**National Council on Disability**

An independent federal agency making recommendations to the President and Congress to enhance the quality of life for all Americans with disabilities and their families.

# Letter of Transmittal

July 21, 2017

President Donald TrumpThe White House1600 Pennsylvania Avenue, NWWashington, DC 20500

Dear Mr. President:

The National Council on Disability (NCD) is pleased to submit its report, *Mental Health on College Campuses: Investments, Accommodations Needed to Address Student Needs*, the culmination of a study conducted to determine the current challenges facing**college students with mental health disabilities on campus and to provide practical, targeted recommendations to resolve them. Report findings highlight laws, policies, and procedures that pose substantial challenges to the academic success of college students with mental health disabilities.

NCD is an independent federal agency, composed of nine members appointed by the President and the U.S. Congress. The purpose of NCD is to promote policies, programs, practices, and procedures that guarantee equal opportunity for all individuals with disabilities and empower individuals with disabilities to achieve economic self-sufficiency, independent living, and inclusion and integration into all aspects of society. 

Consistent with NCD’s overall purpose, this report:

· Identifies institutional barriers to mental health service on campus;

· Identifies federal law and policy barriers to academic achievement for students with mental health disabilities; and

· Offers solutions through targeted recommendations and best practices, to Congress, federal agencies, and colleges. 

NCD stands ready to be a resource to the Administration, Congress, and other federal agencies on the contents of this report. We encourage the White House and Congress to engage college students with disabilities, college administrators, and federal agencies whose policies impact college students, as mental health services and supports on college campuses are discussed now and in the future.

Sincerely,

Clyde Terry

Chair

(The same letter of transmittal was sent to the President Pro Tempore of the U.S. Senate, the Speaker of the U.S. House of Representatives, and the Director of the Office of Management and Budget.)

**National Council on Disability Members and Staff**

**Members**

Clyde E. Terry, *Chairperson*

Benro T. Ogunyipe, *Vice Chair*

Billy W. Altom

Rabia Belt

James T. Brett

Bob Brown

Lt. Col. Daniel Gade

Wendy Harbour

Neil Romano

**Staff**

Rebecca Cokley, Executive Director 

Phoebe Ball, Legislative Affairs Specialist

Stacey S. Brown, Staff Assistant

Lawrence Carter-Long, Public Affairs Specialist

Joan M. Durocher, General Counsel & Director of Policy

Lisa Grubb, Director of Operations and AdministrationAmy Nicholas, Attorney Advisor

Amged Soliman, Attorney Advisor

Anne Sommers, Director of Legislative Affairs & Outreach

Ana Torres-Davis, Attorney Advisor

Keith Woods, Financial Management Analyst

**Acknowledgments**

The National Council on Disability wishes to thank RTI International, particularly Jay Feldman and his team—Deborah Tull and Remmert Dekker—for the research conducted in developing this report.

Table of ContentsA Note on Terminology	9Definition of Mental Health	9Mental Health Disability	9Determinants of Mental Health	10List of Acronyms	11Executive Summary	13Objective	13Methodology	14Key Findings	14Key Recommendations	15Recommendations to Congress	15Recommendations to U.S. Department of Education (ED)	16Recommendations to the U.S. Department of Health and Human Services (HHS), Substance Abuse and Mental Health Services Administration (SAMHSA)	17Chapter 1. Introduction and Background	19Prevalence of Students with Mental Health Challenges in Institutions of Higher Education	19Chapter 2. Benefits of Providing Mental Health Services and Supports	21Improved Academic Performance	21Increased Resilience and Reduced Stress	22Reduced Substance Abuse	22Reduced Suicide Rates	22Economic Benefits for Colleges	23Chapter 3. Purpose and Structure of Report	25Chapter 4. Methodology	29Interviews	29Practitioner and Expert Interviews	29Student Interviews	29Questionnaires	30Practitioner/Expert and Student Questionnaires	30Twitter Chat	30Chapter 5. Federal Laws Impacting College Mental Health Services	33Federal Disability Laws	33Section 504 of the Rehabilitation Act	33The Americans with Disabilities Act	33Postsecondary School Provision of Auxiliary Aids	34The Fair Housing Act	35Federal Privacy Laws	35Family Educational Rights and Privacy Act	35Health Insurance and Portability Accountability Act	35Policies and Practices Negatively Impacting Provision of Campus Mental Health Services	36Threat to Self Policies Requiring Mandatory Withdrawal or Mandatory Leave of Absence	36Readmission Policies	39Financial Aid and Other Financial Policies	40Funding Policies for Programs and Supports	42Confidentiality	43Chapter 6. Access to Quality Mental Health Services	45Policies and Practices That Enhance the Inclusion, Retention, and Graduation of Students with Mental Health Disabilities	45Improving Access to Services	46Increased Training for Faculty and Staff	47Policy Reforms	47Outreach and Education	48Integrated Services	48Availability of Mental Health Services on Campus	49Hours of Service	51Afterhours Access to Counseling and Helplines	51Fees at Counseling Services	51Waitlists at Counseling Services	51Limited Sessions at Counseling Services	52Streamlined Referral Network to Outside Agencies	53Availability of Counseling Staff with Mental Health Licensure	53Availability of a Diverse Mental Health Counseling Staff	53Availability of Psychiatric Services	53Barriers to Services Faced by Students	54Physical Accessibility and Paperwork Requirement Barriers	54Providing Services to Students with Physical or Sensory Disabilities	55Reasonable Modifications and Accommodations	55Chapter 7. Promising Best Practices and Emerging Trends	57Student and Practitioner Perceptions of Emerging and Best Practices	57Stigma Reduction, Education, and Outreach	58Training and Other Anti-Stigma Activities	58Orientation	60Transparency	60Campus-Wide Conversations	62Universal Design	62Student Engagement	63Peer-to-Peer Support Services	63Student Voice	64Faculty and Staff Training	67Faculty and Staff Training to Identify and Provide Support to Students Who Have Mental Illnesses or Are Experiencing Extreme Emotional Distress	68Faculty, Staff, and Academic Advisors	69Faculty and Staff Training on Mental Health Issues and Reasonable Accommodations	70Suicide Prevention	71Crisis Management Plan in Place	71Behavioral Intervention Teams	72Pedagogy	73List Service Sites and Accommodation Policies on Class Syllabi	73Faculty Discusses Stress	73Integrate Stigma Reduction and Help-Seeking into Classes	74Increased Access: Multiple Touchpoints	74Anchor Adults	74Coordinated Support	75Case Management Approach	75Parent and Family Programs	76Telecounseling	76Substance Use Recovery Center on Campus	77Partnerships with Mental Health Providers in the Community	79Other Organizational Collaborations	80College Collaboration	80College Collaborations with Other Organizations	80Postvention	81Considering the Needs of Diverse Populations	82Students of Color	82Foster Youth	83International Students	83Veterans	83Sexual Orientation and Sexual Identity	84Students with Disabilities	85Graduate Students	85Community College Students	86Student Athletes	86Chapter 8. Full Findings and Recommendations	87Recommendations to Congress	87Recommendations to ED	89Recommendations to HHS/SAMHSA	91Recommendations to Colleges	92References	109Appendix A: List of Interviewees	119Interviewee Questions	122Appendix B: Student Interviews	123Student Interview Questions	123Appendix C: Questionnaires	125Practitioner/Expert Questionnaire	125Appendix D: Twitter Chat Questions	127Appendix E: Sample Screening and Assessment Tools	129Appendix F: Common Modifications	131Endnotes	135

# A Note on Terminology

## Definition of Mental Health

“Mental health is defined as a state of well-being in which an individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community. The positive dimension of mental health is stressed in the World Health Organization’s (WHO's) definition of health as contained in its constitution: “Health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.”[endnoteRef:2]” [2:  “Mental health: a state of well-being.” World Health Organization, accessed March 22, 2017, http://www.who.int/features/factfiles/mental_health/en/] 

“Mental health and well-being are fundamental to humans’ collective and individual ability to think, emote, interact with one another, earn a living, and enjoy life. On this basis, the promotion, protection, and restoration of mental health can be regarded as a vital concern for individuals, communities, and societies throughout the world.[endnoteRef:3]“ [3:  “Mental health: strengthening our response.” World Health Organization, accessed March 22, 2017, http://www.who.int/mediacentre/factsheets/fs220/en/] 

## Mental Health Disability

The definition of disability in the Americans with Disabilities Act (ADA) includes people with mental illness who meet **one** of these three definitions:[endnoteRef:4] [4:  42 U.S. Code § 12102] 

· A physical or mental impairment that substantially limits one or more major life activities of an individual

· A record of such an impairment

· Being regarded as having such an impairment

A mental impairment is defined by the ADA as “any mental or psychological disorder, such as mental retardation, organic brain syndrome, emotional or mental illness, and specific learning disabilities.”[endnoteRef:5] [5:  45 CFR 1181.103] 

When applied to higher education settings, a mental health disability is defined as a persistent psychological or psychiatric disorder, emotional or mental illness that adversely affects educational performance. A mental health disability is a condition which: 1) is listed in the most current American Psychiatric Association Diagnostic and Statistical Manual and/or the ADA, as amended, and/or the International Classification of Diseases (ICD); 2) reflects a psychiatric or psychological condition that interferes with a major life activity; and 3) poses a functional limitation in the educational setting.[endnoteRef:6] [6:  California Community College Chancellors Office, 2015 Implementing Guidelines for Title 5 Regulations, Section 56042, Mental Health Disability.] 

Reference is made throughout this report to students who manifest the symptomology of mental illness. Terminology used includes: mental illness, mental health disorder, mental health disability, and mental health challenge. Increasing numbers of students have mental health challenges, which impair or limit their ability to succeed academically and attain life success; some of these challenges rise to the level of a mental health “disability” for purposes of civil rights protections. 

## Determinants of Mental Health

Multiple social, psychological, and biological factors determine a person’s level of mental health. Persistent socioeconomic pressures are recognized risks to mental health for individuals and communities. The clearest evidence is associated with indicators of poverty, including low levels of education. Poor mental health is also associated with rapid social change, stressful work conditions, discrimination, social exclusion, unhealthy lifestyle, risks of violence, physical ill-health, and human rights violations. In addition, specific psychological and personality factors make people vulnerable to mental disorders. Lastly, there are biological causes of mental disorders, including genetic factors which contribute to imbalances in brain chemicals.[endnoteRef:7] [7:  “Mental health.” World Health Organization, accessed March 22, 2017, http://www.wpro.who.int/mediacentre/factsheets/fs_201203_mental_health/en/] 

National mental health policies should not be solely concerned with mental disorders but should also recognize and address the broader issues that promote mental health. Mental health promotion should be mainstreamed into policies and programs in governmental and nongovernmental sectors. In addition to the health sector, it is essential to involve the education, labor, justice, transport, environment, housing, and welfare sectors.[endnoteRef:8] [8:  “Mental health.” World Health Organization, accessed March 22, 2017, http://www.wpro.who.int/mediacentre/factsheets/fs_201203_mental_health/en/] 

# List of Acronyms

ACCA		American College Counseling Association

ADA		Americans with Disabilities Act

AHEAD	Association on Higher Education and Disability 

APA		American Psychiatric Association

AUCCCD	Association for University and College Counseling Center Directors

BIT		Behavioral Intervention Team

CalMHSA	California Mental Health Services Authority

CCC		California Community College

CCMH		Center for Collegiate Mental Health

DHH		Deaf and hard of hearing

DOJ		U.S. Department of Justice

DSS		Disability Support Services

ED		U.S. Department of Education

EMR		electronic medical records

FAFSA	Free Application for Federal Student Aid

FERPA	Family Educational Rights and Privacy Act of 1974

FHAct		Fair Housing Act

FSA		federal student aid

HHS		U.S. Department of Health and Human Services

HIPAA	Health Insurance and Portability and Accountability Act of 1996

HOH		hard of hearing

ICD		International Classification of Diseases

LGBTQ	lesbian, gay, bisexual, transgender, queer, or questioning

LOA		leave of absence

NCD		National Council on Disability

NSCCC	National Survey of College Counseling Centers

OCR		Office of Civil Rights

SAMHSA	Substance Abuse and Mental Health Services Administration

TAO		Therapy Assisted Online

VA		Veterans Administration

# Executive Summary

The percentage of students seeking support for mental health disabilities, including those of a severe degree,[endnoteRef:9] while attending institutions of higher education (colleges) is increasing,[endnoteRef:10] however too many are not receiving treatment. Given the increased demand for mental health services on campus and limited funding for campus mental health services,[endnoteRef:11] some have argued that the nation has reached a “campus mental health crisis.”[endnoteRef:12] Students with mental health disabilities who do not receive assistance are not as academically successful as their peers, with lower GPAs and higher dropout rates; however, when students get support, they are successful.[endnoteRef:13]  [9:  Reetz, David R., Carolyn Bershad, Peter LeViness, and Monica Whitlock. “The Association for University and College Counseling Center Directors Annual Survey.” (2016). https://www.aucccd.org/assets/documents/aucccd%202016%20monograph%20-%20public.pdf; In Gallagher, Robert. National Survey of College Counseling Centers 2014. Project Report. The International Association of Counseling Services (IACS), 2015, counseling center directors report that 52 percent of center clients (students) have severe psychological problems (up from 44 percent in 2013). Of these, 8 percent have impairment so serious they cannot remain in school or can only do so with extensive psychological or psychiatric help; 44 percent experience periods of severe distress (e.g., depression, anxiety, panic attacks, suicidal ideation) but can be treated successfully with available treatment modalities. In schools with more than 15,000 students, percentages are higher, with 59 percent of clients having severe problems. Of these, 50 percent are successfully treated and 9 percent cannot remain in school or can remain only with extensive help, which is not generally available.] In a 2016 survey by the American College Health Association, 70 percent of directors said the number of students on their campuses with severe psychological problems had increased in the past year.]  [10:  Snyder, T. D., C., de Brey, and S. A. Dillow, Table 311.1. “Number and Percentage Distribution of Students Enrolled in Postsecondary Institutions, by Level, Disability Status, and Selected Student Characteristics: 2007-08 and 2011-12.” In Digest of Education Statistics 2014 (NCES 2016-006). National Center for Education Statistics, Institute of Education Sciences, U.S. Department of Education. Washington, DC, 2016. https://nces.ed.gov/programs/digest/d13/tables/dt13_311.10.asp; Robert Gallagher, National Survey of College Counseling Centers 2014. Project Report. The International Association of Counseling Services (IACS), 2015]  [11:  Gallagher, Robert, National Survey of College Counseling Centers 2014 ]  [12:  Kadison, Richard, and Theresa Foy Digeronimo. College of the Overwhelmed. New York, NY: John Wiley & Sons, 2004.]  [13:  Klein, M., J. Behen, and N. Roy. National College Depression Partnership. Depression, Recovery, and Student Success. (2010). ] 

Strong mental and behavioral health supports on campus can improve the academic performance of students and increase their resilience and ability to handle stress, with reduced suicide rates, substance abuse, and eating disorders, but this study reveals that students with mental health disabilities continue to face barriers to accessing counseling services on campus and in receiving disability-related accommodations that are necessary to help them participate in their education on an equal footing with students without disabilities.

