The College Catch 22

By Caitlin McCabe

Some days, Priya Balagopal couldn’t get out of bed.

It was her senior year at UNC-Chapel Hill, and things seemed to be going well: She had good grades and good friends. She was involved. She was writing a senior honors thesis – her dream since freshman year. It was going to be published.

But she couldn’t shake the depression that began to creep back into her life. She had managed depression and anxiety since high school, but a sexual assault during her junior year of college left her reeling. Slowly, she felt herself losing control. Responding to texts and emails became difficult; going to class and finishing assignments was nearly impossible. When she asked for help, she was denied. “You can’t have an unfair advantage over other students,” a professor told her.

In February 2013, as feelings of depression and isolation became all-consuming, Balagopal took 8,000 milligrams of her prescribed antidepressant medication in an attempt to overdose.

The minutes and days that followed were a blur, she said. As Balagopal recounts the story, she was rushed to UNC Hospitals, transferred from floor to floor and communicated with only briefly about her condition. She was stripped of her clothing and belongings – including her phone and basic toiletries – and spent six days under the watchful eye of a “sitter,” a nursing assistant who was required to be with her at all times.

“I never had a single moment of privacy, even in the bathroom,” Balagopal said.

When she smiled at doctors, she was told her condition was not something to smile about, she said. When her friends brought her a balloon to wish her a quick recovery, it was taken from her, she said, at risk she could use the string to harm herself.

According to the UNC’s Department of Emergency Medicine’s 2009 procedures manual, policies such as surveillance by a nursing assistant and removal of clothing are standard for patients who are suicidal and involuntarily committed to the hospital.

Balagopal’s experience in dealing with mental health at UNC highlights a growing issue at universities across the nation: How students who pose a threat to themselves are handled on campus.

Balagopal said her experience was similar to one of a prisoner or a criminal, as if she were being punished for thoughts of self-injury. Those feelings were only exacerbated by how her case was handled by the University, she said.

The University, while unable to comment on specific cases, said it makes all decisions regarding mental health based on what is safest and most supportive for a student.

“We want to get you connected with whatever support, services, resources or treatment we can,” said Desirée Rieckenberg, UNC’s senior associate dean of students.

When Balagopal was released from UNC Hospitals six days later, she was required to meet with a representative from UNC’s Emergency Evaluation and Action Committee before she could return to class. The committee serves to evaluate students and situations that might pose a threat to campus.

Immediately, she said, she was encouraged to withdraw.

“There was all this pressure of that’s what I was supposed to do,” Balagopal said. “I kept saying I just wanted to graduate and get out of here – I only had a couple of months left. But I just kept getting pushed to withdraw, as if that were so easy and idealistic.”

“I’m on a tuition-grant from my high school. I’m a National Merit Scholar,” she said. “I could lose them if I withdraw. How can you tell me this is the best thing for me if I’m going to put myself and my family through unimaginable financial burden?”

Balagopal said she emphasized that she wanted to stay, but was continually told by administrators and counselors that leaving would be the best thing for her. Ultimately, unsure of how to proceed, she voluntarily withdrew from UNC just months before graduation.

Some students who have interacted with UNC regarding their mental health conditions say they were treated as a liability – sent away from campus for counseling and highly encouraged, even threatened, to withdraw. University administrators and counselors say they make every effort to keep students on campus, only encouraging withdrawal if students are at risk of ruining their grades, or if a more stable environment can be provided at home.

For years, colleges and universities interpreted federal regulations to mean they could remove students who were dangerous to themselves. UNC was among the schools that imposed involuntary withdrawal on students, but the administration says that hasn’t happened in more than a year. UNC could not provide data for how often mandatory withdrawal was used beyond the past year.

Recent updates to those federal regulations suggest schools should move away from involuntary withdrawal. But the changes are confusing and vague, experts say, making it difficult for schools to craft policies that are supportive for students and self-protective from legal liability if a student dies by self-harm while enrolled.

Colleges and universities seek balance between competing interests: autonomy versus intervention, confidentiality versus disclosure. Ultimately, schools want policies that encourage students to seek help for mental health conditions.

