When Sherry Benton started her teletherapy company, TAO Connect, six years ago, college counseling-center directors had two reactions: “Benton, you’ve lost your mind,” or “Benton, you’re ruining the field.”
But Benton had directed the counseling center at the University of Florida, where she was also a professor of psychology. She had learned firsthand, she says, that there would never be enough hires to satisfy the demand for counseling.
“I had one of the biggest budgets in the country, and I couldn’t meet the need,” she says. She realized that it was crucial for colleges to find more ways to help more people.
Since then, demand has become even greater, and counseling directors have turned to a range of triage and treatment options. The idea of “stepped care” — treatment ranging in time, platform, and intensity depending on circumstances — is gaining in popularity. As a result, wariness toward teletherapy has softened considerably since Benton founded her company.
By chat, voice, or video, with self-help modules or live-streamed therapists, for onetime crisis consultation or regular treatment, students are finding solace and support on their laptops and smartphones. And companies are entering the increasingly competitive market to serve those students.
Eight years ago, according to an annual survey conducted by the Association for University and College Counseling Center Directors, teletherapy was almost nonexistent on campuses. By 2017-18 (the most recent figures available), 59.2 percent of counseling centers offered some kind of teletherapy. More than half of that service was for screening to see how acute a student’s needs were, but close to 25 percent was for therapeutic interactions. And practitioners say the percentage is growing.
Advocates say that while teletherapy might not be as effective as face-to-face therapy, it can be a helpful supplement, a steppingstone, or an alternative for students who won’t visit the counseling center because they can’t get an appointment quickly enough, or for reasons of stigma, geography, schedule, or disability.
To be sure, some experts are still skeptical, among them Joshua Altman, associate director of the Student Counseling Center at Adelphi University. He said he is contacted weekly by teletherapy vendors but has so far resisted them. He’s no Luddite — he agrees that mental-health care is due for a digital disruption — but he awaits solid evidence that it works: independent longitudinal studies as opposed to quick ones conducted by the teletherapy companies themselves.
He understands that demand can outpace resources and is open to a small pilot partnership with a teletherapy company. But effective therapy, he says, often relies on having clients in front of you, being able to see their mannerisms, reactions, expressions. In the highest-risk situations, he and his colleagues ask students whether they have had thoughts of killing themselves.
“We ask that question multiple times a week with students,” Altman says, “and I need to be able to see their reactions outside of what they say. A change in breathing, their eyes looking different, any reaction that they can continue to explore. To be in the room with them is essential.” When necessary, he does the occasional phone session, but only with clients he knows well and has seen often in person.
The most important factor in successful treatment is the relationship between client and therapist. Those in the field call it “the therapeutic alliance,” and whether it can be created over the phone, Altman says, “is a big question.”
There are trade-offs, acknowledges Peter Cornish. An honorary research professor of psychology at Memorial University, in Newfoundland, he will become director of counseling and psychological services at the University of California at Berkeley in April. He’s an authority on “stepped care” — treatment that is tailored in degree and type to the client’s situation.
You lose some connection not being in the room, but you gain other things.
“You lose some connection not being in the room,” he says, “but you gain other things. The face is right in front of you. You see every tear or expression.”
Some clients might feel more comfortable at a physical remove. If that sounds strange, consider that Morneau Shepell, which provides tele-mental-health services for New York University, the University of Denver, and other institutions, has found that three-quarters of college students prefer the option of in-the-moment mental-health support by text chat to regular support by telephone or video from a dedicated clinician.
End-of-session surveys at NYU show that 87 percent of its chat teletherapy users have not previously used the university’s support services. Zoe Ragouzeos, executive director of NYU’s counseling and wellness services, says chat therapy is an on-ramp to other mental-wellness offerings. Since the telechat therapy was launched, in August 2018, it has handled 4,200 clinical cases and significantly more contacts, she says. It complements the 62 hours of face-to-face drop-in hours available; the 9-a.m.-to-9-p.m. crisis hotline, which handled 27,000 calls last year; and an after-hours hotline that fills the gap. Telechat users who offer their names receive follow-ups to check in and tell them about other available wellness services.
Wellness directors evaluate a service first and foremost on the basis of its clinical effectiveness, Ragouzeos says. Teletherapy will not be the answer for complicated, continuing clinical issues like bipolar disorder, she says. In addition, there can be internet and other technical hiccups, and clinicians and college lawyers alike worry about hacking and privacy issues. But, she says, if teletherapy helps overcome physical challenges, social anxiety, inconvenience, or a lack of diverse community-therapist options, those are all obvious pluses.
“It’s akin to FaceTiming a family member or a friend,” says a college sophomore in Boston who has had sessions with her longtime therapist both in person and online via Zoom. “It’s still them. You get the feeling of caring and support.”
