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(p. 725) Psychotherapy with College Students 

(p. 725) Psychotherapy with College Students
(p. 725) Psychotherapy with College Students

Rachel G. Smook

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date: 01 October 2020

I am a licensed psychologist in independent practice in Northborough, Massachusetts. I completed my doctoral education at the Massachusetts School of Professional Psychology, now William James College. Following an internship and postdoctoral fellowship at Harvard University, I took some time away from practice to care for my young children. During this time, I stayed connected to the field through speaking and writing engagements and through committee and leadership roles in several American Psychological Association Divisions. I began my private practice in 2007 and have been in Central Massachusetts ever since. Northborough is a small suburb about 40 miles west of Boston. My practice typically draws from five surrounding towns, five local colleges and universities, and the nearby University of Massachusetts Medical School.

The Niche Activity

I have a niche practice providing psychotherapy services to college students and young adults. At any time, 30% to 50% of my practice is dedicated to the young adult population. I initially began working solely with college students within this niche, but as my practice has grown, I’ve expanded to include services to recent college graduates, graduate students, medical students, and young physicians in residency. I have worked consistently at marketing locally so that when there is a referral for someone in the 18-to-24-year-old age range, my name comes quickly to mind as a good resource.

(p. 726) Developing an Interest and Training in this Niche Activity

I fell into young adult mental health somewhat by accident. My early-career goals centered around child and family therapy, and so my first two practicum experiences focused on work with children and their parents. It was with some reluctance in my third clinical placement that I sought to train at a college counseling center. My aim was to correct for the fact that I had learned about working with children and with adults, but not with people who were developmentally on the bridge between the two. Secretly I was a little worried about it; it just was not my interest area. I expected to check off that box on my own internal human development roster and then return to my original plan. Instead I fell in love with working with this population. The work I did at the college counseling center felt stimulating and challenging, and I developed a tremendous fondness and respect for the work that young adults are doing as they come into their own. Although I did spend another year at a clinical placement that offered the chance to work with children as well as adults, I missed the college population and was very clear that I wanted to return to that setting for internship. I accepted an internship at the Bureau of Study Counsel at Harvard University. When Harvard also offered me a postdoctoral fellowship, I accepted with enthusiasm. My training at the Bureau of Study Counsel allowed for in-depth psychotherapy with both undergraduate and graduate students, extensive psychodiagnostic testing and consultation experience, group psychotherapy, and structured small-group supervision.

Joys and Challenges Related to this Niche Activity

Young adulthood is a wonderful time for psychotherapy. For most students, college offers the first extended chance to begin figuring out who they are and what matters most to them without being under the daily watch and influence of their parents. They are learning to manage their day-to-day experiences, desires, needs, and challenges. They are sorting through close friendships and romantic relationships and exploring their sexuality. They are handling crises as they arise without having a parent at the ready to help them. As college nears its end, they are making ongoing decisions about where and with whom they want to live, what and whether they wish to continue to study, and which kinds of employment opportunities they will pursue. They are dealing with the tremendous transition of not having an automatic next step for the first time in their lives. For most of them, the knowledge of what comes next has been automatic and quietly comforting: after first grade, they will go to second grade; after junior year, they will go on to senior year. Many of the students I see have viewed college the same way: after high school, they knew they would go to college. After college, though, what comes next is entirely up to them, and the process around preparing for that and navigating its challenges is a unique and important piece of developmental and therapeutic work.

(p. 727) I am nearly always impressed to watch them do this work and am grateful to have the chance to offer support. Eighteen years after I first trained in a college counseling center, I am still excited to get a new college student or young adult on my caseload, and I still feel challenged, interested, and fulfilled in that work.

The challenges of this niche area are often financial ones. Many of the students I see have no idea how payments work when they first come in, and they have never navigated asking questions of their own health insurance companies. Mine is a self-pay practice, and often for young adults, this means that their parents are paying for their treatments. This leads easily to an ethical gray area in which the person paying my fee is not automatically entitled to any information at all about what is taking place in psychotherapy, since most of my students are 18 years of age or older.

I have found that privacy is especially important to young adults regardless of the quality of their relationships with their parents. I broach the financial and ethical issues in a phone consult prior to the first appointment, and then again at the intake session. I have found accepting credit cards to be an important part of being paid for this population. Many of the students I work with have credit cards that are funded by their parents and I can charge them at the time of the session. I also have parents who choose to pay online through a secure link on my website, and other parents who prepay for a block of sessions (I keep those numbers small so that I am not faced with reimbursing a large amount of money if the patient doesn’t stay in psychotherapy). I have found that most long-distance parents are extremely grateful to have someone helping to care for their adult child in distress, and I rarely run into payment issues. Occasionally I have parents who balk at the confidentiality constraints, but I have become fairly comfortable handling those concerns. Being direct with students about these issues when they first come in is a helpful and necessary part of the work. The same is true for talking about money when I have a young adult who needs to self-pay and cannot afford my full fee. The skills I have developed in those conversations are useful in the rest of my practice as well.

Business Aspects of this Niche Activity

Local colleges and the local medical school have been important referral partners for me. I work to cultivate ongoing working relationships with local college counseling centers and am active with a referral network of colleagues in the area. Because I was starting my practice in an area in which I had no local professional connections, learning to market and network was critical in building a successful practice. I think of marketing as talking with people who need my help about why I love what I do and how that enthusiasm translates into making THEIR jobs easier. I find that professors, counseling center staff, and physicians are relieved to know where to send their students and residents when they are in distress, and that most people are open to sharing what their needs are from a mental health professional. When I can explain how my work fills those needs, I can likely solidify a lasting relationship with a good referral partner.

