Testing Three-Item Versions for Seven of Young’s Maladaptive Schema and Wait Impact for Briefly Counseled Non-Urgent Clients

The purposes of this study were to: further test the reliability and discriminant validity of three-item measures of seven maladaptive schema scales on a sample of non-urgent university counseling center (UCC) clients; test the relationships of waiting variables to these maladaptive schema; and test if these waiting variables were related to changes in these maladaptive schema for briefly counseled UCC clients. The results supported the test-retest reliabilities and discriminant validity of these seven scales. Independent sample t-tests between two different types of wait variables, i.e., minimal versus considerable wait bother, and less than two weeks wait versus at least two weeks wait, did not show any significant differences for these scales. However, one scale, mistrust and abuse increased during brief counseling for both the considerable wait bother and at least two weeks waiting groups. It is important to make sure that non-urgent clients get timely counseling.

Using various pre-counseling and post-counseling measures, Brunner, Wallace, Reymann, Sellers and McCabe (2014, p.264) called today's college students the "most stressed" generation of college students. Based on data from the National Comorbidity Survey Replication, Kessler et al. (2005) estimated that three-quarters of lifetime mental disorders (e.g., anxiety, mood, impulse control) have their first onset by the general college age range of 18-24. A supplemental survey of Center for Collegiate Mental Health or CCMH (2016) University Counseling Centers (UCCs) members in 2015 examined change in institutional enrollment and UCC utilization over the last 6 years (2009-2010 through 2014-2015). Data from 93 institutions showed, on average, the growth in number of students seeking services at UCCs was more than five times the rate of institutional enrollment growth. The most recent CCMH (2017) survey found that, with increased demand for mental health services, "on average UCCs are providing 28% more 'rapid-access' service hours per client and 7.6% fewer 'routine' service hours per client over the last six years" (p.3). The report also noted that, especially for UCCs with flat funding models, this increased demand may negatively impact the availability of routine services after initial client contact.
Initial contact is increasingly happening with the use of a triage system in which during a shorter-than-intake appointment (Shaffer et al., 2017), the triage counselor assesses the client's need-for-care level (e.g., emergency, urgent, routine or non-urgent). Non-urgent clients are given an intake (first regular appointment) slot, as soon as possible, depending on the number of higher priority cases, overall service demand, and therapist availability (DiMino & Blau, 2012). The purposes of this study were: (1) to further test the reliability and discriminant validity of seven three-item measures of maladaptive schema; (2) to test the relationship of waiting variables for pre-intake non-urgent clients on these maladaptive schema; and (3) to test if these waiting variables were related to changes in these maladaptive schema for briefly counseled non-urgent UCC clients.

Young's Maladaptive Schema
The Young Schema Questionnaire (YSQ) was designed to help assess early maladaptive schemas in individuals suffering from depression (Young, 1990;Young & Klosko, 1993). A maladaptive schema represents a deeply The YSQ in either long-or short-form versions has clearly demonstrated its usefulness for clinical practice (Hawke & Provencher, 2012). However, even a 75-item "short form," particularly when combined with other measures, can represent a lengthy "research-oriented" survey, where respondent fatigue may become an issue (Edwards, 1997). This may result in a significant non-response bias, including missing data (Roth, 1994). Using two samples, 102 triaged pre-intake undergraduates in counseling and 962 undergraduates not in counseling, Blau et al. (2015b) found initial psychometric support for reliably measuring seven three-item schemas: unrelenting standards, subjugation, mistrust and abuse, abandonment, dependence, entitlement and social exclusion for both samples. These seven (of 15) maladaptive schema were selected based on the following criteria: (1) the first author's aggregated polling of undergraduate classes taught over the prior several years after students' read Young and Klosko (1993) and listed the two most important schemas (life traps) they had faced; (2) a fall 2013 meeting among counseling services' clinicians at the UCC research site which indicated that these seven schemas were well-represented in undergraduate clients the clinicians had and were currently seeing; and (3) several of these schema either being identified as descriptive of many millennial college students, i.e., entitlement, dependence (Much et al., 2014); or identified as prominent mental health issues for millennials, i.e., unrelenting standards and social exclusion (Brunner et al., 2014) . One research goal of this study was to further test the reliability and discriminant validity of these seven three-item measures of maladaptive schema. Pinkerton, Talley and Cooper (2009) noted that it is best to have a therapist appointment within 24 hours of a students' request for help. In a national survey of 228 College Counseling Directors, Gallagher (2011) found that 46% of Directors reported that once counselor schedules are filled wait lists begin to develop, and 88% of these Directors reported that such wait lists led to concerns that some students may not be getting help when they needed it. Using a wait list system at their university counseling center, Levy et al. (2005) found that regardless of race, students who waited longer than three weeks were less likely to return to their first scheduled counseling session versus students who waited three weeks or less. DiMino and Blau (2012) found a significant positive relationship for non-urgent undergraduates between length of wait time after triage and no-show rate for scheduled intake (after triage).

