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Liability Issues Shape Colleges' Response to Suicide Attempts

The incidence of suicide on college campuses raises issues of student safety, protection of the integrity of the educational environment, confidentiality of psychiatric records, and liability.

Rachel Glick, M.D., and David Fassler, M.D., are co-chairs of APA's Task Force on College Mental Health.

"Life sucks and I want to kill my.... " That was the slightly ambiguous message a college student left on the blackboard of a classroom at a midsize, private university in New Jersey.

An alarmed professor who saw the message alerted the university's director of psychological services, who was able to track down and confront the student about the statement on the blackboard.

In this case, it turned out to be a bit of youthful, exhibitionist anger—not true suicidal intent, said Franca Mancini, Ph.D., director of counseling and psychological counseling at Monmouth University in West Long Branch, N.J.

In other instances, however, ominous behavior and outright suicidal actions by students at the campus have been the signal for a campuswide interdisciplinary intervention team to go into action.

"We try to spread a net around the student without becoming a therapeutic community," Mancini told Psychiatric News. "We have a lot of collaboration among the different offices and departments on campus, especially with residential life and student services. We also have a line of communication with faculty. We try to cover the campus and let people know to inform us about suicidal behavior or intent."

Students who are deemed to be truly suicidal are taken to the psychiatric screening center at the local hospital. After appropriate assessment, they may be hospitalized by the treating professionals there or discharged if there is no imminent risk.

"Either way, we inform them that if they are residents [in campus housing], they are not going to return to residency until they receive clearance from the hospital," Mancini said. "They must bring discharge plans and also agree to the recommended follow-up care."

Nonresident students who are transported to the hospital go through a similar "clearance" procedure through her office, she said.

"Those nonresidents who go to the hospital for an emergency psychiatric screening are informed of our services through the emergency psychiatric service staff," Mancini said. "Many choose to be referred back to the university counseling center, and in fact the hospital will call to schedule an appointment while the student is still there. They share the discharge recommendations, and we work on a treatment plan if it is appropriate for the student to be seen through our counseling services."

Almost always, students accept the conditions, and almost always they come back to school if they are willing to comply with the recommended treatment.

"We've never had to forcibly take someone to the hospital," she said. "And we have not reached a point where we have had to say a student can't come back to school."

Issues of Confidentiality, Liability Raised

The system at Monmouth University is typical of the kind of zero-tolerance response a number of colleges and universities are adopting to cope with student suicide threats or attempts and other forms of self-harm. It is a phenomenon that engages a host of thorny issues involving the safety and care of the student, protection of other students and the integrity of the educational environment, confidentiality of medical and psychiatric records, and the school's liability.

In April a suit against the Massachusetts Institute of Technology (MIT) was settled out of court regarding the April 2000 suicide of Elizabeth Shin, a student there. The student's family agreed not to proceed with the suit against four MIT psychiatrists; another suit—this one against the university— had been dismissed in June 2005.

As part of the settlement, the amount of the payment must be kept confidential at the request of the Shin family, according to a university statement.

Also recently at George Washington University, Jordan Nott, a former student there, filed suit against the school when it dismissed him after he sought hospitalization for depression and suicidal thoughts

Schools Not Therapeutic Communities

In general, psychiatric leaders—as well as university administrators and campus mental health professionals—agreed that proper treatment on campus of severely depressed or suicidal students is ideal and that dismissal from school is to be avoided, certainly if the student is seeking treatment.

"Students should not be suspended or forced to withdraw from school for seeking psychiatric services or other mental health-related treatment," said David Fassler, M.D., co-chair of APA's Task Force on College Mental Health. "Such policies are clearly discriminatory. They also discourage students from asking for help."

Yet as Mancini suggested, schools cannot allow themselves to become "therapeutic communities," and administrators do have a responsibility to the larger student body and the university community.

"I would have grave concerns if there really was a case of a student who asked for help but who was not disruptive and was then put on mandatory leave without due process," said Rachel Glick, M.D., co-chair with Fassler of the APA task force. "It's clear that universities can take disciplinary action when behaviors are disruptive, but they can't take action when the person is ill and the behavior is not disruptive—that's protected under the Americans With Disabilities Act."

But Glick said college and university administrators feel a need to protect themselves and the learning community they are shepherding from what might be disruptive behavior.

"Those of us who are clinicians may not consider a suicide attempt disruptive, but if it happens in a dorm and there is blood all over a bathroom floor, it's disruptive to some degree," she said.

University of Illinois Models Prevention

Though suicides among young people in college often make headlines, a number of studies have established that the rate of suicide is lower than that of young adults in the general population, according to Paul Joffe, Ph.D., director of the suicide prevention team at the University of Illinois.

For instance, a study reported in the fall 1997 Suicide and Life Threatening Behavior, found that the overall student suicide rate of 7.5/100,000 in the "Big Ten" schools was one-half of the computed national suicide rate (15.0/100,000) for a matched sample by age, gender, and race. (The Big Ten are the University of Illinois, University of Minnesota, Northwestern University, Purdue University, University of Wisconsin, Indiana University, University of Iowa, Ohio State University, University of Michigan, Michigan State University, and Pennsylvania State University).

But even if suicide is not more likely to occur on a college campus than anywhere else, it does seem to be an ideal place to try to prevent it. Approximately 1,100 young adults kill themselves in the nation's colleges and universities every year, according to Joffe.

Joffe said that prior to 1984, the University of Illinois had a policy of "invite and encourage" regarding reports of suicidal behavior. "We would contact a student who was reported and tell that student we'd like for him or her to come in to the counseling center," he said. "What we found was an enormous amount of resistance along the lines of `Who are you to call me in?'

"We were faced with a practical and ethical conundrum," he said. "Resistance to treatment could lead to fatalities, but what about the right of students to make their own choices? But then we began to think about whether someone who was ready to make a choice to kill themselves over a romantic disappointment would rationally make a choice to seek mental health treatment."

So in fall 1984, the university instituted a formal program requiring any student who threatened or attempted suicide to attend four sessions of professional assessment. The consequences for failing to comply with the program included mandatory withdrawal from the university.

Since then, reports on 2,017 suicide incidents have been submitted to the university suicide prevention team. The rate of suicide decreased from 6.91 per 100,000 enrolled students during the eight years before the program started to 3.78 in the 21 years since then.

This represents a reduction in suicides of 45.3 percent at the university, while suicide rates were stable both nationally and among peer institutions within the Big Ten, Joffe said.

Since the program's inception at the University of Illinois, it has become a model for more than a few institutions across the country. Some of these include Case Western Reserve University, University of South Dakota, the University of Puget Sound, and the University of Washington, Seattle.

"Our approach to suicidal students is very proactive and is about retaining students, not dismissing them, so they can stay in school and finish their degree," said Houston Dougharty, associate dean for student services at the University of Puget Sound. "We have taken the Joffe model from the University of Illinois and adapted it in several ways to meet the needs of a small liberal arts college."

Members of the student affairs staff at the university are required to complete a Suicide Incident Report (SIR) when they learn that a student has commented about suicide, has made suicide threats, has attempted suicide, or has engaged in intentional self-harming behaviors.

The data from a completed SIR are evaluated by the Suicide Prevention Team, a committee composed of two staff members and one faculty member. If this committee determines there is sound basis for concern about a student's suicidal or self-harming behaviors, the committee may require the student to participate in four sessions of psychological assessment with a member of the campus counseling staff or with a provider off campus. As at the University of Illinois, the program has demonstrated success.

"We have been overwhelmed by the receptivity of students to mandated assessment," Dougharty told Psychiatric News. "Typically, they are relieved that they can do something about it. Not only do we want students to stay alive and healthy, but we want them to finish their degree."

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