Mental Health and Substance Use: A Qualitative ...

Reingle, J., Thombs, D., Osborn, C., Saffian, S., & Oltersdorf, D. (2010). Mental health and substance use: A qualitative study of resident assistants’ attitudes and referral practices. Journal of Student Affairs Research and Practice, 47(3), 325–342. doi:10.2202/1949-6605.6016 Available at http://journals.naspa.org/jsarp/vol47/iss3/art5/ Innovations in Research and Scholarship Feature

Mental Health and Substance Use: A Qualitative Study of Resident Assistants’ Attitudes and Referral Practices Jennifer Reingle, University of Florida Dennis Thombs, University of North Texas Health Science Center Cynthia Osborn, Kent State University Steven Saffian, BMOC Inc. Dan Oltersdorf, Campus Advantage, Inc.

This study described mental health and substance use referral practices of resident assistants (RAs). Interviews were conducted with 48 RAs at three campuses. RAs generally had positive attitudes toward helping residents,

Jennifer Reingle, M.S., Institute for Child Health Policy Pre-Doctoral Fellow, Department of Health Outcomes and Policy, College of Medicine, University of Florida. Cynthia Osborn, Ph.D., Counseling and Human Services Development Program, Kent State University. Dan Oltersdorf, CampusAdvantage, Inc. Steven R. Saffian, Ph.D., Director of College and University Relations, BMOC Inc. Dennis Thombs, Ph.D., FAAHB, Professor and Chair, Department of Social and Behavioral Sciences, School of Public Health, University of North Texas Health Science Center.

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RA’s Attitudes and Referral Practices

and believed that existing norms supported their referral actions. However, many perceived referring residents to be emotionally burdensome, and they were not confident referrals would lead to positive outcomes. RAs reported referring residents for professional assistance only when problems were judged to be severe, essentially engaging in a form of clinical evaluation to make referral decisions. Recommendations for enhancing the continuum of care provided to distressed residents are discussed.

Each year U.S. institutions of higher education employ approximately 51,000 resident assistants (RAs) to work and live in college student residence halls. This estimate is based on a U.S. Census (2000) figure for number of students in these facilities and application of a 50-to-1 resident–RA ratio. Typically upper-class undergraduate students, RAs encounter a myriad of complex issues including roommate conflicts, date rape, interpersonal violence, academic problems, depression, and substance misuse. From an institutional perspective, RAs are expected to be the “eyes and ears” of residential campuses (Sharkin, Plageman, & Mangold, 2003). When a resident violates a university policy (e.g., consuming alcohol in a residence hall), the RA is expected to assume an enforcement role and initiate the disciplinary process (Rubington, 1990). Simultaneous, RAs are expected to be the community leaders for their living area, serve as advocates for their residents, and cultivate a sense of unity and cohesion among their residents (Perkins, 2002).

Literature Review RAs also should be able to recognize and refer residents who may have mental health or substance use problems. These issues are commonplace in the undergraduate population. According to Mowbray and colleagues (2006), the prevalence rate for diagnosable mental illness in the college student population is 12–18%. The most common of these include personality disorders, major depression, bipolar disorder, schizophrenia, other psychotic disorders, anxiety disorders, and eating disorders. In a recent national study, 43% of students indicated that in the past school year they “felt so depressed it was difficult to function,” 9.0% seriously considered attempting suicide, and 1.3% attempted suicide (American College Health Association, 2009). Excessive alcohol use is another problem behavior among college students. According to the National College Health Assessment, 37.7% of students reported that they consumed five or more alcoholic drinks the last time they “partied” (American College Health Association, 2009). Each year in the U.S., alcohol use is associated with approximately 1,400 student deaths, 500,000 injuries, more than 600,000 assaults (by another student who has been drinking), and 70,000 reported incidents of sexual assault or “date rape.” Approximately 400,000 incidents of the unprotected sex reported annually are alcohol related (Hingson, Heeren, Zakocs, Kopstein, & Wechsler, 2002). An estimated 2 million college students drive under the influence of alcohol and over 3 million ride with impaired drivers on an annual basis (Hingson, Heeren, Levenson, Jamanka, & Voas, 2002).

