A utilitarian approach to student wellbeing:

How McGill’s stepped care model has failed students and practitioners alike

By Nicholas Jasinski, Editor-in-Chief -- April 11, 2017
(Noah Sutton/ The McGill Tribune)

McGill’s Counselling and Mental Health Services have come under fire in recent years, as changes meant to improve care have instead focused on reducing wait times and seeing as many patients as possible. Interviews with current and former counsellors at McGill Counselling Services—some of whom would only speak off the record because they feared repercussions from their employer—reveal that while these quantifiable metrics may have improved, they translate to a lower standard of care for students, and come at a cost to morale and retention of experienced staff.

Until 2007, all student services on campus were under the provision of the Coordinating Committee on Student Services (CCSS), a McGill Senate parity committee composed of an equal number of student and staff members. The CCSS was responsible for overseeing the operations, budget, and other administration of student services includingHealth Services, First Peoples’ House, the Mental Health Service, Career and Placement Services (CaPS), and International Student Services (ISS). Staff members included McGill administrators, directors of various services, and professors, while student committee members included the presidents of the Students’ Society of McGill University (SSMU) and the Post-Graduate Students’ Society (PGSS), as well as representatives from each faculty.

The Deputy Provost (Student Life and Learning) [DPSLL] position was createdin early 2006 following one of the preliminary recommendations of the Principal’s Task Force on Student Life and Learning at McGill. In spring 2005, the Task Force was assigned to review issues affecting student life and learning at McGill, and released its final report in December 2006. The first DPSLL, Psychology associate professor Morton Mendelson, began his term in July 2006.

“The idea behind my position was to have someone in the senior administration who represents student issues, so those issues would be considered at the senior table and other issues would be considered with reference to how they affect students and student life,” Mendelson told the McGill Reporter in August 2012 . Current DPSLL Ollivier Dyens declined a request to comment for this story.

Administration of Student Services moved to the DPSLL’s portfolio in 2007, with students losing the direct oversight of services they had had as part of the CCSS. An additional administrative position of Executive Director, Services for Students (EDSS) was created to supervise all non-academic services at McGill and report to the DPSLL. Currently, the Committee on Student Services (CSS) remains a student/faculty parity committee of Senate, but can only advise the EDSS on Student Services policies and budgetary priorities.

According to former director of McGill Mental Health Services Dr. Norman Hoffman, who led the service from 1992 until 2007, several directors of services raised their concerns and confusions over the reorganization.

“We understand that the McGill Administration wishes to have a stronger liaison with Student Services, but the proposed structure would leave Directors one step further removed from the Provost,” Dr. Hoffman and other directors wrote in the Student Service Response to the Draft Report of the Principal’s Task Force on Student Life and Learning at McGill at the time. “This appears to be going in the opposite direction to all of our goals [....] In Student Services [...] we do not have a management problem, nor do we have any need for a purely administrative manager. What we do have [...] is a communication problem with the McGill Administration. An Executive Director, who would be the employee of the Administration, would only accentuate this communication difficulty. The position would also likely jeopardize our partnership with the students, thus leading Student Services and McGill to become less student-centred.”

In an interview with The McGill Tribune, Dr. Hoffman lamented students’ reduced oversightof essential student services after the CCSS.

When they created the office of the Deputy Provost [Student Life and Learning] it was basically a hostile takeover of Student Services,” Dr. Hoffman said. “Before [students] were the bosses. So every year as director, if I felt I needed more therapists, more psychiatrists [...] I would put it in my budget and would then present the budget to CCSS [....] What [having a parity committee] meant is that as long as the students had one staff member on their side, they had control over what the budget was. And they always had one staff member on their side because usually the student services people were on their side. The McGill faculty that volunteered to be on it were pro-student. Basically if [students] wanted something they got it, if they didn't want something it didn't happen.”

Control over the direction of student services was increasingly ceded to the administration, as directors of individual student services saw the scope of their roles decrease as well.

