A study published Tuesday paints a grim picture of America’s increasingly stressed medical students, in what researchers say they hope will be a “wake-up call” to the nation’s medical schools and health care policy makers.
The study, led by the Cambridge Health Alliance, a hospital system near Boston, includes data from 115 of the nation’s medical schools, looking specifically at what type of health insurance they offer to students with mental health and substance abuse problems.
SAN FRANCISCO — How far can colleges go to stop students who are threatening to commit suicide?
It’s a fundamental question for college and university officials who work in the fields of student affairs, counseling and mental health -- and for the lawyers who may have to deal with the aftermath, and sometimes see mental health issues as a minefield of potential litigation.
Mental illness and depression are public health issues, which have been the subject of debate on college campuses long before the tragic shooting at Virginia Tech.
Last year, the Bazelon Center, a nonprofit, legal advocacy organization for which I work, represented a George Washington University student who voluntarily sought hospital treatment for depression and as a result faced disciplinary action by the university administration and was subsequently suspended from school and barred from campus. In another suit, we represented a Hunter College student who also voluntarily admitted herself to the hospital for treatment of depression and as a consequence was locked out of her dorm room by the college administration.
Such responses by colleges send students who seek help for mental illness the wrong message. When students have done the right thing and reached out for help, removing them from colleges sends the message that they have done something wrong and are not wanted on campus. It also inappropriately isolates these students from their community and the supports they need during a time of crisis. Moreover, these policies may actually increase the risk of harm by discouraging students from getting help for themselves or others.
In the aftermath of incidents like that at Virginia Tech, people often look for quick solutions to re-establish a sense of safety. Many commentators have suggested removing students who show signs of mental illness from campus. Some lawmakers have even suggested removing students’ privacy protections. However, these short-sighted reactions will only discourage students from seeking help. Instead, colleges should be committed to the success of all students, including those with depression or other mental illnesses.
To that end, colleges should make suicide prevention a priority and acknowledge, but not stigmatize, mental health problems. Whether on campuses or in our communities, individuals with mental health problems need ready access to counseling and other support systems without long delays and without fear of repercussions. Colleges can take actions to encourage students to seek counseling and mental health treatment through campus services or other available avenues. Colleges can integrate mental health information into student orientation and other aspects of campus life. Colleges can provide training so that faculty, staff and students know what supports and services are available, how to make referrals, and how to access supports and services. They can encourage the formation of peer-run groups on campus to support students with depression and other mental illnesses. Colleges can ensure that emergency psychiatric services are available at all times, either on campus or in the community. Mental health programs need to get out of the clinic and reach out to people who demonstrate a need for services in order to engage them and keep them engaged.
Students are often faced with a dilemma: to seek help or accommodation of their mental illness and jeopardize their education, or to forego needed mental heath treatment. Colleges need to address this dilemma by removing barriers to seeking treatment and by providing accommodations.
In educational settings, such accommodations should include an offer of liberal voluntary leave for students who feel that they would benefit from time off, ensuring that their education is not jeopardized for taking leave. Colleges can also provide for reduced course loads, exam extensions or postponements, medical withdrawal and pro-rated financial reimbursement.
Privacy is also critical. Students are often fearful that they will be denied jobs, housing or educational or social opportunities if they disclose their mental illness. To encourage students to seek treatment, colleges must ensure confidentiality. Those who suggest changing privacy rules wrongly imply that the laws prohibit colleges from disclosing information about students who may be a danger to themselves or others. However, under current laws, counseling centers and colleges can disclose information about a student to the extent needed to protect the student or others from imminent and serious injury, if the student will not consent to interventions that will ensure safety. Colleges can also act proactively before a crisis occurs. For example, they can ask students upon matriculation to identify individuals who can be contacted in case of a medical or psychiatric emergency.