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Although a serious problem on campus, rates of illicit drug use in the college student population are considerably lower than alcohol use. In the past 30 days, any illicit drug use involves approximately 20% of students versus any alcohol use involving 68% of students. Drug use disorders are significantly less common among college students than among their noncollege-attending peers (Blanco et al., 2008; Johnston, O’Malley, Bachman, & Schulenberg, 2006). The most commonly used illicit drug in the college student population is marijuana (past 30-day prevalence rate equals 17%). Recent studies relying on national probability samples indicate that most college students who experience mental health or substance use problems do not receive early intervention or treatment services (Blanco et al., 2008; Wu, Pilowsky, Schlenger, & Hasin, 2007). Approximately 18% of U.S. college students with a psychiatric disorder report receiving treatment in the previous year (Blanco et al., 2008). Those with a mood disorder are the most likely to access treatment (34%; Blanco et al., 2008), whereas those with an alcohol or alcohol/drug use disorder are the least likely to do so (4–5%; Wu, Pilowsky, Schlenger, & Hasin, 2007). RAs are on the “front lines” of addressing these serious issues (Elleven, Allen, & Wircenski, 2001; Ness, 1985). When a resident exhibits problem behavior or experiences significant distress or crisis, the RA is responsible for recognizing the problem and referring the student for professional assistance. Depending on institutional policy or practice, these referrals may be to a professional staff member in residence life and housing or mental health services on- or off-campus. Unfortunately, for some time it has been recognized that referrals for mental health and/or substance use problems have not been dealt with consistently by RAs and other residence hall staff (Ness, 1985).

RA Training Specific standards for RA training have not been developed. The Professional Standards for Higher Education published by the Council for the Advancement of Standards in Higher Education (2006) is recognized as the student affairs profession’s guide for best practices and professional standards. In the recent sixth edition, there is only one reference to referrals by student employees (including RAs): “They must be trained on how and when to refer those in need of assistance to qualified staff members and have access to a supervisor for assistance in making these judgments” (p. 215). The inadequate attention given to this critical RA function is even more striking when evaluated in the aftermath of the 2007 Virginia Tech shootings. Research on the RA role and the influence of RAs on residence hall communities is rather limited. Studies focusing on recognition and referral practices of RAs are virtually nonexistent. A search of the scholarly literature using the Web of Science databases dating from 1980 to 2009 produced 20 published articles on RA training and practice: four from the 1980s (Andrews, 1987; Ness, 1985; Schuh, Shipton, & Edman, 1986; Shipton & Schuh, 1980), 12 from the 1990s (Bowman & Bowman, 1995; Deluga & Winters, 1991; Denzine & Anderson, 1999; Hardy & Dodd, 1998; Komives, 1991; Murray, Snider, & Midkiff, 1999; Palmer, 1996; Rubington, 1990, 1993, 1996; Thomas & Seibold,

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1995; Twale & Burrell, 1994), and four from 2000 to present (Jaeger & Caison, 2006; Perkins, 2002; Shaller & Wagner, 2007). The majority of these articles describe RA training programs or general problems facing RAs in residence halls. Although five articles evaluating the knowledge and behavior of RAs in alcohol-involved situations were identified (Andrews, 1987; Ness, 1985; Perkins, 2002; Rubington, 1990, 1996), no articles describing RAs’ recognition and knowledge of mental health issues in residence halls were found. To respond to the need for additional research and literature concerning the role of RAs, we undertook a qualitative study of RAs. The purpose was to understand the attitudes and intentions of a purposeful sampling of 48 RAs concerning their helping role. We sought to understand their attitudes toward residents who may have mental health and substance use problems as well as their referral practices. The Theory of Planned Behavior (TPB) provided a framework for developing and guiding the individual RA interviews. This theory explains intentional actions in the near future that require preparation or planning (Azjen, 1991). Widely used in the field of social psychology, the TPB is an expectancy-value theory stating that the most important determinant of behavior is an individual’s behavioral intention (Montano & Kasprzyk, 2002). Behavioral intention is directly produced by (a) attitude toward performing the behavior, (b) the subjective norms associated with the behavior, and (c) perceived behavioral control in executing the task (Montano & Kasprzyk, 2002). Figure 1 provides a visual depiction of the TPB as applied to RA referral decisions and highlights the theory’s focus on factors influencing behavioral intention. The theory is well suited for explaining these RA decisions because the behavior of approaching and referring (or avoiding) a troubled resident depends upon deliberate, reasoned planning prior to taking action.

