Cost-efficiency should not be the marker of success
Content warning: This article contains discussions of suicide and mental illness.
I began my undergraduate degree at the University of Toronto in September 2015 and, like many others, sought mental health care early on. As a first year student, I was entirely unaware of the new “streamlined process.” My entry into the system was a complicated process requiring me to advocate for myself with college registrars, counsellors, and staff at Health & Wellness, while experiencing unabated health challenges which brought me there in the first place.
There is no question that students need better access to mental health care, and that the mental health crisis is a long-standing issue. In September 2015, in an effort to meet this demand, the University integrated their Counselling and Psychological Services (CAPS) with Health & Wellness in order to create a “streamlined process” called “stepped care.”
Within this model, the least resource-intensive treatments are offered to students first, and more intensive services are offered based on the patient’s need. Stepped care seems like a miraculous solution. Stepped care is efficient. Post-secondary institutions can increase access to services with the same budget.
In 2019, the University further developed this model and launched various programs such as same-day counselling, drop-in counselling, and “MySSP,” a counselling service which provided immediate telephone or online chat help. These services were to complement the already-present short-term intensive counselling.
Success is tracked by the number of appointments offered by Health and Wellness for both medical and mental care. In Annual Reports for both the 2017-2018 and 2018-2019 academic years, Health & Wellness facilitated around 58,000 appointments. This means an average of four appointments per student. In the 2019-2020 academic year, however, the same 14,000 students made almost 73,000 appointments (an average of five appointments per student). Data for the 2020-2021 has not yet been released.
This increase in appointments is commendable, but an individual’s mental health is not measured in aggregate data. The question is whether the quality of services is enough to address the University’s crisis.
I eventually did see both counsellors and psychiatrists, but they would only provide a limited number of sessions. When I had exhausted my allotment, I was told to seek outside resources, without support. Even now, in 2021, I have a fraction of the care team that I once had.
Moreover, even after completing one-on-one and group therapy, I was dismayed to find that these sessions were not making any difference.
The treatment I received at CAPS was largely based on Cognitive Behavioural Therapy (CBT) and its related therapies, like Dialectical Behavioural Therapy (DBT). These therapies are considered a highly effective treatment for a variety of “illnesses,” such as depression, anxiety, and post-traumatic stress disorder (PTSD).
CBT is based on the idea that distress is caused by “faulty or unhelpful ways of thinking.” However, CBT, at least in the therapy I attended, makes no allowance for mental distress caused by issues entirely outside my control. I would “fail” to respond to CBT because I wasn’t trying hard enough to change my thoughts.
Of course, this is based on the assumption that I was causing my own mental distress. The idea that mastering internal thought patterns—if that can be done at all—will make one happy is an effective way to individualize mental health issues and ignore the systemic causes of illness. Attempting to master control of my inner thoughts did nothing to solve systemic problems such as racism, homophobia, and gender discrimination.
Though CBT may be helpful for some, I am not the only one to find CBT unhelpful. As Dr. Farhad Dalal explains in his book, CBT: The Cognitive Behavioural Tsunami, CBT was originally used to treat a very small number of disorders, namely phobias. However, the treatment became popular for a wide variety of mental illnesses after researchers in the United Kingdom published “The Depression Report: A New Deal for Anxiety and Depression Disorders” in 2006.
This report reasons that people who are mentally ill tend to be absent from work and seek healthcare. This “total loss of output” due to mental illnesses like depression and anxiety costs an estimated £12 billion a year, £7 billion of that in taxes. In comparison, an investment of £600 million in CBT-based therapy could dramatically reduce the expenses associated with sickness.
In short, CBT was a way to get people well enough that they could return to work. Because of this reportedly high return on investment, these ideas became popular in the United States and Canada. This is why they are especially prevalent in online self-help resources.
For example, the Ontario government has made Lifeworks’ AbiliCBT free for residents aged 16 or older. Participants complete an assessment questionnaire and are contacted by a professional therapist. Afterwards, they move through “structured modules” while the therapist monitors their progress. This program is also marketed in terms of its ability to “reduce costs” and “boost productivity.” Lifeworks is the same producer of MySST.
While this seems like a convenient solution for institutions, data from the UK in 2018, examined 12 years after the “Depression Report”, showed that the widely advertised effectiveness may be significantly overblown. The system itself is burdened by an incredibly high demand and low staff morale. Many people are turned away because their illnesses are too complex. Patients who, for any reason, refuse or fail to respond to treatment are diagnosed as “CBT-resistant”, further pathologizing normal reactions to a treatment that fails to account for the lived realities of many people.
For many, myself included, these issues in the UK sound familiar in our University context. We know that even with the “improved” system, wait times are very long and that six sessions are not enough. Students have trouble actually navigating the bureaucracy of the medical system and securing appointments.
Even without resorting to the University Mandated Leave of Absence Policy, students with complex or difficult issues are encouraged to leave the University instead of being given the support they need to maintain their health in their University community.
Only those who are actively in crisis qualify for the more “resource-intensive” treatment options. Those who are not yet a harm to themselves or others are directed to community resources, which have their own extensive wait times, or online resources like MySSP. This is antithetical to crisis prevention.
My mental health does not exist only to make me a productive worker or student. In my undergraduate spaces, people would talk about how students are more than “just a number.” Increasing the number of appointments per student will not improve anyone’s situation if it is not the kind of care which acknowledges the “intolerable and inhumane social pressures” in which students—people—live.
Editor’s Note: Alisha Krishna is the outgoing Chair and Treasurer of Students for Barrier-Free Access and a caseworker in the Academic Appeals Division of Downtown Legal Services.