“Schools are in a really tough spot,” said Victor Schwartz, medical director for The Jed Foundation, a nonprofit organization devoted to addressing mental health and suicide in college. “They’re caught between these seemingly conflicting demands – to take care of their students and to not have them in school because of safety, liability or bad press.”

“It all comes down to using sensible judgment,” Schwartz said.

Students whose behavior is threatening to themselves magnify the already difficult challenges schools face when handling mental health on campus.

Self-threatening behaviors are not formally defined, but Rieckenberg, UNC’s senior associate dean of students and chairwoman of the Emergency Evaluation and Action Committee, said they include suicidal ideation, eating disorders, cutting, burning and mutilation. UNC evaluates each case individually, Rieckenberg said.

These behaviors have become increasingly prevalent on campuses in recent years.

Suicide is the second leading cause of death among college students, according to the National Alliance on Mental Illness, trailing only motor vehicle accidents. It’s estimated that more than 1,100 college students will die by suicide this year, according to Active Minds, a national nonprofit organization devoted to mental health awareness.

At UNC, in the six months between July and December 2013, Counseling and Psychological Services saw 1,535 students, 36.6 percent of whom expressed “some” or “serious” suicidal ideation in the past year.

About 28 of those students – 1.8 percent – attempted suicide during that time.

Other self-threatening behaviors are equally troublesome.

Anorexia nervosa has the highest mortality rate of any mental illness, according to the National Alliance on Mental Illness.

Ten percent of college-aged students, both at UNC and nationally, binge one or more times a week, according to a 2010 study from Healthy Minds, an annual survey-based study that examines college mental health. Four percent of UNC students reported an eating disorder. Twenty-nine percent of UNC students reported they feel too fat, even when others say they are thin.

Non-suicidal self-injury – or behaviors of deliberate self-harm, such as cutting, burning and scratching – is also exhibited among UNC students. The 2010 Healthy Minds study found that 17 percent of UNC students, a percentage point above the national average, reported non-suicidal self-injury in the past year.

The statistics often force university personnel to intervene, said Allen O’Barr, director of CAPS, UNC’s mental health services.

“Legally, we have to keep you alive,” O’Barr said, citing an obligation he has as a mental health clinician to protect those he deems dangerous to themselves or others. If he does not, it constitutes neglect, he said.

But that law applies only to clinicians and health care professionals, such as O’Barr, a psychiatrist. It does not apply to university administrators, said Schwartz, the medical director for The Jed Foundation.

“Universities don’t have an obligation to provide mental health care to students,” Schwartz said. “They provide a standard of care because it’s a good idea, but legally, they don’t have to.”

In the 1960s, administrative involvement was dictated by the concept of “in loco parentis,” a Latin phrase for “in the place of a parent.” Universities were expected to act as guardians, intervening in cases of at-risk students.

“Then we had the ‘70s; we had power and freedom, sex, drugs and rock ‘n’ roll,” O’Barr said. “And students were saying, ‘Leave me alone, I’m an adult.'”

The introduction of federal laws, such as the Family Educational Rights and Policy Act – a law that emphasizes privacy and autonomy in education – reaffirmed that shift.

But rapid growth in the college suicide rate – which jumped from 4.5 deaths to 13.7 deaths per 100,000 students between 1950 and 1994 – sent universities into a panic. Schools began forcing students off campus simply for being suicidal, O’Barr said. Forceful withdrawal for other self-injurious behaviors followed.

At the same time, Gary Pavela, a national consultant on policy for universities, emerged in the national conversation. Pavela thought removing students for being suicidal – discriminating against them based on health – was wrong. He suggested universities should instead deal with suicidality and self-injury as a behavioral problem, allowing schools to remove students who exhibited violent behavior toward themselves.

Pavela’s goal was to keep students in school, not to dismiss them, hoping students who faced disciplinary action would be motivated to get help. But many universities misunderstood, Schwartz said, and began writing into codes of conduct that students could be removed for self-threatening behavior.

UNC has a similar provision.

