The Flexible Care Model (previously known as the Urgent Care Model) is a mental health treatment delivery system focused primarily on college campuses. There is a broad trend internationally for college students seeking help for mental health concerns in record numbers. This has taxed nearly all university counseling centers, and has created the need for a re-imagining of mental health care on campus. The model has it’s roots in common factors research, multicultural psychology, and urgent care medical centers, and is designed to provide faster access and more options for individual care than traditional systems. Defining features include same day access, variable sessions lengths, an immediate treatment approach (goal-focused counseling), and customizable follow-up plans.
(Inter)National Campus Trends
There are a range of trends happening in the United States and beyond related to mental health and providing care on campus. These include:
- Increased demand for care
- Greater student diversity
- Increased acuity / complexity
- Increased suicideality
- Increased anxiety
- Access challenges
- Destigmatization campaigns
- Whole campus approaches
- Media attention
- Staff morale issues
Of particular importance to this model are the increased demand for care, and greater student diversity. More specifically, the demand for mental health care on campus has never been higher, and many counseling centers are unable to meet current needs. Much of the attention paid to this issue focuses on students with more severe and complex conditions. However, many counseling centers also see a substantial number of students that have very developmentally normal or sub-clinical concerns. This group has likely benefited from destigmatization campaigns and encouragement to seek help from professionals even without a serious mental health issue, and they make up a meaningful percentage of the increase in demand at college counseling centers.
Increasing Severity of Symptoms?: There is a common narrative that students are presenting with greater mental health challenges in the current era than in the past, and there are reports back at least to the 1980s documenting this trend (e.g. Koplik & DeVito, 1986). However, there is also evidence of cyclic trends rather than a linear worsening over time. Examining 20 years of the National College Health Assessment (NCHA) data is a good way to look at the more recent past with this. Here are some specific depression related items for an example:
|NCHA Question Comparison||’00||’09||’19|
| Felt very sad||81%||60%||71%|
|Felt so deprssd it was diff. to function||44%||30%||45%|
Student Requests and Demands: It’s also important to acknowledge that there is not just more demand for counseling on campus, but that there are some common requests for changing how that care is accessed and delivered. Students have been asking for faster access, having more frequent and unlimited sessions, multiple ways to schedule and places to meet, various formats and modalities of treatment, and services that are provided by diverse and multilingual professionals that are helpful.
Increasing Diversity: College students are also more diverse than they have ever been, and more than when most counseling centers were established. In 1976, only 18% of all college students in the United States identified as students of color, and that has increased to 44% in 2019. The age of college students has also increased, and now 37% of all college students are over the age of 25. There are also many more international students than in previous decades. All of this means that students’ experiences with mental health, and beliefs about treatment are also more diverse.
Traditional Counseling Center Practices
Most university counseling centers have a set of system practices that have been used throughout their existence. These include:
- Scheduling sessions in advance
- Conducting a full assessment before treatment
- Providing traditional 50-minute psychotherapy sessions
- Provider expectations that there will be an ongoing process
Embedded in these practices are Eurocentric assumptions about how mental health care is provided. This includes having help be planned in advance rather than in the moment, that it cannot begin without an interview about a range of topics that may or may not be relevant to the person but may be important to the provider creating a diagnosis, that the meeting length and structure fits all people, that it is a formal treatment interaction, and that the person will want to keep returning. In other communities and cultures around the world, mental health care is not always conceptualized or provided in this way.
- An exception to the above practices is almost universally made for students in “crisis” situations, most often related to suicidal ideation. In those cases, students are told to just walk in when they need help, they meet with someone quickly who does some assessment of the immediate situation, and who then focuses on intervening regardless of how many minutes that takes (sometimes longer or shorter than 50 minutes).
- One of the early ideas that led to the Flexible Care Model was realizing that the way crisis care is provided was exactly what many students were asking for who were not in crisis. So why not offer this approach to everyone?
Shefet (2017) highlights the common moves counseling centers use in managing systemic pressures. These include adding staff, waitlists, session limits, and increasing referrals off campus. However, for most counseling centers, these have been temporary fixes as growth in demand outpaces what these solutions offer, or they have been unacceptable on their individual campuses.
