Insider’s Guide: Review of “The Sneaky Way Colleges Try To Sell Students Health Insurance”

This is a review from the article The Sneaky Way Colleges Try To Sell Students Health Insurance
by Ann Brenoff at the Huffington Post from October 10, 2017. Here are the Highlights:

  1. Students must have insurance to be in school. Not only do students need insurance, they need insurance that meets the school’s minimum coverage standards. This standard is different from school to school.
  2. College health plans are often already on the tuition bill. This is a classic aggressive marketing technique of forcing a customer to opt-out rather than opting in. Students must request a waiver if they have insurance that already meets the school’s requirements. A request is just an application, not a guarantee the student will be granted the waiver.
  3. Waiver’s must be requested every year. That’s right folks, not only do you have to opt-out from insurance, you have to opt-out each year.
  4. Premiums vary from campus to campus and can inflate the cost of going to college significantly. There is no standard for premiums. The average cost is $1,500 and $2,500 per year.
  5. There is often little choice. Schools often have one or very few health plans and often have health centers who do not accept anything other than the insurance they sell.
  6. Rules for waivers vary. Some schools want to see low in-network deductibles while others want to ensure there are adequate in-network providers in the school’s area.
  7. Students can take out loans (or use scholarship money) for insurance. Since insurance is a line item right next to tuition, loans and scholarships are fair game for paying for insurance.
  8. Big impact on students if the Affordable Healthcare Act changes. If the employer mandate or the coverage for kids 26 and younger is removed, the burden of insurance will pass from the large employers to the students and their families.

My opinion of the article and it’s focus is that students should definitely be mandated to have insurance while at school but there should be government oversight for what insurance is offered, how it’s disclosed to students and what provider options exist in the school’s area. Right now college insurance seems like the unregulated wild west and most families don’t even realize it. When we pay for something, we should have a right to know what we’re paying for and not be forced to opt-out. Often, this insurance payment is in addition to a ‘Health Fee’ which covers minor health and wellness interventions. For example, here at Indiana University’s counseling center (CAPS), there is a $30 fee for each session during each semester after the first two ‘free’ sessions. IU does not accept insurance and offers to provide an itemized invoice that can be sent to a student’s insurance company so the family can be reimbursed.

I recommend that if you have a kid that’s heading off to college next Fall and will likely need healthcare support for medical or mental health, do your homework to find out whether their health centers accept your insurance. Research how to complete the waiver and make sure you know how much out of pocket healthcare expenses could be.

Anxiety and 7 Ways to Help Your Struggling College Kid

As excited freshman or experienced sophomores, juniors and seniors settle in for another Fall semester around the country, I wanted to put together a quick list of 7 things parents can do to hep their college kid suffering from anxiety. It’s scary to put so much freedom and responsibility into the hands of your son or daughter when you know worry and fear is always lurking around social, academic or career decisions. Before I discuss what to do about anxiety, I think it’s important to review some details about anxiety.

Everyone feels uneasy or anxious occasionally like when we are running late for a meeting or got caught doing something we’re not supposed to. It’s a normal.

Anxiety disorders are different than regular, situational anxiousness. They are a group of mental illnesses that are characterized by intensity, duration, origin and how they impact life domains like work/school, relationships, and health.

For people who have an anxiety disorder, worry and fear are constant and overwhelming, and can be disabling. With the correct treatment, most can overcome the anxiety disorder and lead a fulfilling life.

Types of Disorders

Anxiety disorder is a broad category that includes:

  • Panic Disorder. Feeling overwhelming sense of terror or dread that seemingly strikes randomly. During a panic attack, the person may sweat, have chest pain, and feel unusually strong or irregular heartbeats. Sometimes they may feel like they’re choking or having a heart attack.
  • Social Anxiety Disorder. Also known as Social Phobia, this is when someone feels overwhelming worry or judgement while in social situations. They may obsess over others judgment or being embarrassed or ridiculed.
  • Specific Phobias. This is when someone has a very specific fear of something such as spiders, heights or flying. The fear goes beyond what’s appropriate based on actual risk and may cause them to avoid regular situations.
  • Generalized Anxiety Disorder. This is what I see most when working with college students. They describe having excessive, unrealistic worry and tension with little or no reason.

