Before COVID-19 came to campus, mental health treatment was an in-person affair. Fewer than 8% of colleges offered telephone therapy in 2019, and only 3% offered video, a survey of campus counseling center directors worldwide showed.
But when the coronavirus forced classes nationwide to go online in March 2020, it did the same to campus counseling.
At first, the shift was challenging. State licensing requirements made it difficult for colleges to treat out-of-state students, while some students lacked the privacy or technology to attend counseling remotely. Some students and counselors also found the online format awkward.
But now, more than a year into a pandemic that has upended much of higher education, college administrators say they've come to see the advantages of online counseling and plan to preserve it as an option post-pandemic.
"It's allowed us to reach a different population," said Brian Mitra, dean of student affairs at Kingsborough Community College, in Brooklyn, New York. The school's shift to virtual counseling, along with expanded evening hours, has enabled students who aren't comfortable meeting with a therapist in person or who work during the daytime to meet with counselors online, he said.
The global health crisis is reshaping campus mental healthcare in other ways, too. With many students still studying remotely, colleges have had to rely on faculty to recognize and respond to signs of student mental distress. To better prepare them for this role, many colleges have added or expanded training to help faculty members identify students who are struggling and connect them with counselors.
"The focus has really been on educating the faculty, because they're often the only people that students are interacting with," said Nance Roy, chief clinical officer for the Jed Foundation, a nonprofit focused on emotional health and suicide prevention in teens and young adults.
Adapting to the virtual world
College counseling centers worldwide conducted nearly 70 times more video sessions from mid-March 2020 to June 2020 than were held on average over the previous eight and a half months, according to a survey from the Association for University and College Counseling Center Directors. Over that timeframe, they averaged 1,165 video sessions.
Still, colleges struggled to serve some students in those early months, particularly those who were living in another state or abroad. Though some states temporarily relaxed requirements that providers be licensed in their state to treat students living there, they each decided how long and for whom to waive the rules, said Barry Schreier, communications chair of the association.
Keeping up with the patchwork of rules "became a master class in state and international law," said Schreier, who heads up the counseling center at the University of Iowa.
To support students in states and countries off-limits to them, counseling center leaders created modules, videos and guides that could be accessed anywhere and built referral lists of local clinicians, Schreier said.
Some wealthier and smaller colleges, including Grinnell, in Iowa, subscribed to virtual care networks, so that even uninsured students could find providers who spoke their native languages or shared their racial or ethnic identities.
"That kept me up at night — how in the world can we provide support for students from out of state who don't have insurance?" said Terry Mason, Grinnell's dean for health and wellness.
By contracting with The Virtual Care Group, a company based in Los Angeles, the college could offer students unlimited access to medical and mental health care, 24 hours a day, for less than the cost of hiring another campus counselor, he said. Mason expects requests for counseling to spike as more students return to campus in the fall due to the trauma associated with the pandemic, and he has submitted a budget request to continue the service for the upcoming academic year. He declined to share the contract costs.
"I would love not to have to put students on the waitlist," he said. "And there are some students who aren't comfortable going to an on-campus service — who (mistakenly) think it will impact their ability to graduate, who don't want their parents to know, or who want to go in the evening, after classes."
"It's allowed us to reach a different population."
Dean of student affairs, Kingsborough Community College
On many campuses, demand for counseling services has outstripped supply for years, and the stress and isolation students have experienced over the past year is expected to widen that gap. Close to half of students surveyed in this past fall's Healthy Minds Study screened positive for clinically significant symptoms of depression and/or anxiety – the highest prevalence of any term since the annual survey's launch in 2007.
Kevin Kruger, the president of NASPA-Student Affairs Administrators in Higher Education, said he's seen virtual care providers emerge during the pandemic specifically for higher education institutions. Some of them are adapting services from companies' employee assistance programs — which help workers resolve mental health issues and personal problems — to the campus context.
Meanwhile, companies that existed before the pandemic have seen business boom.
TimelyMD, which provides immediate and scheduled counseling with licensed providers in all 50 states, now serves 10 times as many students as it did in early 2020, and grew its client base from 15 campuses to 90, said Katie Neal, a company spokesperson. Uwill, another provider, has tripled its client base from 10 to 30 colleges since the start of the pandemic and gone from 500 sessions a month to 5,000, said Michael London, its founder and CEO.
"Campus counseling centers are great, but it's not possible for them to hire in accordance with need," London said. "We want to be an extension of what schools are doing."
But Victor Schwartz, a clinical psychiatry professor at New York University and a college consultant for counseling centers, cautions schools against hiring outside providers to meet rising demand.
"The problem is, the people you're offloading services to don't understand college students in general, and don't understand the dynamics of your specific campus," Schwartz said.
"The problem is, the people you're offloading services to don't understand college students in general, and don't understand the dynamics of your specific campus."
Clinical psychiatry professor, New York University
Besides, he added, most companies base their pricing on the number of students served, making them cost-prohibitive for larger schools. (Though some companies offer discounts based on volume).
Harvey Goldstein, director of Virtual Care Group, declined to say how much colleges pay for its services, but TimelyMD and Uwill officials cited prices in the five- to six-figure range.
Teletherapy has its drawbacks. Nonverbal signals can be misconstrued or missed by therapists, and not everyone has reliable internet access. But studies have shown video therapy to be as effective as in-person sessions, and officials say students want to keep it.
It is convenient and expands access to counseling, Kruger said. "The new normal will be a mix of in-person and virtual counseling," he said.
A shared responsibility
The pandemic has also underscored that student well-being is no longer the sole preserve of campus counseling — it has become a campuswide responsibility.
Even before the health crisis, more colleges were offering mental health "gatekeeper training" to help faculty and staff identify and support students struggling with mental health issues, particularly those at risk of suicide. Some faculty had begun adding mental health statements to their course syllabi, encouraging students to reach out if they needed help and providing contact info for campus counseling services.
When campuses closed and classes moved online, faculty became mental health first-responders, according to a recent poll. The survey, which queried nearly 1,700 faculty at 12 colleges in early 2021, found that roughly 80% had conducted one-on-one phone, video or email conversations with students in the past year about mental health and wellness.
"Faculty's involvement in student mental health has become increasingly important given their proximity to and relationship with students, especially in remote learning environments," said Sarah Ketchen Lipson, the survey's lead researcher and a public health professor at Boston University.
Yet the findings also showed that many faculty still don't feel comfortable in this role. Only half said they had a good idea of how to recognize that a student is in emotional or mental distress, and around one-quarter reported that they'd taken mental health gatekeeper training. More than 60% said such training should be mandatory for all faculty.
Zoe Ragouzeos, executive director of counseling and wellness services at New York University, suggested during a webinar about the survey that colleges find ways to incentivize gatekeeper training, rather than require it.
"Mandatory does take on this four-letter-word idea," Ragouzeos said.
Roy, of the Jed Foundation, said training in recognizing and referring students experiencing mental health challenges should not be limited to faculty, but rather should be offered to everyone on campus.
"We're not asking people to be therapists. We're asking them to be empathic and compassionate human beings," she said. "Campus counseling is one small cog in a large wheel."