Brian Van Brunt, Ed.D. Brian.vanbrunt@wku Director of Counseling and Testing

1. 2009 NASPA Mental Health Conference Boston, MA Brian Van Brunt, Ed.D. Brian.vanbrunt@wku.edu Director of Counseling and Testing Western Kentucky University Threat Assessment and Management of At-Risk Students

2. Threat Assessment • There is an increase in discussions surround threat assessment following the Virginia Tech and NIU shootings. • This presentation is designed to assist counselors and psychologists and student affairs personal to improve their communication and expectations surrounding threat assessment and treatment. 2

3. Common Language • Though we are being asked to do more with threat assessment---let’s remember: • With the exception of sexual assault, College and Universities remain safer then the general community and provide more support, supervision and monitoring (for 18-24 year olds compared to non-college sample). 3

4. Common Language • We are concerned with addressing behavior, not targeting those with mental illness. We are concerned with aggression, threats intimidation, hoarding of weapons and the frustration, anger and isolation that leads to an act of violence. • Those with mental illness are more likely to be the victims of violence, not perpetrators (Choe, Tepin, Abrams; 2008). 4

5. Mandated Assessment • The process where a third party involved with a student refers a student for some number of individual sessions with a counselor, psychologist or therapist. • This often is a result of the student breaking a campus policy • i.e., suicide threat, cutting behavior, angry outburst, stalking behavior, alcohol or drug use, sexual harassment. 5

6. Mandated Programming • Third-party requires a student to attend a group or classroom presentation. • These often are psycho-educational and are commonly offered in the areas of drug or alcohol policy violation, although models exist for interpersonal violence as well. • These programs may focus on reducing anger, improving social interactions with others or addressing sexual harassment issues. 6

7. Mandated Treatment/Counseling • Mandated treatment often follows the initial assessment and occurs in either a group or individual setting. • Students are referred by a third party to counseling in order to meet sanctioning requirements or to stay involved in a club, organization, class, team or enrolled in the university. 7

8. A bit about Mandated Referrals… • There is no assessment that will predict violence – most assessments are not designed to try. • The most useful assessment looks at situations rather than individuals and offers insight as to levels of concern. • There is no treatment that will guarantee prevention of further acts of violence for any particular individual. There are group data that treatment reduces the likelihood of future violence. 8

9. A bit about Mandated Referrals… • The best we can hope for with individuals is an “educated guess” at the level of risk and likelihood of threat and danger. • We base this on past behavior, current symptoms, the student’s general attitude & compliance, and the situation surrounding the individual of concern. 9

10. A bit about Mandated Referrals… • Treatment provides skills and tools. The student is responsible for making use of these tools. (horse to water) 10

11. A bit about Mandated Referrals… • Referrals work better when there is an on-going positive relationship with the referral source. Everyone is stressed with the heightened “hot potato” issues raised with threat teams and judicial referrals. • Take the time to form relationships during the down times of the year so that the relationship is solid when the difficult situations arise. A crisis is not a fruitful moment for creating a positive relationship. 11

12. Pre-Assessment Information What information would you need to perform an accurate assessment? (golden rule) • Incident report, witness statements • Past judicial history, staff reports • Academic transcript, GPA, class list • Situational (life) information • Housing records • Follow up contact numbers 12

13. Pre-Assessment Information • It is always easier to have a student sign a release of information during the initial meeting than attempting to track them down afterwards for a signature • Contact referral source to see if they have preferred forms (HIPAA, ROI) • Explain why you are requesting information, what you need and when you need it. (build rapport) 13

14. Pre-Assessment Information • Be clear about what they are looking for as a result of the assessment, treatment or programming. • When the referral is done, do they need a letter? • Does that letter need to include specific statements or come from a particular provider? • Ask for these things prior to the referral. • Be clear at the start what you need. 14

15. Pre-Assessment Information • Conduct periodic follow-up calls with referral agent, particularly if this is an off-campus referral (summer example). 15

16. HIPAA • HIPAA applies if: • Does the person, business, or agency furnish bill, or receive payment for, health care in the normal course of business? • If the answer is yes, does the person, business, or agency conduct covered transactions? • If yes, are any of the covered transactions transmitted in electronic form? • If the answer to this question is yes, the person, business, or agency is a covered health care provider and must comply with all HIPAA regulations 16