Financial issues are often paramount. While students may have adequate health insurance covering inpatient and outpatient services while in college, coverage often terminates upon medical leave from the university. Health insurance may also exclude inpatient services and place limits on the number of outpatient visits. Colleges should be cognizant of this reality and work to assist students without coverage and advocate for expanded coverage.
Finally, colleges can ensure that students will not be penalized or suffer negative consequences for seeking help. Institutions must guarantee that each student will be treated on a case-by-case basis. In limited circumstances, when individualized assessment suggests that even with accommodation a student cannot safely remain on campus, the student can be placed on leave. Such individually tailored practices ensure that if students are asked to take leave, it will only be due to dangerousness, not discrimination.
The Bazelon Center has done important legal work to remove the stigma and punitive cloud surrounding campus mental health. Clearly, in the coming weeks many students at Virginia Tech and other schools will suffer the emotional repercussions of having lost their friends and peers. Like the plaintiffs at George Washington and Hunter, they will need help and will need to know that it is safe for them to ask for it.
Universities need to be at the forefront of this effort, ensuring that counseling centers get the support and staffing they need to do their jobs effectively and removing all of the barriers that now keep students from getting help. They must afford students ready access to appropriate resources, provide confidentiality, remove stigma, and adopt policies that make help-seeking safe. Disciplinary measures or automatic suspensions have no place in campus health care.
Karen Bower is a senior staff attorney at the Bazelon Center for Mental Health Law.
If you believe the pundits and talking heads in the aftermath of the Virginia Tech tragedy, every college and university should rush to set up text-message-based early warning systems, install loudspeakers throughout campus, perform criminal background checks on all incoming students, allow students to install their own locks on their residence hall room doors, and exclude from admission or expel students with serious mental health conditions. We should profile loners, establish lockdown protocols and develop mass-shooting evacuation plans. We should even arm our students to the teeth. In the immediate aftermath, security experts and college and university officials have been quoted in newspapers and on TV with considering all of these remedies, and more, to be able to assure the public that WE ARE DOING SOMETHING.
Since when do we let the media dictate to us our best practices? Do we need to do something? Do we need to be doing all or some of these things? Here's what I think. These are just my opinions, informed by what I have learned so far in the reportage on what happened at Virginia Tech. Because that coverage is inaccurate and incomplete, please consider these my thoughts so far, subject to revision as more facts come to light.
We should not be rushing to install text-message-based warning systems. At the low cost of $1 per student per year, you might ask what the downside could be? Well, the real cost is the $1 per student that we don't spend on mental health support, where we really need to spend it. And, what do you get for your $1? A system that will send an emergency text to the cell phone number of every student who is registered with the service. If we acknowledge that many campuses still don't have the most current mailing address for some of our students who live off-campus, is it realistic to expect that students are going to universally supply us with their cell phone numbers? You could argue that students are flocking to sign up for this service on the campuses that currently provide it (less than 50 nationally), but that is driven by the panic of current events. Next fall, when the shock has worn off, apathy will inevitably return, and voluntary sign-up rates will drop. How about mandating that students participate? What about the costs of the bureaucracy we will need to collect and who will input this data? Who will track which students have yet to give us their numbers, remind them, and hound them to submit the information? Who will update this database as students switch cell numbers mid-year, which many do? That's more than a full-time job, with implementation already costing more than the $1 per student. Some students want their privacy. They won't want administrators to have their cell number. Some students don't have cell phones. Many students do not have text services enabled on their phones. More added cost. Many professors instruct students to turn off their phones in classrooms.
Texting is useless. It's useless on the field for athletes, while students are swimming, sleeping, showering, etc. And, perhaps most dangerously, texting an alert may send that alert to a psychopath who is also signed-up for the system, telling him exactly what administrators know, what the emergency plan is, and where to go to effect the most harm. Would a text system create a legal duty that colleges and universities do not have, a duty of universal warning? What happens in a crisis if the system is overloaded, as were cellphone lines in Blacksburg? What happens if the data entry folks mistype a number, and a student who needs warning does not get one? We will be sued for negligence. We need to spend this time, money and effort on the real problem: mental health.
