The following is a transcript of an episode of From the Front Row: Student Voices in Public Health, the University of Iowa College of Public Health’s student podcast. This episode features a discussion between CPH students Lexi Fahrion and Steve Sonnier with Dr. Barry Schreier, director of the University Counseling Service at the University of Iowa and professor of counseling psychology. They discuss delivering mental health and counseling services to college students during the COVID-19 pandemic and how counselors and students have adapted to mental health tele-therapy.

Lexi Fahrion:
Hi, everyone. Welcome back to From the Front Row, brought to you by the University of Iowa College of Public Health. My name is Lexi Fahrion and I’m joined today by Steve Sonnier. And, if this is your first time with us, welcome. We’re a student-run podcast that talks about major issues in public health and how they’re relevant to anyone, both in and out of the field of public health. Today, we’ll be talking with Dr. Barry Schreier, director of the University of Iowa’s counseling service, also known as UCS, and professor of counseling psychology. Welcome to the show.

Barry Schreier:
Thank you very much. I’m glad to be here.

Steve Sonnier:
What got you into the field of psychology, and what was the way that you ended up in your position now?

Barry Schreier:
Sure. Great question. So, when I was in 11th grade, which would have been in 1982, my high school for the very, very, very first time taught… you could take a semester of sociology and a semester of psychology and I thought, “Cool. That beats shop and drafting.” So, there I am. I got about halfway through the semester of psychology and thought, “I think this is what I want to do. This is so cool.” And then graduated from high school and ended up at the University of Michigan, and declaring one’s major, one had to go see one’s advisor. One had to fill out a card, like a 3×5 note card. There were no computers back then to do that.

Barry Schreier:
So, I went in and had my card all filled out and gave it to my advisor like the fourth or fifth day I was on campus as a first year student, and I remembered my advisor saying, “Oh, well, hm, this is unusual. Most people don’t fill out their major until they’ve been here for a while. You might want to take some time and think about this.” And I said, “Well, tell you what, let me leave my card with you, and if I change my mind, I’ll come back.” And of course I never went back.

Barry Schreier:
So that, I just early on decided I think this is what I wanted to do, and I think that I always, even back then, thought the practice side of this. Because one could go be a researcher, one could do IO, industrial organizational psychology, one could do experimental work. I think I always wanted to be on the practice side of things. So, I graduated from Michigan and went directly into a doctoral program. I don’t even have a master’s. I just went right for the doctorate and have never looked back. So, that’s kind of how I got into it.

Barry Schreier:
And then I always knew I wanted to work on a college campus, and really the decision was whether I wanted to go to the faculty side or the counseling center side, and clearly chose the counseling center side, until I got to Iowa where this position uniquely, really in the country, has both roles rolled into it, where most do not. So it really is a unique opportunity, and achieves both pieces for me at this point in my career.

Steve Sonnier:
That’s awesome. And then what specifically about the college side of things drew you into this position? Why out of all these other things you mentioned, industrial organization, and everything along those lines, it’s a huge field out there. Why college?

Barry Schreier:
But my let’s look at more serious response is, look at the people we get to work with on this campus, these bright, thoughtful, well-intentioned, civically-minded people all the time. It’s just such a wonderful place to be, so many resources, working with students. I mean, working with you all, it’s such a joy to work with students all the time who are eager and developing and want to do better and are trying to make their way in the world. It’s just a really unique population to encounter at the time that we encounter you all here on college. So there’s just a lot of really good reasons why being on a campus has really been just the best place for me to be.

Lexi Fahrion:
So, you talked a lot initially about the practice of this, and how you could go into so many different sides of it. Especially on a college campus, I imagine there is just a ton of different avenues. But right now, I feel like a lot of those mainstream, traditional avenues are closed off with the pandemic and the safety issues. I know you guys have been able to develop and adapt your services during this time. Could you talk a little bit about that?

Barry Schreier:
Sure. You know, had you come to us a year ago and said to us, “You probably should be doing teletherapy. Why don’t you offer counseling services to students via Zoom?” We would have said to you, “No. Nobody wants to do that, and it’s too hard, and it doesn’t work.” And then one week in March, we quite literally in one week in March converted our entire system over from all in-person to exclusively and only via tele-mental health. So, it’s a major, major shift.

