On March 11 last year, the same day that the World Health Organization declared COVID-19 a global pandemic, York University student Sarah Pope* met with her therapist on campus.
“At first, I was one of those people who legitimately thought we’d be locked down for two weeks, so I wasn’t super worried about getting back to counselling,” says Ms. Pope, who had been attending therapy for months. “But after a couple weeks, I was very worried about how I was going to access counselling services because York didn’t have a plan in place.”
In 2019, only five percent of Canadian postsecondary institutions offered online therapy sessions, according to a survey from the Canadian Association of Colleges and University Student Services (CACUSS). A follow-up survey in 2020 revealed that within three weeks of campus shut-downs, 90 percent of postsecondary institutions pivoted to offer remote mental-health services. CACUSS researchers noted that under normal circumstances, this shift would have taken years to execute.
Many university counselling centres started offering video and telephone services for the first time. Campus wellness centres posted pandemic-specific material to their websites, hosted webinars on managing stress and anxiety, and held events like virtual pet therapy and online meditation classes. Some offered text-message based therapy. This change came as the pandemic exacerbated the mental health struggles challenging postsecondary students, a demographic that was already struggling.
Experts compared the sudden shift by Canadian universities to creating long-overdue virtual mental-health services and online infrastructure in the midst of a global mental-health crisis to building a plane while flying. The rapid transition has come with its challenges in the form of technology, confidentiality, funding and how to adapt professional care specifically for the virtual space.
“Honestly, we just entered into this online world,” says Tayyab Rashid, a clinical psychologist at the University of Toronto Scarborough and a co-author of the CACUSS survey. “We still have to figure out lots of issues.”
Technology: the solution and the problem
When it became clear that the pandemic wouldn’t be short-lived, Ms. Pope and her therapist continued sessions by phone until York got its video counselling platform up and running. Signing on from home may seem convenient, but Ms. Pope says the first few minutes of each session are dedicated to troubleshooting the technology.
Meghan Brown*, a third-year student at Memorial University, experiences similar issues while accessing her institution’s online therapy services. Her technical difficulties are due largely to an unstable WiFi connection that often requires her to turn her camera off to conserve bandwidth.
“There’s a lot of issues around doing therapy and video conferencing that people really need to think through.”
At Ryerson University, second-year journalism student Charlize Alcaraz has a great relationship with her therapist, whom she has been seeing since 2019. But sometimes during their Zoom sessions the audio cuts out and Ms. Alcaraz, who has anxiety, finds it hard to ask her therapist to repeat herself. Where in-person therapy felt like being able to vent to a friend, Ms. Alcaraz says Zoom therapy feels more formal.
These tech issues can be more than frustrating, they can be dangerous, explains clinical psychologist Sherry Benton, former director of counselling at the University of Florida and founder of Therapy Assistance Online (TAO) Connect, an online mental-health resource available to students at 28 Canadian postsecondary institutions. As Dr. Benton’s company helps universities transition to online therapy, she has noted that it’s not just students who are struggling with the new format.
“There’s a lot of issues around doing therapy and video conferencing that people really need to think through,” says Dr. Benton. Virtual therapy, she explains, raises entirely new questions like: What happens if the call or connection drops while a student is in crisis?
Since professional training for remote therapy varies by institution, Canadian practitioners will have different answers to that question. During one training session, Dr. Rashid recalls asking the instructor how to respond if a student has a panic attack during a virtual appointment. The trainer recommended treating the situation the same way he would in person.
“My jaw dropped,” Dr. Rashid says.
In person, a counsellor can notice subtle signs, like queasiness or increased heat rate, without relying on the client to verbalize how they’re feeling. In response, the counsellor might guide the student through deep breathing, which Dr. Rashid notes is easier to demonstrate in person, as is maintaining eye contact. He explains that in virtual therapy, responding to these situations is still possible, but the approach needs to be adapted. He said he plans ahead for crisis situations in collaboration with the student to establish a clear procedure in the case of a crisis – such as a panic attack. The 2020 CACUSS report also recommends that counsellors confirm a student’s place of residence at the beginning of each session and ask them to download the keep.meSAFE app so they can connect to local crisis resources.
While there are national and provincial training resources available to mental-health practitioners, the CACUSS survey indicates that most professional development for remote counselling is self-initiated. That was certainly the case at the University of Calgary where, prior to the pandemic, none of the counselling staff had ever provided virtual health care.
“We were doing some really quick online learning in terms of how we practice in order to provide the best quality of service that we can within a virtual environment” says Jennifer Thannhauser, associate director of counselling at the university.
Adapting body language cues for online therapy was a significant challenge that had staff members sharing resources on everything from reading facial expressions through video to making eye contact while on camera. For instance, since Dr. Thannhauser can’t see a student bouncing their leg or fidgeting on video, she started encouraging students to articulate those physical experiences and reactions so that she has more information about what the student is going through. Dr. Thannhauser adds that her team uses frequent feedback from students to inform their practices, a co-design approach that several experts have called essential for improving university services.
Privacy not guaranteed
With counselling sessions being conducted from home, both participants have less control over their environments and, despite best intentions, patient confidentiality cannot be guaranteed. The setup can add stress to an already stressful situation.
Ms. Brown’s parents don’t know she’s in counselling and she tries to schedule her sessions for when her family is out of the house – a tall order depending on current pandemic restrictions. Ms. Pope, who is also living with her parents, wears headphones and lowers her voice when speaking with her therapist since some of their discussions focus on her feelings of isolation or anxiety around her family.
