On a chilly afternoon in the fall of 2005, "Jane," a 19-year-old junior at Brown University, sat on her dorm bed and decided to follow through with her plan to kill herself. In despair over a psychology paper she couldn't finish, and unable to shake her choking depression, she swallowed, two by two, the 120 pills she had stashed -- the antidepressant Lexapro, Tylenol and sleep aids. When she failed to pass out, she got nervous and asked a friend to take her to the hospital, where doctors gave her charcoal to soak up the drugs.
Somehow, the school learned what Jane had done. So when she returned to campus a week later, a Brown dean and a campus psychologist called her into a meeting with this message: "We need to talk about where you're going from here." They meant it literally -- the school would encourage her to take a leave of absence.
Overwhelmed by a rise of troubled students in the past several years, colleges are dealing with mental health issues with renewed intensity. A 2006 survey found that more than 9 percent of college students seriously contemplated suicide in the previous year. Further, college researchers estimate that more than 1,000 kill themselves each year, making it the second leading cause of death among college-age men and women (after auto accidents). Many colleges are responding by beefing up counseling centers, offering free therapy sessions and forming support groups on everything from body image to stress management. But they're bewildered about what to do with students like Jane who quietly collect pills and attempt suicide under their noses. Increasingly, they are worried about their own institutional liabilities and policies regarding troubled students.
The main reason is that in 2002, the parents of MIT student Elizabeth Shin filed a $27 million wrongful-death lawsuit against the school after their daughter set herself on fire in her dorm room two years earlier. They claimed that the school's counseling services didn't adequately respond to her depression. Last spring, MIT settled for an undisclosed sum. Similarly, a Virginia federal court recently found that Ferrum College had a legal "duty of care" to a student who hanged himself on campus after his girlfriend showed a letter in which he threatened suicide to a resident assistant and other college officials.
To try to prevent suicides, colleges are taking the usual precautionary steps: controlling access to prescription drugs at medical schools, keeping track of lethal substances like cyanide at chemistry labs, blocking rooftop access to tall buildings. In 2003, NYU installed plastic windows on open-air crosswalks in Bobst Library after two students jumped onto the marble floor below. College counseling centers are also training dorm supervisors and campus staff to recognize the warning signs of suicidal behavior.
But universities are taking more drastic -- and controversial -- measures to head off legal trouble. Many schools are drafting or enforcing rigid withdrawal policies that could boot mentally ill students off campus at the first sign of worrisome behavior. Others, such as the University of Illinois and the University of Washington, are requiring students who even talk about suicide to meet with counselors or take medical leave. (In 2004, students from NYU and Columbia accused the schools of forcing them to take leave for seeking treatment for depression.) Some colleges, fearing malpractice lawsuits, have considered eliminating counseling services altogether.
The idea that universities are somehow responsible if a student takes his or her own life may seem preposterous -- akin to suggesting they're to blame for "freshman 15" weight gain or too many tequila shooters. In fact, in the '60s and '70s, courts declared that colleges were no longer in loco parentis, or surrogate parents. Rather, 18-year-olds were to be considered full-fledged adults who were responsible for their own behavior. That's news, however, to some of the current generation of "helicopter" parents, who expect colleges to be involved in nearly every aspect of their children's well-being. "When anything goes awry on campus, parents will sue," says Sheldon Steinbach, a higher education attorney with Dow Lohnes, in Washington, D.C.
So just what is a school's legal obligation to try to prevent student suicide? That's still up for debate, say legal experts. But one thing is clear: If a student behaves in a troublesome way that threatens the student or others, the university must respond, says Steinbach. "To have knowledge about a potential danger to the community and fail to act is opening an invitation to liability," he says. But short of referring students to counseling, there's no established protocol on what that response should be. Should schools call students' parents? Should counselors alert administrators about a despondent student? What about teachers or dorm staff?
"This is something that every university mental health center is really grappling with," says Todd Sevig, director of Counseling and Psychological Services at the University of Michigan. Schools must navigate confusing privacy laws that vary by state. "Some places notify parents when a student is in trouble and some only in extreme circumstances. A whole bunch are in between," he says.
