Veterans’ Mental Health in Higher Education Settings: Services and Clinician Education Needs

Implemented in 2009, the Post-9/11 GI Bill is an education benefit program for individuals who served on active duty after September 10, 2001. The program expanded existing GI benefits by increasing tuition and providing a monthly housing allowance, a stipend for books and supplies, and a one-time relocation allowance. The number of individuals using Post-9/11 GI Bill benefits increased 20-fold from 34,393 people in 2009 to 715,527 in 2012 (1,2).

Combat veterans who pursue higher education are at increased risk of psychosocial, academic, and mental health difficulties compared with their nonveteran peers. Student veterans have lower GPAs and less social support compared with their nonveteran peers, and they are more likely to experience anxiety, stress, depression, suicidal ideation, and hypervigilance (3–5). A survey of 525 student veterans found that nearly half showed significant symptoms of posttraumatic stress disorder (PTSD), a third suffered from severe anxiety, and a quarter experienced severe depression (3). PTSD symptoms are associated with greater alienation on campus, problematic drinking, smoking, suicide attempts, and high-risk behaviors, such as fighting (6–10).

The central message of many organizational reports and news editorials has been that specialized programs and policies are necessary to assist student veterans and their loved ones with the transition and reintegration into higher education (11). However, without meaningful data to identify gaps in the mental health services available to student veterans, this need has yet to be met (12). This study helps to fill this gap by identifying the mental health resources and services available at college psychological counseling centers to address the mental health needs of student veterans as well as areas in which clinical staff need more education to better serve this population.

Methods

Colleges and universities in three Southern California counties were identified via the Internet. To be included, schools were required to offer an undergraduate program, be accredited by the Western Association of Schools and Colleges, and to enroll over 500 students. In addition, all campuses of the California State University and University of California systems were included, regardless of their location in the state. In total, 113 schools met these criteria.

Depending on the location of mental health services at the institution, the director of the counseling center or the director of student health services was contacted. Occasionally, directors referred the recruiter to another staff member who they thought would be better able to respond to the interview questions. If a school had only one mental health clinician, that person was classified as the director. Interviews were completed with 71 directors, including 27 (38%) directors of mental health services, 16 (23%) mental health clinicians, 13 (18%) deans or directors of health services, nine (13%) assistant directors of mental health services, four (6%) clinical training directors, and two (3%) program administrators. The title of director is used to describe all participants.

Two directors worked for a consortium of schools. Therefore, the 71 directors interviewed represented 80 (71%) of the 113 recruited schools. Participating schools consisted of 26 private four-year schools, 27 public four-year schools, and 27 public two-year community colleges. Directors of 13 schools could not be reached, two directors declined participation, and 18 of the 113 recruited schools (16%) did not offer mental health services.

Participants completed a semistructured quantitative and qualitative interview that consisted of 117 questions about staffing, demographic characteristics of veterans receiving services, mental health services available, and topics and type of mental health education in regard to student veterans that they would like to receive. Assessors took notes during the interviews, which took about 30 minutes and were not compensated. Three coders independently coded the notes for each interview question, and the codes were grouped into conceptual themes in an iterative process. One coder examined all the data again to identify additional themes that may have emerged across interview questions.

Results

Schools had an average of .5±.9 providers who specialize in combat-related PTSD (range 0–5). [A table describing the number of mental health providers from various disciplines employed by the campus counseling centers is available as an online supplement to this report.] Directors at most schools were unable to report how many veterans received mental health care or to describe the demographic characteristics or presenting problems of veterans who received mental health care. Directors at 44 (55%) schools estimated how many veterans received services [see the online supplement for estimates of the number of veterans receiving services]. Only 23 schools reported the gender of veterans receiving services, and only nine schools could describe veterans’ marital and parental status.

Table 1 shows the primary sources of veteran referral. All centers except one use a standard intake form, and only 43 schools ask about veteran status or military service in this form. Seven schools offer veterans priority access or access to special mental health services. Two centers allow veterans to exceed the usual maximum number of sessions, and one center reported priority access. Four centers employed a clinician who was familiar with military culture either through professional training or personal experiences.

One school offers a readjustment group for student veterans, one offers assessment and treatment for traumatic brain injury, and 57 offer treatment for military sexual trauma. Thirty-nine of these schools described treatment for military sexual trauma as the same as treatment for “regular” sexual trauma. Medication management is offered at 42 schools within the student counseling center. An additional 13 schools offer medication management through other on-campus entities. At 27 schools, there are limits on the types of medication prescribed (for example, psychostimulants, antipsychotics, or benzodiazepines were not prescribed). Only short-term medication management is available at eight schools. The availability of services and the specific treatment modalities offered for PTSD, depression, and alcohol and substance abuse are reported in Table 1.