Wait Time Impact on Non-urgent Clients
Using a sample of 99 non-urgent undergraduates presenting for counseling, Blau et al. (2015a) divided these non-urgent clients into two groups based on wait time from triage to intake, "less wait time" (up to two weeks, n = 48) versus "more wait time" (at least two weeks, n = 51). Blau et al. (2015a) found that the less wait time group showed higher willingness to recommend the university, higher institutional commitment, and lower perceived stigma for receiving psychological help, versus the more wait time group. Therefore, wait time for non-urgent clients is important to test. In addition, being bothered by the waiting time or "wait bother" is also important to measure. Blau, DeMaria and DiMino (2017) found that wait bother significantly explained perceived UCC service promptness by 117 non-urgent clients beyond controlled-for demographic variables (e.g., gender, ethnic background, status entering university, age). Finally, what happens to a student's need for counseling while they are waiting for intake? For example, DiMino and Blau (2012) speculated that the waiting could lessen non-urgent clients' counseling needs if they sought out support from other referent groups (e.g., family, friends, non-counseling college staff). The second research goal was to test the relationships of waiting variables for pre-intake non-urgent clients to these seven maladaptive schema.

Brief Counseling as Typical for College Students
Given the increased demand for services on many university campuses (CCMH, 2016;, counseling with college students is typically of short duration. Using data gathered from 1,698 college student clients across 42 universities, Draper, Jennings, Baron, Erdur and Shankar (2002) found that the average number of sessions per client was 3.3. In another review, Ghetie (2007) noted a median of 4-5 counseling sessions and a mode between 1 and 2 sessions. The 2016 CCMH report (CCMH, 2017) noted a mode of one for the number of appointments.  Mahon et al. (2015) found that 37/124 (30%) of undergraduate clients completed a minimum of three counseling sessions, with the remaining 87 either never returning for a second session or dropping out after two sessions. Prior research suggests that even a shorter-term intervention can help non-urgent clients (Alcée & Sager, 2017;Mahon et al., 2015). The third and final goal of this study was to test if waiting variables were related to changes in these maladaptive schema for briefly counseling non-urgent UCC clients. Therefore, the following three hypotheses were tested:

Study Hypotheses
Hypothesis 1 -Further testing will support the reliability and discriminant validity of these seven three-item measures of maladaptive schema.
Hypothesis 2 -Wait bother and wait time will be related to pre-intake non-urgent clients' maladaptive schema.
Hypothesis 3 -Wait bother and wait time will be related to changes in the maladaptive schema of briefly counseled non-urgent clients.

Samples and Procedures
Two undergraduate samples in counseling participated in this study. All data were voluntarily collected using two on-line surveys at the main campus of a large state-supported urban university's (University X) UCC in the Mid-Atlantic region of the United States. The first (pre-intake) sample was labeled as Time 1. The subsequent sample derived from this initial sample was labeled as Time 2. For any given client, the nature of their mental issue, as well as client/therapist availability did not allow for a standardized number of sessions or time-periods to represent when clients filled out the subsequent survey. Given this non-standardized time-period and number of counseling sessions provided for participants before taking the subsequent survey, a range of sessions and time-periods were used (reported below).
Data were collected for 205 undergraduates who registered for counseling services at the UCC between the fall of 2013 through the spring of 2017. Institutional Review Board (IRB) approval was given for all data collection, and data went directly into Qualtrics' databases. These pre-intake undergraduate participants had been designated at their initial counseling session (i.e., an in-person triage interview), as non-urgent (non-suicidal or no risk to self/others) by the triage therapist. Non-urgent clients were asked by their triage therapist if they wished to voluntarily participate in a research study looking at the impact of counseling on student outcomes. The Time 1 pre-intake clients took their survey after triage but before beginning counseling (i.e., intake). The time span between triage and intake could be anywhere from that week to over several weeks, depending on current client demand for services and therapist availability. Sample demographics for the Time 1 complete-data pre-intake sample are reported below.
Undergraduate clients (n = 205) who completed the initial survey (Time 1) were given the option of listing the last four digits of their nine-digit university identity number so that their responses, while receiving counseling, could be tracked over time while their individual identities would remain protected. Clients could take the Time 1 survey either at the UCC's self-help center or at home using a survey link. Using their email addresses recorded at triage, clients were contacted after their triage appointment at a four-week interval, i.e., at Time 2 (four weeks from triage). A general email was sent out to all post-triage clients on a rolling weekly basis during a semester. As a check, clients were asked what survey they were filling out (Time 1, Time 2). Given the anonymity of respondents (using only the last 4-digits), it was not determined if a particular client had stopped coming to the UCC.
A sample of n = 62/205 (30%) filled out the second survey at Time 2. This Time 2 sample reported a median of three counseling sessions after intake (range 1 to 8) over a median period of six weeks (range 4 to 10 weeks). In order to improve the longitudinal response rate a $50 random-drawing lottery for matched ID repeat-respondents was approved by the IRB partway through the data collection process. However, this incentive had little impact in improving the matched respondent participation rate.

