Mental Health in Ontario's Postsecondary Education

Mental Health in Ontario’s Post-Secondary Education System

Policy Paper May 2012

By Tamara Popovic Research and Policy Analyst [email protected]

The College Student Alliance 301-372 Richmond Street West Toronto, ON M5V 1X6 T: (416) 314-1212

About Our Organization:

The College Student Alliance (CSA) is a member-driven advocacy organization that has been proudly serving Ontario’s college and college-university students since 1975. The CSA currently represents students from 16 colleges and 23 student associations with over 130,000 full-time student members throughout the province.

Table of Contents

EXECUTIVE SUMMARY ...... 1 WHAT IS MENTAL HEALTH? ...... 2 YOUTH AND MENTAL HEALTH ...... 2 INCREASING PRESSURES ON COUNSELLING SERVICES ...... 3 RECENT DEVELOPMENTS IN ONTARIO ...... 4 ROLE OF PSE IN MENTAL HEALTH PROMOTION AND TREATMENT ...... 4 ONTARIO MENTAL HEALTH STAKEHOLDERS MAP ...... 7 WHAT ARE THE MOST FREQUENT ISSUES STUDENTS FACE? ...... 9 FIGURE 1.1 MOST FREQUENTLY IDENTIFIED STUDENT HEALTH ISSUES/CHALLENGES ...... 9 FIGURE 1.2 SERVICES MOST FREQUENTLY USED TO ADDRESS STUDENTS’ HEALTH CONCERNS ...... 9 FIGURE 1.3 THE MOST FREQUENT IMPACTS OF STUDENTS’ HEALTH-RELATED CONCERNS ...... 9 LACK OF ACCESS TO MENTAL HEALTH SERVICES ...... 10 ONTARIO STUDENT ASSISTANCE PROGRAM (OSAP) AND MENTAL HEALTH ...... 10 RECOMMENDATIONS ...... 12 CONCLUSION ...... 20

Executive Summary a mental health in PSE policy framework (jointly with stakeholders) and for (2) a greater ex- This document discusses what it means to be change of knowledge through collaboration and mentally healthy and how it relates to the post- the sharing of best practices. Another recom- secondary education (PSE) sphere in Ontario. It mendation (3) is increasing the levels of funding provides recommendations to improve the for institutions so that they can develop and recognition of mental health issues on campus maintain support services, and (4) a the devel- and to enhance support services. It explores opment of a mechanism that allows students to current youth trends and how the student ex- identify themselves as needing additional sup- perience in PSE can be used to set the founda- port in the early stage of their college career. tion for healthy lifestyle habits and choices as the role of PSE institutions during the students’ To further this, (5) institutions must have clearly time in post-secondary education is critical. The articulated confidentiality and disclosure poli- recommendations explore the options that in- cies, and (6) all stakeholders must ensure that stitutions, government, and stakeholders have students are able to access a coordinated sup- available to them to support students’ mental port system on campus or across the province health as they pursue higher education. with external agencies. In order for PSE institutions to support students in a more efficient The increasing pressures that counselling ser- way, (7) support and train staff and administra- vices have been experiencing in supporting tion on all levels to recognize, and appropriately more complex and frequent mental health is- deal with mental health and addiction issues as sues are investigated, as are recent develop- necessary. ments in Ontario’s PSE spheres as they relate to metal health. Included is a discussion of the role In terms of the measurement of success in men- of PSE in mental health promotion and treat- tal health support, (8) stakeholders must have a ment as well as a description of the recent shift clear statement of aims and outcomes for men- to a collaboration of counselling efforts. To help tal health initiatives with clear indications of readers understand the different policy actors how these will be achieved, measured, and involved, there is a map on page 7 of Ontario’s evaluated. With respect to the promotion of PSE mental health stakeholders. An overview of mental health, (9) the government, external what the most frequent issues are for students stakeholders, and institutions should promote a is provided as is a description of the issues that healthy lifestyle that includes the reduction of arise due to a lack of access to mental health alcohol, tobacco, and substance misuse. Indeed, services. (10) sector stakeholders must work together to raise awareness and de-stigmatize mental In the conclusion of this paper, there are 13 health and substance use issues across the recommendations to improve mental health province. and support in Ontario’s PSE sphere. These recommendations can be easily implemented by Lastly, (11) governments, institutions, and government and sector stakeholders to improve stakeholders must make sure that students students’ mental health across campuses, and have access to support services for mental they are focused on bringing about more col- health, including the (12) reestablishment of the laboration among stakeholders and the promo- Ontario Special Bursary Program and (13) the tion of mental health. engagement of students in development and evaluation of mental health initiatives and ser- These 13 recommendations are made so that vices in their post-secondary education institu- there is more fairness, access and equity in the tion. PSE sphere. They call for (1) the development of

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What Is Mental Health? students is paramount for their overall health and that the promotion of mental Mental health refers to our cognitive and health is an effective way to improve the emotional well-being. According to the overall quality of the college students’ lives. World Health Organization (WHO), mental Promoting mental health is a reliable way to health is “a state of well-being in which the develop the potential of the students and individual realizes his or her own abilities, can help build a healthy atmosphere and can cope with the normal stresses of life, campus culture. Mental health difficulties can work productively and fruitfully, and is on campus can have the potential to disrupt able to make a contribution to his or her individual student performance, classes, community.” Mental health can also be de- and student activities and may lead to criti- fined as “…the capacity of each and all of us cal incidents that impact the campus com- to feel, think and act in ways that enhance munity. our ability to enjoy life and deal with the challenges we face. It is a positive sense of Youth and Mental Health emotional and spiritual well-being that re- spects the importance of culture, equity, The mental health of youth is as important social justice, interconnections and personal as their physical health. Those who suffer 1 dignity.” Mental illnesses, in contrast, are from mental health issues are also more characterized by alterations in thinking, likely to manifest both physical and mental mood or behaviour—or some combination health and problematic substance use. The thereof—associated with significant distress onset of most mental illnesses occurs dur- and impaired functioning. ing adolescence and young adulthood; more specifically the 15-25 is a natural age The symptoms of mental illness vary from range for the onset of mental disorders, a mild to severe, depending on the type of time when many young people are attend- mental illness, the individual, the family, ing college and university.3 The post- 2 and the socioeconomic environment. Men- secondary student population falls into the tal health is recognized as a major contribu- highest-risk age group for mental illness and tor to maximizing the benefit that students problematic substance use. Indeed, 18% of derive from their experiences at a college or youths aged 15–24 reported symptoms as- university, and the contribution that stu- sociated with mental health and addiction dents make to the community. issues, compared with 12% of 25–44- yearolds and 8% of 45–65-year-olds. The College Student Alliance (CSA) believes that the importance of mental health for Studies have shown that stress, sleep loss, and depression are commonplace in the student population. Excessive stress induces 1 Lakaski, Carl. 2008. “Mentally Healthy Communi- ties: An Exploration” Mentally Healthy Communities: A Collection of Papers. Last accessed April 25, 2012 3 Gail MacKean. 2011. Mental health and Well-Being 2 Government of Canada. 2006. The Human Face of in Post-Secondary: a Literature and Environmental Mental Health and Mental Illness in Canada. Re- Scan to Support Planning and Action in Canada. Last trieved from http://www.phac- accessed April 12, 2012, from: aspc.gc.ca/publicat/human- https://www.cacuss.ca/content/documents/Link/CA humain06/pdf/human_face_e.pdf. CUSS/Post%20Sec%20Final%20Report_June6.pdf