Barry Schreier:
Then we had to encounter things like how do we manage confidentiality, and what if you say to me, “I’m suicidal”? When you used to say that to me you were sitting in my office, so it was easy to manage, but you could be in Des Moines and telling me that. So, trying to figure out how to manage all those systems. We also had to figure out… I’m licensed to practice in Iowa, and so you could technically now be anywhere in Iowa and I could see you, but if you’re a University of Iowa student, you could be in Texas. What do we do about that? Now all of the sudden you’re a University of Iowa student and you call state counseling and I’m like, “Can’t help you. You’re not in the right state. Your state prohibits us from doing that.” So, trying to figure out all those cross-state policy matters.

Barry Schreier:
So, converting our whole system clinically if you will, trying to figure out how to do group therapy online, also sort of a big challenge, and would students do it became a big question. We have found out that students are doing it, and seem rather committed to it, which has been great. And then we had to really increase our online presence hugely, bigly, I think as they say, which was coming up with a lot of synchronous workshops and seminars and drop-in opportunities so students could just synchronously drop in and participate as they felt able. And then come up with a lot of asynchronous things, so students could seek help anytime.

Barry Schreier:
The nice things about these subclinical services, effectively you can participate in a support group or a drop-in workshop or use our videos that we’ve created no matter where you are in the country or world. So there’s still ways that we can serve our students, so we had to figure out all those kinds of things. It’s just been a huge, huge adjustment. Now we’re trying to think, “Now what? What happens next?”

Barry Schreier:
We certainly have come to the conclusion that tele-mental health, it’s no longer whether we’re going to use it, it’s simply how we’re going to use it at this point. It’s always going to be part of the work that we’ll do moving forward, and so we just need to figure out the best ways of how to manage that. Especially, because I think that students will prefer to have the option. Some will want to do in-person, or some may want to do in-person, but, “Today it was pouring and I don’t want to walk all the way across campus. Can I see you online this week?” So, trying to figure out all those kinds of iterations.

Barry Schreier:
Then, the last thing we’ve done that really is, for somebody with my age, we really have hugely increased our presence on social media. It’s just not my wheelhouse in a lot of ways, but we have a number of really young staff who are super into it, and so we really have hugely increased our presence on social media because of, again, we’re not standing out on the T. Anne Cleary Walkway handing out flyers, so we have to hand out flyers some way, and social media has become a really great way for us to be able to do such things.

Steve Sonnier:
What does the uptake look like that on the ground level, because you’re talking about this massive change from in-person to tele-mental therapy opportunities, who is driving all of this aside from yourself? What are these individuals involved in, in a day-to-day basis to make this actually work and run?

Barry Schreier:
Who is making it all happen? Us. Thank you for that great question. It’s us. Yeah, I mean, it’s all us. It’s been really interesting. We’ve been the ones that have gone to legal counsel to say, “Hey, do you know about cross-state practice laws?” And they’re like, “Nope. What do you know about them?” And I was having to dig out research and do our work to go to our legal counsel to say, “Here’s what we found. Can you help us review these to see can we practice across these states?” And then they have to pick up that basket and do their own research so that we can see if we’re in agreement, but we’re driving a lot of it.

Barry Schreier:
Now, the nice thing for us is we have lots of networks nationally, so we can always plug into… like I’m in contact with all the Big 10 counseling center directors, and can find out quickly from them, “What are you all doing about this?” Or there’s all these counseling center directors across the state of Iowa, everything from Grinnell to the University of Iowa, to DMACC, to all these other campuses on the campus. And we all are in contact with each other as well saying like, “What are you doing?”

Barry Schreier:
Then, I’m connected with all the other counseling mental health centers, RAC, the Seashore Clinic, the counseling center at the medical college, the Employee Assistance Program. We all talk to each other right here on this campus saying like, “What are you all doing about this? How are you handling this? Do you have a copy of that form you developed so we don’t have to develop a separate one. We can just use yours.” So there’s been a lot of communication in ways that we have never have had to lean on each other as much before, so that’s been an opportunity we all have seized up just to offer support. Every day is navigating unknown waters, just like it is for everybody for sure. It’s not unique to us by any means, but every day it’s navigating unknown waters, and so we’re looking for any boat or life jacket we can get our hands on to do that together.

