Removing Suicidal Students From Campus: The Significance Of Recent Changes In Federal Policy

1. Removing Suicidal Students From Campus: The Significance Of Recent Changes In Federal Policy Dr. MJ Raleigh Director of Counseling and Psychological ServicesUniversity of North Carolina at Pembroke mj.raleigh@uncp.edu

2. Presenter MJ completed a PhD in environmental studies at Antioch University, focusing on the interaction between environment and mental health. She is currently the CAS director representing ACCA at the national council and is a past ACCA president (2011-2012). MJ has over 25 years of experience working with college students on campus with 20 of those years as a director of mental health services. She is currently the Director of Counseling and Psychological Services at the University of North Carolina at Pembroke. mj.raleigh@uncp.edu

3. OCR Title II Shift Who Are We Talking About? Campus Impact & Opportunity Policy Implications Beyond Separation: Treatment Resources for Prevention

4. OCR Title II Shift • In 2010, Title II of the Americans with Disabilities Act was revised (effective March 15, 2011): • Applies to public colleges & universities • Likely also extends to private colleges & universities through OCR’s similar interpretation of Section 504 • Added direct threat language into Title II • Aligns Title II and Title III by clarifying that use of the direct threat standard applies to cases involving harm of others, not harm to self www.ada.gov/regs2010/titleII_2010/titleII_2010_withbold.htm

5. OCR Title II Shift So what? This demonstrates a shift from some prior interpretations of Title II, where guidance was given to apply the direct threat standard to self-harm. “Direct threat means a significant risk to the health or safety of others that cannot be eliminated by a modification of policies, practices or procedures, or by the provision of auxiliary aids or services.” www.ada.gov/regs2010/titleII_2010/titleII_2010_withbold.htm

6. OCR Title II Shift • To determine if a direct threat exists, a college must make: • An individualized assessment • Based on reasonable judgment • That relies on current medical knowledge OR on the best available objective evidence, to ascertain: • The nature, duration, and severity of the risk • The probability that the injury will actually occur • Whether reasonable modifications of policies, practices, or procedures or the provision of auxiliary aids or services will mitigate the risk. www.ada.gov/regs2010/titleII_2010/titleII_2010_withbold.htm

7. OCR Title II Shift • What does this mean? • As a result of the change in language in Title II of the Americans with Disabilities Act (ADA), the revised regulation now deems it unlawful to take adverse action (i.e. involuntarily separate, suspend or expel) towards a student solely on the basis of self-harmful or suicidal behaviors. • This is why most of you are here with us today.

8. OCR Title II Shift • Additional Resources: • The National Center for Higher Education Risk Management (NCHERM) and the National Association of Behavioral Intervention Teams (NaBITA) offer a white paper to address this issue. www.nabita.org/documents/2012NCHERMWHITEPAPERTHEDIRECTTHREATSTANDARDFINAL_000.pdf

9. OCR Title II Shift • The National Association of College and University Attorneys released a document with a focus on New Title II Regulations Regarding Direct Threat: Do They Change How Colleges and Universities Should Treat Students Who Are Threats to Themselves? http://counsel.cua.edu/nacuanotes/titleIIregulations.cfm

10. OCR Title II Shift • The National Association of College and University Attorneys (NACUA) created a webpage with case examples, articles and information addressing distressed and suicidal students. www.nacua.org/lrs/NACUA_Resources_Page/SuicidalStudentsResources.asp

11. Who Are We Talking About? • Who is a chronically suicidal student? • Daria has a history of suicide attempts in high school. During her first semester at college, she overdosed on pills resulting in a hospitalization. She often tells other students “I’m always depressed and think of killing myself.” Her friends are beginning to complain to faculty/staff that they feel like they have to keep an eye on her, especially after she has been drinking. Last week, medical and counseling staff responded to her when she was in crisis and she refused to be transported by the paramedics when they suggested she go to the hospital.

12. Who Are We Talking About? • How do we identify suicidal students? • Actual Attempts (taking pills) • Direct Verbal Clues (I’ve decided to kill myself) • Indirect Verbal Clues (I just want out) • Behavioral Clues (giving away items, acquiring weapon, previous suicide attempt) • Situational Clues (loss of relationship, suspension)

13. Who Are We Talking About? • Who is a delusional/paranoid student? • David has OCD and is prone to panic attacks during high anxiety times. One day, he sought out his counselor and informed her that he usually carries a knife with him for protection, but he was concerned because today on the bus he felt like his mind was telling him to stab someone else. He agreed to be evaluated and was hospitalized for a 3-day inpatient stay.

