1. Campus Policies and Practices
    1. Recommendations
  2. Inclusive and Supportive Campus Culture
    1. Recommendations
  3. Mental Health Awareness and Communication
    1. Recommendations
  4. Prevention and Early Intervention
    1. Recommendations
  5. Service Access and Delivery
    1. Recommendations
  6. Summary/ Broad Recommendations
    1. Recommendations

Campus Policies and Practices

Several of the panels considered the general topic of “university policy” as it relates to mental health. The Mental Health Experts Panel addressed the question, “What are the conditions needed to promote mental health on campus?” by drawing attention to the importance of creating a culture that is conducive to positive mental health. Speaking specifically about mental health staff, they noted that culture is related to morale and turnover, and that this has impact on clinical care. Presumably, there is an analogous effect with other student-facing relationships. The Mental Health Experts recommended that future review of formal University policy include a lens of mental health; in other words, whether a given policy is likely to adversely affect the mental health of students.

The current policy regarding academic accommodations for mental health concerns was discussed by several panels and subject to many submissions to the PAC-SMH website. It was noted that there are several difficulties with the current Verification of Illness (VIF) process, ranging from inconsistent application across faculties to inconsistent fee procedures. There have been some innovative on-campus approaches, including the use of tracking systems of VIFs to ensure that students who are not otherwise identified as struggling will be noticed in the academic system. Some campuses have implemented self-declaration of short-term illness reporting by students along with tracking systems to encourage responsible self-management of illness and disability behaviour such as is expected in the workforce.

The academic panel additionally drew attention to several academic policy areas. It recognized that there are significant differences across and within faculties. In addition, it highlighted that there are aspects of post-secondary education that are inherently stressful and aspects of academic policy that create undue stress. Further along these lines, the group noted that a stressful academic environment might be experienced as challenging for many students. This stress might push individuals with pre-existing mental illness into a “red zone” in which they are unable to function. It is for this reason that the University needs to have a robust and consistently applied system of accommodations. Indeed, there are likely students on campus living with mental illness who are able to complete their education with the effective use of these accommodations. The academic panel also made reference to course design features (known as Universal Design) that allow for successful learning outcomes for diverse learners, including those with mental illness.

Several panels commented on various situations in which students might experience stress beyond what is reasonable given the academic context. The academic panel highlighted that there are preventable stresses related to the scheduling of exams. In many areas, students don’t know exam schedules until well into the semester. The emphasis on examinations being the dominant approach to assessment was also raised. Submissions from the academic and student experience panels called for consideration of alternative methods of determining student outcomes, recognizing that this will not be consistently possible across the institution. Student groups, as well as panel members, also highlighted that certain co-op configurations, in which students are applying for co-op positions in their first semester, create difficulties in adjusting to the university experience. The academic panel suggests that these areas be examined further to minimize stress and promote student wellness through these key adjustment periods.

Features of the educational experience for some faculties and programs may not be conducive to student wellness. The Academic Panel noted that in areas where competition among students is prominent, the wellness of some students can be compromised. The panel made a distinction between the use of rankings as an extrinsic motivator for success versus intrinsic motivation for growth, noting that both forms of motivation can be helpful in education. Some alternatives to strict ranking are presented in the panel report.

General Policies and Practices

Recommendation #1:

  • The University should facilitate a wellness and mental health analysis when new academic programming is proposed.
  • The University should develop a mental health framework for use when writing new, or reviewing existing, policies and procedures.

Accommodation Policies and Recourse Procedures

Recommendation #2:

  • Equip AccessAbility Services with the capacity to review mental health-related accommodation requests on campus while maintaining the confidentiality of the student.

Recommendation #3:

  • Develop a centralized physical and online system for submitting Verification of Illness Forms that notifies all students’ instructors while maintaining confidentiality of students’ medical conditions and history.

Recommendation #4:

  • The University should develop proper recourse mechanisms for students who allege staff or faculty have violated an approved accommodation request related to mental health.

Academic Policies and Practices

Recommendation #5:

  • Strike a working group that recommends implementable best practices around exam and evaluations with a wellness viewpoint in mind. This includes but is not limited to an examination of:
    • Final exam schedules and availability of the exam schedule during the course enrollment period.
    • Weighting and overall number and type of evaluation/assessment in courses.
    • A more efficient system for deferred exams.
    • Confidentiality around communication of grades to students to ensure practices aren’t promoting an unhealthy competitive environment (e.g. rankings).

Recommendation #6:

  • Academic programs should review for unnecessary stress sequences where students acquire their first co-op position in the second term. The PAC-SMH recommends that a committee be struck to investigate how to reduce the stress levels associated with this sequence.

Recommendation #7:

  • Consider universal instructional design as a valuable perspective that can be used to improve course delivery. Consider a collaborative effort between the Centre for Teaching Excellence and faculties to include universal instructional design in existing and new courses.
  • Develop an online resource to record good practices for embedding universal instructional design and mental wellness into teaching.

Openness and Transparency

Recommendation #8:

  • Openly communicate the process the University undertakes when communicating about student deaths on campus.

Recommendation #9:

  • Develop a protocol to include community partners when communicating adverse events that involve a member of the community, while ensuring that support services are available to those impacted by the event.

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Inclusive and Supportive Campus Culture

Similar to the above section, this section speaks to University features that affect all members. The CACUSS model identifies the need to examine the level of inclusivity and support that is experienced by members of the community. The experience of a supportive community is expected to be conducive to positive mental health and wellness.

