Finding ways to identify – and help – troubled students

Universities across the country have been discussing issues of student mental health, privacy, and security in light of the shootings in April at Virginia Tech. PAW brought together four experts for a discussion: Katherine Newman, a professor of sociology and public affairs who has researched school shootings; Janet Dickerson, vice president for campus life; Daniel Silverman, executive director of University Health Services; and Peter McDonough, the University’s general counsel.

When there’s concern that a student could cause harm to himself or herself or to others, what happens?

Dickerson: One of the great advantages that Princeton has is that we have a very taut network of deans, directors of study, upperclass deans, faculty advisers, and other administrators and staff members who are very observant. So we think that we are in a relatively good place as far as being a small-enough campus and an intimate-enough campus so that students who are in trouble might be observed by people.

Silverman: There’s a great deal of formal structure in place ... Our first goal is to help the student, not necessarily to be disciplinary or intrusive, but it’s really about making sure that a student’s medical and mental health needs are being met. Dr. [John] Kolligian, director of counseling and psychological services, shares a watch list of students of concern throughout the academic year, and those students are discussed in conferences on a monthly basis with members of the deans and directors group, and [Associate Dean] Hilary Herbold. So hopefully the students stay on our radar and have been offered help.

We also instituted a policy of so-called mandated evaluation so that any responsible adult on campus can initiate a request for formal evaluation of a student in distress. This is done literally scores of times throughout the aca-demic year, and it helps us make a connection to a student and begin to assess the level of their risk. [Through the] Princeton Depression Awareness Program, for the past two years, we have trained roughly 500 adult first responders on campus to recognize early signs and symptoms of depression and other forms of emotional stress in students at Princeton, to learn how to begin a conversation with the student, and to do everything they can if they have a high level of concern about a student to bring it to the attention of the appropriate responsible adult on campus.

Finally, we’re screening students with a validated depression-screening tool when they come in for primary care medical visits. Again, the hope is that we’re finding additional ways to identify students at risk who might not self-refer to mental health services. One of the tragedies is that of the 1,500 students [nationwide] who take their own lives on a college campus each year, we know that a thousand of them have never had a single visit to their university health service or their college counseling center. Those are the students that keep us up at night, because we don’t know about them.

What about privacy and the parent/family role?

McDonough: I’ve been here at Princeton for 16 years, and for all 16 years, I’ve been periodically over at the McCosh Health Center talking to the counseling people about what would we rather deal with: a contention or claim of a privacy violation, or a death? That answer is very easy to arrive at in the abstract. It gets harder when the folks in the counseling center present a continuum — the anorexic student who is on her way to a real problematic physical place, but even physicians can disagree about how far along on that continuum she is. So at what stage do we “act?”

We respond to conduct, not condition. But do it in a nuanced way, as Danny [Silverman] has suggested, so that hopefully we are supportive and not imposing discipline or restrictions or adjustments to rights and responsibilities, but bringing someone to that place as close to voluntarily as possible. I think it’s fair to say that, being as respectful as we possibly can be to the various laws, at the end of the day, we’re going to try to preserve life.

Newman: As a faculty member, I am very well aware that we have an abundant set of resources for helping our students. But it’s not always clear, at least to those of us who are relatively new to the campus, that we actually know how to activate these resources. I think there is some productive work that we can do to raise awareness and to be cognizant of the many things that faculty have in their minds. ... I am very reassured to hear my colleagues say two things: first, that protecting a student’s life is very important, and [second, that] protecting the safety of students and faculty around them is critical, because in my mind that should be really quite paramount. Everything else — being sued, being hauled in front of a regulatory board — all of that pales by comparison.

As a researcher I am aware of the extraordinary tension that students in this age group are under. I do worry about that. I think we have an extremely gifted student body, and they come to us as hypercompetitive people who are accustomed to being at the top of their game, and then they’re thrown into a cauldron in which everyone else is also at the top of their game. As someone who has taught freshman seminars and seen them when they first arrive here, there is a bit of a shock that comes with the readjustment of the pecking order. ... It can produce in some people extreme vulnerability.