This study identified two main areas that pose barriers to the academic achievement of students with mental health disabilities: 1) institutional policies and practices, and 2) federal laws and policies. All need attention and reform in order to remove barriers that impede the academic success of students with mental health disabilities on campuses across the nation. 

Objective

This National Council on Disability (NCD) study examines and assesses the status of college mental health services and policies in the United States, and provides recommendations for Congress, federal agencies, and colleges to improve college mental health services and post-educational outcomes for students with mental health disabilities. 

Methodology

To understand the challenges, best practices, and emerging trends of supporting college students with mental health disabilities and to provide relevant, practical recommendations for reform, NCD’s research team conducted structured 45-minute telephone interviews with 37 key informants, including social science researchers, advocates, college administrators, college policymakers, college legal counsels, disability specialists and mental health service providers, and specific subpopulations, including individuals (both at the college and in the community serving college students) who are Deaf and/or hard of hearing (HOH), graduate students, those involved in Greek life, and athletes.

NCD’s research team trained eight college students with knowledge of mental health services on leading in-person interviews with 48 fellow students, aged 18 or older, to gain an understanding of students’ experiences on campus, students’ need for services, available services on campuses, the services students found most helpful, and challenges or barriers to accessing mental health services on campus. 

NCD’s research team also administered an open-ended questionnaire to provide context for the themes identified in the interviews and received over 101 responses from practitioners and 148 responses from students.

Key Findings 

NCD provides detailed findings and offers recommendations for reform aimed at the most significant barriers to postsecondary success of students with mental health disabilities in Chapter 8 of this report. The recommendations are directed to Congress, the U.S. Department of Education (ED), the U.S. Department of Health and Human Services (HHS), and colleges. Key findings are as follows:

· Colleges are struggling to provide adequate mental health services and supports for students with mental health disabilities due largely to increased numbers of students with mental health challenges attending college and a lack of financial resources.

· Students frequently are placed on waiting lists for college mental health services due to the high demand for services and insufficient numbers of mental health staff. This is particularly problematic for students in crisis.

· The U.S. Department of Education, Office of Civil Rights (OCR) has not provided guidance to colleges on how to respond to students that pose a threat to themselves. 

· Multiple restrictions in the provision of federal and college financial aid negatively impact the ability of students with mental health disabilities to complete their postsecondary education. 

· College faculty, staff, and administrators need training to 1) identify and support students with mental health disabilities and 2) responsibly provide disability-related modifications and accommodations as required under federal disability laws.

· Community colleges are the least equipped to deal with college student mental health issues when compared with state colleges and universities, even though they serve the most at-risk student populations. Many rural community colleges lack on-campus mental health services and access to community mental health services due to geographic limitations.

· College counselors do not typically reflect the diversity of the student populations that they serve. 

· There are many emerging trends and best practices in college provision of services and supports to students with mental health disabilities.

Key Recommendations

### Recommendations to Congress 

**Recommendation:** Congress should fully fund Section 9031of the 21st Century Cures Act (mental health and substance abuse disorder services on campus) to assist colleges in meeting the increased need for mental health services and supports for students.[endnoteRef:14] [14:  114 P.L. 255 (2016). See Section 9031: Mental Health and Substance Use Disorder Services on Campus] 

**Recommendation:**Congress should increase funding for the Garrett Lee Smith Campus Suicide Prevention Program.

**Recommendation:**Congress should make federal financial assistance available to colleges contingent on those colleges implementing a mental health program, just as federal law makes federal financial assistance available contingent on a college’s implementation of a program to prevent student use/abuse of illicit drugs and alcohol.[endnoteRef:15]**** [15:  20 USC §2011i.] 

**Recommendation:**Congress****should substantially increase Pell Grants to provide opportunities to students with disabilities who are disproportionately low-income, so they are able to attend and achieve higher education. 

**Recommendation:** Congress should amend the Higher Education Act to extend the length of time a student with a disability is eligible for federal financial aid when, due to the disability, a student needs more time to complete degree requirements than is allowed under federal financial aid time parameters. 

**Recommendation:** Congress should amend the Higher Education Act to allow students whose disabilities cause them to require additional semesters of financial aid to retain their eligibility for Pell Grants beyond 12 semesters.[endnoteRef:16] [16:  20 U.S.C. § 1070a(c).] 

**Recommendation:** Because college students with disabilities may require a medical leave of absence (LOA) that extends past six months while they are pursuing a degree, Congress should amend the Higher Education Act requirement that loan repayments begin six months after leaving college,[endnoteRef:17] to allow a time-extension as a disability-related accommodation.  [17:  20 U.S.C. § 1078(b)(7).] 

### Recommendations to U.S. Department of Education (ED) 

**Recommendation:** ED/OCR should provide colleges with best practices for responding to students who exhibit or threaten self-harming behavior.

**Recommendation:** ED/OCR should provide colleges with best practices for providing legally required modifications and accommodations for students with mental health disabilities. 

**Recommendation:**ED should****modify the Free Application for Federal Student Aid (FAFSA) to allow students to directly input disability-related expenses. ED should provide technical assistance to financial aid offices to ensure that they apply disability-related expenses when determining the amount of a student’s financial aid. 

**Recommendation**: ED should clarify to colleges that Student Support Services funding can be used to provide mental health counseling services.[endnoteRef:18] Further, ED should direct technical assistance providers for Student Support Services Projects to stress the need for mental health services. Additionally, during grant competitions, ED should direct technical assistance providers conducting workshops to inform applicants that mental health counseling is a permissible service. [18:  28 U.S.C. § 1070a-14(c).] 

### Recommendations to the U.S. Department of Health and Human Services (HHS), Substance Abuse and Mental Health Services Administration (SAMHSA)

**Recommendation:**SAMHSA****should****take actions to increase the awareness of colleges about mental health grant funding opportunities, including funds available under the 21st Century Cures Act.

**Recommendation:**SAMHSA should****require colleges that apply for mental health-related grant funding to hire mental health staff, describe how they will recruit and hire culturally-competent and diverse counselors, and have a system in place to ensure that colleges that receive grant funds comply with these requirements. 

**Recommendation:**SAMHSA should****require colleges that apply for mental health-related grant funding to provide, as part of each application, their policies on providing reasonable modifications, reasonable accommodations, and auxiliary aids for students with disabilities. SAMHSA should also require colleges to post these policies on their websites, at their offices of Disability Support Services (DSS), and in their counseling centers.

**Recommendation:** SAMHSA should require colleges that apply for mental health-related grant funding to describe, as part of each application, how they will collaborate with community mental health service providers to meet student needs, as currently required from applicants under the Garret Lee Smith Campus Suicide Prevention program.

**Recommendation:**SAMHSA should give mental health****grant-funding priority to colleges that will use the funds for direct services that are proven best practices in providing mental health services to college students.

**Recommendation:**SAMHSA should liberally approve waivers to the matching funds requirement for mental health grant funding to colleges that do not have the financial capacity to provide campus mental health services without federal grant funds, and that show that they have high populations of at-risk students and students with multiple disabilities. 

# Chapter 1. Introduction and Background

## Prevalence of Students with Mental Health Challenges in Institutions of Higher Education

The percentage of students seeking support for mental health disabilities, including those of a severe degree,[endnoteRef:19] while attending Institutions of higher education (colleges) has increased even within the last three years.[endnoteRef:20] While expanding access to college is positive, the growth in the number of students needing mental health services highlights weaknesses in current services and supports offered by colleges. Students with mental health disabilities who do not receive assistance are not as academically successful as their peers, with lower GPAs and higher dropout rates. Given increased demand and limited funding for mental health services, some have argued that the country has reached a “campus mental health crisis.” Considering this, colleges must develop a culture that supports the mental and emotional well-being of students. [19:  Reetz, D. R., C. Bershad, P. LeViness, and M. Whitlock. The Association for University and College Counseling Center Directors Annual Survey. (2016). https://www.aucccd.org/assets/documents/aucccd%202016%20monograph%20-%20public.pdf; In Gallagher, National Survey of College Counseling Centers 2014, counseling center directors report that 52 percent of center clients (students) have severe psychological problems (up from 44 percent in 2013). Of these, eight percent have impairment so serious they cannot remain in school or can only do so with extensive psychological or psychiatric help; 44 percent experience periods of severe distress (e.g., depression, anxiety, panic attacks, suicidal ideation) but can be treated successfully with available treatment modalities. In schools with more than 15,000 students, percentages are higher, with 59 percent of clients having severe problems. Of these, 50 percent are successfully treated and nine percent cannot remain in school or can remain only with extensive help, which is not generally available.] In a 2016 survey by the American College Health Association, 70 percent of directors said the number of students on their campuses with severe psychological problems had increased in the past year.]  [20:  Snyder, Table 311.10; Gallagher, National Survey of College Counseling Centers 2014. ] 

Many issues have contributed to the rise in the number of students with mental health disabilities. The number of people going to college is increasing. Enrollment in degree-granting institutions increased by 11 percent from 1991 to 2001 and another 32 percent from 2001 to 2011, per the National Center for Education Statistics.[endnoteRef:21] The number of nontraditional students on campus, such as veterans; lesbian, gay, bisexual, transgender, queer, or questioning (LGBTQ) students; first-generation students; international students; and foster youth, has grown significantly. Members of these groups are believed to be at greater risk for mental health challenges due to stressors such as racism, prejudice, low socioeconomic status, undereducation, and acculturation.[endnoteRef:22] Further, people with mental health disabilities have a strong interest in higher education and are enrolling in college in greater numbers. Finally, for many students, college is their first attempt at independent living, one they undertake while trying to balance a high level of academic achievement and adjusting to a new social environment. In this context, many college students experience the first onset of mental health and substance use problems or an exacerbation of their symptoms.[endnoteRef:23]  [21:  Digest of Education Statistics. 2012. p. 307. Accessed March 22, 2017, https://nces.ed.gov/pubs2014/2014015_3.pdf]  [22:  See McMillen, J. C., B. T. Zima, L. D. Scott Jr., W. F. Auslander, M. R. Munson, M. T. Olie, and E. L. Spitznagel. “Prevalence of Psychiatric Disorders among Older Youths in the Foster Care System.” Journal of the American Academy of Child and Adolescent Psychiatry 44, no. 1 (2005): 88–95; Shin, S. “Need for and Actual Use of Mental Health Service by Adolescents in the Child Welfare System.” Children and Youth Services Review 27 (2006): 1071–1083; DiRamio, D., R. Ackerman, and R. Mitchell. “From Combat to Campus: Voices of Student-Veterans.” NASPA Journal 45, no. 1 (2008): 73–102; Ostovary, F., and J. Dapprich. “Challenges and Opportunities of Operation Enduring Freedom/Operation Iraqi Freedom Veterans with Disabilities Transitioning into Learning and Workplace Environments.” New Directions for Adult and Continuing Education 2011: 63–73. doi: 10.1002/ace.432; Garofalo, R., C. Wolf, S. Kessel, J. Palfrey, and R. DuRant. “The Association between Health Risk Behaviors and Sexual Orientation among a High School Sample of Adolescents.” Pediatrics 101, no. 5 (1998): 895–902; Westefeld, J., M. Maples, B. Buford, and S. Taylor. “Gay, Lesbian and Bisexual College Students: The Relationship between Sexual Orientation and Depression, Loneliness and Suicide.” Journal of College Student Psychotherapy 15 (2001): 71–82; M. B. Neilans. Today ’s College Students and Their Mental Health Needs Are Requiring a Change in the Way College Campuses Address Mental Health Issues. The College at Brockport, Counselor Education Master's Theses, 2007. ]  [23:  Pedrelli, P., M. Nyer, A. Yeung, C. Zulauf, and T. Wilens. “College Students: Mental Health Problems and Treatment Considerations.” Academic Psychiatry : The Journal of the American Association of Directors of Psychiatric Residency Training and the Association for Academic Psychiatry 39, no. 5 (2015): 503–511. http://doi.org/10.1007/s40596-014-0205-9] 

