Extending the Reach of Mental Health Therapy

As the coronavirus pandemic has highlighted the ongoing and exacerbated mental health challenges that students face, it has also opened the door to virtual counseling companies at colleges wanting to meet a serious and growing need to provide services to increasingly anxious and stressed-out students.

Telehealth applications and web platforms marketed specifically to colleges as a way to provide students teletherapy or tele-mental health services have gained renewed attention as campus counseling centers get increased requests for mental health services and conduct significantly more therapy sessions virtually.

In general, these platforms allow students to use their computers or phones for remote appointments with licensed therapists and are either directly funded by colleges or through student health services fees. The teletherapy platforms can cost colleges anywhere from tens of thousands to hundreds of thousands of dollars depending on the services provided and size of the institution.

The pandemic has accelerated this already-emerging market as more workplaces and colleges embrace teletherapy as an alternative to in-person therapy sessions that could pose health risks. The American Psychiatric Association reported that while most of its member clinicians did not use telehealth prior to the pandemic, 85 percent of respondents to a June 2020 membership survey said that they were serving more than three-quarters of their patients through telehealth.

About 52 percent of college counseling center directors said their center used no form of telehealth as of last year, according to a 2019 survey report from the Association of University and College Counseling Center Directors, or AUCCCD. Only 3.4 percent of the directors surveyed said they offered counseling via videoconferencing and 7.6 percent offered it via phone, the report said.

While a growing number of colleges have invested in partnerships with teletherapy companies, there's no consensus among college mental health providers and advocates on whether or not they are a good long-term investment. There are also no standard costs or expectations on how much college administrators can or should spend on teletherapy providers.

Sharon Mitchell, president of the AUCCCD, said in an email that many institutions simply cannot afford to spend more on mental health services due to the economic downturn caused by the pandemic. Some colleges now have budget shortfalls after switching to fully remote instruction last semester or refunding payments to students for unused campus housing and meal plans. Enrollment also declined at some four-year institutions this semester, which means less tuition revenue in addition to diminished housing and meal plan payments.

Teletherapy also may not be a panacea even for institutions that can afford to provide it, or for students who need mental health services.

Kelly Davis, director of peer advocacy supports and services for Mental Health America, a national mental health advocacy organization, said students who've already spent a portion of last semester taking all their courses remotely and doing so this semester may simply be “Zoom fatigued” and not want to do more video calls, even if it is with a therapist.

“It’s a mixed bag on whether they’re any good,” Davis said about the platforms.

She noted in an email that there is not much evidence to support the efficacy of the relatively new teletherapy platforms for colleges, and whether they work or not depends on each student's personal preference.

"It is important that we make sure we are promoting tools that are effective and also honor that students want to receive support in different ways," Davis wrote. "Even when students return to campus, some will want to receive in-person support and some will want to continue with virtual resources."

The various platforms and their proponents say teletherapy services “supplement” the counseling resources already provided by most institutions and can help with persistent challenges, such as long wait times for appointments and too few therapists, that some counseling centers face. Teletherapy company representatives also say their platforms are worth the investment by providing the support students might need to stay in college and do well academically.

Students often criticize long wait times to see on-campus counselors, and some centers struggle with staffing limits and lack funding to hire additional therapists or licensed psychiatrists, who are medical doctors and typically more expensive. Campus counseling centers tend to operate during normal business hours, but a student might only be able to speak to a therapist during evenings or on weekends.

The campus closures that sent students home during the spring, and some closures related to new coronavirus outbreaks this fall, also created another hurdle -- counseling centers quickly shifted to all-virtual services and some encountered difficulties with state licensure regulations preventing a therapist licensed in the state where a college is located from providing care to a student in another state.

Kevin Shollenberger, vice provost for student health and well-being at Johns Hopkins University in Baltimore, said that while many states temporarily exempted health-care providers from this requirement, the terms of the exemptions varied by state. And now that public health orders that offered such exemptions have been lifted in many states, licensure rules are returning to the status quo, he said.

These licensure limitations drove Hopkins to partner last April with TimelyMD, a telehealth company focused on physical and mental health services in higher ed. The university extended the partnership, which includes only teletherapy services, through this fall semester once administrators decided to keep undergraduate instruction fully online, Shollenberger said. The university didn’t “seriously” look into investing in a third-party teletherapy service until the pandemic began to complicate the services it already provided, he said.

“At Hopkins, we did contact all our patients at our counseling center to make sure we were providing continuity of care, but it was limited because of those licenses,” Shollenberger said. “It was hard for students who had developed trust and relationships with counselors.”

TimelyMD currently has about 50 partnerships with colleges and universities across the country, including Emory University, Duke University, Abilene Christian University and the Claremont Colleges, said Alan Dennington, the company’s chief medical officer. It offers two teletherapy applications, or web-based options, that are accessible to students through phone or videoconferencing. One of those options, Talk Now, provides on-demand, 24-7 access to a counselor. The other option is recurring counseling appointments that students can schedule with the same therapist, Dennington said. TimelyMD also recently began offering remote psychiatry and medication management, he said.

