There is a growing body of evidence demonstrating increasing levels of mental health disturbance and emotional distress in students, as well as amongst young people in general. This was recognised by the Committee of Vice Chancellors and Principals (CVCP) when they published their Guidelines on Student Mental Health Policies and Procedures for Higher Education (CVCP, 2000).

In response to these pressures, University Counselling Services have developed a variety of integrated approaches to meet institutional needs, as well as establishing working links with other local service providers, such as NHS Trusts. The in depth exploration of psychological pressures faced by students and staff which is carried out in counselling services means that counselling is uniquely well placed in higher education to comment on the current national debate on participation and retention of students.

Decisions to withdraw from studies or outright failure are seldom straightforward processes. By understanding the complexity of emotional and psychological processes inherent in student life, counsellors play a critical part in helping students make the connection between mental health and their ability to learn. Factors which affect the student experience include:

• Capacity to manage the late adolescent maturational tasks
• The impact of a range of change and transitional events, both practical and emotional
• Attachment and identification with other students, academic staff and the University. Failure to do this effectively is likely to result in drop-out.
• The impact of being in a large organisation which can exacerbate or alleviate vulnerability
• Anxiety and depression inhibiting learning

By using their experience and understanding of these psychological demands, counsellors can help individual students and staff through a variety of methods including:

• Individual and group counselling
• Delivery of workshops and training
• Supporting staff through training initiatives and mentoring
• Acting as advisors to the organisation on policies and procedures

Some examples of good practice are provided in Attachments 1 - 3

There is an increasing recognition within the counselling and psychotherapy profession that development of research informed practice is critical to improved understanding of the nature of our work with students. Research activities, both quantitative and qualitative in style, are ongoing in a number of organisations, ranging from the well established NHS-based methodology of the CORE system group (1998) through conventional self assessment questionnaires to a variety of contemporary qualitative approaches (McLeod, 2000).

There have been few substantive research studies exploring the explicit relationship between counselling provision (and efficacy) and student retention. However a recent review of the literature carried out by the Oxford Student Mental Health Network (2001) identified over 60 studies published during the period 1964 - 2001, in which a variety of attempts have been made to ascertain the factors and relationships determining the qualitative nature of the student experience whilst in higher education.

Issues such as withdrawal rates, retention, homesickness, transitional phenomena, counselling efficacy, psychological and psychiatric morbidity, student stress, cultural indicators, social support, suicide rates and indicators, student support mechanisms, economic and financial indicators of stress have been explored.

Approaches adopted in these studies included survey questionnaires and standardised self-assessments although other methodologies such as interviews and analysis of student records were also employed. The following studies of particular relevance to this review are:

1. Rickinson and Rutherford (1995,1996,1998) studied the effectiveness of counselling interventions at two key transition points: first year entry and final year completion. For both groups of students, it was observed that retention was affected by the individual student’s capacity to adapt to the inevitable change and transitional processes triggered by attending University. Evidence was presented indicating the positive impact of counselling on retention through addressing some of the underlying developmental themes. Students attending counselling appeared to be better equipped to manage the challenges of University life.
2. In a cohort study at the University of Cambridge (Surtrees et al, 2000) the mental health of a sample of undergraduate and postgraduate students was monitored through their University careers. 8% of the cohort attended the student counselling service during that period. They reported an increased prevalence of psycho-social problems - of these students, 75% reported that they had benefited from counselling.
3. Szulecka et al (1987) in a large scale survey of first year students at University of Nottingham, reported that emotional factors were more significant than academic pressures or intellectual difficulties in predicting student withdrawal. Positive associations were established between withdrawal and pre-existing difficulties in particular, poor quality relationships with family members and previous psychological difficulties.
4. Both Manthorpe and Stanley (1999) and Monk (1996) observed that awareness and accessibility of student counselling services were key determinants in coping with the emotional and psychological pressures and difficulties that are experienced by students and tutors.
5. The Brunel University Counselling Service Evaluation study (Caleb, 2002) noted a self-reported increase in coping by students from 10% before counselling to over 50% after counselling. Levels of motivation increased from 2% before, to over 50% after counselling. Over 80% of students participating in the survey commented that counselling had helped their studies to a significant extent.
6. Further evidence for positive correlation between student counselling and retention rates is provided by a survey on a random sample of 100 Counselling Service users at Middlesex University (Egert,1999). 98% of service users completed the academic year - the 2% drop-out rate compared favourably with the overall University rate of 11.7%. A follow-up study the following year focussing on counselling service users who were at risk of academic withdrawal or failure. 5% of this cohort had withdrawn (possibly reflecting a core group of vulnerable students) compared to an overall withdrawal rate of over 14%.
7. In a detailed and thorough critique of the emotional difficulties associated with learning in higher education, Ross and Taylor (2002) highlight the importance of psychological therapy provision, in particular counselling psychology, observing that such provision is likely to be most effective when integrated with academic and teaching support provision.
8. The economic impact of changes in student financing is now well established with levels of individual debt in excess of £10K at the end of University. What is not so clear is the full psychological impact of these changes on the student experience. However it is not at all uncommon for financial pressures to be a contributory factor in the emotional (and academic) decline of vulnerable students. The relationship between ill-health, financial stability and student retention is of increasing interest and has recently been reviewed (Roberts and Zelenyanszki, 2002).
9. In addition, a significant number of Universities, both new and old, currently employ some form of self-assessment questionnaire to ascertain impressions of student satisfaction and counselling efficacy. A consistent finding from such approaches is that in excess of 60% of student respondents consistently make an explicit link between their positive experience of counselling and their capacity to stay engaged with their academic work.

