Speech

Emerging Mental Health Issues on the College Campus

Mental Health Association In Suffolk County
Keynote Address
May 8, 2009

Carolyn Reinach Wolf, Esq.
Senior Partner
Abrams, Fensterman, Fensterman, Eisman,
Greenberg, Formato & Einiger, LLP

As we are all aware, the American campus has been permanently altered by the increase in students with significant mental health issues who are now able to attend institutions of higher learning because of the gains made in pharmacological treatment and therapy as well as a cultural shift in the stigma associated with serious mental illness. More than ever before, students with serious mental health issues, psychological disorders, and related psychosocial challenges, are able to attend colleges and universities across the country, from two-year community colleges to four-year institutions, and on to graduate school after that. Medications with less side-effects, more benefit, use of combined classes of medications and ongoing research and development have made this possible.

Kids are more open about being in therapy, needing mental health treatment, and seeking counseling services. Even parents are more aware of the issues surrounding mental illness, treatment options and the need for their children to be stable and functional. A study by Penn State University found that 1/3 of students reported prior use of psychiatric medication, with 10% reporting use prior to college, 14% only after starting college, and 11% both prior and in college.  The internet has also changed everything in the world of information, communication, intervention and available options, mostly for the better, although sometimes, as we are all painfully aware, not.

In a recent article, entitled “Study Paints Picture of Collegiate Mental Health” the writer stated, “Ever since campus counseling centers were established in the 1940s, college officials have known that the prevalence and severity of students’ mental health problems were rising.  They just didn’t know by how much.”  A pilot study, the first of its kind, recently released by the Center for the Study of Collegiate Mental Health, at Penn State University, “hopes to fill that void.”  Schools across the country are increasingly focused on mental health issues on their campuses, some more than others, some more committed to this endeavor more than others, and it shows.

But, with the positive change in our higher education institutions, that is, admitting and retaining students with mental health issues, come the same challenges  faced in the health care/mental health care institutions in which we have worked all these years. These include, students experiencing side effects of their medication, becoming refractory to the treatment, non-compliance due to feeling better or being stunted in their creativity, stigma, the desire to trade around their medications, and the hope that in this new phase of their lives, they can get along without it, or at least they want to try. Student suicides, either threatened or actual is a growing area of concern on campus, as in our communities.  Suicide, I have learned, is the second leading cause of death among campus students.  One study found that the majority of students who die by suicide have never been seen by the counseling center.  Only a small number of students report receiving suicide prevention information from their colleges.  It is often those students who fly below the radar who are the ones with whom we should be most concerned.  They are the ones who can be more of a threat to themselves or others.  These are the students we need to identify timely, then intervene early on to bring them into the light and into appropriate treatment or follow-up.  Why don’t more students in need seek help?   Among the reasons, it has been shown, are negative beliefs and attitudes about the causes of depression and the treatments, a misplaced belief that depression and the symptoms of this should be hidden from family, friends and employers, and a lack of prior helpful or perceived helpful treatment experiences. And who are those students “at risk” of suicide, threatened or actual, and fallout of this? Experts tell me, those with pre-existing mental illness, those who develop mental illnesses while in college and those who lack coping and other life skills, as well as, as above, those who stop their treatments while away from home.  I believe it is incumbent upon parents, providers and the colleges themselves to dispel these misperceptions and offer accurate and realistic information to the kids, clients and students.

Not to mention the incredible stress and pressure the kids of today are experiencing. I have two college students I know.  It started years before the current financial mess, but this has now been heightened by it. What is the result of this? We all see it in our daily work lives in the mental health system: decompensation, return of symptoms, inability to concentrate, complete tasks, function at the level required, isolativeness, or acting out. You know the scenario and you have addressed these in each of the settings in which you practice. This is not new for you; but, it is very new for college and university campuses. Their counseling centers are overwhelmed with students needing their services, staffing shortages and most importantly the need for increased funding.  It is widely known among mental health professionals that “Mental health affects every aspect of a college student’s functioning… the earlier you intervene in mental health issues, the more likely you are to be successful in treating it.”  If mental health services are a priority, financially speaking, along with the appropriate recognition of importance and in some cases an imperative, without the stigma, there is likely a way to head off the outcomes we have seen.

