Moments after being approved as a volunteer “active listener” on the online mental health support service 7 Cups of Tea, Julliard Lin said she was suddenly offering emotional help to someone navigating a violent relationship.
Lin had no training in providing support other than a short, multiple-choice quiz on listening skills that volunteers are required to pass on the 7 Cups website.
After completing the 10-minute quiz, Lin became part of a booming online mental health support industry making its way onto North American university and college campuses.
7 Cups of Tea (7 Cups), which invites volunteers as young as 15 to be “active listeners” for people seeking emotional support, is a leader in the crop of online services being contracted by post-secondary institutions. For budget-strapped universities and colleges, one lure is obvious: 7 Cups typically costs less than $1 per student per year.
But as dozens of Canadian post-secondary schools supplement their on-campus counselling with online services from private firms, questions are mounting about quality of care and privacy, an investigation by the Toronto Star and Investigative Journalism Bureau has found.
“Campuses buy [online counselling services] because it’s an economic decision for them, not a good moral decision,” said Kathy Offet-Gartner, the president-elect of Canada’s leading counselling association- the Canadian Counselling and Psychotherapy Association (CCPA) — and a registered psychologist and university counsellor for 25 years.
“It’s not a good health decision. It’s not even a good liability decision.”
Glen Moriarty, the founder of 7 Cups, billed as “the world’s largest emotional support system,” defends the service’s model.
“I think it is important to note that active listeners are not providing any sort of therapy process,” he said in a written statement. “They are like good friends or neighbors that are simply listening and caring for people that are going through a challenging time. They do not provide advice. They paraphrase, summarize, and empathize.”
The service emphasizes that its active listening platform is not meant to be a replacement for mental health counselling and that their volunteers are not required to be licensed.
7 Cups isn’t alone in its push into youth mental health support where demand is spiking. Among the most popular services on Canadian and U.S. campuses are Aspira Corp.’s Empower Me, TAO Self-Help, and My SSP/Keep.meSAFE by human resources giant Morneau Shepell.
The burgeoning online mental health service industry has caught the eyes of Health Canada and the U.S. Food and Drug Administration (FDA), but they say the tools do not generally meet their definitions of “medical devices,” leaving them beyond the reach of regulation.
That hands-off approach by governments has triggered warnings from researchers, physicians and privacy advocates.
“There has been a flood of many apps that do not necessarily have an evidence base or sufficient oversight of reviewing whether these apps will actually help people,” said Stanford University bioethicist Nicole Martinez-Martin.
That lack of regulation, “exacerbates concerns over how safety, privacy, accountability and other ethical obligations to protect an individual in therapy are addressed within these services,” Martinez-Martin and Karola Kreitmair conclude in a 2018 study published in the Journal of Medical Internet Research.
Some mental health apps connect vulnerable people with minimally trained, non-professional listeners, the study found, and in some cases that counselling is steered by artificial intelligence.
Growing numbers of young people — including students — are disclosing personal and often traumatic experiences to unlicensed ears at 7 Cups and other online services.
Lin, originally from New York, first tried 7 Cups in 2019 while living in Japan and struggling with feelings of isolation.
When she signed up to be an active listener, she said she was paired with someone in an abusive relationship despite having indicated she did not feel comfortable helping with domestic abuse issues. She later was connected with a person seeking advice on undergoing sex reassignment surgery, something she felt equally unequipped to help with.
While the 7 Cups site directs those with serious mental health challenges or those in crisis to seek professional help, Lin found that kind of self-regulation doesn’t always work.
“The fact that the help that you’re getting is not vetted felt so irresponsible,’” said Lin. “This is a situation where it’s super easy to harm someone.”
Another 7 Cups user told the Star that shortly after signing up in 2019 to talk to someone as she wrestled with suicidal ideation, two active listeners began hitting on her.
Lin logged out for good after four days. She said she is wary of schools who are offering 7 Cups as a viable mental health resource for students.
“That’s just really disappointing. It is much closer to telling someone ‘Go deal with it yourself’ than it is to telling someone, ‘Hey, here’s a resource.’”
