The Influence of Stigma on College Students' Attitudes Toward Online Video Counseling and Face‐to‐Face Counseling

In 2012 the National Alliance on Mental Illness (NAMI) surveyed the experiences of college students who were living with a mental health condition. Findings from that study showed that 64% of these students stopped attending school for a mental health reason, and 50% of those who dropped out did not utilize the mental health services accessible to them. Participants reported that stigma was the number one barrier that prevented them from seeking help (NAMI, 2012).

As most college students have access to the internet, and because many feel comfortable using technology (Smith, Rainie, & Zickuhr, 2011), online therapeutic interventions may be a viable alternative to face‐to‐face counseling (F2F) for this population. Online counseling (OC), defined as “any delivery of mental and behavioral health services, including but not limited to therapy, consultation and psychoeducation, by a licensed practitioner to a client in a non‐face‐to‐face setting through distance communication technology such as the telephone, asynchronous e‐mail, synchronous chat and video conferencing” (Mallen & Vogel, 2005, p. 764), has been suggested as a way to provide services to those who are stigmatized because of the concerns they are experiencing (Wallin, Maathz, Parling, & Hursti, 2018). This method of service provides the client with accessibility, anonymity, and flexibility in terms of location (Wallin, Mattsson, & Olsson, 2016). College students have reported finding it more accessible to disclose intimate information in an online therapeutic setting (Mishna, Bogo, & Sawyer, 2015), and the use of video conferencing to practice online video counseling (OVC) offers these benefits as well as allowing for visual communication to be maintained (Austen & McGrath, 2006).

OC has been successfully used to treat depression (Johansson & Andersson, 2012), anxiety (Dahlin et al., 2016), and bipolar disorders (Proudfoot et al., 2012). Therapeutic interventions delivered online have shown similar outcome effectiveness to those provided in a face‐to‐face setting (Attridge, 2011; Barak, Hen, Boniel‐Nissim, & Shapira, 2008; Richards & Richardson, 2012). In a meta‐analysis directly comparing OC and F2F, no statistical differences were found in the effect sizes of treatment interventions; however, when the treatment modality of OC was analyzed, cognitive behavior therapy was shown to produce more substantial effects compared with a psychoeducational or behavioral approach (Barak et al., 2008). OVC is as effective when compared with F2F for providing cognitive behavior therapy to those experiencing panic disorder with agoraphobia (Bouchard et al., 2004), bulimia nervosa (Mitchell et al., 2008), and various other psychological disorders (Day & Schneider, 2002). Although OC has been successfully used to treat specific psychological concerns, attitudes toward this modality have been identified as less favorable when compared with F2F (Lewis, Coursol, Bremer, & Komarenko, 2015; Rochlen, Beretvas, & Zack, 2004; Wong, Bonn, Tam, & Wong, 2018). When investigating how these attitudes and stigma are related, researchers have found that stigma is negatively related to F2F attitudes (Vogel et al., 2017). However, little is known about the relationship between stigma and attitudes toward OVC.

The purpose of this study was to investigate college students' attitudes toward OVC in comparison with F2F while also examining the relationship between stigma and attitudes toward both forms of counseling. Two types of stigma were investigated: (a) perceived public stigma—the perception of being perceived by society as unacceptable (Vogel, Wade, & Haake, 2006)—and (b) self‐stigma—the perception of perceiving oneself as unacceptable because of the internalization of public stigma (Corrigan, 2004).

Attitudes Toward Counseling

The effectiveness of a psychological treatment does not necessarily predict the intentions of an individual to seek help. Attitudes toward seeking professional help, however, predict the intentions of an individual engaging in a help‐seeking relationship. Vogel, Wester, Wei, and Boysen (2005) found that attitudes toward seeking help mediated the relationship between psychological factors, such as stigma, social support, and self‐disclosure, and an individual's intentions to seek help for an interpersonal problem.

Attitudes toward OC have been reported as less favorable when compared with attitudes toward F2F in the college population (Wong et al., 2018). Rochlen et al. (2004) assessed undergraduates' perceived value and perceived discomfort toward OC and F2F in three studies. Findings showed that undergraduates expressed more perceived value, and less perceived discomfort, in F2F when compared with its online counterpart. Replication of these results by Bird, Chow, Meir, and Freeman (2018) added further evidence of the negative attitudes held by college students toward OC when compared with F2F. Lewis et al. (2015) noted similar findings. Although the authors did not test for statistical differences, undergraduates in their sample reported higher value and less discomfort in F2F over OC.

