Transcript

Student Mental Health on Campus: The Current Landscape

Host: Hello and welcome to today’s webinar, Student Mental Health in Higher Education: The Current Landscape. Note that all attendees are in listen-only mode. Today’s program is approximately 90 minutes long. We will answer questions previously submitted in advance during the webinars to the Q&A session. First, some housekeeping items. Submit technical issues using the question box on the bottom of your screen and clicking submit. Webinar resources are available in the resources list to the right of the presentation. If you have problems accessing the resources, please email risk@ue.org after the webinar concludes. Please note that today’s presentation recording will be available in a few days on our website. For UE members attending today, welcome. If you have risk management questions, please reach out to our consulting team at risk@ue.org. For non-UE members, you can and find more information about UE on www.ue.org. And now, here’s today’s moderator, Heather Salko.

Heather Salko: Thank you. And welcome to everyone joining us today. I’m Heather Salko, Manager of Risk Research in UE’s Risk Management department. And today I’ll be moderating our discussion of student mental health on campus. I’m pleased to be joined by three professionals with extensive experience in this area: Dr. Sarah Ketchen Lipson, Assistant Professor in the Department of Health Law, Policy and Management at the Boston University School of Public Health. Sarah is Principal Investigator of the Healthy Minds Network, which includes the national Healthy Minds Study. Amy Gatto, Senior Manager of Higher Ed & Evaluation at the national mental health nonprofit Active Minds. She is interested in the relationship between health and education and has found a niche in working to improve adolescent and young adult mental health. Amy is also a doctoral candidate at the University of South Florida in the College of Public Health. Hannah Ross, General Counsel, Secretary of the Corporation, and Chief of Staff at Middlebury College in Vermont. In addition to advising her institution on the legal issues related to student mental health, Ms. Ross regularly educates student affairs professionals and fellow higher education attorneys on the subject.

Welcome Sarah, Amy and Hannah. One note, despite having a lawyer on our webinar today, this session is designed to provide risk management advice and not legal advice.

With that caveat, we will begin with some background information. Student mental health receives regular coverage in the news, often focusing on increased demand placed on university provided counseling services. Over the past few years through the duration of the COVID-19 pandemic and its related restrictions and stressors, this news coverage and attendance demand has only increased. To help us understand what is happening on campuses nationwide, I will turn the presentation over to Sarah to discuss what she and her colleagues at the Healthy Minds Network have found in their research.

Dr. Sarah Ketchen Lipson: Hi everyone, I’m Sarah Lipson. I’m so happy to be here today and to have a chance to share some of the research that my colleagues and I have been conducting through the Healthy Minds Network and specifically through our annual national survey study, the Healthy Minds Study. What you’re looking at here is a map of the colleges and universities that have participated in the Healthy Minds Study. In recent years, we have over 450 colleges and universities, and that includes community colleges, four-year institutions, public, private institutions. The Healthy Minds Study is open to all institutional types, and we’ve had over 450,000 student respondents.

It's an online survey and at each participating institution, we invite a random sample of students to participate in the online survey. As you can see on the right-hand side of your screen, we have an incredible team with the Healthy Minds Study. My colleagues, Daniel Eisenberg and Justin Heinze, as co-principal investigators of myself, and then a wonderful team of folks who coordinate and manage this national study.

So I’m going to share some statistics from the Healthy Minds Study. And I think one of the most important ways to frame this conversation is around trends in student mental health over time. And in the Healthy Minds Study, we have a number of validated screening tools or measures of mental health. And the first one that I want to share is our measure of positive mental health are flourishing. And here, what you can see is the proportion of students who meet criteria for flourishing on an eight-item scale that we have in the Healthy Minds Study. And generally the takeaway from this slide is that since 2012, when we started using a flourishing measure that we’ve consistently had in the study through the 2020-2021 academic year, you can see a consistent trend of decreasing rates of flourishing over time.

So oftentimes I think it’s tempting to have an entirely bad news perspective about student mental health, but I really want to point out, there’s a big group of students who are flourishing, who are thriving on campus, and we have a lot to learn from those students. We have a lot to learn about the environments that are most conducive to flourishing. But of course, we have seen decreasing rates of flourishing over time. Next, I’m going to turn our attention to looking at some trends in depression, anxiety, and suicidality over time.

So in the Healthy Minds Study, we ask a number of questions about suicide risk. And one of those questions asks students if they’ve seriously considered attempting suicide in the past year. So this is our measure of suicidal ideation. And we’ve had the same measure are in our survey since the very first year in 2007. And what you can see from 2007 through the 2020-2021 academic year is more than a doubling in the rate of students who are reporting suicidal ideation.

Another thing to point out, and we’ll see this as we look at symptoms of depression and anxiety as well, is that in the pandemic, it’s not as if we’ve seen a unique spike in prevalence levels. Rather, we’ve seen a continuation of a very troubling trend.

So what we can see here is similar to the decreasing rates of flourishing and the increasing rates of suicidal ideation over time, we have similarly seen increasing prevalence of symptoms of depression and anxiety over the past eight years. And the reason that some of the years are different in these graphs is just to do with having consistent survey measures. So in 2013, we changed our measure of anxiety to the Generalized Anxiety Disorder-7 scale. So I’m showing the symptoms of depression, anxiety from 2013 through spring of 2021. And you can see that in 2013, 22% of students screened positive for depression and 17% for anxiety. And in our most recent data from spring 2021, 41% of students screened positive for depression and 34% for anxiety.

I want to make it really clear that these are symptoms, not diagnoses. And I’ll talk a little bit about what we know about help seeking behavior as well.

One of the important opportunities with large-scale population-level data like Healthy Minds Study is the opportunity to look at variations and trends across key student identities and demographics. So what we’re looking at here is symptoms of depression, again, so not diagnoses, but symptoms of depression based on the Patient Health Questionnaire-9 by race, ethnicity. And you can see here that for all groups we have seen an increase over time in symptoms of depression.

In particular, among American Indian and Alaskan Native students, we see a really significant increase, but in general, this troubling trend is existing within all of the racial and ethnic groups that we measure in the Healthy Minds Study. So just very quickly I want to really solidify what we know from our most recent data. So this is the prevalence of depression and anxiety from spring 2021, where we had our largest sample of students to date, we had over 100,000 student respondents, and you can see 22% of students are screening positive for severe depression — so more than one in five students. And again, if you add severe, plus moderate, we get to 41% of students with a score of 10 or more on the PHQ-9. Similarly, 17% of students screened positive for severe anxiety, 18% for moderate anxiety, amounting and this accounts for sort of rounding in decimals, but 34% of all students in spring of 2021 screened positive for anxiety.

My colleagues and I at the Healthy Minds Network are really committed to trying to understand inequalities and shed light on those using our data. One of the starkest inequalities that we see in our data is by gender identity. So this is a graph comparing cisgender students to trans and gender-nonconforming students or students whose gender identity does not align with their sex assigned at birth. And you can see more than twice the prevalence of depression among trans and gender-nonconforming students relative to cisgender students. Similarly for anxiety and for suicidal ideation. So over a third of trans and gender-nonconforming students are reporting seriously considering suicide in the past year.

