When she experienced a relapse in her anxiety symptoms last fall, College junior Ariel Epstein decided to visit Counseling and Psychological Services.
Crippling panic attacks would strike at random, just as they used to in high school, and Epstein concluded that it was time for her to seek help. She set up weekly meetings with a therapist and soon started seeing a CAPS psychiatrist who prescribed her medication.
Epstein finished the year feeling better than she had been, but when she attempted to schedule another appointment with CAPS after the summer ended, she was pushed to move off-campus and to seek help from outside providers — a process that CAPS calls "the referral process." This was the first time Epstein had learned that she would not be able to receive long-term treatment.
“My understanding, because no one ever told me anything differently, was, ‘OK, when you come back in three months [after the summer], you’ll maybe have a quick check-in and then get another refill,’” Epstein said, adding that she felt like she had been blindsided by the referrals.
Approximately 15 percent of all students who visit CAPS are referred to an outside provider, said CAPS Director Bill Alexander. Usually, the referral happens after brief treatment at Penn, but sometimes students can be referred at their initial consultation. Some students also contact CAPS specifically requesting a referral.
CAPS resources have expanded in the past few years, but student accounts suggest that resources at CAPS still aren't enough to serve the undergraduate and graduate population at Penn. Alexander estimated that an average of 20 percent of undergraduate students and 16 percent of graduate students receive treatment from CAPS in an academic year. This adds up to roughly 3,836 students who are supported by 45 clinical staff members at CAPS.
Because of the high volume of students in need of treatment, Alexander said the department often has to "practice a brief form of treatment here, just so that everybody gets in the door."
These limitations result in experiences like Epstein's, who said she felt confused by the referral system.
The CAPS website writes that students "make the final decision about whether or not they can work with a particular outside provider.” But various other sources from CAPS, including Alexander, CAPS Deputy Director Michal Saraf and CAPS representatives who interacted with various students, all seem to disagree on what the exact rules for the referral process are.
Why are there no standardized policies for the referral process?
In a series of email threads and phone calls exchanged between Epstein, her parents, her CAPS therapist Meghan Sullivan and Saraf, Epstein's request for ongoing treatment from CAPS was resoundingly rejected. Epstein said during one of these phone calls, Saraf yelled, “‘We never promised you long-term care,’” which made her feel “ambushed.”
“There was absolutely no convincing [Saraf],” Epstein said. “It was like she knew how that conversation was going to go before she got on the phone.”
Saraf declined to comment on these allegations.
Alexander said the reason for this confusion among stakeholders is that there are no formalized rules on the referral system at CAPS.
He explained that mental health is situational and something that should not be left up to formalized rules, particularly when it comes to the decision of whether to point a student towards the referral process.
“Some students just say, ‘No, I don’t want to,'” Alexander said. “We’re not going to get in an argument with them. We’re going to suggest it. We’re going to strongly suggest it, but we’re not going to argue with you about it. If you’re going to refuse to go, you’re not going to get kicked out of CAPS.”
But this message does not seem to be clearly communicated to members of the Penn community like Epstein.
“The letter of the law with their policy is, ‘We’re not gonna make you do anything you’re uncomfortable with,’ but that doesn’t matter when the practice is they coerce people into doing things they’re uncomfortable with anyway because [students] don’t think they have a choice,” Epstein said.
When do CAPS staffers notify students?
There are several different points in their interactions with CAPS when students can be notified that they will not be receiving long-term treatment with Penn.
According to student accounts, however, these conversations rarely give the impression that students can push back against the referral process or opt to continue treatment with Penn. Alexander acknowledged that although this conversation "is inherently a hierarchical situation,” it is important that students feel comfortable speaking out when they're not satisfied.
The conversation on the referral process can happen at an initial consultation, which can be conducted by a wide range of CAPS employees.
“There isn’t anything that clinicians are supposed to say,” Alexander said. “There are no rules because it’s a clinical situation. It’s not policy or procedures, but the clinical [professional] is making the judgment.”
CAPS Referral Coordinator Nicole Nardone said she conducts preliminary consultations where she makes a point of telling students that CAPS can’t provide long-term treatment, but noted that she does not know if other CAPS staff also mention it at the initial consultation. Student accounts suggest that many don't.
College junior Yoni Gottlieb said his therapist at CAPS only told him that CAPS wouldn't provide him with long-term treatment during his second session. At that point, he had already opened up about personal experiences that were difficult for him to discuss at first and said he wished he had been notified of this policy earlier.
“If I were someone who had just learned all this information, I wouldn’t go to CAPS at all. It sounds really confusing,” Gottlieb said. “I can’t trust a place that has therapists that might cut you off, might not cut you off.” He added that even today, when other people ask him about setting up an appointment with CAPS, Gottlieb tells them to go straight to the referral process without setting up an initial consultation session.
Gottlieb’s current therapist is based in Colorado, where he is from, and he currently communicates with his therapist exclusively via phone or FaceTime.
But administrators said they also try to follow up with students after they are referred out of CAPS.
A month after providing students with information about local providers, Nardone said she reaches out to students over email to check whether they have made an appointment with an outside provider. Nardone said she uses the email, which asks for information on the providers, to update her list of recommended providers.
The average response rate to the email is 30 percent among students referred out each month, Alexander said. But for those who do not respond to the email, there is typically no other attempt to contact them, Alexander said.
“We like to believe that if they’re unhappy, they’ll really get back to us," he added.
How does the referral system affect the quality of care at CAPS?
The referral system and the nature of CAPS as a short-term facility also has wider implications on the quality of care that it offers, students say. While the purpose of therapy is often to address underlying mental illnesses, many students describe the treatment at CAPS as focused on crisis management and on transitioning students out of CAPS.
After College sophomore Eliza Halpin was hospitalized following a suicide attempt at the start of the second semester of her freshman year, she sought help at CAPS. Throughout the entire semester, she wanted to work on her depression and devise coping mechanisms, but her therapy at CAPS seemed to remain focused on her suicide attempt in January instead of on her long-term recovery, Halpin said.
“[The focus was on] basically how to make sure nothing happened like that so Penn didn’t look bad,” Halpin said. “The focus was basically like, ‘Is this gonna happen again? Okay, no? Then you’re good.’”
Gottlieb echoed that sentiment.
“It felt like, ‘Oh, we have CAPS here because we need to have it, but we’re just going to refer you to someone else and it’s not really on our hands,” he said.
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