We should consider installing loudspeakers throughout campus. This technology has potentially better coverage than text messages, with much less cost. Virginia Tech used such loudspeakers to good effect during the shootings.
We should not rush to perform criminal background checks (CBCs) on all incoming students. A North Carolina task force studied this issue after two 2004 campus shootings, and decided that the advantages were not worth the disadvantages. You might catch a random dangerous applicant, but most students who enter with criminal backgrounds were minors when they committed their crimes, and their records may have been sealed or expunged. If your student population is largely of non-traditional age, CBCs may reveal more, but then you have to weigh the cost and the question of whether you are able to perform due diligence on screening the results of the checks if someone is red-flagged. How will you determine which students who have criminal histories are worthy of admission and which are not? And, there is always the reality that if you perform a check on all incoming students and the college across the street does not, the student with the criminal background will apply there and not to you. If you decide to check incoming students, what will you do about current students? Will you do a state-level check, or a 50-state and federal check? Will your admitted applicants be willing to wait the 30-days that it takes to get the results? Other colleges who admitted them are also waiting for an answer. The comprehensive check can cost $80 per student. We need to spend this time, money and effort on the real problem: mental health.
We should not be considering whether to allow students to install their own locks on their dormitory room doors. Credit Fox News Live for this deplorably dumb idea. If we let students change their locks, residential life and campus law enforcement will not be able to key into student rooms when they overdose on alcohol or try to commit suicide. This idea would prevent us from saving lives, rather than help to protect members of our community. The Virginia Tech killer could have shot through a lock, no matter whether it was the original or a retrofit. This is our property, and we need to have access to it. We need to focus our attention on the real issue: mental health.
Perhaps the most preposterous suggestion of all is that we need to relax our campus weapons bans so that armed members of our communities can defend themselves. We should not allow weapons on college campuses. Imagine you are seated in Norris Hall, facing the whiteboard at the front of the room. The shooter enters from the back and begins shooting. What good is your gun going to do at this point? Many pro-gun advocates have talked about the deterrent and defense values of a well-armed student body, but none of them have mentioned the potential collateral criminal consequences of armed students: increases in armed robbery, muggings, escalation of interpersonal and relationship violence, etc. Virginia, like most states, cannot keep guns out of the hands of those with potentially lethal mental health crises. When we talk about arming students, we'd be arming them too. We need to focus our attention on the real issue: mental health.
We should establish lockdown protocols that are specific to the nature of the threat. Lockdowns are an established mass-protection tactic. They can isolate perpetrators, insulate targets from threats and restrict personal movement away from a dangerous line-of-fire. But, if lockdowns are just a random response, they have the potential to lock students in with a still-unidentified perpetrator. If not used correctly, they have the potential to lock students into facilities from which they need immediate egress for safety reasons. And, if not enforced when imposed, lockdowns expose us to the potential liability of not following our own policies. We should also establish protocols for judicious use of evacuations. When police at Virginia Tech herded students out of buildings and across the Drill Field, it was based on their assessment of a low risk that someone was going to open fire on students as they fled out into the open, and a high risk of leaving the occupants of certain buildings in situ, making evacuation from a zone of danger an appropriate escape method.
We should not exclude from admission or expel students with mental health conditions, unless they pose a substantial threat of harm to themselves or others. Section 504 of the Rehabilitation Act prohibits colleges and universities from discrimination in admission against those with disabilities. It also prohibits colleges and universities from suspending or expelling disabled students, including those who are suicidal, unless the student is deemed to be a direct threat of substantial harm in an objective process based on the most current medical assessment available. Many colleges do provide health surveys to incoming students, and when those surveys disclose mental health conditions, we need to consider what appropriate follow-up should occur as a result. The Virginia Tech shooter was schizophrenic or mildly autistic, and identifying those disabilities early on and providing support, accommodation -- and potentially intervention -- is our issue.