The above studies highlight the importance of the connection between the provision of emotional and psychological and emotional support through counselling (and other sources such as personal tutors) and the ability to fully engage with the academic and developmental tasks associated with being a student.

From the above studies and additional anecdotal evidence from current counselling practice in Universities the following themes represent the place that counselling takes in relation to student retention.

• Working across the Institution

The value of a whole institutional approach to student concerns has been well documented, most notably, in a collaborative study carried out at the University of Leicester (Grant, 1999). Within this there are a number of roles that staff in University counselling services can take up in support of students. Central to these are training and development of key support staff within the institution including, but not limited to, Tutors, Research supervisors, Heads of Departments, Care staff, Health Centre staff, Student Union managers, wardens and administrative/secretarial staff.

A recent survey (HUCS, 2002) indicated that over 80% of university counselling services offer training in mental health issues to staff and over 50% to students. By working with staff across the institution, counsellors can raise the awareness of the varying kinds of problems that students, and staff, experience, which if not taken seriously, can result in withdrawal from academic and social involvement, leading potentially to drop-out.

'Joined - up' thinking within the care services in higher education is critical in ensuring that vulnerable students do not slip through the net. Such an approach, which may include consultation and referral to external service providers, eg NHS Trusts (see Lago, 2002) allows an effective cross-disciplinary practice to be developed, which is appropriate to the needs of the individual institution.

Such thinking also does not preclude the maintenance of unique specialist contributions and expertise that individual care services such as counselling, advice and careers offer the institution. Collaborative thinking, as well as making economic sense, also allows the development of diverse and innovative approaches to student care.

• Connection between emotional literacy and the capacity to engage with academic work

Implicit in our work as counsellors is the view that encouraging students to engage with the psychological and emotional difficulties of being a student will allow them to foster a more mature view of being a student. In most instances this will allow them to continue as students, albeit with a different perspective, although in a few instances it might be that changing course or leaving University might be the most appropriate choice. Ultimately a key task for student counsellors is to encourage successful engagement with academic work.

• Recognition of and capacity to work with difference

As access and participation are widened, Student Counselling Services have to be able to acknowledge and work with the specific demands that are presented by different student groups. These will range from classical separation/attachment issues associated with adolescent development, through more complex interactions and tensions between study and family requirements with mature students, to the particular challenges posed by varying forms of postgraduate study.

An increasingly diverse international student population has to be engaged with in ways that are sensitive to themes of difference e.g. culture, race, and in a number of higher education institutions, refugee status. A variety of models of good practice are now in operation, many of which have been refined over time as expertise has been accumulated.

This contribution to the debate on student retention has tried to mark out a clear role for student counselling and to identify the positive impact of engaging with students emotionally and psychologically at different times in their academic life.

Student counselling has therefore a key role to play in encouraging students to participate fully in academic life and in seeing their time in higher education as a holistic experience where they can grow both intellectually and emotionally. Investment in counselling will be repaid by a resultant saving in student fees and by an improvement in the quality of the student experience.

AUCC (2002) Annual Survey of Counselling in Higher Education 2000-2001, AUCC, Rugby

Caleb, R (2002) Evaluation Study, Brunel University Counselling Service

CORE System Group (1998) Clinical Outcomes in Routine Evaluation (CORE), The Psychological Therapies Research Centre, University of Leeds

CVCP (2000) Guidelines on Student Mental Health Policies and Procedures for higher education, CVCP, London

Egert, S (1999) Survey on Student Retention and Counselling, Middlesex University

Grant, A (1999) Identifying students’ concerns: Taking a whole institutional approach, in N Stanley and J Manthorpe (Eds.) Students’ Mental Health Needs: Problems and Responses, Jessica Kingsley Publishers, London

HUCS (2002) Survey into Medical, Psychiatric and Counselling Provision in Higher Education, http:/www.hucs.org

Lago, C (2002) The University and the wider community in N Stanley and J. Manthorpe (Eds.) Students’ Mental Health Needs - Problems and Responses, Jessica Kingsley, London.