Methodology Procedure The study protocol was approved by an Institutional Review Board. RA interviews were conducted at three U.S. college campuses over a three-week period in June 2008. The campuses were selected to represent public and private institutions in geographically diverse locations and included a large, public university in Florida; a large, public university in Ohio; and a small, liberal arts college in Wisconsin. Each campus recruited RA applicants from its population of residence hall students. Minimum academic standards were required and applicants could not be under current university or college judicial sanction. The RA selection process varied across institutions, but in each case involved a series of screening interviews with existing RAs and professional staff. All first-time RAs were required to complete a one-semester leadership course either before or after being hired.

Sample Selection A total of 50 RAs responded to an email invitation to participate in the study and 48 met the inclusion criteria (22 in Florida, 9 in Ohio, and 17 in Wisconsin). A 60-minute semi-structured

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Figure 1. Theory of Planned Behavior (TPB) as a Framework for Assessing RA Intentions to Assist Residents with Mental Health and Substance Use Problems.

Beliefs Assessed During Interview

Behavioral Beliefs: Will RA recognition, referral, and follow-up support lead to positive outcomes?

Evaluation: Does the RA place a strong value on helping residents with possible emotional or behavioral problems?

Predicted RA Attitudes

Strength of RA Intentions

Attitude Toward Referrals: RAs’ general attitude toward approaching, referring, and providing follow-up support to their residents

Normative Belief: Does the RA believe their RHD and residents support appropriate referrals?

Subjective Norms: RAs’ perception of the assistance they are expected to provide to their residents

Motivation to Comply: Is the RA motivated to follow their RHD’s leadership on helping students with problems? Control Belief: Does the RA believe referral and support are emotionally burdensome tasks?

Behavioral Intention: RA intentions toward referring and following-up with residents who may have an emotional or behavioral problem

Perceived Behavioral Control: RAs’ confidence in their ability to successfully refer and follow-up with their residents

Perceived Power : Does the RA believe they have the emotional capacity to make referrals and provide follow-up support?

individual interview was conducted by a member of the research team. Budgetary considerations precluded obtaining data from a larger sample of RAs. If an RA was living on campus during the summer term, they were interviewed face-to-face in their residence hall or at another campus location (e.g., library). Otherwise, interviews were conducted by telephone. RAs were interviewed by an associate dean of students (retired), a professor of counseling and human development services, a graduate student, and an undergraduate student. Each interviewer was affiliated with one of the three participating institutions. To enhance consistency and therefore dependability across

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interviewers, all four interviewers were trained by the senior research team member concerning the interview protocol prior to interviewing. To focus on a single topic and encourage a thorough, in-depth interview, each RA was interviewed on mental health or substance use problems, not both. A total of 25 RAs were interviewed on their perceptions and practices of assisting residents with mental health problems and 23 RAs were interviewed on resident substance use problems. A number of RAs questioned whether their responses would be shared with residence hall supervisors. To protect privacy, interviews were not audio-recorded. Instead, interviewers took careful and thorough hand-written notes of RA responses to the semi-structured interview protocol. Each participating RA received $25 remuneration.

Sample Demographics The majority of RAs were upperclassmen (77.1%) and female (64.6%). Approximately twothirds of participants identified as White (66.7%), 18.8% Black or African American, 8.3% Hispanic or Latino, 4.2% Asian, and 2.1% Other. Only one participant reported serving less than one year as an RA, 41.7% served two semesters, and 27.1% served three semesters (one RA had served for eight semesters). The largest proportion of RAs (70.8%) described the architecture of their residence hall as “traditional” (i.e., double-occupancy rooms with a door opening to a common hallway) and their residents as predominantly “freshmen” (37.0%).