In addition to trying to understand prevalence and variations they’re in, it’s really important for us to understand some of the key risk factors that are shaping student mental health. And one of those certainly throughout the pandemic has been loneliness. So a small caveat is that we actually added this three-item measure, the UCLA Loneliness Scale, to the Healthy Minds Study during the pandemic. So we don’t have measures over time, but we will moving forward as this is now a permanent part of the survey. But this three-item scale asks student how often they have felt like they lacked companionship, felt left out, or felt isolated from others. And you can see that about two-thirds of students are reporting each of these core concepts of loneliness. Loneliness is a key risk factor for mental health and in particular for suicide risk. Conversely, a key protective factor, meaning something that is associated positively with mental health, is students’ sense of belonging on campus.

And we have a number of different measures of sense of belonging in our survey. And what I’m showing here is an item where we ask students the degree to which they agree with the statement, “I feel a part of the campus community.” You can see the proportion of students reporting strongly agree, agree, all the way down to strongly disagree. And there is a strong correlation with mental health. So among students with high sense of belonging, those who strongly agree that they feel they’re a part of the campus community, 27% are screening positive for one or more mental health conditions. And that includes depression, anxiety, suicidal ideation. Among students who have a low sense of belonging, those who we disagree that they don’t feel that they’re a part of this campus community, over half of them are screening positive for one or more mental health problems.

Perhaps the most significant predictor of student mental health in our data is financial stress. And you can see here among students who report that their financial situation is never stressful or rarely stressful or sometimes stressful, it’s around 30% of students who are screening positive for one or more mental health conditions. Among students who say their financial situation is often stressful, are up to 45%. And among students who say their financial situation is always stressful, 60% of those students are screening positive for one or more mental health conditions.

We know that the pandemic has amplified financial stress across the board, and that includes in student populations. So this is a risk factor that our team is really closely monitoring.

The last risk factor that I want to share today to kind of frame this conversation is around experiences of discrimination. Not surprisingly, discrimination has a negative impact on student mental health. You can see among students who experienced discrimination with the black bars, significantly higher prevalence of depression, anxiety, and somewhat higher rates of suicidal ideation. My colleague Sasha Zhou from the Healthy Minds Network has also led some work looking throughout the pandemic at the experiences of discrimination among Asian American and Pacific Islander students, and has found consistent with this graph that those students who experience discrimination have higher rates of mental health problems, and, importantly, they’re even witnessing discrimination. So exposure to discrimination, whether that’s by the news, whether that’s social media, is also a significant risk factor for mental health among Asian American and Pacific Islander students.

Now I want to turn our attention to thinking about help-seeking among students and some of the factors that affect whether or not students seek help for their mental health. And what we can see here is a success story. We can see decreasing rates of stigma that students are reporting over time. It’s also important to note, there are many different measures on stigma and what I’m showing here is actually perceived public stigma, which is a statement most people would think less of someone who has received mental health treatment.

We also have a measure of personal stigma that I didn’t include here that says, “I would think less of someone who has received mental health treatment.” And we actually see even more dramatic decreases in levels of personal stigma, though relative to perceived stigma, personal stigma is much, much lower. And personal stigma is a significant predictor of whether or not students themselves seek help. Perceived or public stigma is less of a significant predictor of help-seeking.

But the main takeaway from this side is essentially we have seen decrease in levels of stigma. I’m thrilled that my colleague Amy from Active Minds is here. Much of the work in changing the conversation around mental health on campus has been through Active Minds and their efforts on campus. So this is just to kind of help us understand that more and more students are open to talking about mental health and have positive beliefs about mental health treatment.

So I’m going to turn us now to actually looking at the proportion of students who’ve sought help on campus. I realize that there are a lot of numbers and a lot of bars on this graph. What you’re looking at here are four measures of help-seeking from the Healthy Minds Study. So we have past year treatment, which is a combination of any past year therapy or counseling and/or any past year psychotropic medication use. And then separately, the rates of past year therapy or counseling and separately past year psychotropic medication. And then lastly, lifetime diagnoses. And this is showing from 2007 through the 2016-2017 academic year. And overall, we are seeing increases in all four of these measures of help-seeking.

So I’m going to complicate this picture a bit as we move to the next slide. But we are seeing more and more students open to seeking help and more and more students who are taking advantage of mental health resources.

One of the key statistics that our Healthy Minds team is really interested in is the treatment gap, which actually combines two different statistics. It’s the proportion of students who have not received treatment among those who have a positive screen. So it’s a measure of unmet need. And what you can see here is that among students with depression, only 37% of them have received treatment in the past year. So a 63% treatment gap. A similar treatment gap, 61% for anxiety. [A] 47% treatment gap among students who’ve seriously considered suicide in the past year.

And what we don’t want to imply is that every student with a positive screen necessarily needs mental health treatment, but it’s very clear to us that there’s significant unmet need and there are many students who are not accessing treatment. And many students who do seek treatment are doing so in a crisis, which puts an additional burden on the counseling center, which is the most common place that students are seeking help.

This also creates many missed opportunities for early intervention and prevention if we’re not reaching students until they’re in a crisis. And throughout the pandemic, one thing that has been really challenging is that many students who do seek help do so because they’ve been identified by peers or other gatekeepers on campus who have reached out to them and asked them if they’re all right, had conversations with them and tried to connect them with resources. And many of those key gatekeepers on campus have been less visible throughout the pandemic with the key exception of faculty members, which I’ll talk about a little bit more. So we’ve seen stigma going down. We’ve seen that many students are open to talking about mental health. But there’s still a significant mental health treatment gap.

So before the pandemic began, we knew that there were already large inequalities when it comes to which students are accessing mental health services. I showed a little bit about some of the inequalities in terms of prevalence levels, but really where we see inequalities by race and ethnicity is when it comes to who is accessing services. And overall, students of color are significantly less likely to receive treatment. Throughout the pandemic, we have adapted the Healthy Minds Study to include some measures to try to understand how students’ experiences related to mental health have been changed over the last year and a half. So we’ve asked students, “How has your access to mental health care been affected by the COVID-19 pandemic?” And you can see that about 30% of students are saying that the pandemic has made it more difficult for them to access services.

And then I also just generated this graph on the bottom right from our data interface with the Healthy Minds Study, which is an online data interface that makes it really easy to just jump in and run some quick analysis with the data that’s publicly available. And this is showing the proportion of students who have positive screens for depression and anxiety, who are currently using medication for their mental health. And it’s broken down by race. And you can see much higher rates of medication use among white students. The lowest rates of medication use among Asian and Asian American students and black students.

So like I said, stigma has been going down. Many students with untreated symptoms have positive attitudes and beliefs, but the task of seeking mental health treatment just does not appear to be a salient priority. There seems to be this inertia or lack of urgency surrounding mental health help-seeking. When we asked students with untreated symptoms in the Healthy Minds Study why they haven’t received treatment, the most commonly reported barriers are, “I haven’t had a need. I prefer to deal with issues on my own. I question how serious my needs are. And I don’t have time.” And this is among students, again, who report seriously considering suicide in the past year or students who are screening positive for major depression or generalized anxiety.