Manthorpe, J and Stanley, N (1999) Dilemmas in Professional Education: Responding Effectively to Students with Mental Health Problems, Journal of Interprofessional Care, 13, 355-365

McLeod, J (2000) Qualitative Research in Counselling and Psychotherapy, Sage, London

Monk, E L (1996) Student Mental Health: A Study of the Relationship Between Stressors and the Mental Health of Students, PhD Thesis, Glasgow Caledonian University

Oxford Student Mental Health Network (2001) Research Review

Rana, R., Smith, E and Walkling, J (1999) Degrees of Disturbance: the New Agenda, AUCC, Rugby

Rickinson, B and Rutherford, D (1995) Increasing Undergraduate Student Retention Rates, British Journal of Guidance and Counselling, 23, 161-172

Rickinson, B and Rutherford, D (1996) Systematic Monitoring of the Adjustment to University of Undergraduates, British Journal of Guidance and Counselling, 24, 213 - 225

Rickinson, B and Rutherford, D (1998) The Relationship Between Undergraduate Student Counselling and Successful Degree Completion, Studies in Higher Education, 23, 95-102

Roberts, R and Zelenyanszki, C (2002) Degrees of debt, in N Stanley and J. Manthorpe (eds.) Students’ Mental Health Needs - Problems and Responses, Jessica Kingsley, London.

Surtees, P, Wainwright, N and Pharaoh, P (2000) Student Mental Health, Use of Services and Academic Attainment: A Report to the Review Committee of the University of Cambridge Counselling Service.

Szulecka, T, Springett, N and de Pauw, K (1987) General Health, Psychiatric Vulnerability and Withdrawal from University in First Year Undergraduates, British Journal of Guidance and Counselling, 15, 82-91

Ross, P J and Taylor, A M (2002) Enhancing learning skills, in W. Dryden, J. McLeod and S. Strawbridge (Eds.) Handbook of Counselling Psychology (in press), Sage, London

The University of Edinburgh has a long history of student welfare support. The Student Counselling Service itself has been in existence for over thirty years and is well embedded into the institution. The University Health Service, where the majority of the 20 000 students are registered with general practitioners, also offers a weekly consultant psychiatric outpatient clinic. Referral to this clinic is managed by the GPs and any referral is made through them. However the psychiatrist offers informal consultation directly to advise on any referrals. The other welfare services comprise the Disability Office, the Student’s Association and Nightline, the University Accommodation Service including their Mind’s Eye project. The latter is a specialist service which the Accommodation Service purchase from a specialist housing association. The association provides both training for accommodation staff and also social work support, for students with mental health difficulties, who live in university accommodation. Although the student welfare services operate independently, they share a line manager and are co-ordinated by a welfare consultative committee. This aims to provide coherent policy and service provision for students.

Close working relations are valued by all in the support services, both formally through the committee structure and more informally. We at the counselling service have biannual seminars with the GPs and psychiatrists, liaison meetings with the consultant psychiatrist as well as the chaplain and disability officers and individual meetings with the senior GP. In these we look at particular concerns about our own university, share knowledge, discuss when and where to refer and have confidential case discussions. We have recently started a joint venture with the sports centre promoting exercise as a way to improve mental health.

A case study of Alison, a 20-year-old Psychology student, helps to illustrate the necessity of pre-existing support structures and liaison networks in containing increasing disturbance.

Alison came for counselling under pressure from friends who were concerned about her increasingly withdrawn behaviour. She expressed little emotion, declared doubt about the point of counselling, yet was increasingly agitated in sessions, talking of her disconnected feelings and losing her sense of self. Beyond that she gave very little history other than that she had had a happy childhood. Her parents were both living abroad and suffered from periods of depression. She had an amicable if distant relationship with her siblings, and had had a lot of independence. She had no previous mental health problems, a good academic record, and many friends. There seemed few warning signs of what was to come. Her behaviour became more impulsive and dangerous and Alison was finally persuaded to let the counsellor talk to her GP. Although she expressed no suicidal ideation, the GP and counsellor felt that she was a risk to herself and both of us talked to the consultant psychiatrist. He offered an immediate assessment appointment and Alison was admitted to psychiatric hospital.

