As Cornell University administrators consider the recommendations from a mental health review released last October, Cornell Health needs to cross train all of its clinicians to diagnose and treat substance abuse disorders and other mental health disorders as soon as possible.
Cross training is an important consideration in all health services, but it is especially necessary for clinicians who work with college students. For example, a female student sought help from her college’s counseling program because she was feeling anxious and depressed. She met with a counselor for several weeks but experienced no relief. Her counselor decided to seek advice and brought her case to the counseling service’s weekly clinical meeting. After a lengthy discussion, another counselor asked, “Did you ask about her drinking?” No, the counselor had not asked about her drinking because she focused on the presenting problems, anxiety and depression. In the end, the counselor diagnosed the student as having a serious alcohol use disorder and treated her successfully for both addiction and depression.
Another in an occasional series of articles about student mental health. For more information, go to The Sophie Fund’s Student Mental Health Page
Clinical services, whether in the workplace or on a college campus, have a common problem: most clinicians do not have sufficient training to diagnose and treat both substance use disorders and other mental health disorders. This occurs primarily because clinical training programs often do not provide social workers, psychologists, and psychiatrists with sufficient background and skills to diagnose and treat substance abuse disorders, particularly addiction.
At the same time, programs specializing in training counselors about substance use disorders may give short shrift to the diagnosis and treatment of other mental health disorders. Clinical services can rectify this problem by ensuring that all clinicians are cross-trained to the point of competence where they can identify, assess, and intervene on both substance abuse disorders and other mental health issues.
Cross training is especially important for college counseling services because college students drink, sometimes excessively, and use and abuse other drugs such as marijuana, prescription drugs (e.g. Adderall and Ritalin), Ecstasy, and cocaine. Since the 1990s, college health practitioners have utilized two approaches to prevent and treat substance use disorders among students.
The first is a harm reduction model. For example, it seeks to reduce the harm associated with excessive drinking by teaching students to drink responsibly. Within this framework, college health practitioners think of heavy drinking as a symptom of an underlying social problem, a dysfunctional “culture,” and they create programs such as social norming campaigns and BASICS (Brief Alcohol Screening & Intervention for College Students) to teach students moderate drinking norms with the expectation that students will change their behavior and drink moderately or not at all.
The second approach conceives of substance use as a coping mechanism that students use to relieve stress, anxiety, and depression. By treating the stress, anxiety, and depression, clinicians believe that students will be less reliant on alcohol and other drugs to cope and use alcohol and other drugs responsibly. These interventions work well with students who are not addicted and are abusing alcohol or other drugs, but they are inadequate for treating those who are addicted to alcohol and other drugs.
More recently, colleges have begun to recognize that many college students who drink excessively and abuse other drugs cannot control their consumption because they are dependent upon alcohol and other drugs and many college health services have begun to develop recovery programs to treat their addiction. One study, for example, found that 18 percent of college students have an alcohol use disorder: 12 percent met the criteria for a diagnosis for alcohol abuse and six percent met the criteria for a diagnosis of alcohol dependence.
Interview skills are essential for making an accurate diagnosis and ensuring effective treatment. Mental health clinicians and addiction specialists can learn from one another to improve their skills.
Again, the classic example is the depressed client who seeks help from a mental health practitioner for depression. A male student sees a mental health clinician who focuses the interview on his symptoms of depression and reasonably prescribes anti-depressants and talk therapy. However, the clinician misses the fact that the client is implying that his alcohol consumption is minimal but is actually consuming large quantities of a depressant (i.e. alcohol). The therapist does not consider the patient’s self-medication and prescribes antidepressants.
In the opposite scenario, the same male student sees an alcohol and drug counselor to discuss his potential abuse of alcohol. The counselor does a standard intake evaluation and determines that he does meet all the criteria for alcohol addiction but, because of the nature of the questions asked, the counselor misses the fact that this person has had all the symptoms of depression since before he ever took his first drink. In both scenarios, the most effective treatment requires the clinician to diagnose both the addiction and depression and treat them in an integrated manner. Treating only the depression will perpetuate the addiction, the pain, and dysfunction. Only treating the addiction will perpetuate the depression and likely lead to ongoing suffering and relapse.
Cross training ensures that health services deliver the most competent care in the most cost effective manner. The only thing worse than not getting the help one needs is thinking you are getting help when you are not. Clinicians owe it to their patients to be able to assess issues across the mental health spectrum. As Cornell Health responds to the mental health review, it can ensure that students receive the most effective care by guaranteeing that all of its clinicians have sufficient training to diagnose and treat both substance use disorders and other mental health disorders.
—By William J. Sonnenstuhl and G.P. Zurenda
William J. Sonnenstuhl is an emeritus professor in the School of Industrial and Labor Relations (ILR) at Cornell University. His primary research examines alcohol and drug problems in the workplace and on college campuses. He is the faculty advisor for Sober@Cornell, President of Cornell Collegiate Recovery, Inc., board member of Cayuga’s Watchers, and member of the Fraternity, Sorority, and Alumni Council.
G.P. Zurenda is a social worker and addiction specialist. He holds an MBA from the SC Johnson College of Business.