So I mentioned earlier that throughout the pandemic we’ve not seen a unique spike in prevalence. Rather, we’ve seen a continuation of a troubling trend. A unique change that we have seen throughout the pandemic is the proportion of students who are indicating that their mental health has negatively affected their academic performance. So we ask students about this over the past four weeks and 82% of students in the spring of 2021 said that on one or more days, their mental health has negatively affected their academic performance.

We saw the highest proportion that we’ve ever seen of students reporting six or more days of academic impairment, which is over a quarter of students in our data.

At the Healthy Minds Network, we’ve also started to conduct research among faculty and staff on college and university campuses and tying into this the previous side about academic impairment among students. Eighty-seven percent of faculty have observed that student mental health has gone and worse during the pandemic. I think a reason for this is that faculty has been even more so on the front lines. They’ve been the most prominent gatekeepers in terms of consistently seeing students, particularly during the first year of the pandemic. So it’s not surprising to me that the vast majority of faculty perceive that student mental health has worsened.

So lastly, I just want to touch on some practical actions to support student well-being. Myself as a faculty member, these are things I think about a lot. I think there are really some low hanging fruits in terms of how we can be helping students as faculty members. So faculty play an enormous role in shaping student success. Literature from higher education shows that having a personal connection with a faculty member is associated with higher student satisfaction and higher sense of belonging. Having a supportive professor advisor is associated with higher retention. And again, faculty are really on the front lines in terms of being able to identify students in distress and refer them to help.

One of the easiest things that I have thought a lot about is when are assignments due. If you have an assignment that’s due at 9 a.m., students are very likely to pull an all-nighter and that’s of course, an unhealthy behavior, something that we’d really like to avoid. Sleep is another important protective factor for student mental health. For the student population that I teach, I think of 5 p.m. as being the healthiest time. If faculty are teaching a large student population that works full time, that maybe 5 p.m. is not the most ideal time, but I just encourage faculty to think about when are your assignments due and how can you make assignments due at a time that’s most conducive to wellness. Grading on a curve really encourages competitiveness. It decreases collaboration and is generally a poor way of grading for student mental health as well as for learning. Being flexible with grading and with deadlines is really key right now, particularly as we think about equity in terms of students’ academic performance and retention persistence, as well as their mental health. And then, of course, including mental health resources in the syllabus is another relatively simple way that faculty can bring attention to student mental health and make sure that’s a priority in the classroom.

Salko: Sarah, thank you and your colleagues at the Healthy Minds Network for your insights. As we know, how campuses have responded to these changes and these increasing needs does vary. Some institutions are trying to address this increased student need in some interesting ways, and I’m going to turn it over to Amy to discuss what’s happening on campuses around the country and how Active Minds is helping to address student mental health needs.

Amy Gatto: My name is Amy Gatto. I’m a Senior Manager of Higher Education and Evaluation at Active Minds. Active Minds is the leading nonprofit in the U.S., working to end the silence and change the culture around mental health by mobilizing the next generation. We believe in speaking openly about mental health, creating communities of support, encouraging each other to get help when needed, and taking action for suicide prevention. Together, we’re changing the conversation about mental health. And we do this through the power of peers, reaching people where they are: On campus, at home, at work, and in their community.

A little bit more about Active Minds. We’ve reached over 1.7 million people with our programs. Many of these are within higher ed — colleges and university campuses. We train volunteers to change local culture about mental health, and this could be individually or in policies and programs in order to create healthy communities.

Like many organizations, we’ve shifted during the pandemic. And now we provide programs and presentations both live and in-person and virtually to the Active Minds community and to the broader community interested in mental health.

And so where does this come from? In 2003, our founder, Alison Malmon, established Active Minds following the tragic suicide of her only sibling — her brother Brian. She recognized the need on college campuses to combat stigma that really had caused her brother to suffer in silence before ultimately taking his own life. She created the first Active Minds chapter on her campus at the University of Pennsylvania. Now, in our 19th year, we’ve become the premier [national] nonprofit supporting mental health promotion in education for the next generation. We do this in chapters across the country, within higher ed and K-12. Active Minds has a strong commitment to anti-racism and inclusion. As an organization, we’re working to ensure that all of our work includes a racial and social justice lens. This is important as we develop culturally responsive and equitable youth mental health programming, while also creating avenues to learn, heal, and grow together.

So why do we have to change the conversation? As we just heard from Sarah, there’s so much data supporting the unique needs of college students and young adults and the relationship with their mental health. And when we think about it in the higher ed space, this connection to student success, to overall quality of life, and to outcomes, when we think broadly as a community, suicide is the second-leading cause of death for young adults. Half of students are reporting being depressed or anxious during the pandemic. And, as adults, we know that the pandemic has been a significant source of stress. These trends are the things we’ve been seeing over time. And the pandemic has really provided an opportunity for us to have some of these challenging conversations related to college student mental health in a way where more people can connect to ideas like loneliness, sadness, depression, and anxiety related to the pandemic.

And what we know is approximately 9.2 million college students are experiencing a diagnosable mental health concern. We have continued, prior to the pandemic, seeing an increase in prevalence and severity of mental health concerns on college campuses. As institutions, it’s imperative that we work to address student mental health and think about the overall mental health of those involved in our campus community. We know that early prevention, detection, and treatment has the potential to save lives, and overall, will improve academic outcomes, career trajectories, lifetime earnings, health, relationship satisfaction, and so many more qualities of having a true high quality of life.

So let’s dive a little deeper in, “What does it need to take a proactive approach to support the whole student?” So as Sarah just provided in her presentation, she gave some tips for faculty members to support student mental health. And when we think about supporting student mental health, one of the best things we can do is think about what are the warning signs? So when we’re looking at individuals working with students, some things that come up are when students are missing classes, assignments, or exams, when they are needing extensions and/or have unexcused absences, and when there’s not a conversation happening with the student, when students aren’t responding to outreach. We’ve heard from many faculty members and staff members who work with students, over the course of the pandemic, about how challenging it can be to get in touch with students. A lot of what our students are telling us is they want to respond to faculty, but sometimes the question that they need is, “How are you?” versus “When can I expect this assignment?” So really humanizing your interactions with them.

And then watching out for statements like, “I’m feeling really stressed or overwhelmed.” A student is explicitly telling you that they’re struggling with something during this time, this period, this season. And as a faculty member or staff member, you can support them by starting to have conversations with them about strategies that they’re using to take care of their mental health, whether they are informal help-seeking behaviors, such as talking with friends, having a support network, engaging in self-care activities, or if they’re moving into more formalized treatment processes, working with a clinician at the university counseling center, engaging with a university health and wellness coaching program, making more referrals to offices of support, so students can address the needs that are affecting their mental health.

So when school leaders were asked what they should be thinking about regarding student mental health in the short and long term after the pandemic, some things that have come up are supporting students academically, providing mental health resources, working on soft skills such as empathy, compassion, communication, understanding, and providing opportunities for social connection, such as allowing students to have a college experience like what they anticipated having.