2 | P a g e physical impairments, and it is not uncom- Increasing Pressures on Counselling mon to find students afflicted with persis- Services tent lack of energy, loss of appetite, headaches, or gastrointestinal problems.4 More students are accessing counselling However, due to the fact that Ontario’s PSE services on campus. Counselling centre di- attainment rate is 67% and so many stu- rectors consistently report their perception dents are participating in some form of that the severity of students’ issues and usage of the services in the previous five years post-secondary education, colleges and uni- 6 versities are extremely well placed to deal have been increasing. This trend has been with these issues, and college and university consistently expressed in Canada, the U.S., students have been found to respond par- and the UK since the 1980s, along with the ticularly positively to treatment. fact that students are seeking counselling with increasingly more severe and complex Colleges and universities are learning insti- issues. This is in line with current trends in tutions in which students grow and gain PSE surveys of post-secondary counselling knowledge in their fields of study. Students centre directors’ perception of continually can use this time to develop good habits increasing levels of [the increasing complex- ity of psychiatric disorders] among the stu- and open their minds to new ways of life. 7 PSE institutions can promote the formation dent clientele. of healthy habits that will serve students Counselling center directors are troubled by throughout their lives. It is widely accepted increases in suicide ideation and behav- that early diagnosis and treatment produc- iours, self-injury reports, crisis counselling es better outcomes. PSE institutions are needs, eating disorders, past sexual trauma particularly well placed to facilitate early reports, and sexual assaults.8 When asked intervention that can provide students the what hindered their abilities to address stu- support they need to develop life skills that dents’ health issues, the three most fre- will serve them well so they can be contrib- quently identified factors were a lack of uting members of society. It has been esti- proper staff, a lack of financial resources, mated that every $1 spent on mental health and a need for more (physical) space.9 and addictions treatment saves $7 in health There needs to be changes to resolve these costs and $30 dollars in lost productivity 5 shortages so counsellors can better serve and social costs. increasingly diverse campus populations. As

6 Cairns, Sharon L., Helen F. Massfelle, and Sander C. Deet. 2010. “Why do Post-secondary Students Seek 4 Ranjita Misra and Linda G. Castillo. 2004. “Aca- Counselling?” Canadian Journal of Counselling/Revue demic Stress among College Students: Comparison of canadienne de counselling/2010, Vol. 44:1 p. 34. American and International Students.” International 7 Cairns et al., p 34 Journal of Stress Management. Vol. 11, No. 2, 132– 8 Gallagher, R. P. 2007. National Survey of Counsel- 148 p. 133 ling Center Directors 2007. Last Accessed March 9, 5 Ontario Ministry of Health and Long-Term Care. 2012 from: 2009. Every door is the right door: Towards a 10-year http://www.iacsinc.org/NsccdSurveyFinal_v2.pdf mental health and addictions strategy. From: 9 Patterson, P. and Kline, T. 2008. Report on Post- http://www.health.gov.on.ca/english/public/progra Secondary Institutions as Healthy Settings: The Piv- m/mentalhealth/minister_advisgroup/pdf/discussio otal Role of Student Services. Health and Learning n_paper.pdf Knowledge Centre: Victoria, B.C., Canada. P. 7.

3 | P a g e students become more varied and enter tives.11 These developmental milestones post-secondary education from different frequently have a considerable impact on backgrounds, it is important that mental an individual’s mental health and may con- health professionals acquire the knowledge tribute to the development of a mental dis- and skills required to understand the cul- order. More needs to be done to address tural implications of providing services to the issues that college-aged students expe- diverse groups in order to understand the rience, as discussed below. worldviews of students who are diverse. Recently, the Mental Health Commission of Recent Developments in Ontario Canada released Canada’s first strategy, titled “Changing Directions, Changing Lives: In June 2011, the Ontario government an- The Mental Health Strategy for Canada” to nounced its comprehensive Mental Health improve the mental health of all Canadians. and Addictions Strategy, titled “Open The Strategy focuses on improving mental Minds, Healthy Minds.” Starting this year, health and well-being for all people living in the government will invest a total of $257 Canada and on creating a mental health sys- million over three years in the province’s tem that can truly meet the needs of people mental health and addiction system to help of all ages living with mental health prob- children and youth access support services. lems and illnesses and their families.12 Included in the announcement was a com- mitment to adding additional mental health Role of PSE in Mental Health Promotion workers to college and university campuses and Treatment to help with students’ transition from secondary to post-secondary education.10 Post-secondary institutions are important vehicles for reaching young adults. While This is extremely important as research the government provides support for health shows that many traditional-age students promotion activities aimed at increasing struggle with their transition from high adolescents’ mental health, particularly school to higher education. The years spent from elementary to secondary school, simi- in PSE usually bring about significant chang- lar programs for young adults are less prev- es in the students. Not only do the students alent even though research confirms that tackle academic pursuits, but many face the transition from adolescence to adult- transformations in identity formation, mor- hood is often challenging.13 As mentioned al reasoning, interpersonal relationships, cognitive development, and social perspec- 11 E.T Pascarella and P.T. Terenzini. 2005. How Col- lege Affects Students: Vol. 2, A Decade of Research. San Francisco: John Wiley & Sons, Inc. 12 Mental Health Commission of Canada. Changing Directions, Changing Lives: The Mental Health Strat- egy for Canada. Last accessed May 18, 2012 from: 10 Government of Ontario. 2011. Open Minds, http://strategy.mentalhealthcommission.ca/pdf/stra Healthy Minds: Ontario’s Comprehensive Mental tegy-images-en.pdf Health and Addictions Strategy. Last accessed March 13 The Canadian Council on Learning Health and 4, 2012, from: Learning Knowledge Centre Young Adults Work http://www.health.gov.on.ca/english/public/pub/m Group. 2006. Health and Learning Knowledge Cen- ental/pdf/open_minds_healthy_minds_en.pdf tre—Young Adults Work Group Environmental Scan.