The TPB-Guided Interview of RAs The first half of the semi-structured interview protocol solicited information from the RA participants (33 questions total) about (a) relevant personal characteristics (e.g., academic class rank, sex, race/ethnicity) and those of the residents in their living unit; (b) their training and experiences in dealing with residents who might have mental health or substance use issues (mostly open-ended questions, e.g., “Have you ever had a discussion with a resident regarding his or her mental health?” “Does any particular case stand out in your mind?” “What was the outcome of this discussion?”); and (c) their living environment, including the number of residents in their living area, type of building (e.g., “traditional” dormitory, suites, apartments), and other characteristics of their residents and the residence hall. The second half of the interview consisted of 21 questions assessing TPB constructs (see Figure 1). The TPB construct known as attitude (toward the behavior) is determined by a person’s behavioral beliefs (i.e., beliefs about attributes or outcomes of performing a behavior) and their evaluations of the same attributes or outcomes (Montano & Kasprzyk, 2002). Thus, an individual with strong positive beliefs about behavioral outcomes who also values these same outcomes will have a positive attitude toward the behavior. Conversely, an individual with strong negative beliefs about behavioral outcomes who at the same time does not value these same outcomes will have a negative attitude toward the behavior. To partially gauge RAs’ attitude toward helping residents with

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mental health or substance use problems, the interview included this question: “To what extent will a referral to a professional (such as a counselor) help a resident who has a [mental health or substance use] problem?” Subjective norm, another TPB construct, is determined by normative beliefs (i.e., whether important referent individuals approve or disapprove of performing a behavior) and by the motivation to comply with the same referents (Montano & Kasprzyk, 2002). Thus, an individual who thinks specific referents want him or her to perform a behavior, and at the same time feels compelled to conform to the expectations of those referents, will maintain a positive subjective norm. Conversely, an individual who believes these referents do not want him or her to perform the behavior will have a negative subjective norm. Furthermore, an individual who does not feel compelled to conform to these referents’ expectations will probably hold a neutral subjective norm. To assess one aspect of subjective norms, the question “Do you believe that your residence hall director wants you to recognize and refer residents who might have [mental health or substance use] problems” was asked. Perceived behavioral control, the third TPB construct, is determined by control beliefs (i.e., the presence or absence of perceived facilitators and barriers to behavioral performance) and by the perceived power of each condition to facilitate or inhibit the behavior (Montano & Kasprzyk, 2002). An individual who holds strong control beliefs and believes the conditions he or she operates in facilitate the behavior (e.g., the task is not a burdensome RA responsibility) will have strong perceived behavioral control. Conversely, an individual who strongly believes that existing conditions will impede performing the behavior will have weak perceived behavioral control. In the current study, one interview question for assessing perceived behavioral control was: “How confident are you that you would be able to recognize a resident who might have a [mental health or substance use] problem?”

Data Analysis Preliminary analysis was conducted by the senior research team member and then reviewed by the other members of the research team. Analysis of the interview data was organized by TPB constructs. Data from each interview were sorted into a response summary created for each TPB construct (e.g., attitude toward referrals). Separate response summaries were created for the mental health and substance use interview protocols. The different types of responses within each TPB construct were noted. After responses from each individual interview were identified according to TPB constructs, interviews were sorted by the interviewer and discrepancies among interviewers considered. No interviewer discrepancies were identified using this procedure. Therefore, data from all 48 interviews were pooled and analyzed across RA participants (i.e., this study was not designed as a multiple case study method wherein each RA or institution would represent a separate case). RA quotes judged to best reflect the beliefs and attitudes of the sample were identified and recorded as well.

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Results Training to Address Mental Health and Substance Use Problems The data suggested that RA training concerning mental health and substance use was similar across the three campuses. Training took place prior to the beginning of each fall semester with a review of procedures prior to the start of spring semester. Time was allocated for presentations on mental health and substance use. In most cases, these presentations were provided by campusbased mental health professionals and, when available, substance abuse experts (including faculty members). The training sessions emphasized consultation with the supervising Residence Hall Director (RHD), available resources and referral options. Psychological and behavioral assessment and counseling skills were not typically part of RA training. RAs reported that their most significant training experiences came from participating in role-play exercises where they were challenged by scripted scenarios involving troubled residents. Following role plays, the RAs received feedback from mental health professionals and experienced residence hall staff.