College students deal with a range of mental health challenges. The Healthy Minds Study[endnoteRef:24] surveyed over 16,000 college students on more than 100 campuses using questions from standardized assessment instruments that incorporate criteria from the Diagnostic and Statistical Manual of the American Psychiatric Association.[endnoteRef:25] The survey attempted to identify students who are likely to have a mental disorder and whether they had been evaluated by a professional. The survey suggested that 35 percent of students met the criteria for at least one mental disorder in the prior 12 months.[endnoteRef:26] Further, in any year, six percent of undergraduate students and four percent of graduate students will have seriously considered suicide.[endnoteRef:27] Twenty percent of students have considered suicide at some point during their college career.[endnoteRef:28] [24:  Eisenberg, D., and S. Ketchen Lipson. “Healthy Minds Survey.” In Healthy Minds Network, 2016. Accessed March 22, 2017, Retrieved from http://healthymindsnetwork.org]  [25:  For more information, view here: https://www.psychiatry.org/psychiatrists/practice/dsm]  [26:  This included 20 percent of students meeting the criteria for moderate or more severe depression and 12 percent for major depression, as well as 20 percent of students meeting the criteria for anxiety, with 40 percent of these students meeting the criteria for severe anxiety.]  [27:  The American Psychological Association, Press Release (August, 2008), citing “Key Findings From the Suicide Ideation Survey,” Adryon Burton Denmark, University of Texas at Austin and “Defining the New Paradigm for Addressing Suicidality,” David J. Drum, Ph.D, University of Texas at Austin. http://www.apa.org/news/press/releases/2008/08/suicidal-thoughts.aspx (accessed March 23, 2017). ]  [28:  Douce, L., and R. Keeling. A Strategic Primer on College Student Mental Health. Washington, DC: American Council on Education, 2014. ] 

Too many students with mental health disabilities are not receiving treatment. According to the Healthy Minds Study, 61 percent of those meeting the criteria for a mental disorder were not getting any treatment. The American Psychiatric Association (APA) reports that only approximately 35 percent of students with a mood disorder received mental health services in the previous year.[endnoteRef:29] The 2014 National Survey of College Counseling Center[endnoteRef:30] Directors found that 86 percent of students who died by suicide did not seek help at the school’s counseling center.[endnoteRef:31] Other research uncovered that over half of college students who seriously considered attempting suicide had not received professional help in the past year.[endnoteRef:32] [29:  Eisenberg, D., E. Golberstein, and S. E. Gollust. “Help-seeking and Access to Mental Health Care in a University Student Population.” Medical Care 45 (2007): 594–601.]  [30:  The American College Counseling Association is made up of diverse mental health professionals from the fields of counseling, psychology, and social work, who work within higher education settings. ACCA membership includes professionals and student members who work largely in college counseling settings. Accessed March 22, 2017, http://www.collegecounseling.org/]  [31:  Gallagher, National Survey of College Counseling Centers 2014. ]  [32:  Drum, D. J., C. Brownson, A. Burton Denmark, and S. E. Smith. “New Data on the Nature of Suicidal Crises in College Students: Shifting the Paradigm.” Professional Psychology, Research and Practice 40 (2009): 213–222.] 

# Chapter 2. Benefits of Providing Mental Health Services and Supports

Strong mental and behavioral health services and supports can improve the academic performance of students and increase their resilience and ability to handle stress, with reduced suicide rates, substance abuse, and eating disorders. Additionally, colleges face less liability by addressing student mental health issues and benefit financially by retaining and graduating more students. Colleges have a unique opportunity through which they can “make a positive impact on the mental health of their students—college represents the only time in many people’s lives when a single setting encompasses their main activities as well as health services.”[endnoteRef:33] [33:  Hunt, Justin B., Daphne Watkins, and Daniel Eisenberg. “How Do College Campuses Make Decisions About Allocating Resources for Student Mental Health?: Findings from Key Participant Interviews.” Journal of College Student Development 53, no. 6 (2012): 850–856. Accessed March 23, 2017, https://muse.jhu.edu/article/490942] 

## Improved Academic Performance

Mental health problems can have a negative impact on the academic performance, retention, and graduation rates of students who do not receive support. The American College Health Association finds strong evidence that mental health needs are related to measures of academic success. Their survey found that students who reported psychological distress also reported the following:

They received lower grades on exams or important projects.

They received lower grades in courses.

They received incompletes or dropped courses.

They experienced significant disruptions in thesis, dissertation, research, or practicum work.[endnoteRef:34] [34:  The American College Health Association. American College Health Association‐National College Health Assessment II: California Community Colleges Reference Group Executive Summary Spring 2013. Hanover, MD: American College Health Association, 2013, p. 8. Accessed March 22, 2017, http://www.acha-ncha.org/docs/ACHA-NCHA-II_ReferenceGroup_ExecutiveSummary_Fall2013.pdf, ] 

Students who experience mild or moderate symptoms of depression or anxiety also demonstrate more academic difficulties and lower GPAs than nondepressed students.[endnoteRef:35] [35:  Locke, 2009; Deroma, Leach, and Leverett, 2009.] 

Not surprisingly, students who receive treatment for mental health disabilities report gains in academic performance. For example, 31 percent of students at one university receiving treatment for depression reported an increase in satisfaction with their ability to study or work, and 34 percent reported an increased sense of satisfaction with how much schoolwork they could do.[endnoteRef:36]  [36:  Klein, Behen, and Roy, National College Depression Partnership. Depression, Recovery, and Student Success, 2010.] 

## Increased Resilience and Reduced Stress

Resilience is a personality characteristic that moderates the negative effects of stress, promotes adaptation, and has been associated with increased psychological well-being. Pidgeon et al.[endnoteRef:37] found that university students with low levels of resilience reported significantly lower levels of perceived social support or campus connectedness and higher levels of psychological distress in comparison to those with high levels of resilience. According to the American Council on Education’s *Strategic Primer on College Student Mental**Health*,[endnoteRef:38] “the best way for colleges and universities to nurture resilience among students is to promote health and well-being, especially mental and behavioral health, at both individual and community levels.” Resilient students learn more and graduate more prepared; less resilient students take fewer intellectual and creative risks.[endnoteRef:39] [37:  Pidgeon, A. M., N. F. Rowe, P. Stapleton, H. B. Magyar, and B.C.Y. Lo. “Examining Characteristics of Resilience among University Students: An International Study.” Open Journal of Social Sciences 2 (2014): 14–22. http://dx.doi.org/10.4236/jss.2014.211003 ]  [38:  Douce and Keeling, A Strategic Primer on College Student Mental Health, 2014. Accessed June 21, 2017, https://www.apa.org/pubs/newsletters/access/2014/10-14/college-mental-health.pdf]  [39:  Douce and Keeling, A Strategic Primer on College Student Mental Health, 2014. Accessed June 21, 2017, https://www.apa.org/pubs/newsletters/access/2014/10-14/college-mental-health.pdf ] 

## Reduced Substance Abuse

Arria et al.[endnoteRef:40] found that excessive alcohol and drug use during college is linked to negative academic performance: students who use substances are more likely to have disruptions in their enrollment in college and fail to graduate. Weitzman[endnoteRef:41] found that students with poor mental health or depression were less likely to report never drinking; as likely to report frequent, heavy, and heavy episodic drinking; and more likely to report drinking to get drunk than other students. Further, the former group of students was more likely to report drinking-related harms and alcohol abuse. [40:  Arria, A. M., K. M. Caldeira, B. A. Bugbee, K. B. Vincent, and K. E. O’Grady. The Academic Opportunity Costs of Substance Use during College. College Park, MD: Center on Young Adult Health and Development, 2013. ]  [41:  Weitzman E. R. “Poor Mental Health, Depression, and Associations with Alcohol Consumption, Harm, and Abuse in a National Sample of Young Adults in College.” Journal of Nervous and Mental Disease 192, no. 4 (2004): 269–277.] 

## Reduced Suicide Rates

Suicide is the second leading cause of death among college students.[endnoteRef:42] The suicide rate among people 15–24 years of age has tripled since the 1950s.[endnoteRef:43] In any year, six percent of undergraduate students and four percent of graduate students will have seriously considered suicide.[endnoteRef:44] Community colleges serve a high proportion of students, including older students and commuter students, who are at greater risk of suicide than traditional students. Also at high risk are international students, LGBTQ students, and veterans. The Suicide Prevention Resource Center’s[endnoteRef:45] guidebook to promoting mental health and preventing suicide in college and university settings argues that college campuses with a comprehensive approach in place to assist in early intervention have a greater chance at reducing student suicide rates. This guidebook cites research by Joffe,[endnoteRef:46] who found that suicide rates at one Midwestern university were cut in half when the university instituted a policy requiring students who threatened or attempted suicide to attend four sessions of professional assessment. [42:  Eiser, A. “The Crisis on Campus.” American Psychological Association 42, no. 8 (September, 2011); Wilcox, H. C., A. M. Arria, K. M. Caldeira, K. B. Vincent, G. M. Pinchevsky, & K. E. O'Grady. “Prevalence and Predictors of Persistent Suicide Ideation, Plans, and Attempts during College.” Journal of Affective Disorders 127, no. 1–3 (2010); 287–294.]  [43:  College Degree Search. “Crisis on Campus: The Untold Story of Student Suicides.” College Degree Search. (2012). Accessed March 22, 2017, http://www.collegedegreesearch.net/student-suicides/ ]  [44:  College Degree Search, “Crisis on Campus: The Untold Story of Student Suicides,” 2012. ]  [45:  Suicide Prevention Resource Center. Promoting Mental Health and Preventing Suicide in College and University Settings. Newton, MA: Education Development Center, Inc., 2004. Accessed March 22, 2017, http://www.sprc.org/sites/default/files/migrate/library/college_sp_whitepaper.pdf]  [46:  Joffe, P. “An Empirically Supported Program to Prevent Suicide in a College Student Population.” Suicide and Life-Threatening Behavior 38, no. 1 (2008): 87–103.] 

## Economic Benefits for Colleges

Students who receive support for mental health disabilities such as depression are more likely to stay in school and to graduate. Eisenberg et al.[endnoteRef:47] note that increased student retention leads to higher tuition revenue, a strong financial benefit to the institution. A recent report of a survey to assess the impact of California Mental Health Services Authority (CalMHSA) investments in mental health programs at California public colleges estimated the net benefit of $6.49 for each dollar invested by CalMHSA in prevention and early intervention programs. More students used mental health services, more students graduated after receiving treatment, and these additional graduates will see increased lifetime earnings.[endnoteRef:48] [47:  Eisenberg, D., E. Golberstein, and J. B. Hunt. “Mental Health and Academic Success in College” the B.E. Journal of Economic Analysis Policy 9, no. 1 (2009). Retrieved June 19, 2017, doi:10.2202/1935-1682.2191. ]  [48:  Ashwood, J. S., D. Bradley, B. B. Stein, L. Padilla, M. W. Woodbridge, L. May, R. Seelam, and M. A. Burnam. Payoffs for California College Students and Taxpayers from Investing in Student Mental Health. Santa Monica, CA: RAND Corporation, 2015. http://www.rand.org/pubs/research_reports/RR1370.html.] 

Chapter 3. Purpose and Structure of Report

Providing individualized mental health support to students with mental health disabilities can lead to increased retention and graduation rates. Rather than requiring students to leave school when mental health issues challenge their ability to meet academic and social expectations, colleges can engage students in on-campus interventions such as individual or group counseling, provision of medication, workshops, and disability-related accommodations to help address underlying problems with substance use, mental health, or other issues. This individualized approach has shown promise for improving students’ chances of persisting and eventually completing college.[endnoteRef:49] [49:  Arria, A. M., K. M. Caldeira, B. A. Bugbee, K. B. Vincent, and K. E. O’Grady. The Academic Opportunity Costs of Substance Use During College.” College Park, MD: Center on Young Adult Health and Development, 2013.] 

Based upon interviews and questionnaires with key experts, mental health practitioners, and students, as well as a review of recent research, this report provides an overview of the current mental health services and policies in colleges in the United States. It documents the challenges faced by students with mental health disabilities and highlights the most promising policies and practices that promote their mental health and enhance their ability to access services and to continue in and graduate from postsecondary institutions and seek gainful employment once they graduate. Finally, we provide recommendations to improve mental health services and policies in postsecondary settings for students with mental health disabilities.

The study that informed this report was guided by the following research questions.

**Policy:**This includes gaps, weaknesses, and discriminatory aspects of current federal and college policy and recommendations for policy and system reforms at the postsecondary level.

Q1: What are the federal policies, particularly at the postsecondary level, that can reduce or remove barriers to mental health services on campus? How feasible are these policies in the current context? 

Q2: What is the current landscape of mental health services and policies in colleges in the United States?

Q3: What gaps, weaknesses, and discriminatory policies exist in these services?

Q4: What are schools’ policies regarding voluntary and involuntary leaves of absence, and confidentiality of mental health services?

Q5: What policy and system reforms affecting students with mental health disabilities in postsecondary settings are needed?

**Access:** This includes availability of mental health services on campuses; policy and physical barriers to students accessing services, as well as programmatic barriers; and whether students receive the appropriate reasonable modifications and accommodations to help them remain and succeed in school.

Q6: What barriers prevent colleges from providing accessible mental health services for students that are required by law? 

Q7: What can be done to enhance the inclusion, retention, and graduation of students with mental health disabilities in higher education?

Q8: Are mental health services adequately available on campus, including physical accessibility, appointment availability, and paperwork requirements?

Q9: Does the college provide services to all students regardless of physical or sensory disabilities?

Q10: Are students who disclose mental health disabilities provided reasonable modifications to policies and/or accommodations to remain in school, such as excused absences for mental health treatment, flexibility in class schedules, mental health leave, and emotional support animals in college housing (Fair Housing Act & Section 504)?

**Practice:**This includes the services that colleges provide to students with mental health disabilities, best and/or promising practices and emerging trends in the field in providing support to students, as well as best practices in training mental health professionals and college faculty and staff to effectively provide services.

Q11: What are current promising and best practices and emerging trends in providing support to students with mental health disabilities?

Q12: Have staff and faculty received adequate training to identify and provide support for students with mental illnesses or students who are experiencing extreme emotional distress?

Q13: Are faculty and staff trained on mental health issues and reasonable modifications and accommodations for students with mental health disabilities?

Q14: Does the college maintain relationships with available mental health providers in the community?