Students who exhibit behavior that is dangerous to themselves are handled by the Emergency Evaluation and Action Committee – the committee that interacted with Balagopal – which is composed of administrators, a CAPS representative and UNC’s chief of police, among others. Six to seven representatives sit on the committee for each case, said Rieckenberg, the committee’s chairwoman.

When a student’s behavior is brought to the committee’s attention – whether it be self-reported or reported by someone at UNC – the committee can intervene. Its policy emphasizes that any action taken is not punitive but therapeutic, aimed at the student’s well-being.

In emergency cases, which O’Barr described as “imminently dangerous,” the committee can impose an indefinite medical suspension on a student.

“It’s cases where you’re foreseeably dangerous – where someone has a (suicide) plan, where someone is continuing to lose so much weight that it might affect their heart. Or where we see cutting, and that person is going deeper and deeper with that cutting,” O’Barr said.

Rieckenberg said that in many cases, the committee will require students to take a psychological evaluation administered by CAPS before taking action.

During the indefinite medical suspension, a student cannot attend class or come to campus. Students have a right to a hearing to question the decision, the policy states.

“At the end of the day, we have to do what’s best for the student,” Rieckenberg said. “I’d always much rather have you be here and be successful and doing the things you want to do than feel like you have to leave.”

D., a UNC student who was granted anonymity for privacy reasons, came to UNC excited to start over.

She had struggled with an eating disorder in high school, but she was in recovery. Years of counseling had taught her how to eat and exercise. She felt happy with her body.

“But then, coming to college really throws you for a loop,” she said. “I was stressed out. I was out of my routine. Suddenly, I was losing weight – but I knew how to fix it.”

Unexpectedly, D. received a letter from the Emergency Evaluation and Action Committee, she said. She had never sought help at UNC, but her condition had been reported to the committee.

“The letter basically said that my weight had come to the University’s attention,” she said. “I only had two options at my disposal: Leave and go to the hospital, or leave and go home.”

She was required to take a psychological evaluation, which Rieckenberg said is standard procedure. D. said she asked to speak with the committee to dispute the letter but was told by her case manager – a counselor from CAPS who serves as a middleman – that it wouldn’t help.

Rieckenberg said in some cases, students can meet with the entire committee. In other cases, she is always willing to sit down with students and discuss the situation as many times as needed, she said.

D. said she didn’t know what to do. She couldn’t afford hospitalization – a prior one from high school had left her family struggling. But she also couldn’t leave, she said. Her eating disorder was linked in part to her home life, and going home would exacerbate her condition.

By a fluke, D. never had to leave – as she worked through the logistics of getting hospital treatment, the spring semester came to a close. She gained enough weight to return in the fall.

She was improving, but she said the committee imposed other requirements: Visits to counseling every week, as well as multiple meetings with medical doctors, a nutritionist and her case manager. Her counseling was off campus – she was told by CAPS her condition was too severe for the resources they could provide – adding another financial burden.

O’Barr said about 25 percent of students are referred out to the community for treatment. That’s for conditions, like an eating disorder, that are complicated and require more therapy, he said. Students whose conditions are less severe can utilize CAPS for brief therapy, in which students meet individually with a counselor. There is no limit on the number of those sessions, O’Barr said.

“The committee distracted me from paying attention to my mental and physical health,” D. said. “They took over my life. The things I was doing to help myself before – yoga, meditation, de-stressing, eating regular meals – were taken away. I didn’t have a lunch break anymore because I was meeting with the dean of students during lunch.”

The committee’s actions, she said, discourage students from seeking help.

“A student who thinks they are going to get kicked out of the University will not go to the University for help,” she said.

“If they actually wanted to intervene and care for students, they would offer an option for the student to stay at the University and care for them, rather than pushing them off campus and sending them to be fixed,” she said. “If they cared about us, they wouldn’t treat us as if we were a liability issue.”

“It all comes down to them not wanting us to die on their watch,” she said.