A strong body of research, some of it documented in our panel reports, bears out the centrality of social support as a factor in positive mental health (Barry, 2009). The mental health experts panel spoke of this in terms of “social capital” defined as “… the network of relationships that an individual maintains to support one’s goals and well-being” (mental health experts final report, page 18). The panel report further specified sources of social support deriving from family, faculty and peers, all having important functions for students as they navigate the transitions and daily stress of university life. The student services panel similarly referred to a “community development” model emphasizing an “…engagement of staff, faculty and students toward building a stronger sense of community at Waterloo…” (student service panel final report, page 19). These comments resonate with findings of the NCHA-II 2016 survey results, which suggest that nearly a third of students reported feelings of loneliness in the weeks prior to completing the survey. Clearly, there are individuals who do not experience the campus as a supportive community, and as a result, are not benefiting from the protective advantage of social support.  

Some of the panels identified groups on campus that might be considered vulnerable with respect to the experience of being included and supported. The student experience panel, for example, identified that international, indigenous and LGBTQ communities may be over-represented in the group of students requiring mental health supports. Although the focus of these reports was on adjusting services to ensure that these groups are welcomed and appropriately supported, there were also observations suggesting that individuals represented by these groups experience the additional stress of not feeling fully included in the community experience, and as such, experience distress that may lead to mental health symptoms.  

In response to this recognition that some students are not benefitting from the advantages of a social support network, several panels and direct submissions to the PAC-SMH highlighted the need to build on the strength of formal and informal peer mentoring opportunities. Within some faculties, peer mentoring is offered to incoming students. Senior students make themselves available to more junior students to assist with basic information about all aspects of the university experience. In some cases, these peer connections are more specifically targeted for students potentially struggling with mental health concerns (i.e. MATES). Overall, however, there is recognition that enhancing peer connections through deliberate efforts by staff and faculty can be an important antidote to the experience of isolation for many students.

Discussion of teaching approaches among the academic panel brought forward several known examples of interactions between faculty and students that were identified as sources of undue stress. The group expressed concern that these negative interactions, although relatively rare, could have an impact on the mental health of affected students. They noted that students often feel powerless in their relationships with some faculty. Recognizing that most interactions between students and faculty are positive and professional, the possibility of these few exceptions needs to be taken seriously, and consistently applied methods of redress may need to be developed to support or supplant the current Policy 33 - Ethical Behaviour.

Some groups highlighted the contribution of “built environment” as a mediator of mental wellness and social support. Specifically, we heard about some limitations related to space that may directly affect the mood of students (i.e. lighting, condition of facilities). Further work needs to be done to understand the impact of environments on social interaction. The student service panel drew attention to the potentially positive impact of developing spaces that encourage activity. Some of these developments are underway (upgrading of the Physical Activities Complex and connection with an expanded Student Life Centre, proposed expansion of the Columbia Ice Fields and development of the Field House), while other opportunities for enhancement of space that encourages activity and social interaction are under consideration.

Finally, we heard about opportunities to employ a more general health promotion strategy aimed at creating a stronger inclusive and supportive culture at the University of Waterloo. Several groups pointed to frameworks such as the Okanagan Charter (Okanagan Charter: An International Charter for Health Promoting Universities and Colleges, 2015) as a way to promote actions that increase the sense of community for all members. Several of our panels recommended adopting the Charter, and with this commitment in hand, developing a health promotion strategy that crosses all levels of faculties and student service groups.

Shared Responsibility Amongst All Community Members for Wellness

Recommendation #10:

  • All academic programs and student service departments should include peer mentorship activities in the delivery of their mission for the purpose of:
    • Improving the frequency of connection and collaboration between students, faculty and staff.
    • Developing a greater sense of belonging and community at Waterloo for all students.
    • Increasing cross-campus support and advocacy for student wellness.

Diversity, Equity and Inclusivity Considerations Regarding Student Wellness

Recommendation #11:

  • A committee should be struck to develop and implement a cultural competency strategy for the University regarding health promotion and student wellness. The committee would review campus policies, procedures and practices in consideration of race, ethnicity, faith, gender, sexual orientation, gender identity, and socioeconomic status.

Faculty and Staff Roles

Recommendation #12:

  • Expand the range of options for students who are having challenges in interactions with their supervisors or instructors. For example, consider the model of an ombudsperson employed at some institutions with functions such as support, advocacy, and tracking data/patterns.

Intentional Design and Planning of Student Space

Recommendation #13:

  • Identify and implement University facilities and infrastructure standards and best practices into the design, planning and rejuvenation activities for all campus physical spaces to promote and enhance student wellness and supportive learning environments.

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Mental Health Awareness and Communication

Corresponding with a similarly labelled category in the CACUSS model, this section again addresses the whole of campus as it speaks to the way mental health and wellness and mental illness are discussed across campus. As noted below, there have been improvements in society’s comfort level with these topics, but there are opportunities for further development.

Mental health awareness in Canada has improved significantly in the past 10 years. The establishment of the Mental Health Commission of Canada, and all its associated projects, indicates that there is developing recognition of the importance of mental health as a public health concern, as well as a potential risk factor for many citizens. Similarly, we could surmise that the establishment of the PAC-SMH, and the robust response from all areas of the University of Waterloo community, indicates that the nationally recognized concern is shared at our institution.

