SALT LAKE CITY — While adjusting to the unfamiliar pressures of a new school, a new city, and new anxieties, Polly Moser developed anorexia as a freshman at Stanford University in 2018.
By the end of her sophomore year, Moser, 20, was managing her eating disorder with the help of a therapist through Stanford Health Care. But when school administrators shut down campus due to the coronavirus in early March, Moser had to move home to Maryland — nearly 3,000 miles away from her carefully woven health care safety net.
“I really liked my therapist a lot. It was so convenient. It was on campus, so I could bike there,” said Moser, who has not yet found a therapist to work with in Maryland. “Building a rapport and a relationship with a therapist takes a long time. They would have to learn about my whole history, and I’m just not in a mental place where I could do that in an effective way with someone new.”
Before the pandemic, campus mental health facilities across the country were already struggling to serve a growing number of students experiencing mental health crises. Nearly 20 million students enrolled in U.S. colleges in the fall of 2019, and roughly 10% to 15% seek services at their college counseling centers, according to Higher Ed Today. In 2019, the American College Health Association found that 87% of college students felt overwhelmed by all they had to do, 56% felt things were hopeless and 13% seriously considered suicide.
In recent weeks, therapists at university hospital systems as well as campus counseling and psychological services have scrambled to make adjustments. Most students who live in the same state as their school have been able to continue their treatment via telehealth. But due to licensing restrictions that prevent therapists from practicing across state lines, students who live elsewhere have had to find other treatment options. Less than half of the 356 colleges that participated in an April survey by the American College Health Association said they were able to virtually treat students, regardless of where they were living.
“This is the biggest problem we’ve run into with the whole state law and licensing,” said Klint Hobbs, assistant director over outreach services at Brigham Young University’s Counseling and Psychological Services. Certain government entities, like the Centers for Medicare and Medicaid Services, have temporarily allowed medical professionals to serve rural areas by practicing telehealth across state borders. But state licensing laws say therapists can’t treat clients who live in other states without being licensed there.
“No definitive guidance has been given to universities about this,” said Hobbs. “The law says one thing, but then the government has put out guidelines that offer some flexibility in other areas. And so it’s really up to the university to determine how they’re going to interpret that line.”
For now, BYU is abiding by advice from legal counsel to not offer ongoing therapy to students who reside in other states, said Hobbs.
When Moser called her insurance provider to see if she could continue seeing her California-licensed therapist via telehealth, she was told that “under absolutely no circumstances are you allowed to see someone not licensed in Maryland.”
But feeling that her health depends on it, Moser decided to do so anyway.
“I’d be lying if I said it doesn’t make me a little bit anxious,” said Moser, who worries that she could be presented with a huge bill if the insurance provider catches on and decides not to cover the therapy. “It seems ridiculous to me. I am Stanford student now, my therapist is part of the Stanford Hospital. I believe if these rules aren’t changed, they should be waived for the pandemic.”
Barriers
Some schools, like the University of Utah, stopped taking in new clients when the coronavirus hit in March. Lauren Weitzman, director of the University Counseling Center, said it was hard to turn students away while the counseling center figured out a remote care setup. During that time, students in crisis were still able to call the center. Over the phone, counselors “triaged” students in need and connected them to other resources, Weitzman said. The center also provided several webinars about dealing with stress during the pandemic.
After six weeks, the University of Utah Counseling Center has resumed client intakes, but only for students that live in Utah. For out-of-state students, Weitzman said the center can help them find a local therapist. But whereas short-term therapy at the university counseling center is offered at a reduced fee, students must cover their own costs for mental health care in their community, Weitzman said.
“It’s challenging to not be able to provide somebody with something that they’re looking for,” said Weitzman. “But I think everybody has been pretty understanding. I mean, these are unprecedented circumstances.”
Maryorie Delgado, 23, is a junior at BYU who is currently living in Tennessee. She started seeing at therapist at Counseling and Psychological Services last year while she was a full-time student and simultaneously working full time to run a car dealership with her father in Orem, a business that supports her entire family.