I began marketing by touting a strength area with college students that I had identified as lacking locally. My training at Harvard provided me a good bit of experience with eating disorders, and (p. 728) well-trained eating disorders clinicians are hard to find in my locale. Currently, I need only accept the occasional eating disorder referral, but in the beginning, it gave me an easy way to begin to market myself. Once I was taking good care of those clients, referrals for other presenting concerns started to come in fairly regularly.

It has also been valuable to get to know a good network of other clinicians practicing locally. My colleagues and I often refer to one another and share each other’s names when we need to make a referral. I firmly believe that there is enough work to go around and have steered clear of “turf” issues in a way that has netted me a fairly steady stream of referrals from other clinicians.

Because I have a self-pay practice, as described above, it’s also important for me to be seen as someone accessible and worth calling. If I cannot see a client for payment or insurance reasons, I will almost always help him or her find another qualified mental health professional. This approach results in referrals whether or not the referring party thinks the patient can self-pay. Enough of them can do so that it has been worth my while to stay off insurance panels, but colleagues can refer to me knowing that I will try to help connect the patient with someone good if I am unable to treat.

Developing this Niche Activity into a Practice Strategy

Young adulthood comes with a very particular set of developmental challenges and an almost unlimited range of presenting concerns. I have treated clients with eating disorders, crisis pregnancies, relationship questions and concerns, friendship struggles, learning issues, time management difficulties, depression, anxiety, psychosis, social skills difficulties, grief and loss, difficulty with decision making, struggles around life transitions, sex and sexuality concerns, and many more presenting problems. Each of these is both enhanced and complicated by the developmental tasks of young adulthood. Expertise in any of them will result in a solid marketing strategy for clinicians wishing to develop a niche practice with college students and young adults. Openness to most or all of them will help ensure a busy, thriving practice once a good referral network is established.

I recommend contacting local college counseling centers and talking in person with the directors there. Offer trainings and in-service presentations for staff, consultation off campus, and assistance connecting students with good care in the event that they need to be seen off campus and you are not available. Look for local networking groups and get to know the other clinicians in your area. Find out what off-campus doctors the local colleges refer to and take those doctors out for coffee. Contact the training directors at local medical schools or graduate programs and talk in person; putting names with faces is always a helpful step in securing a good referral base.

The developmental requirements of the young adult life phase mean that there will always be students who need therapeutic support. If you are interested in developing a niche practice area in young adult mental health, it is also important to consider carefully where your office is located. Will it be accessible to students who do not have cars on campus? How far is it from where they have to be for class? In young adult mental health, it is also important to accept credit card payments, as these clients do not tend to carry cash and almost never write checks.

(p. 729) Psychotherapy with college students and young adults differs from psychotherapy at other ages primarily because of the developmental stages of the clients in this population. As with any niche, it is important to train adequately with the population you are serving. I gained a wealth of experience in three years of training on college campuses and highly recommend that setting as a training choice if you are interested in working with young adults. If you have not previously treated young adults, consider seeking supervision from someone who is well versed in the needs of that population as you begin to build this area of your practice. The national professional association of each of the mental health professions and many state professional associations hold conventions, conferences, and continuing education events related to psychotherapy with college students, and these are another excellent resource for continuing your education. There are continuing education courses related to college mental health available from the Association for the Advanced Training in the Behavioral Services ( All are good resources for furthering your education with the young adult population.

If you enjoy psychotherapy with young adults, I encourage you to consider building it as a niche practice area. It is creative, varied, and rewarding work with an ongoing stream of clients in need.

For More Information

The National Alliance on Mental Illness conducted a survey in 2012 about college student mental health that is worth reading if you are considering working with this population ( It is quite a good resource because it illuminates the kinds of presenting issues that current college students are facing and identifies places where the colleges they attend may need your support as a practicing clinician.

Whether or not you plan to work with students with eating disorders, the “Learn” section of the National Eating Disorders Association’s website ( provides a wealth of information. I have not yet had a year in which I didn’t see a student with eating concerns, regardless of whether those concerns were the presenting problem. It is prudent to be well educated about eating disorders if you are treating the young adult population.

The American College Counseling Association is a division of the American Counseling Association and focuses on clinicians who work with college students on campus. It hosts a conference relevant to college student mental health and produces the Journal of College Counseling, which addresses college mental health practice issues. It is available to members as well as nonmembers (

The resources list includes a number of books about college student mental health counseling, incorporating everything from developmental insights to treatment planning to mindfulness-based strategies for working with young adults. College Student Mental Health: Effective Services and Strategies Across Campus by Sherry Benton and Stephen Benton (2006) and College Student Mental Health Counseling: A Developmental Approach by Suzanne Degges-White and Christine Borzumato-Gainey (2014) are accessible and relevant resources for the college population. (p. 730) Mindfulness and Acceptance for Counseling College Students: Theory and Practical Applications for Intervention, Prevention, and Outreach, edited by Jacqueline Pistorello (2013), is also a highly regarded resource.

References and Resources

Benton, S. A., & Benton, S. L. (2006). College student mental health: Effective services and strategies across campus. Washington, DC: NASPA.Find this resource:

Degges-White, S., & Borzumato-Gainey, C. (2014). College student mental health counseling: A developmental approach. New York: Springer Publishing Company.Find this resource:

Pistorello, J. (2013). Mindfulness and acceptance for counseling college students: Theory and practical applications for intervention, prevention, and outreach. Oakland, CA: New Harbinger Publications.Find this resource: