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Position Statement 73: College and University Response to Mental Health Crises
Colleges and universities (“colleges” refers to any post-secondary education) should be committed to the success and health of every student. Mental Health America (“MHA”) envisions healthy college environments in which all students are accorded dignity and fairness, and evidence-based policies are implemented which safeguard students’ opportunity to achieve their full potential free from stigma, prejudice, and discrimination, Consistent with this philosophy, MHA supports services and systems that promote the capacity of college students with mental health conditions to live lives that they value and to have the opportunity to attend college in supportive and welcoming environments.
According to the Suicide Prevention Resource Center, one-fifth of college students experience a mental health condition.[i] Students dealing with mental health conditions often feel unable to seek the help they need from their school facilities.[ii] And many colleges and universities are woefully unprepared and under-resourced.[iii] In addition to limited counseling services, comprehensive supports including peer support programs, disability support services, and ongoing outreach and mental health education, are often limited or nonexistent.[iv] For students, this can mean not knowing how to get help, asking for help and getting wait-listed for services, or receiving inadequate supports to navigate their recovery and succeed in school.[v]
For students in crisis, particularly those who manifest self-injurious or suicidal thoughts or behavior, or appear to pose a potential threat to others, the situation is even more dire. College and university administrations, in fear of liability for failure to intervene in time, have taken measures to remove “problematic” students from the school environment by requiring these students to leave school, evicting them from on-campus housing, or charging disciplinary violations.[vi] These policies foster an academic environment where students may live with fear of discussing their mental health concerns or self-injurious or suicidal thoughts with employees of the school and their peers. These responses discourage students from seeking help. Additionally, they isolate students from social and professional supports within the university at a time of crisis, increasing the risk of harm.
Mental health on campus is a complex issue further complicated by triggering life events that may impair mental health or make it more difficult to recognize one’s own mental health concerns before a crisis. Colleges and universities have a responsibility to develop policies that will encourage students to seek help without repercussions and to create nondiscriminatory approaches to supporting students in crisis.
This position statement builds on The Bazelon Center for Mental Health Law’s Supporting Students: A Model Policy for Colleges and Universities, which led the way in encouraging post-secondary educational organizations to take more responsibility for safeguarding the mental health of their students.[vii] Bazelon’s efforts deserve recognition here.
Age of Onset
Prevalence of mental health issues on college campuses is widespread. An estimated 26% of Americans ages 18 and older live with a diagnosable mental health condition,[i] and half of all serious adult psychiatric illnesses, including major depression, start by age 14, with 75% of all conditions presenting by age 25.[ii] Students have identified depression as one of the top ten impediments to academic performance.[iii] In the 2018 National College Health Assessment, 53.4% of the 104,648 students surveyed reported feelings of hopelessness and 41.9% reported feeling “so depressed that it was difficult to function.”[iv] The percentage of students who purposefully injured themselves rose to 27% in the 2016-17 school year.[v] And the same upward trend existed for the percentage of students who seriously considered suicide, which rose to 34.2% over the same period.[vi] While still rare, suicide is still the second leading cause of death among college students.[vii]
College students, many having left home for the first time, face new experiences that put severe stress on their mental health. These concerns include: academic demands, living away from home for the first time, new financial responsibilities, and the need to build new friendships and relationships. As a result of these pressures, depression or other mental health conditions may manifest for the first time during college. Additionally, some students arrive at their new schools with pre-existing mental health needs that have gone undiagnosed or untreated, while others with a history of receiving services may leave for college with no transition plan. Students often do not disclose mental health concerns to an institution because of fear of retaliation. Students and colleges often have incentives to avoid dealing with problems until they surface in disciplinary proceedings or housing decisions.
