The Social Relations of Student Mental Health Services: An Institutional Ethnography of the Limits of "Stepped Care 2.0" for Sexual and Gender Minority University Students in Canada

Postsecondary institutions have experienced increasing demands for on-campus mental health care services as rates of mental health concerns continue to grow amongst the student population, particularly amongst made marginalized groups of students, including lesbian, gay, bisexual, trans, and queer (LGBTQ+) students. The Stepped Care 2.0 model of mental health care service delivery has emerged as a popular model for restructuring postsecondary mental health services in the face of these demands, as the model claims to be more financially sustainable and easily accessible for students. Our study explored LGBTQ+ students’ experiences navigating and accessing mental health care services under the Stepped Care 2.0 framework of mental health service delivery at a large university in Ontario, Canada. Using institutional ethnography, the experiences of 29 LGBTQ+ students were analyzed to show how the Stepped Care 2.0 model shaped students’ abilities to access care. Accounts from students revealed that the Stepped Care 2.0 model is not sufficiently equipped to adequately address long-term and/or higher acuity mental health concerns given resource constraints. We explore how the deficits of the Stepped Care 2.0 framework produce various forms of work for made marginalized students, such as seeking care off-campus, coping with the lack of ongoing care, and creating communities of care, and discuss the implications for literature, policy, and practice. By conceptualizing the Stepped Care 2.0 as a ruling relation, we highlight how the framework, as an institutional relation, organizes and shapes the experiences of LGBTQ+ students as they seek out support services for their mental health needs on-campus. By viewing Stepped Care 2.0 in this way, we map how Stepped Care 2.0 imposes particular ruling pathways to mental health, including forcing students to seek out mental health care off-campus so that they can access long-term, consistent, affirming, and effective psychotherapy for their mental health needs.