For the past decade, the University of Waterloo has organized a Mental Health Wellness Day as a way of bringing awareness about mental illness, wellness and services. Several of the groups spoke positively about this initiative but would like to see a more consistent effort for mental health promotion year round; in other words, expanding the campaign so that the issues brought forward stay top of mind in the university population. Some examples of how to improve mental health communication include the use of online forums as well as more ongoing, open forums such as discussions during classes or town halls rather than only in response to tragic events (Student Experience report, page 18). The academic panel and many student submissions raised the possibility that some of this information can be promoted as part of the regular interactions between faculty and students. Recognizing that courses often have very focused content delivered in a limited timeframe, there may still be opportunities to insert reminders of services or other wellness-related information. We became aware that some faculty members are already including this content in their interactions with students, and there may be opportunities to disseminate best practices using the expertise of support units such as the Centre for Teaching Excellence (CTE).

The dissemination of information during student orientation was another common theme mentioned by many. This period of time, typically occurring just prior to the start of the fall semester, focuses on transferring information about the institution, services, policies and health promotion (among many other topics). It is noted that orientation activities occur for some students in the winter term and require similar attention. Many commented that it is difficult for incoming students to absorb all the information presented. For example, students may hear repeated references to Counselling Services or Campus Wellness during Orientation, but they may feel it is irrelevant at the time of receiving that information.  

A suggestion that consistently emerged was the need to develop curricula early on in a student’s career with concepts of wellness, including mental health, and this being the focus of a credit course. We are aware that such a course is offered in the Applied Health Sciences (AHS) faculty with the following description: “…course will introduce the student to the basics of health, wellness and disease, with an emphasis on assessing and evaluating the student's own lifestyle and health risk, and committing to a plan to begin or maintain a healthy lifestyle across the life course” (AHS 100 description). The course is available to other students, but the uptake outside the AHS faculty has thus far been limited. The mental health experts panel, in particular, raised the concept of “mental health literacy,” speaking to a student’s general knowledge about mental disorders and potential early intervention approaches.

Along with this general enhancement in interest and awareness, our panels and other submissions noted some gaps in knowledge about student mental health. Many noted that the profile of mental health service remains somewhat limited. From the mental health experts panel, “...the University of Waterloo has a very rich inventory of services that are central to the maintenance of well-being, including athletic, recreational and social activities, a food bank, academic peer supports such as MATES, the Glow Centre, the Women’s Centre, workshops and supports for academic achievement such as the Student Success Office, Accessibility Services and the Writing Centre, and online and in-person workshops and supports through campus wellness” (page 22). This group noted, as did others, the importance of increasing awareness of the opportunities available for students to improve their wellness.

There was wide consensus among our panels and presenters that all faculty and staff could benefit from further education about mental health and mental illness. Many of the student-facing university staff recognize intuitively when a student has crossed the threshold from normal stress to a mental health crisis. However, at this juncture, several respondents indicated that they are uncertain how best to respond. Those who have obtained some of the training that is available have expressed appreciation for this exposure. We heard from some sources that appropriate training is difficult to acquire. Counselling Services staff are able to provide some of this training, but the interest and demand far exceeds the capacity of the staff. In addition, our respondents noted that different levels of training may be needed for different faculty/staff, depending on the kind of contact with students. It appears from our discussions that there is an appetite for further development of a systemic training approach as it relates to student mental health.

Reducing Stigma

Recommendation #14:  

  • Open a continuous dialogue with students, staff, faculty, and the wider community about mental health and well-being, including online forums for discussion of:
    • Prevention of mental health issues and promotion of mental health-care strategies.
    • Suicide prevention.
    • Impact of trauma and sexual violence.
    • Effects of racial injustice.
    • Effects of transphobia.
    • Harm reduction approaches to substance use.

Curriculum Availability

Recommendation #15:  

  • Encourage faculty to integrate curriculum focused on mental health, resilience, and support resources and to develop courses in ways that promote mental wellness.

Mental Health Training

Recommendation #16:

  • Support the professional development of faculty, including the following:
    • Explore ways to share existing best practices between instructors on an ongoing basis, particularly in an online format.
    • Encourage faculty involvement in teaching-related professional development by recognizing these efforts in their merit reviews. Go beyond numbers generated by the student survey. Acknowledge and value up-to-date course assessments, participation in CTE workshops, and pedagogical conferences.

Recommendation #17:

  • Ensure that faculty have appropriate and timely information to support students through the following means:
    • Make mental health training part of the on-boarding process for new faculty.
    • Strongly encourage mental health training in existing faculty.
    • Provide clear guidelines to instructors regarding who they can contact when they have concerns about a student’s welfare, even if he or she does not yet require interventions.

Recommendation #18:

  • The Sexual Violence Response Coordinator should provide training related to sexual violence to other healthcare workers on campus.

Information about Resources

Recommendation #19:

  • Develop an integrated marketing and communications plan to inform students about all the available support options, including the following:
    • Implement opt-in information sharing and transition programming during orientation for incoming students living with mental illness.
    • Create a centrally maintained database of available supports for students. Allow on-campus departments to contribute their own initiatives.

Recommendation #20:

  • Make information and resources about mental health easy to find, including but not limited to the following:
    • Implement one platform to access services and supports. 
    • Develop a comprehensive list of peer supports on campus and provide opportunities for knowledge sharing. 
    • Enhance existing peer support resources.
    • Clearly describe available mental health resources in the Region.