4 | P a g e above, the challenges of young adult devel- work loss, and reductions in health-related opment are often met with the onset or re- quality of life (e.g., increases in pain and alization of mental disorders and mental suffering).16 health issues. PSE institutions can play a major role in mental health promotion There is a strong and growing awareness among the young adult demographic. In- that mental health and problematic sub- deed, it is generally accepted that PSE insti- stance abuse are key dimensions of college tutions now have an added responsibility to and university life and that these affect provide reasonable support for student learning and academic success. Some col- mental health. Mental health promotion leges and universities across Canada are can be understood as the “attempts to en- starting to get actively engaged in develop- courage and increase protective factors and ing comprehensive policies and services to healthy behaviours that can help prevent address mental health issues and problem- the onset of a diagnosable mental disorder atic substance abuse.17 This is a relatively and reduce risk factors that can lead to the recent trend because in the past Canada development of a mental disorder.”14 lagged behind the United States and the UK in documenting students’ concerns and as- It is critical that young adults learn to be sessing distress using standardized mentally healthy individuals earlier on in measures.18 life. With respect to the economy, poor mental health or mental illness can nega- Most people who are going to have lifelong tively impact the government and the mental health and problematic substance economy quite considerably. In 2009–10, use issues will be diagnosed before they 78% of short-term disability claims and 67% turn 24 years of age. Mental health and ad- of long-term disability claims in Canada diction support is very important on cam- were related to mental health issues.15 Ac- puses across Ontario as there is a high cording to a study from the Centre for Ad- participation rate and because 18% of youth diction and Mental Health, diagnosed and aged 15–24 reported symptoms associated undiagnosed mental health issues cost the with mental health and addiction issues. Canadian economy $51 billion a year in health services usage, long- and short-term This high participation rate could potentially address a major concern in mental health promotion, especially as people with mental Last Accessed March 1, 2012 from: http://www.accc.ca/ftp/pubs/studies/200612- health and problematic substance use is- CCL_HLKC.pdf, p. 20. sues will wait a median of 11 years to seek 14 The Substance Abuse and Mental Health Services treatment after the mental health and ad- Administration’s National Registry of Evidence-based Programs and Practices (NREPP).ND. “Glossary.” Last accessed April 17, 2012, from: 16 Lim, K.-L., P. Jacobs, A. Ohinmaa, D. Schopflocher, http://nrepp.samhsa.gov/AboutGlossary.aspx and C. S. Dewa. 2008. “A New Population-Based 15 Towers Watson. 2009. North American Staying at Measure of the Burden of Mental Illness in Canada.” Work Report: The Health and Productivity Chronic Diseases in Canada, 28, 3, 92–98. Advantage. Last Accessed April 20, 2012, from: www.phac-aspc.gc.ca/publicat/cdic-mcc/28- www.towerswatson.com/assets/pdf/648/The%20He 3/pdf/cdic28-3-2eng.pdf. p. 96 alth%20and%20Productivity%20Advantage%20- 17 MacKean, 2011. %20Staying@Work%20Study.pdf p. 22 18 Cairn et al., p. 36

5 | P a g e diction issue’s inception.19 If there is early affected by the presence of depression. 20 detection of mental health and problematic Of all the adverse experiences assessed, fi- substance use, students could learn how to nancial hardship was the only factor to best maintain their mental health. This is show an independent relationship with de- especially true for those students who live pression when pre-entry anxiety and de- with chronic mental illnesses or psychoso- pression were controlled. This indicates that cial disabilities. the direction of causality is more likely to be from financial problems to depression than At such an age, post-secondary students vice versa. 21 face not only the ever-increasing challenges of higher education but also many develop- The urgency to address mental health in mental issues that accompany late adoles- PSE is profound. At the individual level, cence and young adulthood, such as indi- mental health problems can have a devas- viduation and connectedness to family, the tating impact on a student’s academic suc- development of friendships and intimate cess and social functioning. PSE institutions relationships, career choices, and the pur- provide unique circumstances for govern- suit of personal and professional goals. This ment to help set students on the right path is a critical time for people in their lives as and have a positive impact on student men- mental illnesses usually have their first on- tal health. Many students have left home set in young adulthood. for the first time and may be experiencing developmental challenges associated with As it becomes more costly for students to these changes. pursue a higher education, it is important that support exists in the system to help Academic and social stressors may also add students succeed. A UK study recently con- to challenges in maintaining positive mental firmed what has been commonly observed health. If left untreated, these issues can be about student welfare: financial and other traumatic at the individual level and can es- difficulties at the PSE level can increase stu- calate to crises and can have a major effect dents’ levels of anxiety and depression and on the mental health of the rest of the that financial difficulties can have an impact community. As many students attend PSE, on academic performance. they develop habits that will impact their health for the rest of their lives. It is impera- Furthermore, the study has shown that ex- tive that institutions recognize this fact and am performance appears to be adversely promote a healthy lifestyle that students can then adopt.

19 Ronald C. Kessler, Matthias Angermeyer, James C. Anthony, Ron De Graaf, Koen Demyttenaere, Isabelle Gasquet, et al. 2007. “Lifetime prevalence and age- of-onset distributions of mental disorders in the World Health Organization's World Mental Health 20 Andrews, Bernice and John M. Wilding. 2004. “The Survey Initiative”. World Psychiatric Association. Last relation of depression and anxiety to life-stress and accessed March 10, 2012 from: achievement in students”. British Journal of Psychol- http://www.ncbi.nlm.nih.gov/pmc/articles/PMC217 ogy. Nov 2004 v95 i4 p. 509(13) 4588/ 21 Bernice Andrews and John M. Wilding.