Lexi Fahrion:
It seems like you guys have done just an excellent job collaborating with people around the state and around the country like you were [crosstalk 00:08:51].

Barry Schreier:
Survival.

Lexi Fahrion:
Yeah, survival, definitely. What have you seen, I’m curious, on the student side? Have students been adapting to this new format?

Barry Schreier:
Yeah, you know, it’s been very interesting. We actually just surveyed our students to say like, “I don’t know, what do you think of this telehealth thing? Thumbs up? Thumbs down? What say you?” And so we surveyed all of our students this semester who are currently in counseling. We got about 350 students responded, which I would say probably is 80% of our students that were in counseling at the time, so it’s pretty good. We asked them a few questions. We asked them, “If you had the choice to do in-person only, telehealth only, or both, what would you choose?” Overwhelmingly students said both.

Barry Schreier:
So, we take that to mean a couple of things. Students often demand things that they have no intention of using. We have learned that for sure along the years is, “You must do this,” and then we’ll ask, “So, would you use it?” And they’re like, “No, I would never use that.” So, we’ll see what it means in the end, but what we think students are telling us is, “I want the choice, and whether I would actually use teletherapy, I don’t know. We’ll see.” Teletherapy only, in-person only… in-person only was chosen higher than telehealth only, but we had a decent number of students that said telehealth only.

Barry Schreier:
For some students, it’s just simply an accessibility thing. “To get over to your office is very hard for me, and I just can’t physically do it, and so telehealth gives me an option.” Or, “If I’m really depressed, and boy, getting out of my house to come to your office, I don’t know if that’s going to happen today. But if I could stay home, I might have a session, where I might not otherwise,” and so I can see why some students would say telehealth only.

Barry Schreier:
And then we asked students, “Do you think it’s as good as in-person? Is telehealth as good as in-person?” And what students basically told us is, “We’re not sure it’s as good as in-person, but it’s still pretty good. I still think it’s helping me.” Satisfaction overall, we satisfaction surveyed those students to say, “How was it?” And overall our satisfaction ratings were exactly the same as they were a year ago at this time. So students are still expressing the same level of satisfaction with it. So, that’s kind of what we’re at least hearing from students as the report is, “Not our first choice, but given that it’s the choice, it’s a good choice, and you should keep it a choice.”

Steve Sonnier:
It’s great to hear, and especially needing that feedback to see if this is an actual service we should go through and support. I mean, that’s especially tremendous now when it’s like we need the data to make the decision. If I want to flip the script and say, “How are the providers dealing with this too?” Because that’s the other equation is it may be great for the students and all, but what do the providers think on their end? Is it easy to use? Are there hiccups along the way? Are we satisfied? Do you know what that looks like?

Barry Schreier:
Yeah, that’s a good question. You know, I think we’re seeing some differentiations based on generation. So, the staff here at the counseling center span the ages of like early 30s/late 20s all the way up to 60s. So we have some definitive generational changes, differences in our staff. And I think there’s some differences. I think our older staff, which includes myself, I don’t know we’re the hugest fans of it, but again, it works, so we’re willing to lean into it. I think maybe our younger staff are rolling with it better.

Barry Schreier:
We actually thought, “Will students do group therapy? Will they really come to group online?” Yeah, you know, all of our groups are full, and every student that has come has stayed, and the students really, really like it. I don’t know if group is my favorite online. One of the critical things that we note in group is body language. Who are you looking at when you talk? And on screen, I can’t tell who you’re looking at. And so we lose data in the group setting, but it still works, and the students seem very committed to it, and so that’s been really great.

Barry Schreier:
As far as staff, I think staff, again, it varies greatly as whether staff think it’s really great or it’s just kind of what we have to do to now and I can’t wait until we go back to the way it used to be. But we’ll figure out what the new normal will be moving forward. So, I think there’s just a difference. The staff moved quickly. The staff was very flexible. We all got on board. We did training. We all rolled into online training very quickly on how to, “What are the ethical considerations with teletherapy? How do you manage risk from distance? What sort of standards do we need to set up? How do we get students to fill out paperwork online because they can’t come in and do all the paperwork we normally do, and creating portals and the use of the VPN?” All these new things had to be figured out.

