photo: Chris Hildreth
photo: Chris Hildreth

Defusing Confusion

Counseling and Psychological Services not only works to support students in the pressure-filled, often unstructured environment of college, but it also helps them negotiate the difficult ground between teenager and young adult.
August 1, 2002

The second World Trade Center tower had just collapsed and the Pentagon was in flames when Duke's Counseling and Psychological Services (CAPS) went to work staffing a special bank of phones set up to provide psychological assistance. "Although we answered general calls," says CAPS director James Clack, "our staff members handled some calls where people were having a hysterical response."

From morning until midnight for the next several days, he and the other counselors worked the phones. The crisis counseling in the hours and days after the September 11 terrorist attacks was unexpected, but not altogether unusual work for the staff of eleven professional psychiatrists, psychologists, and clinical social workers at CAPS. From their offices in Page, in the shadow of Duke Chapel, the staff works to help students enhance their personal strengths and develop their abilities to deal with the experiences of living, learning, and growing at Duke. CAPS offers limited individual counseling and psychotherapy, consultation, couples and group counseling, and assistance with referrals; and it coordinates personal development groups and outreach education programs.

In spite of all of the effects of the terrorist attacks, counseling services last fall saw more of the same. "What we found out," says Clack, "was that the situation exacerbated the more typical kinds of things we get." The primary "presenting symptoms" students bring to the counselors at CAPS are anxiety and depression: They're down, unhappy, and dissatisfied about something, the counselors say, or they're extremely anxious, panicky, or upset. Rarely are those presenting symptoms actually the problem, says Clack. "In general, a college counselor will ask a student, 'What are you being treated for?' and they'll say, 'I'm being treated for depression' or 'I'm being treated for anxiety.' But we need to find out, what's the problem that lies behind the symptoms?"

For most Duke students who use the services of CAPS--some 12 to 13 percent of the entire student population in a given academic year--the underlying problem has to do with the normal developmental struggles facing today's teenagers and young adults. That can mean difficulties in relationships with parents, siblings, roommates, boyfriends or girlfriends, husbands or wives, faculty members. It might mean trouble meeting expectations, whether the expectations are real or perceived, academic or social, self-imposed or parental. "Even such things as not getting into the 'right' fraternity or sorority can be very troubling," says Clack.

Students caught up in these struggles find safety in the broad net cast by CAPS. Clack uses that analogy to describe his department: "On one end," he says, "we are part of the safety net, but we are also like the primary-care physicians. We take care of the urgent matters that are occurring right now. But we are not the specialists who pick up those students and then carry them for the rest of their college life."

The list of groups that make up the larger safety net at Duke is long. It extends to minority groups all across the university--the Duke Women's Center, the Mary Lou Williams Center for Black Culture, the Office of Intercultural Affairs, the Center for Lesbian, Gay, Bisexual, and Transgender Life, and various religious-life groups--and the lines can blur between counseling functions and social or peer groups that simply provide support and community for students. CAPS itself typically offers counselor-facilitated group meetings such as a coping-skills training group and a support group for dissertation writers.

There is hardly a campus corner, or a demographic, untouched by some aspect of counseling services. And that's the way Jeff Barrow at CAPS works to keep things. Barrow, an assistant clinical professor, helps direct CAPS's outreach education programs. "We try to influence the psychological growth of a wide range of students, not only those inclined to seek appointments at a counseling center," he says. "It's important for us to respond [in advance] to student difficulties and have an active voice in the campus culture."

By maintaining a high profile within the campus community, he says, counseling services can become better known among students and members of the faculty and staff--and can work to counteract the stereotypes some students have about CAPS. If students are more open to counseling opportunities, the reasoning goes, they'll be more likely to make an appointment for themselves--or accept the recommendation of counseling from a friend or faculty or staff member--earlier in the development of a problem.