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Mental Health PSE Stakeholders Map22

22 Adapted from Dr. Su-Ting Teo’s Provincial Stakeholders in Postsecondary Student Mental Health Map, with thanks.

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Collaborative Counselling Efforts intervention. These include interventions at the individual, group or interpersonal, cam- The promotion of mental health on campus, and community and society levels.24 puses is necessarily a collaborative process: These different interventions seek to in- there has been an integration of support crease mental health and problematic sub- services that can work together to address stance use awareness, identify at-risk mental health and addiction issues. This en- students, help students’ development of life gagement is in line with the trend in recent skills, and create a social network. years that has resulted in a shift from focus- ing primarily on improving services for peo- This is important to keep in mind so that ple living with mental health and PSE institutions can provide available ade- problematic substance use issues to pro- quate, accessible, mental health and addic- moting mental and well-being for all. tion services rooted in a recovery and student-centred philosophy, resulting in a This approach has partly developed from campus environment that nurtures, sup- the current economic reality that there are ports, and promotes student mental health. not enough resources to properly address A number of the health promotion activities all services that students may need.23 Due offered on college and university campuses to this fact, institutions are asked to do help to improve students’ mental health more with continually fewer resources. It is literacy by covering topics which help to out of this need that support services have improve mental health such as life balance, became more collaborative in nature, espe- stress management, depression, anxiety, cially as mental health and problematic sub- panic, insomnia and other sleep disorders, stance use issues are multifaceted and exam stress and suicide prevention.25 require a multi-pronged approach. This collaboration between accessibility or disabil- With regards to suicide prevention, there ity services, counselling services, and health has been a PSE initiative developed called or medical services is vital for students’ suc- The Jack Project that is the legacy of Jack cess. Windeler who, in March 2010, died by suicide during his first year of studies at Different post-secondary institutions have Queen’s University.26 The Jack Project col- different responses to mental health, which laborates closely with Kids Help Phone can be placed into four model categories which provides free, anonymous, and confi- and each tries to address a different level of dential bilingual phone and on-line counselling service for youth aged 5-20. The Jack Project provides information and support to 23 Silverman, D., Underhile, R., Keeling, R. 2008. young people as they move from late-high “Student Health Reconsidered: A Radical Proposal school into college, university, or independ- for Thinking Differently About Health-Related Pro- grams and Services for Students”. Student Health Spectrum, June 2008, AETNA Student Health. Re- trieved from: http://www.aetnastudenthealth.com/uploads/docu 24 MacKean, 2011 ments/spectrum/2008%20Summer%20- 25 Patterson and Klein, p. 36. %20College%20Health,%20Health%20for%20a%20Lif 26 The Jack Project. ND. About Us. Accessed May 15, etime.pdf. 2012, from:.thejackproject.org/about-us/about-us

8 | P a g e ent living as this transition is especially diffi- Figure 1.2 Services most frequently used to address cult. students’ health concerns28

In recent years, counsellors and staff have Help Available more frequently undergone training to rec- Health clinic on campus, nurses and doctors on campus ognize and provide support to students, es- Counsellors, psychologists, elders available pecially those that are in high-risk or critical on campus situations. Examples of these training pro- Recreation/fitness centre, gym, pool grams include SafeTALK and Mental Health Social events/clubs organized by student First Aid (MHFA). SafeTALK is a three hour government training program that prepares anyone over Massage, chiropractic, physiotherapy avail- the age of 15 to identify persons with able Career, guidance counselling thoughts of suicide and connect them to Supportive instructors/professors suicide first aid resources. Mental Health Tutors (informal and formal arrangements) First Aid is a two day program which teach- Student Disabilities service es people how to: recognize the signs and Off-campus contact symptoms of mental health problems; pro- Funding, financial aid vide initial help; and guide a person towards Residence life/advisors appropriate professional help. Many institu- Multi-faith chaplains tions have developed their own programs Learning/orientation to help students as the needs and de- Figure 1.3 The most frequent impacts of students’ mographics on campuses can shift from one health-related concerns29 institution to the next and from one campus to another. Impact Identified Effect on academic performance What are the most frequent issues stu- Dropping out/retention/completion dents face? Increased anxiety Poor concentration Figure 1.1 Most frequently identified student health Prone to catch flus and illnesses 27 issues/challenges Domino effect (trying to deal with one issue causes another) Student Health Challenge/Issue Lose Interest in learning Mental health (anxiety, depression) Guilt Sleep Deprivation (fatigue) Poor grades/student learning Stress Lower self-esteem/confidence Addiction (alcohol, drugs, on-line gambling) Depression Poor nutrition (diet), eating disorders, Healthy lifestyle choices weight issues Sense of security for students Flu/colds Recruitment Unplanned pregnancy/STDs, sexual health Productivity Lack of physical activity Not sure Financial concerns

Life balance Learning disability General physical health

28 Patterson and Kline, p. 20. 27 Patterson and Kline, p. 19. 29 Patterson and Kline, p. 21.

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visible in students’ academic work: college Lack of Access to Mental Health Services service providers reported that 67.7% of all students they saw were experiencing aca- The inability of students to access support demic challenges, most frequently difficul- services in PSE directly impacts their ability ties maintaining concentration, being easily to complete their program and graduate on distracted, frequent absences from class, time, as the presence of mental health and not having enough energy to complete aca- problematic substance use illness diminish- demic work and difficulties with organiza- es graduation and persistence rates. To il- tion.34 lustrate this ongoing trend, research shows that 5% of college students prematurely Ontario Student Assistance Program end their education because of a mental (OSAP) and Mental Health illness30 and that disorders of anxiety, mood, problematic substance use, and con- The Ontario Student Assistance Program duct are strong predictors of academic fail- (OSAP) application takes into consideration ure. that those students with disabilities (including mental disabilities) will usually take Research shows that 79% of 34 Canadian more time to complete a program. For the counselling centre directors who responded purposes of the OSAP application, a “per- to a comprehensive survey reported in- manent disability” is defined as a functional creased severity of student issues in the limitation that is caused by a physical or previous five years.31 Many of the students mental impairment that restricts a person’s who attend counselling may be at risk of ability to perform the daily activities neces- dropping out of school. In fact, U.S. counsel- sary to participate in studies at a post- ling centre directors have reported that be- secondary level or in the labour force, and that is expected to remain with him or her tween 7% and 8% of their clients have 35 psychological problems so severe that they for his or her expected life. are not able to remain in school.32 These trends are anecdotally present in the Cana- In order to receive full OSAP, a student dian PSE demographic as well. must have a 60%–100% class load to qualify as full-time student in a study period. How- Based on recent research in Ontario’s col- ever, if a student has a permanent disabil- leges, mood (37.5%) and anxiety (24.6%) ity, students are required to have 40%–59% disorders were the most prevalent individu- of a full course load to be eligible for OSAP al diagnoses.33 The impact of these issues is as a full-time student in a study period. Pri- or to the passing of the 2012 Ontario Pro-