The research that I have done shows very clearly that people [like the perpetrator at Virginia Tech] are problem-solving, as horrible as that may sound, through shooting. The problem they’re trying to solve is to change the image that other people have of them. And the groundwork for that is laid over a fairly long period of time. ... In the cases I studied, there were lots of warning signals. They were difficult to interpret, though, because unless you have in your mind that a shooting like this could happen, what you hear are vague hints and comments that don’t necessarily add up, and they’re often coming from someone who is known to make comments like this all the time.

Dr. Silverman, you’ve been quoted as saying that more than 50 percent of Princeton students report getting severely depressed every year. How do you distinguish between warning signals that require intervention and not-so-serious ones?

Silverman: It is a fact that the students here are under inordinate stress. [But one myth] is that this is particular to elite institutions. We find that this is true across the United States at most college and university settings. The fact should also be stated that the vast majority of people, even with serious mental health problems, do not act out violently.

We’ve been struck by a dramatic increase in students arriving as freshmen with serious vulnerabilities or mental health problems. It’s been estimated that the number of students arriving who have been appropriately diagnosed and treated with a psychotropic medication has grown tenfold in the last 10 to 20 years. It’s not been well studied, but I believe that we do a better job of diagnosing children in middle school and high school with depression, anxiety disorders, OCD [obsessive-compulsive disorder], attention deficit. They came from families of privilege where they could access good mental health care, so they were on medication and sometimes had psychotherapeutic intervention for years, and they were able to start college on time with their own cohort. They are actually coming in droves to us. The students are seeking us out, and it is kind of a good news-bad news story, but also we are providing help to a lot of students.

Are students, in fact, reporting to an adult, “Hey, my friend is having a lot of trouble here?”

Dickerson: I think that students are quite alert to signs and symptoms and really do find ways to report these issues. I’d also say that we’ve had some good intuitions from parents who may have some concerns. The good news is that a parent might pick up some indication that a student is staying in her room, not following through in ways that she should, or not taking her medication.

Silverman: I get lots of calls from parents saying, “Go check on my child.” ... We also encourage students to contact us anonymously if they’re concerned enough about [another] student. We are concerned: The students here are fantastic, and very often they will try to sustain and pump up a friend, a roommate, or a teammate for far too long. And we try to convey the idea that we don’t want you to be psychotherapists or psychiatrists here — your responsibility is to get the student to professional help.

McDonough: One of the things that we haven’t talked about yet directly is the wonderful set of protections for what we would term “disabled” people. And I use that word only because of the commonly known Americans with Disabilities Act, and we have a New Jersey equivalent. It’s always seemed to me that one of the challenges on a college campus is that in many ways we almost celebrate eccentricities, and we have an extremely high tolerance for differences of conduct.

The law says that if someone as an employee or a student can perform the essential functions that are expected of them with reasonable accommodations, then they’re otherwise qualified to be a student [or] an employee. It makes it very hard to deal with that person, even when you’re talking about conduct, because we have wide tolerance for conduct. It’s very hard for us to say, “Geez, this person has acted strangely.” In a lot of our departments, somebody would say, “Yeah, and what’s the point?”

Newman: I think that knowing that makes faculty and other employees very hesitant about how aggressively they should bring forward conduct that makes them nervous. But my rule of thumb is, if it makes you nervous, you should tell someone, because your instincts are telling you something that someone else can help you calibrate. I think it’s also very important to recognize that — and we don’t like to talk about this very much — we are involved in inherently tension-creating situations. I grade people. I know that the grades I give them have an impact on what kind of future they can expect to have. In the aftermath of the Virginia Tech situation, I can tell you that dozens of faculty members have felt anxious about how far can this tension go before you should be worried about the student who’s upset about their grade.

Is there a point at which Princeton says, “We’re so concerned about you that if you don’t get treatment — even though you’re getting straight A’s — you have to leave this campus”?