Toward that end, CAPS coordinates or conducts a full schedule of educational programming. Immediately after September 11, CAPS sponsored a discussion, "Understanding Loss." Last year, Barrow and Clack coordinated "Sons, Daughters, and Parents: Let's Talk About Change," and CAPS staff Mazella Hall and Laura Wagner-Moore made presentations at "Sisters Beneath the Skin," a conference for women from Duke, the University of North Carolina at Chapel Hill, North Carolina State, and North Carolina Central University. CAPS also sponsored three presentations on the multiracial nature of eating disorders, with help from members of the Eating and Body Image Concerns Network. Last fall, Jeff Kulley coordinated Alcohol Awareness Week events, co-sponsored by CAPS, Student Health Services, and other organizations. And CAPS co-sponsored, along with the Center for Lesbian, Gay, Bisexual, and Transgender Life, a coming-out group for students interested in understanding their sexual orientation.

Besides these campus-wide programs, Barrow says, CAPS focuses outreach efforts on training students to play a peer-counseling or peer-education role. CAPS works with resident advisers, Health Peer Educators, and Peer Educators in Eating and Body Image Concerns. "Staff members in other offices who oversee these groups are pleased to have us contribute to the training," Barrow says. "Time that we spend in enhancing their skills pays dividends, since they interact with so many other students."

Grades, a major element in that pressure-cooker that is Duke, regularly prompt students to seek counseling. "Not that they come to us for tutoring, because we don't offer tutoring at CAPS," says Clack, "but because they're not doing as well as they would wish, or as their parents or someone else would wish."

Academic pressure and the desire to excel seem to manifest themselves in opposing behaviors: perfectionism and procrastination. As a lecturer in the University Writing Program and a pre-major adviser, Christina Askounis frequently sees students who put off their work for fear of under-performing, or not performing flawlessly. "It's tough for Duke students, because many of them have powerful perfectionist tendencies," she says, "which can work for you if you know when and how to put them to use, but can hobble you terribly as a writer--and as a person--if you don't."

Perfectionism shows up so commonly at CAPS that Clack quotes a standard dialogue. It all starts, he says, when a student comes in and declares, "I'm having some problems with my grades. I'm just not getting the grades I should be getting."

"Well," Clack will say, "what are your grades like this semester?"

"I'm getting three A's and a B this semester."

"What's bothering you about those grades? What's wrong with a B?"

"It's just not what I should get."

 photo: Les Todd

 

In short, Clack says, he'll have students schedule a counseling appointment because they're earning a 3.8 instead of a perfect 4.0. That intolerance for anything that's less than perfect can send a student into a vicious circle of procrastination. A counselor recently worked with a student who was getting her term-paper grades docked because she turned papers in late. Dissatisfied with her writing, she would churn out rewrite after rewrite, up to the deadline and beyond. Then, knowing her grade would be lowered for lateness, she rewrote again, trying for a higher baseline grade.

Staff psychologist Jeff Kulley sees strong forces at work in cases of procrastination. For students who hurt their psyches--and their grades--by putting off work, Kulley says, the process of academic working is painstaking, even painful. "By procrastinating, they are putting off the bad feelings associated with the work," he says. "So if they can limit the painful work to, say, six hours, that's a reward. They feel less pain."

In critical situations, the interrelated nature of counseling and support services at the university becomes more visible--as does, often, Kulley's job. Kulley came to Duke in May 2001 as a specialist in counseling and education on alcohol and substance abuse--one of the more serious problems that come through the doors of CAPS. In the year before his arrival, one student died and more than fifty students were taken to the ER at Duke Hospital for alcohol-related emergencies. In addition to counseling students and promoting education about alcohol and substance abuse, Kulley was tapped to lead a university-wide committee of officials from Student Development, Campus Police, and Student Health to address the alcohol problem.

College years provide a good window of opportunity to raise students' awareness of dangerous drinking patterns, says Kulley. "If, for instance, students are in a pattern of binge drinking, they can be at risk for developing an alcohol dependency down the road--but most students who binge-drink aren't yet depending on alcohol. So if they're able to gain some awareness of the risks they might face for developing problems later, it's a lot easier to change patterns of drinking if you intervene early than if you wait until the dependency aspect sets in."