These trends in increasing demand, problem severity, student demographic shifts, and counseling center struggles have been happening since at least the early 1980s. In a review of the field at the time, Bishop (1990) called for broader change, warning:
- “Clinging to a traditional counseling and therapy model may prevent a counseling center from engaging in preventative and developmental roles and, even at that cost, may still not be an effective way at responding to the increasing demands placed on it.” (p. 411).
A recent major report by the Chronicle of Higher Education (2020) echoed these calls for change and made recommendations. Aspects of the Flexible Care Model were featured throughout the report, and their first major recommendations was to “Create Flexible Treatment Models” (p45).
Most university counseling centers (or their ancestors) were established in the mid/late-1900s. Alongside that development, three other areas of research and practice were emerging and growing in importance toward the end of the century: common factors research, multicultural psychology, and urgent care medical centers. These areas are the philosophical cornerstones for the Flexible Care Model.
- Common Factors: The common factors literature has been the answer to why so many schools of psychotherapy are equally effective. Frank (1974, 1993) highlights this especially well showing how psychotherapy fits into a larger context of global healing traditions. Essentially, that psychotherapies share a healing relationship, a healing setting, and a shared rationale or myth of illness and treatment. Common factors research provides a theoretical foundation for adapting psychotherapy to new environments, populations, cultures, times, and formats.
- Multicultural Psychology: The premise of this field is the recognition that experience with, and beliefs about mental health and treatment are culturally determined. Transcultural Psychiatry is a closely affiliated field that has a journal with great qualitative reports. Almost all counseling centers strive for cultural-competence among providers, but there’s less attention paid to the system itself. Broadly, counseling centers need to honor this by creating opportunities for people with a range of beliefs about mental health and treatment to access care, creating a culturally-competent system. An example from Brinson & Kottler (1995):
“Because minority clients respond better to less structured and more informal settings, it can be assumed that the usual counseling model of a 50-minute “hour” by appointment will be less effective than more flexible alternatives. Thus, drop-in centers that provide alternative settings in which counseling can occur should be developed and implemented by staff members.” (p. 381)
- Urgent Care Medicine: In the 1980s, several entrepreneurial physicians looked to create a more responsive and efficient way of providing care. Although it took awhile to catch on, urgent care centers have exploded in popularity in the United States. They provide on-demand care (walk in or scheduled the same day) for a wide range of concerns, a focus on providing immediate treatment, and opportunities to return as-needed. These practices also mirror what many students are asking for in their campus counseling center.
It makes sense that university counseling center systems were not initially influenced by these areas because the fields themselves were in their infancy when the centers were founded. Instead, counseling centers used primary care medical centers, private practice clinician offices, and military career assistance systems as models. If counseling centers were just coming into existence now, they would likely look quite different.
The Flexible Care Model
The next section describes the Flexible Care Model, and the defining features of providing same-day access to care for as many students as possible, offering variable session lengths including concise counseling sessions (25-30 minutes), taking an immediate treatment orientation (offering clinically meaningful help at the first session), and a range of customizable follow up options that often involves the broader campus.
Flexibility as a Core Value
The naming of the model is intentional as a way to highlight something central to it, which is flexibility. That includes being flexible with individual student needs, staff support, and larger system adaptability. No system works for everyone every time, including this one. However, being intentional and creative in problem-solving each individual situation allows for better treatment of everyone involved. As you read on, try to think of this approach the way jazz musicians approach a performance. There are structures in place and shared ideas, but the individual players improvise within them to create something new every time.
Our ‘Sandwich’ Style Semester
Here is a visual representation of what a semester looks like in terms of weeks to help clarify how it all fits together as you read the sections below. This model changes a little bit each semester and has evolved over time into this.
Same Day Access
Same day access is a method of providing faster care where the wait is hours rather than weeks. Some ways this has been implemented are providing entire weeks where all clinical staff are only providing same day scheduled sessions, and building in same day access for all levels of needs each day (not just for urgent situations). For our center, this is the primary route into our care.
All Same Day Weeks: In Brown’s semester system, the first 2-3 weeks and last 4-5 weeks are almost exclusively reserved for same day sessions. Each clinician has 8 spots per day available to be scheduled, and students are told to come in for as many sessions as they need. The weeks at the beginning of the semester are busier than at the end. Students with more severe situations or scheduling challenges have follow ups booked in advance (about 10-15%), and others contact the center the next time they want to meet, even the next day.