Perceived Public Stigma and Self‐Stigma Toward Help Seeking

Stigma has been reported as the number one barrier that deters college students from seeking help (NAMI, 2012). Public stigma is created when an individual perceives society to believe those who seek counseling services are unacceptable (Vogel et al., 2006). In contrast, self‐stigma is a view held by individuals toward themselves. Self‐stigma may occur when an individual in a stigmatized group internalizes public stigma and views himself or herself as socially unacceptable (Corrigan, 2004). Perceived public stigma is positively related to self‐stigma. When an individual experiences higher levels of perceived public stigma, his or her level of self‐stigma increases (Vogel et al., 2017).

A relationship between stigma and attitudes toward help seeking has been identified. College students who report higher levels of public stigma are less likely to seek mental health services (Wu et al., 2017), and perceived stigma and self‐stigma are associated with a lower likelihood that students with a mental health concern will seek treatment (Jennings et al., 2017). Vogel, Wade, and Hackler (2007) determined that perceived public stigma was positively related to self‐stigma, that self‐stigma was negatively related to counseling attitudes, and that counseling attitudes were positively related with a willingness to seek help. Furthermore, self‐stigma was identified as a mediator between perceived public stigma and counseling attitudes.

There is evidence to suggest that OC may be beneficial for those experiencing higher levels of stigma. Klein and Cook (2010) investigated the differences between those who prefer to seek mental health help via the internet and those who prefer to seek traditional face‐to‐face help. Levels of perceived stigma reported in those who prefer to seek mental health help via the internet were significantly higher than the stigma reported by those who prefer to seek help in a face‐to‐face setting. Wallin et al. (2018) drew similar conclusions after finding that participants were more likely to choose online treatment if the problem they were seeking help for was stigmatized. Furthermore, Joyce (2012) identified self‐stigma to be negatively related to attitudes toward OC but indicated that this form of stigma was related to OC significantly less than it was related to attitudes toward F2F.

This study aimed to investigate college students' attitudes (i.e., their perceived value and perceived discomfort) toward OVC and F2F, as well as the relationship between perceived public stigma, self‐stigma, and attitudes toward both counseling modalities. It was hypothesized that significantly higher value and less discomfort would be reported in F2F compared with OVC. Also, it was hypothesized that self‐stigma would fully mediate the relationship between perceived public stigma and attitudes toward both types of counseling. This model included a positive relationship between perceived public stigma and self‐stigma, a negative relationship between self‐stigma and value toward both types of counseling, and a positive relationship between self‐stigma and discomfort toward both types of counseling. It was hypothesized that there would be a direct relationship between perceived public stigma and attitudes toward both types of counseling, with a negative relationship between perceived public stigma and value toward both types of counseling, and a positive relationship between perceived public stigma and discomfort with both types of counseling. It was also expected that stigma would demonstrate weaker relationships with OVC than with F2F.

Method

Participants

Participants in this study were 588 students enrolled in a large southeastern university. The sample included 429 women (73.0%) and 159 men (27.0%) with a mean age of 20.41 years (SD = 2.80). Participants were predominantly White (n = 443, 75.3%), but Black (n = 56, 9.5%), Hispanic (n = 48, 8.2%), Asian (n = 20, 3.4%), multi‐ethnic (n = 13, 2.2%), Hawaiian (n = 3, 0.5%), other (n = 3, 0.5%), and American Indian or Alaska Native (n = 2, 0.3%) were represented. The majority of participants reported that they were juniors in college (n = 180, 30.6%), but the sample also included seniors (n = 169, 28.7%), sophomores (n = 127, 21.6%), freshmen (n = 93, 15.8%), and graduate students (n = 19, 3.2%). One hundred seventeen of the participants in this study (19.9%) reported engaging in counseling services during the previous 12 months in contrast to 471 (80.1%) who did not. Percentages in this section do not all total 100 because of rounding.

Measures

Demographic form. A brief questionnaire was administered to collect the participants' demographic information. The questionnaire asked participants to identify their sex, age, ethnicity, and year in school. Participants were also asked to report whether they had sought professional mental health help in the past 12 months.