Lack of Access and Availability
College students can often receive low- or no-cost mental health treatment on campus.[viii] Most four-year residential colleges and universities provide counseling services.[ix] But for students who would like to seek counseling, wait times for an appointment can span weeks.[x] Longer wait times can be dangerous to students who may be at risk of suicide due to their mental health condition, or are experiencing depression. The Center for Collegiate Mental Health reported that by 2015, demand for mental health services had increased by as much as five times the rate of enrollment growth.[xi] However, in the same year, nearly 40% of campus counseling centers reported that their budgets remained unchanged and that they did not gain any professional clinical or psychiatric staff during the past year.[xii] As demand for mental health services continues to outpace supply, students face barriers to receiving the treatments and supports, including disability supports and peer support, they need.
While many college campuses have counseling centers for students, the fear of attracting official scrutiny and the stigma attached to mental health often cause students to avoid such resources.[xiii] Only 20-40% of students who experience a mental health disorder seek treatment while in college.[xiv] In one study, while 59% of students reported that they were “aware of free counseling services on campus” and 49% said that they knew how to access mental health care, only 36% of students who screened positive for major depression received treatment.[xv] Additionally, less than 20% of students who died by suicide had sought on campus counseling.[xvi]
The increasing diversity of college campuses presents additional barriers to accessing mental health services. International students may not engage with campus counseling services because the stigma of mental illness is greater in many countries than in the United States.[xvii] Further, culturally appropriate mental health services may not be available on campus. More than half of campus counseling centers have no staff who identify as Native American, Asian, Black, Latina, Transgender, Gay, Lesbian, or Bisexual.[xviii]
Liability for Colleges and Universities
Colleges and universities historically have not faced liability in cases involving student suicide.[xix] However, in recent years, a few high profile cases have recognized that colleges may have a legal duty to protect students from self-harm and suicide.[xx] In an effort to shield themselves from liability, institutions are enacting policies to enable school officials to suspend a student who exhibits suicidal behaviors.[xxi] These punitive measures conflict with protections under the Americans with Disabilities Act (“ADA”) and Fair Housing Act (“FHA”).[xxii] If these students are removed due to their mental health conditions, the college or university may face liability under the ADA.[xxiii] Additionally, this practice further stigmatizes mental health conditions and risks a chilling effect on students who need to seek help.
Call to Action
Colleges and universities should provide a variety of mental health resources to proactively reach students where they are.
- Provide mental health services and no out of pocket cost to students.[i]
- Include programs in orientation that discuss the available mental health services, including disability support services, on campus and in the community with students and their families.[ii]
- Encourage students with a history of mental health concerns to disclose the concern (with strict confidentiality controls) and to work with the college to create a plan for transitioning to campus.[iii] Advise students on their Family Educational Rights and Privacy Act (“FERPA”) rights at orientation and provide the appropriate procedures to be followed by students if they would like to share any of their records with family members.[iv]
- Encourage students to create psychiatric advance directives designating their preferences, including who to contact, hospital preferences, and treatment preferences, in the case of crisis.[v]
- Create a voluntary program to include the families of students in their counseling services, where family access to treatment is within the sole discretion of the student receiving services. Students should be made aware that they determine the amount of information shared and may revoke this access at any point. This is a controversial idea, but, so long as it is a free choice by the student, family support can be very important, and excluding the family invites conflict with the college.
- Provide education and training so that students, resident advisors, and teaching, administrative, and other staff:
- Are familiar with the signs of mental health conditions, self-harm, and suicide risk;
- Understand and know how to access the range of supports available to students, including peer-run groups, counseling services, and accommodations;
- Know what emergency procedures to follow in a crisis.[vi]
- Create student-led steering committees, including representatives from different academic departments, student organizations, staff, and the administration, to identify students’ perceptions of barriers and develop solutions on an ongoing basis.
- Create student-led peer support programs in partnership with campus counseling centers.[vii]
- Offer on-demand teletherapy services[viii], including anonymous mental health screening tools,[ix] with the option to transition to in-person counseling.
- Create incentives for student-led initiatives to increase awareness of mental health issues on campus.[x]
- Partner with the office of diversity and inclusion, the college administration, and student affinity groups to develop and promote inclusive mental health resources.[xi]
- Offer mental health and wellbeing coursework for credit.[xii]
College and university policies should prevent students with mental health conditions from experiencing stigma and discrimination.
