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Article
Psychiatric Times
Mandatory Leave of Absence for College Students With Suicidal Behaviors: The Real Story
Author(s):
One would easily imagine from a recent TV report that psychiatrically ill and suicidal students are routinely being shipped off to hospitals and removed from their colleges without due process or discussion.
© WK1003MIKE/SHUTTERSTOCK.COM
Full disclosure: I do not know any of the details of these situations. Also, I was interviewed for this story, and several heavily edited and misleading snippets of my comments were included in the report.
On June 20, the Today show ran a story, reported by Ronan Farrow, describing the travails of 22 students who were purported to have been forced out of their colleges after having presented for treatment at their school counseling/mental health services.1 Farrow’s report focused on 3 students.
In the most detailed account, a University of Chicago student reported that she had presented to the counseling service for treatment of depression and superficial cutting. She tells Farrow she had absolutely no suicidal intent but was taken to a hospital and kept there for 2 weeks-an extraordinary duration for someone in no apparent risk or danger. After a year’s leave, she is back at Chicago.
A Yale University student reported having been forced to withdraw from school when hospitalized for depression and made to reapply in order to return. She is back at Yale and is fighting this policy, which requires students to reapply to the university after taking a medical leave.
The other Chicago student reported having been forced to take a leave after a psychiatric hospitalization. Upon her discharge, in a meeting with campus administrators to discuss her situation, her mother described her as “going into a fetal position and sobbing, begging to be readmitted to school.” The student and her mother feel the school’s having her take a leave was reflective of a complete lack of empathy and compassion-rather than a sensible assessment of her level of distress and dysfunction at the time.
In any event, one would imagine from this report that psychiatrically ill and suicidal students are routinely being shipped off to hospitals and removed from their colleges without due process or discussion. Farrow suggests that the fear of this happening may very well be leading students in distress to avoid seeking help at their schools. He is correct about the danger of students having this impression. Unfortunately, it is reports like this one that are creating this impression, which is largely inaccurate.
The context
Currently, there are approximately 20 million college and university students in the US.2 According to the National College Health Assessment, nearly 10% of students reported serious thoughts of suicide in the past year and 1.6% reported a past-year suicide attempt.3 Thus, about 2 million students had serious thoughts of suicide, and 300,000 made a suicide attempt in the prior year. College counseling services typically see slightly more than 10% of their school’s students in a year4; about one-third report having had serious suicidal ideation.5
College counseling centers are treating vast numbers of students with suicidal ideation or past-year attempts. And yet, Farrow found 22 students who were reported to have been forced out of school because of suicidal behavior or ideation (or, as reported, for seemingly meaningless minor acts of self-harm).
The legal setting
The Americans With Disabilities Act (ADA) makes it very difficult for colleges to involuntarily remove students with psychiatric illness-even when they are suicidal. The ADA allows for complaints to be brought to the Office of Civil Rights of the US Department of Education, which provides an indicator of how many students feel they were unfairly or inappropriately forced out of school. The number of civil suits brought against colleges for impinging on students’ civil rights can also be tracked. In fact, there are very few complaints/lawsuits given the number of troubled students seen by college counseling services.6
The best examples of a school overreacting may have been the Jordan Nott case and the Jane Doe vs Hunter case.7 In both cases, students were removed from college after voluntarily seeking inpatient treatment for depression with suicidal ideation. In each case the action was taken without any discussion with the student. In each case the university settled, and at least in the Nott case, George Washington University made substantial changes to its protocols for managing depressed students.
Moreover, it is important to recognize that after the Virginia Tech tragedy, some school administrators understandably became much more skittish about having students with suicidal ideation on campus. One can also find this heightened reactivity and push to remove potentially suicidal students when there has been a recent suicide or suicide cluster on a campus or prominently covered in the news.
There are also situations in which an individual administrator at a college has a particularly hard-nosed or anxious attitude about the risk of having a suicidal or potentially suicidal student on campus. But, all of these problems are quite rare. Most often a student who needs time away from school (and ideally his or her family) is cooperative with university clinicians and administrators, and a reasonable plan can be agreed on-if a leave occurs, it is fully voluntary.
School policies
Some schools have made the leave process more cumbersome or unwieldy by establishing policies that make students uneasy or hesitant to take a needed leave. For example, some schools require students who take a medical or mental health leave to stay out of school for a full year. Some schools do this because they don’t want students to take a leave to get out of bad academic performance. Other schools have rigid academic structures that make it difficult for a student to return the subsequent semester.