We should consider means and mechanisms for early intervention with students who exhibit behavioral issues, but we should not profile loners. At the University of South Carolina, the Behavioral Intervention Team makes many early catches of students whose behavior is threatening, disruptive or potentially self-injurious. By working with faculty and staff at opening communication and support, the model is enhancing campus safety in a way that many other campuses are not. In the aftermath of what happened at Virginia Tech, I hope many campuses are considering a model designed to help raise flags for early screening and intervention. Many students are loners, isolated, withdrawn, pierced, tattooed, dyed, Wiccan, skate rats, fantasy gamers or otherwise outside the "mainstream". This variety enlivens the richness of college campuses, and offers layers of culture that quilt the fabric of diverse communities. Their preferences and differences cannot and should not be cause for fearing them or suspecting them. But, when any member of the community starts a downward spiral along the continuum of violence, begins to lose contact with reality, goes off their medication regimen, threatens, disrupts, or otherwise gains our attention with unhealthy or dangerous patterns, we can't be bystanders any longer. Our willingness to intervene can make all the difference.
All of the pundits insist that random violence can't be predicted, but many randomly violent people exhibit a pattern of detectable disintegration of self, often linked to suicide. People around them perceive it. We can all be better attuned to those patterns and our protocols for communicating our concerns to those who have the ability to address them. This will focus our attention on the real issue: mental health.
Brett A. Sokolow
Brett A. Sokolow is president of the the National Center for Higher Education Risk Management. He is also special counsel to the president at Hobart and William Smith Colleges, special counsel for student conduct issues at Warren Wilson College, special advisor to the dean of campus life at the University of the Incarnate Word, and special counsel to the dean of students at Hendrix College.
The American penchant for noting records marked the Virginia Tech shootings in Blacksburg as the “single worst massacre on an American campus.” Having survived the previous record-setting event, that awful day in 1966 at the University of Texas, I understand the demarcation, but the label doesn’t tell the whole story. In particular, it runs the risk of following Stalin’s cynical comment that “A single death is a tragedy; a million deaths is a statistic.” We know better. Each and every death at Virginia Tech was a tragedy.
The question remains: What will we learn from the experience?
At noon on August 1, 1966, I was in my car at a stoplight in front of the University Co-Op Bookstore, just across the street from the University of Texas campus. By that time Charles Whitman had already begun his assault on innocence from the Texas Tower. Barely 10 feet away from me a paperboy had been felled by a single, incredibly accurate shot just minutes before. Others had died or were dying on the street, across the campus, and at points nearby. That I was not a statistic that day is either a coincidence or a miracle. That I was among the hundreds, maybe thousands, deeply and personally affected by this tragedy is an undeniable fact.
In truth, I had more or less seen it coming. Over the previous few months I had numerous encounters with Charles Whitman, and I had long been fearful of him. Twice a week my senior year I had seen or heard him as he sat on a windowsill or stood in the hallway outside his upcoming class in the Architecture Building. I had a political history class at the same time in the same building, and the windowsill where I waited for class was next to his. The persistent nervous habit of chewing his fingernails with a vengeance had earned him the nickname “Charley Fingernails” in my household. His military bravado and occasional flashes of anger worried me so much that I had confessed to others, “If this guy ever does anything violent, no one had better say, ‘he doesn’t seem the type of person who’d do something like that.’ ” In retrospect, we know now without question that at some point, perhaps during spring semester, Whitman had confessed to the university psychiatrist, “sometimes I feel like going up to the Tower with a deer rifle and killing people.”