- Do not include statements in the student conduct code or administer discipline in a way that stigmatizes students with mental health problems and discourages help-seeking.[xiii]
- Accommodate students with mental health conditions to enable the student to remain in school, meet academic standards, and maintain social relationships. Accommodations may include:
- Allowing the student to take a reduced course load or complete alternative assignments;
- Allowing the student to postpone assignments and exams;
- Allowing the student to work from home;
- Allowing the student to drop courses;
- Allowing the student to change roommates or rooms;
- Allowing guests to stay in the student’s room;
- Allowing withdrawals from courses if the student experiences academic difficulties due to depression or another mental health condition.[xiv]
- Create protocols for students to request accommodations.[xv]
- Consider absences for treatment to be excused absences.
- Provide mental health services on a voluntary basis and allow students to decide whether or not to seek services. But required counseling is often a reasonable alternative to discipline.
Colleges and universities should develop protocols to respond fairly and effectively to students in crisis.
- Make emergency psychiatric services, including alternatives to hospitalization, available to students at all times.[xvi] [xvii]
- Create protocol to disclose student information to emergency services only when the student will not consent to necessary treatment and interventions.
- Train campus police and public safety responders using Crisis Intervention Team (“CIT”) programming[xviii].
- Establish policies and procedures that hold students with identified mental health conditions responsible for conduct only to the extent that students without a mental health condition would be held responsible.
- Permit students to take voluntary leaves of absence for mental health reasons. A student on voluntary leave may maintain contact with, and may visit campus friends and teaching, residence, counseling, and administrative staff and attend campus events.[xix]
- Seek involuntary removal of a student only if the student refuses to seek treatment or has displayed behavior that puts the campus at great risk.
- Involuntary removal should have protocols in place to ensure that it is a final step to the college or university’s mission to provide a safe and stigma-free environment for students with mental health concerns. Involuntary removal must have due process, in which the student has notice and an ability to appeal the decision. [xx]
- All decisions should be made by objective criteria and input from a counseling professional that has been treating the student.
- Do not hold students who have left school for treatment purposes to a higher standard upon return than other students.
- Provide the same arrangements for refunds of tuition or other costs to a student who takes a leave of absence for mental health reasons, whether voluntary or involuntary, as are available for a student who takes a leave of absence for physical health reasons.[xxi]
- Allow a student on leave, whether voluntary or involuntary, to request at any time that the college or university evaluate whether the student is ready to return.[xxii]
- Colleges and universities should take reasonable steps to insure continuity of care for students whose mental health conditions require that the leave the campus and for students returning from a leave of absence or suspension.
- Create re-entry programs for returning students that will help students to build an action plan for academic preparedness, continued wellness, and connection to their community.[xxiii]
Policies should limit liability for colleges and universities to encourage proper protocols.
- Mental health services should operate in a way that puts the students’ needs first, and not the college’s liability concerns. However, significantly, and in distinction from the Bazelon Center’s Model Policy,[xxiv] MHA urges a limitation on the liability of colleges that are providing mental health services to their students. It does so based on the belief that such a limitation is necessary in order to encourage these institutions to provide the broadest possible array of mental health services.
- State and federal tort laws should not extend liability to residential advisors or other college employees who are unable to successfully address students’ mental health needs. Such scrutiny would compromise the advisory function and make identification and remediation of mental health concerns more difficult.
- State and federal tort laws should only hold schools liable for student harm caused by mental health conditions when the school is informed of the student’s mental health concerns and takes no steps to provide, or help provide, the student with mental health services.
Given the large number of students with mental health conditions attending colleges and universities and the importance of higher education for individuals and society, it is vital that these institutions develop policies which are designed to allow students to participate fully and equitably. We encourage colleges and universities to take advantage of the many innovative programs which are being developed. Many of these are descripted in MHA’s “Collegiate Mental Health Innovation Council 2018 Summary Report and Program Highlights”[i] and in the resources referenced in the notes to this report.
The Mental Health America (MHA) Board of Directors approved this policy on March 9, 2019. It is reviewed as required by the Mental Health America (MHA) Public Policy Committee.