Barry Schreier:
How do we convert all of our paperwork to online? Everybody just really pitched in, and we converted so quickly in March, it frankly sort of terrified me slightly about how quick and automatic we all just did it as a group. And then we’ve learned things along the way and have just continued to improve our system. But at this point, it’s pretty foolproof. The only thing that waylays us is when the power goes out, obviously. Or there’s just internet disruptions.

Barry Schreier:
I had a client yesterday, every sixth or seventh word I just didn’t hear because it just kept going silent, and I was like, “Ugh, I hope you’re not saying something really important right now, because I’m missing what you’re saying.” And I swear to God, this is a true, true story. I am not making this up to make it seem more interesting or embellishing it in any way, shape, or form. This is exactly what happened several months ago. I had a client who I’d been seeing for a while who said, “So, I think I’m ready to tell you something I’ve never, ever told anybody, and it’s really hard for me to say, but I just sort of feel like I’ve been sitting in this counseling with you, and I’ve not been telling the entire truth. Okay, here’s what I want to tell you…” And I went, “Oh, no.” I could see lips moving and no sound. I was like, “Oh, you’re kidding.” I couldn’t have written the script this way.

Barry Schreier:
Then, the camera just went off, and I was like, “Oh, my gosh.” So, it took us about five minutes to find each other, and I had to say, “Remember that thing that was really hard to say? You’re going to have to say it again.” So those kinds of things come up in our work on occasion as well, but we’ve even come up with really good ways to manage those as well.

Lexi Fahrion:
It definitely just seems like a testament to how dedicated everyone in your office is, and even just in the community to making this work, because it seems like it’s affecting that, it’s just such an essential thing, especially now.

Barry Schreier:
Sure. And we see this with our private practitioners too, like every private practitioner made their way over to telehealth very quickly. Very few people even in the community are seeing clients in person. Some are, but very few. Most folks even in private practice made the conversion over.

Steve Sonnier:
With that conversion, everything along those lines, because we talked a lot today about how we’ve transitioned with these goals, and where the next steps are. What do you think the next steps are, because you talked about the system being foolproof. Is this about expanding services for multilingual patients? Is this expanding services for folks that are typically not captured by the system? Where do you think this is supposed to head next?

Barry Schreier:
Well, that’s a really good question. Do you know?

Steve Sonnier:
I wish. I wish I knew.

Barry Schreier:
Yeah, [crosstalk 00:15:19].

Steve Sonnier:
I’d help you answer.

Barry Schreier:
Yeah, I sometimes have to say to my staff, “I’m not holding out on you. I don’t know either,” is a lot of what we talk about. Here are the things we’re pondering, and how they’ll play out, we don’t know. Telehealth is for sure going to be a part of our continued work, for sure. What used to be in the past was, when you went home for the summer, you went home for the summer. We’ll see you in the fall. And now, just because you’ve gone home for the summer doesn’t mean you can’t continue in therapy if you’re in the state of Iowa.

Barry Schreier:
And so those busy 32 weeks a year may become busy 52 weeks a year. We’ll just have to see how that rolls out, but things are going to change. Or, when you decided to go do your internship in Ottumwa, we’re like, “Well, that’s too bad. When you’re done with your internship, come rolling back,” but, “I’m going to be leaving on my internship in Ottumwa,” and I can say to you like, “Cool. See you next week.” And so those kinds of things, we’re trying to figure out how to manage that.

Barry Schreier:
The idea that every single staff person is going to come back to the office five days a week, every week of the year, I don’t think that’s going to be in our future either. And so we need to have then some thought about how much residency are we going to require staff to have? Residency meaning you must be in the office. So we’re trying to think about those things. Or, what if I’m the staff person who is a really good staff person and does really good work, and now I’ve got to now move to Illinois. Can I keep my job? So we have to think those things through in terms of residency. How much in the state do you need to be? If you’re licensed in Iowa, seeing students in Iowa, do I have to be in Iowa? So all those questions are coming up for us as well.

Barry Schreier:
And then, just our continued online presence in terms of offering services and how much service do we continue to in bulk provide students online, or do we try to get ourselves back to as much in person as possible at that point when we all feel able to safely and confidently and consistently do that. So, those are a lot of the questions we’re rolling and what’s the continued nature of the provision of service, and what will the market be, and then what will be the nature of work life in the future as well? We have a lot of questions, and not a lot of answers at this point. I’m sure more questions will reveal themselves, but that’s kind of where it is at this point. It makes me want to go on vacation. That’s what I have to say.