Directors at 77 schools (96%) indicated that their centers provide mental health education to faculty and staff [see online supplement]. Although most topics applied to all students, some were veteran specific, such as combat-related problems and military culture. Faculty and staff are seldom required to participate; the programs are primarily optional and are often solicited by faculty and staff.

Two formalized education programs were commonly used, and an increasing number of schools were adopting these programs. The first is Kognito’s “Veterans on Campus,” an online class for faculty, staff, and students. The faculty and staff version aims to increase knowledge of common transitional challenges facing veterans and of available resources for veterans. This version also aims to improve handling of veterans’ mental health needs and veteran-sensitive topics in the classroom. The second program commonly used is Mental Health First Aid, which is designed to provide faculty, staff, and students with a basic understanding of various psychiatric disorders, including the impact of these disorders and how to support recovery.

Directors at 74 (93%) schools indicated that their centers provide mental health education to the general student population [see online supplement]. Education resources included lectures, workshops, special programming (such as Kognito, Mental Health First Aid, and wellness week), online resources, and mental health handouts. The student version of Kognito’s “Veterans on Campus” addresses how to identify and provide support to a struggling or distressed peer.

Directors identified veteran-related mental health topics in which they wanted to receive education for their staff. [A table listing the specific topics identified is available in the online supplement.] The training needs were generally high; the mean number of education topics desired was 5.8±3.3 (range 0 to 14). The interview was modified partway through the study to inquire about participants’ preferred education modalities. In-person training, either in a workshop or lecture format, was the preferred education modality.

Discussion and Conclusions

Given the expanding use of the GI Bill and the unique difficulties faced by veterans, it is important to understand the mental health resources available to veterans in institutions of higher learning to identify potential gaps in care and opportunities for improvement. This study identified the mental health resources and services available to veterans and the education needed by mental health staff to better assist veterans. This study included only California schools, and therefore the findings may not be applicable to other states. It is, however, the first study to comprehensively explore mental health services provided for veterans on college campuses.

Surprisingly, 18 schools (17 private schools and one community college) do not offer any mental health services nor partner with outside agencies. The majority of these schools are either online private schools, law schools, or schools with a narrow focus, such as art, fashion, culinary arts, or music. Future research is needed to identify why these schools do not have a mental health program and what would be needed to implement one or to partner with an outside agency that offers mental health services.

Directors at schools that offered mental health services knew very little about veterans receiving such services. At nearly half of participating schools, intake procedures do not ask about veteran status, and directors of mental health services could not estimate the number of veterans receiving mental health services on campus. Of the 44 schools that provided an estimate of the number of veterans receiving mental health services on campus, only three were able to provide exact numbers. Counseling centers should inquire about prior military service, and if applicable, assess for the mental health symptoms and challenges commonly experienced by veterans. The mental health service needs of veterans cannot be adequately identified if the veterans themselves are not identified. Further, without an accurate count of veterans, centers cannot sufficiently identify the training that staff need to better assist them.

Similarly, directors at only nine schools were able to estimate the number of veterans who were married or had children. PTSD and related mental health concerns among veterans significantly reduce marital satisfaction, increase relational distress, and often result in separation or divorce (13–15). Hence, clinicians should consider the role of partners and children in veterans’ presentation and treatment.

The lack of knowledge about veterans who receive services may explain the lack of veteran-specific services; only a small minority of centers offer veterans priority access or specialized services. Expanding specialized programs and services for veterans may increase their utilization of campus mental health services. Veterans may also benefit from implementation of on-campus readjustment groups to bolster their social support. In some instances, services are offered for veteran-specific difficulties, such as military sexual trauma. The treatment approach, however, does not differ from the treatment approach used with nonveteran students who experience sexual trauma. This highlights a significant need for clinician education on veteran-specific treatment concerns, such as the chain in command in reporting abuses, fears about retribution, and continued interaction with a perpetrator.

Although the vast majority of centers provide general education to students, faculty, and staff on mental health issues, participation is seldom required, and less than 30% of centers provide education on combat-related problems [see online supplement]. Broader dissemination of education on veteran-specific topics may aid in earlier detection of problems by faculty and staff and, hence, earlier referral to mental health. With regard to education for the clinical staff, the directors identified numerous veteran-related mental health topics in which they wanted to receive education. Notably, in-person lectures and workshops were the preferred education modality, contradicting the general trend in education toward online training.

The study findings serve as a call to mental health administrators to collect data on the demographic characteristics, mental health needs, and service utilization of veterans on campus. Such data are necessary to provide veterans with relevant, evidence-based treatments and to ensure high-quality care. This study identified gaps in the provision of veteran-specific services on college campuses as well as the training needed by clinical staff to improve care for veterans. This needs assessment will inform the development and evaluation of mental health education products and workshops dedicated to the mental health needs of veterans on campus. Future research should also assess veterans’ perspective of mental health services on campus to identify further gaps.