Sandy Welsh and Cheryl Regehr explain how the University of Toronto used leadership, partnerships, service tools and research to revolutionise its provision without recruiting vast armies of counsellors, while Joyce Jacobsen considers how far institutions should go to help at-risk students
Just over a decade ago, the rising number of students declaring mental health difficulties was described in a University Affairs editorial as a “tsunami” that threatened to overwhelm university support services.
Since then, universities across the world have invested huge sums to address this growing challenge, but it has often not been enough to cope with growing levels of emotional distress and ever-increasing requests for help. In Canada, for example, many more students reported feeling loneliness, sadness, depression or the sense of being overwhelmed in 2019 compared with 2013, according to data from the National College Health Assessment. Strikingly, some 53 per cent of female students and 37 per cent of male students also tried to access mental health services in 2019, this study found.
The five-year period up to 2018 also brought challenges for our mental health services at the University of Toronto, whose three urban campuses, containing a combined 97,000 students, each provide their own frontline services. Similar to other higher education students across Canada and worldwide, our students reported struggling with mental health and well-being. Despite increased investments in this area, the university (Canada’s largest) was unable to meet the demand.
The mismatch between services offered and student needs and expectations reached an apex in 2018. During the 2017-18 academic year, the university provided 31,300 counselling sessions, up 30 per cent from four years earlier. Nonetheless, demand continued to exceed available services. Our inability to meet requests for help related to several challenges not unique to our university clinics: long waiting times for a first counselling appointment, a confusing array of services, after-hours demand, a multilingual clientele and stigma about seeking mental health supports.
What also became clear was the management of student transitions from hospital back to campus life and the need both for better coordination among our three campuses and for more evidence-based care. At that time, the university community also suffered devastating tragedies related to mental health. Combined with the increasing demand for services, this led to student calls for the university to do better on this front.
The solution to improving mental health services and access could not be provided by our health centres alone, however. Even if we had the funding to do so, simply adding more counsellors to a confusing model of care that was backlogged with waitlists would not bring about the change we needed.
Instead, the university decided to redesign our student mental health services. This transformation encompassed the whole university – undergraduates and postgraduates, international and domestic students, academic divisions, student life portfolios, campus safety protocols, and our online navigational tools and supports.
It is not a trivial task to implement large-scale change at a large university, especially in an area as sensitive and critical as student mental health. We needed to ensure we had both a mandate for change and the engagement of the entire university community.
The first phase of our redesign process was the creation of a presidential and provostial task force on student mental health. This group was tasked with providing recommendations in four key areas: mental health service delivery; coordination of student supports; partnerships with community-based organisations and hospitals; and physical spaces. The task force consulted broadly across our three campuses, building consensus and buy-in throughout by asking students about our draft recommendations. Our eventual proposals reflected what we heard from our students, staff and faculty, giving us a strong mandate for the redesign process.
Previous task forces had taught us that leaving the implementation of major reforms to already busy senior administrators was not the most successful approach. In this case, the redesign team – led by a provostial adviser and including external consultants – was empowered to begin work immediately, allowing us to preserve momentum generated during our consultation and grow support for systemic change.
The team focused on four pathways to system transformation: leadership, partnerships, service tools and research. Through these pathways, we aimed to make significant and enduring changes with the goal of improving access and outcomes in mental health. Key changes included same-day counselling appointments at our health clinics, improved signposting of available services and the establishment of a single electronic medical record for students at all three clinics. We also built partnerships with local hospitals and mental health experts while stepping up research into student mental health at our institution.
Over the past four years, we have transformed our student mental health services. We have trained all mental health service providers on our single-session and follow-up model of care, and our appointment booking system was overhauled to include access to a mental health chatbot NAVI, as well as in-person resources.
The launch of same-day counselling across our three campuses virtually eliminated waitlists and we can now provide timely access to mental health care to students, whether they are dealing with stress, loneliness and relationship issues or more complex mental health needs. The adoption of a single electronic medical record for the three clinics has improved access to our services, patient safety, ease of patient referrals and more efficient use of our services. It has also allowed us to capture improved data to inform decision-making. For example, we are now better able to track high-demand months, which has helped us to better manage staffing during these surge periods.
We have also introduced a 24-hour multilingual counselling service that allows students to access counselling after hours and in their native languages. Use of the service, as well as of NAVI, tends to occur in the late afternoon, evenings and on weekends – times that are typically outside of normal clinic hours, so these tools have expanded our service offerings and allow us to address students’ needs in a timely manner.
Between 2019-20 and 2022-23, mental health visits and interactions rose by 16 per cent across our three health centres, with 2023-24 projections indicating we will see another 7 per cent increase. The move to single-session counselling has meant that we are able to see more students and make better use of our clinical resources and still offer follow-up appointments for those who need additional care. If you include NAVI and our 24-hour service, we have more than doubled our mental health response capacity since 2019.
We have also taken care to maintain high-quality care. Our latest survey found that most students rated their general satisfaction as four out of five, with levels highest among those who used in-person rather than phone appointments. Our investment in a tri-campus senior mental health leader and healthcare data analytics support has led to a more coordinated survey across our three campuses, thus reducing the assessment burden on our already busy clinical staff.