“They took away administrative and financial responsibilities from the Director of Mental Health,” Dr. Hoffman said. “So from that point on the Director of Mental Health has only clinical responsibilities within the service and could not plan for the future, could not plan budgets, did not have the amount of contact with students that the students wanted. Everything from then on was dictated by McGill administration.”

With mounting academic and personal pressures and the stigma surrounding mental health beginning to subside,the number of students who have sought counselling and psychiatric help at McGill has grown by over 35 per cent since 2011 . This increase in demand led to McGill Mental Health Services’ development of a “stepped care model” which it implemented in Fall 2016. Under a stepped care model, the least resource-intensive treatmentis provided to patients first, only stepping up to more intensive or specialized services when determined clinically necessary.

As part of the reorganization, Counselling Services and Mental Health Services (now called Psychiatric Services) were combinedinto one administrative unit,with a single intake and triage area in the Brown Building. Counselling focuses on mental health awareness and helping students through personal or academic issues, while Psychiatric Services assists students with mental health illnesses including depression, anxiety, and eating disorders.Students arrive for a first evaluation with a therapist who will refer them to the appropriate service or resource they require, from self-help tips in an online module to group therapy to professional psychotherapy services. However, according to Dr. Hoffman and current and former counsellors who wished to remain anonymous, this model’s decreased wait times and ease of access have come at the cost of thorough and personal care for some students.

“Before [the stepped care model], we had more professional autonomy,” a former McGill psychotherapist who left the service in the past year after several years in their role told the Tribune.“As a psychotherapist or a psychologist, you could actually determine what your patients needed. Recently, it came out of the [stepped care] mandate that we couldn't give people more than two sessions and we were encouraged to send them all to lower-intensity services such as group [therapy] or online support. About 20 to 30 per cent of the students who come in really require intensive work and those are the ones who are really missing out.”

"The intake model they have now is a superficial information gathering model where, as some counsellors who work there now have told me, their main goal is to figure out how they can get rid of the student [by referring them to a different service or resource.]"

Group therapy options currently offered by Counselling Services include sessions ranging from academic success workshops to multiple-session groups providing cognitive behavioural therapy for social anxiety. Dr. Hoffman compared the current intake approach to a “meat grinder,”and contrasted it with the methods employed in previous years.

When students have a problem, they want to talk to somebody, not be sent to a peer support group or an online module,” Dr. Hoffman said.” [...When] I teach how to approach students [...], I teach what I call therapeutic interviewing, which means [if] you're a student who's upset and you come to see me, I want to make sure that even if it's just an initial interview then by the time you leave, you're feeling better [....] That there's a person you can talk to who will understand your problems. And those problems are addressed to some degree within the first session.The intake model they have now is a superficial information gathering model where, as some counsellors who work there now have told me, their main goal is to figure out how they can get rid of the student [by referring them to a different service or resource.]”

The psychotherapist who recently left McGill also spoke to the intended outcome of a student’s first meeting with Counselling Services under the current stepped care model.

“The first meeting is basically an assessment to determine what services you can offer them,” the former counsellor said. “Very often it's a group. But once a group is started it's very hard to have someone new join. They meet at scattered times. Or you can refer them out or give them therapy assisted online or send them to peer support [....The goal of the first meeting] is to triage them.”

Dr. Hoffman and two of the other counsellors who spoke with the Tribune expressed their disapproval for a high emphasis on simply reducing wait times and seeing more students, and stressed that those two metrics alone do not necessarily align with providing better service.

“It's very difficult if you see somebody come into your office [...] who you know you can help by seeing them on a one-to-one basis, then sending them to a group,” a former counsellor said. “Because you know that you can help but you're not allowed to [....] The whole idea is [to] see a lot of people, [...In counsellors’] reviews, one of the things that is highlighted is how many open appointments they have in their schedules.

Dr. Hoffman believes that the root of this issue goes back to the creation of the DPSLL’s office and its assumption of student services’ administrative responsibilities.