30 Kessler, R., Foster, C., Saunders, W., & Stang, P. 1995. “Consequences of psychiatric disorders: Edu- College Student Population. Toronto: Higher Educa- cational attainment”. American Journal of Psychiatry, tion Quality Council of Ontario., 2010, p. 19. 152, 1026–1032. 34 Holmes, A., Silvestri, R., Kostakos, M. (2011). 2011. 31 Cairn et al., p. 36. 35 Ministry of Training, Colleges and Universities, 32 Gallagher, R. P. 2007. National survey of counsel- Student Financial Assistance Branch. 2011. Instruc- ling center directors 2007. From tions for OSAP Paper Application Form for Full-Time www.iacsinc.org/NsccdSurveyFinal_v2.pdf. Post-secondary Students 2011-2012 OSAP. From: 33 Holmes, A., Silvestri, R., Kostakos, M. 2011. The osap.gov.on.ca/prodconsum/groups/forms/docume Impact of Mental Health Problems in the Community nts/forms/prd003635.pdf. p. 17.

10 | P a g e vincial Budget, students were able to also riod. A loan received from the Ontario Stu- receive the OSAP Disability Grant, and if dent Assistance Program (OSAP) or Canada there was a need for specialized technolo- Student Loan Program (CSLP), which is used gy, students could have accessed the Ontar- for “education costs” and transportation io Special Disability Technology grant for costs, was exempt as income under the assisted learning. However, this program is ODSP.36 not available anymore due to the program funding being cut in the 2012 provincial For students who may have issues covering budget. the assessments used to have the Bursary for Students with Disabilities (BSWD) avail- This is how the program used to be regulat- able up until this year, again, due to the ed and administered: the Canada Student 2012 provincial budget cuts. This bursary Financial Assistance Regulations required was disbursed under the umbrella of Ontar- that students submit documentation to io Student Assistance Program (OSAP) and demonstrate that a permanent disability, as the Ontario Special Bursary Program defined above, existed. They had to have (OSBP), but the OSBP was cut in the 2012 provided a recent medical certificate, report Ontario Budget. The distribution worked in or assessment (e.g., a learning disability as- this way. If currently registered university or sessment) completed by a qualified practi- college students were OSAP eligible, they tioner, or documentation proving that the could have accessed this bursary to pay for students was in receipt of federal and/or their assessment. Students did not have to provincial disability assistance. be receiving OSAP to apply for this bursary and only needed to demonstrate financial These assessments can be very expensive need for $1 of OSAP to access the BSWD.37 for students, as the cost of assessment typi- The BSWD was not a loan and did not need cally ranges from $800 to $1,700, and must to be repaid. However, it was considered be paid upon the initial OSAP application. taxable income. In order to access the Some colleges offer these assessments, BSWD to pay for their assessments, stu- called psycho-educational assessments, dents had to complete an application and through counselling services but these prac- qualify to OSAP. The CSA believes that the tices vary greatly from one institution to Ontario Special Bursary Program (OSBP) another. The CSA believes that the cost of was very valuable to students and that the assessments are too high, especially consid- program should be reinstated especially as ering that the students who have demon- strated financial need through the OSAP application are the least able to pay for 36 them. This expectation is counterintuitive. Ministry of Community and Social Services. 2012. Ontario Disability Support Program—Income Support Directives. With respect to OSAP and the Ontario Disa- www.mcss.gov.on.ca/en/mcss/programs/social/dire bility Support Program (ODSP), when apply- ctives/directives/ODSPDirectives/income_support/5 ing for a student loan, an ODSP recipient _11_ODSP_ISDirectives.aspx. 37 must have identified on the OSAP applica- Regional Assessment and Resources Centre tion his or her family's estimated income (RARC). 2012. Fees and Funding. Last Accessed March 22, 2012, from: from social assistance during the study pe- www.queensu.ca/hcds/rarc/Services/Fees.htm

11 | P a g e it helps student populations from lower- tained, stakeholders can have great impact income families. on policy, even during times of fiscal constraints. The creating of a policy framework RECOMMENDATIONS would go a long way to help institutions or- ganize, collaborate, and address mental More needs to be done in the PSE sphere to health issues across the province in a sys- address the issues outlined in this paper, tematic and strategic way. especially in a time of budget constraints and competing priorities. Recommendation 2: Institutions, government and stakeholders should work in col- Recommendation 1: The government laboration to improve communications needs to develop a policy framework on and knowledge exchange of mental health the provincial level to guide PSE mental promotion across the province. health and addiction policies in collaboration with stakeholders. The ability of stakeholders to meet and develop a mechanism for sharing best practic- The government has recognized the fact es is paramount to the success of mental that youths need support in their transition health promotion. There are many stake- from secondary to post-secondary school. holders in Ontario that have developed sim- With the “Open Minds, Healthy Minds: On- ilar programs and policies independently of tario’s Comprehensive Mental Health and one another: these efforts are fragmented Addictions Strategy,” the Ontario govern- both in the province and in institutions. This ment is seeking to support 16,000 youths is not the most effective use of resources with mental health needs as they transition for cash-strapped services. Ideally, each from secondary to post-secondary educa- campus should have a comprehensive men- tional settings. The students who are al- tal health and problematic substance use ready enrolled in post-secondary need strategy that combines all of the support support too, as the PSE sphere is laden with services on campus. Some campuses have stress, which can trigger mental health and joined with external organizations to im- problematic substance use issues. The age plement programs and supports on campus group that attends PSE is within which on- and have had great success. It is important set of mental illness typically occurs and the for various stakeholders to build on each issue is that responses to address these is- others’ successes rather than have individu- sues are patchy within and between institu- al initiatives that are siloed. tions. Different organizations and stakeholders in The creating of a PSE policy framework British Columbia have joined to create a would go a long way to help institutions or- community of practice to bring stakeholders ganize and collaborate on mental health together to support students in PSE within issues across the province. In Ontario, col- the province. The community of practice is laborations are not widespread and tend to part of the “Healthy Minds, Healthy Cam- be between individuals and groups and stu- puses Initiative. They have developed a dents rather than be systemically oriented. When efforts are coordinated and sus-

