This article is the first in a mini-series examining how Counseling and Psychological Services (CAPS) has responded to increased community scrutiny.
“CAPS sometimes feels like a frustrating black box and that makes it hard to trust them and have confidence in them,” said one student whose counseling appointments were cancelled repeatedly.
“It wasn’t the most life changing therapy I’ve received, but it was support that I needed,” said another.
“While I got the help I needed for the first six months of school, there were other issues that came up,” reflected a third. “But I felt CAPS was too busy for me.”
Those are just a few of the responses The Daily received when it asked students about their experiences with Stanford’s Counseling and Psychological Services (CAPS), the campus mental health service that’s come under scrutiny in recent years. Here, The Daily overviews CAPS’ system and examines CAPS’ mixed success on two fronts often advocated by community members: addressing long waits for care and expanding resources geared toward specific communities at Stanford.
How CAPS works
All students who have paid the Campus Health Service Fee of $203 per quarter can get free mental health and medical evaluations as well as short-term therapy, according to CAPS’ website.
Students typically enter the CAPS system through a phone triage, a short conversation meant to gauge the caller’s situation and the level of care they may require. Other students may be referred to CAPS by University staff such as a Resident Assistant (RA) or Resident Fellow (RF), while others may walk into CAPS’ space in Vaden Health Center directly.
Regardless of how one gets in touch with CAPS, said Vaden Director James Jacobs, the outcome is the same: Students’ first contact is simply a screening rather than a treatment. Walking in and talking face-to-face with a CAPS staffer might lead to a slightly more extended interaction than over the phone, but additional attention is incidental — the result of a last-minute cancellation that it’s too late to fill from the waitlist.
However, wait times vary based on how urgently a student seems to need care.
“Obviously if you walk in in crisis, which happens, you’ll be treated in an emergency fashion rather than be given an appointment,” he said. “Just like if you called in crisis… The answer is going to be, ‘come on over.’”
A student responding to The Daily’s survey recalled dropping in with a former significant other who’d struggled with a manic episode.
“The on-call counselor saw us immediately and was overall pretty great,” the student said.
In cases deemed non-urgent, students are scheduled for an initial intake appointment after their screening. That means that even once students pass through triage, their next interaction is largely administrative, devoted to data collection and understanding patients’ histories rather than intervention.
CAPS Director Ron Albucher wrote in a letter to The Daily last April that wait times for non-urgent care had improved from an average of 11 days in the 2014-15 academic year to an average of about six in 2015-16. Jacobs did not give an exact average for this year, citing large seasonal variations. At the beginning of each quarter, a student can get into CAPS within a few days, he said, but the delay stretches to two or even three weeks as the quarter progresses.
Those typical delays troubled one student who turned to CAPS this school year after the death of a grandparent, amid mounting stress both at home and at school. Feeling “hopeless and lost and numb” and with a history of mental health issues like anxiety, the student called CAPS only to learn that the soonest opening for one-on-one counseling was in three weeks — right in the middle of finals.
Once the student got in, they found CAPS’ therapy helpful. But their next appointment the following quarter was cancelled and pushed back two weeks; CAPS said the delay was intractable unless they had an emergency, according to the student. One appointment later, another meeting was cancelled.
“It’s frustrating… to emotionally prepare yourself to be open for therapy and have that taken away multiple times without really any effort make up for it,” the student wrote to The Daily. “It’s very difficult to rely on any kind of consistent care or support when appointments are cancelled at the last moment with no effort made to fit you in sooner.”
Even when getting appointments goes smoothly, CAPS may not be able to fully meet students’ needs. An anonymous junior who spoke over the phone to The Daily about seeking therapy for her chronic depression and anxiety liked her CAPS counselor but ultimately found her “not very helpful.” She was “sweet,” checked in regularly without asking and knew what sorts of stressors Stanford students in particular were coping with, the student said — but the CAPS sessions just weren’t very effective at addressing her mood disorder.
