The concept of triage in student mental health services


The concept of triage is central to any effective student mental health support service.  The idea is simple, but far from universally adopted. 



When talking to colleagues in university counselling teams, I often pick up on their sense that counselling might be under siege from university senior managers, as though colleagues are scanning for opportunities to cut or weaken these services. 


Our colleagues can misunderstand our counselling services, perhaps not grasping how crucial counselling is for many students and their academic engagement.  And it is unfortunate when an increase in the number of students contacting us for counselling support is perceived as a negative, when these same students making greater use and demands of our libraries or careers services is seen as a trend to be embraced.  However, I do not believe there is a set agenda to undermine counselling.  If colleagues do not see the true value of counselling, we might need to do more to explain why counselling makes such a difference.


That said, there is a siege, although not from management.  It comes from students themselves.


Students are requesting counselling in ever greater numbers.  News story after news story points to increases of 10-20% per year in the number of students requesting counselling from our universities, with recent data showing that Cardiff University has experienced a 72% increase in demand over the past three years.


It is difficult for universities – with our flat, tuition fee-dominated income levels and an ever-growing range of budgetary pressures – to match these increases in demand with equivalent increases in counsellor staffing. 


Pumping more funding into counselling and growing our counselling teams will sometimes be vital, particularly when there has been no increase in their staffing levels for a couple of years, but it should never be the default response.


Another option is reducing the contract length.  Some universities, by default, now only permit students a maximum of three or four counselling sessions per year.  While I understand the temptation, to try to get more students into support as quickly as possible, this is likely to be the option that is most unhelpful for students and most damaging for the broader institution in the long run.  Yes, we will get more students in front of a counsellor, but, by limiting these students to three sessions each, we are severely limiting the positive impact of the counselling that they are accessing. 


An academic programme leader deciding to halve the contact hours their students receive on their course would struggle to claim with any credibility that this would lead to more positive outcomes for students.  They may be congratulated for making budget savings, but the price to be paid further down the line will be in the form of worse academic outcomes and increased student attrition.  The same is true when we cap the number of counselling sessions that students receive at too low a level. 


Capping the contract length at three or four sessions per year can also undermine a team’s ability to secure additional resources in the future.  With fewer sessions for each student, the counselling that students do receive will be less effective, and a counselling team which is less effective in improving student wellbeing and academic engagement will find it increasingly difficult to win the argument that it deserves additional investment. 


Students do not request counselling flippantly or out of an inflated sense of their own difficulties.  In response to these requests, they require a response.  They require support.  However, counselling will not be the most effective response – in the sense of clinical effectiveness and cost-effectiveness – for all of these students. 


Some students who request counselling will be better served with a full mental health assessment from someone trained as a mental health nurse, followed by risk management interventions or a swift external referral into local crisis services.  Other students may find they do well with less resource-intensive interventions, such as guided self-help or digital self-help resources. 


Counselling works.  For many students, counselling will be more important than any additional support or intervention that their academic tutors can put in place, in terms of enabling them to engage with their course.  And the reality is that most, if not all, of us would probably benefit from counselling; an opportunity to reflect on our own emotions, our own interactions, and our own solutions to our own problems is something that would benefit a great many of us.  It would be great therefore if everyone who wanted counselling could receive it. 


However, counselling teams have limited resources, and must dedicate these resources intelligently, based on a proper case-by-case assessment of risk presented by each student – both clinical risk and the level of risk that, without proper support, the student presenting for support will leave their programme early.


Once we get away from the idea that someone who requests counselling should automatically take a place on a waiting list to receive counselling, it opens the door to a much richer menu of options into which we can triage students.  An effective registration form, asking the right questions, can enable qualified staff to triage registrations and utilise the limited resources available to best effect. 


This is something many universities have understood for some time now.  However, those of our institutions still caught up in the helter-skelter of ‘increased demand for support, shorter contract lengths’ might benefit from stepping back. 


By defining more clearly which students we triage into counselling, keeping the number of counselling sessions given to each student at a level nearer to five or six sessions a year, and offering different types of support to other students requesting support, the result will be a significant improvement in student wellbeing and academic outcomes.


Click here to comment on this article or connect with Levi Pay on LinkedIn




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