Experience in Helping Residents with Mental Health Problems Among the 25 RAs who participated in the mental health referral interviews, 12 (or 48%) reported they had never had a discussion with (or made a referral for) a resident about a possible mental health problem. Compared to substance use problems in the residence hall population, RAs reported that mental health problems were much less of an issue in their living area. However, a small number, two RAs, indicated they had at least eight discussions with one or more of their residents regarding a possible mental health problem. A total of six RAs (or 26%) made a referral for a possible mental health problem, with eight (32%) reporting discussions with one or more residents about such a problem. These discussions did not result in referrals. Among those who did not make a referral, no action was taken because the problem was judged to be minor. This action suggests that these RAs engaged in informal screening and evaluation. The following examples illustrate the RAs’ notable experiences in dealing with residents’ mental health problems:

r RA walked into a room and discovered a resident cutting herself. r Resident apprehended while streaking on campus. He had not been taking his prescription medication for a previously diagnosed condition.

r Freshman told a friend that she was thinking about killing herself. r A resident with severe body image issues broke up with a boyfriend, prompting a suicide attempt.

r A resident struggled with gender identity issues and a nonsupportive family. In each of the above cases, the RA involved determined the event was serious enough to warrant a referral. However, when RAs judged a resident’s depression to be “mild,” they did not make a

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referral. Several RAs defined homesickness, difficulty making friends, and romantic breakups as “temporary depression.” In these cases, RAs believed the problem would resolve itself.

Experience in Helping Residents with Substance Use Problems Some RAs were proactive about having discussions with residents and referred students with possible substance use problems. Other RAs were much less involved in proactive discussions and/or referrals. Although two RAs reported having at least 30 discussions with one or more residents about substance use problems, six reported never having had such a discussion with any resident. Among the 23 RAs interviewed about substance use referrals, only eight (or 35%) reported having made a referral for a possible substance use problem. The RAs who reported never discussing possible substance use problems with residents indicated that, in their judgment, incidents were not severe enough to warrant a discussion. For example, one RA reported that, “the [drug or alcohol] problem didn’t seem like a recurring thing.” Another stated, “nothing serious enough came up.” Among upperclassmen able to consume alcohol legally, RAs did not perceive alcohol use to be as problematic as underage drinking. Additionally, RAs reported that upperclassmen have more social networks and consume alcohol or other substances away from the residence hall. RAs indicated that substance use problems among older students were more difficult to detect than among underclassmen. Despite differences in detection, the RAs’ comments suggested that an incident involving substance use would have to be especially egregious or especially harmful before a resident would be approached about seeing a mental health professional. Some examples of substance use incidents reported by the interviewed RAs included:

r A resident fell asleep in another resident’s bed because she was so intoxicated. r A resident disabled his roommate’s car to prevent him from drinking and driving. r A resident fell and split his head open on a desk due to extreme intoxication. r After a fraternity event, a resident was discovered vomiting in a bathroom. r A resident with no history of using alcohol came back to the residence hall very intoxicated.

r A resident fell down stairs due to extreme intoxication. She then called her mother and asked her RA to inform her mother about the severity of her [daughter’s] intoxication. Residents were refereed in only two of these instances. In the case of the resident who became ill after a fraternity event, the RA rationalized that it was “just a fraternity thing. He straightened himself out.” The resident who fell asleep in someone else’s bed was not referred, as the RA assumed that she “figured it out” later. Although they were trained to recognize and refer residents for substance use problems, there appeared to be an ethic among the interviewed RAs. The view is

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summarized in the following: “We don’t make referrals for substance use problems until numbers of violations accumulate and the problem is blatant to others or severe.” Illegal and prescription drug use in residence halls were ignored or would responded to by “look[ing] the other way.” Only two RAs reported an incident involving drugs other than alcohol:

r A resident was given a “date rape” drug while consuming alcohol. Emergency medical services were contacted.

r A resident was not able to perform in dance anymore [after dancing for many years]. RA noticed a change in her demeanor, and friends informed [the RA] that [the resident] was using laxatives. Although the laxative-using resident was referred, the resident who was involuntarily drugged was not because “it was not her fault that time.” Two RAs acknowledged overlooking marijuana use the first time it was detected by them.