That summer of ’66 my wife and I also had reason to worry about another troubled young man in our world, someone whose name I have never learned. We called him simply the “Mystery Man.” He was a squatter in an abandoned Victorian home adjacent to the apartment complex that my wife and I managed. He stole things, harassed young women, and frankly raised more red flags than the Soviet navy. Assuming he was a UT student or recent drop-out, we addressed our concerns to the university psychiatrist, as well as to the Austin police, to our church minister, or to anyone we thought would listen. No one would. The young man was clearly lost and disturbed. We knew the latter because my wife had discovered hundreds of mutilated pictures of women when she bravely investigated his hideout in the abandoned building during one of his absences.
No one thought the Mystery Man’s behavior rose to a sufficient level of concern to intervene, however. Only the pictures had been cut up, we were reminded, and not the women. His menacing and scary habits were a frightful part of our daily routine that summer, so much so that before we learned that the Tower sniper was Charley Fingernails, we speculated that it almost certainly had to be our Mystery Man.
Were the authorities correct in ignoring the antics of the Mystery Man, while simultaneously wrongheaded in ignoring those of Charles Whitman?
Forty-one years and a long career of college teaching later, I wrote a book about all this. Tragically, Summer of ’66 came out the Friday before the fateful Monday at Virginia Tech. In those pages I do not condemn UT authorities, the Austin police, or the campus psychiatrist; in fact, I agree with the recent comments of A Sniper in the Tower author Gary Lavergne that Charles Whitman bears full responsibility for his actions at UT and Seung-Hui Cho carries that heavy weight for Virginia Tech. Both individuals were determined to kill themselves and to take others with them. Such heinous decisions cannot be guarded against even with the heavy security found in Baghdad. How can it be different on an open American campus?
My concern in the aftermath of Blacksburg is for the victims and all others touched by these tragedies: the dead, the wounded, the relatives, the faculty, students and staff. Equally, I fear how they all face the future. The impact of these events is deeply personal and profoundly individual. Their timeframe is infinite. The sense of loss, the disappearance of trust, and the incredible sense of personal vulnerability will not soon or easily disappear.
Meanwhile, as a parent, a friend, and a survivor of August 1, 1966, I say that when confronted with the troubling presence of a Mystery Man, a Charles Whitman, or a Seung-Hui Cho, for God’s sake do something. Intervene. Like Nikki Giovanni, Cho’s courageous English professor, alert someone.
As a professor on a college campus for 36 years, I appreciate the privacy rules that govern our interactions with students and parents. Still, I believe that these laws and strictures must be reviewed. Parents of students under 21 do have a right to know when their child is in a personal crisis, especially one that potentially threatens the lives of others. The privacy strictures regarding financial issues and grades, however, do not seem to apply. I empathize with colleagues who cite not only limitations in their professional training to deal with mental disorders among students but also the roadblocks they face when alerting those better prepared.
Alas, universities must now address these limitations.
Shelton L. Williams
Shelton L. Williams is the John D. Moseley Chair of Government and Public Policy at Austin College in Sherman, Texas, and President of the Osgood Center for International Studies in Washington, D.C.
The recent suicides of college students at Yale and Cornell Universities are rightfully cause for shock and sadness, but also a call to action. No doubt, we wonder how young people with so much talent and promise could end their own lives. In struggling to make sense of these tragic events, it is all too appealing – and unhelpful – to resort to simple explanations and casting of blame. In fact, the science of suicide is highly complex, and suicide prediction and prevention present mental health clinicians, and college administrators, with formidable challenges. Even institutions with quality prevention services, like Cornell and Yale, are not immune from these calamities.
Consider that, after accident, suicide is the second leading cause of death among college students. It is estimated that in any given year approximately 7.5 suicides occur for every 100,000 college students, a figure that translates into some 1,400 suicides. Nevertheless, while any death of a young person is heartbreaking, suicides are numerically rare.
At the same time, we know from our own work and much other research that each year about 10 to 15 percent of college students seriously think about suicide, and approximately 2 to 4 percent will make an attempt. This means that for every college student who dies by suicide, there are hundreds who have tried and thousands who have thought about it. Yet, we still have no overarching psychological theory to explain exactly what moves someone from thinking about suicide to taking action.
