College administrators around the country have Virginia Tech on their minds, and their worries could lead to a compounding of last spring's campus shooting, legal scholar Gary Pavela, M.A., J.D., told psychiatrists gathered at APA's September Components Meeting in Washington, D.C., last month.

"One of the great tragedies, which has not yet unfolded, would be for faculty members to take counsel of their fears and retreat from students," said Pavela, director of judicial programs at the University of Maryland. In fact, what is now needed is better cross-generational communication to counter the disconnection between students and the people who teach them and run their colleges.

Pavela spoke to a combined meeting of APA's Council on Psychiatry and Law and Committee on Judicial Action. Representatives of the Corresponding Committee on Mental Health on College and University Campuses, including its chair, Jerald Kay, M.D., also took part in the meeting.

The discussion, which focused on student suicide, was the starting point for possible APA actions to help colleges deal with difficult issues at the intersection of law and college mental health, said Paul Appelbaum, M.D., chair of the council. Eventually, the process might lead to research documents, guidelines, or position papers to help college administrators, health providers, and attorneys connect better with students and prevent suicide and other tragedies.

Despite some high-profile cases, the suicide rate among college students is roughly half that of an age-matched community sample, wrote Appelbaum in the July 2006 Psychiatric Services. Perhaps 10 percent of college students surveyed in two studies said that they had though about suicide, 1.5 percent said they had attempted it, but only 0.1 percent had actually completed suicide.

Some recent court cases, wrote Appelbaum, "have left many college administrators fearful of their liability should any suicide occur on campus."

However, too often the response to a student in crisis has been harsh and punitive. Students have been expelled from their universities after voluntarily seeking help, said another speaker, Karen Bower, J.D., senior staff attorney at the Bazelon Center for Mental Health Law in Washington, D.C." Schools artificially try to wedge behavior onto a disciplinary mode."

Even if a student remains on campus and enters treatment, some schools require that the counselor report session attendance and content to the dean or other administrator, a violation of confidentiality that can leave students feeling coerced into therapy, betrayed by the counseling center, and hesitant to get any treatment, she said.

"There are a lot of indications that colleges want students with mental illnesses to just go away and not come back until they're 'cured,'" she said.

Kicking students out of school may be the worst possible alternative, especially for a student who wants help, she continued. Being at college offers structure and a social network that, combined with treatment, can be conducive for recovery.

Pavela recommended that college administrators take several steps to better address students' needs and at the same time reduce their liability.

"It is medically, legally, and therapeutically right to hold people accountable for their actions, especially with resistant students," said Pavela. "It helps students see the need for help. I tell administrators to hold them accountable for threatening words or gestures but not to leap immediately to expelling them."

For a start, he said, administrators should talk to high school principals, who by now are familiar with post-Columbine research and legislation on addressing and preventing school violence.

Also, college officials should not wait passively for students to walk into the counseling or health center. Staff in those offices must reach out to students.

Administrators should move from trying to profile suicidal or dangerous students to a "threat assessment" model of intervention, in which all interested parties discuss the students' actions and behavior. Preparations for times of crisis must begin long before, involving faculty, administrators, counselors, students, and sometimes the police.

"You need a candid conversation on campus about confidentiality and what it means, and you need to get students involved in that conversation, he said.

Faculty members need help in understanding how to neither overreact nor underreact when they spot students engaging in troublesome behavior or making a suicide reference in a paper, and guide them to the counseling center.

He also believes in a role for an administrative (but not disciplinary) process that induces treatment by holding students with suspected mental health problems responsible for disruptive, objective actions.

Some large universities are already looking at creative ways to keep students enrolled while they are addressing the students' problems, he said.

Small colleges may have an advantage because they can get to know their students better, work with them, and bring them to point where they are willing to tell their parents about their problems, said Bower. "These institutions want to support students, not turn them in."

Pavela suggested that colleges that do their utmost to keep depressed or otherwise mentally ill students in school can reap another benefit.

"I would argue for this approach in the context of diversity, analogously with racial diversity," he said. "I'd like to see the discussion shift from the problem posed by students with mental illness to what they can bring to campus and what they can teach others. They can teach themselves and us how to learn from and recover from adversity."▪