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.

Background

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.

Stigma

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]

  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]

    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.

      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.

      Conclusion

      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.

      Effective Period

      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