Others, such as Yale, require students who take a leave of absence to reapply to the college. While students are typically readmitted after they have received the necessary treatment and stabilized, this policy has led students to feel as if the school can arbitrarily choose to readmit them or not-in many cases increasing students’ hesitation to take needed leaves of absence.
What is the truth about involuntary leave?
While there are a few situations or policies that may lead to involuntary leave, there are large numbers of students with significant pathology and many with suicidal ideation and past or recent attempts who are being treated and kept in school. In fact, college clinicians and administrators (and campus at-risk teams) are managing many actively suicidal students.
While I am quoted in the Today report as suggesting that colleges are concerned about their reputations and PR, this was only the beginning of my comment. The truth is that campus counselors and administrators primarily care about their students’ welfare and safety (this was the completion of the quote not included in the story) and they recognize that on balance, if a student can be kept in school, it is better for the student (and the system) to remain enrolled. College attendance may actually protect against suicide-the rate of suicide among college attendees is half that of young adults who do not attend college.7
Furthermore, removing every student with suicidal ideation or a suicide attempt would remove many students who might be better off remaining in school.7 And consider that if a student is depressed but functioning, he or she will be more occupied, potentially better socially connected, and probably more hopeful by remaining in school.
Another incentive for colleges to work with students and their families in a cooperative way and arrive at mutually acceptable plans is highlighted in the Farrow report. In the past 20 years, colleges have made substantial strides in increasing student comfort with help-seeking. The number of students who receive treatment at college counseling centers and support through other campus offices (eg, residence life, disabilities) has grown steadily. This in some part accounts for the lower rates of suicide among college students.
When unbalanced reports such as the Today story or the sporadic reports in campus newspapers about forced leaves of absence appear, these may very well have a negative impact on student help-seeking and ironically (and tragically) make students less safe.
Conclusion
Farrow and the complaining students are correct that colleges need to be sensitive and sensible in managing suicidal students. They have, however, created a misimpression of a much larger problem than actually exists. They have also failed to explain how complicated many of these situations are. Students and families are sometimes not fully able to acknowledge the extent of pathology or risk, and college clinicians and administrators sometimes make mistaken or less than ideal decisions. More often than not, the student, family, clinicians, and administrators can mostly agree about the situation and an acceptable plan emerges. In the rare situation in which the student and the campus professionals cannot reach an agreement, it is best to treat these situations as a clinical impasse and work to understand the motivations and conflicts from a dynamic and therapeutic perspective. If an agreement cannot be reached, a mandated leave is possible and may be the leverage needed to get a student to seek needed treatment.
Disclosures:
Dr. Schwartz is Clinical Associate Professor of Psychiatry, NYU School of Medicine; and Medical Director, JED Foundation, New York, NY. He reports no conflicts concerning the subject matter of this article.
References:
1. Mental health policies at universities draw increasing concern. Today. June 2016. http://www.today.com/news/mental-health-policies-universities-draw-increasing-concern-t99441. Accessed July 11, 2016.
2. National Center for Education Statistics. Fast Facts. http://nces.ed.gov/fastfacts/display.asp?id=372. Accessed July 11, 2016.
3. American College Health Association. National College Health Assessment. http://www.acha-ncha.org/pubs_rpts.html. Accessed July 11, 2016.
4. Association for University and College Counseling Center Directors. Director Surveys. http://www.aucccd.org/director-surveys-public. Accessed July 11, 2016.
5. Center for Collegiate Mental Health. 2015 Annual Report. http://sites.psu.edu/ccmh/wp-content/uploads/sites/3058/2016/01/2015_CCMH_Report_1-18-2015.pdf. Accessed July 11, 2016.
6. Lannon OG Jr. Direct threat and caring for students at risk for self-harm: where we stand now. National Association of College and University Attorneys. http://www.higheredcompliance.org/resources/SelfHarm.pdf. Accessed July 11, 2016.
7. Apppelbaum PS. “Depressed? Get out!”: dealing with suicidal students on college campuses. Law & Psychiatry. July 2006. http://ps.psychiatryonline.org/doi/abs/10.1176/ps.2006.57.7.914. Accessed July 12, 2016.