- For our campus of 10,000 students (we see 25% for counseling each year), the busiest we’ve ever been on a single day during an all same day session week was 80. That was in the second week at the start of the new school year. The average is 57/day. For the end of term, the average is lower, and there are actually less sessions total in the clinic than the final week of our middle of the semester system. That allows us to help students in difficult situations much more comprehensively as finals approach.
Same Day Access to Every Provider: During the middle of the semester, we retain same day access as part of it. In those middle weeks, each clinician has 1-2 same day sessions available that are never booked other than that day, and students can also book follow-up sessions after these. That also allows providers to tell students that one of their follow up options can be to return to their care literally any day the center is open.
Same Day vs Drop-In: We differentiate same day access from “drop-in”. Students can technically drop-in and see if someone is available at that time (and sometimes that works), but nearly all of these sessions are scheduled for later in the day. Basically students usually contact the center in the morning and reserve a same day session for later in the day. This prevents any potential for too many people walking in at the same time, allows us to have a plan for how many we offer, and students like it because they know they have it booked at a certain time with a specific person.
Whole Team vs Rotation: a benefit of having the whole staff do same days each day is that students can return as needed to the same provider if they want no matter what the day. Some schools have success in doing this as a rotation, which is a more faithful “single session” approach. The drawback is that there is a disincentive for students to use same days as a follow up plan if they really want to see the same person each time.
Charting: I get asked a lot of questions about how these are documented in the student’s chart. The same day aspect here is simply just a method of scheduling, it doesn’t mean the session itself is anything different than if it was scheduled in advance. We see these as psychotherapy sessions, so we document them as we would any other type of psychotherapy progress note.
Implementation: For directors looking to implement this, there are a few things to consider.
- First, having each provider have 1-2 same day sessions every day is pretty easy to implement, just have a plan for what the follow up options are. For the all same day weeks, the beginning of semester weeks are more challenging than at the end because of making the transition to a more standard model (if you decide to do that). The end of semester weeks are easier and good idea for any model, especially since on many campuses the no show rate is high, some students will never get in of the current model’s wait is too long, and those that do get in late may only get 1-2 sessions anyway. This allows for much better access at that point for those that need it, and the no show rate is very low.
- Additionally, afternoon times are much more in demand than the morning (that’s across all of the universities that do this). Finally, have a plan for what to offer when they sell out. In the all same day weeks, we say they can contact us on another day, that they can talk to someone via phone (through ProtoCall), that we will call them on a day they want to see if they are still interested, or to come in if it is more of an emergency situation. For a student requesting a specific provider that is not available, we also offer someone else that may be available instead. Most people elect to contact us the next time they want a session. For the middle of the semester we give all those options, and also offer to schedule them in advance.
Variable Session Lengths
When considering psychotherapy as a dose, most university counseling centers have every student receive the maximum dose of care that they can offer (a 20 minute “triage”, followed by a 50-minute intake, and then weekly or biweekly 50-minute psychotherapy sessions). The Flexible Care Model offers different session lengths to provide the right amount for each person. On a system level, this allows us to make sure students with the greatest needs are able to get more comprehensive care on campus (reducing the numbers were refer to the community), and to improve the frequency that students return (usually the next week).
Concise Sessions: A concise session is any psychotherapy session length that is less than the traditional 45-50 minute session. In our center, the most common length of session is 25-30 minutes (about 66%), and about one-third have 45-50 minute sessions. Every student starts with a concise session, and each student-therapist pair work together to determine what type of session length would be good for the next week. Sometimes the therapist makes a suggestion and other times it is the student selecting from the menu of options. Usually students stick with a certain length each time but some students will change week-to-week based on their needs.
- Consultation vs Psychotherapy: An important aspect of concise sessions (including when they are booked the same day) is that these are actual psychotherapy sessions that use the same methods from the clinician’s theoretical orientation. It may seem on the surface that they must be different because they are shorter, which makes deeper work impossible. That limitation is only brought into the room by the therapist, not the client. Paradoxically, these sessions often feel more productive than traditional sessions because the frame makes both client and therapist show up ready to work.
- How Common Are Concise Sessions?: Concise sessions are not as common in college mental health (although it is starting to trend), but they are used in other parts of the American healthcare system. CPT codes used for billing are divided into 15 minute increments (30, 45, 60, etc). It’s impossible to get private insurance data on this, but Medicare system data is accessible. I looked at the 2016 data (the most recent available at the time) and found that 22% of all billed psychotherapy sessions that year were for 30-minute sessions (which is actually 17-36 minutes). The majority of them were provided by clinical psychologists, followed by social workers, and then other professionals.
Titrating: When the concise session dose is shown to be ineffective at meeting the client’s clinical goals after a few meetings, clinicians can titrate amount of care to more traditional 45-50 minute sessions and/or increase the frequency. Concise sessions work for students across all diagnostic categories and presenting concerns, so other metrics needs to be used to determine what works best. Ours is basically seeing if the concise sessions are helping enough, and if not, then we make a change. Other times the traditional sessions become the preferred method are when case management or safety assessment is taking up a substantial amount of session time each week.
Student Satisfaction: We did a post-session satisfaction survey for a full week in Spring 2019 where students across both concise and traditional sessions afterward completed an anonymous satisfaction form, asking if they were satisfied overall with the session, if the counselor provided ‘meaningful help’, and if there was good rapport between them. We used 0-3 scale with 0 being “not at all” to 3 “yes, very much”. Results on all questions between the groups were nearly identical (all means were in the 2.8 range), and any differences were statistically insignificant.
- Additionally, 25-30 minutes is a very common amount of time students have meetings with other professionals on campus (faculty office hours, career center, deans, advisors etc). They are used to getting important things accomplished in that format, which is part of why we think they work so well for counseling too.
Empirical Support: No research has ever been done that shows 50-minutes is a necessary or even ideal amount of time for psychotherapy. To our knowledge there are only two studies ever done comparing session length and outcomes.
- The most recent was Turner et al (1996) that found 30min sessions were equal to 50min sessions on adjustment and satisfaction in a college student sample.
- The other was Bierenbaum et al (1976), who compared 30min sessions 2x/week, 60min sessions 1x/wk, 120min sessions 2x/mo. They found that 30min sessions actually produced the most change in MMPI scores, and that the 60min sessions were preferred by people who were highly emotive in session. There were significant methodological issues with this study (one being conflating length and frequency) that are acknowledged in the text.
Dosing Levels: Most of the traditional models counseling centers use, especially when there are only one or two defined tracks for treatment, are making a mistake of over-treating some students and under-treating others. Assuming all students in a counseling center would start with a 50-minute intake and then move to 50-minute sessions, the only variable to control is session frequency. One of the positions the Flexible Care Model takes is in adjusting the dose based on the students needs and preferences to give a more precise dose. The broader range of individual appointments allows for this, especially the ability to also adjust session length. Getting the dose right means more students can to receive treatment on campus since it reallocates clinical time toward those with the greatest mental health needs, while also serving the students with sub-clinical needs effectively. Stepped Care models operate on the same premise.
We are actively involved in outcome research on these types of sessions and collected data in fall 2019 that we hope to contribute to this literature. I am also developing materials that will be added to this website on training for concise sessions, and more about how time is used in psychotherapy.
Immediate Treatment / Goal-Focused Counseling
The first meeting (or 2) at most university counseling centers is primarily focused on assessment. A triage session is a shorter interview designed to get students to the right type of next step. Often that is a longer intake interview that focuses on history and the broader context of the client’s presenting concern. The next session is usually where more of the focus is on the client’s clinical goals. In the Flexible Care Model, even the first session is focused on providing something “clinically meaningful” to the client, and only does assessment enough to help with the immediate concerns and any safety issues. Classic intake interviews are generally not conducted, and clinicians gather relevant information as they go.
Goal-Focused Counseling: The closest siblings to this approach are the Single Session / One-at-a-Time Therapies, and the campus program Let’s Talk. The single session stance assumes this may be the only/last time the therapist may ever work with the client, so all energy should be given to helping them with their stated goals and concerns here-and-now. A key difference is that goal-focused counseling isn’t a theoretical orientation, and doesn’t ask providers to change the content of their practice. Instead, it’s just changing the mindset for providing the same psychotherapy each clinician uses. Additionally, Let’s Talk is a culturally-informed consultation with a clinician designed for students who do not resonate with psychotherapy or the counseling center as a setting. It focuses on brief but meaningful contact where immediate help is provided.
- The Important Stuff: Part of what we think makes these work is that providing immediate treatment makes both the therapist and client focused on the here-and-now and working on the important stuff to the client. Yulish et al (2017) did a meta-analysis on treatment outcomes related to anxiety, and found that time spent on the client’s stated problems was the most beneficial aspect across a range of approaches. This informs our decisions to spend nearly the entire time the client is ever in the room on their stated problems and goals.
- Parallel Assessment: Instead of doing an intake / large history gathering first, clinicians do what I call ‘parallel assessment’, which is where they gather the information they need as they go; in parallel with providing treatment. There is a skill that clinicians develop when practicing like this, and the key is to stay focused on what the client’s goals are for the session, and asking questions that inform that specific purpose. Most therapists that struggle with this ask things that they may be curious about personally, but likely don’t matter that much for the session or to the client. The exception to all of this is for doing assessments for safety, which should be done at the same level as always.
All Orientations: All of this is not a theoretical orientation of psychotherapy. It’s just a framework for doing each clinician’s style of therapy. I also think that all providers from all theoretical orientations can use this goal-focused approach and concise sessions effectively. In our center, people do this that practice from Psychodynamic, feminist/multicultural, interpersonal/humanistic, and ACT/CBT/DBT orientations among others.
Forms: One way to gathering more without taking session time is to get crucial information on forms and instruments before the session. One suggestion is to have clients answer a question like “what do you hope to accomplish in your session today?” every session. That also allows the clinician to begin the session with that goal to immediately get things on track. “Great to see you again, looks like from your check-in form that we are talking about anxiety today, how can I help?”
Customizable Follow-Up Plans
The Flexible Care Model looks to create as many unique pathways through the counseling center as possible. Some centers may only be able to offer a smaller range (concise or traditional follow ups, urgent sessions, same day, or group), whereas others may have a large menu of options. The main philosophy is to allow students to create a unique path (choose your own adventure) through the clinic in a way that meets their individual needs for care, and utilizing broader wellness resources on campus into treatment plans.
Individual Options: Our experience has been that although some students will be open to shifting to another modality for care, most of them ask for individual treatment and epect that it is available. This model creates a few additional options for follow-up planning than other models as a way to honor that preference, namely the ability to have a concise session booked ahead, or a same day session.
- Session Frequency: Research supports session frequency being related to outcomes, and this is often overlooked in counseling centers as an important factor. Erekson et al (2015) found that clients who were able to attend weekly sessions improved at a faster rate than clients with less frequent sessions, and ultimately needed fewer sessions to reach their clinical goals. This model allows for a range of session frequencies, with most students having weekly sessions, but it also would allow for multiple sessions per week for clients that need it.
New Plan Every Week: It’s very hard to predict the course of treatment for anyone including college student clients, so this model also allows psychotherapy to adapt session-to-session based on the student’s needs, motivation, and availability. Most clients will stay with the same type of session, but others will reduce session length or frequency when they are busier, or move from coming in for occasional same day sessions to something booked in advance when they need to focus on something more significant that is happening.
Other Services as Follow-Up: Most campuses have been investing significant resources in student wellness over the past 10 years, and even small schools typically have a range of support services. Now, maybe more than ever, counseling staff need to know what else is available on campus so that treatment can be a whole campus effort. This model intentionally looks to include an array of other wellness and academic resources into follow up plans, so that improvement is not just located in the counseling center.
Toolbox for Providers: The model doesn’t just provide flexible options for clients, it also gives the same flexibility to providers. One way to think of this is that it is a broader toolbox for clinicians to individually tailor treatment. It allows providers to mix and match interventions for students looking for individual care by using session length, frequency, and scheduling options (same day, advanced, urgent, etc) as a way to match student needs to unique formats. Each provider then has a broader array of options for services to offer students than another 50-minute session in a week or two.