Q15: Is there a crisis management plan in place for students and staff to deal with a suicide or traumatic event?

Q16: Does the college use a peer-mentoring model as part of its services?

Q17: Does the college attempt to reduce stigma by, for example, locating mental health services in an area that respects the privacy of students? 

# Chapter 4. Methodology

## Interviews

### Practitioner and Expert Interviews

To understand the challenges, best practices, and emerging trends of supporting students with mental health disabilities and to provide relevant, practical recommendations for reform at all levels, structured, 45-minute telephone interviews were conducted with 37 key informants, including social science researchers, advocates, disability specialist and mental health service providers, and specific subpopulations, including individuals (both at the college and in the community serving college students) who are Deaf or HOH, graduate students, those involved in Greek life, and athletes. Interviews were also conducted with college administrators, college policymakers, and college legal counsel, among others. (For a list of interview questions posed and interviewees, see Appendix A.) A representative sample of key stakeholders was chosen based on several factors, including: type of institution (two- and four-year colleges), type of organization (government, nonprofit, university), role (mental health provider, college legal counsel), and geographical location. Interviewees were notified that all responses would be shared anonymously, thus all data in this report is de-identified. Interviews were recorded to ensure accurate notes. All recordings were deleted after the study. 

### Student Interviews

Eight students with knowledge of mental health services provided on their campuses were trained to lead in-person interviews with fellow students, aged 18 or older, to gain an understanding of students’ experiences on campus; students’ need for services; available services on campuses; the services students found most helpful; and challenges or barriers to access. Students were recruited through a NAMI [National Alliance on Mental Illness] On Campus listserv. Students who completed the questionnaire also had the opportunity to note their interest in interviewing other students. Students represented a sample of universities and colleges based on geographic diversity and type of institution. (For a list of interview questions and universities/colleges, see Appendix B.) Students were trained to ask questions, conduct follow-ups, and document responses. Student interviewers scanned and emailed, or mailed, interview responses, and responses were aggregated and integrated throughout the final report. Interviewees were asked to sign an informed consent that clarified, among other things, the purpose of the study, that the information provided would be de-identified, and that participants were free to withdraw from the interview at any time. After training, these students conducted a total of 48 interviews of other students.

## Questionnaires

### Practitioner/Expert and Student Questionnaires

Open-ended online and paper questionnaires were also administered to provide context for the themes identified in the interviews (e.g., providing rates for how common certain best practices are in colleges). Key informants and stakeholders were asked about the federal and college policies identified as impacting students with mental health disabilities and about practices and barriers identified in the literature review and other research. Practitioners and students were asked to complete an online SurveyGizmo questionnaire with open-ended responses, which was distributed at the 2016 Association on Higher Education and Disability (AHEAD) Annual Conference and the 2016 Disability Summit held by the Los Angeles Community College District. Further, links to the questionnaire were distributed through mental health organization listservs including NAMI, AHEAD, Disabled Student Programs and Services of the California Community College Chancellor’s Office, and Active Minds. In total, NCD received over 101 responses from practitioners and 148 responses from students. The questionnaires can be found in Appendix C.

## Twitter Chat

To engage a wider audience of individuals interested in college mental health, particularly among a younger demographic, NCD hosted a Twitter chat to discuss the current status of the field, the challenges faced by students with mental health disabilities, and the most promising practices to provide these students with support. NCD recruited six panelists with backgrounds in mental health or who were mental health service providers on their college campuses. To ensure a broad reach, NCD recruited organizations or individuals with many Twitter followers who were active users and then chose those accounts that represented diverse perspectives and organization types. Panelists included two mental health advocacy organizations (NAMI and the JED Foundation); two students with backgrounds in mental health advocacy; one student group with a focus on mental health (YouthMove); and one company that develops research-proven, online role-play simulations with the goal of improving individuals’ mental health (Kognito).

NCD’s Twitter account (@NatCounDis) posed the seven questions in Appendix D to panelists over the course of one hour, in roughly nine-minute intervals, in a “Q1/A1” format. The goal of the Twitter chat was to engage other Twitter users in the conversation. There was a total of 598 posts, 448 of which directly addressed the seven questions posed. In addition to the Twitter chat host and six panelists, there were 106 other participants who tweeted directly about the proposed questions. See Appendix D for the list of questions posed throughout the Twitter chat.

# Chapter 5. Federal Laws Impacting College Mental Health Services

## Federal Disability Laws

The two primary federal laws that apply to students with disabilities are Section 504 of the Rehabilitation Act of 1973 (Section 504)[endnoteRef:50] and the Americans with Disabilities Act of 1990 (ADA).[endnoteRef:51]  [50:  Pub. L. 93-112, 87 Stat. 394 (29 U.S.C. 794), as amended.]  [51:  42 U.S.C. §§ 12101-12300] 

### Section 504 of the Rehabilitation Act

Section 504 states, “No otherwise qualified individual with handicaps in the United States . . . shall, solely by reason of her or his handicap, be excluded from the participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving Federal financial assistance.” This prevents any college that receives direct or indirect federal financial assistance, including those that accept students who receive federal financial aid, from discriminating against an individual because of his or her disability. Thus, Section 504 covers almost all colleges and universities, public or private, protecting the rights not only of individuals with visible disabilities but also those with disabilities that are not visible.

### The Americans with Disabilities Act

Both public and private colleges and universities must provide equal access to postsecondary education for students with disabilities. Title II of the ADA covers publicly-funded universities, community colleges, and vocational schools. Title III of the ADA covers privately-funded schools. All schools, public or private, that receive federal funding are required under Section 504 of the Rehabilitation Act to make their programs accessible to students with disabilities.[endnoteRef:52] Title II of the ADA extends section 504's nondiscrimination requirement to all activities of state and local governments, not only those that receive federal financial assistance. Title II states: “[N]o qualified individual with a disability shall, by reason of such disability, be excluded from participation in or be denied the benefits of the services, programs, or activities of a public entity, or be subjected to discrimination by any such entity.”[endnoteRef:53]  [52:  What are a public or private college-university's responsibilities to students with disabilities? Accessed March 4, 2017, https://adata.org/faq/what-are-public-or-private-college-universitys-responsibilities-students-disabilities ]  [53:  42 U.S.C. §§ 12132] 

The protections of Section 504 and Title II, which are generally the same in the context of education, cover all aspects of these institutions’ programs and activities. Under Section 504 and Title II, colleges are required to make reasonable modifications in policies, practices, or procedures when the modifications are necessary to avoid discrimination based on disability, unless it can demonstrate that making the modifications would fundamentally alter the nature of the service, program, or activity[endnoteRef:54] or would result in an undue financial or administrative burden on the institution.[endnoteRef:55] [54:  Department of Justice, ADA Title III, Technical Assistance Manual, covering Public accommodations and commercial facilities, section III- 4.3600 (1993), http://www.ada.gov/taman3.html. A “fundamental alteration” is a modification that is so significant that it alters the essential nature of the goods, services, facilities, privileges, advantages, or accommodations offered.]  [55:  28 C.F.R. § 36.104 (“undue burden means significant difficulty or expense”); 20 42 U.S.C. § 12182(b)(2)(A)(ii)-(iii).] 

### Postsecondary School Provision of Auxiliary Aids

Mental health services require communication between a student and a counselor, but for students with disabilities that impair their ability to communicate, such as students who are deaf or hard of hearing, auxiliary aids may be necessary to facilitate communication. Section 504 and Title II require postsecondary schools receiving federal financial assistance to provide effective auxiliary aids to students who are disabled to enable them to participate and benefit from a school’s services, programs, and activities.[endnoteRef:56] [56:  The Section 504 regulation contains the following requirement relating to a postsecondary school's obligation to provide auxiliary aids to qualified students who have disabilities: “A recipient . . . shall take such steps as are necessary to ensure that no handicapped student is denied the benefits of, excluded from participation in, or otherwise subjected to discrimination under the education program or activity operated by the recipient because of the absence of educational auxiliary aids for students with impaired sensory, manual, or speaking skills.” 34 C.F.R. 104.4(d). The Title II regulation states: “A public entity shall furnish appropriate auxiliary aids and services where necessary to afford an individual with a disability an equal opportunity to participate in, and enjoy the benefits of, a service, program, or activity conducted by a public entity.” 28 C.F.R. 35.160(b)(1).] 

If an auxiliary aid is necessary for students to participate in mental health counseling services provided by the college, the college must make it available, unless provision of the aid would cause undue burden. A student with a disability may not be required to pay for that aid or service; however, a student in need of such aid is obligated to provide notice of the nature of the disabling condition to the college and to assist it in identifying appropriate and effective auxiliary aids.[endnoteRef:57] [57:  https://www2.ed.gov/about/offices/list/ocr/docs/auxaids.html, accessed 4/6/2017] 

The Departments of Justice (DOJ) and Education, Office for Civil Rights (OCR) share responsibility for protecting the rights of college students with disabilities. DOJ enforces title III of the ADA, and DOJ and ED both have enforcement authority under Title II of the ADA. In addition, the ED enforces Section 504 with respect to public and private colleges and universities that receive federal financial assistance from the ED.[endnoteRef:58] [58:  https://www.ada.gov/kindle_ltr_eddoj.htm] 

### The Fair Housing Act 

The Fair Housing Act[endnoteRef:59] (FHAct) makes it unlawful to deny a dwelling to a person based on the person’s disability, and requires housing providers, including colleges that provide student housing, to make reasonable accommodations for persons with disabilities if needed to afford them an equal opportunity to use and enjoy a dwelling.[endnoteRef:60] The FHAct is relevant for students with mental health disabilities who live in college housing and require the assistance of an emotional support animal[endnoteRef:61] as a reasonable accommodation.[endnoteRef:62] Section 504 may also be used to request the accommodation of an emotional support animal in college housing.[endnoteRef:63] [59:  42 U.S.C. § 3601 et seq. ]  [60:  42 U.S.C. § 3601 et seq. ]  [61:  Emotional support animals are expressly precluded from qualifying as “service animals” under the ADA. 28 C.F.R. 35.104.]  [62:  See U.S. v. University Of Nebraska at Kearney, et al., which held that University of Nebraska student housing facilities are clearly “dwellings” within the meaning of the FHA. Accessed May 20, 2017 from https://www.ada.gov/kearney_order.pdf ]  [63:  https://portal.hud.gov/hudportal/documents/huddoc?id=servanimals_ntcfheo2013-01.pdf, accessed 4.4.17] 

The Office of Fair Housing and Equal Opportunity, U.S. Department of Housing and Urban Development enforces the FHAct.

## Federal Privacy Laws

In addition to ADA and Section 504, the key federal laws that apply to students with mental health issues and institutions’ treatment of the students are the Family Educational Rights and Privacy Act of 1974 (FERPA) and the Health Insurance and Portability and Accountability Act of 1996 (HIPAA). 

### Family Educational Rights and Privacy Act

FERPA regulates the keeping and dissemination of education records at all institutions that receive federal funds or who have students receiving federal funds. Consent must be obtained to release education records to a third party, with certain exceptions contained in the law. College officials with a legitimate educational interest in the record may have access to it.[endnoteRef:64]–[endnoteRef:65] [64:  Lannon, Paul. “Using Student Medical Records: Department of Education Issues New Guidance.” (2015). Accessed March 22, 2017, https://www.hklaw.com/publications/Using-Student-Medical-Records-Department-of-Education-Issues-New-Guidance-09-02-2015/ ]  [65:  The U.S. Department of Education issued new guidance on college obligations under FERPA in a “Dear Colleague” letter, dated August 18, 2015, which addressed four exceptions: (1) treatment records, (2) school officials, (3) litigation, and (4) health or safety emergencies. See McBain, Lesley. “Balancing Student Privacy, Campus Security, and Public Safety: Issues for Campus Leaders.” Perspectives, American Association of State Colleges and Universities (Winter 2008); According to the Bazelon Center: “As permitted by law, the counseling center may disclose information about a student to the extent needed to protect the student or others from a serious and imminent threat to safety, for example, by making disclosures to crisis intervention or emergency personnel. Disclosures are permitted only if the student will not consent to interventions that will ameliorate the risk. See American Psychiatric Association. Practice Guideline for Assessment and Treatment of Patients with Suicidal Behaviors, 2003 (disclosures permitted to protect safety of patient and others if patient is or is likely to become dangerous and will not consent to interventions that will ameliorate the risk). Cf. Health Insurance Portability and Accountability Act (HIPAA), 42 U.S.C. 201 et seq., 45 C.F.R. 164.512(j) (disclosures permitted to prevent or lessen serious and imminent threat to a person or the public), 45 C.F.R. 164.512(f) (disclosures permitted for certain law enforcement purposes); Family Education Rights and Privacy Act (FERPA), 20 U.S.C. 1232g(b)(1)(I), 34 C.F.R. 99.36 (disclosures permitted in emergency to protect health or safety of student or others).” (Bazelon Center for Mental Health Law “Supporting Students: A Model Policy for Colleges and Universities,” 2007. Accessed March 22, 2017, https://dmh.mo.gov/mentalillness/docs/supportingstudents.pdf)] 

### Health Insurance and Portability Accountability Act

HIPAA (in addition to state law) governs the release of uniquely identifiable medical information on patients by health care providers. Medical information is defined as all information, either written or oral, obtained during a course of treatment.[endnoteRef:66] [66:  http://www.aascu.org/uploadedFiles/AASCU/Content/Root/PolicyAndAdvocacy/PolicyPublications/08_perspectives(1).pdf ] 

## Policies and Practices Negatively Impacting Provision of Campus Mental Health Services

Interviewees and questionnaire respondents highlighted several significant barriers to the academic success of students with mental health disabilities. This section discusses each of these policy barriers in detail.