Lexi Fahrion:
I feel like that’s how almost every avenue of life is at the moment is there’s so many changes that there are just more questions than answers. One thing that kind of struck me early is you mentioned that we’re not going to go back to what we used to consider normal.

Barry Schreier:
No.

Lexi Fahrion:
And maybe that can be a good thing in a lot of ways. In public health, we’re a very big population people. We look at everything on a population scale, and we want to affect population health. To me, it almost looks like maybe in some ways this could give UCS an opportunity to even expand on that population.

Barry Schreier:
Oh, no. Yeah, no, that’s good. You’re right, don’t panic. That’s good. Okay, yeah, yeah, yeah. Okay.

Lexi Fahrion:
Yeah, in a positive way, like reach more people at once. Yes, this could be a great… maybe there’s a light at the end of the tunnel in some way.

Barry Schreier:
Sure. Yeah, in the end you’re right. I think about our giant increase in our online presence. You know, we’re reaching folks we never would have thought we would have been reaching before. So for instance, I’ll give you a good example. One of the reasons I have to be done with this by quarter to noon is we’re going to be having a virtual mental health panel discussion, and it’s directed at parents and family and guardians. There’s no way we would have done that before. Everybody would have had to come to campus. It never would have happened, and now we’re doing mental health outreach to the parents of University of Iowa students no matter where they are in the world.

Barry Schreier:
I would never refer to the pandemic as having a silver lining because as I look at the 200,000+ people dead, silver lining is absolutely the not correct thing to say. But opportunities have arisen because of it, and you know, we’ve tried to seize on some of these opportunities, as you said, to expand ourselves in ways we just never dreamed possible. But we were doing a seminar for parents on mental health, well they would have had to come here, and now we’re going to them no matter where they are. And so, you’re exactly right on how this has panned out, in a lot ways, given opportunities.

Steve Sonnier:
You’ve talked a lot about the unexpected, and how you’ve been able to quickly transition yourself and your staff into this, and this may be kind of already answered within the podcast, but really, what is one thing that you thought you knew within this whole pandemic and accommodating to the mental health side of things and provision of services that you were later wrong about?

Barry Schreier:
This is where I say something really, like, “Oh, that is sage level wisdom,” but I can’t think of anything that would rise to that level. So I’ll tell you one of the things I thought of: before the pandemic, what we heard from the media regularly, and what all the research was telling us was that this generation of students, I’m sorry to tell both of you, you’re the most mentally ill generation of students we’ve ever seen. I mean, it’s just we’re inundated with that information. It’s exhausting.

Barry Schreier:
And when we do more sophisticated analyses of the data, we find out it’s not true. And things govern why that data is that way because we say to students, “Have you felt so bad on any one day in the last month that you couldn’t do your work?” And students say, “Oh, yeah,” and then we think like, “Oh, depression.” But maybe not. Maybe you were just having a really bad day, and because of whatever reason, you think, “I don’t need to do my work today. I’m just not going to do it, because I’m super smart and I’m super skillful, and I have access to the internet and the world,” and so I answered the question in a direction that makes me seem like I’m really struggling, but I just made a really good self-care choice.

Barry Schreier:
Or, “I just have high levels of distress and I’m a generation that seeks help,” in ways that my generation never did. We just sort of sat with it silently and suffered and put smiles on our faces and pretended it was okay. And your generation is, “It’s not okay. I need to go see someone,” and so you talk all about it a lot more, but your distress may not be any worse than it was the generation before, potentially, but you just talk about it more.

Barry Schreier:
So, there’s lots of work about, “Um, you know…” This generation seems to express its distress a lot more, and things potentially are more distressing because you have access to the world all the time. When I was your age, I didn’t have access to the world all the time. I had to go to the library to see a newspaper other than the one that got put in my mailbox, and the news was only on for 30 minutes a day. And now we have access to everything all the time, everywhere, and it’s distressing.

