Introduction

Current Student Mental Health Context

Post-secondary student mental health is a topic that has captivated the attention of students, faculty, staff and administrators across North American institutions. Now commonly cited, the National College Health Assessment (NCHA-II) survey results for 2016 for Canadian post-secondary institutions estimated that 44% of students actively “felt so depressed it was difficult to function” while 64% “felt overwhelming anxiety” and 13% had considered suicide in the year prior to completion of the survey. For most institutions, the 2016 results suggest that students were struggling more in a range of areas as compared to the 2013 NCHA-II survey. That pattern held true for the University of Waterloo’s students. These important survey results highlight the prominent mental health concerns among students, and point toward a trend of increased concern.

Survey results are one way to take the temperature of current concerns. Some researchers have examined trends in mental health using objective measures of symptoms and comparing the results over several years. Using this methodology, mental health concerns of post-secondary students tend to be more stable, with little variation over a 10-year period (Schwartz, 2015). Xiao, Carney, et al. (2017) found similar trends, but noted that the help-seeking behaviour of post-secondary students has changed significantly, with more students attending formal mental health services. They attribute this change to increased efforts to reduce the stigma associated with experiencing mental health problems.

The current interest in student mental health has led some to speculate that there is a “mental health crisis” on some post-secondary campuses, suggesting perhaps that the psychological presentation of post-secondary students is different than the non-post-secondary cohort. Blanco, Okuda and Wright (2008) found that when using psychometrically valid assessments, the rate of psychiatric disorder in the post-secondary population was no different than non-post-secondary youth. However, Stallman (2010) found that the level of psychological distress was higher among university students than that of their age-mates in the general population. Thus, although post-secondary youth may experience more stress than other youth, this experience is not always indicative of mental disorder.

The Mental Health Commission of Canada (MHCC) (2015) has identified “emerging adults” as a significant population as it concerns mental health. In particular, the MHCC report highlights the 16-25 age bracket, which encompasses most post-secondary students, as a period of transition both in personal development and in institutional responsibility — from the child and youth health system to the adult health system. During this period, it is estimated that 75% of mental disorders emerge (MHCC, 2015). The MHCC does not make a distinction between post-secondary and non-post-secondary youth, instead noting that the planning of supports needs to recognize the tremendous period of change of all emerging adults. The overarching question that could be asked is: are post-secondary institutions, whose primary mandates are associated with research and education, well prepared to provide support to the emergence of these mental health disorders?

A recent report, In It Together – Taking Action on Student Mental Health, prepared by a coalition of the Council of Ontario Universities (COU), the Ontario Undergraduate Student Alliance (OUSA), Colleges Ontario (CO) and the College Student Alliance (CSA), noted that some students in Ontario “…register for courses at colleges and universities for the primary purpose of getting access to mental health care” (page 2). Although there is currently no data to indicate how prevalent this scenario is, attending post-secondary institutions for the sake of getting support for mental health challenges needs to be further explored.

2012 Mental Health Review

Concerns about the mental health of our student population have previously been brought forward at the University of Waterloo. About eight years ago, after several deaths of students by suicide, the community rallied to begin asking the same type of questions that are being currently examined about the University’s response to student distress and mental health. In 2011, a review of the University’s central structures, approaches and processes for addressing student mental health challenges began and was completed in 2012. Through that analysis of stakeholder focus groups, a student survey (N= over 1000), professional literature review and key informant interviews, more than 40 recommendations were put forward for consideration. This review was a significant catalyst for change in the planning and delivery of services on campus.

A primary focus of the review was the programs and services of three University of Waterloo departments: Counselling Services Health Services and the Office for Persons with Disabilities. Since that review, the implementation of the key recommendations has been a top priority.

Three of the overall findings included:

• There is a pressing need for smoother collaboration of all mental health and support services on the University of Waterloo campus(es).
• Staff, and particularly students’, expressed a persuasive need for enhanced access to and availability of best-practice mental health services.
• There is a need to give special attention to prevention and early intervention regarding the distress of students.

Many of the themes that emerged from the 2012 review continue to be relevant and many of the recommendations are still in progress. The following is an overview of key recommendations and progress:

• Organizational Restructuring:
  • A Director, Campus Wellness was hired in 2014 and reorganized Counselling Services and Health Services to be under one Campus Wellness (CW) umbrella. This development of single leadership has created a more collaborative relationship that is fostered through everyday connections between staff working in Counselling Services and Health Services.
    It has advanced further through the development of cross-functional teams and joint staff meetings. Three significant teams that meet regularly are the Collaborative Mental Health Operations Team, Quality Assurance and Program Evaluation Team, and the Joint Senior Management Team. Recently, Campus Wellness has initiated a cross-functional Health Promotion Team as well as a Healthy Workplace Team. Other areas of improved collaboration are with the introduction of a shared clinical record in which physicians, nurses and mental health professionals access the same information (with the client’s consent), improving the ability for joint clinical planning where students have contacts with both services. The re-aligned Campus Wellness organization is addressed in a later section of this report.
  • All administrative responsibilities of Counselling Services and Health Services were realigned under one position: the Manager, Wellness Administration. This position was created in 2012 to bring together administrative functions related to all service provision. A central administrative function for Campus Wellness allows for a common experience for students when interacting with various service providers. It also allowed for the development of common customer service standards and consistent support for the professionals providing these services.
  • The Office for Persons with Disabilities has evolved into AccessAbility Services (AAS) in 2013 and now reports to the Student Success Office. This shift has permitted a stronger connection between AAS and academic units. The working relationship between AAS and Campus Wellness remains strong at a service level.
• Health Promotion Focus:
  • Developing strategies across campus for promoting health and the prevention of mental illness has been a focus for another key hire of the Associate Director, Health Promotion. Since the hiring of this position in July of this year, attention has been given to a range of health issues, in particular, those identified in the recent NCHA-II survey results. There have been several active health education initiatives on campus for many years, including several peer educator teams focusing on mental health. The health promotion emphasis has permitted expanded attention on a variety of risk factors known for this population (i.e. sleep, diet, health-seeking behaviour, sexual health). With the establishment of this position, there are increased opportunities to address risk factors unique to the University of Waterloo, including academic policies that are seen to be a barrier to mental health.

