[The following letter was sent to Vanderbilt graduate workers on 17 September 2017. It responds to the e-mail “Graduate Student Mental Health & Well-being Care,” which was sent to Vanderbilt graduate workers by the Vanderbilt Administration on 13 September 2017. The inset paragraphs are the responses of Vandy Graduate Workers to the administration.]

"Our graduate and professional students’ mental health and well-being is an institutional priority for Vanderbilt. We greatly appreciate all of the feedback we’ve heard from you on this subject over the last year and from those who attended the town hall we hosted with the graduate worker Council Sept. 11. Student engagement and input on these issues is critical to providing the best possible care for our community.

Our goal is always to be as transparent as possible, and transparency regarding your care is no exception. Our model of care has been, and will continue to be, structured around an emphasis on connecting students to a network of care that best suits their individual needs."

While we appreciate the administration’s ongoing commitment to transparency in their communications with graduate workers, the September 11 Town Hall made clear that there has been insufficient communication regarding recent changes to our mental healthcare access at the PCC. Since the beginning of fall semester, Vanderbilt Graduate Workers have collected dozens of reports from our colleagues about new restrictions to their therapy access at the PCC, and over 60 personal testimonies from graduate workers point to a lack of clarity from our administration regarding the PCC’s evolving policies. Specifically, these testimonies demonstrate that the administration has not provided graduate workers with an adequate explanation of the rationale behind the model-shift, the nature of the clinical review process, and the potential impact of this shift on our care. This is despite the fact that our colleagues - many of whom courageously shared their stories at the town hall - have already experienced significant deleterious consequences as a result of these changes. Indeed,  two administrators present at the town hall meeting–Dean Mark Wallace and Interim PCC Director Adriana Kipper-Smith–admitted that the administration’s communications to us about the PCC’s policies have been insufficiently clear in recent months. Both Wallace and Kipper-Smith verbally committed to improving communications about the PCC’s policies in the future. Open, transparent communication is necessary for open discussion of graduate worker concerns regarding PCC policy changes that may conflict with expectations and needs based on our prior experience with the PCC.

"As graduate workers, we understand you deal with real and significant challenges. I want to assure each of you that all Vanderbilt students will be directed to the necessary treatment and resources."

 It is true that we face significant challenges in our work environment as graduate workers. A recent study from UC-Berkeley reports that nearly half of US graduate workers experience depression during their PhD programs–a rate of mental illness that exceeds most other professions.

"We are creating an FAQ that aims to address the questions we have received, which we will share and post on the PCC and Graduate School websites next week. Please submit topics related to mental health services that you would like to see addressed; our aim is for this to be an evolving resource."

 We hope that this FAQ will include a substantive answer to the urgent question raised at the September 11 Town Hall of how much graduate workers should expect to pay out-of-pocket for off-campus therapy. Given the recent increase in off-campus referrals being reported by graduate workers who use the PCC, the urgency of providing us with a reasonable estimate for how much individual therapy will cost us on our Vanderbilt insurance plan cannot be overstated. We understand that costs may vary case by case, depending on the individual’s needs. Yet it was notable that none of the four administrators present at the September 11 Town Hall could offer even a ballpark estimate for how much graduate workers should expect to contribute for off-campus therapy sessions on our insurance plan, suggesting that no systematic attempt has been made to survey the financial landscape of community care. Dean Mark Wallace and Interim PCC Director Adriana Kipper-Smith both claimed that they would have to be calculated on a case-by-case basis, rendering the possibilities “infinite”. However, given that graduate workers are paid roughly the same across disciplines and have the same student health insurance, it is troubling that they have not already estimated any baseline cost for counseling sessions at health care clinics that are said to accept our insurance. One graduate worker reported having to discontinue their therapy altogether because an off-campus referral was going to cost 20% of their income. Furthermore, town hall panelists did not seem to recognize the additional costs in time and transportation imposed upon graduate workers needing off-campus care. It is very concerning to Vanderbilt Graduate Workers that such significant policy changes to our on-campus mental healthcare would be implemented without a guaranteed, affordable backup care plan in place to compensate for these additional costs.

"We’d like to briefly provide some clarity on key issues here as well.

"Earlier this month, we placed more detailed process information on the Psychological and Counseling Center’s (PCC) website to answer concerns, and we know these additional details have been the source of some concern and confusion.

"To clarify, we have always referred students to community providers."

We appreciate the clarification. And while the testimonies of many of our colleagues corroborate this claim, it does little to explain why dozens more of our colleagues have reported quite recently that their therapists have advised them to begin searching for off-campus care after they complete their next six therapy sessions. A few of our colleagues have also reported that their therapy had recently been actively terminated by their providers. On this point, then, we believe that both the administration’s and our colleagues’ claims are demonstrably true: it is true that the PCC has always referred students to community providers; it is also true that community referrals have increased in recent months–to such an extent that graduate workers can no longer expect the formerly unlimited access to on-campus mental healthcare promised us at past orientations.

"Due to the increase in demand for mental health services and the increase in the frequency of complex cases, we must refer more students for long-term and specialized care to providers in the community than we have in the past."