Risks

Early signs of anxiety are super subtle and include distractability, avoidance and sleeplessness. Students with anxiety disorders often report to me that semesters generally start fine but as papers, tests and social pressures mount, their anxiety builds to the point where they start consider drastic changes like dropping out of school. Untreated anxiety can lead to depression, severe drug use and in some instance, suicide. Anxiety and depression seem to be best friends, often presenting together in college students I’ve worked with. 

What to Do

Though anxiety disorders can make someone feel hopeless, there are very effective treatments and interventions we can implement to get their life back on track. Here are the 7 I think are most important for parents to be aware of if they need help with their college kid.

1. Counseling

Right out of the gate, the first thing parents should do is link their child with a) campus health services (often called Counseling and Psychological Services or CAPS) and b) a therapist or counseling like me specializing in college student anxiety in the community close to campus. Ideally, find a therapist/counselor that uses Cognitive Behavioral Therapy (CBT) or Dialectical Behavioral Therapy (DBT). Waiting until the first big meltdown could be too late. Loads of freshman fail to share their struggles with their parents until Thanksgiving and Christmas which, by then, is too late in their minds and they end up not returning for their Spring semester. Invest the time on the front end.

2. Scheduling

Anxiety is fed by fear. Fear is often the by-product of lack of predictability about social events, academic outcomes, and career failures. One solution is increasing predictability. I accomplish this with students by teaching them to download the semester schedule onto their phone calendars before the semester starts. Next, after they’ve received their syllabi, I coach them to put in every single date for every single assignment/test possible. This also includes social events and any non-academic stuff they know about. This may sound like it could be overwhelming, but I’d rather have them feel a bit overwhelmed when looking at the calendars rather than anxious about remember when that next big thing is due.

3. Resources

Not the most used suggestion but one we have to put here – make sure your son or daughter has a list or access to resources that can help them reduce stressors or mitigate things when they’re already starting to spiral down. These resources could include the academic supports found at nearly every university or within the community. Universities have a vested interest in making sure your son or daughter doesn’t bail at semester’s end. Another form of ‘resource’ is the on-call list. Create a formal or informal list of people they can call/text when they are starting to feel overwhelmed. I am on-call for all of my clients and often receive texts from students the night before big tests asking for help in quiet their brains down. I call them or text back strategies and remind them to call if they want to talk through things in more detail. Just knowing there is a safety net and team of support can have a dramatic reduction effect on anxiety.

4. Medication

I am super conservative with medication use and recommendations for students I work with at Indiana University. But, with that said, we also recognize that some folks simply need a bit more support than what counseling and academic support can provide alone. If your college does not have a psychiatrist on staff, we highly recommend finding one in the local community. We rarely encourage use of primary care physicians or nurse practitioners for medication management since they are not specifically trained to diagnose and medically treat those suffering from anxiety. You also want your college kid to work with someone who genuinely understands the risk of some medications that have the potential for addiction. Good kids get hooked on meds the same as bad kids. It’s also important to avoid illegal or non-prescribed drugs (like the roommate’s Xanax).

5. Meditation

I recommend to nearly every client to start participating in weekly yoga, meditation or mindfullness classes. This is an evidence-based approach with only positive side-effects. Plus, every college offers these in their wellness programs for free so encourage your kid to take advantage and put it into the calendar. Meditation, counseling and medication are an incredibly complimentary approach to combating anxiety.

6. Sleep

Not easy when kids have more freedom than ever away from home but we nonetheless push parents to encourage sleep. Not binge sleeping but a healthy 8 hours per night. The ideal for anxiety reduction is a steady sleep pattern so that bedtime and wake time are pretty standard every day. Staying up late on Thursday, Friday and Saturday, sleeping in till 1:00pm and then dragging out of bed Monday morning for an 8:50am class is terrible for anxiety.  Sleep meds only make things worse and really should only be taken with the psychiatrists oversight.