### Threat to Self Policies Requiring Mandatory Withdrawal or Mandatory Leave of Absence 

In responding to students with mental health crises, discussion often focuses on whether, consistent with ADA, schools can use disciplinary action, LOA, or suspension to remove students from campus. Each of the legal experts interviewed and questionnaire respondents identified the need for clear direction from ED OCR on how to respond to a student who may self-harm and for clear guidance on when colleges may require a student that threatens self-harm to withdraw or take a medical LOA.

The regulations under Title I of ADA expressly recognize that employers need not accommodate employees who pose a “direct threat” to the health or safety of themselves or others, and provide a framework for assessing whether an employee poses such a threat.[endnoteRef:67] In the absence of a Title II regulation that provided colleges with a framework that applied to students, many colleges adopted the Title I framework and developed policies and procedures, including those related to medical withdrawal and involuntary withdrawal, to respond to students who posed a direct threat to the health or safety of themselves or others. Colleges anticipated that the 2011 Title II regulations would include “direct threat” provisions applying to students, but the regulations did not. Colleges have not received guidance from OCR or DOJ on how they can properly respond to students at risk of self-harm or harming others while maintaining compliance with disability laws.  [67:  29 C.F.R. § 1630.15(b)(2); 29 C.F.R. § 1630.2(r) (Direct Threat means a significant risk of substantial harm to the health or safety of the individual or others that cannot be eliminated or reduced by reasonable accommodation. The determination that an individual poses a “direct threat” shall be based on an individualized assessment of the individual's present ability to safely perform the essential functions of the job. This assessment shall be based on a reasonable medical judgment that relies on the most current medical knowledge and/or on the best available objective evidence. In determining whether an individual would pose a direct threat, the factors to be considered include: (1) the duration of the risk, (2) the nature and severity of the potential harm, (3) the likelihood that the potential harm will occur, and (4) the imminence of the potential harm. ] 

Students are also impacted by the lack of guidance to colleges. One result of this lack of guidance has been discrimination complaints filed with OCR and lawsuits alleging disability discrimination. Colleges have evicted students from their dormitories or placed them on involuntary leave in response to threats to hurt themselves. Colleges have also encouraged voluntary or involuntary hospitalization for students in response to mental health crises.[endnoteRef:68] Such policies result in students not seeking help for fear of being forced to leave school.[endnoteRef:69]  [68:  Bazelon Center for Mental Health Law. “Campus Mental Health Know Your Rights,” 2008. Accessed March 22, 2017, http://www.bazelon.org/wp-content/uploads/2017/01/YourMind-YourRights.pdf]  [69:  For example, according to the NAMI on Campus survey, a few students reported that they often do not go to campus health centers for fear of being sent to the hospital and thus possibly missing exams, being denied readmittance to school, or suffering other negative outcomes. ] 

A fundamental problem is that, without considering students’ individual circumstances, disciplinary charges or mandatory leaves of absence are imposed on students who appear to have self-injurious behaviors or thoughts and/or seek psychiatric treatment. If students fear reprisal when their efforts to obtain help come to administrators’ attention, many will suffer in silence.[endnoteRef:70] [70:  Bazelon Center for Mental Health Law. “Student Punished for Getting Help,” 2006. Accessed March 22, 2017, http://www.bazelon.org/nott-v-george-washington-university/] 

Colleges should know that they have to consider alternatives to forcing a student with a mental health condition to withdraw.[endnoteRef:71] In a discrimination settlement at Quinnipiac University, a student went to the counseling center, was then “transported to the hospital, evaluated, and released a few hours later. In that brief time, the university had already placed her on mandatory medical leave, pending a review by a university-approved psychiatrist, according to her attorneys.”[endnoteRef:72] Under the terms of the settlement, in addition to compensating the student, Quinnipiac had to “develop a nondiscrimination policy and provide training on the ADA with an emphasis on mental health-related disabilities.”[endnoteRef:73] [71:  Mulhere, Kaitlin. “Illegal Mandatory Leave,” January 20, 2015. Accessed March 22, 2017, https://www.insidehighered.com/news/2015/01/20/mandatory-leaves-mental-health-conditions-raise-discrimination-concerns]  [72:  Kaitlin, “Illegal Mandatory Leave,” 2015. ]  [73:  Mulhere, “Illegal Mandatory Leave,” 2015. ] 

In fall 2004 at George Washington University, a straight-A sophomore sought emergency psychiatric care for depression. “When they learned of [the student’s] hospitalization, university officials charged him with violating the school code of conduct, suspended him, evicted him from his dorm, and threatened him with arrest for trespassing if he set foot on university property.”[endnoteRef:74] The student filed a lawsuit which resulted in an out-of-court settlement.[endnoteRef:75]  [74:  Bazelon Center for Mental Health Law, Student Punished for Getting Help,” 2006. http://www.bazelon.org/nott-v-george-washington-university/]  [75:  “Terms of This Settlement Are Confidential.” Accessed April 4, 2017, http://www.bazelon.org/nott-v-george-washington-university/] 

According to the Bazelon Center for Mental Health Law, the decision to impose an LOA should only be made in the uncommon circumstance that a student cannot safely remain at a university or meet academic standards, even with accommodations and other supports. The same applies to exclusion from university housing, which should be imposed only if a student cannot safely remain in the housing, even with accommodations. A school should impose an LOA or require a student to live off campus only after an individualized assessment. The assessment should consider whether there is a significant risk that the student will harm him/herself or another and whether the risk cannot be eliminated or reduced to an acceptable level through accommodations. Information from mental health professionals may be vital in making this assessment. 

If the school then does decide to act, the student is entitled to what are called “due process protections.” These include notifying the student of the action the school is considering and an explanation of why the school believes that such an action is necessary. The student and his or her representative should have an opportunity to respond and provide relevant information. The school may inquire into a student’s current condition and request recent mental health information and records. But it can only request information and records that are necessary to determine whether the student is a threat. The school cannot insist on unlimited access to confidential information or records. Students have a right to limit a release of information to specific dates, and have a right to approve and to review information that is being made available to the school. At the very least, the school should provide the same arrangements for withdrawal from classes, incompletes, and refunds of tuition or other costs as it does for a student who takes an LOA or leaves college housing for physical health reasons.[endnoteRef:76] [76:  Bazelon Center for Mental Health Law, “Campus Mental Health Know Your Rights,” 2008. http://www.bazelon.org/wp-content/uploads/2017/01/YourMind-YourRights.pdf] 

Interviewees expressed concern that when students are suspended or expelled from school, they must grapple with a cascading set of issues, including treatment options, residency requirements, the impact of the interruption on their academic progress, and economic consequences such as the jeopardizing of scholarship and financial aid eligibility, lost tuition, and effects on student loans and insurance. Furthermore, students on LOAs for mental health challenges often do not get tuition reimbursements or may only get partial refunds. There are instances in which students who take leave for a physical health reason are provided with different supports in terms of their transcript, GPA, and return. The best practice, according to interviewees, is to ensure that course withdrawals are taken off students’ transcripts or to cite “leave of absence” with the dates on students’ academic records to prevent unfairly impacting students.

There are no hard and fast answers—each situation requires individualized assessment of the risk and whether accommodations can be provided that can keep the student in school. In keeping with the guideline of doing what is best to support students on a case-by-case basis, colleges have multiple options depending on the situation. Colleges can employ flexible academic policies for leave, reduced course load, and remote learning, among other methods, to accommodate students with mental health crises. Georgetown University has a policy of “freshmen forgiveness”—grades can be forgiven in recognition of the difficult transition from high school to college. While not currently used for students with mental health challenges, this policy is an example of an accommodation if grades are impacted by such challenges.

OCR held discussions with members of the National Association of College and University Attorneys and the National Association of Student Personnel Administrators through 2016 to discuss the organizations’ concerns and requests for guidance, but to date, OCR has not provided guidance on the issue. Colleges reported that they continue to rely on individual campus-by-campus settlements, OCR resolution agreements, and court cases to shape their policies.

### Readmission Policies

Legal experts also expressed the need for practical guidelines on readmitting students to colleges after mandatory LOAs, particularly if they can require medical records or other documentation before allowing students to be reinstated. The experts noted that some colleges may have onerous requirements for readmittance, including stipulating that students submit applications to return by a certain date. In some cases, this date is four months in advance—too long a period for situations involving students’ mental health. Colleges also often have blanket policies requiring one or two semesters off, rather than the length of time that best supports each student on a case-by-case basis. Often, students get their letters of readmission in August, so close to the beginning of the semester that it is difficult for students to return.

Cases resolved by OCR inform on practices that do not discriminate on the basis of disability, including mental illness.[endnoteRef:77] Based on these cases, students do not need to be “cured,” “well,” or “no longer needing accommodations” to return to school, nor does it have to be the case that the “disability-related behavior not recur unless that behavior creates a direct threat that cannot be reduced to an acceptable level with accommodations.”[endnoteRef:78] Further, students are not required to submit medical records as a condition of return from medical leave because the University did not require students taking medical leave for other reasons to submit medical records.[endnoteRef:79] [77:  http://www.bazelon.org/wp-content/uploads/2017/01/12.16.10-Spring-Arbor-University-OCR-Letter.pdf]  [78:  Bazelon Center for Mental Health Law, “Campus Mental Health Know Your Rights,” 2008. http://www.bazelon.org/wp-content/uploads/2017/01/YourMind-YourRights.pdf]  [79:  Petitions from students with mental illness may be handled differently only to the extent necessary to prevent direct threats to the safety of others. http://www.bazelon.org/wp-content/uploads/2017/01/12.16.10-Spring-Arbor-University-OCR-Letter.pdf] 

The Bazelon Center outlines a model policy, based upon these court cases, that allows students to request a return at any time, honors opinions on students’ capabilities to return to school from their treating mental health professionals, treats standards or procedures to return to school equally for students who have taken leave for physical health or mental health reasons, and asks colleges to consider accommodations that would allow students to meet academic standards and remain safely in school.[endnoteRef:80] [80:  Bazelon Center for Mental Health Law, “Supporting Students: A Model Policy for Colleges and Universities,” 2007. Accessed March 22, 2017, https://dmh.mo.gov/mentalillness/docs/supportingstudents.pdf] 

### Financial Aid and Other Financial Policies 

The second most common policy change suggestion (nine percent of suggestions) from practitioner questionnaire respondents was for more flexible financial aid policies and financially forgiving policies (i.e., no penalties) if students must take LOAs. Student respondents also noted the need for supportive medical LOA policies, including a full tuition refund and the ability to enroll part time and still access scholarships and financial aid. 

The Higher Education Act includes several provisions for the financial needs of students with disabilities, including funds for student support services, increased student financial aid when disability-related expenses are significant, and discretion for financial aid officers to adjust aid packages according to special circumstances. However, practitioners and students still noted that restrictions in the provision of aid negatively impact the ability of students with mental health challenges to succeed in school. For example, the Pell Grant program provides need-based grants to undergraduate students and is the foundation for all federal student aid (FSA) awarded to undergraduates. To be eligible to receive Pell Grants, students must meet the general eligibility criteria for all FSA programs and be enrolled at eligible colleges to earn degrees or certificates. Students are subject to a cumulative lifetime eligibility cap of 18 full-time semesters (or the equivalent), which is prorated for students who attend on less than a full-time basis.[endnoteRef:81] However, many students with mental health disabilities are not able to complete what is considered full-time course loads and are much more successful taking one or two courses at a time. According to one survey respondent, “the majority of the students at my institution are receiving federal financial aid, and because they find partial course loads more mentally achievable than the full load, they are more successful in completing the requirements of their associate’s degrees. Unfortunately, the college is being held to students completing degrees within the [set] time frame, and so the pressure falls on students who have mental challenges to take full loads**even though they are more likely to have mental lapses in their various diagnoses.” [81:  Title IV, Subpart A of The Higher Education Act of 1965. Section 401c: Period of Eligibility for Grants. The HEA was last comprehensively reauthorized in 2008 by the Higher Education Opportunity Act of 2008 (HEOA; P.L. 110-315), but has been extended. “The period during which a student may receive Federal Pell Grants shall not exceed 18 semesters, or the equivalent of 18 semesters, as determined by the Secretary by regulation. Such regulations shall provide, with respect to a student who received a Federal Pell Grant for a term but was enrolled at a fraction of full-time, that only that same fraction of such semester or equivalent shall count towards such duration limits. The provisions of this paragraph shall apply only to a student who receives a Federal Pell Grant for the first time on or after July 1, 2008.’’] 

Other federal student support services programs, such as TRIO,[endnoteRef:82] primarily serve individuals who are or would be low-income, first-generation college students, but also serve students with disabilities, students at-risk of academic failure, veterans, homeless youth, foster youth, and individuals underrepresented in graduate education by providing financial assistance through grant aid,[endnoteRef:83] as do veterans’ benefits programs.  [82:  The Federal TRIO Programs (TRIO) are Federal outreach and student services programs designed to identify and provide services for individuals from disadvantaged backgrounds. TRIO includes eight programs targeted to serve and assist low-income individuals, first-generation college students, and individuals with disabilities to progress through the academic pipeline from middle school to postbaccalaureate programs. TRIO also includes a training program for directors and staff of TRIO projects. https://www2.ed.gov/about/offices/list/ope/trio/index.html?exp=4]  [83:  Section 317 (a) Section 402D of the Higher Education Act of 1965 (20 U.S.C. 1070a-14).] 