Expiration: December 31, 2024
[i] Suicide Prevention Resource Center. http://www.sprc.org/settings/colleges-universities
[ii] Public stigma of mental illness in the United States: a systematic literature review. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3835659/pdf/nihms524527.pdf
[iii] According to Penn State’s Center for Collegiate Mental Health 2017 Annual Report, from 2010-2015 “counseling center utilization increased by an average of 30-40%, while enrollment increased by only 5%.” https://ccmh.psu.edu/files/2018/02/2017_CCMH_Report-1r4m88x.pdf
[iv] Beyond Awareness: Student-led Innovation in Campus Mental Health. http://www.mentalhealthamerica.net/beyond-awareness-student-led-innovation-campus-mental-health
[v] Center for Collegiate Mental Health 2017 Annual Report. https://ccmh.psu.edu/files/2018/02/2017_CCMH_Report-1r4m88x.pdf
[vi] Feeling Suicidal, Students Turned to Their College. They Were Told to Go Home. https://www.nytimes.com/2018/08/28/us/college-suicide-stanford-leaves.html
[vii] Hereafter “Bazelon Center’s Model Policy.” http://www.bazelon.org/wp-content/uploads/2017/04/SupportingStudentsCampusMHPolicy.pdf
[i] Prevalence, severity, and comorbidity of twelve-month DSM-IV disorders in the National Comorbidity Survey Replication (NCS-R). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2847357/pdf/nihms176704.pdf
[ii] Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. https://jamanetwork.com/journals/jamapsychiatry/fullarticle/208678
[iii] American College Health Association. American College Health Association-National College Health Assessment II: Reference Group Executive Summary Spring 2018. https://www.acha.org/documents/ncha/NCHA-II_Spring_2018_Reference_Group_Executive_Summary.pdf
[v] Center for Collegiate Mental Health 2017 Annual Report. https://ccmh.psu.edu/files/2018/02/2017_CCMH_Report-1r4m88x.pdf
[vii] Causes of Mortality Among American College Students: A Pilot Study. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4535338/
[viii] While free mental health counseling is the norm on a majority of college campuses, 15 percent of counseling services nationwide still charge students out of pocket, creating a financial barrier to mental health treatment. https://www.aucccd.org/assets/documents/aucccd%25202016%2520monograph%2520-%2520public.pdf
[ix] However, only 8 percent of two-year colleges offer psychiatric services. https://www.theatlantic.com/education/archive/2016/10/the-most-popular-office-on-campus/504701/
[x] According to the 2017 AUCCCD Director Survey the average wait time at college counseling for all clients was 6.7 business days. https://www.aucccd.org/assets/documents/aucccd%202016%20monograph%20-%20public.pdf
[xi] Penn State’s Center for Collegiate Mental Health 2017 Annual Report. https://ccmh.psu.edu/files/2018/02/2017_CCMH_Report-1r4m88x.pdf
[xii] The Association for University and College Counseling Center Directors Annual Survey 2015. https://www.aucccd.org/assets/documents/aucccd%25202015%2520monograph%2520-%2520public%2520version.pdf
[xiii] Public stigma of mental illness in the United States: a systematic literature review. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3835659/pdf/nihms524527.pdf
[xv] Help-Seeking and Access to Mental Health Care in a University Student Population. https://pdfs.semanticscholar.org/515b/5cc53ff418e226ccb64ad8d8238508bb5075.pdf
[xvi] National Survey of College Counseling Centers 2014. http://d-scholarship.pitt.edu/28178/1/survey_2014.pdf
[xvii] Utilization of Counseling Services by International Students. https://web.a.ebscohost.com/abstract?direct=true&profile=ehost&scope=site&authtype=crawler&jrnl=00941956&AN=12010682&h=wpNvRhp1GPdenYM1nw5H9JKTrZkYetF2mMds0ym34ti7H9om9XjSvm10VYwq0vTbY6wTNkmw74D7J1oOUwHJ4w%3d%3d&crl=c&resultNs=AdminWebAuth&resul
[xviii] The Association for University and College Counseling Center Directors Annual Survey 2017. https://www.aucccd.org/assets/2017%2520aucccd%2520survey-public-apr17.pdf
[xix] The Emerging Crisis of College Student Suicide: Law and Policy Responses to Serious Forms of Self-Inflicted Injury. https://www.stetson.edu/law/lawreview/media/the-emerging-crisis-of-college-student-suicide-law-and-policy-responses-to-serious-forms-of-self-inflicted-injury.pdf
[xx] See Schieszler v. Ferrum College, 236 F. Supp. 2d 602, 609 (W.D. Va. 2002) (court determined college had an affirmative duty to protect suicidal student from foreseeable harm); Shin v. MIT, No. 020403, 2005 WL 1869101 (Mass. Super. June 27, 2005) (following a student suicide, parents were allowed to advance claim against university administrators).