7. Exercise

Encourage your kid to sign up for the intramural leagues, especially for sports where there is little standing around time. Distraction and flow experience are essential in helping him or her focus on non-academic activities. It’s also a great way for them to be social without needing a drink in their hand.

Ok folks. Hope this helps you figure out the best way to help that college kid who may be struggling as you’re getting through the fear of letting go. It’s an exciting time and, with the right strategies in the beginning, can be the start to a fantastic semester.

Mental Health Support on College Campuses: What Parents Need to Know

Most larger universities like Indiana University (close to where my office is located) have health programs called CAPS which stands for Counseling and Psychological Service. They are often staffed with licensed therapists/counselors and psychiatrists with a range of experience and expertise. Their primary goal is to act as a stabilizing resource for most mental/behavioral health or substance use issues. Many university CAPS typically offer individual, group and couples counseling along with occassional free workshops. Here’s the list from IU CAPS on what they typical help with:

  • Academic Concerns
  • Relationship Concerns
  • Stress Management
  • Power and Privilege
  • Time Management Help
  • Sleeping Issues
  • Adjusting to College Life
  • Anxiety
  • Depression
  • Substance Use
  • Body Image, Eating, and Exercise Concerns
  • Sexual Assault or Abuse

They have the same confidentiality requirements as counselors like me off campus but are limited in many ways. CAPS limits the number of unpaid sessions (IU CAPS allows for two) and mandates that a student must be working with one of their counselors if they want to meet with a psychiatrist for medication management/evaluation. Here’s a breakdown of IU CAPS fees:

COUNSELING  With IU Health Fee  W/O IU Health Fee
First two sessions (per semester) No charge $55 per session
Additional full sessions $30 per session $55 per session
Additional half sessions $20 per half session $35 per half session
Additional group counseling $15 per 60 min. session

$17 per 90 min. session

$29 per 60 min. session

$35 per 90 min. session

PSYCHIATRY
First visit $55 $105
Follow-up visit $30 per visit $55 per visit

IU CAPS does not accept insurance but does provide a super detailed invoice to be submitted to a student’s insurance company for reimbursement.
Over the last few years, I’ve noticed many CAPS programs around the country have had a huge increase in demand for their services while also having budget cuts or mediocre increases that leave them without the full team of professionals they need for each semester. At IU CAPS, every one counselor is responsible for 2,110 students (yikes!). This is not a new problem at IU and not isolated to IU.

So what can a parent or student do? If CAPS doesn’t seem like a good option, look for a therapist/counselor convenient to campus who specializes in college students. Therapists should be flexible to accommodate busy course loads and social events. In my practice, I have extended evening and weekend hours since many students a slammed with class 9-4pm most days. It’s also important that the therapist be willing to talk with parents and provide updates and suggestions. Parents can sometimes feel like their kids are a million miles away. A good therapist can often act as a bridge and lower the anxiety associated with having kids at school.

Finally, talk with CAPS (or encourage your son or daughter to) the first week of school. It’s easier to cancel an appointment than to stand in line after all the students are back on campus. The intake process should be thorough and your kid shoul feel like the therapist/counselor will really understand their issues and help.

Indiana University Students: Anxiety, Depression and Drug Use (and how to fix them)

Since moving to Bloomington, home of Indiana University, a few things have become clear. One – everyone here wears red clothing, drives a red car or paints a room in their house red. They don’t mess around with school pride.

Second thing I’ve noticed is the super-driven nature of IU students. They are high achievers and have big goals. Awesome. Big goals are great. Unfortunately, these same students are often not equipped for the challenges of living on their own and the intense academic load. Anxiety, depression and drug use are common here (as with most other big schools). Since there are so few counselors/psychotherapists in the area, I see a heavy load of students, especially when the pressure starts to creep in around mid-September. The partying picks up, parents are gone and classes start to dial-up intensity. It’s a toxic mix.

A great place to start is IU.

IU offers respite in the form of their counseling center (CAPS) but it’s a) triaging a problem, b) only short term and c) often doesn’t get to the underlying issues which are often years in the making. Don’t get me wrong, CAPS does a great job and the best they can considering how underfunded they are. The first two sessions for each semester are free. Each following session is $30. They generally have a waitlist so I recommend that students sign-up early.