12 | P a g e website (www.healthycampuses.ca).38 The “College and university accessibility ser- initiative is managed and coordinated on vices, for example, are funded by the Access behalf of the BC Partners for Mental Health Fund for Students with Disabilities Fund and Addictions Information by the Canadian (ASFD) and allocated funding by the Minis- Mental Health Association (CMHA) BC Divi- try of Training, Colleges and Universities sion and the Centre for Addictions Research according to institutional enrollment num- of BC. The BC Partners are a group of non- bers. They also receive funds based on the profit agencies working together to help number of students using their services and individuals and families manage mental the number of students with certain target- health and substance use concerns by ed disabilities. providing quality information and resources. The Healthy Minds, Healthy Cam- Though the funding from the Ministry is on- puses website serves as a site for going, there are numerous demands and communication towards action within and requirements imposed on the service that between post-secondary institutions in BC, necessitate further funding from the their communities, and researchers. The postsecondary institution, which are subject overall goal is to support students’ mental to financial pressures and inter- health and reduce problematic substance departmental competition for funds found use.39 within each college/university. Funding for counselling services may come from the in- The development of a system such as this in stitution, from student fees, from third par- Ontario would not only move mental health ty insurers or from a combination of these forward, it would be very cost effective for sources”.40 the government and PSE institutions. This community of practice model would allow Campuses across Ontario are struggling to stakeholders to interact regularly to build meet students’ demands for mental health relationships, learn from one another, share and problematic substance use services. challenges, successes and best practices, as Support service staff are asked to do more well as develop a collaborative model of work, but with fewer resources. This can problem solving that will foster knowledge result in higher waiting times to access ser- mobilization. vices, which causes a backlog that increases as students with crises take priority during a Recommendation 3: Increase levels of period of a mental crisis. As a result, longer funding for institutions or create incentive wait times increase crises because issues for institutions so that they can develop are not dealt with early on, thus perpetuat- and maintain support services for mental ing the problem. When this lack of ade- health and problematic substance use on quate resources is coupled with more campuses. students entering the system with more complex and difficult mental health and

38 For more information, visit healthycampuses.ca 40 Ontario College Health Association. 2009. Towards 39 Please visit healthycampuses.ca and a Comprehensive Mental Health Strategy: The Cru- http://heretohelyp.bc.ca/campus#CoP for further cial Role of Colleges and Universities. Last accessed information. May 15, 2012, from: p. 16

13 | P a g e problematic substance use issues, the stu- basis. This creates a phenomenal opportuni- dents’ mental health is negatively impacted ty for the institution to identify that they and can lead to student attrition. need greater mental health support.

Recommendation 4: The government must Another possibility is the expansion of the work with institutions to develop a mech- Ontario Education Number (OEN), which anism that allows students the option to elementary and secondary students have identify themselves as needing additional assigned to them in their K-12 studies. The support for mental health and addiction expansion of the OEN to post-secondary problems in the early application stage of school would help notify institutions which their college career. students would potentially need to have more support as they go into higher educa- Institutions must have the ability to identify, tion. This, of course, is with the condition track, and monitor students who need addi- that the OEN not be used in a harmful way tional mental health support, especially if and that the confidentiality, rights and pri- they have chronic mental health problems. vacy of the students are maintained. In order to support students with mental health issues, institutions need to be able to Recommendation 5: Institutions must have identify students early on in their academic clearly articulated confidentiality and dis- careers. The support systems that students closure policies. with chronic mental health issues may vary from case to case, but in order for them to To go with the recommendation above, as have higher participation and graduation students and staff identify mental health rates, it is very likely that they will need issues among the student population, con- added attention to help them cope with the fidentiality must be a priority and an in- ever-competitive and challenging issues grained consideration. Due to the extremely that students experience at the PSE level. private nature of mental health issues, students need to be assured that their privacy The University of British Columbia (UBC), for is maintained in the process of them receiv- example, has a new enrolment process in ing support. Students with psychiatric disa- which all new undergraduate students at bilities often have problems with UBC Vancouver will be assigned to an en- concentration, short-term memory, fatigue, rolment services professional (ESP) who can as well as periodic crises related to their ill- answer questions and help students resolve ness. problems involving financial planning, eligi- bility for bursaries and scholarships, emer- As a result, they may require certain ac- gency funding, registration, and a host of commodations, such as extensions on as- other services. The project is part of a signments, or permission to write exams broader UBC initiative aimed at enhancing separately from the rest of their class. Or student engagement. ESPs will be assigned they may need to drop classes without fi- to students in June as they register for fall nancial penalty. But to qualify, they will classes, and they will meet with students need to disclose their disability. Students once or twice over the course of their un- are often reluctant to do so. They may not dergraduate experience or on an ongoing be aware that the accommodations are

14 | P a g e available, or they may find it too difficult to substance use issues. If a student cannot admit that they have a mental illness.41 All access services on campus, he or she should institutions have some policies related to be able to access them easily in their com- disclosure, but there is a lack of a single co- munity. In the event of the PSE institution hesive policy that covers everything relating not being able to provide support services, to disclosure and confidentiality. the institution must develop and maintain relationships with external and community In 2010, law firm Hicks-Morley provided stakeholders to better serve their popula- Colleges Ontario and the Council of Ontario tions. This collaboration will address mis- Universities with a legal opinion of case law communication issues. For example, a surrounding the powers of post-secondary student can be admitted into hospital and institutions in mental health protocols on then discharged back to the PSE services campuses. Within this document, the Free- without any information which can lead to dom of Information and Protection of Priva- less appropriate care on campus. cy Act (FIPPA) and the Personal Health Information Protection Act (PHIPA) are dis- Institutions should work to increase effi- cussed in relation to institutions sharing in- ciency by practicing greater collaboration of formation42 and sharing information with health providers on and off-campus. In the parent,43 as well as the Accessibility for On- time of fiscal constraints, PSE institutions tarians with Disability Act (AODA) and what are being asked to do more with less, espe- it means for campus mental health proto- cially with the secondary function of the cols.44 institutions being the offering of student support, with the primary function being Recommendation 6: Stakeholders must the delivery of education. Institutions are ensure that students can access a coordi- nowadays expected to provide support for nated Mental Health support system on students with mental health issues, espe- campus or across the province with exter- cially as populations are much more diverse nal agencies. and issues become more and more complex. It is paramount then to the success of The government must be able to support student support services that the different students across the province outside of the health providers on campus work in tan- realm of the PSE sphere. Many external dem, especially due to the nature of mental stakeholders already provide support for health issues being so multifarious. youths with mental health and problematic The Halifax Shared Mental Health Care Pro-