On the other hand, besides occasional screen freezes and other technological glitches, there’s what the student calls “a third space … that’s not there when you’re in the same room with them.” Even so, teletherapy is “such a priceless resource,” she says.
“There is some value in the spontaneous ability to reach out to somebody when you’re in crisis,” the student says of 24/7 on-demand services. For treatment of her anxiety, obsessive-compulsive tendencies, and depression, however, “I value it more as a maintenance sort of thing, so I like its being weekly.”
She can see how “having constant access to therapists is helpful to some, like someone with bipolar disorder with a manic episode.” But for her, she says, the weekly schedule is “sort of a practice in self-soothing … using strategies my therapist has taught me to help myself through situations.”
Robin Wilbourn Lee, who directs the Center for Counseling and Psychological Services at Middle Tennessee State University, says a teletherapy option would have been helpful for a student who uses a wheelchair and had to take two buses to get to appointments there. It would be helpful too for clients in remote locations. A rural county recently inquired about the availability of therapists among Lee’s graduate counseling trainees.
When Peter Cornish gave talks on stepped care at professional conferences five years ago, he’d get a handful of listeners. Now it’s standing-room only as overwhelmed counseling directors seek solutions to seemingly unmeetable demand for their services.
The good news, says Cornish, is that a generation of students has been encouraged to unabashedly seek help when they need it — and they do. The problem is that counseling centers have traditionally provided just one kind of help — the 50-minute, face-to-face, repeated appointment — when what’s really needed might be a short one-time intervention in whatever form.
Short-term teletherapy can be part of that mix. Younger therapists tend to be more comfortable with that than older ones, Cornish says, but two-day video-therapy training in groups, with regular follow-ups, have had success.
Here are just a few of the providers that have recently entered the field:
- Some colleges want students to work with therapists near the campus, whatever the medium. The teletherapy company BetterMynd, a start-up begun several years ago, connects students at Colgate University, Hamilton College, and elsewhere with therapists in each campus’s vicinity whom college personnel know and respect. The focus, says Cody Semrau, BetterMynd’s CEO, is on local networks, but more convenient, immediate, and with a roster more diverse than what campus counseling centers might be able to offer.
- Other colleges want wider options. Illinois-based META offers students an array of therapists nationwide, like a therapeutic Amazon. It makes sure only licensed therapists are listed, but it’s not a medical company and doesn’t endorse them. META is a subsidiary of Ceannate, which focused on student-loan servicing, debt collection, and financial-literacy programs before its leaders recognized, in 2017, the market for web-based mental-health services, too. Balaji (Raj) Rajan, CEO of Ceannate and META, said he is an immigrant and hopes that META will help students of color and others who, for cultural or family reasons, would otherwise be wary of seeking help.
- San Francisco-based Brightside is a year-old telehealth company specializing in the treatment of depression and anxiety disorders. It is in contract talks with colleges, says Mimi Winsberg, a psychiatrist who is Brightside’s chief medical officer. The company has already treated hundreds of college students, she says. Brightside connects clients with psychiatrists and, through a partnership with a company called Truepill, delivers medication to clients’ doorsteps. Rather than refer severe cases elsewhere, it engages them online. More than 80 percent of its clients begin treatment with moderately severe or severe depression, 52 percent with suicidal ideation, Brightside says. Treatments include on-demand video sessions with affiliated doctors, medication, and self-guided modules with exercises tailored to various diagnoses, symptoms, and circumstances. Within three months, 80 percent of the company’s clients feel better and 60 percent of them achieve “remission level” relief of their symptoms, Winsberg says.
- Michael LaFarr, executive director of the University of Denver’s Health and Counseling Center, chose to work with Morneau Shepell on chat, voice, and video options for student therapy, not just because of the growing demand for counseling services, but because that demand was increasingly for online, multilingual, and multicultural counseling. Morneau Shepell, based in Toronto, has a track record in international employee-assistance and tele-mental-health support for international students and study-abroad programs. The company says it has call centers in the United States, Australia, and Canada, and master’s-level clinicians in 170 countries. So it can refer on-campus and online students in Denver, nationally, and internationally for what LaFarr calls “unlimited mental-health support.”
In this quickly growing and increasingly competitive market, geographical and market niches abound. The common denominator, in contrast to some counseling centers’ waiting periods of days or weeks, is speed and access.
“Competition is good in our world,” META’s Rajan says. “The more, the merrier. If you can make it OK to ask for help, then our college kids will do better.”
“The simplest tools with the fewest barriers to adoption are often the most desirable,” says Gary Vonk, president of Keiser University’s flagship campus in West Palm Beach, Fla., which recently signed a teletherapy contract with META that “allows students to discreetly access resources.”
Vonk says that “the speed with which a student can feel they are accessing support can, in and of itself, provide the needed comfort.”