CAPS also offers psychiatric care for those needing medical attention, like help or oversight with medication. The wait list is often even longer since there are fewer psychiatrists than counselors. Psychiatric visits are not covered under student health fees so insurance or out of pocket payment is expected.

For those struggling with more serious drug issues, IU offers OASIS/Journey. Students that sign-up for Journey get an assessment to determine the best level of care. Staff then decide between two evidence-based interventions in both group and individual settings, the Journey Program operates under 3 phases, designed to provide progressively more attention based on the student’s need.

Students referred from the Office of Student Ethics are charged $200. Alcohol and drug charges are applied separately. If a student was found responsible for both an alcohol and drug policy violation within the same incident, they get billed $400. For non-offense participants,they get charged a one-time fee of $25.00 after their first visit.

If IU doesn’t have the availability or discretion you and your family needs, reach out to me. If I can’t help, I’m happy to provide insight into other providers in the area who can.

The best thing for parents to do is start searching for professional support either through IU or the community in July and August. Getting appointments set and providers lined-up will be much easier when the semester has not started. Once the semester starts, a good counselor will work closely with parents and the school to ensure that everyone is aware of progress and prepared in case the students experiences more severe issues.

Hopefully, your son and daughter will not need any of this but if they do, act early and expect everyone to act as a team.

Insider’s Guide: Top 5 Things for Your College Student Transitioning to Fall Semester

Most of the students with whom I work have depression, anxiety and mild substance abuse. One of the easiest, cheapest and most effective tools for combating these struggles in college is detailed planning. Below, I’ve outlined the Top 5 things I tell every student to implement as they are showing up for Fall semester.

  1. Syllabi Dates. Encourage your college student to plug-in all dates into their calendar from the syllabi they receive over the coming days. Once all the test dates are put in, reverse engineer two weeks prior to the test dates and put study dates into the calendar for no longer than 90 minute chunks. If it’s not scheduled, it will get pushed off till the last minute.
  2. Professor Office Hours. Everyone will want to meet with professors the Thursday and Friday before Thanksgiving. Have your above-average college student pull their professor’s office hours from the syllabus (yes, all professors put office hours on there) and plug into the calendar.
  3. Download Your University’s Academic Calendar. In June, I downloaded the Indiana University’s academic calendar for Fall 2016. It is a small file from Indiana University’s Academic page for any student or parent to view or download. Once downloaded, your college student can upload it into their calendar. Now, they’ll know Add/Drop dates, Fall Break, Winter Break, Finals, etc.
  4. Don’t Talk Every Day. Plan to talk 2x/week – (eg. Wednesdays and Saturdays). It’s time to intentionally create more autonomy, build trust, and not feel like you need to hover over them.
  5. Set up Counseling Early. Counselors and mental health providers get slammed since there are so few of us in most college towns. There are even fewer psychiatrists for medication management. Start looking for a counselor/therapist now before the semester gets in full swing. Psychiatrists are often scheduled out 2-3 months.

Good luck and please reach out for more suggestions and strategies to mitigate the challenges your college student is facing with depress, anxiety or substance abuse. Don’t go it alone.

5 Signs of Suicide Risk in College Students

FACT: 15% of graduate and 18% of undergrads have seriously considered attempting suicide

FACT: 15% of graduate and 18% of undergrads have seriously considered attempting suicide

There is nothing more exciting than dropping of your college freshman in late August as the cool nights of Autumn return. But not all students carry with them the same energy and positive outlook for the Fall. Some are carrying some heavy baggage from High School or even younger while others don’t start to develop any major issues until they first get to college (and their first taste of freedom from parents). What parents don’t know is that you likely know your college friends (or at least a side of them) better than their own parents do, and you may be able to tell that something is wrong way before anyone else. This quick list is as much for parents as it is for you students out there. 