The number of institutions TimelyMD services grew from 15 to 50 colleges since the pandemic was declared in March, according to Katie Neal, a spokesperson for the company. And by April, students at all the institutions TimelyMD serves were more frequently using the platform’s mental health services than its medical services, Dennington said.

Neal said in an email that the company's overall telehealth program is typically a "five- or six-figure investment annually" for colleges, depending on factors such as the size of the institution and what specific services are included. The company recently launched a partnership with the Jed Foundation, a youth mental health advocacy and suicide-prevention organization, to offer a discount on TimelyMD’s services to the more than 300 colleges in the JED Campus program, according to a press release about the initiative.

Hopkins students have had 1,030 total appointments with a TimelyMD-provided therapist during the past five months, Shollenberger said. Twenty-two percent of those visits were outside the normal business hours of the university's counseling center, which is a sign that the platform has provided mental health support to students who wouldn't have otherwise gotten it, he said.

“It helps us in reaching a broader group of students that we might not be reaching through our traditional counseling services,” Shollenberger said. “We have been surveying students to get a sense of their experience … I’ve been struck by the number of students who said if we didn’t have TimelyMD in place, they wouldn’t have reached out.”

This idea of “meeting students where they are” was the primary reason that Fairfield University, a private Jesuit institution in Connecticut, began a partnership earlier this month with Uwill, a teletherapy platform that was launched in July, said Jill Buban, vice president of digital strategy and online education. Uwill allows students to connect directly with a licensed counselor from anywhere in the country. Its services do not include psychiatry, but Uwill does allow students to text with their therapist, in addition to video and phone options.

“There was a definite need for schools to have what I felt was a complementary teletherapy solution,” said Michael London, founder and CEO of Uwill and a leading ed-tech entrepreneur. “As far as the pandemic goes, we obviously have more demand than we ever thought we would at this time.”

London estimated that the minimum cost to a college for one year of Uwill's services is about $25,000, or a range of $10 to $20 per student per year. The company is also offering discounted rates to institutions that may be struggling financially and in greater need of the teletherapy service due to the pandemic.

Fairfield is providing Uwill only to its expanding online graduate student population in response to repeated calls from these students -- many of them adult learners who live away from campus. The university was prompted by requests for services by these students and nationwide research that shows graduate students suffer with mental health issues at higher rates than the general population and do not have the same access as undergraduates to college support services, Buban said.

While the pandemic may have created more of a need for the service, Fairfield was considering a teletherapy platform before spring 2020, she said. Buban believes platforms such as Uwill will likely still be needed on campuses beyond the pandemic.

"I think globally in higher education, it’s the right student service to provide from the research," said Buban, who was previously the senior director of research and innovation for the Online Learning Consortium.

Since sending initial information to online graduate students about the new Uwill services three weeks ago, Fairfield has seen about two dozen students use the platform, Buban said. The university can view usage of the platform through an administrative dashboard that doesn't identify students but provides information indicating the reason why they are using the service, if they choose to provide it, she said. So far the reasons have been “anxiety” and “stress,” but administrators will be able to monitor and adjust their strategies for supporting students as their needs change and communicate these findings with faculty members, she said.

Another teletherapy platform, Mantra Health, offers licensed therapists and psychiatrists to students in a select number of states. Ed Gaussen, CEO and co-founder of the company, described the platform as a “virtual extension” to what most college counseling centers already offer, but it also addresses specific barriers to getting support such as a shortage of psychiatrists in the community where the college is located who could prescribe medications.

Davis, of Mental Health America, was diagnosed with bipolar disorder when she was a sophomore at American University in Washington, D.C., in 2012. She noted that teletherapy options that provide a more streamlined referral process could be a solution for students with more severe mental health diagnoses. When Davis sought help, American’s counseling center referred her to a list of off-campus providers and it added multiple steps in the process of getting care, she said.

“It would be OK if you have insurance and you’re at a functioning level where you can deal with calling a bunch of therapists,” said Davis, who graduated in 2015.

Mantra Health's platform addresses these challenges by allowing counseling center staff and the off-campus provider to communicate through its platform and monitor the student, Gaussen said. Each partnership with an institution is built for the college’s needs; the college selects hours that it wants additional mental health care providers available and what type of providers they would be, he said.

“All campuses at times have to refer to community providers when the demand outstrips the resources on campus,” said Harry Rockland-Miller, a clinical psychologist who directed the Center for Counseling and Psychological Health at the University of Massachusetts at Amherst for more than 20 years and a medical advisory board member for Mantra Health. “There’s always going to be that, and psychiatry is like that in particular. If you’re a student and it takes six to eight weeks to get a provider, how much of the semester has already passed?”

Rockland-Miller, and other current counseling directors that have started to work with these companies, generally agree that the new options for remote services cannot fully replace the benefits of in-person counseling.

Shollenberger said he views teletherapy services as being “in partnership” with the counseling resources campuses already provide, not a total replacement. He anticipates more colleges will begin to have both in-person and teletherapy options available to students at the same time.

“Over a telemedicine platform, you don’t get the same nuances around body language … that you get talking to someone during a counseling session,” he said. “But if we’re reaching a broader group of students that need help, it’s a very useful platform.”