These situations are familiar to Dr. Rashid, who has worked with many students whose living situations mean they cannot discuss certain issues, such as past trauma or sexuality (a particular concern for LGBTQ+ students who are not out to their families). In an attempt to create an ad hoc safe space, he’s conducted remote therapy sessions with students on their balconies or in their closets. And some students have told him they can only do therapy via text, a tool that not all universities allow due to confidentiality issues.
In response to concerns around privacy, the University of Ottawa equipped a room on campus for students participating in virtual therapy. Though some local students have used the room, Rachelle Clark, the university’s director of wellness and recreation, recognizes that it’s not much help during lockdowns, or for students outside of Ottawa.
Helping students who have moved out of province provides an additional challenge for universities since mental-health professionals are typically only able to provide services within the province where they are registered. When campuses closed, many universities were no longer able to provide counselling to students who left their jurisdiction. That’s why Ms. Pope hasn’t officially told York’s counselling centre that she has been living in New Brunswick with her parents, though she has mentioned it to her therapist. “This is supposed to be temporary and I don’t want to jeopardize [my] access for being away for a couple of months,” she says.
While some provinces allow practitioners to get temporary licenses to provide mental-health care for out-of-province students, Dr. Thannhauser says the process “continues to be a significant barrier to providing remote mental-health services to our student body.” Vannesa Peynenburg, a University of Regina PhD student researching internet-delivered therapy for postsecondary students, adds that situations like Ms. Pope’s create an ethical dilemma for clinicians: they risk disciplinary action from their regulatory body for providing care outside of their jurisdictions, but they also have a duty to help their patients and to honour their right to confidentiality while in session.
Funding, access and choice
Funding is also a concern for postsecondary institutions when it comes to mental-health supports. While there are sophisticated online platforms available to purchase or license, Dr. Rashid explains that these services are too costly for some colleges and universities. Students’ access to a variety of in-house services ultimately becomes an issue of have and have-not institutions, he says.
Both the private and public sectors have attempted to bridge some of these funding gaps. Last year, the province of Quebec promised $10 million to fund mental-health services for college and university students waiting on treatment, and later hosted consultations for an action plan on student mental health. This year, Bell launched a $2.5-million fund to help colleges and universities implement the new National Standard of Canada for Mental Health and Well-Being for Post-Secondary Students, the first of its kind in the world. In February, the Ontario government pledged $7 million to increase mental-health and addiction services for postsecondary students. (It is not yet clear how those funds will be distributed.)
In the meantime, institutions that can’t afford upgrades have gotten creative, says Lina Di Genova, director of strategy, assessment and evaluation in student services at McGill University and co-author of the CACUSS survey. Rather than the usual 50-minute appointments, she says some counselling teams have opted for short check-ins through secure online portals or phone calls in order to maintain continuity of care. Many have also leaned more heavily on virtual peer-to-peer supports, like CAMH’s COVID-19 discussion forum and other existing resources from third-party providers such as TAO, keep.meSAFE, Jack.org and provincially-funded tools for postsecondary students including Saskatchewan’s UniWellbeing, British Columbia’s Here2Talk, Alberta’s text-based Text4Hope, Nova Scotia’s HealthMindsNS and Good2Talk, a phone service for students in Ontario and N.S.
Dr. Thannhauser says that while tons of new services, apps and websites have popped up during the pandemic, not all tools are worth the investment. “One of the pieces that slowed us down in terms of enhancing or adding more virtual services is that it is so hard to figure out which services truly are legitimate and also meet the privacy needs of our institution,” she says.
Filtering through all the options also presents a barrier for users. Patrice Cammarano, founder and co-president of St. Thomas University’s mental health society, says there’s no doubt that students are feeling lonelier and more stressed than previous years, however “the overlapping resources makes it hard to know who to contact.” Perhaps that is one of the reasons why, despite a marked increase in rates of depressive symptoms and anxiety among postsecondary students, CACUSS research suggests university counselling centres have largely seen a decline in appointments.
While most university counselling centres were able to pivot quickly during the pandemic, Dr. Rashid worries about complacency now that the online programs exist. He says he hopes universities will keep up the momentum behind these new offerings, and that they will continue to evaluate how effectively they respond to students’ diverse needs – particularly since students may face new issues after living through lockdowns.
It’s been a year since the pandemic pushed Ms. Pope into online counselling at York and “it’s become a chore,” she says. She recently changed her appointments from weekly to biweekly because they were feeling overwhelming. Ms. Brown recognizes that online mental health services are not ideal, but is thankful they’re available. She had previously considered trying therapy to better manage her anxiety, but only made an appointment after Memorial’s counselling centre began offering online services. It made reaching out for help feel doable because “it could just be a phone call,” she says. As universities prepare for the return to on campus services, Ms. Brown says she likes the idea of being able to meet a counsellor online before agreeing to an in-person session.
Ms. Clark at U of Ottawa predicts we’ll see more of these types of hybrid models in the future. After seeing universities go from few or no online counselling tools to only offering remote services, she says that going forward, “we need to find ways to engage with students that are based on what they want, what they need, and in a way that they choose.” After all, postsecondary institutions might still be navigating the world of online mental-health supports, but one thing is clear: these services are here to stay.
*Names have been changed to protect privacy.
The professional colleges, generally, have stated formally that they do not intend to fully enforce jurisdiction in the shutdown era, recognizing that a line on a map is a poor justification to deprive people of much-needed services & continuity of service. Maybe this will be much-needed impetus to create a national licence?? North American jurisdictions already have a singular competency exam…