[xxi] Giving Them the Help They Need. https://www.chronicle.com/article/Giving-Them-the-Help-They/25347
[xxii] Americans with Disabilities Act of 1990 (ADA), 42 U.S.C. §§ 12101-12213 & 47 U.S.C. § 225 (2006). The ADA prohibits discrimination against students whose mental health problems “substantially limit a major life activity,” including learning. Under the ADA, colleges and universities must provide protected students with “reasonable accommodations”, reasonable modifications to normal rules and procedures to allow those students to continue and succeed in higher education.
[i] If students are referred to off-campus services requiring out of pocket expenses, colleges and universities should implement programs to subsidize these costs, such as Georgetown’s Off-Campus Therapy Stipend Program. http://www.saxafund.org/off-campus-therapy-stipend/
[ii] Currently three states, Ohio (http://codes.ohio.gov/orc/3345.37), Texas (https://statutes.capitol.texas.gov/Docs/ED/htm/ED.51.htm%2351.9194), and West Virginia (http://www.wvlegislature.gov/Bill_Text_HTML/2015_SESSIONS/RS/pdf_bills/HB2535%2520ENR%2520PRINTED.pdf) require their institutions of higher learning to provide students with information regarding available mental health and suicide prevention services with various requirements including dissemination to staff and graduate students and the posting of all materials online.
[iii] See Jed Foundation’s Transition of Care Guide. https://www.settogo.org/wp-content/uploads/2017/03/Transition-of-Care-Guide.pdf
[iv] Such procedures can be modeled after Illinois’ Student Optional Disclosure of Private Mental Health Act. http://www.ilga.gov/legislation/ilcs/ilcs3.asp?ActID=3654&ChapterID=18
[v] See MHA’s guide to psychiatric advance directives. http://www.mentalhealthamerica.net/psychiatric-advance-directives-taking-charge-your-care
[vi] See the Bazelon Center’s Model Policy. http://www.bazelon.org/wp-content/uploads/2017/04/SupportingStudentsCampusMHPolicy.pdf
For example, the University of North Carolina’s Mental Health Ambassadors Program trains its ambassadors in Mental Health First Aid, as well as campus-specific policies and procedures so that these ambassadors know how to address mental health crises and can disseminate preventive resources. https://uncstudentorgs.campuslabs.com/engage/organization/mha
[vii] The Wolverine Support Network (https://www.umichwsn.org/) is an example of a cost-free peer-led resource that reflects the needs of the University of Michigan’s student body. Peer support programs can extend to virtual communities like the Buddy Project, which pairs students and young adults interested in raising awareness for mental health. http://www.buddy-project.org/ It is vital that peer service be provided by persons who are trained to do so. See MHA Position Statement 37 for a detailed discussion concerning peer support services.