Attitudes toward online counseling. The Online Counseling Attitudes Scale (OCAS; Rochlen et al., 2004) was administered to assess attitudes toward OC. This 10‐item instrument is composed of two subscales: Value of Online Counseling (OC‐V; e.g., “I would confide my problems with an online counselor”) and Discomfort With Online Counseling (OC‐D; e.g., “I would dread explaining my problems to an online counselor”). Questions are rated on a 6‐point Likert scale ranging from 1 (strongly disagree) to 6 (strongly agree). Instructions for administering the OCAS ask participants to consider OC as the interaction with a counselor via email or online chat. For this study, participants were asked to consider OC as the interaction with a counselor through video conferencing. In a sample of college students, the test–retest reliability of the OC‐V and OC‐D subscales was found to be .88 and .77, respectively, and the internal consistency reliabilities (alphas) were .88 to .89 for the OC‐V and .77 to .83 for the OC‐D. Construct validity of this measure has been recognized with significant moderate correlations being found between both subscales and existing measures of help‐seeking attitudes (Rochlen et al., 2004).

Attitudes toward F2F. Participants' attitudes toward F2F were measured using the Face‐to‐Face Counseling Attitudes Scale (FCAS; Rochlen et al., 2004). The FCAS is a 10‐item instrument composed of two subscales: Value of Face‐to‐Face Counseling (FC‐V), and Discomfort with Face‐to‐Face Counseling (FC‐D). The questions in these FCAS subscales are identical to those of the OCAS; however, “online counselor” is replaced with “face‐to‐face counselor.” Participants rate each item on a 6‐point Likert scale ranging from 1 (strongly disagree) to 6 (strongly agree). Test–retest reliability coefficients were .85 for the FC‐V and .87 for the FC‐D, and the internal consistency reliabilities (alphas) were .85 to .90 for the FC‐V and .69 to .87 for the FC‐D in a sample of college students. Both subscales have revealed construct validity with significant moderate correlations with existing measures of help seeking (Rochlen et al., 2004).

Self‐stigma. The Self‐Stigma of Seeking Help Scale (SSOSH; Vogel et al., 2006) was used to measure self‐stigma. The SSOSH is a 10‐item unidimensional questionnaire designed to assess self‐stigma in the context of seeking psychological help (e.g., “If I went to a therapist, I would be less satisfied with myself”). Participants rate items on a 5‐point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). The SSOSH has displayed test–retest reliability coefficients ranging from .86 to .90 and has demonstrated levels of internal consistency (measured by alpha) between .89 and .91 when used on a college population. This measure has shown construct, criterion, and predictive validity (Vogel et al., 2006).

Perceived public stigma. Participants' levels of perceived public stigma were measured using the Perception of Stigmatization by Others for Seeking Help Scale (PSOSH; Vogel, Wade, & Ascheman, 2009). The PSOSH is a five‐item instrument in which participants rate how they believe those in their social network would interact with them if they were seeking counseling services (e.g., “Think of you less favorably” and “See you as seriously disturbed”). Responses to items are rated on a 5‐point Likert‐type scale: 1 = not at all, 2 = a little, 3 = some, 4 = a lot, and 5 = a great deal. The scale has displayed test–retest reliability over 3 weeks (r = .82) and has been found to have internal consistency (measured by alpha) between .88 and .89 in various samples of college students. Additionally, it has been validated against numerous measures assessing stigma (Vogel et al., 2009).

Procedure

Data for the current study came from college students who were unused matched controls of a larger data set that we collected previously. In the previous study (Bird et al. 2018), college students were matched to a group of student athletes for comparison on the variables of interest. Thus, there was no overlap of data between the previous and current study. Participants were recruited through a human subject pool at a college within a large southeastern university following approval from the institutional review board. Participants received 30 minutes of credit for completion of the study that contributed toward research requirements set by the college. Participants received all surveys online through the Qualtrics secure server. After giving informed consent, participants completed the demographic section of the survey followed by the OCAS, the FCAS, the SSOSH, or the PSOSH assigned at random to reduce the likelihood of a threat to validity due to order effects (Deshefy‐Longhi, Sullivan‐Bolyai, & Dixon, 2009).