One thing that we recommend is, continue to embed well-being when possible. So Sarah provided some examples of things that faculty can do, but across campus, there are multiple opportunities to embed well-being. One of the first things are looking at policy change institutionally. So how do we integrate well-being, specifically mental health, into our strategic plan, and what resources do we provide to students? One of the biggest things we can do is normalizing mental health issues by showing students that there’s an array of support, and then promoting resources supporting student mental health, as well as after-hour support, such as the National Suicide Prevention Lifeline, the Crisis Text Line. We know that institutions might be limited in everything that they can offer, but when we take a collective approach to address student mental health, we can think beyond our campus bubble into what are the other resources that we can incorporate to know that we’re supporting their mental health?

Other things that we can do on campus level but also that can be brought into classrooms and to group meetings are using guest lecture approaches to incorporate health and wellness topics. So there’s no need to be a mental health expert to support student mental health. And for many of our students, hearing from guest lecturers, whether it’s story sharing about a mental health treatment experience, whether it’s about self-care or meditation or mindfulness, these can help students start to integrate health and wellness into their routine, or maybe this is this place where the students decide to take the step to seek professional help.

Other ideas, and Sarah said this one, and I echo the same sentiment, of set deadlines for assignments and applications at times of days that support sleep. And so we can think of this in the classroom with assignments but also, as a staff member, if students are applying to leadership positions on campus or to jobs on campus, or what if we, as admissions professionals, started to think about when should applications be due for scholarships in financial aid in ways that supportive of student mental health. And other things that can be done and that maybe take a little less time, but just some planning, would be starting meetings with a mindful moment, taking a pause that many of us could use these days, whether it’s a breathing exercise or a short meditation. And we have plenty of two-minute mindfulness moments on the Active Minds’ website. Or assigning and requiring proactive wellness. This could be journaling. It could be trying a campus resource.

And then, as a faculty and staff member, it’s key to be aware of what services are offered on campus. Where can students go and how do students get there? And then incorporate any sort of mindfulness into programming. Again, this could be in long lectures or in the virtual world, taking breaks to support student mental health, engaging in breathing exercises, or even stretching, just incorporating mindfulness. And so students really start to see that mental health is a priority on campus, broadly, and in the classroom by their faculty members, and across campus, through engagement in student activities with other staff members.

And there are times, especially as we move through the pandemic, where you’ll probably notice that students are not performing in the same way that they were in the past or something’s going on. And so understanding where you are and being willing to check in with students can really help students feel cared about by campus and also has the potential to connect them to the services that they need in order to improve their mental health and their student outcome.

So when you do talk to a student, you want to be discreet. It might be pulling them aside after class, sending them an email, scheduling a separate time to meet via Zoom. But don’t promise confidentiality. And then focus on the things that you’ve noticed. Share observable behaviors. And when students are sharing with you, you want to engage in that active listening, giving them a space to talk, asking clarifying questions, and validating their experiences.

One way we do this at Active Minds is our program VAR, which stands for Validate, Appreciate, and Refer. And we use that to engage in active listening, express care and concern, and then, for many of us, referring students to the appropriate resources. As I said earlier, you don’t have to be a mental health expert to help improve student mental health. And this referral, connecting students to the appropriate resources, is key on campuses to make sure students are getting the support that they need. So just sharing a little bit more about VAR, Validate, Appreciate, and Refer. It’s three steps. Active Minds offers about 30-minute training on how to use it, but V’s all about validating. So letting the person who’s sharing with you know what their feeling’s OK and that you believe them. A is appreciate, letting them know they did the right thing by sharing and that you’re here to support them. So sometimes that sounds like, “Thank you for sharing that.”

And then refer, let them know that help’s available, and connect them to appropriate resources. It might be the counseling center. It might be an academic advisor. It might be a referral to your campus behavioral intervention team, sometimes known as the Cares Team, where the students would work with a dedicated case manager on whatever that they are struggling with. This program, while it was developed by students and our students use it, it can also be used broadly with coworkers, other faculty members, staff members on campus. Really, the tenets behind it focus on active listening.

And so when we get to that R, refer, there’s some things that you can do in advance to be fully prepared to make appropriate referrals. One is, keep a reference sheet with your mental health resources recommended by the campus counseling center handy, or at least be familiar with your campus counseling center website. If you’re concerned that a student might need to speak to a professional, ask them to speak to someone on campus. You can also walk with students to the counseling center. You can call the counseling center with the students in your office, and they can set up an appointment. You also can report your concern to the behavioral intervention team.

And then, at any point, your counseling center should be a resource for you. And for campuses without counseling centers, there are other resources supporting student health. Typically, when we think of the Dean of Students office, there’s going to be individuals there who can provide guidance to you to address student mental health concerns. One of the biggest things is you don’t have to just sit with it. There’s people on your campus who can help support student mental health, and you’re not doing this work alone. Active Minds have plenty of resources to help you dive deeper into action items that you can implement at a campus level changing campus policy, and also at individual levels, working to improve student mental health, on our website.

Some of the ones I’d really like to highlight are the transform your campus guides. So we have recommendations on how to add crisis center numbers to student ID cards. We provide a postvention guide for what happens following a campus suicide. We have guides to help elevate the voices of students from marginalized identities, our BIPOC students, our LGBT+ students, on ways that we can integrate them and support their unique mental health needs.

We also are grounded in our Active Minds chapter network. These chapters are focused on students, students leading and creating change on campus to improve mental health. And then two other resources, in February, our national conference is coming up. We bring together lots of speakers who are improving mental health on college campuses. And then, lastly, our Send Silence Packing program is one of our signature events on college campuses, where we bring backpacks to have a visual representation of those who’ve been lost to suicide. During the pandemic, like many places, we transitioned, and now we have a completely virtual exhibit to supplement that, called Behind the Backpacks, that goes deep into story sharing and now is accessible across the country. So I encourage you to examine any of the Active Minds resources for your campus. They’re all available at activeminds.org.

Salko: Thank you, Sarah and Amy, for your interesting insights and help with addressing these issues. We’ll pause here to address just a few of the questions that we’ve received from listeners. Sarah, I’m going to turn to you first. Obviously, the pandemic looms large in the background of everything we discussed. And we have a lot of teens who are now on campus that have spent the last part of their high school in pandemic mode. Do you think they’re going to have different mental health needs, either now or going forward? And then, I guess, also if you have any thoughts about students who are even younger than that that will be coming to campus in the near future, any thoughts on what we might expect to see?

Lipson: Yeah, so I think that’s a very, very important question and one that I have thought a lot about and that my colleagues have thought a lot about. It’s also a really challenging thing to ask a research team to predict in the future.

But one of the ways that we like to frame things is in terms of the opportunity. And so with students who spent, say, the last two years of their high school experience primarily online or started college and have been in a remote environment is that we have even more opportunities to orient them to campus life and to do so in really proactive ways to re-envision what we think about when we talk about first-year student orientation tends to be this whirlwind of information that comes at students all at one time. And I’ve increasingly been hearing campuses talk about orienting not just first-year students but second-year students as well and spreading that out over time and thinking about the ways that we can really be shaping what students think about in terms of campus life, bringing mental health into those conversations over time, rather than just spewing mental health information at them during orientation. And that’s a time when there’s just so much information coming at them to the point of, “What are we thinking about with students who will be coming to college in the future?”