We understand that increased demand and frequency of complex cases necessitates adjustments in PCC care administration, however, we would also ask: to what extent has this challenge been addressed through the allocation of additional resources to the PCC? If there has indeed been an increase in demand and frequency of complex cases, has there been a proportional increase in the administration’s investment in on-campus mental healthcare services? If so, wonderful! Would it be possible to see the data regarding the relationship between these increases and the university’s allocation of resources to the PCC? If not, why not? This seems particularly important in light of  our recognition of the additional costs imposed upon graduate workers needing off-campus care. Given the fundamental importance of employee mental health to a university’s productive output, it would seem rational, if not imperative, for Vanderbilt to ensure that its investment in employee mental health keeps up with employee demand for on-campus services.

"To address this change, the PCC has revised its process for evaluating clients – establishing criteria and a clinical review team that will support individual providers’ care planning. This new process will allow for greater consistency regarding referral decisions."

Since the administration plans to move forward with more outside referrals, we hope to see a systematic process with consistent results put in place soon. We would expect this process to be explicitly articulated on the PCC’s website so that all students have access to the new terms of campus mental health care. We have received multiple reports from colleagues who have been told their sessions would be limited despite the fact they continue to express a need for long-term care. Thus, we also expect that graduate workers’ reports of their long-term care needs will form an integral part of the clinical review process and have a significant bearing upon the review team’s decisions. In the event that the clinical review board decides that a particular graduate worker can no longer receive long-term care on-campus, we expect that an explanation be provided to the worker in question, or an appeals process be possible should the worker feel they need continuing care.

"For over a decade, we have successfully used a mixture of PCC-provided care and referral of some patients to vetted community resources, including the specialty clinics at VUMC.

"This summer, we worked to expand and refine that list of community partners to ensure they are taking patients and that they accept insurance. The Dean of Students is also hiring a full-time case manager to connect students to these resources, based on feedback we heard last year from students at the town halls we held on this topic."

We appreciate the administration’s efforts to expand and refine the list of community partners that have an interest in providing care for Vanderbilt graduate workers. We are also ready to see detailed out-of-pocket cost analyses for the various providers that have expressed this interest posted soon on the PCC web site. It remains a serious concern after the September 11 Town Hall that precious few community providers currently accept our Vanderbilt insurance plan, while the ones that do vary in terms of affordability and accessibility. A Vanderbilt graduate colleague, J (name anonymized), had to file for bankruptcy after a community referral cost them tens of thousands in medical bills–this despite being fully insured on our plan. The additional costs in session fees, time, and transportation impose significant burdens on graduate workers, threatening to undermine their research and teaching productivity and, thus, the productive output of the university.

"The short-term care offered by the PCC for the last several years reflects best practices of college and university counseling centers nationally. Research supports short-term care as an effective intervention for students. For instance, short-term psychotherapies have consistently produced comparatively fast improvement on the psychosocial functioning and quality of life of clients who struggle from mood or anxiety disorders (Baldwin, Berkeljon, Atkins, Olsen & Nielsen, 2009; Knekt, Heinonen , Härkäpää, Järvikoski, Virtala, Rissanen, & Lindfors, 2015). The nature of short-term care can vary, but the approach to care emphasizes access for all students, rather than special services to a more limited population."

There is no reason to doubt the findings of these studies about the efficacy of short-term care models at universities, although it should be noted that neither study looks at the efficacy of short-term care for graduate workers. Further, Knekt et al. acknowledge that short-term therapy may be insufficient for patients with certain psychological characteristics. On a related note, Baldwin et al. observe that patients undergoing psychotherapeutic treatments do not change at the same rates and thus need different doses (numbers of sessions) of treatment. While we recognize that the “6 session average” is not a hard and fast limit, we are concerned that it will function as such due to institutional pressures to see more clients. This concern has been partially verified by colleagues who have reported that their session access has indeed been limited to 6 sessions despite their expressed need for open-ended care. This trend is alarming, and suggests a serious neglect on the part of the PCC and university administration with respect to the particular needs of individual graduate workers who are at much greater risk of psychiatric disorders than highly educated employees in the general population.

In a local campus environment of increasing demand and complexity of need, it is concerning that the administration has decided to change the PCC’s former policy of offering graduate workers unlimited access to individual therapy, including long-term care, in favor of a short-term care/cure model. For example, Dr. Catherine Fuchs, the former Director of the PCC, told graduate workers during a presentation on PCC services in Fall 2015 that unlimited one-on-one counseling was available to graduate workers as often as once every two weeks, and more frequently in cases that required a higher level of attention. Emphasis on a short-term care model as a means of intervention does not account for the long-term management model required by many students with chronic mental health issues. Students have reported having to decide on “goals” to be addressed over the course of their six sessions, and many have expressed worry about having to “ration” their sessions. If the administration indeed believes that the solution-based model is more effective for graduate workers, it has not made this point clear. This lack of clarity has created significant anxiety and disappointment regarding mental health care, and thus, ironically enough, exacerbated the problems this shift in approach was supposed to resolve.