The following signs might indicate a student is considering suicide:

  1. A good student who’s behavior suddenly changes – they start ignoring assignments and missing classes which are likely signs of depression or drug and alcohol abuse, which can affect their health and happiness and put them at risk of suicide. And yes, good students and good kids use drugs. Seriously. 
  2. Anyone who doesn’t have friends or who suddenly rejects their friends may be at risk. A friend who suddenly rejects you, claiming, “You just don’t get it,” may be having emotional problems.
  3. College students may be physically or emotionally abused by a member of their family or their girlfriend or boyfriend – or suffering from abuse that occurred long ago but triggered by the new college environment. Abusive relationships can make a college student feel like crap about themselves. Signs that a person may be in an abusive relationship include unexplained bruises or other injuries that he or she refuses to discuss. 
  4. This is a common one – Significant changes in a someone’s weight, eating or sleeping patterns, and/or social interaction style may indicate that something is wrong. Eating disorders are super common at college. Lot’s of perceived competition, anxiety and stress that translates into really unhealthy views of one’s self. 
  5. Coming Out? College students may suffer from depression or have thoughts of suicide if they have a difficult time adjusting to their sexual orientation or gender identity. Gay, lesbian, bisexual, and transgendered students have higher suicide attempt rates than their heterosexual peers.

We understand regret and their could certainly be a real consequence of getting help for someone who seems to be really hurting. They might get pissed at you for not minding your own business. But think of it this way – is the regret of possibly losing a friend better or worse than the potential of knowing you could have saved your friend’s life but did nothing? Tough choice but that’s part of the burden of mental illness. 

Is CRAFT the Best Unused Substance Abuse Treatment?

Community Reinforcement Approach and Family Training

Today I’d like to introduce you to one of the most effective treatments/interventions for substance abuse that is rarely used and even-more rarely discussed. It’s called CRAFT and is a behavior therapy approach designed primarily for those with substance abuse issues. Developed by Nate Azrin in the 1970s, his technique focused on operant conditioning to help people learn to reduce the power of their addictions and enjoy healthy lifestyle. CRA was later combined with the FT (…family training), which equips family and friends with supportive techniques to encourage their loved ones to begin and continue treatment, and provides defenses against addiction’s damaging effects on loved ones.

The first part of this acronym – Community Reinforcement Approach (CRA) was originally created for individuals with alcohol issues. Clinicians later went on to apply it to a variety of substance use disorders for more than 35 years. The clinical premise is based on operant conditioning (…type of learning in which an individual’s behavior is modified by its antecedents and consequences), basically, CRA helps rearrange the client’s life so that healthy, drug-free living becomes more interesting/stimulating and thereby competes with substance use.

CRA is designed to be a time-limited intervention. The time limit is decided upon between the clinician and client. For example, a set number of sessions (for example, 16 sessions) or time limit (for example, one year) may be decided upon either at the very beginning of therapy or within the early stages of therapy.

One major goal of CRAFT is to increase the odds of the substance user who is refusing treatment to enter treatment through close support of family members, as well as improve the lives of the concerned family members. CRAFT clinician and participants teach and reinforce the use of healthy rewards to encourage positive behaviors. Additionally,  it focuses on helping both the substance user and the family strengthen their relationships which is often torn apart.

In the model, the following terms are used:

  • Identified Patient (IP) – the individual with the substance abuse issues that is refusing treatment
  • Concerned Significant Others (CSOs) – the relevant family and friends of the IP.

Three goals

When a loved one is abusing substances and refusing to get help, CRAFT is designed to help families learn practical and effective ways to accomplish these three goals:

  1. Move their loved one toward treatment
  2. Reduce their loved one’s substance use
  3. Improve their own lives

This comprehensive behavioral program accomplishes these objectives while avoiding both the detachment espoused by Al-Anon and the confrontational style taught to families by the Johnson Institute Intervention.

CRAFT and these traditional approaches all have been found to improve CSO functioning and increase CSO-IP relationship satisfaction. However, CRAFT has proven to be significantly more effective in engaging treatment-resistant substance users in comparison to the Johnson Institute Intervention and Al-Anon (or Nar-Anon) facilitation therapy. 