Data Analysis

Frequencies and descriptive statistics were calculated for the demographic items, and internal consistency reliabilities and bivariate correlations were also produced for the primary measures. Two paired‐samples t tests were conducted using IBM SPSS, Version 19, to analyze differences between reported levels of value toward both types of counseling and reported levels of discomfort toward both types of counseling. A path analysis was conducted using Mplus (Version 6; Muthén & Muthén, 2010). Following the guidelines of Enders (2010), maximum likelihood estimation was used to produce a model investigating the mediating effect of the SSOSH between the PSOSH and attitudes toward OVC and F2F (OC‐V, FC‐V, OC‐D, and FC‐D) and the direct effects of the PSOSH on these outcome variables. A bootstrapping procedure was used to maintain an accurate estimate of the standard error of the indirect effects (MacKinnon, Lockwood, Hoffman, West, & Sheets, 2002). Four model fit indices were used to evaluate the adequacy of the model. For the comparative fit index (CFI) and Tucker–Lewis index (TLI), good fit indices are higher than .95, and reasonable fit is greater than .90. For the standardized root‐mean‐square residual (SRMR), the model demonstrates good fit below .08, and reasonable fit if less than .10. For the root‐mean‐square error of approximation (RMSEA), the model demonstrates good fit below .05 and reasonable fit between .05 and .08 (Hu & Bentler, 1999; McDonald & Ho, 2002).

Results

Bivariate correlations, means, standard deviations, and internal consistency reliabilities for the four measurement scales are reported in Table 1. As hypothesized, participants reported more value, and less discomfort, in F2F compared with OVC. The first paired‐sample t test revealed a significant difference between the OC‐V (M = 18.66, SD = 5.61) and FC‐V (M = 23.12, SD = 4.54) subscales, t(587) = –18.30, p = <.001, 95% confidence interval (CI) [–4.94, –3.99], d = –.87, indicating that participants reported significantly higher levels of value in F2F compared with OVC. In addition, the second paired‐sample t test showed a significant difference between the OC‐D (M = 17.45, SD = 5.56) and FC‐D (M = 15.24, SD = 5.71) subscales, t(587) = 8.92, p = <.001, 95% CI [0.72, 2.70], d = .39, indicating that participants reported significantly higher levels of discomfort in OVC compared with F2F.

Table 1

Intercorrelations, Means, Standard Deviations, and Internal Consistency Reliabilities of Attitudes Toward Counseling and Stigma

Note. Scores for attitudes toward counseling can range from 5–30, scores for perceived public stigma can range from 5–25, and scores for self‐stigma can range from 10–50. OC = online counseling; F2F = face‐to‐face counseling.

*p < .01.

Based on findings from previous research (Vogel et al., 2007), a fully mediated model with direct effects was specified to investigate the relationship between perceived public stigma, self‐stigma, and attitudes toward OVC and F2F. In addition to the direct and mediating effects, all outcome variables were correlated with each other. The initial model was just identified: χ2(0, N = 588) = 0.00, p = < .001 (CFI = 1.00, TLI = 1.00, SRMR = .00, and RMSEA = .00). This model showed nonsignificant direct paths from perceived public stigma to both counseling value variables, partially supporting the hypothesized model. As this was the case, these paths were removed, and the model was respecified. The respecified model showed excellent fit to the data: χ2(2, N = 588) = 5.92, p = .051 (CFI = 1.00, TLI = .97, SRMR = .02, and RMSEA = .06). Figure 1 shows the final model with significant paths. Perceived public stigma was a significant positive predictor of self‐stigma (β = .421, p < .001), F2F discomfort (β = .146, p < .01), and OVC discomfort (β = .147, p < .01). Self‐stigma was found to be a significant negative predictor of OVC value (β = –.150, p < .001) and F2F value (β = –.517, p < .001) and a significant positive predictor of OVC discomfort (β = .230, p < .001) and F2F discomfort (β = .528, p < .001).

Figure 1

Final Mediated Model With Direct Effects Note. F2F = face‐to‐face counseling; OC = online counseling. *p < .001.

For indirect effects to be significant at the .05 level, the 95% CI for the bootstrap analysis should not include zero (Shrout & Bolger, 2002). The indirect effect of perceived public stigma on attitudes toward F2F was significant. For FC‐V, β = –.218, 95% CI [–.254, –.183], and for FC‐D, β = .223, 95% CI [.188, .259]. The indirect effect of perceived public stigma on attitudes toward OVC was also significant. For OC‐V, β = –.063, 95% CI [–.093, –.034], and for OC‐D, β = .097, 95% CI [.065, .131]. Results suggest that self‐stigma mediates the relationship between perceived public stigma and attitudes toward counseling.