"The PCC does not have session limits. Rather, the average number of sessions a student receives is six. When a student is approaching six sessions, the providers at the PCC evaluate the best plan for continued care, which may include more sessions at the PCC, a referral to a campus or community partner, or a more intensive treatment recommendation. VUMC has found this   medical review of treatment to be effective in allowing therapists to draw on perspectives other than their own in recommending the best course for an individual patient, and this is best practice in the medical community. Our goal is to ensure that all of our students are receiving the appropriate type and level of care at the right time. We have not and will not place a limit on the number of sessions available to students seeking help."

It is good news to us that the administration does not plan in the future to limit the number of sessions available to graduate workers seeking help at the PCC. But we respectfully disagree with their claim that such limitations have not been happening before now. Our disagreement is based on dozens of first-personal testimonies given by our colleagues who use the PCC and are presently experiencing limited access. Several graduate workers in attendance at the September 11 Town Hall reported being told directly by their PCC therapists that they will no longer be able to access on-campus care after six sessions. S (full name anonymized), for example, reported that their therapist will have them take an “assessment” on their sixth session to gauge the amount of “progress” they have made over the course of their therapy as a means of determining the “best” course of action for them moving forward. This shows a sudden shift away from a model of care that focused on building a personal rapport between therapist and client for optimal long-term care (and as S was told by their provider, proof of the PCC’s shift from a “clinical” model to a “developmental” model). Further, while there is no official policy limiting therapy access, limitations will be imposed in cases where the clinical review board decides (without student input) that the student no longer needs clinical care.

"We’ve also heard concerns around access and wait-time. We acknowledge that treatment is not often available the same day, but we are confident that it is usually same week. In cases of acute need, we always have immediate crisis services available. Last year, the PCC was able to see over 70 percent of students seeking therapy and/or medical attention within one week and nearly all of the students were able to be seen within two weeks. In every case, students are given options to ensure they’re able to make the best decision for their individual situation."

We are happy to hear this, however, we have a simple question: what constitutes an “immediate crisis”? Our colleague E (name anonymized) courageously shared their experience of what many could reasonably consider to be a crisis situation requiring more frequent sessions. In July of 2016, their car was stolen at gunpoint and, approximately one week later, they had their first appointment with what they thought would be a long-term provider. During E’s first two years at Vanderbilt, they had unlimited access to therapy to help manage their existing moderate-to-major depressive disorder and anxiety symptoms. They have fortunately had access to an excellent meds provider at the PCC throughout their time at Vanderbilt and have greatly benefited from the PCC’s group therapy services. However, they find the phasing out of long-term care to be incredibly harmful to graduate workers with trauma histories and chronic mental illnesses. To read E’s story in full, scroll to the asterisks after the letter’s end.  

"As part of our commitment to continue to strengthen our offerings, we’ve invested in a new Center for Student Wellbeing (CSW) to provide additional direct support to students. We’ve also added new resources to the PCC to address graduate worker care specifically resulting in additional therapy hours and broader attention to the special circumstances of the graduate worker population. The CSW is the newest piece of Vanderbilt’s holistic and coordinated system of care which also includes the PCC, Student Health Center, a network of community providers that accept insurance, VUMC physicians and specialty clinics, pastoral counseling at the Office of the University Chaplain and Religious Life, support from the Dean of Students and its many offices, and Graduate School staff."

Again, we express our concern that important parts of this holistic network of care–such as accessible community providers that accept our insurance with affordable co-pays–were not put securely in place before the recent policy changes being reported by grad students were rolled out. Additionally, as the CSW explicitly states: “Coaching is not intended to provide treatment for physical, mental, emotional, or psychological disorders. Students who experience these conditions will be referred to the Student Health Center or the Psychological and Counseling Center (PCC) as indicated.” The administration itself recognizes that the CSW is no substitute for the access to the PCC services that they are now restricting. Thus, we ask, how does this address the chronic challenges faced by graduate workers with psychiatric disorders?

"We recognize the unique challenges and intensity many of you experience as graduate and professional students, and have created new, dedicated resources over the past year to build the university’s cultural competence around these stressors.

"Thank you for taking the time to read this lengthy email and please continue to stay involved. There are several opportunities for you to engage:

"Submit your questions, concerns and topics you would like to see covered in the FAQ to GSmentalhealthservices@vanderbilt.edu;

"Share your concerns with the Chancellor’s Strategic Planning Committee on Mental Health and Wellbeing;

"Engage in dialogue with your elected leaders with the GSC."

You can also report your concerns and thoughts about mental healthcare to Vanderbilt Graduate Workers, who are currently organizing a petition to restore the PCC’s former policy of providing unlimited access to individual therapy for all students and graduate workers who seek it. Additionally, if you would like to contact J, S, or E, send a message request through the gradworkers.org contact portal and we will put you in touch with them.

"We appreciate each of you and your contribution toward making Vanderbilt such an exceptional place to study and work.

"Sincerely,
Mark Wallace
Dean of the Graduate School"