College can be a tough environment in which to try to make those kinds of changes. The consequences of alcohol abuse are not as severe for people ages nineteen or twenty as they are for people thirty-five or forty. The physical effects of heavy drinking haven't yet developed, and it's easier to skip class than it is to skip work. Plus, Kulley says, it's easy for a college student to compare himself or herself with peers and see no problem. "They can look at the group they spend their time with," he says, "and if the group tends to drink heavily, they can get a sense that this is sort of normal behavior and doesn't need to be a concern."

Even when a student schedules a first appointment with a CAPS counselor--whether by his or her own volition or on the advice or request of a friend, faculty member, or administrator--it can take some work to expose the real problem. "It's kind of rare," says Kulley, "for a student to come into the counseling center and say, 'I have a problem with alcohol or drugs.' " More often, the student comes in because of a problem with relationships or depression or academics. "You talk with them for a while and you come to realize that alcohol or drugs is playing a part behind the presenting problem."

Clack sees the same thing. "I cannot think of one student who's come into CAPS and said, 'My problem is alcohol abuse, and I'd like help with it.' Not one, and I've been here five years now."

Late last August, as the new academic year began, Student Affairs administrators announced sweeping changes to the university's alcohol policy, aiming to increase individual and group accountability for irresponsible drinking and the behaviors that result. Among other things, the policy requires more supervision of social events on campus by student monitors and an independent company. The university will begin notifying parents of students whose drinking puts their health at risk. All violations of the alcohol policy are now referred directly to Kulley, as well as to Kacie Wallace '89, associate dean of student development, and Stephen Bryan, assistant dean of student development.

Policy might help in the case of alcohol, but in the case of eating disorders--another serious issue for Duke counselors--the solutions are not so straightforward. Though there are no actual counts, university officials estimate that half of all women at Duke either have an eating disorder or will have developed one by the time they leave. "I do know," says Clack, "that we start seeing a large number of women when they arrive here and continue to see them all the way through their education. We also see a large number of people who are concerned about their friend's or roommate's eating."

Sue Wasiolek '76, M.H.A. '78, LL.M. '93, Duke's assistant vice president for student affairs and dean of students, and a pre-major adviser, points out that the new freedoms students encounter at college contribute to eating problems. "Of course, we have students arrive here with relatively severe eating disorders," she says. "But we'll find students who come here with only somewhat disordered eating and find that the lack of schedule and relative freedom lead to more disordered eating." Even less serious eating problems, she says, can be major sources of stress for the sufferers, as well as for their friends and roommates.

Then there are days--and nights--at CAPS when the work goes beyond daily developmental struggles or more involved psychological issues into critical, life-or-death situations. Counselors work in concert with Duke Medical Center and its emergency room to deal with the rare cases of psychotic, extremely violent, even homicidal or suicidal students. Plain-clothed Duke police officers are available to transfer severely troubled students to emergency care. "[The students] can get good treatment immediately," Clack says, "which is something many colleges that don't have a medical center right next door don't have." Duke Medical Center is also a resource for outpatient psychiatric counseling, where students who need longer-term treatment can get it at a low cost. Now that psychotropic medications such as Prozac and Zoloft are more commonly prescribed, those medical resources are even more important.

Family relationships, dating and intimacy, stress management--all are normal developmental struggles for which CAPS provides education and outreach. "Since many of these are directed at students in general," Clack says, "attendance can be unpredictable. What works best is to do a program at the invitation of an intact group, such as a sorority." When CAPS does offer programs on its own, staff members advertise in The Chronicle, post fliers around campus, and use campus e-mail lists--a method Barrow says is very effective.

