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Warning Signals

Warning Signals
September 26, 2008

As she read news stories about a former Illinois college student who killed five people and then himself in February, Anna Scheyett wondered if anything could have been done to prevent the tragedy. Would friends and loved ones have been able to sense that something was wrong with Stephen Kazmierczak, the 27-year-old shooter with a history of mental illness, if he had told them in advance what to look for?

Scheyett, a clinical associate professor at the University of North Carolina at Chapel Hill, is now exploring ways that mentally ill college students can better communicate with university officials, and even close friends, about their problems. Specifically, Scheyett is researching so-called “advanced directives” for mental health. Not unlike a living will, an advanced directive for mental health allows people to designate their preferred treatment options, while also documenting warning signs that may suggest a looming crisis.

“The whole [advanced directive] is about really enhancing student autonomy,” said Scheyett, who is associate dean for academic affairs at North Carolina’s School of Social Work. “When you get sick, this is a way for the healthy part of the person to keep speaking.”

Scheyett is now conducting a feasibility study at Chapel Hill, asking students with histories of mental health problems to consider completing advanced directives. Students who participate will fill out directive forms and share information, including lists of medications or treatments that have been effective in the past. Students can choose how much they want to divulge, but they would be asked to name possible triggers for their mental health problems, preferred hospitals and emergency contacts.

Students will be responsible for deciding who should receive copies of their directives, but possible recipients include the campus counseling center, social workers employed by local police, the dean of students, and even resident advisers, friends and faculty.

Scheyett’s research is just that -- research. Chapel Hill officials have not said they want students to fill out these forms routinely, and Scheyett says she would object to any future policy that would in any way mandate the forms for students with mental health histories.

Directives Raise Privacy Questions

By asking students to fill out advanced directives, colleges would begin to address one of the thornier issues currently facing academe: what to do when a student loses control.

One of the key concerns on college campuses, as evidenced in the wake of the Virginia Tech shootings, is protecting student privacy, while also protecting the campus at large. Dr. Marvin Swartz, director of the National Resource Center on Psychiatric Advanced Directives, said the use of advanced directives at colleges might well make it easier for officials to act quickly and efficiently without being “hamstrung” by student privacy laws.

“This is a way to kind of resolve that because the student can give a waiver of confidentiality and be clear about who has the right to know,” Swartz said. “Often in these situations, people get so hung up on confidentiality issues that they can’t do the right thing.”

But widening the distribution of sensitive medical information is sure to raise its own set of privacy questions, and Scheyett said she’s already heard those voiced by the university board that approves on-campus research.

“[Privacy is] something we thought about, and that’s something our institutional review board made us think about really, really, really hard,” Scheyett said.

Copies of the directives will be kept under lock and key, but students will also be asked to sign a consent form that acknowledges the risk of having “a piece of paper out there in the world” that may contain intimate details about their history, Scheyett said.

In recent years, universities have been criticized for mishandling student mental health records. Such cases have been of great interest to the Bazelon Center for Mental Health Law, which has represented students who have alleged privacy violations. Karen Bower, senior staff attorney for the Bazelon Center, said she believes advanced directives have some clear benefits in a university setting, but she cautioned that students shouldn’t be pressured to distribute the information to those who don’t have a true need for it.

“It should be limited to individuals who would be able to respect it,” Bower said. “It’s your preferences for treatment. Why would you give it to your landlord? Why would you give it to your [resident assistant]?”

The Bazelon Center has also taken cases alleging that students were disciplined or barred from school after they reported mental health problems to university officials.

Within advanced directives, students may be asked whether they would benefit from being secluded during mental health episodes. So might college officials be given more leeway to bar students from campus in some cases? Scheyett says she doesn't think so.

“I’ve never thought of it in terms of cover," she said.

Swartz, a professor of psychiatry at Duke University Medical Center, said he would be disappointed if advanced directives were used for "risk management."

"I wouldn't want it to be seen as a risk management tool for the institution. It's not the intention," he said. “But [the directive] helps a lot because by giving them permission to talk and follow a treatment plan."

Directives Still Untested at Colleges

Advanced directives for mental health, which are sometimes called psychiatric advanced directives, are a relatively new phenomenon. Introduced in the late 1990s, the directives were a response to concerns that mentally ill patients feel a loss of control during treatment if they are incapacitated.

Swartz said advanced directives are largely untested in college settings. That said, a college campus may be one of the places where advanced directives could be of most value, he said.

“A university doesn’t have a regular health care system,” Swartz said. “Often students are relatively transient. They are there for four years at best. They may have very little record at that institution. This is a way for them to make it clear what treatment they’ve had, their whole history.”

There may be other benefits to advanced directives as well, according to Swartz’s research on the subject. Those who fill out directives may build relationships of greater trust with health care providers, while also learning more about their own illnesses, Swartz said.

“We have published papers in which we’ve shown the benefits to the people who created them,” he said. “It improved their relationship with their mental health provider. It reduced their crises, so they had fewer crises as a result, and those crises resulted in less involuntary treatment.”

Kevin Gaw, president of the American College Counseling Association, said he’s interested in the potential benefits that advanced directives might have for students. On the other hand, he also thinks any requirement for directives would be misguided.

“That would feel pretty coercive,” said Gaw, a psychologist and director of career services at Georgia State University. “I don’t think that would actually protect people. It would harm people in a way we don’t want to do as educators.”

But Gaw said he’ll watch the developments in North Carolina’s research carefully.

“It’s new, and I think this study is pretty innovative, and it will be very fascinating to see what happens,” he said. “There’s pros and cons. Obviously there will be pros and cons we don’t even know about.”

 

 

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