“It was a lot of stress happening with school, providing for myself, for my family,” said Delgado. “It was so much.”
After Delgado left campus, her therapist told her she wasn’t authorized to provide therapy out of state; she would only be able to provide one final teletherapy session to wrap up loose ends.
Delgado initially struggled to adapt to pandemic life, but said she now feels stable enough to forgo therapy for the time being.
“My therapist has taught me different exercises I can do to help with anxiety,” said Delgado. “I’m pretty self-sufficient now, but if something were to hit again, and it was really an emergency, I know she would be there for me.”
Hobbs said that BYU Counseling and Psychological Services is still offering crisis sessions to students, regardless of whether they live in state or out of state.
“If we were to look ethically at how we practice, if we were to deny services to somebody in crisis because they were across state lines, that would be a worse thing to do than to be flexible with that rule,” Hobbs said.
Change
Beginning in April, the Centers for Medicare and Medicaid Services temporarily suspended certain regulations, making it possible for health professionals to care for patients at rural areas across state lines via telehealth. In addition, the vast majority of state medical licensing boards have loosened restrictions so that physicians and other medical practitioners can practice across state lines in a limited capacity. But these adjustments are not necessarily geared toward college mental health services, which may serve students rural and urban settings in 50 different states, with a variety of different types of licensed professionals.
Dallen Allred, CEO of Salt Lake City-based virtual mental health startup Tava, said the fact that each state has its own licensing rules is “extraordinarily silly.” The requirements in each state are essentially the same in terms of education, training and professional conduct. The laws are meant to protect consumers, but in reality they do more to protect business, Allred said.
“Each state wants to protect the compensation and need for clinicians in their state — kind of like a guild,” said Allred. “Basically, they don’t want a bunch of out of state clinicians coming in and disrupting their business or disrupting patient flow.”
Allred has been pleased to see the loosening of Medicaid rules and state regulations in light of COVID-19.
“The rub will be — does it stay improved or does it go back to the way it was?” he asked.
Janet Orwig, the executive director of PsyPact, says her organization offers a long-term solution. PsyPact is an interstate compact that will allow licensed psychologists to practice telepsychology across states without requiring an individual become licensed in every state to practice. Twelve states, including Utah, have enacted legislation to join the pact. But the program is still rolling out applications and doesn’t come into effect until July of this year. In addition, it only applies to psychologists who are licensed at the doctoral level, as opposed to therapists, who typically have fewer years of academic training.
Going home
According to Ben Salazar, a therapist who works with BYU Counseling and Psychological Services, the late teens and early 20s are a time when a person experiences major life changes and mental and emotional disorders are most likely to manifest. For that reason, many young people pursue therapy for the first time at college.
One 20-year-old Stanford sophomore from a northern suburb of Chicago, who asked that he not be named, said mental health struggles were never something his family talked about growing up. But at the beginning of the school year, he started experiencing depressive episodes and decided to get help, first through Stanford’s counseling and psychological services, then through a program for first-generation college students, and finally through counseling offered at the school’s Vaden Health Center.
He liked it because the service was free and didn’t require he use his parents insurance. He didn’t want them to know he was seeking help for mental health.
Now that he is back at home, the student’s relationship with his parents is improving, but he has struggled to open up about his mental health and is reluctant to find a local therapist. Meanwhile, he’s had to adapt to remote schooling, changes to summer internship and study abroad plans, and a more isolated life.
“It’s difficult to go from a place like Stanford where you can reach out and talk to people and have casual conversations, to being stuck in your room all day,” said the student. “Everything is default by yourself.”
Salazar said his concerns about doing teletherapy have mostly subsided. He initially felt uneasy about not being able to see his patients face to face, especially those who are at risk of self-harm. But Salazar has been pleasantly surprised by how well therapy has gone over Zoom.
Still, he still worries about clients who may not be comfortable taking therapy calls at home, for fear that their parents might overhear them, or clients who are struggling with social distancing conditions.
“There are people who come to mind who are not in great living situations, or are very isolated,” said Salazar. “That isolation can make their depression or anxiety worse.”