The issue of self-harm at college was thrust into national attention in 2000 when Elizabeth Shin, a student at the Massachusetts Institute of Technology, set herself on fire and died. Prior to her death, Shin reached out to counselors and deans multiple times about her self-mutilation and suicidal thoughts, but her condition was given little attention, and her parents were never notified. Her family sued M.I.T. for $27 million, claiming the university failed to prevent Shin’s suicide. Six years later, the lawsuit was settled for an undisclosed amount.

It kick-started a national conversation: Legal experts worried schools could be held liable if they entangled themselves in a student’s mental health and the student later died. Medical experts worried it would prompt schools to haphazardly force students off campus, discouraging them to seek help.

Similar lawsuits followed. One of the most prominent was the 2005 Jordan Nott case. Nott, a sophomore at George Washington University, was forced off campus when he sought treatment for depression and thoughts of suicide. The university cited his “endangering behavior” as a violation of the student code of conduct. His case also ended in a confidential settlement.

“It’s important to note that there has never been a case where a school has been found liable for failure to prevent a student suicide,” said Karen Bower, an anti-discrimination lawyer who represented Nott.

Bower said some schools act too promptly in removing students.

“There are a lot of problems associated with that. It can affect their academics, their scholarships, their financial aid. It can separate them from their treatment providers if they’re receiving treatment on or near campus,” she said.

Bower said recent changes to federal regulations have complicated the way schools handle students who are dangerous to themselves.

Public schools have always been bound by federal anti-discrimination laws – namely, Title II of the Americans with Disabilities Act. The act aims to protect individuals with disabilities – including mental illness – from discrimination, particularly at state colleges and universities.

For years, based on guidance from the U.S. Department of Education’s Office for Civil Rights, schools interpreted the law to mean they could remove students who were a threat to themselves.

But in 2011, a new regulation was issued by the Department of Justice. It made clear that schools could dismiss students who are a threat to others, but it omitted any reference to what could be done when violence is self-directed.

It’s left universities confused, Schwartz said, and prompted many schools to think they can no longer remove students from campus.

“It’s ambiguous,” he said. “But it hasn’t changed anything in a substantive way.”

Schools have always been – and will continue to be – able to kick students off campus, Schwartz said, but only if there is adequate justification.

“Simply being self-injurious is not an adequate justification,” Schwartz said. “But if a student can’t be safely managed in school and get the treatment they need, clinically, it might make the most sense.”

“But you also have to think, students in school settings are hopeful about the future, they have connections to friends – those things might be good for them,” he said. “You need to figure out a course of action that is safe and sensible for a student.”

Schwartz said he’s worried that because schools have no explicit guidance, they might begin underreacting to situations.

“There is always a tendency to overreact, but now, we might find just as much underreaction,” Schwartz said. “Schools will be afraid of running afoul of the (Americans with Disability Act) and will not encourage students to take time off when that is the best thing.”

Rieckenberg said amid the federal changes, UNC plans to update its policies to place less of an emphasis on mandatory indefinite suspensions. She did not offer any timeline for the updated policies.

“I would venture to guess that if you talked to students who interacted with this committee three or four years ago, the experience they might have had is very different than they have today,” Rieckenberg said. “And that has nothing to do with staff, it was just before any of the new regulations.

“We utilized medical suspensions probably much more heavily back then.”

She’s been leading the emergency committee for about a year, and since she took over, she said the committee has not imposed a mandatory indefinite suspension. Rieckenberg is the named designee for Vice Chancellor for Student Affairs Winston Crisp, who is formally in charge of the committee. Crisp could not be reached despite multiple attempts for comment.

Rieckenberg said the committee still encourages students to voluntarily withdraw in some situations. Balagopal, the UNC senior, was one of those students.

O’Barr said that option is used if other options – such as postponing exams or taking a temporary incomplete in a course – seem unfeasible.

In the six months between July and December 2013, CAPS allowed 89 students to voluntarily withdraw from the University for psychological reasons.

“It’s not that we’re highly encouraging someone to withdraw to get them out of the University so they’re not a risk to the University – that’s not it at all,” O’Barr said.

Rieckenberg said every action the committee takes is tailored to a student’s situation.

“We want students to experience a seamless support network,” Rieckenberg said.