TPB Construct—Attitude Toward Referrals Overall, the interviewed RAs believed referrals would produce positive outcomes for residents who may have either mental health or substance use problems. Mental health professionals were viewed as useful resources for residents willing to seek help. As one RA noted, “[mental health professionals] will be able to identify exactly what the problem is and they have adequate training to deal with it.” All RAs interviewed could recite multiple positive outcomes of discussing and referring residents about whom they were concerned (e.g., get residents the information they need, build trust, and motivate the resident to seek treatment). Potentially negative outcomes of referring a resident were more difficult for the RAs to identify, perhaps because few had done so. In a number of interviews, no negative attributes or outcomes were mentioned. RAs anticipated defensiveness, internalization of the problem, and resentment toward the RA from residents if a discussion or referral occurred. In these cases, RAs were concerned that mentioning the problem might cause residents to react negatively, worsen the situation, hide the problem from others, and/or avoid the RA to evade further interaction, evaluation, or discipline. Helping residents who may have mental health or substance use problems was recognized as a high priority by the interviewed RAs. Although mental health referrals were perceived as more important than substance use referrals, both ranked in nearly all 48 interviewed RAs’ “top three” responsibilities. It should be noted that these positive attitudes toward referral did not translate into action however.

TPB Construct—Subjective Norms All RAs indicated their RHD wanted them to refer residents who may have mental health or substance use problems. Although they may have felt pressure to provide socially desirable

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interview responses, a large majority of the RAs appeared highly motivated to comply with the guidance of their supervisor to help residents with potential substance use or mental health problems. Only three (or 6%) of the RAs reported that it was not important to follow their RHD’s guidance. Those who indicated they follow their RHD’s guidance pointed to their more advanced training and greater experience as the primary reasons for accepting the RHD’s guidance. The few RAs who indicated they would deviate from their RHD’s guidance believed their personal knowledge of the resident would allow them to make a better decision.

TPB Construct—Perceived Behavioral Control Research findings suggest that perceived behavioral control is the TPB variable most likely to weaken RA intentions to refer residents. RAs expressed substantial disagreement about how burdensome it would be to approach and refer a resident who needed help. A large portion of RAs reported that approaching a resident to discuss their concerns and make an initial referral would indeed be an emotionally taxing process. As one RA put it, “you feel like you are betraying them a little bit [when you refer them for an alcohol problem].” Other RAs described the task as less burdensome, but only because they believed it was an ethical obligation or duty. For example, one RA noted that, “If I didn’t refer, that would be a burden morally—to not do something. If I didn’t act, maybe something worse would happen.” Another RA stated, “not a burden, but challenging— a good challenge.” The sensitive nature of discussing mental health and substance use problems with residents appeared as though it may be a substantial barrier to making referrals among many of the RAs in this study. Once a mental health or substance use problem was recognized, most RAs felt confident they could make a referral. The RAs who were not confident attributed it to a fear of losing the community that had been built in the living unit. In addition to any communitywide repercussions, they were far less confident that their attempt to help would be well received by the resident. They were not confident that a referral would result in the resident obtaining professional assistance. Most RAs believed that only 50% of their residents would seek help if referred. The range of estimates for successful referrals was 40–75%. These estimates suggest that RAs’ judgments balance the prospects of help-seeking with a desire to maintain a positive relationship with the resident.

TPB Construct—Behavioral Intention According to the TPB, behavioral intentions are jointly influenced by attitude toward the behavior, subjective norms, and perceived behavioral control. The beliefs and attitudes expressed by the 48 RAs suggest that they (a) have a positive attitude about helping residents connect with mental health care and (b) perceive that existing norms support their referral actions. However, many of the RAs seemed to view the task to be personally challenging and emotionally difficult and doubted their ability to make a referral that would motivate residents to accept (and obtain) professional assistance. These conditions suggest that without adequate training, supervision,

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support, and encouragement, the RA referral of distressed or troubled residence hall students is an inconsistent practice across residence hall environments.