The graph below is another way to conceptualize the types of appointments based on how they are scheduled and how long they are. Each center also has codes that solve certain local problems or because they have more / different clinical offerings. Ours has special codes for “Returner” and “Fast Track” in the blue box, and “Urgent” in the yellow box. Another example is that some centers do same day sessions for 45-50 minutes so their “Same Day” would actually be in the red box, and the yellow box would be “Provider decides to shorten the session”. Other places may have “Triage” in the yellow box. This all just depends on what each center decides to offer and how, but it can be helpful to plot it out.
For context about our campus, we have just under 10,000 students and we see 25% of them each year at the center. Our Clinical Load Index (CLI) is 165, and we do not have session limits. About two-thirds of students on campus are undergrads, and they are a very diverse, global community. The university is competitive for admissions with an 8% selection rate. We have a very diverse and multilingual staff, and each clinician has a certain number of access appointments (same day and advanced scheduled) as the way to democratize the flow of new clients into the center each week.
The system-wide outcomes from the semester before we changed were pretty significant. The wait for a first session reduced from 2-3 weeks to just under 3 days, most students are able to return for another session the next week when the previous standard was two weeks, and we have reduced our off campus referrals from around 35% to under 10%. Our no-show rate reduced from 11% to 6%.
There is some variance between providers in how they practice within the model. Some providers have higher percentages of concise sessions than others, which leads to differences in number of students served per clinical hour (1.41-1.85). On any given week, that range could be 1.27-2.00. That also shifts the clinical time percentage per week each clinician has, and that range across the semester is 20-65% (IACS maximum, V.D.1), with it building up over time for each person. That is because although they are seeing relatively the same number of clients, they create different paths through the center for those clients.
Another set of positives that is harder to capture empirically is in suicide prevention. A conversation I had with staff at the JED Foundation (who offer a free Flexible Care Model webinar for JED campus schools) highlighted some of the thinking. The idea was that the combination of providing fast clinical access, seeing more students more frequently, and referring fewer students off campus also means that suicide safety questions are also being answered by more students more frequently. The model essentially creates more points of detection than other models, allowing for more opportunities for intervention.
There are some suggestions and lessons learned from implementation at Brown and other universities that have been early adopters. In the big picture, we transitioned to this from a triage system with about 3 months of planning and no additional staffing resources. Having a reasonable number of staff is crucial, but having more or less than Brown wouldn’t necessarily change the model. Instead, it would impact which features to emphasize (e.g. high CLI may use more same day sessions, low CLI may offer more traditional sessions, etc). We then scaled it up every semester for the past 3 years and continue to adjust and improve it.
- Building in a spirit of continuous trying of new things helps an organization stay nimble and responsive, which is important to consider if you are looking to implement Flexible Care or any other changes at a counseling center. This idea was even encoded in the original guidelines for college counseling centers (Kirk et al, 1971), which later became the IACS standards:
“A major responsibility of any Counseling Service is to be alert to the changing needs of its university community. To be responsive to them, the Counseling Service must maintain an attitude of thoughtful experimentation and careful innovation: conceptual, strategic, and programmatic.” (p. 586)
One of the biggest concerns about implementation is how counseling center staff will buy-in to such a different approach. I’ve found in the schools I’ve worked with that there is a range of excitement about doing things differently from some being very enthusiastic, most being curious or hopeful with reasonable questions or concerns, and some being very resistant. So the experience of change in each center will be different, and the human factors related to this are the same things present with any type of transformational, institutional change (individual personalities, historical staff dynamics, etc)
- If a center has a very committed, open-minded and experimental staff, then this likely will go well (and you may consider going for a bigger splash). If it’s the other side, there will likely be more challenges (and you may consider a more limited pilot first). The thing to avoid is spending too much time deliberating as a team rather than trying parts of it and having concrete examples in house to work from rather than just hypotheticals.
- One suggestion for an apprehensive staff is to develop a clear goal or two (e.g. reduce wait for a first session), and try a new approach for a semester as a proof of concept. If it doesn’t work, go back to the same model currently being used.
- Furthermore, college counseling center work is emotionally demanding, and this model is not an antidote for that, although it does provide some benefits like more autonomy. Staff have valid concerns if they are expected to go past some of the standard guard rails like 65% clinical time with regularity while also seeing more people.
- Staff also need reminders and encouragement about practicing differently since there is an inertia to doing things how they have always been done. There is also a difficulty for some staff seeing more students per week, even if they are also having more open time for administrative work and consultation.