Priorities on the higher education campus needs to change, but is changing at a slow rate, with priorities in this area, I believe misplaced. Gadgets take the place of living, breathing human interaction and intervention; crisis management and reactivity takes the place of prevention and proactivity.  Where are the dollars on college campuses really going with respect to safety and security? Right now, the money goes to text messaging systems, email programs, alarms, sirens, some increase in security personnel and other fancy and nifty technology and gadgetry. Now that is all well and good to some extent, we all feel safer knowing that the cavalry can respond quickly and efficiently once the shooting starts, but that is exactly the point, once the shooting starts, some will fall, it only becomes a question of how many and can we minimize the numbers. But, in reality, it is already too late.  It has been shown over and over, that identifying students who are deemed to be “at risk” or demonstrating “red flag” behavior early on, has a good chance of heading off a tragedy later on.

One recommended, very effective way to do this, I believe, is the development and implementation of what are called “Behavioral Intervention Teams” or “Behavioral Assessment Teams”.  These teams, which are multidisciplinary in nature, are educated and trained in discussing, evaluating and deciding upon the level of threat, possible responses and follow up action, when a student or employee is referred to them. What this means is that the so-called “person of concern” is on the radar screen of a non-stigmatizing, non-judgmental and highly specifically trained group of campus individuals, who can prioritize the concern or concerns brought to their attention and develop a thoughtful and timely plan of intervention. Being multidisciplinary in nature, means usually including representation from administrators, counseling center staff, campus law enforcement, residential life, as appropriate, risk management and/or legal counsel. Invited participants may include faculty, various other campus staff, parent liaison office or others as deemed necessary by the Team. Plans of response can include anything from a referral to the counseling center to temporary medical leave, to suspension to expulsion, which happens very rarely, to any others in between. In addition, what this system does is allow campus leaders to work within the law, but think “out of the box” in many instances, which is what is also sorely needed in this area. As I often tell clients, there is the legal answer and then there is the common sense answer, and sometimes it is the common sense answer which really is the correct answer. The law can’t possibly cover all areas of questions and incidents and the use of common sense often comes in very handy in these cases.

Still another emerging mental health issue on the college campus is that of the need for extensive education and training of the campus-wide community, and it certainly is a community. In addition to the academic subjects offered to students, there are a myriad of other issues on a higher education campus which did not exist, or at least did not exist out in the open, the way they do now; one of these being the issue of students with mental health issues on campus, as we have been discussing. By training the campus community to be sensitive and aware, learning to report appropriately, without stigma and agenda, we can identify students at risk and intervene early on, before the situation escalates.

By educating and training faculty, that they can bring their concerns to a centralized “team” or to a person in authority on campus, and that their concerns will be followed up timely, thoughtfully, goes a long way toward good risk management and assistance in a positive way. In doing this training, however, we make it very clear that there are confidentiality concerns, unlike other campus issues, and that the information flow may need to go only in one direction, but yet they should be content in the knowledge that there will be an intervention and that they have done their job to the fullest extent they are able.

Lay faculty can be trained in identifying “red flag” behaviors or students “at risk”. They do not have to become therapists themselves, nor should they, but they are often the first line in seeing behavioral changes, changes in writings and expression and so on. They need to be made comfortable in the idea that they have brought their concerns to those in authority who are empowered to access services and take appropriate and timely action. 

Additionally, students can be trained in identifying “at risk” or “red flag” behavior. The trick with educating students in this area is to focus on the behavior of concern and not any possible mental health issues. They do not have to assess, diagnose, know the history or make a judgment, nor do their parents, who are often brought into this scenario.  Students need to feel comfortable that when they take their concerns to someone in authority they are not “tattle-taling” or “ratting out” their roommate, classmate or friend, but that the life they may save could be their own and others. Again, students need to be educated to the fact that appropriate action will be taken in a thoughtful, respectful and supportive manner. 

Finally, staff of the campus community can be trained as well. They too do not need to become therapists or have a degree in the mental health area, but they do need to feel comfortable about identifying and reporting situations of concern. One recent instance of the success of training all levels of campus staff is a housekeeper in a dormitory who kept seeing vomit in the wastebasket of one student’s room. She reported it to the Intervention Team on campus, as she had been trained, and sure enough the student was experiencing symptoms of anorexia, and becoming more and more a danger to herself.  In addition, her roommates had become overwhelmed and overburdened with dealing with her illness, but were unable to successfully get her to treatment. The school intervened and what could have become a tragedy for the student, her family and those around her, became a successful and possibly life-saving intervention.