We’ve actually just started, what we call, HMS2, our secondary school study of middle school and high school students, that my colleague Justin Heinze is leading. So we’re going to have much more data to be able to answer that question empirically, but I think the pandemic, I think school shootings, just the enormous amount of real existential threat and dread that many young people experience is one of the biggest differences when I think about my own college years to the students who are starting college now. I didn’t have to think about school shootings. They weren’t at the front of my mind. A pandemic was not a part of my college experience, and climate change was not front and center either.

So those just being examples, and I think to Amy’s point about really humanizing these conversations, I think there’s a part of what faculty and what staff can do on college campuses to make students realize that we are aware of these stressors in their lives. I heard students reflect on their first couple of classes after the pandemic, saying, “Suddenly, we were on Zoom and our teacher just jumped right into the same material that we’d been doing the week before as if nothing had happened.”

And that, in a way, really amplifies that sense of isolation, like, “Is everyone else able to just move forward, and I’m the only student sitting here in this major sense of anxiety?” When the reality is, of course you’re not the only student experiencing that. And if we can just pause and recognize the setting in which we’re trying to learn, I think that that goes a long way, but it’s a really important and complicated question and one that I think would take a little bit more time to really dive into in detail but one that I think we’ll be talking about for many years to come.

Salko: Great. Thank you, Sarah. And we look forward to hearing more about your research on the K-12 level in the future. Amy, I’m going to turn to you briefly. We have a question from someone saying they’re considering starting a peer support group and doing that through their counseling center. Do you have any dos and don’ts you might share through Active Minds and their experience with peer support?

Gatto: Yeah, great question. So Active Minds is less about peer support and more peer-to-peer conversation. What I would recommend when starting or considering any peer support groups is bringing students into the conversation. What do they want to hear? When would they meet? What does it look like to provide peer support? And then, from other levels at an institution, what level of staffing support and oversight do we have for this group? Do we train our peers in how to make appropriate referrals? When a student says something to a peer, are they promised confidentiality? Is it just privacy? So really looking at some of these nuances in a peer support program really what your campus is exploring and needing. Is it more peer to peer education to create awareness and resources? Is it peer coaching on other habits? Or working through things like study management, procrastination? Things that we know affect mental health and academic performance that can be provided by a peer while also continuing to bolster the mental health supports that we provide clinically in a confidential manner by a trained professional.

So I think there’s quite a bit of nuances when developing a peer support program. But looking to the outcomes, what are your goals of doing this? And is a peer support program the best program you would provide versus any other peer to peer or peer-based programs that can be provided by students to other students?

Salko:

Thank you. That’s a lot of helpful insights. And thank you to Sarah as well. We’ll move on now to the rest of the program.

Moving on to the next section. As many of us already know, there are legal cases involving student mental health issues that have come to the fore in the past few years, including some against UCLA, MIT, and Harvard. These are reminders that our communities expect us to do our best to protect our campus students. We know how hard most institutions and individual staff and faculty members already work to meet this growing demand that’s been discussed by Sarah and Amy. And so to discuss the institution’s legal obligations and best practices, let’s bring in Hannah Ross.

Hannah Ross: Hello, I’m Hannah Ross, and I’m going to talk about the legal framework that institutions of higher education operate within as we work to support students who are at high risk of harm, either to themselves or others. As many of you know, we are balancing two key legal interests, two key legal frameworks, as we try to support students, work with their families, think about what their academic needs are, and push toward keeping them safe. We are, first and foremost, thinking about our obligation not to discriminate against individuals with disabilities. That flows from federal and state statutes. We are also thinking about the messages we get from our communities that we need to take steps to protect students from harm, whether it’s harming themselves or engaging in some sort of violence towards someone else.

I’m going to start by talking about the civil rights laws that we work within, because they are central to our mission of creating inclusive access to the public good of education that all higher education institutions are trying to deliver. We want to do that in the most diverse, inclusive, equitable way that we can, as my have talked about on this webinar. Our non-discrimination laws in the United States flow both from the Rehabilitation Act starting in 1977, the Americans with Disabilities Act of 1990, and analogous state laws, some of which actually predate the federal laws. So you will need to look at your specific setting where you are located and the laws that apply to you. It is always good to be consulting with your lawyer at this point.

But in general, non-discrimination laws require that a public institution, institutions of higher education, make individualized assessments of a particular student’s facts and circumstances, and do that through an interactive process. A two-way street where we take information that the student offers, we consider it, we offer back our perspective, our expertise, and we ultimately try to reach reasonable accommodations. Reasonable accommodations is a term of art in the legal field. Again, this is a place where you want to consult with your particular lawyer. But in general, a reasonable accommodation means it is not an undue burden on the institution and it does not fundamentally alter the educational program that your institution offers. Those will be very fact-specific depending on your particular institution.

These civil rights laws are concurrently enforced by both the Department of Education Office for Civil Rights and the Department of Justice at the federal level. We have seen significant activity by the Department of Justice and the Department of Education over the last 10 years in situations where students were at risk of self-harm or harm to others. I’m going to talk about the Office for Civil Rights offering guidance, which reflect a series of resolution agreements that the office reached with individual institutions, and then I’m going to be briefly touch on DOJ’s settlement agreements that underscore what I think OCR has talked about more fully.

So OCR first articulated orally principles of best practices in January of 2018 for dealing with situations where students were at risk of self-harm, primarily self-harming students. And then those principles were published by the American Council on Education in Higher Ed Today, their blog. So you can find these principles in their full text at the link provided on this slide. But they really boil down to three core values that the Office for Civil Rights is expressing through these principles. You’re going to notice that this similar to the non-discrimination laws because they are, of course, enforcing the civil rights laws.

So first, students must always be treated as individuals. An institution may not make judgements based purely on a diagnosis or a speculation about what might happen in the future with a particular student. We have to look at the student as an individual and we have to get information about their particular facts and circumstances. Of course, we should not be thinking about stereotypes or generalizations about particular diagnoses, particular types of mental health issues.

Secondly, institutions should be in an interactive, good faith conversation with the student about what they need and what the institution’s expectations are. We’re going to come back to that idea of what does the institution expect for students to be able to flourish, in Sarah’s words.

Finally, institutions are permitted to take actions intended to protect a student’s safety, even if those actions are opposed by the student. And that can, as a last resort in rare cases, involve a separation from enrollment over the student’s objection. We’re going to talk in more detail about what procedurally you need to do if you are considering an involuntary separation from enrollment for a student.

If you have actually had a student go on a leave, whether voluntarily or involuntarily, you may have a practice or you may want to initiate a practice, of having individualized conditions for their continued enrollment, if they’re still enrolled, or their return from a departure. Again, those conditions must be individualized to the particular student and the circumstances that they are facing.

As just one example of a resolution between the Office for Civil Rights and Rutgers, I’ll share the case that was published by the Office for Civil Rights in April of 2018, a few months after they first articulated their best practices. It gives us a good understanding of how Rutgers uses a safety intervention policy permissibly without discriminating against students. So a student at Rutgers was hospitalized several times during the spring semester for risks of self-harm. The Threat Assessment and Safety Committee, which is the committee empowered under their policy, conducted a risk assessment, an individualized assessment of how this particular student was doing. Following that assessment, Rutgers concluded that the student could not safely and effectively participate in the educational program she was enrolled in, and they involuntarily withdrew her. That’s their language under their policy. They involuntarily withdrew her as a safety intervention.