Helping students who are returning or coming to campus following hospitalisation has been particularly successful. Under the university’s Navigator scheme, set up in partnership with Toronto’s Centre for Addiction and Mental Health, Canada’s largest mental health teaching hospital, those transitioning to campus are connected to on-campus and community-based resources. Providing this support reduces the risk of recurrent crisis and 86 per cent of those in the first year of the Navigator scheme did not return to the emergency department in the following six months.
Thanks to modest investment in new targeted resources, better use of existing resources and the innovative use of new tools and collaborative processes, our operating costs for student mental health have stayed relatively stable in the past three years, even with the added costs of developing partnerships with hospitals and other organisations.
As our redesign initiatives mature, we will evaluate and build on our successful programmes. This is a continuous process and the tide of student requests for help shows little sign of falling. But changing how we operate has been crucial to ensuring that it will not overwhelm us.
Sandy Welsh is vice-provost (students) at the University of Toronto, where Cheryl Regehr was vice-president and provost from 2013 to 2022 and is now professor of social work.
Are universities legally responsible for their students’ mental health?
Do universities have an in loco parentis duty of care to look after their students? And, if so, is it a binding legal responsibility that requires them to minimise risks to its charges – including potential threats to students’ mental well-being?
Those fraught and contested legal issues are among those that former Wesleyan University provost Joyce Jacobsen has wrestled with in her new book All The Campus Lawyers, which charts the “lawyerization of higher education” in the US and beyond since the 1960s. Written with Lou Guard, an adjunct professor at Cornell Law School, the book describes the staggering range of legal issues that those leading US universities now face, with students, staff, applicants and other parties ready to lawyer up on all manner of issues, including admissions refusals, sex discrimination cases, free-speech challenges and Covid-related compensation.
But most compelling to Jacobsen, also a former president of Hobart and William Smith Colleges in upstate New York, was the emerging law surrounding student welfare. “It’s possibly our most important chapter,” reflects Jacobsen, now a professor of economics at the private liberal arts institution near Syracuse, where Guard is chief legal officer.
“We’ve seen the pendulum swing back and forth on this issue,” she reflects. “Until the 1960s, women at co-ed institutions were highly supervised, for instance, and would need to check in and out of college when they went on a date. When I was at college, however, there were no checks at all and everything was very easy-going. But things have now swung back the other way,” says Jacobsen.
Several landmark cases may explain why this has happened. Jacobsen’s book, published by Harvard University Press, recounts a case brought against Delaware Valley College in 1979 by a student who was paralysed in a car accident after attending a sophomore picnic where alcohol was served. A faculty member had helped organise the event and signed off payment for seven half-kegs of beer for the 75 guests, but the legal action was rejected by an appeal court judge, who unsentimentally noted that the “modern college student [is] an adult, not a child of tender years”. Bradshaw v Rawlings became emblematic of a “bystander era”, in which institutions often washed their hands of inconvenient happenings on and off campus, including abusive hazing rituals and sexual assaults.
Mental health issues came clearly into view with a 2009 case filed by the father of Han Nguyen, a 25-year-old graduate student who died by suicide while pursuing a PhD at MIT’s Sloan School of Management. A judge affirmed that MIT had no duty to prevent Nguyen from dying by suicide but, in 2018, the Massachusetts supreme court ruled that when an institution knows about a suicide attempt by a student, “a special relationship and a corresponding duty to take reasonable measures to prevent suicide may be created between a university and its student”.
In effect, “a future court could…impose a duty on an institution to prevent a student from committing suicide,” the book explains. Case law means that this potential ruling is currently limited to Massachusetts, although similar actions have been brought with varying degrees of success elsewhere in the US.
While Jacobsen and Guard are clear that universities “cannot be bystanders” and there is an “expanding willingness of courts to find a legal duty for an institution”, efforts to reduce liability will also come at a cost, they say. Institutions may start “overspending on damage control” and “[lose] sight of their mission” as educational institutions that have traditionally challenged students and pushed some out of their comfort zones.
“Should we have trigger warnings ahead of difficult discussions, or trigger warnings for particular professors?” wonders Jacobsen. “Students cannot go through life being protected from potentially upsetting things. That’s a high legal standard to hold universities to when they won’t get that in normal life,” she says.
If universities are held liable for failing to prevent self-harm by students, do they need to start pushing for more information from incoming freshmen? “We don’t collect that kind of information, and students might push back if we did, even though we might ultimately be liable in this area,” reflects Jacobsen on the “clash between students’ right to privacy and tort law issues [on liability]”.
With institutions on the hook if they know about a student’s mental health, however, it might be more legally convenient if they do not pry too much – even if the results of such wilful ignorance are devastating for students, families and ultimately institutions. And institutional culpability becomes even trickier on potentially riskier off-campus experiences provided by universities but not directly within their control, such as year-abroad programmes.
Ironically, when universities were firmly viewed as having in loco parentis powers, it proved a barrier to any legal action against institutions as “no child could sue their parents”, the book observes. Things have changed, and the “caretaker role of universities is not receding”, it concludes. Yet Jacobsen is also cognisant of what higher education risks losing as it assumes this role.
