Four perspectives on the tragedy and mental health
Helping Troubled Students
Suggested mental health policy for colleges
by Elia Powers
One of the major questions to emerge from the Virginia Tech shootings is whether colleges are prepared to handle a situation in which a student with mental illness is identified as posing a potential threat to campus.
An advocacy group for people with mental disabilities says there is no consensus among college leaders on how to respond. Many campuses have free counseling services, but when a student’s behavior raises red flags, colleges often worry about legal liability, lack a comprehensive plan or having a plan that is overly punitive, according to officials at the Bazelon Center for Mental Health Law.
In a new report, “Supporting Students: A Model Policy for Colleges and Universities,” the center outlines what it describes as best practices for colleges when dealing with the above scenario and others. The policy, which Bazelon officials hope colleges use as a model, calls on institutions to stay away from rigid rules that could discourage students from seeking treatment but that still allow campus officials to intervene when necessary.
“One of our goals here is to send a clear message to students that they can seek help early on and not be penalized,” said Robert Bernstein, the center’s executive director.
Late last month, center officials said they were troubled by the response to Virginia Tech, which Bernstein called a “hunger for quick fixes and quick legislation” instead of a closer look at what could have been done to treat the gunman long before he attacked. (The center began work on its policy before the Virginia Tech tragedy, although Bernstein said that event makes the recommendations “timely.”)
In dealing with cases of troubled students, the report says that colleges should make clear all counseling options and allow them to voluntarily decide whether to seek help. Colleges should suggest that students visit a counseling center when it learns that the student shows academic or behavioral difficulties that “appear to be due to depression or another mental health condition,” or when the student has been known to have contemplated suicide.
If a referred student doesn’t proactively seek the help, the center officials should then reach out. As state law permits, colleges may seek involuntary treatment of the student in “exceptional circumstances,” which the report doesn’t define, in order to “encompass a range of behaviors,” said Karen Bower, senior staff attorney at Bazelon. As a last resort, a college can consider using an outside crisis outreach team to contact the student.
Bower said the policy addresses the two areas that are often the stickiest for colleges: confidentiality and student leaves of absence. The report says that in almost all cases, the counseling center should not share information about a student with faculty, staff, administrators or others unless the student consents. When appropriate, the counseling center can encourage the student to consent to sharing the information.
Depending on state law, a center should only disclose information about a student “to the extent needed to protect the student or others from a serious and imminent threat to safety,” the report says, adding that “disclosures are permitted only if the student will not consent to interventions that will ameliorate the risk.” Colleges should “reasonably” accommodate students who are mentally ill by allowing them to remain enrolled, or make concessions such as allowing them to take a reduced course load and work from home, according to the report. Bower said it’s also important that colleges don’t take disciplinary action against students who choose to take time off or who display “self-injurious” behavior. A counselor’s role is to help the student decide whether to take a leave, and in some cases to help the student secure time off. The report says the student should be able to attend campus events while on leave, unless there are documented safety concerns.
Only in “uncommon circumstances,” in which students cannot remain safely on campus or meet academic standards, should a college require a student to take a leave – and the decision should be made by a committee that includes the counseling center director, the report says. (It adds that the committee can look into the student’s mental condition and seek records, but the search should be limited to essential documents and not rely on access to all confidential records.)
Robb Jones, senior vice president and general counsel for claims management and risk research at United Educators, an insurance company for colleges, said that while he supports the idea of a policy that promotes the individual rights of students with mental illness, colleges should go beyond Bazelon’s guidelines by considering the rights of all students and faculty members, and by including safeguards for counselors who find it necessary to share student records.
It would be easier to agree with the report if its rules applied only to cases of depression, Jones said. “But since colleges are often dealing with more serious forms of mental health problems, and determining a student’s prognosis can be difficult, there’s a problem with coming up with guidelines that will apply to virtually all cases,” he added.
Jones said a complete report would go further by noting that in some cases, students are better off seeking treatment away from campus, and that the campus would be better off without the student’s presence. The company agrees with Bazelon that the best practice is to begin with a voluntary leave policy, and that involuntary removal should be the last resort.
Bernstein said the center is working on another guide that covers what students should know about their rights in mental health cases.
Reprinted with permission from Inside Higher Ed., Editor Doug Lederman. http://insidehighered.com
Forced Treatment has Undesired
by Ron Ungar
Many people imagine that a mental health treatment system that relies on force will be more effective, for example, at keeping people from hurting themselves or others. Typically, people think of a situation where someone refuses treatment, but then is a danger to themselves or others: they imagine it going much better if the system is allowed to force treatment on the person. But from a “whole systems” viewpoint, we have to look at all the consequences of forced treatment, and then wonder if we are really creating more safety in the overall picture.