The resolution agreement affirmed that Rutgers’ policy was permissible and Rutgers’ actions under that policy had been appropriate. They had done an individualized assessment, they had focused on the particular student in front of them, they had gotten information from her preferred provider and considered that information, and they had ultimately expressed their concern about her safety by telling her that she needed to withdraw to focus on her health. There were agreement terms that addressed how the student would make up work or convert her status to withdrawn. But the core of the resolution agreement was to approve that Rutgers’ involuntary action, the action that the student opposed, had been appropriate under its written, publicly available safety intervention policy.

Rutgers’ safety intervention policy remains public on their website as a public institution. That can be a helpful model for those who want to look at a policy that has been considered and approved by the Office for Civil Rights. I would note that it includes a number of procedural details that may be particular to Rutgers. The Office for Civil Rights did not require particular time frames or the participation of specific administrators. They simply focused on the process of getting information from the student and considering that information in an individualized way.

As I mentioned, because the Office for Civil Rights and the Department of Education shares jurisdiction over the civil rights laws with the Department of Justice, we also see enforcement activity by the Department of Justice. The Department of Justice reached settlements with, for example, the University of Tennessee Health Science Center and with Princeton during 2016. In both of those settlements, this particular language was repeated. It’s important to see the way that this connects to the best practices principles that have been articulated by the Department of Education. Because even though their language differs a little bit, in general, the Department of Education and the Department of Justice are both acting in consistent ways. They are endorsing that institutions may have legitimate safety requirements necessary for safe operations.

This is a regulatory provision that has been present in the ADA regulations from the beginning that says safety requirements must be based on actual risks, the particular situation that you’re looking at, and they may not be based on mere speculation, stereotypes, or generalizations about individuals with disabilities. But when schools like the University of Tennessee Health Science Center or Princeton had policies that focused on students being able to safely participate in their education, the Department of Justice has found those schools policies to be in compliance with the Americans with Disabilities Act. At the end of a 30-month investigation compliance review, looking at hundreds of different cases where Princeton worked with students that it considered at risk of self harm or harm to others, the Department of Justice concluded that there was no evidence of non-compliance in those cases.

Many of us watched with interest the announcement of a settlement between the Department of Justice and Brown University this summer. There were claims that Brown had discriminated against students who had taken mental health leaves and wanted to return from those leaves and were denied readmission at that time. Many of them were readmitted subsequently, but they had experienced being denied readmission at the first moment, perhaps, that they wanted to return. After a review of a number of cases, the Department of Justice and Brown reached a settlement. The Department of Justice concluded the students had been denied readmission after mental health leaves where a treating provider supported their return to Brown and the student had met other criteria for return.

In conversation with the Department of Justice, Brown revised its policy on readmission and published a new policy that the Department of Justice had approved, clarifying that it would evaluate students on an individual basis going forward, giving serious consideration to the treating providers’ recommendations, and that they would make readmission decisions on a rolling basis. There was, I think, a concern that Brown would receive requests for admission and act on a group of requests at once. That may make sense, depending on an institution’s academic calendar and the schedule for students to return to study. But they wanted to make sure that students were being treated as individuals and making decisions on a rolling basis was Brown’s solution for that.

It’s important to note that in this settlement, despite the concerns that the Department of Justice had about how Brown handled requests to return from leave, there was no suggestion of Brown counseling, encouraging, or even requiring students to take a leave, a mental health related leave or other, was inappropriate. That’s consistent with the other settlements that we just talked about, where it is permissible to communicate to a student that you are very concerned about their safety and their well-being and that you need them to focus on their health. It should be used only as a last resort. You’ll hear me say that over and over again as we talk about supporting students with needs.

As we think about whether students are flourishing in our educational environments, our often resident educational environments if we follow a traditional college model, we need to think about the expectations we set for our students. How do we communicate to them? Do we do it in the blitzkrieg of information called student orientation for first years? How do we communicate to them what they need to accomplish, not only academically, but how they take care of themselves? How do we communicate to parents about how students succeed at college and how they can support their well-being?

Increasingly, schools are turning to offering comprehensive well-being curricula to support young adults developing skills to manage stress, to develop study techniques, to learn how to engage in self-care, and when to reach out for additional resources. These are important tools that I want to encourage us to think about holistically across our campuses for exactly the reasons that we’ve heard from Sarah and Amy are so important. We have very high numbers of students on our campuses who are struggling. Struggling with anxiety, struggling with depression, considering suicide as a possible option.

We may not be able to hire enough counselors, even if we had all the money in the world. The shortages in the health care profession at this moment may make it difficult to hire counselors to treat 41% of our students or 60% of our students. And so we should be thinking about, as Amy said beautifully, “How do we embed well-being in not only our administrative or student life-oriented communications with our students, but also in our academic conversations with our students?” How do we offer the kinds of resources that Amy and Sarah have provided to our faculty to engage with, to adopt a syllabus statement? Thinking about what those expectations are for our students and communicating them intentionally is important.

It’s been wonderful to work with Sarah and Amy on this webinar because their research demonstrates this more powerfully than I can speak to. The isolation, uncertainty, and fear created by the global pandemic we have all lived through as adults has significantly heightened risks for our students. Especially for students that we are particularly interested in supporting at this moment in our nation’s history as we reckon with our history of systemic racism, our challenges around gender norms. We want to be able to create communities where all of our students belong, and right now we are not there.

This is a snapshot of some well-being resources that my institution, Middlebury College, offers to students. Wake Forest has done fantastic work in this area and is doing great research on how to support students’ well-being. So there are examples out there if this is something that your institution is interested in exploring.

Now I’m going to talk about the other side of our legal scales to balance, which is our obligation to protect students. Many college administrators, general counsels, and others have been watching the caselaw and Massachusetts where we’ve had the Nguyen v. MIT case, the Tang v. Harvard case. We’ve seen Doe v. RISD and Rosen v. the Regents of UCLA. All of these cases voicing an expectation that institutions need to work hard to protect our students.

I love this picture to illustrate how impactful any suicide is on a college campus. It comes from Active Minds’ project Send Silence Packing, one of the programs done with actual physical backpacks. I think it’s a tremendously powerful advocation of what those of us who live and work on college campuses know of the tremendous impact any student death has on a campus.

So let’s talk for a moment about what the Nguyen case means for those of us who are in Massachusetts where it is governing law, or potentially outside of Massachusetts, but looking at this as a case that may be influential in other jurisdictions. The Nguyen case held that a college must, has an obligation to, take reasonable measures to prevent a student’s death by suicide if the college has actual knowledge. And that is not imputed knowledge, not knowledge of you should have known, but actual knowledge of a prior suicide attempt while the student was enrolled or just prior to enrolling. Or the student has a concrete and specific plan to commit suicide, a stated plan or intention to commit suicide. As those of us who work closely with clinicians know, this is more than suicidal ideation, where a student might wonder or speculate a little bit about ending their life. This is the point at which a student actually makes a plan and then expresses that to someone. And one of the college’s staff members must have knowledge of that expressed plan or intention for this obligation to apply.