7 Cups’ active listeners are trained by the company, and must pass a multiple choice quiz with the help of text and video instruction before being paired with a user seeking support.
Prospective “active listeners,” who can be as young as 15 with parental consent, take an oath to treat people with dignity and respect and, upon completion of the training quiz, have access to an additional 70 training courses that are “provided at no cost,” 7 Cups’ Moriarty said in a written statement.
Sandy Amodio, a registered social worker and counsellor in Burlington for more than 12 years, completed the 7 Cups active listener training for this investigation, estimating that it took her roughly 30 minutes.
“The questions they ask potential listeners were multiple choice, simple, general, and didn’t require a whole lot of thought or experience,” she said.
One example of the questions: “Why is it important to recognize a person’s strengths? a) It builds self esteem and confidence; b) It helps them feel strong and empowered; c) Both of these.”
Another: “Which of the following is an open-ended question: a) Do you still feel sad?; b) How are you feeling?; c) Are you feeling better now?”
If a prospective listener fails to answer enough questions right, the site directs them to do it again until they pass.
“I don’t know how they can just offer a short video and say that you’re ready to be a listener,” Amodio said, adding the training should be longer and conclude with a more rigorous test.
“If you’ve got somebody that hasn’t had a lot of life experience, hasn’t had a lot of training, sometimes they can…take on the role like they are an actual counsellor when they’re not.”
Before entering a conversation, 7 Cups users seeking help are required to agree with the following statement: “I am not in crisis, homicidal, suicidal or abusing anyone, and I agree to the 7 Cups Terms of Service and Privacy Policy.”
But the risk still exists, said Amodio.
“Even though (7 Cups) emphasize that a listener is just there to support, not provide therapy, it is not easy to control this.”
Given current unmet demands for mental health support, 7 Cups’ Moriarty said the model fills a gap.
“In our world, now with COVID and more lockdowns, we have people that are increasingly suffering. There are not enough clinicians in this world to meet the demand. That means we need to find ways to train non-licensed people (people without master’s or doctoral degrees) to emotionally support one another,” he wrote.
“The increasing suffering that humanity is facing requires that we get smarter and better at finding ways to scale compassionate care. We are far from perfect. We are working very hard to try to help meet this demand.”
He said traffic on the website has increased over the pandemic to 800,000 daily messages from a previous level of 500,000.
“A growing number of people do not have family or friends that they trust to lean on and many do not have the resources available to pay for therapy at the rate of $100-200/hour. We believe that training people to care for one another is one way we can help decrease suffering.”
There is no dispute about 7 Cups’ success.
Since 2013, users have sent more than 1.3 billion messages, with over 400,000 active listeners and just under 54 million “people reached” across 189 countries, including more than three million reached in Canada, according to the company’s website.
There has been significant growth of its use on Canadian campuses, too.
Bow Valley College (BVC) and the University of Lethbridge in Alberta use 7 Cups, as does Memorial University of Newfoundland. Eleven post-secondary institutions in Nova Scotia access the service through a government-funded program called Healthy Minds NS.
In May 2019, 7 Cups had hosted only seven conversations for BVC students, with four more occurring between January and April that year.
In May of this year, the service hosted at least 863 student conversations — an increase of more than 12,000 per cent compared to the same time the year before.
School officials attribute at least some of that spike to COVID-19 causing increases in stress and anxiety among students.
Lindsey Fiebig, a registered psychologist for BVC, said the training provided by 7 Cups is enough to prepare people for active listening in the context of mental health.
“I think anybody who has a good intent and a little bit of skill will be fine in peer-to-peer interactions,” said Fiebig. “I think it’s important always to remember that although peer interactions are incredibly important and helpful, they’re not therapy.”
Healthy Minds NS offers free digital mental health services to roughly 45,000 post-secondary students across Nova Scotia. 7 Cups is one of five services offered through the program and costs the province roughly $50,000 annually — a per-student cost of roughly $1.
Last year, Memorial University of Newfoundland paid $4,554 to 7 Cups for one of a variety of wellness services offered at the school. That works out to about 25 cents per each of the 18,100 students enrolled in 2018/19.