Two multiple‐group path analyses were conducted to test for any differences between the relationship of variables due to gender and previous counseling experience. A nonsignificant chi‐square difference test, χ2(7, N = 588) = 8.45, p > .05, between a model with all parameters freely estimated and one where all parameters were held equal showed the relationship between variables did not differ for gender. A similar comparison was made between those who had previous counseling experience and those who had none. A chi‐square difference test, χ2(7, N = 588) = 18.16, p < .05, revealed a significant difference. A model where all parameters were freely estimated was compared with a model where only the relationship between self‐stigma and OC‐D was freely estimated. A significant chi‐square difference test, χ2(6, N = 588) = 12.72, p < .05, confirmed this difference. A stronger relationship between self‐stigma and OC‐D was seen for those without counseling experience (β = .243), compared with those who had such experience (β = .057).

Discussion

This study found that students reported higher value, and lower discomfort, in F2F compared with OVC, and it adds to a growing body of literature with similar findings (Bird et al., 2018; Rochlen et al., 2004; Wong et al., 2018). As this generation of college students view using the internet as a tool for communication as part of university life (Jones, Johnson‐Yale, Perez, & Schuler, 2007), findings from this study and previous studies may be counter to expectations. Although the frequency with which OVC is being utilized is unclear, an explanation for these negative attitudes toward this form of counseling might be associated with its relatively low use (compared with F2F) on college campuses. If OVC is not being offered, the potential benefits of utilizing this modality of delivery are not conveyed, and prospective users may not be able to recognize the value of its application. Quarto (2011) found that college students reported significantly more positive attitudes toward OVC after they viewed a simulated videoconferencing counseling session designed to inform them about this counseling modality. It remains unclear, however, whether potential consumers of OVC are being educated about its application in practice.

Similar to previous research (Bathje, Kim, Rau, Bassiouny, & Kim, 2014; Vogel et al., 2007), a relationship between perceived public stigma, self‐stigma, and attitudes toward counseling emerged where self‐stigma mediated the relationship between perceived public stigma and attitudes toward counseling. The relationship between stigmas can be explained as self‐stigma being considered to be the internalizing of perceived public stigma (Corrigan, 2004). The modified labeling theory proposes that as individuals are socialized, they negatively conceptualize mental health help seeking. As these views are internalized, individuals develop a negative perception of what it looks like to suffer a mental illness and confront their own stigmatized beliefs (Link, Cullen, Struening, Shrout, & Dohrenwend, 1989). As self‐stigma involves internalizing perceived discrimination from the public (Corrigan, 2004), and individuals labeling themselves as socially unacceptable (Vogel et al., 2006), higher self‐stigma may result in an individual placing less value in therapy and may be associated with higher levels of discomfort toward both types of counseling. A relationship between public stigma, self‐stigma, and attitudes toward counseling was identified in a study by Vogel et al. (2007) in which it was shown that public stigma was positively related to self‐stigma, self‐stigma was negatively related to attitudes toward counseling, and attitudes toward counseling were positively related to willingness to seek help. Although this earlier study used a unidimensional measure of attitudes toward counseling, a negative relationship between self‐stigma and value and a positive relationship between self‐stigma and discomfort toward both forms of counseling on the multidimensional measure used in the current study could still be interpreted as an overall negative relationship between self‐stigma and counseling attitudes. Furthermore, the current study found perceived public stigma to predict discomfort in both forms of counseling positively, but not value, suggesting that perceptions of others may influence individuals' uneasiness with seeking help, but not how they judge the benefits of therapy.

Even though less value and more discomfort were reported toward OVC, the online method can be viewed as a viable alternative for those experiencing higher levels of stigma who wish to engage in therapy. An important conclusion of this study is that the standardized beta coefficients of the path model indicated that stigma had less influence on students' attitudes toward OVC compared with F2F. This finding could help explain why individuals who report higher levels of stigma are more likely to seek mental health help via the internet (Klein & Cook, 2010). Consistent with the present study, Joyce (2012) found self‐stigma to be negatively related to attitudes toward OC significantly less than it was related to attitudes toward F2F. As OC offers benefits such as privacy (Glasheen & Campbell, 2009) and the anonymity of not entering a waiting room (Wallin et al., 2016), those who engage in this form of therapy may receive treatment without visiting a mental health counseling location. This could decrease factors associated with increased stigma such as reducing the likelihood that one will be discovered engaging in a help‐seeking relationship.