- Staff also need adequate time for documentation. Writing more psychotherapy notes requires a bit more time, so managers should explore documentation efficiencies to streamline note writing. Additionally, if your system will no longer be doing full intake interviews and requiring those extensive write-ups from staff, that time saving alone may be enough to cover the larger number of progress notes.
- An additional unique layer of resistance may be that therapists often would choose a different type of therapy for themselves than the general public prefers. Cooper et al (2019) found that clinicians prefer their own therapy to be less directive and more emotionally intense than the general public does. The authors warn that therapists should not project their own desires onto their clients. This belief in less directive and more emotionally intense care also favors historical counseling center practices, and can build resistance to new approaches.
- Change Management: There is an entire subfield of the organizational psych world focused on how to facilitate change. Depending on the specific team / campus, a more intentional process may be necessary to help, and is beyond the scope of this page.
Challenges & Training
Challenges: There are obviously challenges with this model like all others, although we think the benefits outweigh the issues. Students that have problems being motivated for treatment or setting any goals at all for a session can struggle in this model, but we think that is pretty similar to more traditional models. It also can be a big departure from traditional business in some campuses, and university staff in other offices as well as students can sometimes not understand. Having clear messaging and materials is important for a good rollout and keeping things positive.
Training: Although every clinician could practice in this model competently right away, some training could be important depending on staff dynamics. If you are going to do same day sessions or have the immediate treatment focus, the Single Session Therapy folks can definitely teach staff new skills that can help them do this effectively. I offer a training course for concise sessions that I’ll do in person or video conference. However, if you have staff that are ready to go, they also may not need any further training.
Special Considerations: There are a couple areas at some schools that have implemented this that need special decision making.
- The first is what to do for students who got used to the previous system, particularly as long term clients. I suggest working with each individual student and therapist pair to see what makes sense rather than a blanket policy, and maintain a spirit of flexibility and collaboration to make a path that works.
- The second is what to do for students that really don’t resonate with the model, like folks that have extreme difficulty asking for help, or where not having sessions booked in advance actually causes significantly more stress for them. Again, in these cases, I suggest bringing a spirit of flexibility and look at all the options for each unique situation to find a path forward that makes sense for the student. Sometimes we can find a creative way forward within the model that works, and other times it’s best to just make exceptions.
- The third is sorting out how many advanced scheduled new clients each provider should have. I’m working on a formula that may be a guide that I hope to add here soon. However, each center has to decide what ways they want to use the tools like same day and the follow-up options, and that may change how new clients schedule in advance.
Suggested Starting Points
These are the easiest starting points that have real returns. They requires the lowest investment and are the easiest to change back if they aren’t going well.
- Change triage assessments into concise psychotherapy sessions
- Do all same day sessions for the final two weeks of the term
- Offer a some non-urgent same day sessions every day
- Allow staff to book concise sessions for follow ups for some clients
Additionally, a lot of schools have been using smaller teams to pilot some of these things rather than making the entire center shift, and that has worked well especially for larger universities or places where there is more concern about changing practices.
Common Clinical Models
There are three major clinical models that most centers use, although there is wide within-group variance. I’m highlighting the pathways to individual psychotherapy in each as a way to show similarities and differences, and also to highlight areas that some of the Flexible Care Model ideas can help boost a well functioning model rather than going through a larger remodeling.
- Traditional Model: In this model, the student’s first visit is usually a 50-minute intake session that is scheduled in advance. Then the follow-up options are usually traditional 50-minute sessions or another service. For this model, intakes could be scheduled the same day, and follow ups could include concise sessions for some clients.
- Triage Model: This model adds a brief assessment offers as soon as the same day, to help determine needs and provide some immediate guidance. Follow-up options can be an urgent session, a 50-minute intake assessment, or other service. In this approach, students could be offered concise sessions after the brief assessment rather than an intake depending on level of need.
- Stepped Care: This approach drew inspiration from the UK healthcare system. Students start with a triage assessment like above, and they are guided to a level of care that matches their needs. Usually there are a wide range of options (steps) from self-help to a 50-minute intake assessment. For this model, concise sessions could be offered as a step between group and traditional psychotherapy.