We do know that most young people who die by suicide have a diagnosable, and often treatable, psychiatric condition, and, frequently, they have told someone of their plan. Regrettably, numerous studies have found that less than 50 percent of depressed college students seek help. And not all manifest obvious signs of their depression.
Recent research has shown that the brain continues to mature throughout one’s 20s, with the area most responsible for decision-making developing last. Some young people, therefore, may act impulsively, without fully appreciating the real consequences of their actions. As a result, suicide in young people sometimes occurs without any apparent warning, either in a setting in which the young person -- most often a young man -- has hidden his despair from others, or as the result of an abrupt and intense impulse, often in the context of judgment-blurring intoxication.
Despite this, it is important to keep the issues in perspective. While universities are seeing larger numbers of students with psychiatric difficulties -- in part because improvements in treatment make it possible for more students with such problems to successfully attend college – the number of suicides on campuses has remained stable over the past 10 years. This suggests that we may be doing a better job at identifying and treating the underlying causes of suicide, such as depression, bipolar disorder, schizophrenia and substance abuse.
We also know that elite colleges do not have higher rates of suicide than others. Academic competition and pressures are not frequent precipitants of suicide in undergraduates. More often, suicide is precipitated by family or relationship problems, often in the context of substance use.
Moreover, we have learned quite a bit about college suicide prevention in the past 15 years. We know that keeping the means used for self-harm out of the hands of potentially suicidal people will save lives. College students have about half the rate of suicide of non-college-attending young people, in part, it appears, because few guns are allowed on college campuses. And there are definitive measures that can prevent an impulsive young person from taking tragic action. The securing and alarming of windows and roofs have been helpful deterrents. Actions such as Cornell’s adding barriers on its bridges are therefore prudent and sensible.
Educational outreach programs are also effective in assisting students, faculty and administrators to identify psychological problems and decreasing the stigma often associated with seeking treatment. Preparing entering students with previously treated disorders to establish a system of continuing care while on campus is vital, as is communication with parents on the importance of such care.
Interestingly, we have learned that we don’t prevent suicides by focusing solely or even too intensively on suicide prevention. Rather, it is essential that colleges offer comprehensive, accessible and affordable systems of general physical and mental health care, and that they utilize community and public health approaches to educate parents, students, faculty and administrators about the need to communicate, support and care for each other. Steps such as "gatekeeper training," in which people most likely to have direct contact with troubled students (resident assistants, writing instructors, academic advisers, athletic coaches and chaplains, among others) are taught to identify and refer such students for counseling and peer education programs, have a proven track record. For example, the award-winning Active Minds on Campus, with chapters across the country, provides a forum in which students present programs focused on promoting acceptance and understanding of people with mental illness.
Many colleges employ online surveys to help students identify problems and utilize other technology-based modes of support, including appointment and medication reminders, to engage troubled students in a way they feel comfortable.
Among all key members of the college community, communication focused on the support and care of students in distress, while respecting the students' privacy, is also essential. Finally, we know that whenever possible, it is best for troubled students to remain in school among their friends and working toward a positive future. At the same time, colleges and universities must allow for students who temporarily cannot function to return home for more intensive assistance and treatment.
In fact, it turns out that when it comes to suicide prevention, students, faculty, administrators and parents are all in this together.
Victor Schwartz and Jerald Kay
Victor Schwartz is university dean of students at Yeshiva University and associate professor of clinical psychiatry at Yeshiva's Albert Einstein College of Medicine. Jerald Kay is professor and chair of the psychiatry at Wright State University’s Boonshoft School of Medicine. They are the editors of Mental Health Care in the College Community (Wiley).
PHOENIX -- A quarter of students surveyed in the latest National College Health Assessment reported that stress has hurt their academic performance, with such impacts as lower grades or dropped courses. That proportion has fluctuated in the vicinity of 30 percent for more than a decade.