessions. Though, a lack of resources strains its ability to adapt to a growing demand, Robinson said.
What’s driving the demand?
For senior Sarah Cederberg, the catalyst was the fear of being rejected from Western’s highly competitive design program.
“I hadn’t gotten into my major yet, and I was really stressed about it,” Cederberg said. “It came down to the deadline, and I realized I couldn’t get everything in on time.”
So, she went to her room and began to rip her sketches and old sketchbooks to pieces. Her boyfriend, afraid and unsure of how to calm her down, dialed Western’s after-hours crisis line, and handed her the phone.
The next day, she went to the counseling center and scheduled her first appointment.
For a 2016 Western alumnus, the catalyst was a physical, almost out-of-body experience.
The former student, who wished to remain anonymous because he fears discrimination in the workplace, recalled lying on the floor, shaking. In 72 hours, he had neither slept nor composed his racing thoughts since experiencing a manic episode. Still lying on the ground, he called a Western counselor.
“I’m literally on the floor, shaking,” he told the counselor. “I can’t deal with this.”
Shortly after, he walked to the counseling center for a same-day crisis appointment. His counselor helped him to breathe, and then created a plan for when the mania hit.
The center connected him to an off-campus psychiatrist, sent him to the Student Health Center for prescriptions and set up confidential accommodations through the Disability Resources Center, he said.
Fifty-seven percent of counseling center directors reported that the severity of student mental health concerns and related behavior on their campus had increased, according to a 2016 report from the Association for University College Counseling Center Directors.
Mental health experts can only speculate as to why. Their theories seek to explain why a greater number of college-age adults than ever before are seeking access to mental health resources.
Robinson believes the nation is currently experiencing a mental health crisis. Anxiety, depression and suicide are at all-time highs, and those numbers continue to rise every year, she said.
“If mental health in our country and in our society is on the rise, then our college students or our high school students who are transitioning, they’re not going to be immune to that,” she said.
As the head of Western’s chapter of the National Alliance on Mental Illness, a mental health advocacy group, Cederberg believes shifting societal attitudes toward mental illness contribute to the surge in students seeking counseling services.
She said spreading mental health awareness and making efforts to normalize mental illness allows more people to realize that it’s OK to seek help.
Earl Martin, who was named “Counselor of the Year” by American College Counseling Association in 2016, also cited destigmatization as a factor.
Martin said in certain regions in the United States, specifically on the East and West Coasts, many people feel proud to say they have therapists and boast about their counseling. That glamorization, which normalizes mental illness, has helped soften the stigma surrounding mental illness in other parts of the country, he said.
Serving as a counselor at Everett Community College for 27 years has led Martin to some other conclusions.
He emphasized that an increased demand for mental health counseling does not necessarily equate to an increase in mental illnesses. Rather, the increase may be due to improvements in reporting and identifying mental illnesses, he said. He used ADHD as an example of a disorder that seems more prevalent today than it did a decade ago because of improvements in identifying mental illnesses.
“As our society gets more comfortable with recognizing that there are psychiatric conditions and diagnoses,” he said. “We’re getting more tuned-in on some of the symptoms and things we weren’t picking up on or recognizing before.”
Yet, Martin also conceded economic and social factors unique to the college-age generation may play into an increase in mental illnesses among students.
An economic factor, he said, could be fallout from the recession in 2008.
“We just went through a great recession,” he said. “I think that put a lot of pressure on people, and that may have squeezed out into society in terms of trying to find ways to cope with the economic pressures of losing your job or worrying about your future.”
Martin said pressures of this kind sometimes contribute to substance abuse, depression and anxiety.
A social factor, Martin said, could be increased feelings of isolation among college-age adults.
Whereas in the previous generation a person might have more human-to-human, direct conversations and support, today’s college-age adults communicate mostly through text or online social media, he said. This saturation in technology inhibits one’s ability to talk, express emotion, work out differences and cope with conflict, Martin said.
Likewise, Robinson attributes a rise in mental illness to today’s society.
Robinson said Western students live in a world where it doesn’t feel safe, which undermines a personal, emotional and psychological sense of safety. And that has long-term impacts.
Like others, Cederberg reasoned against seeking help, she said.
It was difficult enough to bring herself to the counseling center on campus, so when she was referred to an off-campus provider, Cederberg dreaded the distance, cost and logistics.
She felt more comfortable going to Western’s center on north campus, though “comfortable” may be a stretch, she said.
“It’s close,” she said. “And I didn’t really want to go to the counseling center either. I did it because I needed to.”
Robinson also cited distance as the greatest barrier to off-campus counseling.
“At the end of the day, it’s easier to access services on campus,” she said. “It’s more convenient to walk five minutes to Old Main than to walk or bike or take a bus to an off-campus [counselor].”
Other students opt to see an off-campus counselor for more consistent sessions.
Freshman Sarah Vanlandinghan was diagnosed with anxiety and depression in her junior year of high school. She came to Western with a prior counseling history and a familiarity with her diagnoses.
But the transition from high school to college activated her depression.