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Prevention and Early Intervention

In this section of our report, we collapse two categories of the CACUSS model. Our conception of “prevention and early intervention” encompasses the needs of those students who have begun to notice and/or express concerns with their coping ability. We note that at any given time there will be a proportion of the student population coping well with the challenges of their education, there will be those who recognize that their distress is temporary — perhaps relating to situational pressures — and there will be those who are ready to seek assistance to cope better. The CACUSS model categorizes these areas as “community capacity to respond to early indicators of student concern” and “self-management competencies and coping skills.”

For some years, Counselling Services has offered a series of workshops designed to assist students with self-management and coping. Counselling Services offers the following seminars and/or workshops:

  • Managing Emotions
  • Cultivating Resiliency
  • Challenging Thinking
  • Strengthening Motivation
  • Calming the Panic
  • Developing the Compassionate Mind
  • Mindfulness Meditation
  • Preventing Depression Relapse

These supports are available on an ongoing basis and are designed to provide students with tools they can use to address low levels of stress or mental health symptoms. It has been a challenge for Counselling Services staff to provide as many workshops and seminars as are requested. Providing more of the current programs and adding other topics is likely a necessary next step in this area.

In recent months, some of these seminars have become available online. Some respondents encouraged the expansion of this kind of self-management activity with the exploration of additional applications developed specifically for this population. It is likely that the use of mental health apps and websites will continue to grow. It is estimated that nearly 300,000 such apps have been created and new ones are being developed at a rate of 80,000 per year (Hatcher, 2017 – Centre for Innovation in Campus Mental Health conference).

The topic of resiliency deserves special attention as it was a common theme discussed by all panel groups and presenters. The student service panel used a definition provided by the American Psychological Association: “Resilience is the process of adapting well in the face of adversity, trauma, tragedy and other significant sources of stress. Having strong resiliency skills doesn’t remove challenging or distressed feelings altogether, but rather can help reduce the time it takes to return to ‘normal’ everyday functioning. Luckily, resilience involves behaviours, thoughts, actions and skills that can be learned and developed” (as cited in the student service panel report, page 14). It is important to note in this definition that resilience is not being conceptualized as a fixed trait that individuals either possess or don’t possess; rather, it is a set of skills that can be acquired. Multiple submissions observed that resilience is lower in today’s students compared to past years. Recognizing the applicability to the post-secondary environment, several institutions have invested heavily in training programs. Furthermore, the development of these skills prior to attendance at university or college has been the pre-occupation of some high school and middle school educators. The In it Together report (referred to earlier) made a strong recommendation that governments invest further in this curricula beginning in primary grades and extending through high school. Our groups have thus joined the chorus of voices supporting a stronger investment in programs that help students become more resilient.

Recommendation #21:

  • Develop a campus-wide training program in resiliency.
    • Ensure that a common definition of resiliency is used across all program delivery platforms and training providers.

Recommendation #22:  

  • Implement a comprehensive education and training strategy to increase mental health literacy among students, staff, and faculty. Create situational mental health training based on role and/or faculty and make it available to all.
    • Ensure training is offered for receptionists and student staff who may deal with students struggling with mental illness and suicidal ideation. Invest in a dedicated full-time resource for mental health training.
  • Invest in a dedicated full-time resource for mental health training.
  • Stagger or reiterate orientation presentations throughout the year.
  • Encourage capacity building through a train-the-trainer approach.
  • Ensure all staff and faculty are aware of the supports for students that already exist both on campus and off campus and what to do in case of an emergency or when they suspect a student is in need of additional support.
  • Distribute the Do You Need Help poster detailing what people should do in particular situations to all Waterloo campuses, faculties, schools, departments, etc. so they know where to find help in the event of a crisis.

Self-Assessment and Digital Applications as Early Intervention

Recommendation #23:

  • Use research on best practices and review opportunities for self-assessment/self-management and early intervention through digital applications.

Coordination of Peer-to-Peer Activities

Recommendation #24:

  • Assess the current level of coordination of peer support networks. Create a mechanism for coordination and knowledge sharing.

Mental Health and Harm Reduction

Recommendation #25:

  • University of Waterloo should join the Canadian Centre on Substance Use and Addiction Postsecondary Education Partnership — Alcohol Harms, a partnership that other universities across Canada have joined. It focuses on:
    • Reducing harm associated with drugs and alcohol.
    • Developing an institutional implementation and measurement plan based off the framework.

Training and Education Programs

Recommendation #26:

  • Develop new training programs in the following areas:
    • How parents can support their students.
    • Strategies to prevent sexual violence.
    • Bystander intervention training in orientation leader training.

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Service Access and Delivery

In this final section of observations, analysis, and recommendations, we bring together the two categories of information listed in the CACUSS model that pertain to students with mental health concerns. It is likely that when people refer to student mental health, they may be thinking first of “accessible mental health services” or “crisis management.” We wish to give these important facets of the model proper attention with the view to contextualizing the services in the broader model as listed above.

As discussed earlier in this report, the University of Waterloo provides a range of formal and informal supports in its Counselling and Health Services, more recently presented as an integrated Campus Wellness response. Members of the PAC-SMH were provided information about the services through summary reports and through detailed discussions with service providers. From these reviews, we recognized that there are many services available, ranging from peer support efforts to formal treatment services provided by highly trained professionals. Panel presentations suggested that there may be a disconnect between students’ awareness or perceptions of what is available and the actual availability of services. If this is the case, it will be important to continue to develop effective communication about mental health services along the lines discussed in earlier sections of this report. For example, students need to have ongoing exposure to information about on-campus and off-campus options so that during times of acute need, the path to an appropriate service is accessible.