Mental health policies at schools were in the national spotlight again in January after Rachel Williams, a freshman at Yale University, published a first-hand account in the university’s student newspaper about the way the University treated her after she willfully harmed herself.

After years of managing an eating disorder that emerged in high school, Williams came to Yale in fall 2012 and began to relapse, she said in an interview.

“I would binge, and then I would be suicidal,” Williams said. “And then I’d binge again, and would be suicidal. And then I would wake up the next morning and go to class.”

After engaging in cutting one night in January 2013, Williams voluntarily admitted herself to the psychiatric ward of the emergency room, where she described an experience similar to Balagopal’s. She was stripped of her clothing, including her pants – which included a drawstring – and her hair band. She was told she could use them to kill herself, she said.

She felt humiliated.

After a brief meeting with the chief psychiatrist at Yale University’s Mental Health and Counseling Department, she was told she would have to withdraw. It was mandatory, Williams said, and she was given one night to move out.

“She told me, ‘It’s just too dangerous to have you here,'” Williams said. “My first reaction was, ‘Why do you think it’s going to be better at home?'”

“It wasn’t clear that she really believed I would be safer at home,” she said. “And I told her, ‘My parents work. They’re never home. It would be very easy, maybe easier, for me to kill myself at any day at home.'”

Lorraine Siggins, chief psychiatrist at Yale’s Mental Health and Counseling Department who made Williams’ withdrawal decision, could not be reached for comment.

Williams left school, taking a year off before returning in January. She said her experience highlights how the assumptions universities make about home life and parental involvement can be shortsighted.

The decision to involve parents in a student’s mental health condition is a dilemma many universities face.

Parents of students who have died by self-harm, such as M.I.T student Elizabeth Shin, say they want to know when their child is exhibiting dangerous behavior. Some students, however, have mental health conditions that stem from family situations and don’t want parents involved, O’Barr, the CAPS director, said.

The dilemma forces counselors and administrators into a tough decision: Notify parents, and potentially discourage a student from seeking help in the future. Or, respect a student’s confidentiality – only to face blame from parents if a student dies.

Bower said universities are bound by the Family Education Rights and Privacy Act, often called FERPA. She said many schools misunderstand FERPA and believe the law prevents them from releasing any information related to a student’s academic record.

But the law includes exceptions which allow – but do not require – disclosure of information without consent when there is “an articulable and significant threat” to the student’s safety. Among law enforcement and medical personnel, information can also be disclosed to a student’s parents.

Both O’Barr and Rieckenberg said UNC ultimately tries to maintain confidentiality.

“We recognize that students come from varying and very diverse backgrounds,” Rieckenberg said. “That student and what they’re experiencing might be a direct result from a parental relationship, and so one thing we’re very cognizant of is not wanting to exacerbate situations that could make it worse for the student.”

O’Barr said it’s entirely dependent on how willingly a student works with a counselor.

“If we start working together and we have a good working relationship, if I’m getting you into therapy and you’re staying in touch with me – if your parents call, I’m not telling them a thing,” O’Barr said.

“But in the event you drop off, or you say, ‘I told you I wasn’t going to kill myself but now I am,’ I’m calling your parents,” he said. “When there is imminent danger, confidentiality is out the window.”

Today – nearly one year since she left – Balagopal is back at UNC.

Balagopal said the transition back was hard, with weeks spent arranging meetings and check-ups and sending dozens of emails. She lost her National Merit Scholarship.

At times, she feels isolated because of her experience. She can no longer write her thesis, nor can she graduate with honors because of miscommunication – a problem she said was common during her time away.

“Getting back here is nightmarish,” Balagopal said. “They make it so you really have to commit to coming back. It’s like you’re being punished – like you made a bad choice.”

Ultimately, she’s happy. She’s back with her friends. She’ll graduate in May.

“Part of me thinks, “They tried to take something from me,’ but that doesn’t mean I can’t be successful and strong,” Balagopal said. “I’ll show them, I’ll graduate.

“But the rest of me is thinking, “This has been absolutely exhausting.”