“Funds from campus-based programs (Supplemental Grants, Perkins Loans, and Work Study) can be awarded to students with any level of attendance. However, first preference in granting these scarce funds is usually given by financial aid administrators to students pursuing the standard full-time course load,”[endnoteRef:84] which places burden on students with mental health disabilities who may not be able to successfully attend full time. [84:  Wolanin, Thomas R., and Patricia E. Steele. “Higher Education Opportunities for Students with Disabilities.” The Institute for Higher Education Policy, 2004. Accessed March 22, 2017, https://www.ahead.org/uploads/docs/resources/ada/Opportunities%20for%20Students%20with%20Disabilities.pdf ] 

Students with mental health disabilities often have expenses related to their disabilities, further increasing their need. These expenses impact students in many ways. First, the FAFSA does not explicitly ask about disability-related costs, instead advising the student, “If you or your family have unusual circumstances that should be taken into account, contact your college’s financial aid office.”[endnoteRef:85] This stipulation requires students with disabilities to navigate an additional step and make their cases to the student financial aid administrator. Further, disclosure of a disability does not always result in increased aid.[endnoteRef:86] Second, many students with disabilities, including mental health disabilities, are worried about student loans because of their disability-related needs. They worry that they may not be able to work enough to repay the loans. Third, financial aid often comes in a package of grants that need not be repaid, loans, and work. Students with mental health disabilities—many of whom need to have reduced course loads anyway—may not be able to add work study hours on top of their course loads due to limitations of their time, skills, or capacity for work.[endnoteRef:87] Fourth, if students are required to leave school for a semester or a year, the repayment on their loans kick in, which can create enormous financial stress and increase the psychiatric issues students already have.  [85:  Accessed March 22, 2017, https://fafsa.ed.gov/fotw1617/pdf/PdfFafsa16-17.pdf]  [86:  Moore, Rebecca for the Youth Advisory Committee of the National Council on Disability. Students with Disabilities Face Financial Aid Barriers. Washington, DC: National Council on Disability, 2003. Accessed March 22, 2017, http://www.ncd.gov/publications/2003/09292003-2#3]  [87:  Moore, Students with Disabilities Face Financial Aid Barriers, 2003; Wolanin, Thomas R. “Students with Disabilities: Financial Aid Policy Issues.” NASFAA Journal of Student Financial Aid 35, no. 1 (2005): 17–26. Accessed March 22, 2017, http://files.eric.ed.gov/fulltext/EJ965779.pdf] 

### Funding Policies for Programs and Supports

Practitioner questionnaire responses highlighted issues of access to and provision of quality services to students with mental health disabilities, and that a key barrier to increasing access, providing services, and training faculty and staff was a lack of financial resources.

Forty-seven percent of practitioners believed that restricted availability of mental health services due to funding limitations was a major problem impeding the success of students with mental health disabilities. Thirty-three percent noted that services provided currently were not adequate (only two respondents said they did have comprehensive services, and the remaining participants did not respond). Practitioners noted the lack of funds to hire additional staff to provide services to the increasing number of students seeking aid. Practitioners also said that the services colleges did offer need to be enhanced, and community health providers were sometimes not available to meet students’ needs. Practitioners reported that lack of funding was the reason that many colleges have limited hours of operation, fees, waitlists to see a counselor, and may suffer from a lack of licensed counselors. They also noted the need for increased training for faculty and staff.

### Confidentiality 

Finally, three interviewees noted challenges in understanding and adhering to confidentiality laws as related to student treatment records. Responses to a survey of 765 students conducted by NAMI also found that a top five reason why some college students did not disclose their diagnoses to receive accommodations, was because they feared the lack of confidentiality.[endnoteRef:88] Fear of lack of confidentiality is a key barrier in students not seeking help. [88:  Gruttadaro, Darcy, and Dana Crudo. “College Students Speak: A Survey Report on Mental Health.” NAMI. Arlington, VA: 2012. Accessed March 22, 2017, https://www.nami.org/getattachment/About-NAMI/Publications-Reports/Survey-Reports/College-Students-Speak_A-Survey-Report-on-Mental-Health-NAMI-2012.pdf] 

Legal counsel who were interviewed reported that some colleges are confused over how FERPA and HIPAA work together and what information may be disclosed about a student, under what circumstances, and to whom. Several student and expert interviewees noted that students are not likely to go to the school counseling center if they worry about the confidentiality of the visit, noting that some students prefer off-campus services because of the confidentiality. Another tension is between college confidentiality for adult students and parents wanting to know what is going on.[endnoteRef:89] “Universities walk a fine line when providing treatment or mental-health services to students. If campus officials don’t know what’s going on or disclose too little, they risk being blamed if a student harms himself, herself, or others. If they pry too deeply, they may be accused of invading privacy, thereby discouraging students from seeking treatment.”[endnoteRef:90] [89:  See Christina Cauterucci. “At Universities, Students’ Medical Records are Open Territory.” October, 2015.http://www.slate.com/blogs/xx_factor/2015/10/23/university_students_have_little_right_to_privacy_in_medical_records.html; and Charles Ornstein “When Students Become Patients, Privacy Suffers.” October, 2015. https://www.propublica.org/article/when-students-become-patients-privacy-suffers]  [90:  Ornstein, “When Students Become Patients, Privacy Suffers,” 2015. ] 

# Chapter 6. Access to Quality Mental Health Services

The bottom line is services. If you don’t have services available when students need it, nothing else is going to correct for that. If you have a mental health challenge and you need access to services in that moment—it’s not that you need service a month later. If you’re going to treat the student, you need to provide full treatment up to specialty referrals. This would enable the vast majority of students with mental health challenges to be successful. —College Counseling and Psychological Services Director

This section discusses the availability of mental health services, provision of qualified mental health professionals on campuses, barriers to services faced by students, and whether appropriate reasonable accommodations are provided for students to remain and succeed in school.

## Policies and Practices That Enhance the Inclusion, Retention, and Graduation of Students with Mental Health Disabilities

Seventy-six practitioners and 148 students responded to the question about what practices their colleges engage in to enhance the inclusion, retention, and graduation of students with mental health disabilities. Table 1 shows their responses as percentages. 

Table 1: Percentage of practitioners and students who named certain practices their colleges should engage in to enhance inclusion, retention, and graduation of students with mental health disabilities

### Improving Access to Services

The largest number of respondents (47 percent) believed that restricted availability of services due to federal, state, and college funding limitations was a major problem impeding the success of students with mental health disabilities. Of these respondents, 83 percent believed that mental health services could be improved through having more trained staff on campus, including counselors, case managers, academic advisors, and support staff, and making available psychiatrists and medications, as well as support from peer-to-peer workers who have been successful in their own mental health recovery efforts and educational pursuits. Increasing the number of trained staff would decrease (or eliminate) waiting lists for appointments. Seventeen percent of respondents suggested improving the process to better support students, including the following:

developing better screening and diagnostic procedures,

giving students access to more technology-based tools to help them succeed, 

referring students in a timely and streamlined manner to outside services and supports and following up, 

increasing community support as well as campus outreach, 

developing appropriate new programs, 

creating individualized success plans with students, and 

training counselors on cultural diversity. 

Fifty-four percent of students reported that providing adequate services and accommodations, including more counselors, free appointments, case managers, mentoring, and flexible accommodations, would most help students succeed. 

### Increased Training for Faculty and Staff

The second most common response to the practitioner questionnaire regarding barriers to access for students with mental health disabilities was the need for increased training for faculty and staff (34 percent). Thirteen percent of students also argued for more training of faculty and staff. Most respondents suggested increased faculty and staff mental health awareness training in general; a few suggested, more specifically, specific training on the ADA's requirements and compassionate responses to those seeking help, best support strategies and available resources, identification and referral of students in crisis.

### Policy Reforms

Questionnaire respondents suggested various policy reforms (33 percent). The most common suggestion (36 percent of policy suggestions) was to allow students to take reduced course loads and extended degree completion timelines, and still be eligible for financial aid and support from other categorical programs and federal programs, such as Student Support Services Projects. One respondent wrote, “Federal guidelines for financial aid can discriminate against mentally ill or physically ill students (who have to drop out due to illness) and then do not meet the 75 percent enrollment rate. There is a need to make taking a reduced credit load more commonly accepted. This would allow students to carry a more manageable course load, which helps significantly with symptom management for many students with mental health conditions.”

Other policy reform suggestions aimed at enhancing the inclusion, retention, and graduation of students with disabilities included implementing financial forgiveness policies (i.e., no penalties) if students with mental health disabilities need to take LOAs (24 percent of policy responses), mandating education of faculty on accommodating students with mental health disabilities, avoiding discrimination on the basis of mental health assumptions, and providing risk assessment (or ways to reach out to campus colleagues at the first signs of student distress) (8 percent of policy responses). Other suggestions included flexible deadlines for assignments and class attendance leniency, having transparent guidelines for LOA and other enrollment policies, more mental health services, and more financial support for students with mental health disabilities.

### Outreach and Education

Respondents suggested increased and more effective outreach and education for students (17 percent of all responses) including, in about equal numbers, self-advocacy training, support to more easily seek help, training in resiliency skills, and education on campus policies and federal regulations. Full transparency of available services was a key factor in these suggestions.

### Integrated Services

Respondents (14 percent) discussed integrating mental health promotion into the larger college community through making diversity and inclusion a priority (including hiring a chief diversity officer), modifying the campus climate to acknowledge disability as a diversity issue (e.g., other aspects of diversity are valued, both visible and invisible forms of disability should be recognized and respected), and providing “universal design” in the classroom and in the campus community: a comprehensive mental health system of services and supports throughout the campus rather than in just counseling services and disability services.

Thirty-four percent of students reported that creating a culture of support, not currently in place, and reducing stigma would help students with mental health disabilities succeed. Students thought that colleges have “a culture that does not recognize the need for a more robust system of mental health services” and that they have a lack of “will power” when it comes to supporting students with mental health disabilities. Other students believed that “a lot of it is due to image. [Colleges] want to protect their image and think that by not acknowledging the issue this will protect them. The fact that they kick out students who have attempted suicide proves this. It’s awful.” Students also suggested increasing opportunities for students to be heard, such as through student organizations.

One respondent noted that it is “critical that students with disabilities have a voice in shaping the services on their campus. The understanding of this population has frequently been through the lens of the medical model centering on illness issues, and not a recovery model. Thus, many times the student voice has not been valued when making decisions about their own lives, never mind about policies and practices at colleges.”

## Availability of Mental Health Services on Campus

Per interviewees and practitioner questionnaire respondents, colleges ensure, to the extent possible, that they use their resources to meet the largest need; however, they face multiple barriers to providing access to mental health support for students. 

In the practitioner questionnaire sample, as noted earlier in the Funding Policies for Programs and Supports section, 33 percent of respondents noted that currently provided services were not adequate (while only two respondents said they did have comprehensive services and the remaining participants did not respond). One respondent wrote,

No, available services are not adequate. That said, our health center provides 55 hours a week of individual therapy, group therapy, crisis intervention and outreach. We try to collaborate with our county mental health department, but with limited resources we are often not present at our service area meetings to collaborate with them. In addition, without the presence of a full-time supervising psychologist, staff and faculty training is minimal. Our mental health department is paid for by student health fees, meaning they only see students. We need a psychologist paid for out of the general fund so faculty/staff training can be incorporated into the [psychologist] job description. —Health Center Director, Community College

Most students interviewed were not sure (15 percent) or did not respond to the question (52 percent) of whether their colleges provided adequate services. Twenty-one percent of students believed that their colleges provided adequate services and 13 percent reported services were not adequate. One student said, “I think they are adequately available, for students who have the initiative to seek them out.” Even when students generally thought that services were available, they still recognized barriers to access.

In addition to the questionnaire and interviews, the study drew upon three other nationwide surveys and data sets that document services that colleges provide to students.[endnoteRef:91]  [91:  While these surveys are administered to community colleges as well as four-year institutions, community college respondents are a very low percentage of overall responses. In addition, the survey administered by the Association for University and College Counseling Center Directors does not provide publicly differentiated data according to two- and four-year institutions.] 

**The Association for University and College Counseling Center Directors (AUCCCD**). The 2015 AUCCD survey, which captures institutional demographics and services, counseling center staffing and service trends, and counseling center director demographics, was completed by 529 counseling center directors.[endnoteRef:92] Public (46 percent) and private (44 percent) institutions were equally represented, with an additional four percent representing community colleges (n = 20). [92:  Reetz, David R., Brian Krylowicz, and Brian Mistler. “The Association for University and College Counseling Center Directors Annual Survey.” 2015. http://www.aucccd.org/assets/documents/aucccd%202015%20monograph%20-%20public%20version.pdf] 

**The National Survey of College Counseling Centers (NSCCC)**. This survey includes data provided by the administrative heads of college and university counseling centers in the United States and Canada. The purpose of the survey has been to stay abreast of current trends in college counseling and to provide counseling center directors with ready access to the administrative, ethical, and clinical issues faced by their colleagues in the field. The 2014 report includes data from 246 four-year institutions and 29 two-year institutions.[endnoteRef:93] [93:  Gallagher, National Survey of College Counseling Centers 2014, 2015. ] 

**Center for Collegiate Mental Health (CCMH)**. This annual survey, administered by Penn State University, is based upon standardized data embedded within electronic medical records (EMR). This data set is a large collection of standardized questions, answers, and instruments that CCMH makes available to participating counseling centers through EMR vendors. The 2016 report was based upon data contributed by 139 four-year college and university counseling centers, describing 150,483 unique college students seeking mental health treatment, 3,419 clinicians, and over 1,034,510 appointments.[endnoteRef:94] [94:  Center for Collegiate Mental Health. “2016 Annual Report” (Publication No. STA 17-74). January, 2017. Accessed May 1, 2017, https://sites.psu.edu/ccmh/files/2017/01/2016-Annual-Report-FINAL_2016_01_09-1gc2hj6.pdf ] 

In general, these surveys support the finding from the questionnaires and interviews that colleges provide some access to a variety of services, but those services may be limited by time availability, fees, extensive waiting lists, and limited access to a diverse, qualified staff.

### Hours of Service

Only 24 percent of campus mental health centers offered services outside the normal 8 a.m. to 5 p.m. hours, five days a week and just over 1 percent offer services 6 or 7 days a week. Forty-seven percent did not offer any services outside of these hours.[endnoteRef:95] [95:  Reetz, Bershad, LeViness, and Whitlock. The Association for University and College Counseling Center Directors Annual Survey, p. 40.] 