17. HIPAA • HIPAA does not apply to most centers since most centers don’t bill clients or transmit electronic billing. • If HIPAA does apply, it just requires the signature of a release of information to get permission from the student to share information. • We suggest judicial offices obtain these HIPAA ROI forms prior to mandating a student to counseling. 17

18. HIPAA • Gene Deisinger (2008) of Iowa State makes a good point in his recent book Handbook for Campus Threat Assessment and Management Teams: • “…The Threat Assessment Team can provide the information it knows to an individual’s therapist or counselor…this may enhance the treatment that the mental health professional is able to provide.” p.91 • “…access to mental health information may be helpful …but it is more important to consider incorporating any treating mental health professionals into the case management plan.” p. 92

19. FERPA • FERPA offers departments working together for a student’s best interests a wide latitude to share information. These individual’s must be “educational officials with a legitimate need to know.” Deisinger (2008) suggest threat assessment team members are given this classification. • FERPA does not apply to medical or counseling records. • A signed release of information addresses information sharing in a way that removes any guesswork.

20. HIPAA and FERPA

21. Mandated? • There are some counselors and psychologists who aren’t comfortable with “mandated” anything when it comes to their clients. • They make arguments against this based on the idea of autonomy---that all clients must choose to enter treatment or assessment willingly. • Mental Health professionals on a college campus are not like private practitioners; the greater good of the community needs to be taken into account. 21

22. Mandated? • Nearly every community utilizes court mandated involuntary treatment. Like many states, VA, often mandates treatment for those assessed for mental health concerns and released into the community. • In the VA Tech case, mandated treatment was ordered, but never provided due a complex set of circumstances. That omission has been identified as one of the places where the tragedy might have been avoided. • I suggest this resource is needed in the university community as well.

23. Mandated? • Mandated treatment is used commonly in other areas: • DUI and substance related offenses • Domestic violence and restraining orders • Sexual assault • Anger management treatment programs • Employee Assistance Programs (EAP) related to work performance • Sexual harassment and sensitivity 23

24. Mandated? • In a survey of 603 counseling center directors, Oetting, Ivey, and Weigel (1970) reported that 20% of centers provided disciplinary counseling and 33% of counseling center directors evaluated disciplinary cases referred to their centers. 24

25. Mandated? • In national survey data, Dannells (1990) documented "a huge increase in disciplinary counseling in counseling services, from 38% in 1978 to 60% in 1988" (p. 412). 25

26. Mandated? • More recently, Gallagher (2006) surveyed college counselors in the American College Counseling Association (ACCA). • Results included data showing 88% of counseling centers offering some sort of mandated assessment service. 26

27. Mandated? Gallagher 2006 ACCA survey (n=367)

28. Mandated? • The ACA ethics code states “Clients have the freedom to choose whether to enter into or remain in a counseling relationship...” A.2.a • “Centers may provide mandatory assessment and other consultations to campus units, but must not make admissions, disciplinary, curricular or other administrative decisions involving students.” -IACS 2005

29. Mandated? • “While AUCCCD is opposed to ongoing mandated treatment, we recognize the value of mandated assessment when it is precipitated by clear problematic behavior and violation of college and university conduct codes.” -2007 position paper 29

30. We will now explore the ethical codes related to counselors providing mandated assessment and counseling along with a review of commonly used testing measures.

31. STATE LAW • Ethics Code • ACA, AMA, APA College Policy • There are several ethical obligations that first must be met. • The authority counselors and psychologists typically follow…

32. Ethics • The clinician must be primarily concerned with the dignity and welfare of the client. While there may be pressure from another source, the counselor cannot force or compel the student. (ACA: A.1.a; A.2.a; IACS:4) • The clinician must define their role for the client. Dual relationships (evaluation vs. counseling, being a director of counseling at a college) must be disclosed before the assessment. (ACA:E.13.b)

33. Ethics • The clinician must perform within their scope of practice. They must have training and knowledge of the assessment or treatment. This applies to any tests they will administer. (ACA: C.2.a, D.2.a) • The clinician cannot have a prior counseling relationship with the student. (ACA E.13.c) • The clinician should not be in the position of making decisions in a disciplinary or judicial case. They should consult, always providing services which respect the dignity and welfare of their client. (IACS: A)

