Rachel Glick, M.D., and David Fassler, M.D., are co-chairs of APA's Task
Force on College Mental Health.
"Life sucks and I want to kill my.... " That was the slightly
ambiguous message a college student left on the blackboard of a classroom at a
midsize, private university in New Jersey.
An alarmed professor who saw the message alerted the university's director
of psychological services, who was able to track down and confront the student
about the statement on the blackboard.
In this case, it turned out to be a bit of youthful, exhibitionist
anger—not true suicidal intent, said Franca Mancini, Ph.D., director of
counseling and psychological counseling at Monmouth University in West Long
In other instances, however, ominous behavior and outright suicidal actions
by students at the campus have been the signal for a campuswide
interdisciplinary intervention team to go into action.
"We try to spread a net around the student without becoming a
therapeutic community," Mancini told Psychiatric News."
We have a lot of collaboration among the different offices and
departments on campus, especially with residential life and student services.
We also have a line of communication with faculty. We try to cover the campus
and let people know to inform us about suicidal behavior or intent."
Students who are deemed to be truly suicidal are taken to the psychiatric
screening center at the local hospital. After appropriate assessment, they may
be hospitalized by the treating professionals there or discharged if there is
no imminent risk.
"Either way, we inform them that if they are residents [in campus
housing], they are not going to return to residency until they receive
clearance from the hospital," Mancini said. "They must bring
discharge plans and also agree to the recommended follow-up care."
Nonresident students who are transported to the hospital go through a
similar "clearance" procedure through her office, she said.
"Those nonresidents who go to the hospital for an emergency
psychiatric screening are informed of our services through the emergency
psychiatric service staff," Mancini said. "Many choose to be
referred back to the university counseling center, and in fact the hospital
will call to schedule an appointment while the student is still there. They
share the discharge recommendations, and we work on a treatment plan if it is
appropriate for the student to be seen through our counseling
Almost always, students accept the conditions, and almost always they come
back to school if they are willing to comply with the recommended
"We've never had to forcibly take someone to the hospital," she
said. "And we have not reached a point where we have had to say a
student can't come back to school."
The system at Monmouth University is typical of the kind of zero-tolerance
response a number of colleges and universities are adopting to cope with
student suicide threats or attempts and other forms of self-harm. It is a
phenomenon that engages a host of thorny issues involving the safety and care
of the student, protection of other students and the integrity of the
educational environment, confidentiality of medical and psychiatric records,
and the school's liability.
In April a suit against the Massachusetts Institute of Technology (MIT) was
settled out of court regarding the April 2000 suicide of Elizabeth Shin, a
student there. The student's family agreed not to proceed with the suit
against four MIT psychiatrists; another suit—this one against the
university— had been dismissed in June 2005.
As part of the settlement, the amount of the payment must be kept
confidential at the request of the Shin family, according to a university
Also recently at George Washington University, Jordan Nott, a former
student there, filed suit against the school when it dismissed him after he
sought hospitalization for depression and suicidal thoughts
In general, psychiatric leaders—as well as university administrators
and campus mental health professionals—agreed that proper treatment on
campus of severely depressed or suicidal students is ideal and that dismissal
from school is to be avoided, certainly if the student is seeking
"Students should not be suspended or forced to withdraw from school
for seeking psychiatric services or other mental health-related
treatment," said David Fassler, M.D., co-chair of APA's Task Force on
College Mental Health. "Such policies are clearly discriminatory. They
also discourage students from asking for help."
Yet as Mancini suggested, schools cannot allow themselves to become"
therapeutic communities," and administrators do have a
responsibility to the larger student body and the university community.
"I would have grave concerns if there really was a case of a student
who asked for help but who was not disruptive and was then put on mandatory
leave without due process," said Rachel Glick, M.D., co-chair with
Fassler of the APA task force. "It's clear that universities can take
disciplinary action when behaviors are disruptive, but they can't take action
when the person is ill and the behavior is not disruptive—that's
protected under the Americans With Disabilities Act."
But Glick said college and university administrators feel a need to protect
themselves and the learning community they are shepherding from what might be
"Those of us who are clinicians may not consider a suicide attempt
disruptive, but if it happens in a dorm and there is blood all over a bathroom
floor, it's disruptive to some degree," she said.
Though suicides among young people in college often make headlines, a
number of studies have established that the rate of suicide is lower than that
of young adults in the general population, according to Paul Joffe, Ph.D.,
director of the suicide prevention team at the University of Illinois.
For instance, a study reported in the fall 1997 Suicide and Life
Threatening Behavior, found that the overall student suicide rate of
7.5/100,000 in the "Big Ten" schools was one-half of the computed
national suicide rate (15.0/100,000) for a matched sample by age, gender, and
race. (The Big Ten are the University of Illinois, University of Minnesota,
Northwestern University, Purdue University, University of Wisconsin, Indiana
University, University of Iowa, Ohio State University, University of Michigan,
Michigan State University, and Pennsylvania State University).
But even if suicide is not more likely to occur on a college campus than
anywhere else, it does seem to be an ideal place to try to prevent it.
Approximately 1,100 young adults kill themselves in the nation's colleges and
universities every year, according to Joffe.
Joffe said that prior to 1984, the University of Illinois had a policy of"
invite and encourage" regarding reports of suicidal behavior."
We would contact a student who was reported and tell that student we'd
like for him or her to come in to the counseling center," he said."
What we found was an enormous amount of resistance along the lines of
`Who are you to call me in?'
"We were faced with a practical and ethical conundrum," he
said. "Resistance to treatment could lead to fatalities, but what about
the right of students to make their own choices? But then we began to think
about whether someone who was ready to make a choice to kill themselves over a
romantic disappointment would rationally make a choice to seek mental health
So in fall 1984, the university instituted a formal program requiring any
student who threatened or attempted suicide to attend four sessions of
professional assessment. The consequences for failing to comply with the
program included mandatory withdrawal from the university.
Since then, reports on 2,017 suicide incidents have been submitted to the
university suicide prevention team. The rate of suicide decreased from 6.91
per 100,000 enrolled students during the eight years before the program
started to 3.78 in the 21 years since then.
This represents a reduction in suicides of 45.3 percent at the university,
while suicide rates were stable both nationally and among peer institutions
within the Big Ten, Joffe said.
Since the program's inception at the University of Illinois, it has become
a model for more than a few institutions across the country. Some of these
include Case Western Reserve University, University of South Dakota, the
University of Puget Sound, and the University of Washington, Seattle.
"Our approach to suicidal students is very proactive and is about
retaining students, not dismissing them, so they can stay in school and finish
their degree," said Houston Dougharty, associate dean for student
services at the University of Puget Sound. "We have taken the Joffe
model from the University of Illinois and adapted it in several ways to meet
the needs of a small liberal arts college."
Members of the student affairs staff at the university are required to
complete a Suicide Incident Report (SIR) when they learn that a student has
commented about suicide, has made suicide threats, has attempted suicide, or
has engaged in intentional self-harming behaviors.
The data from a completed SIR are evaluated by the Suicide Prevention Team,
a committee composed of two staff members and one faculty member. If this
committee determines there is sound basis for concern about a student's
suicidal or self-harming behaviors, the committee may require the student to
participate in four sessions of psychological assessment with a member of the
campus counseling staff or with a provider off campus. As at the University of
Illinois, the program has demonstrated success.
"We have been overwhelmed by the receptivity of students to mandated
assessment," Dougharty told Psychiatric News. "Typically,
they are relieved that they can do something about it. Not only do we want
students to stay alive and healthy, but we want them to finish their