CRA Breakdown of Treatment

The following CRA procedures and descriptions are typical recommended clinical content areas for the substance user:

  1. Functional Analysis of Substance
    • explore the antecedents of a client’s substance use
    • explore the positive and negative consequences of a client’s substance use
  2. Sobriety Sampling
    • a gentle movement toward long-term abstinence that begins with a client’s agreement to sample a time-limited period of abstinence
  3. CRA Treatment Plan
    • establish meaningful, objective goals in client-selected areas
    • establish highly specified methods for obtaining those goals
    • tools: Happiness Scale, and Goals of Counseling form
  4. Behavior Skills Training
    • teach three basic skills through instruction and role-playing:
    1. Problem-solving
      • break overwhelming problems into smaller ones
      • address smaller problems
    2. Communication skills
      • a positive interaction style
    3. Drink/drug refusal training
      • identify high-risk situations
      • teach assertiveness
  5. Job Skills Training
    • provide basic steps for obtaining and keeping a valued job
  6. Social and Recreational Counseling
    • provide opportunities to sample new social and recreational activities
  7. Relapse Prevention
    • teach clients how to identify high-risk situations
    • teach clients how to anticipate and cope with a relapse
  8. Relationship Counseling
    • improve the interaction between the client and his or her partner

Communication 

With CRAFT, CSOs are trained in various strategies, including positive reinforcement, various communication skills and natural consequences. One of the big pieces that has a lot of influence over all the other strategies is positive communication. 

Here are the seven steps in the CRAFT model for implementing positive communication strategies.

  1. Be Brief
  2. Be Positive
  3. Refer to Specific Behaviors
  4. Label your Feelings
  5. Offer an Understanding Statement – For example, “I appreciate that you have these concerns, … [or] I understand that you really want to talk right now, and that this feels urgent, … [or] I would love to be there for you.”
  6. Accept Partial Responsibility – This step “is really designed to decrease defensiveness on the part of your loved one. … It’s not about accepting responsibility for things you are not responsible for. … [Rather, it’s to] direct you towards the piece that you can own for yourself. … [For example, ] what you can take responsibility for are the ways that you communicate,” etc.
  7. Offer to help

Take home message – Help decrease defensiveness on the part of the loved one that you are speaking to, and increase the chances that your message is really going to be heard—so, increasing the ability that you have to really get across the message that you want. 

Consequences with specific limits/expectations being in place is essential in terms of communicating your message, but it’s also really important, maybe even more so, to be consistent in following through with those consequences and rewards.

Al-Anon 

As an organization, Al-Anon does not currently adopt, hold, or promote the view that CSOs can make a positive, direct, and active contribution to arrest compulsive drinking, which is the opposite premise of CRAFT. Al-Anon is a fellowship with a focus on helping families and friends, themselves, without promoting a direct intervention process for alcoholics. Because “no one ever graduates” from Al-Anon, it can be viewed as an open-ended program, not time-limited.

Al-Anon view

Regarding the CSO’s relationship to alcoholism and sobriety, the view from the Al-Anon organization can be summarized:

  1. PowerlessnessAl-Anon‘s First Step promotes a powerless view for families and friends, “We admitted we were powerless over alcohol—that our lives had become unmanageable.”
  2. Disease viewAl-Anon writes, “As the American Medical Association will attest, alcoholism is a disease.” Al-Anon also states, “Although it can be arrested, alcoholism has no known cure.”
  3. Three C’sAl-Anon has a dictum called “the Three C’s—I didn’t cause alcoholism; I can’t control it; and I can’t cure it.”
  4. Loving detachment. Al-Anon “advocates ‘loving detachment’ from the substance abuser.”
  5. Family illnessAl-Anon writes, “Alcoholism is a family disease,” and “we believe alcoholism is a family illness and that changed attitudes can aid recovery.”

Summary

CRAFT is not perfect and is not easy to implement partially due to lack of clinician training and also because of having multiple people involved (ie. IP, concerned others, and clinician). Programs, agencies and clinicians may not even be aware of CRAFT if you ask so if you or a loved one are in need of a non-residential approach that’s well researched and effective, find a substance abuse therapist able and willing to use it.