What became rapidly clear was that hospitalisation provided relief to the friends and family involved with Alison, but not to her. She was treated for a major depressive disorder but medication relieved only some of the symptoms. Talking helped a little but gave limited containment. Remaining in hospital seemed to increase her self-harming behaviour (cutting, paracetamol overdoses). The effects of Alison’s illness impacted on her carers and friends in a significant way. Her personality changed and her disturbance grew as did her suicidality. Her constant denial of feelings resulted in everyone around her being highly anxious and helpless.

A care plan was agreed between myself, the consultant psychiatrist, GP, and to some extent Alison. The consultant advised that it would be best to keep hospital admissions to a minimum as Alison’s self-harming increased there. We agreed there should be regular GP appointments, weekly counselling appointments and fortnightly psychiatric outpatient’s appointments. As returning to her flat was not possible, the University Accommodation Service provided a room in a small warden supported student house. Alison was put in touch with a social worker through the Mind’s Eye scheme and continued to receive weekly (or more) support from them throughout her illness.

It was obvious that Alison would be unable to complete her year’s study but that the support would be available during her time out from her studies.

Throughout the period of her illness, Alison had four formal carers to support her, Two from the NHS, one from the university and one paid for by the university. This treatment and therapy undoubtedly helped to contain her. This was achieved through structured support but also by the care team understanding and containing the unconscious dynamics.

Alison herself later said, prior to returning to her studies ‘I don’t know if I would be here but for you all’

A course in student support and guidance has been offered once or twice a year for the past five years and is always very well received. It runs for half a day over ten weeks – is open to any member of staff with some responsibility for supporting students. In practice the majority have been academics and all Faculties have been represented.

The first part of the session is given over to consideration of particular issues or practice in developing particular skills. Topics covered include recognising students at risk, how, when and where to refer, the impact of transitions, the responsibilities and limits of the personal tutor role, managing one’s own stress, and the needs of particular categories of students – e.g. international students, those with disabilities. Relevant readings are provided for each session. The majority of the input is from the counselling service but there are invited speakers from other student services, from the Faculties and Student Union so that a picture of a network of care is established. The second half of each session is given over to the presentation by course members of aspects of their own contact with students and to the group’s thinking together about the implications of the situations that are presented.

It is possible to take the course for credit: members who wish to do so write a paper applying their learning from the course to a pastoral care issue in their own Faculties. Many of these – on inter alia student induction, students on hospital placements, needs of disabled students have resulted in improved practice in departments. At the end of the course most participants report increased confidence in their ability to help students, a better grasp of student issues and a clearer sense of what central support services can offer. They tend to become better judges of when students need more specialist help than they can themselves offer and to refer appropriately. Past course members frequently comment on the continuing relevance to their various responsibilities

The Peer Support Programme was set up in Oxford University eleven years ago, initially as a pilot project. This programme provides a thirty-hour training to students in basic counselling skills, after which they make themselves available by offering support and a ‘listening ear’ to other students. It provides a support network within the University for those students who wish to talk about problems they are facing, but are not yet ready, or do not feel they need professional help.

Although mainly basic counselling and support skills are taught on the course, those trained are called peer supporters. In fact, although the peer supporters employ basic counselling skills (listening, support, empathy, clarification, helping a person to come to their own decisions, limit-setting, giving referrals, etc.), what they mainly do is offer support to fellow students. The concept of peer support appears to be acceptable to many students seeking help. Therefore, the Peer Support Programme is designed to complement, not compete with, the University Counselling Service. It is preventive as peer supporters are often the ‘first stop’ for those seeking help, and trained supporters can help a person before a problem becomes too severe.

Panels of students are trained in twenty-one of the undergraduate colleges in the university. The panels are made up of a minimum of four and maximum of twelve students, and consist of undergraduate and post-graduate students, and, sometimes, a member of the Senior Common Room (i.e. academic staff, Chaplain). The training is thirty hours long, and takes place over a ten-week period. It is designed to build on skills as training progresses, as without the earlier group-bonding and skill-building sessions, and the structure they bring to the training, it is difficult for the trainees to grasp the importance of the "issues", especially crisis management, which come in the latter part of training. Individual sessions concentrate on confidentiality, listening, values clarification, decision-making versus advice giving, and getting to know the group. These are followed by two sessions on assertiveness training with the remaining sessions focus on "issues" such as family concerns, crisis intervention and suicide prevention education, limit-setting and referrals. All the work is underpinned by the listening and support skills the peer supporters have learnt throughout.

Following training, fortnightly supervision is provided for the students. Supervision provides continuity for the training group who have moved on to becoming the peer support panel. It is a mandatory and integral part of the existence of such a scheme because through supervision the students’ anxieties are contained and worked with. It is crucial for this type of post-training follow-up in order to hold the boundaries of the sometimes very heavy, upsetting and confusing issues the supporters confront. As they are not trained to be counsellors, it is imperative that this support is provided for the students.