41 Addiction Research Foundation. 2000. “Supports gram is one such collaborative model and is for higher education (of people with a psychiatric delivered through family practice clinics and disability)”. The Journal of Addiction and Mental community agencies. Halifax uses a model Health. March-April 2000 v3 i2 p. 4. 42 of shared mental health care in which men- Hicks-Morely. 2010. “Re: Mental Health Protocols” tal health care providers, primary care pro- Last accessed May 8, 2012, from http://studentseyeview.files.wordpress.com/2011/0 viders and community agencies work 6/letter-from-hicks-morley-re-mental-health- collaboratively to provide care. Physical and protocols-may-20-2011.pdf p. 15 mental health issues are looked at together 43 Hicks-Morely. 2010, p 17 in an effort to provide better continuity of 44 Hicks-Morely. 2010 p 18

15 | P a g e care. It grew from needs identified within Mind Your Mind, and it gives students ac- the community and takes a holistic, team cess to web based tools and resources and approach to care. Nurses are a pivotal part access to campus resources.47 of that team and are frequently the first contact person and usually the liaison be- Recommendation 7: The institution must tween health care providers, patient, and provide support and training of staff and agencies.45 administration on all levels to recognize and deal appropriately with mental health Collaboration with other service providers and addiction issues. to deliver mental health services is a key component of the Halifax model and in- When students experience issues with cludes direct clinical care, consultation, and mental health or problematic substance education. Mental health workers and psy- use, there are external indicators of their chiatrists are hired by the hospital facilities internal struggle. These warning signs and are deployed to the community agen- are not obvious to the untrained eye and cies and primary care sites to work with may be falsely attributed to the everyday primary care providers such as physicians, stresses of students’ experiences. In or- social workers and nurses, as well as other der to prevent mental health issues from professional care providers, including com- worsening or to prevent the loss of life, munity agency workers. all faculty, staff, and administration must be trained to recognize signs of mental Some institutions have partnered with ex- illness, as the indicators are most likely ternal organizations to better provide men- to not be obvious to one person only. tal health services to students. For example, This collaborative model has proven to Fanshawe College partnered with Mind be quite effective in helping students Your Mind to implement iCopeU on their access treatment and support services. It campuses. Mind Your Mind is a non-profit is dependent on communication and mental health program that “engages youth, shared responsibility within the institu- emerging adults and the professionals who tions. Institutions need to be able to serve them to co-develop reliable and rele- train their staff to better recognize these vant resources. These resources are de- issues and in order to do that, there signed to reduce the stigma associated with must be government or administrative mental illness and increase access and use support for such programs. of community support, both professional and peer-based”.46 iCopeU is a program of As colleges and other PSE institutions are financially constrained, a recent trend

45 has emerged where institutions partner Pamela Chisholm and Donna Lemoine. 2002. “A with private organizations to build and shared mental health care model: an effective treatment approach that is supported by consumers, operate student residences and this community agencies and traditional service providers, this Halifax-based program includes nurses as a http://mindyourmind.ca/about-mym/who-we- pivotal part of the team.” The Canadian Nurse. 98. are?start=1 9:, p. 22–24. 47 iCopeU, Fnashawe College. ND. Last accessed May 46 Mind Your Mind. 2012. “Who we are”. Vision of 14, 2012 from: mindyourmind. Last Accessed May 7, 2012, from: http://icopeu.com/fanshawe/home.html#

16 | P a g e partnership can provide revenue. Stu- guides mental health policies goes a long dents that live in residences generally way toward creating a mentally healthy have positive experiences and tend to campus environment in which the entire have higher grade averages than those campus is supportive of and engaged. that live off-campus. This is due to the availability of support services that stu- Recommendation 8: Stakeholders must dents can access, as well as a more well- have a clear statement of aims and out- rounded college experience. As the comes for mental health initiatives with trend to have private companies build clear indications of how these will be and operate residences, there are major achieved, measured, and evaluated. factors that must be considered for student success. In order to develop strong policy, there has to be research available to measure and Private companies that run residences evaluate mental health and supports ser- do so for profit as and are a business. vices on campuses across Ontario. While Historically residences were built and recent trends have highlighted to the lack of operated by the institution for the pur- data in the Canadian case, the push for re- pose of providing housing, student sup- search has been primarily independent, es- port and ultimately enriching the pecially with respect to the Ontario college educational experience. As students are sector when compared to the Ontario uni- presenting with a range of mental health versity sector. The lack of clear measures issues, there have to be supportive sys- and evaluations are problematic because tems in place. Students have to be able they hinder the development of a cohesive to access a trained staff person, such as and effective policy, which has resulted in a Resident Advisor (RA) or a senior resi- the current piecemeal approach to mental dent manager who is on-call in case of health that varies from one institution to emergencies. These staff should be ac- the next. The development, monitoring, and cessible to students based on a ratio evaluation of performance indicators in ser- (e.g. 1 RA for every 40 students) to en- vices offering support to students with sure prompt, professional support for mental health difficulties is something that every student that needs it. needs to be addressed in Ontario’s colleges. Ideally, the government could support and A mental health framework that guides incentivize research in indicators such as the development of mentally healthy the Multi-Year Accountability Agreements campuses exists at many institutions. (MYAAs) of mental health and then tie Two of the more exemplary models are funding for mental health initiatives to the from Cornell University48 and Carleton indicators. University49. Having a framework that Recommendation 9: The government, ex- 48 Cornell University. 2012. CU Mental Framework. ternal stakeholders, and institutions Last accessed May 3, 2012 from: should promote a healthy lifestyle and http://www.gannett.cornell.edu/pdf/cmhw/loader.c fm?csModule=security/getfile&PageID=52463 49 Carlton University. 2009. Student Mental Health http://www1.carleton.ca/studentsupport/student- Framework. Last accessed May 3, 2012, from: mental-health-framework/

17 | P a g e promote the reduction of alcohol, tobacco, health and problematic substance use is- and substance misuse. sues across the province.

