Taylor*, 27, a graduate student at Stanford University in California, was having a phone session with her psychiatrist when they told her they could no longer treat her.
She hadn’t seen it coming. She met with the psychiatrist through Stanford's mental health services. And though Taylor had paid the on-campus health clinic fee and was up to date on the university-sponsored health insurance, due to the pandemic, she was currently residing outside of California. And that, apparently, was a problem.
"My psychiatrist on campus told me since I was outside the state of California, they could no longer treat me. I’m on the university-sponsored health insurance and because I’m an international student, I had no coverage back at home, either," she messaged Refinery29 via Twitter. "At my last appointment, my Stanford psychiatrist basically told me to find a provider at home — although I hadn’t lived at home for 8 years. Then [they] more or less hung up the phone."
Taylor says her anxiety was already high due to the pandemic. Having her mental health care suddenly ripped away only worsened her symptoms. "It made me feel like Stanford couldn’t give less of a shit about their students, which frankly reflects their general attitude around mental health even pre-pandemic," she says.
The inability to provide care for out-of-state and out-of-country students is not unique to Stanford University. Colleges and universities across the country are facing this same issue. The problem lies in licensing and legal requirements: Healthcare providers, like psychiatrists and therapists, get licensed in a particular state; with a few exceptions, they’re generally unable to practice outside of that state.
During the beginning of the pandemic, some states were given temporary emergency allowances. These permitted counselors to continue treating students who’d left campus due to COVID-19, regardless of where they currently resided, explains Amy L. Hoch, PsyD, associate director of the wellness center at Rowan University in Glassboro, NJ.
But few people expected that colleges would still be teaching a large percentage of their students remotely into this fall. Now, some emergency allowances may be starting to expire. Even when extensions have been granted, navigating which states are allowing what can be confusing and time-consuming. For instance, New Jersey is allowing out-of-state healthcare providers to provide healthcare to NJ residents, via telemedicine or in person, through February 2021. But providers licensed in New Jersey who are hoping to provide care to residents of another state would have to look up the regulations of that state to see what’s allowed. They may have to submit proof of their license to that state, or apply for an emergency out-of-state license. And right now, a counselor could be working with five students who are currently residing in five different states.
At Rowan, “We can’t cross state lines in providing mental health services,” Hoch says. “Since many students have been sent home or are choosing to stay at home, there might be a gap in services for those students. It's a huge issue.”
This withdrawal of access to mental health care for college and university students couldn’t come at a worse time. "Even before the pandemic, mental health for young adults is a key issue to really navigating this transition from childhood to adulthood," Hoch says. "Prior to the pandemic, mental health issues were on the rise for young adults." Now, she adds, students may be feeling isolated, and may have lost their sense of community, because they're unable to connect with their classmates or their peers in the ways they’re used to. As a result, college students are more vulnerable now than ever before.
Young adults have reported elevated levels of anxiety, depression, and mental health symptoms, the Centers for Disease Control and Prevention report. Black people of all ages have been disproportionately affected. In general, LGBTQ+ youths are also more likely to experience mental health disorders, according to a 2020 survey conducted by The Trevor Project.
Right now, students need more mental health care — not less.
The problem of providers being unable to provide care across state lines predates the pandemic, though “COVID has kind of amped it up on steroids,” Deborah Baker, JD, director of legal and regulatory policy at the American Psychological Association, tells Refinery29. She says the APA is looking at supporting national legislation that could help address this gap.
One option is PSYPACT, an agreement that lets psychologists practice via telemedicine in states other than where they’re licensed, with the goal of improving access to mental health care. PSYPACT legislation has been enacted in 14 states, according to the APA: Arizona, Colorado, Delaware, Georgia, Illinois, Missouri, Nebraska, Nevada, New Hampshire, Oklahoma, Texas, and Utah, with Pennsylvania and Virginia joining the ranks back in May.
"The hope is that eventually all 50 states plus D.C. will sign onto the PSYPACT," Baker tells Refinery29. She says there has been a definite increase in interest from more states since COVID-19 began. "[States are] considering more seriously the needs of interstate practice as it relates to telehealth,” she says. Besides college students, who travel frequently between states, in certain areas it’s relatively common to live and work in different states. “Technology has enhanced mobility and the licensing laws aren't nimble enough to be flexible for other options," Baker says.
Getting a PSYPACT agreement signed by all 50 states is a long-term process. In the meantime, Hoch tells Refinery29 that if a student is in crisis and needs their services, the school’s mental health providers wouldn't turn them away. "If a student calls from out of state, we would never say that we can't provide crisis service," she says. “And I hope most universities would follow that route. We would get them the help they need in the moment." But, she continues, they aren’t able to provide ongoing care for out-of-state students. And that leaves a lot of people — like Taylor — in a lurch.
Refinery29 reached out to Stanford University to ask about their inability to continue providing Taylor with treatment. They responded with this statement: "Our Counseling and Psychological Services (CAPS) remains focused on student mental health and wellbeing, especially at this time of crisis and isolation for so many students. Licensing laws change from state to state and vary according to the degrees of the mental health providers (psychiatrists, psychologists, and master’s level therapists), which can affect the support and access we can provide across state lines. For students outside of California, we provide care management services, help students connect with mental health resources in their local communities, and provide interim support for their needs. Regardless of where they live, we encourage students to reach out to CAPS when they need support. We want to hear from students so we can help address their needs and concerns in real time."
Stanford University also voiced support for the TREAT Act, which is legislation recently introduced in the U.S. Senate that would support the ability for full cross-state care for all licensed providers through the duration of the pandemic emergency. The statement given to Refinery29 said that Stanford's CAPS "has also been working with mental health representatives from the university’s student leadership who are engaging student support for this legislation."
But for now, students like Taylor may be without care. "It took me two years to get a therapist [at Stanford], because all of the providers taking the Stanford health insurance in the area weren’t taking new patients," she says. “Who knows how long I’ll be out of state, so I don’t even know if it’s worth trying to find a provider.”
The gap left by the pandemic in student mental health services isn't going to be closed overnight. But the need for services like this is only going to get more dire the longer the pandemic goes on. "Unfortunately there's no quick fix to address the constraints and the immediate needs that we're seeing in light of COVID, particularly in the states that haven't adopted [PSYPACT] yet," Baker explains. "It creates these unfortunate situations and it just highlights why we need to look at the compact as a viable solution."
*Name has been changed
If you are in crisis, please call the National Suicide Prevention Lifeline at 1-800-273-TALK (8255) or the Suicide Crisis Line at 1-800-784-2433.