14. Who Are We Talking About? • How do we identify delusional/paranoid students? • Delusions are strongly held beliefs despite evidence to the contrary (schizophrenia, manic bi-polar) • Bizarre delusion: strange and completely implausible • “My blood is green and I can see other people’s thoughts.” • Non-bizarre delusion: false, but plausible • “I’m under constant FBI and police surveillance.” • Common Themes: control, nihilistic, grandiose religious delusion, persecutory

15. Campus Impact & Opportunity • A single event can have rippling effects throughout the community • Faculty in the Classroom • Residence Hall/Floor • Athletic Teams • Clubs and Organizations • Family and Parents • Admissions and University PR • Students already struggling “on the edge”

16. Campus Impact & Opportunity

17. Campus Impact & Opportunity • Consider the impact: • Is it actual or speculative? • Is it threatening or disruptive? • Is it annoying, uncomfortable, or unknown? • Consider the opportunity: • Does this provide a way to learn more about the individual’s behavior and motivations? • Does this open the door to develop or utilize caring relationships or support? • Are there interventions the College can take that might not otherwise occur for the individual?

18. Campus Impact & Opportunity • Everyone’s goal is for the student to be successful. Instead of jumping immediately to separation as the solution, look for ways to support him or her. • Conduct appropriate assessment, which usually involves a person talking to the student. • Determine if “reasonable modifications of policies, practices or procedures” can be made. • Determine if “auxiliary aids or services” can mitigate the risk. • Relationships, conversations, and an ethic of care promote student success more than separation does.

19. Campus Impact & Opportunity • Institutionally train and support people at all levels: • Value of interdisciplinary teams and approaches • Empower the person that the student trusts • Educate faculty and front line staff • Talk to parents . . . AND to students • Invite the people you need to the table • Create a culture of reporting • Do not let FERPA get in the way of helping a student • Develop policies and procedures that balance the student’s rights with the institution’s concerns

20. Policy Implications General Suggestions • Involve the student in the conversation. • Discuss common goals for the student and the school (e.g., graduation, good grades, financial aid eligibility) • Involve family in a cooperative process; build alliances • Have conversations ahead of time about behavioral agreements, leave vs. withdrawal, what it means to be a qualified student, etc.

21. Policy Implications • General Policies & Procedures • Ensure that policies are published and followed – including if your BIT has authority to act. • Adverse action based solely on self-harm, or policies that describe conditions that are protected are not permitted. • Have campus dialogue about what constitutes disruption and threats, and what to do about them. • Offer basic procedural protections (notice, hearing, appeal).

22. Policy Implications Conduct Procedures & Codes Offer appropriate due process and follow your process. Use clearly written codes and referrals based on behaviors, not disabilities or conditions. Address actual significant disruption to campus, not simply risk of disruption. Be consistent in referrals – the same disruptive behavior should warrant a conduct process, regardless of the individual. Sanctioning should also be consistent. Do not treat students with disabilities differently than other students, other than providing reasonable accommodations under the law.

23. Policy Implications Behavioral Intervention/Risk Assessment Educate the campus to identify behaviors (not conditions) that warrant a referral. Have a risk assessment and intervention model that you apply consistently, including when to refer to conduct. Consider BIT as a proactive intervention when there is a risk of disruption or harm. Conduct can serve as the process for an actual disruption. Distinguish between BIT and the conduct process.

24. Policy Implications Voluntary Medical Leave Be flexible and generous with voluntary leave Advocate for student with regard to grades Offer tuition refund/vouchers Talk about future plans and return Cover evaluations costs Involve family or support systems Assist with referrals – get everyone at the table once

25. Policy Implications Involuntary Separation Interim suspension or involuntary leave may still be invoked if there is a determination that a student poses a direct threat of harm to others. Ensure that the policy is well-written, and is applied narrowly and appropriately. Action should be invoked based on a student’s behaviors (actions, statements, etc.), and not speculation or a student’s disability.

26. Policy Implications Returning After Leave/Separation Students who are suspended through a conduct process may have to complete sanctions to return. If there are guidelines for return after leave, they should apply regardless of a disability, not because of it. Can’t require “treatment” but you can require documentation of resolution of the behaviors of concern, so long as you require that of ALL students who qualify for and receive a comparable leave.

27. Policy Implications Consider: The types of disruption on a residential vs. a commuter campus What constitutes “reasonable” Potential for increased risk (triggers) due to separating students “Discomfort” ≠ Disruption

28. Beyond Separation: Treatment • It’s a simple word, ‘treatment’, but what do we mean? • Case management • Understanding level of care • Expanding scope of practice; understanding referral

29. Beyond Separation: Treatment • Invest in Case Management • Counseling Center Models • Administrative Models • Student Affairs • Behavioral Intervention Team • Student Conduct • Emergency Management • Provost’s Office/Academic Affairs • Human Resources • Third party company as a pay service

30. Beyond Separation: Treatment • Student Affairs: Case management runs out of the student affairs/dean’s office or through campus BIT. Focus on meeting with students, follow-up, ensuring connection to various departments and that a student doesn’t “fall through the cracks.” Open in terms of communication (FERPA). • Counseling: Case management focuses on at-risk counseling students and students who need direct connection to counseling. Communication may be more difficult given the limits of the client relationship (State Confidentiality law). • Off-Site: Case management is run through a third-party company and offers similar service as a student affairs or counseling approach. May be a pay-for-fee service.