Colleges have no choice but putting suicide on their radar. A recent report found that 10 percent of students sought counseling for psychological problems, and some 40 percent of those students had severe problems -- 8 percent of whom needed extensive help to stay in school, says Robert Gallagher, former director of the counseling center at the University of Pittsburgh, who has tracked college mental health trends for the past 25 years.
Despite the surge of troubled students, however, the actual number of suicides doesn't appear to be increasing. (The most recent data, from 2004, shows that the rate of suicide for young adults ages 20 to 24 has stayed consistent over the past decade.) Observers credit everything from increased use of antidepressant drugs, earlier diagnoses of mental problems and less stigma for those seeking treatment to better and more services at college counseling centers.
Expanding services is relatively easy, though, compared with the task of trying to anticipate who will try to hurt themselves. Harvard relies on one indicator: Research shows that nearly 80 percent of successful suicides occur within a week of the person's being hospitalized, so the school now screens all students when they leave the hospital and requires that they have a treatment plan before they're allowed back in residence. The university has an involuntary leave policy that can be invoked if an administrator feels that a student is a danger to himself or herself or disruptive to community, but it has been used only once in the past 10 years, says Richard Kadison, chief of the campus Mental Health Service. "Most of the time, students recognize they need to take time off," he says.
The problem is that suicidal students often don't seek help. That's why Paul Joffe, chairman of the suicide prevention team at the University of Illinois, favors a more paternalistic approach known as "mandated counseling" that he claims has cut his school's suicide rate in half to 1.4 students a year. When Joffe started the program in 1982, he was astonished that of 19 suicides in the previous eight years, only one student had seen a counselor.
The University of Illinois' rigid policy requires that any student who threatens or attempts suicide attend four sessions with a counselor or risk being withdrawn from the university. "We have standards you must adhere to, such as paying library fines, maintaining a GPA, not harming others and being able to take care of yourself," Joffe explains. "A suicide threat or attempt is a breach of contract. We're saying, 'If you want to be a member of this community, then you need to take suicide off the table as an option.'"
The approach sounds heartless, but Joffe says the controversial program works because it challenges suicidal students' assumptions that they have a right to end their lives. "I tell them, 'You think you're in charge, but you live in a community,'" he says. Of the roughly 2,000 students who have undergone mandatory counseling at Illinois, none has committed suicide to Joffe's knowledge, and the school has withdrawn only 1 percent of them. Other schools are taking notice: Joffe estimates that 20 other colleges and universities have since adopted the model.
Critics say schools risk overstepping their bounds with such programs. "You can't mandate treatment unless people show several criteria, such as being a danger to oneself or others," says Gerald Amada, former mental health co-director of the City College of San Francisco. He agrees that troubled students need to be reminded that they're part of a community. He has lectured at more than 100 schools, encouraging them to make use of their disciplinary system, which forbids disruptive behavior. After watching how upset students became around classmates who talked incessantly of death or cut their arms in self-mutilation, Amada concluded that a student's suicidal behavior unavoidably disturbs others. "Most times if you have highly suicidal students, you'll find people around them ripped apart," says Amada.
Schools, he says, should inform suicidal students that they're hurting others and warn them that they'll lose their academic standing or campus housing if they continue their behavior. That message can snap them out of a suicidal mind-set. "It can be very psychologically awakening," Amada says. "It disrupts the student's narcissism."
Such harsh policies aim to protect schools legally, but they may not actually be in their best interests, warns Gary Pavela, author of "Questions and Answers on College Student Suicide: A Law and Policy Perspective," who estimates that hundreds of schools rewrote medical withdrawal statements in reaction to the Shin case. "They were making it as easy as possible to remove someone," he says. "They were asking staff members to promptly report individuals at risk for suicide in order to remove them. Counselors feel under constant pressure to divulge confidential information. It's not prudent risk management."
Pavela says administrators are overreacting, especially given that other courts have maintained that schools aren't responsible for student suicidal behavior. A Pennsylvania court ruled last year that Allegheny College was not liable for a student hanging death in 2002. In a case involving a student death at the University of Iowa, the state Supreme Court found that college administrators had no duty to prevent suicide.
Schools could be accused of violating the Americans With Disabilities Act, which protects students with mental impairments. "It's really kind of crazy that many college administrators focused on a lower court ruling in one state, while they are blissfully ignorant of federal requirements that do apply nationwide," Pavela says, adding that about half the schools he has consulted do not have ADA grievance procedures. "They risk losing federal funding. It's really stupid."