### Afterhours Access to Counseling and Helplines

Almost 92 percent of respondents indicated that there is an active crisis hotline available in the community that students can use, while almost 45 percent said there is an active crisis hotline provided by the campus that students can use.[endnoteRef:96] [96:  Reetz, Bershad, LeViness, and Whitlock. The Association for University and College Counseling Center Directors Annual Survey, p. 70.] 

### Fees at Counseling Services

According to the 2017 STAT survey of four-year colleges, 88 percent of colleges reported offering free counseling services and nine percent offered between one and nine free sessions before charging $10 to $30 per session.[endnoteRef:97] In the CCMH survey, 16 percent of university and college counseling centers charge a fee for initial psychiatric medication evaluation, 17 percent charge a fee for ongoing medication psychiatric follow-up, and 10 percent charge a fee for formal psychological assessment, which provides a diagnosis and establishes functional limitations. Likewise, according to the NSCCC survey, 5 percent of college counseling centers charge fees for counseling (no community college centers charge a fee), and that the average cost for such a fee is $20. It should be noted that fees for services most negatively impact students of color and low-income students, who may most be in need of such services.[endnoteRef:98] [97:  https://www.statnews.com/2017/02/06/mental-health-college-students/. NCD staff interviewed the author of this article who shared her survey data from all of the colleges that responded to the STAT survey in the categories of fees, limits on counseling sessions and waiting lists.]  [98:  Volpe, Vanessa. What We Know About the Mental Health of Students of Color during College: A Review and Call to Action. The Steve Fund, University of North Carolina at Chapel Hill.] 

### Waitlists at Counseling Services

Waitlists for mental health services have been documented for several years and in several studies. Ninety-seven percent of four-year colleges responding to a 2017 STAT survey reported having waiting lists that spanned from a couple of days to over a month, depending on the time of year.[endnoteRef:99] Only three of these colleges required staff to screen students for emergencies when the student sought help. In 2016, 36 percent of college counseling center directors reported having a waiting list for clients to receive treatment. The maximum number of clients on the waiting list during the year (mean) ranged from 18 to 75, depending on the school.[endnoteRef:100] The 2011 NAMI On Campus survey of 765 students found that 39 percent of students reported having to wait longer than five days for an appointment.[endnoteRef:101]  [99:  See endnote 105. ]  [100:  Reetz, Bershad, LeViness, and Whitlock. The Association for University and College Counseling Center Directors Annual Survey, pp. 65–66.]  [101:  Gruttadaro and Crudo. “College Students Speak: A Survey Report on Mental Health,” 2012. ] 

### Limited Sessions at Counseling Services

According to interviewees, most institutions focus on access—getting students through the door—but the quality and quantity of counseling services, especially ongoing ones, are lacking. Interviewees described services offered by colleges as short term or used for crisis management and as varying in availability based on the semester. 

The surveys showed some variation in the percentage of colleges that limit the number of counseling sessions offered. Seventy percent of colleges did not limit sessions according to the 2017 STAT survey,[endnoteRef:102] and the colleges that did have limited sessions provided anywhere between 6 to 16 sessions. Another study showed 54 percent of colleges have a maximum number of counseling sessions before clients are referred out.[endnoteRef:103] About one-third of college counseling centers provide a limited number of counseling sessions (35 percent offer limited sessions, according to the CCMH survey, and 30 percent limit the number of sessions of counseling they allow, according to the NSCCC survey). The ability to provide counseling sessions seems to be determined to some degree by the size of the college. According to the NSCCC survey, 49 percent of schools with over 15,000 students limit the number of sessions offered compared to just 19 percent for schools with less than 7,500 students. Community colleges are more likely to limit sessions compared with four-year colleges. Some colleges provide referrals to community mental health providers for students that need longer term care. [102:  Gruttadaro and Crudo. “College Students Speak: A Survey Report on Mental Health,” 2012.]  [103:  Reetz, Bershad, LeViness, and Whitlock. The Association for University and College Counseling Center Directors Annual Survey, p. 65.] 

### Streamlined Referral Network to Outside Agencies

According to interviewees, some colleges have Memoranda of Understanding which allow for streamlined referral of students with mental health needs to County Mental Health Clinics. However, priority care is usually given to students who have severe and persistent mental illness. Optimal streamlined referral processes have signed releases in place so colleges and clinics can most effectively share information about the student to support their academic and wellness goals.

### Availability of Counseling Staff with Mental Health Licensure

Colleges can offer mental health services in a variety of locations, including health centers, standalone mental health sites, programs for students with disabilities, and counseling centers. Only 70 percent of four-year college counseling center professional staff were required to be licensed to practice in the center, although 96 percent of them were expected to get licensed to continue practicing. Eighty-five percent of four-year college counseling centers provided new staff the supervision required for licensure of mental health professionals in their states.[endnoteRef:104]  [104:  Reetz, Bershad, LeViness, and Whitlock. The Association for University and College Counseling Center Directors Annual Survey, p. 23.] 

### Availability of a Diverse Mental Health Counseling Staff

More than 70 percent of professional counseling staff are White, while the percentage of Black or African American (10 percent) and Latino/a (7 percent) staff makes up less than 20 percent. An additional eight percent are Asian/Asian American, and less than 10 percent make up the other racial categories: Multiracial (two percent), Other (two percent), and Indian/Native American (less than one percent).[endnoteRef:105] Respondents highlighted the need for mental health counseling staff to be as diverse as the student body they serve as there are important cultural considerations to take into account when providing mental health services. [105:  Reetz, Bershad, LeViness, and Whitlock. The Association for University and College Counseling Center Directors Annual Survey, p. 28.] 

### Availability of Psychiatric Services

Sixty-four percent of four-year college respondents reported having counseling center mental health psychiatric services on campus; another 27 percent reported not having access to psychiatrists except as a private referral; three percent reported not having mental health psychiatric services on campus but contracting with external psychiatrists for a fee. The remaining six percent of respondents replied “Other,” though about 50 percent of those mentioned having a referral system in place with a community provider.[endnoteRef:106] [106:  Reetz, Bershad, LeViness, and Whitlock. The Association for University and College Counseling Center Directors Annual Survey, p. 57.] 

According to the NSCCC survey, only seven percent of community colleges have access to on-campus psychiatrists.[endnoteRef:107] Thus, outside referrals are the only option for community college students if they need to be treated by a psychiatrist. [107:  Gallagher, National Survey of College Counseling Centers 2014, 2015. ] 

## Barriers to Services Faced by Students

This section examines potential barriers faced by students in accessing services, including physical accessibility and paperwork requirements and the ability of colleges to provide services to all students, regardless of their physical or sensory disabilities. 

### Physical Accessibility and Paperwork Requirement Barriers

One serious access barrier for students, mentioned by one student and multiple practitioners in the questionnaire, is the basic process students must engage in before receiving mental health services. Institutions may have extensive paperwork students must fill out before receiving services or require students to provide their own disability verification prior to service. Additionally, as detailed earlier, appointment backlogs are extremely problematic for crisis-ridden students who need immediate assistance and follow-up care.

The ADA stipulates that all colleges must have barrier-free and physically accessible facilities. According to interviewees, most colleges adhere to these regulations; however, there are times when elevators cease to work or some other barrier exists within mental health program areas so that entry is impeded. It is also possible that students in mental health crisis, with physical or sensory disabilities may not be able to travel to the mental health site for help. To appropriately attend to these possibilities, college mental health providers must ensure their policies allow for flexibility as to where counselors can meet with students and ensure that accessibility features such as elevators, ramps, automatic doors, and communication devices are maintained. 

### Providing Services to Students with Physical or Sensory Disabilities

In general, interviewees and practitioner questionnaire respondents believed that colleges try to provide services to all students as required by federal law (ADA, Section 504, Fair Housing Act). However, barriers to receiving accommodations do exist. Practitioners noted each of the following barriers: difficulty finding transportation to community mental health providers; physical barriers; a lack of training in cross-cultural counseling (to help treat students with disabilities, students of color, and undocumented students); and a dearth of mental health counselors fluent in American Sign Language and aware of the different levels of hearing loss and low vision with hearing loss. One respondent noted that international students with language barriers are often deprived of immediate access to foreign language interpreters.

Deaf and hard of hearing (DHH) students face barriers to accessing care in their preferred language modality and finding people who understand the nuances of their culture. In DHH culture, there are many people who have difficulty signing, but counselors cannot tell if this is a result of a mental challenge or lack of proper training. Further, access to sign-fluent clinicians is a challenge. While technology supports (such as remote interpreting) have helped, these supports are not always available during a time-sensitive crisis period. One interviewee noted that access to sign-fluent clinicians through video phone is underutilized because of insurance difficulties and other related policies that block or prohibit provisions across state lines.[endnoteRef:108] Finally, DHH students who are also blind or students of color have more of a barrier to finding counselors with similar experiences. [108:  In some cases, a state will require that you be licensed in the “remote” site state. For example, someone may need to be licensed in Ohio in order to take a video call from an Ohio resident. Psychologists' licenses do not have automatic reciprocity as is the case with many MD licenses. Also, some insurance companies do not reimburse “telemedicine” at all or reimburse it at much lower rates than an in-person visit. ] 

## Reasonable Modifications and Accommodations 

Under the ADA and Section 504, colleges must provide students with disabilities reasonable modifications to their policies, practices, and procedures unless doing so would fundamentally alter the nature of its service, program, or activity. Modifications are made on a case-by-case basis. Colleges should, however, have reasonable modification policies in place and ensure that all staff that work with students receive training on those policies. Colleges should ensure that students have access to those policies as well. The University of Washington is a good example of how a college can share information about modifications/accommodations for students with disabilities via the college website.[endnoteRef:109] Reasonable modifications may include flexible class and/or attendance schedules, LOAs without financial penalties, and other changes to standard polices that allow students with mental health disabilities to remain in, and succeed in, college. (See Appendix F for a list of common modifications.) [109:  See http://www.washington.edu/doit/academic-accommodations-students-psychiatric-disabilities] 

In addition, the Fair Housing Act[endnoteRef:110] and Section 504[endnoteRef:111] require colleges to allow students with mental health disabilities who require an emotional support animal to keep such animals in college housing as a reasonable accommodation.  [110:  42 U.S.C. § 3601 et seq. ]  [111:  https://portal.hud.gov/hudportal/documents/huddoc?id=servanimals_ntcfheo2013-01.pdf, Accessed April 4, 2017.] 

According to NAMI’s survey, 62 percent of students said they knew how to access accommodations, and 43 percent did access them.[endnoteRef:112] Students reported that their most important accommodations were excused absences for treatment (54 percent), medical LOAs and course withdrawals without penalty (46 percent), adjustments in test settings (34 percent), homework deadline extensions and adjustments in test times (33 percent), and increased availability of academic advisors (32 percent). [112:  Gruttadaro and Crudo, “College Students Speak: A Survey Report on Mental Health,” 2012. ] 

Ten percent of the practitioner questionnaire respondents reported that institutional bias could be creating barriers to mental health services and supports. Some believed lack of training for faculty allowed some students to slip through the cracks. One respondent noted that there is likely “some institutional cultural bias that colleges should not be providing health services to students and/or a reluctance to promote service availability” that helps lead to barriers that keeps students away. 

Because mental health disabilities are invisible, students often find themselves trying to negotiate accommodations with faculty members who do not understand their disability-related needs. Students must be diagnosed with a disability to request reasonable modifications/accommodations, as students without a verified disability are not covered by the ADA, Section 504, or the FHAct. Faculty that have not received training can be resistant to making “exceptions,” especially for “invisible” disabilities, even when appropriate disability verification is in place.[endnoteRef:113] This finding relates to previous findings from both practitioners and students that faculty need more training in disability-related accommodations. [113:  Burgstahler, Sheryl, and Tanis Doe. “Improving Postsecondary Outcomes for Students with Disabilities: Designing Professional Development for Faculty.” In Phase II (MS#060d(2)-H01) Product of Study #23. University of Hawaii. Accessed March 22, 2017. http://www.rrtc.hawaii.edu/documents/products/phase2/pdf/060d(2)-H01.pdf] 

# Chapter 7. Promising Best Practices and Emerging Trends

## Student and Practitioner Perceptions of Emerging and Best Practices

Forty-two of the practitioners and 48 of the students interviewed named current promising or best practices trends, shown in Table 2. Both groups (26 percent of practitioners and 65 percent of students) selected training and anti-stigma activities, such as campus-wide discussions, normalizing activities, or disability as part of diversity efforts as the most promising practices. Both groups (17 percent of practitioners and 15 percent of students) also highly ranked student engagement, such as peer-to-peer models or student clubs. Practitioners noted a trend of increasing access to services for students, such as hiring more psychologists or providing more counseling sessions. This section discusses these practices in greater detail.

Table 2: Percentage of practitioners and students who named certain practices as best practices in mental health services

## Stigma Reduction, Education, and Outreach

### Training and Other Anti-Stigma Activities

Only 50 percent of the students NAMI surveyed disclosed their diagnoses on campus. They did so to receive accommodations, to be role models and educate others, to avoid disciplinary action, and to receive financial aid.[endnoteRef:114] Students who did not disclose their diagnoses did not need accommodations, did not realize they could receive accommodations, worried about lack of confidentiality, or feared how they would be perceived. This concern over stigma prevents students from disclosing their disabilities and results in students not receiving accommodations and possibly dropping out of school. Colleges attempt to reduce stigma in multiple ways. According to the practitioner questionnaire, 41 percent of respondents said they conduct outreach, 30 percent facilitate staff workshops and professional development, 20 percent note the efforts of student groups and student-led programs (such as those provided by Active Minds and NAMI), 18 percent mention campus-wide events or activities, and four percent work with external groups such as NAMI. [114:  Gruttadaro and Crudo, “College Students Speak: A Survey Report on Mental Health,” 2012. ] 

Thirty-eight percent of the students interviewed believed that student groups were most responsible for reducing stigma on campus. Thirty-two percent thought that awareness events helped reduce stigma, though most students did not specify whether these events were college run or student run. Thirteen percent reported creating integrated support services throughout campus to promote general inclusivity. One student said the department “asks us to evaluate teachers on how they include mental health resources in their class, as they expect teachers to break social stigma.”

