The Chronicle of Higher Education. Jan 13, 2013.
Three years ago, facing a particularly acute demand for services, the Counseling and Wellness Center at the University of Florida managed to add four full-time positions to the existing 33. That bought the director, Sheryl A. Benton, and her colleagues just two weeks without a waiting list for appointments.
Concluding that she would never hire her way out of the problem, Ms. Benton set about to expand the center's capacity by developing an online psychotherapy program, an approach long used and studied in Australia, among other countries.
Therapist Assisted Online, or TAO, began at Florida this past fall. Designed specifically for students battling anxiety—a primary mental-health issue on college campuses—it is the first research-supported program of its kind in the United States, Ms. Benton believes.
In the pilot program, 26 students treated under TAO showed more improvement, calculated using a system called Behavioral Health Measure-20, than 26 participants in the in-person group-therapy sessions at the counseling center. The students treated under TAO also made more progress than about 700 students receiving individual in-person therapy.
"The results blew me away, not to mention the fact that it stunned all of my counselors, who I think are still trying to come to terms with what happened," Ms. Benton says.
The director is the first to point out the limitations of the pilot. Both the student patients and the counselors self-selected, indicating a certain level of motivation and comfort with new technology. The pool of participants was small. Other research studies show that online patients experience results equal to those of in-person patients.
Still, the model could spell major change for mental-health services in higher education, where the number of students in need of treatment and the severity of diagnoses has climbed steadily during the past decade, according to professionals in the field.
"Within a couple of years, I think, most college campuses are going to be offering this, and it won't just be college campuses," says Jeffrey W. Pollard, a consultant on campus threat assessment who is a former director of the counseling center at George Mason University. "People are still going to want to come in and be across the room from the person that they are working with, but there are other people who are going to be fine looking at a computer monitor and talking to it."
TAO consists of seven interactive treatment modules meant to be completed during a seven-week period. It includes assessments of current symptoms and level of function, as well as cognitive-behavorial and mindfulness exercises. Student patients participate in 10- to 15-minute video consultations with their counselors once a week, and receive daily encouraging text messages.
The online-treatment program falls between self-help and traditional therapy, Ms. Benton says. The relationship between the counselor and the patient remains paramount. The weekly video consultations and the content of the modules work in concert.
Counselors monitor progress, and layers of risk management are in place. Participating students must provide emergency contact information and authorize the counseling center to use it, if necessary.
Much of the technical work is being done within the E-Learning, Technology, and Creative Services division of the university's College of Education. Glenn E. Good, dean of the college and a licensed psychologist, estimates that the university has spent about $200,000 to develop TAO.
Officials are exploring the licensing potential of the program, he says, although the priority is to produce an effective, replicable treatment rather than a profitable business.
TAO and other types of online psychotherapy are inappropriate for seriously ill patients, counselors at the University of Florida and others say. Moreover, the regulation of mental-health professionals in the United States is done at the state level, creating geographic limitations even though the treatment is done online.
"There are interjurisdictional problems," says John C. Norcross, a researcher and professor of psychology at the University of Scranton. "If you launch a website in Pennsylvania and the therapist you are talking to is in Florida and the patient is Louisiana, it is a regulatory and malpractice nightmare."
Where the licensing and regulation of mental-health professionals is done at the national level, such as in Australia and Britain, online psychotherapy has been in use for years, Mr. Norcross says.
Nevertheless, TAO promises clear advantages for mental-health professionals in higher education and their patients, experts say. They cite time and cost savings, the flexible and discreet nature of delivery, and the potential scalability.
The weekly video conference in TAO takes up less than a third of the time spent in face-to-face therapy, freeing up counselors to work with individuals who are more seriously ill.
Students in TAO programs can complete the treatment modules as their schedules permit. The model can help temper the stigma surrounding counseling-center visits, especially for students from cultures in which discussing personal or family troubles remains taboo, mental-health professionals say.
And it has the potential to expand access.
"When you get right down to it, psychotherapy in the U.S. has always been a luxury for the affluent," Ms. Benton says. "If you have good-enough insurance or enough money, you can get really effective treatment, and if you don't, you are pretty much out of luck.
"If the tools that we have now in the digital age can begin to match what we do with face-to-face therapy," she continues, "this could be a social-justice issue that brings effective treatment to all kinds of people who have little or no access today."
Therapist Assisted Online comes at a time when the mental-health landscape on campuses is growing increasing complex. In the 2013 National Survey of College Counseling Centers, 95 percent of directors at four-year institutions reported an increase in students with severe psychological problems.
Eighty-eight percent reported a "steady" increase in the number of students arriving on the campus already on psychiatric medication. Suicide is the second-leading cause of death (after auto accidents) among college students.
"When I first started this work, the most common things we would see were things like homesickness, roommate issues, that kind of stuff," says Mr. Pollard, of George Mason. "You don't see that anymore. That gets handled at the residence-hall level. We see people who have profound depression, people who have debilitating anxiety. We have people who are bipolar, people who are actively schizophrenic. It's an entirely different can of worms."
App on the Way
The work being conducted at the University of Florida is one example of how practitioners and researchers have worked in recent years to harness technology in order to push the boundaries of mental-health services. The standard has advanced well beyond static web pages and other forms of pure information delivery, to highly technical, interactive forms of education, assessment, and intervention.
A suite of gatekeeper-training programs created and licensed by Kognito Interactive, a company in New York, puts users through lifelike scenarios and conversations with avatars in which users learn to recognize warning signs of mental illness, navigate sensitive conversations, and seek professional help. It is used throughout the California community-college system and elsewhere.
This semester the counseling center at the University of Michigan at Ann Arbor plans to introduce an iPhone and Android app designed to help students manage stress, says Todd Sevig, director of counseling and psychological services. It will include videos, contact information, and a daily message of encouragement tailored to Michigan students.
Meanwhile, under a contract with the U.S. Department of Defense, a team of social workers and computer scientists at the University of Southern California is building a virtual patient to help train mental-health professionals for therapeutic engagement with military veterans, says Anthony Hassan, director of the Center for Innovation and Research on Veterans and Military Families at USC's School of Social Work. The virtual patient—named Staff Sgt. Alamar Castilla—currently responds to 2,000 questions with 900 different responses. The goal is to quadruple those figures.
At the counseling center at Florida, Ms. Benton and her colleagues plan to increase the number of students being treated by Therapist Assisted Online to about 70 this semester. They have begun work on online treatment for depression, and a sequence of modules on mindfulness. Treatments for trauma, substance abuse, and eating disorders are planned, as are supplementary modules on anger management, panic, and relationships.
Working as a mental-health professional in higher education is a specialty all to itself, says Ms. Benton. "It is a population who might suffer a lot from mental-health problems, but they are also the most responsive to treatment," she says. "We know if you can effectively treat people when they are adolescents or young adults, you have the possibility of changing the entire trajectory of their lives. That's pretty exciting."