Discussion In the higher education community and among parents of college students, it is generally believed that residence hall living provides some degree of protection against risky behavior. This protection, it is believed, is enhanced by the structure and dynamics of residence hall living and presence of residence hall staff. Unfortunately, this belief may not be well founded. Many RAs in this study acknowledged that they did not always refer residents who misuse substances or present mental health issues. Given the relatively prevalent rates of these problems in the college student population (Blanco et al., 2008; Hingson, Heeren, Zakocs, Kopstein, & Wechsler, 2002), it is reasonable to speculate that the respondents were not adequately responding to the needs of their residents. These findings challenge the conventional notion that residence halls are necessarily protective environments.

Hesitation to Approach Residents and Make Referrals The current study revealed a number of factors that weakened RAs’ intentions to approach and refer distressed or troubled residents. First, the hesitance stemmed from perceptions that the referral process is emotionally burdensome or stressful, indicating that it is a social taboo to discuss mental health and substance use issues with residents. Second, some RAs explained that infrequent contact with residents made it difficult to identify problems. This was attributed to (a) a large number of residents in their area, (b) academic rank of their residents (upperclassmen who are not around as much as underclassmen), or (c) the physical environment of their building (apartments and suites promote less social interaction than “traditional dorms”). Third, some RAs rationalized that if a resident had a problem, it would fix itself. They seemed to convince themselves that many problems were not severe enough to warrant a referral. Fourth, some RAs were hesitant because of concerns that a referral would disrupt social cohesion in the living unit. Fifth, a large majority of the RAs held the position for an altruistic motive: to help others. However, in a small number of cases, the primary motivation was monetary compensation (i.e., tuition waiver, stipend, or no or lowered housing costs). In these circumstances, the sometimes challenging and risky task of helping residents with mental health or substance use problems may have been regarded as intrusive tasks to avoid or left to others.

The Severity Threshold for Approaching and Referring Residents The study findings suggest that RAs frequently engage in a form of clinical screening and evaluation to determine whether a referral to their RHD or a campus mental health professional is warranted. Although RAs generally understand and accept that they are not trained mental health professionals, department expectations require that they adopt criteria for determining whether to take the most preliminary steps to help a resident. This includes consultation with their RHD.

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Yet, respondents were not aware of formal department guidelines for this purpose. The only informal guideline for approaching and referring residents consistently reported by respondents was based on severity of resident problems. RAs using informal severity criteria were unaware that their judgments could be construed to represent a diagnostic process. In the absence of department guidelines, reliance on informal severity criteria is understandable and related to RAs’ need to be “certain” (a word used by a number of RAs) about both problem severity and resident willingness to accept help. The need for certainty likely results from a cost-benefit analysis in which the RA weighs the potentially negative consequences of referring a resident (considered in the context of having to continue to live with this person) against its potential benefits (positive treatment outcomes). The role conflict inherent in the RA position (community builder and resident advocate versus disciplinarian) also appears to influence referral decision-making. Not surprisingly, “severity” judgments seemed idiosyncratic, and deviated from official university policy (and state law) on substance use. Experienced RAs attributed their “screening” ability (i.e., when to approach a resident) to their overall experience and “common sense,” not to formal training. One RA reported that, “not every situation is by the book.” It is not clear whether length of experience on the job decreased or increased the probability of approaching and referring troubled or distressed residents. Regardless, these findings suggest a need to systematically develop and evaluate mental health and substance use training to bolster the recognition and referral skills of RAs.