Measures
Respondent demographic variables. These variables collected only at Time 1 as single items were: main mental health issue for presenting to counseling, gender, ethnic background, status entering university, current residential status, parents' highest education level, self-reported grade point average (GPA), age, referral source for coming to the UCC, and full-time student status (taking at least 12 credits/semester).
Seven three-item maladaptive schema. As noted by Blau et al. (2015b), the item content of these seven schema was pilot tested among four counseling center clinicians, as well as 10 undergraduates who were interning at the UCC self-help center before any survey administration. In condensing each schema scale down from longer measures, careful attention was paid to keeping the face validity of each item for a particular schema (Stone, 1978). In addition, the previous 6-point response scale used by versions of the YSQ long-form/short-form (1 = completely untrue of me to 6 = completely true of me) was replaced by a 7-point response scale to capture greater response variation (1 = strongly disagree to 7 = strongly agree, as well as to allow a neutral response). The three items measuring each of the seven schema (21 total), along with their internal consistency estimates (coefficient alpha) for the Time 1 sample are shown in Table 1. All coefficient alphas are greater than .70 (Nunnally, 1978) except for entitlement, which was .64. These scales were also collected at Time 2.

Data Analyses
All data analyses were done using SPSS-PC (SPSS, 2013). Demographic data on the sample are presented below.
Analyzing the test-retest reliability and discriminant validity of these seven three-item measures of maladaptive schema was done using correlational analyses (Stevens, 1996). Independent sample t-tests (Stevens, 1996) were used to test the relationships of wait bother and wait time to each schema. For wait bother, when collapsing the data into two larger groups, there was a group size comparison imbalance since 75% said it was minimal (no bother or a little bit bother) while 25% indicated it was considerable (moderate or a lot bothered). For wait time, the median split was up to two weeks (55%) versus at least two weeks (45%). Finally, the third hypothesis was tested using paired-sample t-tests over Time 1 and Time 2 for both briefly counseled groups in the wait bother and wait time samples. Prior to testing this third hypothesis, comparisons between complete versus missing data samples were made for both wait bother and wait time samples. Since direction was specified a priori in the hypotheses, one-tailed t-tests were used (Stevens, 1996). When a significant t-test value was found, effect size was calculated (Cohen, 1988). Finally, additional chi-square analyses on relationships between the wait variables, and the wait variables to premature termination were performed.

Sample Demographics
A demographic variable breakdown for the sample at Time 1 is shown in Table 2. Anxiety and depression were the two most frequently mental health concerns mentioned by clients; clients were primarily self-referred white females who lived on or close to campus and were not transfers. By comparison, for the fall of 2016, based on 28,767 matriculated undergraduates at University X: 52% were female, 56% were white, 91% were full-time, 65% were non-transfer, and the mean age was 22 years old. Thus in terms of representativeness, the UCC client sample had higher percentages of white females who were generally younger. However, the UCC client sample gender and ethnicity were consistent with data from CCMH (2016; 2017).  Other (e.g., family, friend) 39%