“I think that’s because, from experience and also from talking to some other friends who’ve been to CAPS, the CAPS counselors are very good at general, everyday problems, like if you’re really stressed about homework or going through a bad breakup,” she explained, suggesting that CAPS should better advertise itself a place for broad guidance rather than for help with chronic issues.
After entering CAPS’ system, students may need to be referred elsewhere, either to Stanford Psychiatry or to other therapists in the area. Referrals can happen at any point in an interaction with CAPS, from right after the initial phone screen to the end of many months of therapy.
Sometimes a student may need specialized care that CAPS is not equipped for, while sometimes the students needs longer-term attention. As Jacobs explained, CAPS can only provide short-term care on the order of maybe eight to 12 visits. Otherwise, he said, counselors would quickly book up.
Stretched to the limit
The wait to see a CAPS counselor can be frustrating for students in need, and appointment backlogs were a major concern in 2014-15 as criticism of CAPS peaked and a movement for improved mental health on campus emerged.
A 2015 Stanford Review article detailing one person’s disappointing experience seeking therapy declared that “CAPS is Broken,” arguing that “Stanford is failing where other supposedly more ‘impersonal’ and ‘cold’ academic institutions are succeeding.” That same year, CAPS increased its staff following a town hall that surfaced frustrations with an often-delayed appointment process. An ASSU survey conducted shortly after the town hall found that nearly 80 percent of respondents wanted more mental health resources, while only about two-thirds of students who used CAPS felt like they had benefited.
Today, CAPS continues to work to improve its services, according to Jacobs. But with minimal budget growth, CAPS’ staff and thus its capacity have changed little, even as the organization is called on to do more and more — to meet not only students’ individual needs but also to address campus reactions to current events amid a politically turbulent 2016.
Jacobs listed a series of national news items that affected segments of Stanford’s student body, First, he said, some students with sexual assault trauma were troubled by former student Brock Turner’s highly publicized sexual assault case and sentencing last summer. Then Donald Trump’s victory in the 2016 election left many students on a largely liberal campus in shock or fear for themselves or their communities. Trump’s subsequent executive orders on immigration and rhetoric around undocumented immigrants added to certain groups’ stress, Jacobs said.
Amid such tensions, CAPS has stepped in to provide support — for example, by participating in a town hall on Trump’s now-stalled immigration ban. These new demands of current events-driven outreach are part of the reason why CAPS’ staff remain so stretched, according to Jacobs.
“That’s something that a year ago no one would even think about,” he said of CAPS’ representation at the immigration town hall.
The most obvious solution to CAPS’ struggle to meet demand is adding more counselors. CAPS’ website lists 31 staff in addition to three interns, who serve a student body of almost 17,000 undergraduates and graduates.
Two years ago, Student Affairs approved funds to hire three new counselors for the fall as part of its plans to increase staff by five for the 2015-16 school year. But with little change in its budget, according to Jacobs, staff has stayed more or less steady in the years since. However, CAPS does intend to add two psychologists next school year; a later article in The Daily’s series on CAPS will examine its plans for the future.
CAPS Director Albucher explained at a town hall last January that staff turnover exacerbated CAPS’ appointment overload in 2014-15. An unusual number of people left for a variety of personal reasons, he said.
Jacobs pointed to the same medley of factors like job opportunities and family relocations as a cause for turnover, but also noted an important structural issue that he says most people don’t understand: the unique demands of being a short-term counselor. Some staff leave because the CAPS model simply isn’t the right fit for them, he said.
“If you were used to working in practice where you could hold onto your patients for as long as you want… and then you come and work for us,” Jacobs said, “we’re basically telling you you have to add at least two, preferably four new patients to your schedule every week, which also means you have to get rid of four patients every week. That, for some people… based on your training, based on your personality, you might not feel comfortable.”
Jacobs is the first to admit that desire for mental health services still outstrips capacity, despite the fact that CAPS staff-to-student ratio is solidly above the national average. When asked what trends he’s observed in CAPS’ usage, he compared CAPS to an ever-busy fast food restaurant: In a “resource-limited operation,” he said, just keeping up with demand takes priority over tracking details.