Mental health services delivered on campus exist in the broader context of local services. One of the significant questions that the mental health experts panel addressed was: “How far can/should an organization like the University go in providing treatment for mental illness?” They took the position that the University needs to provide a comprehensive range of treatment, recognizing that the local (regional) mental health system, including hospitals, other publicly funded health organizations and counselling agencies, may not have sufficient capacity to provide all the necessary services for students. It is not clear whether local health planning fully takes into account the significant influx of students and the service requirements that they represent.

A recent document created by a collaborative of student groups and post-secondary leaders in Ontario, In It Together: Taking Action on Student Mental Health, spoke of a “whole of community” approach in which post-secondary students are considered a priority group in health services planning. With this approach, there may be an opportunity for better integration between community services and campus-based services. The report also recognizes that there are significant gaps in funding for mental health services in the community at large, and that as a result, post-secondary institutions are under significant pressure to create comprehensive services.

“Over the past several years, the increase in mental health issues among students has put increasing pressure on post-secondary institutions to move beyond their academic counselling role to providing ongoing mental health treatment. Acute and long-term support of this nature rightfully falls within the mandate of health-care providers and community agencies. A distinction must be made between the triage role of post-secondary institutions to direct students with serious or complex needs to appropriate care and the acute and long-term service provision role of health and community service agencies. Clear boundaries for each institution, coupled with an integrated approach to service delivery, mean students will obtain faster access to mental health and social services.” (In It Together, page 3)

Clearly, there needs to be ongoing discussion about the roles of campus service providers and the community. Locally, this may require the development of an understanding of what the capacities and expectations are of each respective provider, followed by the development of protocols to ensure collaboration.

Through the process of the PAC-SMH, some promising areas of discussion were opened. The community partner panel provides some examples of how the University of Waterloo can benefit from connections with various agencies. The group noted that additional efforts could be made to ensure students have accurate and full information about services in the community. Further, the panel saw opportunities for ongoing information exchange between on-campus and off-campus providers in community forums that address mental health. The community partners and student experience panels noted that some concrete steps might be taken to facilitate referrals to agencies such as having intake staff help the student make a first call. The PAC-SMH sees these and other community-oriented recommendations as a potential “re-set” in relationships that will benefit students’ access to service going forward.

An important point of discussion given the context of this report is students’ satisfaction with campus mental health services. The student experience panel collected data from students and also referenced the external Maclean’s annual survey. About three quarters of the survey sample rated Waterloo’s mental health services as “fair” or “poor.” They also noted that the services rank among the lowest in student satisfaction (including services and academics) in the recent Maclean’s survey. It is not clear whether the survey ratings are specific to individuals who actively use mental health services, or whether these ratings reflect the general perceptions of services on campus. In contrast, for example, the most recent satisfaction ratings taken by Counselling Services of students who received service suggest that 94% “agree” or “strongly agree” that they were satisfied with the service they received. In any case, these results draw attention to how the University of Waterloo’s services are viewed by a significant number of students. As noted by the student experience panel, they point us in the direction of more consistent and rigorous data collection to ensure that we better understand how consumers of the services view them, and that we adopt strategies to improve all areas of practice.

With respect to the services themselves, there were several areas of analysis provided by the mental health experts panel that may lead to further study or action. Although not directly stated, a common theme — and one of the drivers of the current review — focuses on questions about capacity in mental health services. Students, staff and faculty expressed their frustration and disappointment with reported difficulties accessing mental health services when they were needed. The general topics of capacity and adequacy of on-campus services was one of the most frequent areas of comment in submissions to the PAC-SMH website. These issues were also raised in other public forums, as well as in interviews with service provider staff.  

It is a difficult step for many individuals to decide to seek help for their psychological distress. The comments about dissatisfaction with access indicate that University of Waterloo services (Health Services and Counselling Services) have not met the expectations of some students that reach out for help. The service providers in response have tried to understand the nature of the barriers to access.

A recent study prepared by the Campus Wellness Quality Assurance and Program Evaluation Committee for the University’s Institutional Analysis and Planning (IAP) department, suggests there has been movement in how wait lists for mental health services are addressed. In the past three years, Counselling Services adjusted standards for wait times based on the level of urgency of the request for service. For emergency referrals, the standard requires a same-day response, and this standard was met 97% of the time in the 2016-17 year. For urgent referrals, the standard was for an appointment within three business days; this standard was met 85% of the time. For brief individual counselling, the standard for a first appointment is 3-5 weeks; this was met 92% of the time. All these results represented significant improvements from the first reporting period of 2013-14. Although any period of waiting may not present an ideal scenario for students requesting help, the study documented a steady improvement in responses. It also confirmed that not all students seeking services are looking for an immediate response and that a response can be tailored to individual needs. It will be important to continue documenting the waiting periods, and perhaps more importantly, communicating this to the larger campus community.