•  Service Delivery Improvements:
  • A comprehensive, “seamless” range of services is now available, which includes an integrated intake process. This shift allows for Counselling Services and Health Services to essentially have no wait list for critical cases. As presented currently, students self-identify their level of acuity. Those who express significant risk, either through declaration of suicidal intent or other significant psychological symptoms, are prioritized for same-day assessment. The data shows that most are seen within two hours. The intake process further clarifies the level of acuity, with some individuals receiving assessment within a three-day period, and others with less immediate needs placed on a wait list for the next available mental health professional. While waiting for their appointment, students have access to a variety of options such as workshops and seminars, walk-in appointments, or single-session appointments. This approach parallels services offered in the community and ensures that safety concerns are addressed in a timely manner. Other improvements in the continuum of service coming about as a result of the 2012 student mental health review are the enhancements of psychiatric services. Currently, the equivalent of two full-time psychiatrists are available for students, based on referrals from family doctors. The work of psychiatrists is supported by a mental health nurse, as well as collaborations with other mental health staff. In the past five years, there has been an increase of 7.0 full-time equivalents in mental health staff representing a variety of specialities. A summary of available mental health services and supports at the University of Waterloo is provided in Appendix H.
  • The crisis response has been enhanced with the creation of Counselling Services’ flexible appointments to ensure that students facing mental health emergencies have access to professional help. These crisis appointments have varied from being regular staff protecting time for “immediate response” or, more recently, the hiring of dedicated staff for crisis appointments. In recent years, an on-call system has been piloted, allowing campus police and/or housing staff to call for counselling support.

Overall, it should be understood that there have been significant movements in how mental health services are conceptualized and delivered at the University of Waterloo since the pivotal 2012 Student Mental Health review.  

There were some recommendations in the report that have not been completed and remain relevant to the current review (including substance abuse services and a comprehensive response to international students). The Campus Wellness leadership understands, however, that the field is dynamic and needs to constantly review the opportunities for improvement.

Cross-Section of Mental Health Services at University of Waterloo

Mental health services on campus are delivered in both Counselling Services and Health Services. Counselling Services has approximately 22.0 full-time equivalent (FTE) counselling staff and 5.0 FTE management level staff who routinely provide clinical supervision and care as part of their roles. They represent a variety of disciplines, including psychology, social work and psychotherapy. Most of these staff are located centrally at Needles Hall or Health Services for some or all of their time. Several staff have assignments in satellite offices, which might include faculty administrative offices or at programs/schools located off main campus.

Counselling Services staff provide a range of services including psychological assessments, intake assessments, immediate (crisis) response sessions, individual psychotherapy, walk-in sessions, single sessions, workshops and skills building/therapy groups. The mix of these assignments varies by semester depending on the most pressing needs and the availability of other staff. As noted earlier, the details of the range of services are listed in Appendix H.

In 2016/17, Counselling Services provided 19,500 hours of service to nearly 4,000 unique students (A unique student, or individual, refers to each student who attended the service, Counselling or Health, on at least one occasion during a given time period, in this case, a fiscal year). The number of appointments represents an 11.4 % increase from the previous year. The trend in the past five years has been a steady increase in demand for counselling, leading to additions in staffing as listed above. Counselling Services management has, at the same time, been adjusting the service model to ensure that students are matched with the most appropriate service based on their requests and clinical assessment. As noted in the previous section, the adjustments have included changes in intake procedures, inclusion of more pre-treatment educational options, and the introduction of walk-in and single-session options.

Health Services staff also provides a range of mental health services. Nurses conduct triage assessments to determine the level of urgency. Physicians provide assessment and treatment, some of which is medical and some of which is physician psychotherapy. In 2016/17, Health Services provided 71,000 appointments for approximately 15,500 unique individuals. Of these, it is estimated that 20% (14,200) were mental health appointments. Health Services report that some appointments may be initiated for a physical, but after assessment, a mental health intervention may be indicated. As is the case for Counselling Services, the number of appointments has increased each year for most of the past five years. Physicians often make referrals to other mental health providers, including Counselling Services or psychiatry. In 2016/17, psychiatrists provided nearly 3,000 appointments for 570 individuals. Several of the individuals seen by the psychiatrists are also being supported by a mental health nurse. They are generally students who require support to return to campus after hospitalization.

This listing of service availability outlines a vibrant set of mental health services at the University of Waterloo. Not listed here are informal supports such as MATES, the Glow Centre and the Women’s Centre available to students through peer support programs. Informal analysis of services offered at other campuses suggests that Waterloo has as much or more service available than most post-secondary institutions in Canada. However, it is also known that many campuses are aware of the increasing expectations for on-campus services. Accordingly, it is likely that many are increasing their resources to address the newest demands.