Forced treatment has many undesired “side” effects, such as:
• Many people are traumatized by coercive treatment. This trauma contributes to future mental health problems which in turn contribute to future suicidality. The system doesn’t keep people forever, so they just commit suicide sometime after being released. (Like my partner’s flute teacher, who was not only coercively treated but also with unnecessary rudeness, and then killed himself shortly after he got out.)
• Clients who have been coercively treated in the past, or those who are aware of the system’s capacity for coercion, are likely to avoid the mental health system. They won’t reach out for voluntary treatment because they know they could lose control of what treatment they get. Lack of treatment can then lead to suicide (as with my brother, who avoided the system after seeing what it did to his older brother).
• When treatment is forced, people often end up on medications they don’t really want. So when they get out, they quit the medications suddenly. This causes withdrawal reactions that can lead to more instability than was ever present to begin with. (Also, of course, people often end up on medications that increase suicidality, though this seldom gets noticed; it is just attributed to their “mental illness.”)
With all these negative effects related to the use of force, the overall suicide (and other complication) rate may be going up due to the use of force, rather than being reduced. A voluntary system could reach many people who are frightened by the coercive system, and it would ultimately discharge people who are less traumatized and more emotionally healed.
A system allowed to use force may easily learn to rely on it instead of going to more effort to “sell” its services to clients, so that much of the force used may be unnecessary in that respect. This is especially true for a system that doesn’t have to even count how often it uses force, a system that doesn’t have any pressure on it to minimize the use of force. We’d at least like to see a goal of minimizing force, along with some accounting of how much force is used, so progress can be tracked.
Ron Unger is a mental health counselor in Eugene, Oregon, specializing in recovery-focused psychosocial methods, and is also a county coordinator for MindFreedom, advocating for change in the mental health system.
The VA Tech Tragedy
Distinguishing mental illness from violence
statement of Ken Duckworth, NAMI Medical Director
The National Alliance on Mental Illness (NAMI) extends its sympathy to all the families who have lost loved ones in the terrible tragedy at the Virginia Polytechnic Institute. We are an organization of individuals and families whose lives have been affected by serious mental illnesses.
Despite media reports, Cho Seung Hui, the shooter in the tragedy, may not actually have had a serious mental illness relative to other diagnoses. But the possibility opens the door for reflection on the nature of mental illnesses-what they are and what they are not- with regard to symptoms, treatment and risks of violence.
The U.S. Surgeon General has reported that the likelihood of violence by people with mental illness is low. In fact, “the overall contribution of mental disorders to the total level of violence in society is exceptionally small.” More often, people living with mental illness are the victims of violence.
Severe mental illnesses are medical illnesses. They are different from episodic conditions. They are different from sociopathic disorders.
Acts of violence are exceptional.
Treatment works, but only if a person gets it.
Questions must be answered about whether the mental health care system responded appropriately in this case. We know that Cho Seung Hui was referred to a mental health facility for assessment. Did he receive the right treatment and follow-up? If not, why not?
[April 18, 2007]
Mental Health Services and
the VA Tech Massacre
by Nathaniel S. Lehrman
More mental health services, and even involuntary mental health screenings, have been proposed to prevent repetition of the Virginia Tech massacre. But mass murderer Cho Seung Hui did get mental health care in a hospital. He
then rejected further treatment. The drug-only treatment he got may well have aggravated his disturbance.
Good mental health care is based on continuing, caring human contact: knowledgeable people helping troubled people with problems, while strengthening and reassuring them. Medication, often with little or no meaningful human contact, has now almost entirely replaced that older care pattern. And that’s what Cho got. And anti-depressant drugs, like those he was given, can themselves intensify suicidal and homicidal thoughts and behavior.
When considering the effectiveness of mental health services, we should recognize that in the fifty years since drugs began to be psychiatry’s main treatment modality, there has been a five-fold increase in the fraction of mentally disabled in the population. Before hurrying to expand mental health services, we should examine more critically the results of current treatment methods.
Nathaniel S. Lehrman, Roslyn NY, is former Clinical Director, Kingsboro Psychiatric Center, Brooklyn NY; former Assistant Clinical Professor of Psychiatry, Albert Einstein and SUNY Downstate Colleges of Medicine
This letter was first published in Newsday.