[viii] An example of a teletherapy service is BetterMynd, an online therapy platform that allows college students to have live video-therapy sessions with licensed mental health counselors. BetterMynd is the only teletherapy platform that focuses exclusively on college students. https://www.bettermynd.com/
[ix] Mental Health America offers free evidence-based screening tools for depression, anxiety, bipolar, psychosis, eating disorders, PTSD, work health, and addiction. https://screening.mentalhealthamerica.net/screening-tools
[x] Harvard’s University Student Health Coordinating Board created the Vincent Prize to award $1,500 to students who came up with the most innovated and practical ideas about promoting mental health awareness. https://news.harvard.edu/gazette/story/2001/03/prize-to-reward-innovative-ideas-on-mental-health/
[xi] For an example of an effective partnership, see Emory University’s Black Mental Health Ambassadors, which advocates for Black undergraduate and graduate students and held the university’s first ever Black Mental Health Week. http://studenthealth.emory.edu/cs/outreach_services/volunteer_opps/bmha.html
[xii] The University of Illinois at Chicago successfully piloted a 2-credit mental health course and will continue to offer the course in subsequent semesters. http://studenthealth.emory.edu/cs/outreach_services/volunteer_opps/bmha.html
Yale’s most popular course, “The Science of Well-Being,” is now available on-line. https://news.yale.edu/2018/02/20/yales-most-popular-class-ever-be-available-coursera
[xiii] The Jed Foundation recommends that colleges and universities do not include statements in their student conduct code that “prohibit suicidality or self injurious behavior” because those statements may stigmatize students with mental health problems and discourage help-seeking. http://www.jedfoundation.org/wp-content/uploads/2016/07/student-mental-health-and-the-law-jed-NEW.pdf
[xiv] See the Bazelon Center’s Model Policy. http://www.jedfoundation.org/wp-content/uploads/2016/07/student-mental-health-and-the-law-jed-NEW.pdf
[xv] The Bazelon Center’s Model Policy suggests that colleges and universities should not require students to disclose their mental health conditions in order to receive accommodations. http://www.bazelon.org/wp-content/uploads/2017/04/SupportingStudentsCampusMHPolicy.pdf
[xvi] See Mental Health America’s Position Statement on Responding to Behavioral Health Crises. http://www.mentalhealthamerica.net/issues/position-statement-59-responding-behavioral-health-crises
[xvii] New Jersey law now requires colleges and universities to have mental health counselors available to students 24 hours a day, seven days a week either on campus or by phone. https://www.njleg.state.nj.us/2016/Bills/S1000/557_T1.HTM
[xviii] Crisis Intervention Training is the most comprehensive police officer mental health training program in the country and CIT training programs are offered in 45 states as well as the District of Columbia. https://www.theatlantic.com/health/archive/2013/10/how-police-officers-are-or-aren-t-trained-in-mental-health/280485/
[xix] See the Bazelon Center’s Model Policy. http://www.bazelon.org/wp-content/uploads/2017/04/SupportingStudentsCampusMHPolicy.pdf
[xx] Decisions to impose involuntary leave or otherwise respond to a student with depression or another mental health condition should be informed by the guidance issued by the U.S. Department of Education, Office for Civil Rights, in three decisions, OCR # 03-04-2041 (DeSalle Univ. 2/17/05), OCR # 15-04-2042 (Bluffton Univ. 12/2/04), and OCR # 09-00-2079 (Woodbury Univ. 6/29/01). The letters discuss the application of the ADA’s “direct threat” provisions, procedural requirements, probative evidence and other matters. They counsel that, among other things:
- “In a direct threat situation, a college needs to make an individualized determination of the student’s ability to safely participate in the college’s program, based on reasonable medical judgment relying on the most current medical knowledge or the best available objective evidence.”
- “In exceptional circumstances, such as situations where safety is of immediate concern, a college may take interim steps pending a final decision regarding adverse action against a student as long as minimal due process (such as notice and an initial opportunity to address the evidence) is provided in the interim and full due process (including a hearing and the right to appeal) is offered later.”
[xxi] See the Bazelon Center’s Model Policy. http://www.bazelon.org/wp-content/uploads/2017/04/SupportingStudentsCampusMHPolicy.pdf
[xxiii] Programs such as Fountain House College Re-Entry help students who take leave due to mental health concerns to improve academic performance, learn wellness tools, and build a supportive network for a successful return to college. https://collegereentry.org/
[xxiv] See endnote No. 7 above