In order to help students develop into men- Mental health problems are highly stigma- tally healthy citizens, they must be aware of tized in our society. Stigma refers to a clus- practices and actions that contribute to ter of negative attitudes and beliefs that their mental health. These factors can be motivate the general public to fear, reject, stress-coping exercises, the development of avoid, and discriminate against people with a school/work balance and, in the case that mental illnesses. With regard to other as- it’s necessary, the ability to locate and ac- pects of health and health issues, there is a cess support services. This is especially im- lot more popular support for the improve- portant as youth are susceptible to form ments of other ailments, especially if they unhealthy habits as they relate to drug, to- are easily understood. However, because bacco, and alcohol misuse, which can be mental health issues are not treated in the very detrimental to their overall health. As same way, there is a lot of embarrassment youths in Ontario have such high PSE partic- and discomfort when it comes to speaking ipation rates, they are well-placed to be in- about treatment options and health promo- formed on mental and physical health tion. For example, a person who has the flu development that they can use as they ma- or a chronic physical illness is more com- ture. The strengthening of collaboration be- fortable about speaking about their experi- tween different sectors, agencies, and ence in comparison to someone who may professional groups to share the responsi- be diagnosed with bi-polar disorder or suf- bility for the mental well-being of Ontario’s fer from anxiety. Societal support is not as students must be made a priority. widely given to mental health issues, and while there has been more support and un- Institutions must also market and promote derstanding of mental health and problem- campus services so that students can be atic substance use issues, there needs to be aware of and utilize services. Many students greater efforts to de-stigmatize mental are often not aware of the available mental health and problematic substance use is- health resources on campus or may be re- sues so that those who may encounter luctant to use them, so it is important to them are able to access support. conduct an ongoing education, outreach, and advertising campaign to inform them Popular culture shows a lack of support for about mental health issues and encourage those with mental illness and problematic them to use the services available to them. substance abuse. It commonly portrays Residence halls, student orientations, and people with mental health issues as being seminars are excellent places to conduct violent or vicious. The stigma and shame outreach presentations and make contact associated with mental health issues are with a large number of students. still prevalent and are one of the major factors that preclude young people from seek- Recommendation 10: Stakeholders must ing help. There is a growing body of work together in a collaborative effort to research that suggests that many mental raise awareness and de-stigmatize mental

18 | P a g e health education programs reduce stigma.50 that students have access to support ser- Research also shows that stigma reduction vices for mental health. is most effective when participants have one-on-one contact with an individual who Students who encounter mental health and suffer with and is surviving mental illness.51 problematic substance use issues must have the ability to access support services easily. There are three types of strategies— This may be due to longer wait times, low protest, education, and contact—that are counsellor to student ratios, and the grow- consistently utilized to reduce stigma. “Pro- ing prevalence and severity of mental test is a reactive strategy; it diminishes neg- health issues. Some institutions simply do ative attitudes about mental illness. not have very well-developed or well- Education provides information so that the marketed student support services. As evi- public can make more informed decisions dence shows that students that access men- about mental illness. Education strategies tal health services are at higher rates of are augmented by face-to-face contact.”52 dropping out of school, institutions must be As stigma continues to be a barrier to high- able to provide support to the students er education in several ways (student reluc- from the time they enter the institution to tance to identify themselves to disability the time that they fulfill their credential re- services, inaccurate media portrayals of quirements. This is especially important in persons with mental illness, less acceptance Ontario’s colleges as they attract students of persons with psychiatric disabilities than from varied backgrounds that are tradition- those with physical or sensory impairments, ally under-represented in the PSE sphere. A etc.),53 the PSE community must continue way to address this is to develop standard to be instrumental in fighting the stigma student to counsellor ratios to ensure that that discourages persons with mental illness there is sufficient institutional support for from succeeding in college environment. all students that pursuing a post-secondary education. Another consideration is for in- Recommendation 11: Governments, insti- stitutions to ensure that educators are en- tutions, and stakeholders must make sure couraged and supported in their efforts to incorporate mental health into the curricu- lum.

50 Goldney RD and Fisher LJ. 2008. “Have broad- Recommendation 12: The Ontario Special based community and professional education programs influenced mental health literacy and treat- Bursary Program must be reinstated so ment seeking of those with major depression and that students can access necessary sup- suicidal ideation?” Suicide Life Threat Behaviour. port. Apr;38(2): 129–42. 51 Corrigan, P. W. and Penn, D. L. 1999. “Lessons This support for the Ontario Special Bursary from social psychology on discrediting psychiatric stigma.” American Psychologist, 54, 765–776. Program (OSBP) was cut in the 2012 Provin- 52 Corrigan, P. W. and Penn, D. L., p. 768. cial budget. Prior to the cuts, students were 53 Collins, Mary Elizabeth and Carol T. Mowbray. Au- able to also receive the OSAP Disability gust 2005. “Understanding the Policy Context for Grant, and if there was a need for special- Supporting Students with Psychiatric Disabilities in ized technology, students could have ac- Higher Education,” Community Mental Health Jour- nal, Vol. 41, No. 4, p. 449. cessed the Ontario Special Disability

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Technology grant for assisted learning. Stu- dents who applied for OSAP had to show they had a financial need and were fiscally Conclusion constrained. The removal of this program due to budget cuts is worrying on many lev- Mental health is an important component els but especially as it relates to access, af- of a healthy lifestyle. As students experi- fordability, and fairness. Students who are ence more frequent and intense issues re- in receipt of or qualify for OSAP do so be- lated to their mental health, they must be cause they come from families with lower supported in order to be successful in incomes. The removal of this program will school and in their development of good greatly and negatively impact those stu- habits. The PSE sector has a key role to play dents that have financial need and are in this support as they are instrumental to therefore less likely to access a post- the promotion of mental health and the secondary education. This, coupled with the treatment of mental health issues and prob- mental health/disability, can only limit stu- lematic substance use issues at a very criti- dents’ progress. It is imperative that funding cal time in students’ developments. In order for the OSBP be reinstated so that all stu- for proper support to be in place, institu- dents have a fair and equitable chance to tions, stakeholders, and government must access an education. be able to put in place mechanisms that ensure mental health, such as educational and Recommendation 13: Students must en- anti-stigma campaigns, mental health pro- gage in developing and providing input in- motion initiatives, and counselling services, to mental health initiatives and services in to name a few. their PSE institution. As there are increasing pressures on coun- As students are the recipients of counselling selling services to provide services in the and mental health promotion efforts, they face of more complex and frequent mental must be able to engage in the development health issues, counselling services must be of and provide input into mental health ini- better supported. As governments and in- tiatives and services in their PSE institution. stitutions are fiscally constrained, greater Students should be consulted, whether on efforts must be made to collaborate and an institutional level (through student gov- amalgamate services for greater efficiency. ernments or clubs/groups), or on a provin- There must be a shared understanding of cial level (College Student Alliance [CSA] and the issues and how to help resolve them the Ontario Undergraduate Student Alliance across all policy actors. Students must be [OUSA], for example), or the national group able to access a safe and confidential men- (the Canadian Alliance of Student Associa- tal health system that will not only treat tions [CASA], for example). Students could mental health and problematic substance have the chance to engage in institution- use issues, but one that also promotes good specific campaigns as well. health. It is only when there is a collaborative effort from all sectors, stakeholders and policy actors that a comprehensive mental health program can be achieved.

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