The emotional atmosphere at Duke remains challenging--a quiet truth that's echoed by counselors, administrators, faculty, and the students themselves. Sometimes, though, the strongest pressures in a student's life come from forces outside of Duke, says Wasiolek, a longtime administrator. "I do feel many students are more anxious than they used to be twenty or twenty-five years ago, when I was a student," she says. "I believe there were more first-generation college students at Duke then. Getting a loan to go to school simply did not carry the kind of burden it does today. People felt comfortable having some debt as they were leaving school." Additionally, she says, students must work harder to maintain or surpass the style of living in which they grew up. "It was easier [in the Seventies] to improve upon a lifestyle," she says. "I think it's difficult for many students to even dream about maintaining their parents' lifestyle."

And today's parents of college-aged students, she points out, are much savvier--and push harder--than the parents of her generation. Most of them have been to college or have post-graduate degrees; as a result, they often think they know what's best for their children in terms of a major and a career. "They themselves know how to network, so they want their sons and daughters to network in the same way," says Wasiolek. "Meanwhile, we as academic and administrative advisers try to tell students, 'Follow your passions. Do what you like.' So we struggle with students sometimes as they sit here and tell us they're being encouraged by their family to major in, say, economics--and become an investment banker, and go to work on Wall Street--when that's not what they want to do."

This has led to what Clack calls "the existential crisis," overwhelming questions of identity, direction, and goals for life at Duke and afterwards. Some people, he quips, call it the "liberal-arts conundrum." "If you get a degree in liberal arts--and this [problem] does tend to show up more in liberal-arts majors--and it's getting close to graduation time," he says, "what are you going to do with that degree?" In those cases, CAPS counselors help students think through their options and plan a strategy for the future.

Like the CAPS counselors, Wasiolek says she does find solutions to such pressures through one-on-one encounters with students, the kind of work she does daily. And writing instructor Askounis says she helps deflect perfectionism by deliberately creating margins of error for her students. "Writing--at least in the early stages--is all about failure. I'm of course interested in helping students produce writing of excellent quality, but in order to get there, I think it's absolutely necessary," she says, "to create a psychological space in which it's okay to mess around and mess up, to see what happens, to experiment, without fear of penalty. I have the sense there's very little of that space in general at a place like Duke, either in our heads or in the classroom, and I think that's unfortunate.

"On the other hand, students do perform beautifully despite, or perhaps because of, the pressure they're under, and I am constantly astonished at the variety and quality of their projects, in the classroom and the community. These are amazing, accomplished young people."

In the end, this is the goal of CAPS and the campus groups and services with which it collaborates: to support students as they work within a pressure-filled, often unstructured environment, and at the same time negotiate the difficult ground between teenager and young adult. A note of pride seeps into Jim Clack's voice as he declares that CAPS is accomplishing that goal. The staff maintains a strict policy of confidentiality that instills trust and acceptance among students and the wider campus community. ("You can't just pick up the phone and say, 'How's this student doing with this issue?' They'll not even say they recognize that name," says Wasiolek.) Duke's counselors have a higher visit rate than do their counterparts at most peer schools, he says, and enjoy a good reputation on campus.

Each semester, CAPS conducts what it calls "Sweeps Week," when all students who are using CAPS at the time can rate their experiences with the services. The department consistently scores a 6.3 or 6.4 on a 7-point scale, Clack says. And in the routine pre- and post-testing of students using an outcomes questionnaire, CAPS finds that 92 percent of students who use the counseling services show statistically reliable, positive change.

As the fall semester wound down, Clack was looking ahead to a routine accreditation visit from the American Psychological Association. All the use rates and outcomes, he says, show that students see Duke's counseling services as a helpful place and a place they can trust--nearly 87 percent of students seen at CAPS seek out the services on their own or are referred by another student, while others come at the advice of a faculty member or administrator.

"So, most of the people coming to CAPS are coming of their own volition, and that's a good way to have your people coming in," he says. "It means they have some kind of motivation and commitment to make changes to the way things are going in their lives."

--Davis '91 is an editor and writer living in Raleigh.