Implications for RA Training and Supervision Although the current study identified a number of factors that contributed to inconsistent referral practices, it must be pointed out that those students who serve as RAs are the “right group” to train and invest in as community leaders. When asked why they had become an RA, most respondents said: “I wanted to help others.” Many reported that they wanted to give back to a community they had found nourishing. Indeed, the RA selection process seeks these same attitudes. Training needs to give considerable time and attention to bolstering RAs’ perceived behavioral control (roughly translated to “self-confidence”) in carrying out this task. The common sources of anticipated anxiety and uncertainty surrounding the task need to be highlighted with multiple and repeated role-play exercises specifically designed to address these concerns. In addition to feedback on their performance in mock scenarios, specific instruction needs to be provided to RAs to help them anticipate resident responses and teach them how to react. They also could be educated about practical referral techniques (e.g., accompanying residents to a campus counseling service) that will maximize the likelihood of professional assistance acquisition. In addition to RA training techniques, priority could be given to the role of the RHD in ongoing training, supervision, and support of the RA. Bernard’s (1979) Discrimination Model of Counselor Supervision provides a conceptual framework that could be adapted for training RHDs to supervise RAs on helping residents with mental health and/or substance use problems. The

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Discrimination Model identifies three supervisor roles (teacher, counselor, and consultant) and three foci of supervision (intervention skills, conceptualization skills, and personalization skills). As the supervisor moves from one role to another, he or she intentionally addresses one of three supervisee needs (Bernard, 1979). Student affairs graduate preparation programs could incorporate these clinical supervision skills into coursework designed specifically for students seeking to pursue careers in residence life. Given the relatively high prevalence of mental health and substance use problems in the undergraduate population, RAs’ reluctance to approach troubled and distressed residents (unless their problems are judged severe), as found in the current study, is a major concern (Furr, Westefeld, McConnell, & Jenkins, 2001; Hingson, Heeren, Zakocs, Kopstein, & Wechsler, 2002; Kadison, 2006; Mowbray et al., 2006). The nature of the RA role, with its inherent conflicts, suggests that RA hesitancy to refer is a problem that will not be eliminated and, therefore, requires continual monitoring by professional staff. One way to increase confidence levels of RAs to approach and make initial referrals is to develop a continuum of care on campus that involves mental health professionals, residence hall professional staff, and RAs, and in some cases, parents of the affected student resident and their faculty (Mowbray et al., 2006). A formal system of this type will help RAs understand that they have an important, but constrained role in linking students with needs to professional mental health services. In hectic campus environments, establishing such care networks is a challenging endeavor, and highlights the need for developing online programs that could appropriately share confidential information with the resident, their clinician(s), residence hall staff, and others according to ethical guidelines and laws governing disclosure of educational and clinical information.

Implications for Mental Health Services In the wake of recent campus shootings, many colleges and universities have opted to refer more students to counseling services early (Foley, 2008; Virginia Tech Review Panel, 2007). Although its purpose was not to assess the extent of unmet need for mental health services in the college student population, this study pinpoints one crucial link in the campus continuum of care—the RA. One consequence of earlier referral may be the inadequate capacity of campus mental health services to manage increased student usage. Under current campus referral conditions, many institutions report difficulty finding additional resources to meet student needs (Frey, 2007; University of Wisconsin System, 2008). This challenge is likely to continue for many years as the number of students with existing mental health and substance use problems increases on campus (University of Wisconsin System, 2008). Higher education professionals can advocate for increased funding to support these vital services.

Limitations Six limitations must be considered when interpreting study findings. First, the data consisted entirely of RA retrospective self-reports. The interview responses were not corroborated.

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Second, despite assurances to the contrary, some RAs expressed suspicion that the interviewers were employed by their residence life and housing department. Therefore, some RAs may have provided less than candid responses to some interview questions. Third, data were not collected to establish inter-rater reliability among the interviewers prior to data collection. Fourth, to honor respondent concerns about confidentiality no audio recordings were made of the interviews. Therefore, the reliability and validity of interviewer note-taking cannot be established. Fifth, although consistent data were reported from respondents representing three different campuses, the findings may not be typical of RAs in the broad spectrum of U.S. campuses. Finally, the initial contact with RAs to elicit study participation was made by a senior residence life and housing officer at each campus. This method might have generated a biased sample of RAs who held exceptionally positive attitudes toward their job and residents, compared to non-interviewed RAs. Therefore, it is possible that the general population of RAs is less likely to recognize and refer residents for mental health and substance use problems than reported herein.

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