Any discussion of service capacity logically leads to the examination of human resources. The mental health experts panel addressed this from several angles. Questions were raised about the adequacy of the numbers of staff available to serve the student population, as well as what kinds of professionals were needed. The panel also provided an analysis of recent organizational changes in Counselling Services, concluding that an external review should be conducted to assess the utility of the new structure. In addition, the PAC-SMH heard presentations from Counselling Services and Health Services staff to understand the workflow of these services as well as the experience of clinical staff. It was heard that staff working in these areas often feel over-taxed by the volume of the work, as well as the complexity of the clinical situations that they face. More will be said later about the impact of this work on the staff themselves. One proposed solution was to adjust the overall student-to-counselor ratio, thereby increasing significantly the human resources devoted to mental health. The position of the PAC-SMH, in light of this submission, is that the increase of human resources is likely required, but exactly how much is needed and how additional resources should be deployed needs to be examined further. We acknowledge the recommendation that staffing needs to increase to a ratio of one mental health staff for each 1,000 students. The accrediting body for post-secondary counselling centres, the International Association of Counseling Services (IACS; 2013), states that “…every effort should be made to maintain minimum staffing ratios of one F.T.E professional staff member (excluding trainees) for every 1,000 to 1,500 students, depending on services offered and other campus mental health agencies.” Using the IACS ratio that includes dedicated counselling staff and counselling/administration staff, the University of Waterloo is on the high end of this ratio (1:1,370). This does not include the mental health service provided by Health Services staff (noted below). This point further needs to consider the following:

  •  The counselling staff-to-student ratio requires situational analysis. For example, the Centre for Innovation in Campus Mental Health (2015) provided a ratio of 1:3,000 students as acceptable in counselling centres in which professional staff are not required to provide academic-related counselling. Using this analysis, Waterloo exceeds this standard. This discrepancy suggests that when making blanket recommendations about staffing, we need to examine the comparability of our services to reference groups.  
  • In the University of Waterloo context, mental health services are provided by various professionals, including physicians, nurses and nurse practitioners. It is not clear if the ratio as recommended takes into account the contributions of these professionals and the efforts of integration of mental and physical health at Waterloo since the 2012 review.
  • Several discussions and presentations throughout the PAC-SMH process acknowledged capacity limitations and access difficulties for students while at the same time raising questions about whether a significant increase in mental health staff is the best answer. Previous sections of this report argued for significant changes in the institution that presumably will reduce the need for direct service. To summarize, the changes could be in some academic policy areas, university culture to promote mental wellness, improved social support, and improved and enhanced efforts to prevent the occurrence of the most serious of mental health outcomes.  
  • Through this process, many participants have expressed a desire to create a campus environment in which fewer students come to the point of needing specialized professional help. Although it might be easy to assume that “pushing back” on recommendations to increase professional staff is tantamount to an effort to reduce expenditures, we may need to look beyond the cost of professional staff as we develop an ideal system of care.
  • The mental health experts panel correctly noted that the actual capacity of mental health services can be significantly influenced by the numbers of staff on leave, and that the current budget model does not permit backfill for the first year of leave. The impact of leaves needs to be better addressed in the future.

These points of reflection are included here to ensure that recommendations for additional resources consider the totality of the analysis — in particular, considering “upstream” resources that the University of Waterloo may have thus far de-emphasized. Having stated these qualifications, the consistently expressed concern about accessibility to formal mental health services requires attention, and it is likely that some human resource enhancement will help remove what the mental health experts panel has appropriately called a “barrier” to students receiving appropriate help.

Concerns regarding capacity are a key facet in the analysis of service. There were other important discussions brought forward leading to recommendations. The student experience panel looked at the opportunities associated with “embedded” counsellors. The University of Waterloo has been a pioneer in locating dedicated staff in faculties or schools, some of which are located away from the main campus (i.e. Cambridge, Stratford). This approach has resulted in convenience for students, particularly those in programs that are more tightly scheduled, and it has also permitted some counselling staff to become more specialized in addressing the unique challenges of faculties, schools or locations. A review of the current situation suggests a decided unevenness in how these embedded positions are implemented. The student experience panel and others on the PAC-SMH noted that this could be perceived as an inequity, as faculties with more available resources and space have been able to arrange for enhanced local service than others with more limited resources. It is clear that the “embedded” model benefits students as a service option. However, it appears that it lacks a full systemic analysis, including the establishment of criteria for what constitutes a legitimate need and therefore should be centrally funded.

Several groups highlighted the demand for better response to the diverse needs of the student population. Specifically noted were the needs of international students, both in terms of the unique stresses they experience and because of the impact of religious or cultural beliefs on their adjustment to a Canadian post-secondary context. The unique needs of indigenous students were noted, as well, with the question of whether or not mental health services available on campus provide culturally sensitive supports. The student experience panel emphasized in its report that training for mental health staff needs to improve the response to individuals who are disproportionately represented in the population of those seeking mental health services. Specifically noted were transgender and non-binary students, students who have experienced sexual assault, and racialized students, specifically those who have experienced racial discrimination while on campus. At present, Campus Wellness staff are recruited and trained in a manner that ensures sensitivity to these matters of diversity. The reports of the student experience panel, as well as some individual submissions, have indicated that the current approaches have not been sufficient for all.

Previous sections of this report addressed some of the informal services that are in place and made statements about further areas of development. In particular, on-campus groups (such as MATES, Glow, the Women’s Centre and the Off Campus group) provide important supports to students. These elements of service need continued support and connection with the formal service system.

Elements of the formal mental health system at the University of Waterloo and in the community were addressed with some detail in the mental health experts and community partners panel reports. They were also the topic of representations of staff as well as submissions to the PAC-SMH online, speaking to the kinds of services being offered and how they are organized to serve the intended population. We need to acknowledge that the nature of mental health services has undergone significant transition since the 2012 Student Mental Health Review. Without repeating the milestone changes, it should be stated that Campus Wellness, including Counselling and Health Services, has adopted a mindset of continuous improvement. We acknowledge that similar thinking characterizes the planning and operations of other student services. Within Housing and Residences, the Student Success Office (including AccessAbility Services) and Athletics and Recreation, we observe thoughtful analysis of changes in the student population and corresponding adjustment in service. In all these areas (as well as others around campus), there is strong evidence of activity designed to promote student wellness, including collaboration between units.  