Consequently, this form of counseling may be a better alternative for those who are hesitant to seek services because of the attached fear of being labeled. Additional analyses identified a stronger positive relationship between self‐stigma and OC discomfort for those who had no previous counseling experience. This finding emphasizes how attitudes toward therapy change as individuals engage in help and is consistent with findings on how past experiences influence attitudes toward help seeking (Deane, Skogstad, & Williams, 1999).

Findings from the current study should be interpreted in light of its limitations. Because of the cross‐sectional design of the study, causal relationships cannot be inferred. Wording of two questions on the SSOSH and PSOSH may have led participants to interpret this form of stigma as being related to F2F, therefore skewing scores toward this form of counseling. In addition, the PSOSH is a measure of social network stigma. In addition, the PSOSH is a measure of social network stigma and may not be generalizable to the more general form of societal stigma (Vogel et al., 2009). As a majority of students in this sample had not received counseling in the previous 12 months, many may not have experienced attitudes or stigma toward seeking help. These variables might present themselves differently if a student is experiencing a mental health concern and contemplating seeking help. Also, college students may be some of the most comfortable using technology as they identify it as part of their university life (Jones et al., 2007), thus making it difficult to generalize results to other populations. The reported value and discomfort in OVC may vary depending on how much experience a given population has had in communicating through video conferencing. It is also important to acknowledge the rapid speed at which technology is advancing. As video communication becomes more accessible and more efficient, attitudes toward this form of service may change.

Future directions for research investigating attitudes toward OVC should include clear definitions and descriptions as to what OVC involves from the client's perspective, because lack of knowledge regarding what OVC entails has been given as an explanation for this difference in attitudes between the two counseling modalities (Carper, McHugh, & Barlow, 2013). Forthcoming research should include participants who are presenting with psychological concerns to assess the attitudes and stigma of those who are seeking help. Future research investigating OVC should include covariates that have been seen to influence counseling attitudes or intentions to seek help such as the anticipated risks and benefits of seeking help (Shaffer, Vogel, & Wei, 2006), the individuals' perceived social support (Vogel & Wei, 2005), and psychological distress (Vogel & Wei, 2005). Because attitudes toward a behavior, such as engaging in a therapeutic relationship, do not necessarily predict that behavior, the relationship between attitudes toward OVC and actual help seeking warrants investigation. Future research investigating stigma toward different types of counseling may additionally benefit from measures that assess stigma specific to individual counseling modalities.

This study has important implications for college counseling centers. Although college students reported higher value and less discomfort in F2F compared with OVC, self‐stigma did not influence participants' value toward OVC to the same extent as it did F2F. Given that stigma was identified as the number one barrier a college student faces when seeking psychological help (NAMI, 2012), OVC may offer a viable form of service delivery beneficial for those who do not wish to be seen entering a counseling center on campus. When incorporating this form of counseling into practice, it remains paramount to consider the potential ethical issues that may arise from utilizing this communication method. Although a full list of ethical considerations is beyond the scope of this article, challenges such as understanding the legal issues entailed in providing services at a distance, ensuring confidentiality of electronic transmissions or records, and knowing the limitations of technology use are faced by those who deliver services using technology. Section H of the ACA Code of Ethics (American Counseling Association [ACA], 2014) provides guidelines in this area. As college students report more discomfort in using OVC, mental health professionals should also be reminded of the nonmaleficence principle of the ACA Code of Ethics (ACA, 2014, Preamble). In this case, students may benefit from education as to the uses of OC before the onset of any services, because such education has been shown to improve their attitudes (Quarto, 2011). Educational materials should follow the knowledge and beliefs about professional help component of mental health literacy outlined by Jorm (2012). These guidelines suggest informing college students about what the therapeutic relationship looks like in an online setting and educating them as to the potential outcomes of this form of therapy. Also, the Higher Education Mental Health Alliance provides a distance counseling guide for those who wish to learn more about integrating OVC into practice (Higher Education Mental Health Alliance, 2018).