Silverman: I can give you so many examples. The one that comes to mind is the student with a severe eating disorder that is beginning to cross over the line into medical emergency and urgency — a situation in which there is irreversible bone density loss — and yet the student is still passing all of her courses. You ask the parents to come in, and the parents say that she would do much worse at home, because there is so much more structure here, and she loves her courses. Of course she’s dealing with her courses the way she’s dealing with her body, which is in a terribly perfectionist, driven, and hypervigilant style of coping. And at the end, when asked the question of what’s the right thing to do, we say that we’re a residential college, not a residential treatment center. And in fact, we think that your current health behaviors are putting your long-term health and well-being at grave risk.

And we’ve had parents who have said that you [Princeton] entered into a contract to educate my daughter, and under the Americans with Disabilities Act, she’s meeting her academic requirements, and if she’s harming anyone, she’s harming herself. Although students with severe emotional distress often create an enormous stress and tension for what I refer to as the “surround.” They are having an impact on the residential life of the University, so we’re always balancing what’s in the best interest of the individual student and what’s in the best interest of creating and sustaining a healthy environment for the entire campus.

Dickerson: There is a range of responses that we can provide, from requiring a student to live off campus, to requiring a student to go home for a year and get medical treatment or psychiatric or psychological treatment before returning. Pete’s comment about our response to conduct, not condition, is very important here. But if there’s evidence of bad behavior, we can expel a student from school.

Do parents have a realistic expectation of what the University can and cannot do?

Dickerson: It depends. We have what we have been commonly calling “helicopter parents.” You name whatever the fastest, fiercest, most hovering helicopter is — we’ve got those kinds of parents here at Princeton. I think some people understand, and others really want the University to deal with the problems or challenges that they feel they can’t deal with at home.

Silverman: I do think that certainly in the area of university health and mental health, the pendulum of the in loco parentis concept has really swung back to the feeling that these are partially formed adults who still need a great deal from us.

We’ve done some fairly amazing things with keeping students in school by providing intensive treatment. But there’s a certain point, clinically, where these problems are so severe that the level of clinical intensity that is needed to treat the student makes it impossible to be a fully engaged student at Princeton. Very often [a] year off is very helpful. We often send them home with a very detailed bill of particulars of what is expected in terms of treatment, counseling, medication, exercise, support, and we also ask and receive written permission from the students and the parents to let us talk to their caregivers so that we follow them during the time that they’re away from Princeton. And we’ve had enormously successful returns of students to this campus.

McDonough: I want to emphasize that 99 percent of those times, it’s through a process of collaborative and voluntary conversations.

What’s important for parents to know about these issues as their children go off to college?

Newman: I think parents have to learn to trust their children and trust their instincts, and understand that the launching of the child into the world is always something that is going to be accompanied by a certain amount of anxiety. At the other end is a fully formed adult human being, which is what we’re all looking for colleges to help us produce. ... When a case like [Virginia Tech] happens, everyone feels shaken. Everyone feels like they can’t judge how safe an environment is. And it takes time for us to equilibrate and recognize that it’s been 40 years since something like this happened [on a college campus]. That doesn’t mean we take no lessons from it, but it should not mean that we overreact to it and see a shooter around every corner, because they are not there.

Dickerson: First of all, having communications with one’s student is very important, because if you are an observant parent and listen and are open to hearing what students have to say and are trustworthy, you can usually find out or know what is going on. And the other thing I would offer is that most campuses are very safe environments, but no place is completely safe. So for parents to have realistic expectations about what the community will be like is a very important thing.

Silverman: The message I would like them to share with their children is not to be afraid to ask for help. It takes a strong person to ask for or use help; it’s not a sign of failure or weakness or moral failure to look to the adults and various kinds of support services that are here for the very reason that people need them. Finally, encouraging students to understand that there is so much more that goes into a Princeton education than simply what goes on in the classroom. My hope is that students not only come out with a great font of knowledge after being at Princeton, but also a great deal of experiential enrichment.