A significant challenge for Counselling Services and Health Services has been to ensure that students requesting a service are matched with the appropriate level of care. In both these services, matching students with appropriate service options depends on a well-done assessment. Over the last several years, there have been adjustments to the assessment approach. Although none of the panel groups explicitly reviewed the current assessment process, there were some recommendations regarding the importance of basing “intake” decisions on a reliable and valid assessment. Several options were reviewed. One approach that was not mentioned was the Counselling Centre Assessment of Psychological Symptoms (CCAPS). CCAPS implementation has been under way since 2013, but has thus far not achieved consistent use. In discussing standardized assessment, we need to understand the barriers to implementation of CCAPS and determine the benefits/risks of continuing with this measure as opposed to implementing other similar approaches. In any case, the suggestion of improvements in assessment needs to be
pursued further.

Using appropriate assessment data, the mental health experts panel recommended that students can be engaged in a “stepped care” process, ultimately resulting in matches of students to appropriate level of care. It should be noted that a version of stepped care has been in practice at Counselling Services, and to a lesser extent at Health Services. Students self-indicate the level of urgency of their request, and based on this report, they are streamed into “emergency”, “urgent” or “standard” streams. The helpful addition of a standardized assessment is a further check into the students self-declared level of urgency.  

Other aspects of a stepped-care approach that exist include the option for a less intrusive level of care based on need. There are “pre-treatment” options that are deemed sufficient for some students, including seminars and workshops, both in-person and online, as well as connection with a peer-support approach. It should be noted that in this regard, many students coming to a mental health professional may expect that the best intervention will be a one-to-one interaction with a counsellor, psychologist or physician. The stepped care or levels of care approach advances the idea that there are several options for service and that an appropriate assessment and care plan will be influential in determining the best option for each individual.

A relatively new adjustment in service approaches at the University of Waterloo that falls in line with the stepped-care approach is the introduction of walk-in or single session mental health services. The introduction of this service in the fall of 2015 was influenced by the work of other local (Waterloo Region) providers including a study (Stalker, Horton, and Cait, 2012) that showed some promise as a service option. The use of “just-in-time” mental health service is further support by the observation that the modal number of counselling sessions used by students is one (1). Students requesting mental health services on campus are given this option along with the option to pursue the above-named informal resources or other more intensive services. As relatively
new additions to the mental health services continuum, walk-in and single session counselling are the subjects of program evaluation, and the results of these evaluations will continue to inform ongoing applicability.  

Several of our panels and submissions noted the contribution of technology to potential service improvements. Earlier in this report, we referenced the growth of apps designed to support self-management and coping skills. Similarly, there has been growth in the use of therapist-assisted online therapy (TAO). Both the mental health experts panel and the student experience panel encouraged further examination of these approaches with a specific focus on after-hours availability. Some universities (i.e. Memorial University), have explicitly included various apps and TAO options in their stepped-care offerings. We should also note that during the course of this review, several informal submissions were made to the chair and other members about possible products to be considered. Fortunately, there is also a growing body of research, partially documented in the mental health experts panel report that supports the efficacy of TAO. There are, therefore, compelling reasons to explore the applicability of these innovations in the University of Waterloo continuum of services.

In recent years, Campus Wellness at Waterloo has established a Collaborative Mental Health Operation Team (CHMOT) with the primary purpose of ensuring ongoing collaboration in the delivery of mental health services among key partners. Currently, there is representation from Counselling Services, Health Services, and AccessAbility Services (AAS). Among the topics being addressed by the group is an analysis of patterns of service usage by a group of individuals who have frequent contact with one or all these providers. Supported by research conducted by the senior psychiatrist, a recommendation was made to develop a Collaborative Complex Care (CCC) team, similar to that being employed in some American colleges. The team will develop care plans for individuals on campus who present with serious mental illness. The recipients of these team-based services will receive a more integrated response involving multiple professionals and will be supported by a case manager(s) whose role is to help the student with follow-up on recommendations of the care plan. Planning for the team is actively under way. This development was supported by the mental health experts panel as a necessary addition to the continuum of services. As CCC evolves, it will be important to establish robust connections with other case management-like services on campus (i.e. Housing and Residences, AAS) and in the community (Canadian Mental Health Association – Grand River Branch).

Individuals working in the mental health field are exposed on a regular basis to difficult emotions. The clients of mental health professionals seek support for difficult personal dilemmas, sometimes seemingly hopeless prospects and challenging relationships. In many cases, diagnosable mental illness is the realm in which our professionals work on a daily, even hourly basis. Staff in this area, no doubt, cherish the opportunity to work with students throughout their challenges and until they are in a more healthy state. However, this “success” is not always evident at the time
of the intervention. 

A significant aspect of mental health professionals’ training is to be comfortable maintaining perspective or “boundaries” while in the throes of these difficult interactions. What we have heard through our discussions with service providers is that staff, at times, may have difficulty protecting their own wellness. The response for some may be the use of some of the same strategies that the helping professional prescribes for their clients. These could include techniques such as mindfulness or cognitive restructuring, or ensuring a healthy work/life balance. Others emphasize the need for professionals to have ample opportunity to connect with peers, either for emotional support or professional consultation. The increase of opportunities for connections with peers and supervisors was a main impetus of the organizational changes in Counselling Services, ensuring that staff would not be isolated in conducting this difficult role. However, we accept that the organizational model is not a preferred approach for some. Organizational models should be reviewed regularly to ensure that the clients of the service receive the best possible outcome.