31. Beyond Separation: Treatment Counseling Model Administrative Model Primary focus on balancing individual and community Connection to on or off-campus resources Communication within institution Code of Conduct offers accountability for behavior that causes disruption • Primary focus on the individual • Connection to treatment options • Communication between medical providers • Self-care through assessment of obstacles and obtaining solutions

32. Beyond Separation: Treatment • Understanding Level of Care • Online support/para-professional (RA)/friend • Consulting evaluation (stop by) • Outpatient treatment: • Weekly or bi-weekly • Psychological Testing • Medication Referrals • Case Management/Team meeting • Partial Day treatment (1x/week) • Crisis Stabilization Unit • Inpatient Unit

33. Beyond Separation: Treatment • Scope of Practice/Referral http://chronicle.com/article/Giving-Troubled-Students-the/130838/

34. Beyond Separation: Treatment • Scope of Practice/Referral • Expanding training for counselors, psychologists and social workers • Removing session limits, following 75/25 rule • Avoid blacklisting certain disorders • Make sure a referral ‘sticks’ • Social Advocacy • Health services (WKU example)

35. Resources for Prevention • Educate the campus & demystify: • Orientation programming • Creative speakers to talk about mental illness • Awareness campaigns • Train those who see students: • Faculty and administrators • Office staff • Coaches and advisors • Police, parking, and custodial • Student leaders and RA’s

36. Resources for Prevention • Resources: • The JED Foundation • Active Minds: www.activeminds.org • www.facebook.com/BipolarBoy

37. Resources for Prevention QPR • QPR is one approach to educating staff, faculty, and students in order to prevent suicides on campus. • This approach is similar to CPR in its focus on training those in a short, 90-minute session provided to non-clinical staff • Question signs/symptoms of suicidal behavior • Persuade people to get help • Refer them directly to that help • QPR training is $495 for 1 day training that allows the trainer to offer it on campus. http://www.qprinstitute.com/ 37

38. Resources for Prevention safeTALK: • safeTALK: is suicide alertness for everyone and teaches participants how to recognize when thoughts of suicide are present & initiate alert steps to get some assistance. • The TALK steps are Tell, Ask, Listen, and Keep Safe. The training includes discussion of why persons might miss, dismiss, or avoid the idea of suicide and offers participants the opportunity to practice TALK steps. • safeTALK participant cost is $6 (resource book, pocket card, sticker, and certificate). safeTALKtraining for trainers cost is $400-600 (cost is lower if you have 10 trainer candidates). Trainer prerequisite is ASIST training. www.livingworks.net

39. Resources for Prevention ASIST: • ASIST stands for Applied Suicide Intervention Skills Training and is a 2-day workshop for professionals and non-professionals. • ASIST complements safeTALK because persons who are identified by suicide alert helpers receive the first aid intervention they need. Beginning with a full exploration of caregiver attitudes, ASIST is highly interactive and participatory. Over ½ of the workshop involves working with suicide intervention simulations. • ASIST participants receive workbook, prompter card, sticker, suicide intervention handbook, and National Suicide Lifeline card. • Workshop participant costs vary by location ($50-300). They often offer 15 CEUs. 5-day Training for Trainers is around $2600. 39 www.livingworks.net

40. Don’t Do This • Things to avoid when working with at-risk students • Take an ‘Us vs. Them’ approach • Think issues are “resolved” like conduct cases – conditions change over time • Let FERPA/HIPAA and confidentiality law limit your communications unnecessarily • Adopt a ‘no parents’ approach • Let students with mental health conditions ‘off the hook’ when they violate a conduct code • Coerce students into a voluntary leave • Stick your head in the sand and hope you don’t see these situations

41. Do This • Things to do when working with at-risk students • Don’t be afraid of conversations • Empower and support the faculty and staff with whom the student has a relationship • Involve parents/support early and often • Assist and support students through medical withdrawal options (academics, tuition, support) • Create clear policies that show care for students • Ensure campus leadership, legal counsel, and the front line subject matter experts are on the same page

42. Questions?

43. Check out: www.studentaffairsenews.com Presentation designed by: Dr. Brian VanBrunt