Vanlandinghan, ordinarily an early arriver and 4.0 student, knew she needed help when it felt impossible to get out of bed – or even budge her limbs – to walk to class in the morning.
“In my head, I’m freaking out,” she said. Yet, the depression suspended her body. “Even the prospect of missing class is like, ‘So what?’”
When she called the counseling center, it took two weeks to book her first appointment and another two weeks to schedule a second. She was told art therapy would bridge the gaps.
“Yet, they’re telling me weekly is for best results,” she said.
During Vanlandinghan’s third session, a counselor referred her to an off-campus provider. Because the cost did not pose an issue for Vanlandinghan, she was pleased to pursue the referral, she said.
“I’m very lucky in that way because I know a lot of people aren’t.”
Ajeto couldn’t access off-campus counseling for about 14 months because of its cost and a lack of insurance. Those 425 days mark the lowest point in his 21 years.
“I really don’t think it’s a coincidence that it was the lowest of lows,” Ajeto said.
He attended mostly sporadic sessions at Western’s Counseling Center for about five months until he was referred to an off-campus counselor and attended those weekly sessions for two months.
Then, Ajeto lost his insurance plan through Molina Healthcare, and his payments rose to $120 per month.
“I already can’t afford everything,” he said. “I thought about asking my parents [for money] but I didn’t want to burden them.”
Because he couldn’t foot that kind of money with a job bussing tables, he stopped attending counseling for nearly a year and a half.
“When I needed them most, [the counseling center] left me out to dry,” he said.
Without access to a mental health professional, Ajeto’s generalized anxiety, social anxiety and obsessive-compulsive disorders catalyzed his depression.
Slipping grades unhinged his self-esteem, and social interactions felt like a performance he could never win. He would return from a day of classes to find all his roommates sitting on the couch, either watching Netflix or playing video games: usually, Super Smash Bros or Call of Duty Black Ops. When Ajeto sat down, each left for his own room – and shut the door.
“I thought they hated me,” he said.
So, he would retreat to his own room and listen to Nirvana and Kid Cudi songs that matched his feelings of isolation and depression.
“It was a vicious cycle. [All my diagnoses] act on each other and make it worse,” he said. “I was definitely not planning and I probably would never, but I was having a lot of suicidal ideations.”
Those living in that place may never recognize the crisis at hand until someone else physically unveils the hurt.
For Cederberg, it took her boyfriend dialing the crisis line and passing off the phone.
When depression deals its worst hand at 2 a.m., a student is not in the position of scheduling a counseling appointment, Cederberg explained, until another person steps in.
“The next morning you rationalize it like, ‘It’s fine. I don’t need to go,’” she said. “Until you go, ‘It is that bad,’ or someone else tells you, ‘It is that bad.’”
New models of delivery
Robinson is not unaware of the barriers that prevent some students from continuing – or even seeking counseling in the first place.
She came to Western as the director of the counseling center in 2015 after spending 11 years at the University of Florida. There, she started as a staff psychologist and left as the interim director of one of the largest counseling centers in the nation.
Coming from a staff of 70 mental health professionals, Robinson said she’s accustomed to a certain standard of care. She’d like to replicate that benchmark at Western.
Robinson said the center examines its data every year and based on that, its utilization rates are growing steadily. With increased usage of college counseling centers nationwide, Robinson has some ideas to change the system of care offered at Western.
Robinson wants to overhaul the counseling center and promote its visibility on campus, which includes embedding counselors across campus and offering more alternatives to one-on-one counseling.
“In an ideal perfect world that we don’t live in, I would want the counseling center not to be in Old Main, not to be in your central administration building [and] not to be on the fifth floor of any building,” she said.
But change doesn’t happen overnight.
While increased usage of the counseling center might be beneficial for addressing stigma, the number of counselors per student remains the same.
“If your numbers increase, and your staff doesn’t increase, then we got an inverse relationship going on here,” Robinson said. “The repercussions of that is that we don’t get to offer as much services as we would like to our students.”
Currently, the center’s average wait time for an initial assessment is 6.8 business days, according to records obtained from a public records request. The average wait time for a counseling center with a student population similar to Western’s is 5.81 business days, according to a 2016 survey by the Association for University and Counseling Center Directors.
The center provides group therapy and other wellness options, such as yoga events, in addition to one-on-one counseling. While some options open up access to mental health care, others are met with disagreement.
Currently, the center is able to provide short-term, brief counseling to 11 to 12 percent of the student population, Robinson said. If the center didn’t operate on this model and let students use the center unlimitedly, Robinson said the center would only be able to see 2 to 3 percent of the student population.
To continue treating people, the center has to refer students off campus.
“You want to open your services up so as many students can access it sooner and quicker – even if it’s for a limited [number of sessions]. It’s a hard decision to make,” she said.
While referrals occur on a case-by-case basis, in the 2014-2015 academic year, the center hired a case manager to assist with referrals. The case manager works with students and their insurance companies, as well as counselors in the community, to see who is taking new clients, Robinson said.