With respect to the PAC-SMH process, we heard from some individuals that the current opportunities to emphasize staff wellness have not been adequate. This is a concern. The basis of a strong student mental health service is a staff system in which individual staff members remain energized and fully prepared for their role. Some spoke specifically of the requirement of five clinical hours per day as being taxing, while others noted that being at full capacity all year is more difficult compared to other post-secondary institutions that don’t work on a three-semester system. These are areas that should be the subject of further investigation with the result of all mental health service providers experiencing the support they need to respond to the range of concerns brought in by the students daily.

Human Resources

Recommendation #27:

  • Review staffing practices and plans in Counselling Services, with an emphasis on the following:
    • An external review to determine whether a recent reorganization, as well as the existing on-call system, has achieved its purpose.
    • Investigate the utility of embedding counsellors within each faculty and residence.
    • Within cost constraints, implement the recommended ratio of 1 counsellor/psychologist FTE for every 1,000 students (36.67 FTE), taking into account counsellor leave and other absences. Further ensure there are additional resources to meet increased demand during peak periods (e.g. exam time).

Services for Disproportionately Affected Students

Recommendation #28:  

  • Invest in training and research for underserved/ disproportionately affected populations.
    • Ensure counsellor training is kept up to date and relevant to student needs (with a specific focus on cultural competence).
    • Conduct a climate survey on the experience and perception of supports specifically designed to meet the needs of international students.

Extended Health Care Funding

Recommendation #29:

  • Update and promote available funding for mental health services on and off campus.
    • In light of the recent government change in funding of prescription drugs, use any surplus from the Student Health Plan toward mental health (including off-campus services).
    • Inform students about the funding and services available to receive mental health services off-campus.
    • Review the feasibility of funding a 24/7 service providing counselling by telephone, video-counselling, or internet-based counselling.
    • Review the need for expanding services on campus relating to substance abuse.

Recommendation #30:

  • Mental health supports and resources for student’s off-campus (e.g. international placements, co-op placements) should be developed and the level of support available should be clearly communicated.

Community Partnerships

Recommendation #31:  

  • Engage with off-campus mental health services and community partners (e.g. Connectivity KW4 and Here 24/7) to better support students, particularly during peak times.
    • Develop a protocol to connect students from an on-campus wellness service to an off-campus service (e.g. have a Campus Wellness staff member connect via phone directly with an off-campus service provider with the student present to arrange ongoing/additional supports).
    • Organize outreach sessions with local community partners (e.g. high school teachers) to explore innovative ways to serve student mental health needs.

Services for Individuals with Complex Needs

Recommendation #32:

  • Tailor the level of mental and physical health care provision to the needs of the individual.
    • Continue to develop a complex care team to respond to students with more complex mental health issues.
    • Continue to develop and implement a stepped-care approach within Health Services and Counselling Services.

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Summary/Broad Recommendations

This report has laid out several observations and recommendations regarding actions that the University of Waterloo should consider to enhance its response to concerns expressed about student mental health. A review of the recommendations will likely lead to the conclusion that this is an ambitious agenda. Additionally, there are a series of recommendations made by panel groups that have thus far not been listed in this report but deserve further attention. The following set of recommendations are stated to ensure that mechanisms are in place to continue the process initiated by the PAC-SMH. As noted, the timeframes for completion of this analysis were compressed. However, many of the respondents, including panel members and staff contributors, noted that the University needs to commit to ongoing review and action concerning the mental health of its students (and the community in general).  

Implementation Committee

Recommendation #33:

  • A committee should be established to oversee implementation of the recommendations of this report, as well as to provide consistent feedback and advice regarding the strengths and limitations of the University response to the mental health and wellness of students. In the Implementation Committee's early deliberations, the PAC-SMH recommends that the committee determine priorities and classify proposed actions based on what is needed from the University (e.g. statement of commitment, financial commitment, human resources, standing committee, or working group) to move forward.
  • Make the full collection of recommendations, strategies, and ideas brought forward through the PAC-SMH process to the implementation committee for ongoing consideration.

Adoption of the Okanagan Charter

Recommendation #34:

  • Undertake a full adoption and promotion of the Charter. A significant transition for the University will be the movement from a perspective in which mental health and wellness is the responsibility of a few professionals to an environment in which a healthy campus becomes the business of all stakeholders. The Okanagan Charter affords an opportunity to support this transition.

Research on Student Mental Health and Wellness

Recommendation #35:

  • Further exploration of the development of a research institute or speciality area in student mental health and wellness. It was evident that there is a strong base of expertise relevant to the topic of student mental health in our institution, including researchers in Applied Health Sciences faculty and the Centre for Mental Health Research (Psychology). There are some examples of institutions that have marshalled this expertise to create a research institute dedicated to addressing questions that are, so far, difficult to answer. These might relate to our population of students, to the range of service options, or the most effective promotion, prevention and intervention options.

Provincial Advocacy

Recommendation #36:

  • The PAC-SMH recommends University of Waterloo endorse and actively advocate to the provincial government, using its government affairs/relations apparatus, to implement the 26 recommendations in the In It Together report. The report and its recommendations outline sector-wide consensus of the role of the provincial government has to play in order to address mental health concerns in post-secondary campuses.

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