BVC did not disclose the price of the 7 Cups services it receives.
“In terms of our overall budget for mental health supports, this is a very small, very, very small cost in subscription for an additional support service,” said Lynn Connell, director of learner success services at BVC.
In a study released last year in the journal Healthcare Policy, an estimated 2.6 billion people globally would use mobile health apps by this year, spurring an industry that is worth $31 billion (USD). The figure is almost certainly far larger now with significant increases in the use of digital counselling tools triggered by COVID-19.
Researchers have warned about the impacts.
A 2018 study published in the journal Annals of Family Medicine that reviewed 61 apps that offer mental health self-diagnosis concluded the tools may, “promote medicalization of normal mental states” and can lead to “unnecessary treatment and divert resources from those who really need help.”
A repeated message to app users, the study found, was that individuals “can easily manage their own mental health problems with apps.” And yet, developers offered “very limited scientific evidence for the apps’ claimed benefits,” the study found.
In addition to its voluntary “listener” support model, 7 Cups offers licensed therapy for a $150 monthly fee. The Canadian university and college 7 Cups contracts obtained by this investigation do not include licensed therapy.
Other third-party services with school contracts blend the online model with licensed care providers, including human resources giant Morneau Shepell’s Keep.meSAFE program.
Five years ago, the company adapted its employee-focused remote counselling service for use at universities. Much like clinics run by the schools themselves, the service offers wellness resources, 24/7 counselling and pre-scheduled appointments – all online, with trained counsellors.
The company’s counselling staff are trained at the university level and are registered with “the appropriate governing body of the province in which they reside,” said Stephanie Walker, director of student support at Morneau Shepell.
“Safety is paramount…We would always pre-establish a notification system with an institution if there is a serious risk of harm to a student.”
If you are thinking of suicide or know someone who is, there is help. Resources are available online at crisisservicescanada.ca or you can connect to the national suicide prevention helpline at 1-833-456-4566, or the Kids Help Phone at 1-800-668-6868.
In Canada alone, Morneau Shepell works with 75 post-secondary institutions supporting 300,000 students, the company said, and the pandemic has increased the number of schools seeking their services for the 2020-2021 school year.
Vito Pilieci, spokesperson for the Privacy Commissioner of Canada, said the surge in online service usage is creating “new risks” in privacy rights.
“This is particularly concerning in light of the fact that our current federal privacy laws do not provide an effective level of protection suited to the digital environment,” he said in a written statement to the Star.
Those seeking mental health care online may be forgiven for thinking the process follows the same rules as entering a mental health professional’s office, including the assumption that their private medical information is kept strictly confidential.
But for regulatory purposes, they are in some cases not considered patients. And that means oversight of everything from the quality of care they receive to the protections around their personal health information is very different.
When a wellness application sells student data to an insurance company, the company can identify the student as having a pre-existing mental health condition and choose not to cover certain medical conditions in the future, according to Maria Jogova, a professor of medicine at the University of Toronto. She said the lack of online counselling app privacy protections pose a range of risks that few young users know about.
“A lot of the time university students aren’t thinking about the downstream ramifications of their information being out there,” said Jogova.
A 2019 study published in The BMJ found 19 of 24 popular mobile health apps surveyed — 79 per cent — shared user data with outside companies. The study did not include 7 Cups.
Personal details including a user’s full name, date of birth, email, their pharmacy and doctor’s name, medical conditions, list of drugs and their current “feelings” and symptoms were shared with app developers, advertisers, social media firms, consumer health management companies and multinational technology firms including Google, Facebook, Amazon and Microsoft.
While some believe the push for privacy in the digital mental health industry must start with students, others believe the onus falls to post-secondary administrators to more actively oversee the services they contract.
“It’s going to take a bit more time to get [developers] on board with building in privacy as part of their design process,” said Camille Nebeker, research ethicist and associate professor at the University of California, San Diego.
“They’re not incentivized to do that…It is up to universities, it is up to decision makers who are buying or getting the product to vet it.”
With files from Declan Keogh
This story was also published in the Toronto Star.
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