Those in need of training cross multiple campus lines, including campus law enforcement, residential life staff, parents and others deemed appropriate by the institution itself. Keep in mind in all of this, however, that the goal is early and proactive intervention, not big brother watching, pointing fingers or stigmatizing one group or another.  What happened at Virginia Tech and other school tragedies: there were signs, some were noted, some were addressed, many fell through the cracks, but no one, no one, connected the dots.

Which actually brings me to something about which I have been very concerned since I started in this newer area of my practice, years before the Virginia Tech, Northern Illinois and other of these tragedies. That is, equating mental illness directly with threat and violence. I have included in my talks across the country, to multiple and varied college and university audiences, the fact that people who suffer from mental illness are more likely to be victims of violence than perpetrators of it. I am acutely aware of the media stories, misinformation and misrepresentation of the issues which came to the fore following Virginia Tech and the others, which lead people to ask first, was the shooter mentally ill and then conclude that that alone led to the injury and death which insued. We need to continue to dispel this idea and to focus on the realities of mental illness, the statistics of associated violence, and the factual information about cause and effect in these situations.

And what’s this we keep hearing about “helicopter parents” and another term, I hadn’t  heard before, “cleaners parents”?  Helicopter parents are those parents of the current generation who have become “over involved” in the day to day development and experiences of their children. They “hover” over their children, even in college, ready to swoop down at any moment, making all the decisions for their kids or advocating ad nauseum for them with a teacher, administrator, counselor or other parents. The result, as one counselor told me recently, many students are totally unable to made decisions and more importantly, problem solve for themselves. Add the issue of a student with mental illness to the mix and the concerns mount. This, as with most things, requires a balance and it should be the school which seeks to and then pursues this balance with whatever supportive resources are currently, or need to be, made available.  “Dry Cleaner” parents are those who simply drop off their unruly children and expect them to be all cleaned up four years later.  One article I read recently suggested what many schools consider the ideal parent:  “a partner but not a pest, engaged and not obsessed, with a sense of perspective and patience.” Survey campus mental health center counselors or administrators and see what their statistics look like on this front.  Although, interestingly, in a recent study of college students, when asked if they wanted their parents involved in their college experience, the majority said yes.  Go figure.  I still believe, however, the technology, the media and now the financial crisis may make much of this “too much”.  Time will continue to tell.

Another emerging mental health issue, which is really also a generalized issue on college campuses, is that of technology, its use and misuse.  That actually could be a topic for another hour, but suffice it to say, particularly in the mental health field, confidentiality issues abound and students have little awareness and even less education with regard to the implications of putting out across the world, through the internet, their personal and often confidential information. In discussions with Deans and Campus Counselors, we are astounded by the push by students to restrict the release of their education or health information, with which we are bound by law to comply, yet three minutes after leaving the counseling center or dean’s office, the students are cell phoning, text messaging, emailing and putting up on Facebook and MySpace all of this same information. The wide-ranging implications of this going right over their young heads. We are seeing the beginning of lawsuits being brought out of this new and emerging free-flow of often sensitive information. Once again, the immediate gratification flying squarely in the face of long-term detriment. College admissions officers, employers, graduate schools and the like are more and more searching these sites to gain background on applicants, which information being exposed is often confidential, potentially stigmatizing and discriminatory. Education and training is a must in controlling the risk on all fronts in this regard.

Yet another emerging mental health issue on the college campus is that of on- and off-campus communication and sharing of information. Questions of confidentiality, the realities of the law, significant misinformation about both the FERPA Education and HIPAA and State Health Care laws abound. What referrals are in the forefront of a college campus? Two main areas come to mind: law enforcement and health care interventions. What are the main areas which confront a college campus in this area: Confidentiality, access of information, parental notification, release of medical or safety records, exchange of education or health information records, and modes of communication such as phone, email, fax or others.

First and foremost, particularly those families with students with mental health issues, should be encouraged to request from the student the signing of a release of information form.  Such release can and often should be narrowly tailored, giving access only to parents and/or off campus mental health professionals. That, in and of itself, provides for a sharing of confidential information which can inure to the benefit of the student. If campus counselors or other health care professionals can communicate freely with those who have the most history and clinical information about a student, issues can be addressed timely and accurately with regard to treatment, oversight, intervention or on- and off-campus referrals. Next, on-campus behavioral health professionals should take what I like to call a “class trip” to off-campus mental health facilities, such as the local psychiatric emergency room, in-patient unit, community mental health center, and off-campus individual practitioners, such as psychiatrists, psychologists, social workers, case managers, etc. Important to these visits is introducing campus staff and sharing campus confidentiality and related policies and procedures with off-campus staff, ascertaining their policies and procedures with regard to confidentiality, sharing of information, and attempting to clarify what constitutes in all minds, a danger to self and/or others and what allows for an appropriate breach of the confidentiality. Once again, communication and effective and thoughtful early intervention is key.  Finally, the same should be done in the world of on- and off-campus law enforcement personnel, making sure that both are coordinated and linked in some manner, appropriate to their lines of authority and legal guidelines.