To understand the context for this obligation, it’s important to look at the facts of the Nguyen case. Although the holding said that it’s important for MIT to take steps to protect its students, it also concluded that MIT had done that, and there was no responsibility on the institution for the student’s death. Nguyen had reported to having difficulty with exams, and he was referred to MIT’s Disability Services office. He declined to seek accommodations from Disability Services, as any adult is entitled to do.

He was also referred to the counseling center, had a handful of appointments, and decided that they were useless and stated to MIT that he was making other arrangements for treatment. He did, in fact, the lawsuit found, make those other arrangements, and over the course of two years, saw a series of nine private counselors in the Boston area over the following years. At no point in that two-year period did any of those nine professionals identify him as an imminent suicide risk. This is all only available after the fact through litigation, but we do have a 2020 picture in this case. And his academic advisors understood that he had some medical issues, and they made various formal and informal accommodations for him in his academics.

So the court considered Nguyen’s death by suicide and the actions that MIT had taken based on the knowledge that MIT had, which was limited. And they concluded that a non-clinician, an administrator or a dean, would have an obligation to take reasonable measures if they had actual knowledge of a prior suicide attempt or a stated plan to die by suicide. And the reasonable measures that they should consider could include, and this is not an exhaustive list, but it could include initiating a suicide prevention protocol if the institution has one; arranging for clinical care, contingent on the student agreeing and participating voluntarily; and if care is refused, notifying the student’s emergency contacts.

This is not a checklist. This is not a comprehensive list of all of the reasonable measures to intervene that we might be able to take. But it is important to understand that these are only triggered at the moment that an institution has actual knowledge, and that these are reasonable — in and of themselves — to initiate a protocol, to arrange for clinical care and encourage the student to seek that care, and if care is refused, to notify the student’s emergency contact.

So when we look at the facts and circumstances in the Nguyen case, we can see that what the court was doing was balancing the different interests. The court concluded that the obligation to act in these narrow, limited circumstances is the appropriate way to respect the privacy and autonomy of adult students in most circumstances, because it relies in all but the emergency circumstances on the student’s own capacity and desire to seek help to address their mental health issues.

The court also recognized that non-clinicians cannot be expected to read a student’s mind to discern a suicidal intention that is not expressed by the student and made evident. So it’s important for higher education institutions to interact with our students as the legal adults that they are and rely in all but emergency circumstances on their own capacity to address their mental health issues, their own desire to get help, to be well, to thrive. And non-clinicians are not expected to be able to read the mind of the student and understand that they may be considering suicide if the student says nothing about that.

But when a student is talking about an intention to commit suicide or discloses that they have a past history of suicide attempts, that is when we need to start thinking: We are in an emergency situation where we need to intervene and take reasonable steps to try to get the student to help that they need to be safe.

And when one of those moments occurs, I want to talk to you about what is in your toolbox. What are the best practices for responding to these circumstances, appropriately balancing these two interests, non-discrimination and protecting against serious harm. I call this the institutional toolbox. You might use only one of these tools, or you might use all of them and see them as a continuum. It really depends on the situation and your institution’s resources and strategies for supporting students.

So, first and foremost, we have that broad-based, comprehensive, well-being kind of education that I talked about because we all engage in different levels of education and resource provision to students about their own health and wellness. In fact, as we come out of the pandemic and move toward the world where COVID is endemic and does not cause major disruptions in our society, we will have the opportunity, maybe, to repurpose some of the training and education time that we’ve spent on students needing to learn how to go get asymptomatic testing done or wear proper face coverings. We might be able to use some of that space to talk to them about other kinds of well-being and maintaining their own health in different ways.

But when we move on to a more serious kind of intervention, often the first step that we utilize is behavioral contracts, a kind of letter agreement that we write with students that says: “You agree that it’s really important that you take care of your health. We want you to follow these kinds of steps.” And I encourage you to make sure that those are focused on the student’s success, the student being able to thrive, being able to stay enrolled, which is usually one of their goals. Of course, if they are interested in taking some time off, we can counsel and support them down that path. But often a student wants to stay enrolled, and a behavioral contract can be an institutional tool to get clarity about what is necessary to maintain a basic level of safety.

Safety is at the heart of the residential and academic experiences offered by higher education institutions. And this is why that regulatory provision that I showed you from the Princeton Settlement Agreement is so important. We are permitted to have legitimate safety requirements.

So the question for us, as we think about any of the tools in the toolbox, is, “Can the students safely and effectively participate in the educational program at this time?” We know from the data that most students who have any kind of interruption because of a mental health challenge, most of those students return to study at their original institution and graduate from that institution, and they have great opportunities. So the period of time that they may have been on leave or out of active enrollment allowed them to gain better control over whatever they were struggling with and then return. And it’s important to communicate that expectation to our students, that we expect them to return. And our data shows that students do return and do well.

So behavioral contract terms and any required evaluation that you might want to move to, if that’s the next step at your institution, should be focused on whether the student can safely and effectively participate, and what are the resources and practices that will enable that. Sometimes what’s most important to a student is their extracurricular activities or their research that they’re doing for their concentration or their major. Take the time to listen to what’s important to the student to achieve. And then think about whether you can frame some of your safety concerns in terms that enable them to achieve what they are focused on. That will often be much more effective as an intervention, and it will really be focused on setting up conditions for success, which is what we want when we’re thinking about either a behavioral contract or a required evaluation.

And as a situation gets more and more concerning, we might start thinking about the other two tools in the toolbox — some kind of departure, voluntary or mandatory. In any situation where an evaluation or assessment is being conducted to understand where a student is on a spectrum of being able to be safe, I recommend to you that you think about the question you are asking a clinician is to make a recommendation about what level of treatment will reduce the risk so that the student can safely live and learn in your environment. This separates, for the clinician, questions about what the student is willing to engage in, what insurance might pay for, where there might be a bed and really asks the clinician for their best medical, psychological judgment about what is needed to reduce the risk.

The types of answers that are appropriate for this question should be things like the student can be supported well by weekly psychotherapy, or they would benefit from being in weekly psychotherapy and a group, or they need to take medication and also go through psychotherapy. When a clinician starts recommending a level of more robust treatment, the institution has to consider whether that level of treatment is compatible with full-time enrollment or a reduced course load enrollment or not compatible.

And I will say that I have seen cases where the clinical recommendation for the level of treatment was to receive intensive outpatient treatment, which is often done on a 9 to 5 schedule. That may be incompatible with a student regularly attending their scheduled classes. Partial hospitalization programs might be valuable. That might also be challenging for a student to attend classes and also fulfill the expectations of the therapy program. And finally, inpatient hospitalization, which is appropriate in rare cases, when students are serious threats to themselves or potentially threats to others. Inpatient hospitalization is almost always incompatible with the kind of liberal arts education that many colleges and universities are trying to provide.

Asking this question and being clear with the clinician that you use will help the institution, the deans or vice presidents of student affairs, make the decisions that they need to make about whether the student can safely and effectively be enrolled at this time. And so this question is relevant, whether you are thinking about a required evaluation, whether you are counseling a student to consider a voluntary leave and you want to understand what clinical care would really support them best, or whether you are reaching the point of thinking about an involuntary departure from campus.