- Flexible Care Hybrid: Developing some type of hybrid model or parallel Flexible Care system is another way schools are working with some of these ideas. Having Flexible Care as more of a true “urgent care / rapid access” system as an auxiliary to a more traditional “primary care” style system is also a common starting point.
Other Things that Helped
There are a handful of other ideas we implemented at the same time that aren’t necessarily part of this model, but are important to how the center functions overall. Sharing those here in case it is helpful.
- Emergency Services Clinician: We hired a full time emergency services clinician who is an expert at crisis assessment and stabilization, and manages nearly all of those situations at our center including wrap around communication with local hospitals. This position has completely changed how urgent needs are managed in our clinic for the better.
- Fast Track: This is our program to try and use any open clinical time that is available for the coming week to help people use it for time-sensitive or brief treatment needs. Each week I personally look at who is booked out more than 7 days for a first time appointment and what time we have open, and then I email to ask them a set of questions to see if we can get them help faster. I move the sessions up depending on what they are looking for.
- Paced Reservation System: We have providers maintain a number of new students to bring into their caseloads each week. This maintains a steadiness so that they are never actually full. So even though they could at times add more new students, we hold to this flow so that students currently and in the coming weeks get good service. It’s mirrored after the way restaurants seat customers in waves, rather than seating all tables at once, which overwhelms the kitchen.
- Moving Unfilled New Spots Forward: Part of our success in keeping the wait time down for new clients coming in that want to book in advance (rather than schedule for the same day), is that when a new client spot goes unfilled (from a late cancel, no show, or provider absence), the provider moves that spot into the future so that they can maintain their pace of bringing new clients into the center.
- CAPS Labs: This is our program to increase transparency about what we are experimenting with. We keep a log every semester on our website of our pilot projects and the results of previous labs. We also encourage students to suggest labs too. Having this shows our community how much new stuff we are trying, and it also makes us stay thinking about how to improve at all times.
- Staying With Original Provider: Since we don’t do classic intakes, each clinician and student are starting psychotherapy from the first session. To maintain and build on the relationship that gets established right away, and also minimize the student needing to tell their story multiple times, we almost always have the original pair stay together. That means we do not have a post-intake case assignment process.
- Streamlining Outreach: We have developed an outreach program with clear objectives and programs that are important for our expertise like suicide prevention education. Although we also do respond to special requests, we have streamlined this work to be higher impact and easier to see the direct impact, and refer other requests to more appropriate offices.
Development of the Model
If you made it this far, you may be curious about how this all developed. The idea for the Flexible Care Model didn’t just come to mind one day. It is really the result of 10+ years of experimenting with different approaches and listening to what the student’s experience was with them.
The origin was in my first job as a one-person counseling center for 4000 students at Washington State University Vancouver, where I as also the first full time clinician. Part of my job was to actually create the basic ways the center would operate. Because of that situation, I had to think creatively about seeing students and started experimenting with minor changes to session length, scheduling, and intakes. When student feedback on these alternative practices was positive I kept going with it, and eventually really reduced what an intake was, did more 30-minute sessions (often at the necessity of the student’s schedule), and had more people return as-needed.
At my next campus with our staff of 4, we stopped doing intakes altogether and used a lot of 20-minute sessions focused on immediate help, which dramatically reduced wait time, improved access overall, and led to virtually no students being referred off campus. We did this while demand tripled in 4 years, from 8-24%.
When I arrived at Brown in 2017, our staff came together and decided on a set of solutions to implement the next semester, many of which were descendants of these previous systems and from student requests and collaborations, but it was going to be a much larger and intentional effort. We launched what is now the Flexible Care Model that fall and have scaled it up every semester from that point.
- Our approach was originally called the Urgent Care Model because it borrowed heavily from the practices of urgent care centers. I changed the name because there was too much misunderstanding, thinking that it was only doing crisis work, or that it was only drop-in with whatever provider was available (in our system almost all students keep working with the same provider each time). So we changed the name to reflect a core value of the model: flexibility in individual student care and also in the larger system.
I have additional materials that are regularly updated that I am happy to share that includes schedule examples, caseload charts, and more implementation FAQ. Contact me if you are interested and I will happily send you more or connect via phone to talk through this more ([email protected]).