What has struck me over and over, given my being born a health care administrator and working in the health care and mental health systems first, are the parallels in the higher education system specific to mental health issues. Misinformation about the law, the need for clarification of confidentiality guidelines and requirements, exceptions in the law which allow for the exchange of information and communication between and among professionals, and the need to break down “silos” jump out as the frontrunners in the parallels. After Virginia Tech we heard about FERPA, the education law, and HIPAA, the health care law, preventing information about Cho from being shared, the inability and constraints in contacting his parents, the interventions, both voluntary and involuntary which were not accessible…wrong, wrong, wrong and wrong. I stress to anyone who comes to my presentations, more important than knowing the laws themselves, which I agree is important, is knowing the EXCEPTIONS in these laws, that is from where the true guidance and decision making options come.

Playing “pick your liability” is another adage I espouse. Do you want to be sued for breach of confidentiality or for wrongful death, of one or many? I know which one I pick, each time I am asked to render a legal opinion.

Additionally there is good news and bad news.  The good news is, there are very few lawsuits in this area, at least for now; the bad news, if you will, is that legal advice and  guidance, comes from case law and precedent.  Since there are few lawsuits, happily for campuses and  the mental health  world, there is less in the way of having “the legal answer” or rendering a solid “yes you can” or “no you can’t”.  Remember what I said earlier about the “common sense” answer and “thinking out of the box,” I wasn’t kidding.

Before I conclude, there is one emerging mental health issue on the college campus which is truly an emerging issue and which could and does form the basis for an entire day’s conference. That issue of course is our returning veterans from Iraq, Afganistan and other areas of conflict around the world. Our returning vets are covered by the GI Bill and have been since World War II. The GI Bill has recently been expanded to offer increased services for our returning vets. Many of our returning vets are headed to college, either for the first time, or to pick up where they had left off in their education. But sadly, many of our returning vets suffered both physical and mental health injuries during the course of their service to our country. Post Traumatic Stress Disorder and Traumatic Brain Injury are the leading mental health injuries among returning vets who are coming onto our college campuses. In addition, we are seeing an increase in domestic violence, self-injurious behavior and aggression toward others, which of course impacts on our campus communities as well.  With these diagnoses of PTSD and TBI and related symptomatology, comes the increased need for services and interventions, particularly in the mental health area. Once again, our college campuses are ill-equipped and certainly ill-funded to address these needs. We must take special note, give special attention, and provide specialized services to our returning war veterans to appropriately identify those “at risk,”  utilize early intervention programs, be proactive rather than reactive, reduce the stigma, educate and train our campus communities and connect the dots sooner rather than later, as we’ve been discussing today.

I truly could go on and on as there are numerous more emerging mental health issues on the college campus, including but not limited to, as we say in the trade: 

1. The significant increase in community college enrollment due to our economic times, and resultant space, finance and resource allocation issues;
2. The building of dorms and other residences on the community college campus, the resultant space, resource and residential life issues, which before were faced only by four-year schools;
3. Mature Individuals and Retraining of Retirees due to the economic crisis, returning to our campuses and the resultant issues of later in life major changes, expectations and hobnobbing with the younger generation in an environment which is expected to be mostly the younger generation; as well as loss, major life changes and older adult issues, not generally seen or anticipated on a college campus; and,
4. Distance Education and the Potential Liability Exposure this presents, particularly with students who have mental health concerns, who may benefit more from face to face interaction, and where “students of concern” can better be identified and engaged in person; again, little in the way of liability, but certainly an area which could be ripening

In conclusion, then, there are ever-increasing emerging mental health issues on the college campus today, as in life, some positive and some negative. But, as in the mental health system at large, training and education, eliminating the rumors and fears, and building upon the facts and advances, as well as increased funding and priority of services needed, will hopefully lead to the greater good and successes for all.

Thank you.