The Family Educational Rights and Privacy Act protects student privacy, specifically students who use the counseling center. Once a student is referred off campus, that student is no longer protected by the act, and they must pay – sometimes out of pocket – for private counseling. Often, students use their parents’ insurance to cover the cost.
However, that means students must either tell their parents or await their reaction when the insurance statement comes back, Robinson said.
Western’s case manager works to address those concerns by telling students it’s OK to seek help, she said.
Alternatives to 1:1 counseling
In an attempt to keep pace with the demand, the counseling center also offers various group therapy and wellness workshops as supplements to one-on-one counseling.
The center hosts eight to 10 group sessions per quarter that meet every week, the mindfulness group being the most popular. The groups meet Monday to Thursday – group sessions aren’t well attended on Fridays – for about 90 minutes. Those meetings are facilitated by mental health professionals associated with the counseling center.
While these alternatives to one-on-one therapy sessions open up access to students, its effect is sometimes lost in the mix.
Sophomore Sumner Ames, the vice president of Western’s chapter of To Write Love on Her Arms, attended one-on-one counseling sessions at Western until her counselor said group sessions would better suit her needs.
However, Ames struggles to disconnect her emotions from the unhealthy, abusive relationships that surround her, she said. She described herself as the “mom friend,” the one who gravitates toward those in need and expends all her energy to help.
“I couldn’t figure out where their emotions ended and where mine started,” she said. “I lost a sense of self.”
Ames sought counseling for that reason. Contrary to her counselor’s advice, Ames felt one-on-one counseling served her needs best.
“The whole reason I’m coming [to counseling] is because I can’t separate myself from groups.”
So, she stopped attending mental health counseling sessions, and opted instead for academic advising at the Student Outreach Center. Talking about her future played a significant role in managing her depression and anxiety, she said. She did return to the counseling center a quarter later, but this time requested a different counselor – one who didn’t push group sessions.
The average raw number of group and workshop sessions offered from 2006-2016 was 539.9, according to data obtained in a public records request.
In 2006, the counseling center offered 31 group sessions. In 2016, the center provided 999 group sessions, compared to the national average of 70 for an institution of Western’s size, according to data submitted to the Association for University and College and Counseling Center Directors annual survey.
Part of Robinson’s proposal includes something known as the “embedded counseling model.”
The model places licensed mental health professionals associated with the counseling center in various colleges across the campus.
“[The counselor] will definitely be affiliated with the counseling center, but they will also be affiliated with that department where their office is located so they’ll get to know that staff [and] they’ll probably provide professional training,” Robinson said.
Robinson also hopes to embed counselors in residence halls, where she says the need is greatest.
Other schools such as the University of Michigan, University of Texas at Austin, University of Iowa and Northwestern University have also experimented with this model.
Currently Western’s counseling center is located on the fifth floor of Old Main, the university’s administration building. In actuality, Robinson said the counseling center should be neighbors with the Student Health Center, since they work closely together.
A biofeedback lab, therapeutic massage chairs and more space in general are a few examples of what Robinson wants to see change at the counseling center.
“My wishlist could be endless,” she said.
But if Robinson were to receive any of those wishes, the counseling center has exhausted all of its spaces, turning them into usable offices. “Even if I’m given a salary line, which I hope I will be, where will I put these counselors?” she said.
While Robinson recognizes this increased pressure on the center’s services, she also thinks the demand has a silver lining.
“I think colleges and universities have done a much better job with destigmatizing mental health and making it accessible. Our students are coming in saying, ‘We need these services, we’re entitled to these services, we want these services.’ That’s a win-win,” she said.
Speaking ‘in our own voice’
On April 17 and again on June 10, 2017, Ajeto publicly recounted his “Dark Days” at a presentation, called “In Our Own Voice,” for Western’s chapter of the National Alliance on Mental Illness.
Ajeto cried when he wrote his speech for the first time.
“I don’t get very emotional talking about any parts of my presentation except the ‘Dark Days,’” he said. “It felt good to re-explore those emotions and see how far I’ve come, but it felt like opening up a wound again.”
Ajeto’s presentation, like his story, braves the “Dark Days” to end on a brighter forecast: Ajeto’s “Successes, Hopes and Dreams.”
Once Ajeto returned to regular off-campus counseling, his GPA rose steadily, from 3.1 to 3.2, 3.2 to 3.56 – and finally to 3.89. He developed coping mechanisms, and created an “uplifting” playlist on Spotify. Spending time with his girlfriend and younger brother, taking intentional study breaks and lifting weights at the Wade King Recreation Center now afford him greater balance in his life.
“I’ve felt a lot better than I’ve felt in a long time,” he said.
Ajeto aspires to become a mental health counselor himself. One day, he hopes to return to Western to teach clinical counseling before starting his own private practice, he said.
Although some pieces are painful to recount, Ajeto feels emboldened to share his full story.
“I think it’s important to share what I’ve dealt with, because people have such a skewed representation of what mental illness looks like,” he said. “If I can help one person in the audience at each presentation understand mental illness more, or help that one person understand their own mental illness more, then that’s all I need to feel satisfied.”