Full-time Student (12 plus credits) 96%
Note. n = 205. Table 3 shows the Time 1-Time 2 matched correlations for the seven maladaptive schema scales. The test-retest reliabilities (bolded) for each of the seven schema were at least .70 (Nunnally, 1978), except for entitlement (r = .69). In addition, these test-retest reliabilities were stronger than the correlations between different schema within and across time-periods, supporting each scale's discriminant validity (Stevens, 1996). These results supported H1.   The results for testing H2, are shown in Table 4. In order to perform the independent samples t-tests, two wait bother groups (minimal versus considerable) and two wait time groups (less than two weeks and at least two weeks) were created. The results in Table 4 show that there were no significant differences within either of the two wait bother groups or two wait time groups on any of the schema scales. Thus, there was no support for H2.  The final hypothesis (H3) was tested using paired sample t-tests for briefly counseled samples across Time 1 and Time 2, comparing first the minimal versus considerable wait bothered samples, and then comparing the less than two weeks versus at least two weeks wait time samples. The complete-data sample sizes were reduced from n = 205 to n = 45 (22%) for the wait bothered and from n = 205 to n = 60 (24%) for the wait time. There were no significant differences between the complete-data versus incomplete-data samples for either group. The results are shown in Table 5 for the minimal versus considerable wait bother groups, and in Table 6 for the less than two weeks versus at least two weeks groups. Overall, the results shown in these tables were weak. There was one significant t-test change within the wait bothered groups, i.e., for the considerable wait bothered group, the means (M) of mistrust and abuse increased from Time 1 (M=4.60) to Time 2 (M = 5.07), t(13) = -1.99. A similar significant increase in the means of mistrust and abuse was also found from Time 1 (M=3.79) to Time 2 (M = 4.13), t(23) = -2.18, for the at least two weeks wait time group. In addition, the entitlement means also increased from Time 1 (M=2.97) to Time 2 (M=3.36), t(23) = -2.08, for the at least two weeks wait time group. The effect size for each significant difference was medium (Cohen, 1988). Overall, these results provided weak support for H3.   In addition, the relationship between wait bother and wait time to how waiting affected the need for counseling was examined. Using the two wait bother and two wait time groups, four groups were formed (sample size): (1) minimal wait bother/up to 2 weeks wait (n = 105); (2) minimal wait bother/at least two weeks wait time (n = 58); (3) considerable wait bother/up to two weeks wait time (n=16); and (4) considerable wait bother/at least two weeks wait time (n=37). For the chi-square analysis, there were 12 groups, the four wait bother/wait time groups times the three categories of how waiting affected counseling (increased, no impact, helped to partially resolve). The chi-square test result was significant, χ(6) = 57.63, p < .01. Interpreting the breakdown showed that for the first two jedp.ccsenet.org

Hypotheses Tests
Journal of Educational and Developmental Psychology Vol. 8, No. 1;2018 10 wait bother/wait time groups, the waiting either had no impact or helped to partially resolve clients' counseling needs. However, for the third and fourth wait bother/wait time groups, the waiting variables were related to increased clients' counseling needs. Finally, the relationship between wait bother and Time 2 premature termination could not be tested because none of the six respondents was in the considerable bother category. However, the relationship of wait time to premature termination could be tested. The chi-square test result was significant, χ(1) = 6.00, p < .05, and the results showed that those who waited up to two weeks (n = 5) planned their counseling termination, but the one client who waited at least two weeks to begin counseling prematurely terminated.

Discussion
Demands for mental health services are increasing for many UCCs (CCMH, 2016), and the triage approach to screening students seeking counseling has been increasingly adopted across UCCs to deal with this increased demand (Shaffer et al., 2017). However, the routine treatment for non-urgent clients may be suffering (CCHM, 2017). This study extended earlier research (Blau et al., 2015b) and found encouraging support for seven short scales measuring Young's (1990) maladaptive schema. These scales demonstrated good test-retest reliabilities and discriminant validity (Stevens, 1996). The only exception was entitlement, which exhibited a less-than-desirable (under .70) coefficient alpha and test-retest reliability. As Young and Klosko (1993) noted, entitlement is a less typically self-reported maladaptive schema. Shorter scales can be useful to help minimize respondent fatigue for college student-based research surveys (Fan & Yan, 2010).
Non-urgent clients who waited longer after triage were less likely to show up for their intake appointment (DiMino & Blau, 2012). Being bothered by the wait time has also been shown in previous research to be important to consider (Blau et al. 2017). Two groups were created for wait bother (minimal/considerable) and wait time (less than two weeks/at least two weeks). Considerable wait bother increased the clients' counseling needs. No results were found for significant differences between the two wait bother or wait time groups on any of the seven schema scales for the pre-intake sample (Time 1).
Brief counseling is typical for most college students (Draper et al., 2002;Ghetie, 2007). The final hypothesis tested for the impact of brief counseling separately for both types of wait bother and wait time groups. The results showed that for the considerable wait bother group and the at least two weeks wait time group, the mistrust and abuse schema increased from Time 1 to Time 2. In addition, the entitlement schema also increased from Time 1 to Time 2 for the at least two weeks wait time group. These results collectively suggest that for non-urgent clients who either waited longer for intake or if this waiting bothered them, higher mistrust and entitlement could hurt the therapeutic alliance formed during brief counseling between the client and therapist. The therapeutic alliance represents the collaborative and affective bond between a therapist and patient (Pinkerton et al., 2009), and it has been shown to affect subsequent treatment improvement (Bergin & Garfield, 2013). A poorer therapeutic alliance can also lead to premature termination by a client (Hatchett, 2004). Follow-up analyses showed that higher wait bothered-waiting time also increased the clients' need for counseling. Thus at the same time a clients' need for counseling has increased, those wait-bothered/longer waiting clients may be more mistrustful of the counseling process, making therapeutic progress potentially more difficult. In addition, those who waited less time for intake were more likely to avoid premature termination of their counseling.