They also risk lawsuits from students who feel they were unfairly removed. Jordan Nott sued George Washington University after the school barred him from campus because he checked himself into a hospital with depression. He had been haunted by the recent suicide of a fellow student, who jumped out of his dorm window while Nott and two other friends were trying to open his door. According to court records, the university told Nott that his "endangering behavior" violated the student code of conduct and he was given a choice of taking medical leave or facing expulsion. If he showed up at school, he could be arrested as a trespasser. Nott withdrew from the school and last fall reached an undisclosed settlement.
In another case, Hunter College agreed to pay $165,000 to a student who sued after her suicide attempt resulted in her removal from school housing. Both schools have agreed to review their policies.
Karen Bower, a lawyer with the Bazelon Center for Mental Health Law, who helped litigate the Hunter case and represented Nott, is also bringing a suit on behalf of a student at a New England boarding school who was put on involuntary leave after being hospitalized with depression. She says all three schools' responses are violations of the ADA, which requires individual assessments of each student, with input from a mental health provider. The Bazelon Center is currently drafting ADA-compliant guidelines for schools to follow.
"We've seen more schools implementing these policies, and I'm hoping that our lawsuits will stop that trend," says Bower, explaining that school policies unnecessarily stigmatize students and may deter them from seeking help. Amada, the former college mental health co-director, agrees. "You can't discipline someone for being depressed," he says. Going the disciplinary route makes withdrawal about students' disruptive behaviors -- not their psychological ills.
At least four students have made similar complaints to the U.S. Department of Education's Office for Civil Rights, claiming they were discriminated against because of a mental disability. The office ruled that two students had legitimate claims; their colleges refunded their tuition and changed their policies. In one of the cases, OCR found that Marietta College in Ohio discriminated when it withdrew a male freshman in 2004 after his counselor told an administrator about previous suicide attempts. OCR said a school cannot act based on a "slightly increased, speculative or remote risk."
Lawmakers are now getting involved. In one of the first such measures of its kind, Virginia last month passed legislation preventing public universities from expelling or punishing students for attempting suicide or seeking treatment for suicidal thoughts or behaviors.
It's unclear how many universities have withdrawn students on the grounds that they may be suicidal, but Bower says she has recently spoken with several dozen students or their parents in similar situations and knows of others suspended from campus housing who are now living in hotels, homeless shelters or even in cars.
Liability questions aside, what is best for students? Dr. Morton Silverman of the Jed Foundation, a nonprofit organization that focuses on college suicide prevention, says administrators may sometimes be wise to advocate a leave so students can get a break from academic stress and focus on getting better.
For Juliana of Johns Hopkins University, that was just the advice she needed. When Juliana told her therapist that she was thinking of overdosing on pills during her freshman year, both agreed she should take time off. Back in Virginia after a stay in the hospital, she basked in the cocoon of home. Her mom made her favorite French toast in the mornings and they watched "Law and Order" reruns together. Doctors tinkered with her drug regimen, and when she felt up to it, she picked up some babysitting gigs and earned her driver's license. "By the time school started again, I was feeling good and was anxious to get back. I missed dorm life and being with my friends," Juliana says. She promised school officials that she would continue therapy.
The difficulty for school officials is determining whether what's healing for some students is harmful for others -- especially if home is full of dysfunctional family members. College may be a pressure cooker, but it's also a setting that provides a lot of structure, support, camaraderie and access to healthcare, says Silverman. "Removing [students] from that supportive environment may be detrimental to their ability to recover," he says, adding that schools should try to keep students enrolled whenever possible. "Students come to college to be students. Removing that identity has its own set of problems -- in one's self-esteem, sense of the future and identification with the institution and what it stands for."
When Brown University suggested that Jane go back home, she protested, explaining that her depression likely would get worse. She complained that her overprotective parents tried to control what she did, wouldn't let her drive and made her feel suffocated. The administration listened and welcomed her back as long as she enrolled in counseling. Last spring, Jane had the best semester yet. She aced all her classes and hit it off with a new therapist. She's on track to graduate next year.