Barry Schreier:
So, I think there’s lots of factors that go in, to walk us back from the precipice of mentally ill generation. But this is the platform, pandemic, “Oh, my gosh, all the students are struggling and suicide rates are up, and I bet you guys are overwhelmed, and I bet students are so depressed and so anxious, and this has probably just been awful.” And none of that’s panning out. We belong to a thing called The Center for Collegiate Mental Health. It is housed at Penn State. It is the largest campus mental health database in the world. And University of Iowa, along with several hundred other colleges and universities contribute data to it.

Barry Schreier:
We took a look at the data. Now, these are people coming to counseling, so it’s just that group. It’s not the general population. It’s just that group. But, for the students seeking help, you would think, “Oh, these are the students that maybe are struggling the most.” We took a look at data, so every time you come to the counseling center, you fill out a symptom checklist for us called the CCAPS, the Counseling Center Assessment of Psychological Symptoms, CCAPS. So we upload that data.

Barry Schreier:
We took a look at CCAPS data of mental health symptoms between January and May of this year, and compared it to January and May of last year, and nothing went up, other than family discord because everybody had to roll home whether you wanted to or not, so family discord went up, and academic difficulties went up, because everything had to go online. But in terms of things like anxiety and depression and all that, none of it went up. None of it was low, but it didn’t go back up. It didn’t go up as a result, right? In fact, suicidal thinking went down. Are we overwhelmed? No, we’re as overwhelmed as we always are, but are more students rolling into counseling than they ever have before? No, they’re not.

Barry Schreier:
So, we’re aware that people are really turning to their networks. Folks are really resilient. If we were flexible to roll with it, so were you all. All this, “Oh, my gosh, this poor, poor generation,” is simply not true. It is a generation with a lot of strength. You are probably the most civically-minded generation we’ve had in a long time, and you all believe that you can get your hands on anything, anywhere in the world because you can. You’re adept at looking things up and, “I’m depressed. What do I do about that?” “I suffer from this. What are people doing about this?” And, “I’m going to go join my online support group,” and folks are really sort of taking care of themselves in a lot of ways.

Barry Schreier:
So, folks are still struggling at levels that they always have, and folks are still engaging in help-seeking behavior like they always have, but this generation continues to be resilient, and it doesn’t surprise me, but it seems to surprise a lot of folks, and I’m glad for that. You should be surprised because it’s such a good group of students.

Steve Sonnier:
I think it’s a really positive, empowered comment, because we really do aim for that self-actualization and wanting to make sure that we are capable of handling things.

Barry Schreier:
That’s right.

Steve Sonnier:
It’s really good to hear that data because I don’t think a lot of us see it sometimes, and it really is that, “If you don’t see it, then I don’t think it’s there, and I’m just going to continue on with how things are, how I think they’re going to pan out.”

Barry Schreier:
And this generation is doing well. That is not super sexy cover for the media. It’s much sexier to say, “Oh, gosh, it’s terrible and people are really struggling.” That’s headlines. We think the generation is doing actually pretty well in taking care of themselves. Though they struggle, it doesn’t get a lot of copy, so it’s important to say it.

Steve Sonnier:
No, and I appreciate you saying it, and taking the time today to talk with us about these issues because they are critical for our students to recognize, and people in our community hear about, because it is, like you said, not top news at any media site that you go to. They are important things to consider. Barry, I want to thank you for your time today. I mean, thanks for coming on. We really appreciate the opportunity to interview you, and we wish you guys the best of luck. We’re happy to see wherever UCS takes it from here.

Barry Schreier:
Good. Thank you for this platform, and I appreciate your thoughtful questions. Hope you guys just spread the word about campus mental health. I hate to sort of wax like a Hallmark card, but it really does take a village, and the more hands we have in helping each other, the better it seems to go.

Steve Sonnier:
That’s it for this week’s episode of From the Front Row. Huge thanks to our guest, Dr. Barry Schreier for coming on today. This episode was hosted and written by Lexi Fahrion and Steve Sonnier. This episode was edited and produced by Steve Sonnier. You can find more about the University of Iowa College of Public Health on Facebook. Our podcast is available on Spotify, Apple Podcasts, and SoundCloud as the University of Iowa College of Public Health.

Steve Sonnier:
If you enjoyed this episode, please share it with your colleagues. Our team can be reached at cph-gradambassador@uiowa.edu. This episode was brought to you by the University of Iowa College of Public Health. Keep on keeping on out there.