When they created the office of the Deputy Provost (Student Life and Learning), they switched from giving [annual reports from each service] to a system [...] in which you're supposed to only report things that you can measure,” Dr. Hoffman said. “For mental health, what could you measure? If you want to measure actually how students improve and what are their long-term outcomes you would have to spend a million dollars doing studies. So you measure how many students you saw, what the waiting times were. If your goal is to improve your measurements of waiting times [...] you do all triage and no treatment, then your wait times go down. [That] doesn't tend to lead to people giving better help. The metrics don't line up.”

Counsellors who spoke to the Tribune believe that a focus on quantity over quality has had negative effects on students and therapists alike. They stated that there have been multiple staff departures from Counselling Services and Psychiatric Servicesover the past two years due to low morale, especially among the most experienced and longest-serving members.

“When you're sitting in your office and you're having somebody pour their guts out to you, it's intense and it takes a lot out of you,” one former counsellor said. “And if you're watching the clock and you have five minutes to wrap up and see another person, it's demanding and people get burned out [....] I have seen really really excellent therapists there, but those things weren't valued. What was valued was 'can you find a resource that isn't therapy.' That was valued [....] That's what really took a lot out of people, to see someone break down in their office and then say, you have to go to a group, you have to go online."

In addition to demanding work schedules, counsellors who spoke to the Tribune described a “shape-up-or-ship-out” attitude from administrators in Counselling Services that demands buy-in with the service’s new mandate.

“You cannot express any dissatisfaction as a counsellor or a therapist with the stepped care model,” the former psychotherapist said. “People have been called into [Executive Director of Student Services] Martine Gauthier's office, they've been reprimanded. We were told a long time ago that the model was here to stay.”

"All the stepped care, peer support, online modules, these are all good as adjuncts to good care. You want to provide good care where people can come in and see a counsellor or psychotherapist quickly, who will give them what they need and then you want to add something to that for follow-up, for extra support."

Dr. Hoffman, who now has a private practice in downtown Montreal, said that he has seen numerous students who felt so poorly treated at their initial intake session that they chose not to return to McGill’s mental health services.

It's not that stepped care is inherently bad,” Dr. Hoffman said. “All the stepped care, peer support, online modules, these are all good as adjuncts to good care. You want to provide good care where people can come in and see a counsellor or psychotherapist quickly, who will give them what they need and then you want to add something to that for follow-up, for extra support.These things are fine as adjuncts. But they're using them at McGill as primary modalities of treatment instead of providing proper treatment, and that's the problem.”

In December 2017 Dr. Hoffman sent a six page letter to Principal Suzanne Fortier outlining his concerns with the management of mental health services at McGill. In a four sentence response over a month later, Provost and Vice-Principal (Academic) Christopher Manfredi reaffirmed McGill’s priorities as “amplifying the range of services available to students and reducing wait times”–underlining the focus on quantifiable metrics that counsellors criticized for detracting from providing adequate care to all students.

At the March 28 meeting of the McGill Senate, EDSS Martine Gauthier introduced the new Rossy Student Wellness Hub (RSWH), a new umbrella service with the goal of further integrating and streamlining student health, psychiatry, and counselling at McGill. The Hub is planned to open in the Brown Building by January 2019.

“Health promotion includes awareness, prevention, and early intervention,” Gauthier said at the meeting . “At this point, Student Services, in terms of our approach to student mental health, has been largely reactive. So we’re moving to a more proactive model. We’re trying to get into where students are working, learning, and living, […] and providing support before students get to a crisis point where they need to be accessing a counsellor or psychiatrist.”

The psychotherapist who resigned in the past year gave a pessimistic assessment of the future of mental health services at McGill should the current focus on achieving easily-measurable goals continue.

"They will continue to see a lot [of patients], there will be a lot of window dressing,” the psychotherapist said. “It will look good and they will see good numbers but someone should go in and look at the dropout rate of the groups, see how many people who get referred out for therapy actually follow up, and what happens to those who really have a severe disorder can only be seen once a month or very rarely. I think a lot of therapists who have the intention of doing what they trained for but can't do therapy, they will leave. It’s not a pretty picture."