Over the next few weeks, millions of college students will log on to virtual classes and activities after universities closed their campuses in response to the coronavirus pandemic. In an effort to continue supporting students, campus mental health counseling centers are also going virtual, through live video conferencing or phone calls.
With no in-person interaction during counseling sessions, students, counselors, and experts are wondering: How effective will virtual therapy be?
Abby, a Carleton College student who asked that her last name be omitted, met weekly with a counselor on campus during the winter trimester. She liked the privacy the in-person counseling offered, giving the option of not telling family or friends. With online sessions, that’s changed.
“Having teletherapy removes a lot of that confidentiality that I personally really value,” Abby said. After her first online appointment, Abby said her family questioned her about why she had absconded to the basement: “My sister was like ‘oh what are you doing? Why were you down there? That’s so weird.”’ The lack of privacy made her feel “more on edge.”
“There’s always just like the little voice in the back of your head like, ‘oh my god’, someone could walk-in, someone can hear me literally spilling my guts to this person,” said Abby. “I feel like I was self-censoring in a way.”
Abby’s mother walked in during her phone interview with Teen Vogue.
Even if the telehealth platforms themselves are secure, patients having the physical space for a confidential conversation in their house with family members around during the day is one of the main challenges with teletherapy, according to Dr. Jack Turban, resident physician in psychiatry at The Massachusetts General Hospital.
“For many people, therapy is the one place where they can share everything openly, and that just isn’t always possible with family members around,” said Turban. “This is a big problem for LGBTQ youth who may not be out to their families. Many of them will simply forego mental health treatment during this period, as they are too afraid of being outed.”
Despite this, Turban said patients are getting creative: taking appointments in their cars, going for long walks, or going to places like parks to create physical distance from those who may be able to overhear the conversation. But poor weather or living in a place where many people don’t own cars, like major cities, can make this difficult. And, as governments make it increasingly difficult to leave home or enter public space, such options are getting more limited.
Distance is also proving to be a problem in offering mental health services to students who aren’t on campus.
States, not the federal government, manage licensing laws for mental health professionals, meaning under the current rules, a therapist licensed in a state is only allowed to practice in that state (with few exceptions). If their patient goes back home in another state, therapists may not be able to have a session.
But, the rules are in flux. An early March Coronavirus Preparedness congressional bill relaxed “geographic and site restrictions to telehealth in Medicare,” but “did not expand the eligible provider list,” according to analysis by the Center for Connected Health Policy, which is tracking each state’s changes.
“We are in uncharted water,” said Dr. C. Barr Taylor, Professor emeritus of Psychiatry at Stanford University and Research Professor and Director of m2Health at Palo Alto University, who added that some individual states have been separately changing their rules and issuing guidelines. “I would encourage practitioners to check with their state regulatory boards and their counseling services.”
Dr. Sherry Benton is a psychologist and the Founder and Chief Science Officer of TAO Connect, an online platform with both self-help and therapist-assisted components. She said there has been an increased demand for the platform as universities and others scramble to make sure their services are up and running virtually.
Many counselors had never done virtual therapy and “many of them never really imagined that they would be doing it,” said Benton. “It has been quite a challenging process.”
Many university counseling centers have spent the last three weeks ensuring they have HIPAA-compliant video conferencing tools and training therapists, according to Benton.
The two hardest things for therapists to get used to in a virtual session, Benton said, are the difference in the level of non-verbals—such as body language and facial expressions—and level of control they have over crisis management during an in-person appointment.
The nightmare scenario for providers, Benton said, is if their patient shared something extremely emotional or they said they’re starting to have thoughts of suicide, and then the internet connection goes out. “You don’t have the same control and the same ability to make sure that you stay with someone,” said Benton. It’s something “therapists who’ve never done it before really worry about.”
Providers are urged to have points of contact from the very beginning of a telemental health appointment, she said. That means providers and patients should agree to exchange the contact information of someone personal, such as a parent or spouse; someone professional in their home community, such as a primary care physician; and a crisis intervention contact, such as a local crisis line or 911 call.
In addition to non-verbal cues and crisis management, Turban said other elements of treatment are lost when going virtual. For example, part of treatment for an anxiety disorder can involve exposure to in-person situations.
"Many patients with depression have 'behavioral activation plans' that require them to get out of the house and interact with people to combat their depression,” said Turban. “Sadly, these are very difficult in the current situation.”
Going virtual can be more difficult for group therapy programs, and some school counseling centers have decided to temporarily cancel them. Physical environment is crucial to the dynamic of the group, and ultimately the success of the program, said Joi-Michelle Rhodes, senior Social Work student at Oral Roberts University and member of Mental Health America’s Collegiate Mental Health Innovation Council (CMHIC).
Rhodes created and facilitated a group mental health program that spurred from a social work class project. She said the relaxed environment of snacks and games during peer-to-peer interaction led to the creation of the groups’ family-like bond.
“I think that’ll be a lot more difficult to form that kind of natural cohesion and community among people when you’re not physically sharing a space together,” Rhodes said.
The decision to move group programs online has to do with the therapist’s comfort level, said Benton. New Jersey psychotherapist Joanna Kleinman, LCSW has hosted her adult “Dethroning Your Inner Critic” group program in-person and online for several years. She said once the program was offered online, the “intimacy level skyrocketed,” attributing it partly to people’s comfort in their own home.
“There’s a little bit of a barrier between you and the person because you’ve got the distance,” said Kleinman, who added that it is important to familiarize patients with the technology before the meeting.
Generally, students say they have been impressed with the quick pivot by their university counseling centers. Ananya Cleetus, a junior at the University of Illinois Urbana-Champaign and a member of the CMHIC, said not only is the offering of online appointments impressive, but also the published list of other digital, self-help tools.
The computer science major created an app Anemone, which is meant to be a safe space in your phone. The app offers assistance creating crisis plans, coping skills, personal affirmations and a virtual grounding box.
Cleetus said it's important for college students to be proactive in an uncertain time and a new routine: “It’s all about building a support system where you are right now.”