Study Limitations and Future Research
One limitation of this study was not measuring all 15 of the maladaptive schemas using three-items/schema (45-items), as well as not comparing the 75-item YSQ short-form version (Schmidt et al, 1995) to a full 45-item version. The research goal here was more modest in extending prior research working with the initially studied seven schema (Blau et al, 2015b) and showing these seven scales had good test-retest reliabilities and discriminant validity. Clearly, the next step would be to develop a full 45-item version (three items for all 15 schema). Then ideally comparing the 45-item "research" scale to the 75-item short form scale, to test the schema scale correlations between these two different versions.
Another limitation was that only the impact of brief counseling was tested. Longer counseling might have led to a significant decrease for some of the maladaptive schema, including mistrust and abuse. However, brief counseling is typical for most college students (Draper et al., 2002;Ghetie, 2007). It is possible that the increase in mistrust and abuse found was due to outside trauma that flared up during brief counseling (e.g., relationship breakup). There were no standardized procedures to assess the therapeutic methods employed during the brief counseling. There were no also controls for assessing the number of therapists, or the same therapist counseling different respondents over the course of the study. By comparison, Surrette and Shier (2017)'s participant sample consisted of four counselors and 102 counseling service recipients who participated in at least three counseling sessions. In addition, only non-urgent clients were sampled. The loss in client sample size over time was another limitation, although such client loss was consistent with prior research (e.g., Mahon et al., 2015). The relationship of wait time to premature termination, in particular, was found with a very small sample size. One solution to the difficulty of a single UCC collecting sufficient data is for the UCC to become part of a larger research network so that common data collection from multiple UCCs can be aggregated across universities and colleges (Kopta et al., 2014).
All data were self-report and no record-based measures were used. The therapeutic alliance was not formally measured (Pinkerton et al., 2009). The results were found with limited samples of undergraduates at the main campus of a large state-supported Mid-Atlantic urban university. Comparisons to non-urgent counseling samples from other types of universities or colleges (e.g., private, non-urban) are needed to hopefully extend the generalizability of these initial findings.

Conclusion
Study results showed that non-urgent clients who waited longer and were more bothered by this waiting period had their mistrust increase during brief counseling. This could jeopardize the therapeutic alliance which ideally is quickly formed between the therapist and client. Given the increasing demands made on UCCs and their use of the triage system to cope, it is important to make sure that non-urgent clients are not inadvertently "neglected" due to higher priority cases. A UCC needs to have adequate staffing resources to ideally follow-up more quickly with non-urgent clients who may be more bothered by waiting for intake. During triage, when assigning an intake therapist, the triage therapist can assess or ask about the non-urgent client's "waiting capability." Perhaps clients with lower capabilities can be contacted while they wait, and if necessary brought back into walk-in triage so they do not become discouraged and stop the process. With resources, the UCC can also provide alternatives to non-urgent clients who have to wait longer for intake, such as a self-help center or group counseling.
It is important to recognize that a UCC plays an important and useful role in the recruitment, retention and risk management of students for a university (Bishop, 2010). One co-author anecdotally reports that in recent years he and his staff have fielded a greater number and variety of questions from both parents and students about the resources of the counseling center both before and after a commitment is made to the university.