34. Ethics • Clinicians cannot release information without client’s permission. They cannot release information that will harm the client (ACA:B.2.c, B:1:c) • When using tests (ACA: E.2, E4,E.6.a, E.9.a, IACS: 1.b, APA: 9.01.a) • Must be appropriate, Reliable and Valid • Clinician must have training • Must take diversity issues into account • Only release raw data to qualified source • Findings based "on information and techniques sufficient to substantiate” APA: 9.01.a

35. Informed Consent • Develop a clearly worded informed consent spelling out for the student what will happen and how the results will be shared. • This must be done prior to the assessment 35

36. Informed Consent • Outline the scope of your assessment • The tests, costs and time involved in completing • Limit access to raw test data to qualified individuals with client written consent • Outline who will receive the assessment • List kind of information will be collected (past therapy, past inpatient, past court involvement, arrests, felonies) • Clearly spell out what happens if the student no-shows appointments (who is notified)

37. Advocacy • If a judicial office requires off-campus assessment, the counselor/psychologist can help advocate for the student to ensure a smooth process. Ask: • The specifics of what they require, • If the clinician/center has acceptable credentials for the assessment being asked for • Help the student understand the time and cost issues as they related to insurance, self-pay and scheduling their assessment 37

39. When thinking about assessment, remember the Saxe poem about the blind men and the elephant…

40. Choosing your Assessments • When reviewing tests and measures to better assess symptoms and risk be aware… • There is no measure that predicts future violence • There is no substitute to a solid clinical interview • You must have the training needed to choose, administer, score, interpret and report the results for a given test 40

41. Choosing your Assessments • When performing assessments, there is no test or measure that substitutes for common sense and clinical judgment. • An effective assessment can measure risk on a comparative basis • When writing reports and letters, base your observations and conclusions on the information at hand. 41

42. Choosing your Assessments • Avoid “going out on a limb” and making statements that cannot be reasonably backed up by the facts at hand. • As a professor of mine once said, “While it makes for a more interesting report, be careful when using speculation and opinion that can’t be substantiated.” 42

43. Types of Assessments • Structured Clinical Interviews • MOSAIC, HCR-20, HARE-PCL-R • Deception Detection • TOMM, PDS • Baseline Measures • MMPI-2, MSE • Symptom Based • STATIC-99: Sexual, STAXI-2: Anger, FAVT: Violence • EDIT: Eating Disorder, Beck Scales, FAST/FASI: self-harm • Anti-social • JI-R 43

44. Referral and first session Attendance Treatment Suggestions Build Rapport Assessment Baseline Functioning Case History Diagnosis Medication Referral Cognitive Behavioral Psychoanalytic Gestalt Therapy Motivational Interviewing Client-Centered Rogerian Prochaska and DiClemente AA/NA group model Reality Therapy

45. Referral and first session Attendance Treatment Suggestions Build Rapport Assessment Baseline Functioning Case History Diagnosis Medication Referral Cognitive Behavioral Psychoanalytic Gestalt Therapy Motivational Interviewing Client-Centered Rogerian Prochaska and DiClemente AA/NA group model Reality Therapy

46. Treatment Suggestions • When working with someone who is trying your patience, being hostile or being unmotivated---remember your goal. • Your goal should be to assist the person move towards a higher stage of change, maintain positive momentum or gain a better understanding of their current situation and their decision to make a change.

47. Treatment Suggestions • A connection is the start. It is the first step towards motivation, persuasion and compliance. • It may be that the “going somewhere” is too big of a step to take all at once. • Consider the subtle move of “No, I’m not going to do that.” to “I’ll think about it”. • Let’s take the example of a client with a anger problem who isn’t ready to address it.

49. Treatment Suggestions • Help an aggressive client understand why their current behavior isn’t in their best interest. • Build a bridge between you and the aggressive client. Trust is not instinctual, it must be earned. • Use open ended questions to encourage the them to talk. • What have they got to gain? What have they got to lose? What can I use to persuade him away from aggression?

50. Treatment Suggestions • I was at a training where a therapist who worked with at-risk, adolescent girls was sharing from her 20 years of experience. She said: • “It is imperative that someone in the therapy room has hope for the future. Sometimes it is the patient, sometimes it is the therapist. But someone must always have hope that things will improve.”