“If McDonalds only makes 500 hamburgers a day… at some point you can’t really tell trends because the only trend you know is that you sold all 500 hamburgers,” Jacobs explained. “We’re at 100 percent capacity all the time… You paddle as fast as you can.”
Serving underrepresented communities
In addition to pressing for more consistently prompt care, community members continue to ask for increased attention to diversity in CAPS’ staff and programs — a priority that shows up in ASSU executive candidate platforms, Senate meetings and student groups’ agendas.
“Students with marginalized backgrounds have been underserved by counselors that do not share their identities,” stated a student groups-led petition that garnered about 500 signatures last year. “These additional counselors and administrative staff must be better equipped to serve these students and also improve CAPS outreach on campus to their communities.”
CAPS has indeed sought to diversify its staff. At last year’s town hall, for example, Albucher noted the addition of five clinicians focused on mental health support for Stanford’s African-American community. These hires filled and built on three vacancies left by counselors with similar specialties.
However, according to Jacobs, recruiting people who specialize in particular areas of diversity has proved difficult, even as turnover provides more opportunities to change staff makeup. CAPS recently sought to hire someone with particular interest and experience working with Muslim students. Unfortunately, Jacobs said, the posting received no applicants, and Stanford had to hire a general practitioner instead.
“Otherwise we have this position open all year, which would have not served anybody’s purposes,” he explained.
In fact, all of CAPS’ postings for jobs with a diversity focus were unsuccessful this school year. But CAPS filled those vacancies with generalists using “fixed-term” temporary positions, meaning that Stanford can reopen the searches shortly to try again.
Despite the stall in its staff diversification, CAPS continues to grow and fine-tune its outreach to specific communities.
For years it has offered drop-in hours at ethnic community centers and other areas it thinks will be convenient for students, such as the School of Engineering, the School of Medicine and the Graduate Student Center, which hosts a grad student support group.
This year, CAPS moved its longstanding gender and sexual identity drop-in hours from the Fire Truck House to LGBTQ-themed Terra House, a change that CAPS psychologist Inge Hansen says has made services more accessible for many students (Vaden continues to offer similar drop-in hours as well). Hansen also plans to create a new student position to focus on queer and transgender mental health.
One example of CAPS’ evolving resources underrepresented minorities and students across the LGBTQ spectrum is the Weiland Health Initiative, which promotes mental health across genders and sexualities at Stanford. As founding director of the initiative, Hansen has overseen CAPS’ push to make as many center staff as possible well-versed in LGBTQ issues and identities.
“My vision for [the Weiland Health Initiative] was really to try to get to a place that we had mental health and wellness focused around all genders and sexualities, rather than just having a single clinician who’s a specialist that you either get along with well or you don’t,” Hansen said.
Since the Weiland Health Initiative has grown from its small-scale launch in 2011, Hansen has also watched Stanford adapt to a growing demand in services for transgender students. The number of students seeking gender-related surgeries remains below 20 per year, but it’s steadily growing, she said. She attributes that partly to the fact that Stanford’s insurance plan, Cardinal Care, started covering gender confirmation and gender transition services in 2010 — a major draw for certain prospective students, she believes.
As Stanford’s medical offerings for transgender students grow, CAPS has had to build up infrastructure around them, particularly because those seeking gender-transition and gender-affirmation surgeries need at least one and sometimes two letters of support from therapists. In advising students considering surgery or hormones, Hansen said, CAPS has shifted from a “gatekeeper” model in which students must meet a checklist of criteria to qualify for surgeries toward an “informed consent” model emphasizing students’ ability to make their own decisions about their bodies, barring serious concerns on the part of their counselors.
“I went to a conference in Amsterdam — the World Professional Association for Transgender Health (WPATH) has their annual conference in Amsterdam last year — and even the Netherlands has far more obstacles than Stanford does in getting [transgender] care,” she said. “That’s really the direction I want us going.”
Editor’s Note: The Daily has allowed all students quoted in this piece to remain anonymous due to the personal nature of the stories they are sharing.
Contact Hannah Knowles at hknowles ‘at’ stanford.edu.