As I said, there are rare circumstances, I would say in a student body of under 5,000, I typically only see a handful of cases like this in a year, but COVID has made everything extraordinary at this point. In a handful of cases in a year, an institution may need to consider involuntary separating a student from enrollment after doing a number of the kinds of steps that we’ve been talking about: Utilizing other tools in the toolbox, often counseling, encouraging a student to take a voluntary leave, pursuing a number of voluntary options is important to do before you reach the step of saying to a student, we may involuntarily separate you.

But if you have reached that step, if a student cannot safely participate in your educational program at the particular time, then you need to be following all of the best practices that have been articulated by the office for Civil Rights and thinking about the Department of Justice’s guidance, you need to be doing an individualized assessment. You need to be looking at that particular student, what modifications might allow that student to remain enrolled. This is the reasonable accommodation obligation. We are always obligated to be thinking about reasonable accommodations.

Keep in mind that COVID has added to our repertoire things that we have never considered in the past. And we will probably have discussions about whether it is reasonable or unreasonable for us to offer remote learning in circumstances we didn’t imagine before we all managed to switch to remote learning in March of 2020.

After we have considered and counseled about voluntary options, after we have done an individualized assessment and we have offered the student an opportunity to provide their own information, the opinion of their preferred treating provider, and given serious weight and consideration to that provider’s opinion, we may reach a point where we say the student’s health and safety is more important than their continued enrollment at this moment. They need this kind of treatment. Their clinical team is recommending inpatient hospitalization. And for most institutions, if a student is inpatient hospitalized, they are not able to fulfill your ordinary expectations of attending class, turning in work, being in residency, being on campus.

When you make that decision, the student needs to be notified of the decision and have an opportunity to appeal it. This should probably be a process that only takes a few days or a week or so to evaluate, and it can be done so that the student is required to leave, is removed from enrollment, and then the appeal takes place after they are off campus, perhaps home with their parents, if that’s what they’re doing during their time away. But they need to have that opportunity to challenge the decision. And we need to think about what the appropriate mechanism for review of our decision is.

When we think about students returning from leave, all of these same principles apply. We should still be asking the questions, “What does this particular student need to be safe on our campus? Has this particular student developed better coping mechanisms, better strategies for handling the challenges that they encountered? And are there conditions for this particular student, individualized to them, that will set them up for success and thriving on our campus?” That is always our goal.

Before we wrap up, I want to offer a practical tip and remind folks that parents can be an important part of the conversation about protecting a student’s safety. FERPA permits disclosure to parents in a health and safety emergency, which we would clearly be in if we were worried about the when case and our obligation to protect a student. It also permits disclosure if the student has consented, and we can require a student to consent to disclosures in this process of mandating an evaluation or considering whether we’re going to have a voluntary leave or an involuntary leave.

We can also share information with parents at our discretion if the student is a dependent for tax purposes. The majority of 18- to 22-year-old college students are traditionally dependents for tax purposes. If the information disclosed is not from an education record, we can also share under FERPA because it’s not an education record. And I would point out that personal observations by the person who has made the observation, whether they are a faculty member or a student life administrator who has perhaps seen a student who looks physically unwell, that information may not be an education record. That may simply be the individual staff member or faculty member’s personal knowledge. And that kind of information can be shared without consideration of FERPA when it’s not become an education record.

So FERPA has options and discretion for higher education institutions in situations where we are seriously concerned about the health and safety of our students. And I think parents can be a key part of the conversation in expressing how important the student’s safety is to us.

I want to give you three key takeaways. Again, it’s going to sound familiar. As we balance these different legal values, keep in mind that individualized assessments are group work. Get input from lots of different places and get it from the student and their family. Institutions are permitted to take actions that are focused on protecting students, even if students and their parents disagree. And we do that only as a last resort after we seek voluntary cooperation, pursue voluntary options, and we’re always thinking about the individual in front of us. Finally, I want to say that striking the balance here is an art, not a science. But I encourage you to think about the issue that our students’ lives are more important than their uninterrupted enrollment. And there are rare situations where, speaking in the strongest voice that the institution has, is the most important thing to tell the student that we need them to be safe.

Salko: Well, thank you very much for that, Hannah. It’s really, really important information that you’ve imparted to everyone listening. We’re going to pause here for brief question and answers about student mental health from the legal perspective. And the first is someone asked, “How do you address a risk assessment if a student is showing a threat to others on campus and not themselves?”

Ross: I think that’s a great question. And so much of my comments focused on students at risk of suicide, but the Rosen case in California is also a reminder that we need to protect students from harms that can come from other students. I think the way to think about this is very similar. Although the legal framework has the label of direct threat, we are really still thinking about safety, and we are looking for that moment when we know enough information that we believe that there may be a risk to another student on campus. And then we need to be acting. We need to be intervening. That may be when a CARE team or a BIT team becomes involved. That might be when you use threat assessment. It depends on your institutional resources and strategies, but those are moments to pay attention to and to figure out what are the resources? Do you use similar kinds of tools? Is your toolbox also behavioral contracts, required evaluations, consideration of taking a leave, taking some time away?

There may be similar kinds of considerations. You might have additional tools in your toolbox, such as separating people who are a potential target from the student who’s struggling with some perception that they’re at risk from that student or need to defend themselves against that other person. Those kinds of actions can sometimes significantly reduce the risk and where there’s some sort of tension or history between two students. I would say that that’s another option in the toolbox.

Salko: Great. Thank you. And then our last question is from someone who asks about the best way to work with students who have mental health concerns, if they want to study abroad. Maybe they have a history of mental health problems, or maybe you know that they’ve had suicidal ideation in the past. How do you help them prepare if they want to study abroad? Or should they study abroad, maybe?

Ross: I think it’s a similar analysis to the one that we’ve done, but of course, the resources that may be available in the other country may look very different from what’s available in the U.S. And so that has to weigh into the consideration of whether there are appropriate tools and resources to support the student in the other location.

So a student who has been actively engaged in psychotherapy and is seeing a provider once a week and going to a group and also taking medication may find that they can’t see anyone local, and there isn’t a group for their particular set of issues. And that should be considered as you evaluate whether a student can be safe.

In the context of international students and travel, I will also mention that there are circumstances where a student that you didn’t anticipate becomes unsafe while they’re abroad. We’re familiar, many of us, with the process for having our medical evacuation insurance come assist us with bringing that student back to their home. It’s also possible to use that tool, that insurance, the other direction. If they’re on your campus and they actually are an international student from another country, Global Rescue or ISOS, sometimes can help medically evacuate a student who’s really struggling to go home to their home country. Having that extra safety net in place for students when you send students abroad or have international students on your main campus is a valuable tool.

Salko: Great. Thank you, Hannah. That’s really helpful. I want to take this opportunity to sincerely thank Sarah, Amy, and Hannah for sharing their expertise, their experience, and most importantly, their insights and guidance on how we can support student mental health now and in the future. So I would like to again, say a sincere thank you. Thank all of you for listening and say that this concludes our webinar, and you may now disconnect.