According to interviewees, best practices for reducing stigma include normalization, such as campus-wide wellness initiatives; integrating mental and physical health; and framing disability as a diversity issue. 

In general, there does have to be ongoing efforts to reduce stigma and discrimination. Not just against people who have mental illness, but also racism and systemic issues that favor certain types of students over others. For example, the stigma within the African American community around mental illness is greater than in the White community. We need to get rid of discriminatory practices that are woven into our policies. Working with folks who aren’t themselves clinicians or mental health providers but have a lot of access to the students—training those people on when a student is having a problem and being able to point that out and refer them to the right person. —College counseling center counselor

An example, given in interviews, of such integration would be the co-location of mental and physical health services. According to interviewees, co-location places physical and mental health at the same level. Further, students are more likely to seek services when the mental health center is not in a separate location and it is not obvious they are seeking mental health support. Also important is the nonpejorative naming of the mental health area, such as The Life Skills Program.

According to an AUCCCD survey, only about 23 percent of physical and mental health centers shared a floor or suite in the same building; in 31 percent of cases, physical and mental health centers were located across campus from each other; 28 percent of physical and mental health centers were in separate spaces in the same building; 10 percent were adjacent, but in separate buildings; and eight percent of campuses did not have health services.[endnoteRef:115] [115: Reetz, Krylowicz, and Mistler, “The Association for University and College Counseling Center Directors Annual Survey,” p. 53.] 

### Orientation

Respondents believed that outreach to students about mental health and mental health services should begin before students even start school, with information posted on college websites. Then, when students arrive on campus for orientation, they could be supported in developing skills like time management, decision making, resilience, and coping—skills that will help students avoid mental health problems. Orientation could help set up a culture where mental health is not viewed as a disease or permanent state and the complete normativeness of anxiety and other mental health concerns is acknowledged, which is more empowering to students than saying “we have these programs for special needs.” Students want to be seen as “normal,” so mental health services should not be separated. Pre-enrollment in support services should be allowed at orientation, as it provides an easy, confidential manner for students to identify themselves. Additionally, orientation could include a simple, self-scored mental health assessment with resource listings.

In 2016, NAMI and The Jed Foundation developed a guide,[endnoteRef:116] including information on HIPAA and FERPA, for college-bound students and families. The guide asks, “How do we incentivize students to talk with their parents about mental health, even if students do not have mental health issues?” Standardized survey questionnaires are also available to campuses for measuring student mental health. Some widely used tools are provided in Appendix E. [116:  NAMI and the JED Foundation. “Starting the Conversation: College and Your Mental Health.” 2016. Accessed March 22, 2017. http://www.nami.org/collegeguide/download] 

### Transparency

Many college students go online to access information about the mental health services offered by their colleges. The NAMI survey on college student experiences found that 64 percent of students responded either “no” or “did not know” to the question of whether their colleges’ websites included information on mental health resources. Forty-six percent of students who did use their colleges’ websites found them to be “helpful” or “very helpful.” Students reported that helpful websites provided the following:

Information about resources on and off campus

The ability to make appointments online

An online mental health screening tool that links to help when needed

Frequently asked questions about mental health

Information on when and where to access accommodations and free mental health services and supports.[endnoteRef:117] [117:  Gruttadaro and Crudo, “College Students Speak: A Survey Report on Mental Health,” 2012. ] 

The NSCCC survey cited that 96 percent of campus counseling centers had websites: 100 percent of websites provided information about center services, and 70 percent provided educational information on psychological issues.[endnoteRef:118]  [118:  Gallagher, National Survey of College Counseling Centers 2014, 2015.] 

The Center for Mental Health Services funded the Center for Psychiatric Rehabilitation and NAMI’s STAR Center to collect and analyze web-based resources for college students who have mental health concerns. The Center for Psychiatric Rehabilitation reported the following preliminary trends in the provision of online promotional mental health material:[endnoteRef:119] [119:  Center for Psychiatric Rehabilitation. Supported Education Initiatives at the Center for Psychiatric Rehabilitation. 2009. Accessed March 22, 2017. https://cpr.bu.edu/resources/newsletter/supported-education] 

All schools provide a similar range of services and share many of the same means of contacting students, but schools in different parts of the country target different mental health problems.

More than half of schools target depression, yet only slightly more than a quarter target suicide.

Schools located east of the Mississippi River target a wider variety of mental health challenges, yet regardless of where they are located, schools provide basically the same services.

Public schools both provide more services and target a greater number of mental health challenges than private schools.

Thirteen percent of all schools had no online resources for mental health issues.

While some people believe that listing accommodations in a transparent fashion for students to review could mislead students into thinking that they have a shopping list of services to choose from, doing so is intended to educate and empower students—when they know what is available, they have better opportunities to find what they need. Ultimately, college professionals and students collaborate on the necessary services.

### Campus-Wide Conversations

One key approach campuses are taking to highlight mental health and integrate mental and physical health into the culture is using different communication strategies. These strategies include hosting public speakers and holding events, including national awareness campaigns on suicide prevention; mental health awareness days; and fun runs to raise money for depression, autism, and anxiety, among other issues.

Additionally, by openly discussing mental health issues and supports, college leaders create a culture where these discussions are the norm. As an example, one interviewee spoke of how a speech teacher asks students to give speeches on suicide prevention. College presidents could convene committees made up of students with disabilities, LGBTQ students, foster students, veterans, faculty, staff, and counseling center staff to understand the mental health challenges within their colleges and how to address them.

### Universal Design

Research cites many benefits of applying a universal design approach to mental health promotion. This approach promotes mental health for all students, not just those with a specific mental health disability, and integrates mental health supports into everyday college activities (such as having advisors link academic success with mental health well-being). Universal wellness services and policies would benefit all students, removing liability for self-disclosure of disability and helping identify those with undiagnosed mental health disabilities.

Treating mental health as part of wellness for the entire campus would improve academic success and promote safety. One interviewee spoke of a spa center, available to the entire campus community, which offered a light room, meditation room, and individual and group therapy sessions, among other things. Participants would go to the spa in support of overall wellness, not just to target mental health disorder symptoms.

## Student Engagement

### Peer-to-Peer Support Services

Both students and practitioners reported that student-led groups and activities are key ways to address and reduce stigma. 

The AUCCCD survey found the following:

Sixty-three percent of counseling directors reported that their campuses had a student mental health organization.[endnoteRef:120] [120:  Reetz, Bershad, LeViness, and Whitlock. The Association for University and College Counseling Center Directors Annual Survey, p. 42.] 

Sixty-two percent of counseling directors reported that students are provided gatekeeper training (designed to increase the knowledge and skills to identify those at risk of mental health disorders and make referrals when necessary).[endnoteRef:121] [121:  Reetz, Bershad, LeViness, and Whitlock. The Association for University and College Counseling Center Directors Annual Survey, p. 42.] 

Only 22 percent of respondents reported that students are directly involved in their counseling centers’ strategic planning.[endnoteRef:122]  [122:  Reetz, Bershad, LeViness, and Whitlock. The Association for University and College Counseling Center Directors Annual Survey, p. 41.] 

Sixty-nine percent of respondents reported that their counseling centers included students in outreach strategies.[endnoteRef:123]  [123:  Reetz, Bershad, LeViness, and Whitlock. The Association for University and College Counseling Center Directors Annual Survey, p. 41.] 

Thirty percent reported that campuses had trained peer counselors.[endnoteRef:124] [124:  Reetz, Bershad, LeViness, and Whitlock. The Association for University and College Counseling Center Directors Annual Survey, p. 42.] 

Student-led organizations are bringing mental illness into the light to lower suicide rates among young people.[endnoteRef:125] Postsecondary institutions could train student leaders to counsel classmates, as some students may be uncomfortable meeting with a counselor or resident advisor, providing an alternative for students hesitant to seek support.[endnoteRef:126] Colleges would need to recruit a diverse group of students to serve as leaders. It is crucial for colleges to acknowledge and validate the unique experiences of students of color or students that reflect other populations by ensuring their representation within student leadership. [125:  Jackel, Donna. “How College Students Are Resisting the Mental-Illness Stigma.” Yes Magazine, November, 2015. Accessed March 22, 2017, http://www.yesmagazine.org/issues/good-health/how-college-students-are-resisting-the-mental-illness-stigma-20151124]  [126:  Walker, Larry. “The Importance of Mental Health Check In’s for College Students,” The Good Men Project, February 16, 2016. Accessed March 22, 2017, http://project375.org/news-posts/the-importance-of-mental-health-check-ins-for-college-students-see-more-at-httpgoodmenproject-comfeatured-contentthe-importance-of-mental-health-check-ins-for-college-students-kerjs/] 

### Student Voice

It is clear through the practitioner questionnaires, student questionnaires, and interviews that students play a key role in supporting their peers through formal and informal networks and by having a voice in campus policy, helping create a culture that normalizes discussion of, and support for, mental health challenges. 

First, respondents believe that students should play an integral role in holding college leadership accountable. For example, the need for college and university leadership to create a committee on campus mental health was discussed. This committee would include a racially diverse group, including students with disabilities, LGTBQ students, foster students, veterans, faculty, staff, and counseling center staff. The committee would focus on understanding the scope of mental health challenges and how to address them. Including students as stakeholders in the decision-making process regarding the mental health services available on campus would increase trust among the campus leadership, mental health professionals, and students.

Second, the role of students beyond that of resident advisors, as peer support leaders, and the research on gatekeeper training programs suggests that training a high percentage of students on campus would help create a supportive peer environment. It is key to train students who represent campus diversity, and the training should help students recognize warning signs, question suicidal intent, listen to problems, and refer students for help.

Third, student-led organizations are a key formal structure in which students can support other students. Two such groups are Active Minds and NAMI on Campus. They raise mental health awareness on campus, educate peers and faculty about mental health challenges and supports, advocate for improved mental health services, and support fellow students. These student-run clubs can access a wide range of programming to support their work on campus.

Finally, campuses could expand nonprofessional support, such as informal networking groups of students, staff, and faculty. Increasing the number of informal networks around campus increases student connections, which is particularly helpful for students of color[endnoteRef:127] and other nonmajority groups. [127:  Grier-Reed, Tabitha. “The African American Student Network: An Informal Networking Group as a Therapeutic Intervention for Black College Students on a Predominantly White Campus.” Journal of Black Psychology 39, no. 2 (2013): 169–184; Constantine, M. G., L. Wilton, and L. D. Caldwell. “The Role of Social Support in Moderating the Relationship Between Psychological Distress and Willingness to Seek Psychological Help Among Black and Latino College Students.” Journal of College Counseling 6 (2003): 155–165. doi:10.1002/j.2161-1882.2003.tb00236.] 

#### Greek Life 

Greek life offers many benefits to students. It promotes policies and procedures that support wellness and academic success and allows students to network and expand their social circles, develop leadership skills, and live in housing with a family structure.

Sororities and fraternities can play a key role in supporting the mental health of their members. Many chapters have engaged in campus-wide events and partnered with different organizations to give their members the mental health support they need, as well as to raise awareness on campus. 

Kappa Alpha Theta started Sisters Supporting Sisters, “a mental health initiative designed to increase the dialog concerning support for all aspects of mental health, with the goals of creating a safe environment for members to discuss mental health issues, providing guidance for recognizing signs of and helping members with mental health challenges, and supporting members facing mental health challenges and disorders.”[endnoteRef:128] [128:  Kappa Alpha Theta. Accessed March 22, 2017, https://www.kappaalphatheta.org/alumnae/programs/sisters_supporting_sisters.cfm?from=HomeHeaderLink] 

At Cornell University, the Greek system partnered with health services; representatives of chapters, named Health and Wellness Chairs, undergo training and meet every two weeks to inform their houses about wellness-related events and resources offered by the university.[endnoteRef:129]  [129:  Cornell Daily News, 2013. https://issuu.com/cornellsun/docs/05-01-13_entire_issue2] 

At Michigan University, the Greek Council sponsored a campus-wide mental health speak-out.[endnoteRef:130] The goal of the event was to raise awareness about mental health and allow for open discussions among students and faculty. [130:  St. John, Alexa. “Members of Greek Life Share Struggles at First Mental Health Speak Out.” Michigan Daily, December 5, 2016. Accessed March 22, 2017, https://www.michigandaily.com/section/news/mental-health-speak-out-call-action-better-counseling-services-campus] 

#### Social Media

Social media (e.g., Facebook, Twitter, and Snapchat) has drastically changed the student environment by allowing users to exchange ideas, feelings, and activities at an unprecedented rate. Teens and young adults heavily use social media—a large part of their social and emotional lives now happens on the Internet. Because social media is relatively new, few studies have examined its overall effect on users’ mental health and well-being.

Social media can have both negative and positive impacts on students. It could prompt unfavorable comparisons between peers.[endnoteRef:131] Students are likely to publish the most impressive and attractive versions of themselves, providing a false impression of how much happier or more successful they are than their peers.[endnoteRef:132] The natural inclination toward comparison can lead to anxiety in students and intensify their symptoms of mental health disorders. Negative feedback such as cyberbullying—or no feedback at all—can also increase anxiety. [131:  Holterman, Ally. “Mental Health Problems for College Students Are Increasing.” Heathline, August 25, 2016. http://www.healthline.com/health-news/mental-health-problems-for-college-students-are-increasing-071715#7]  [132:  Griffin, Riley. “Social Media Is Changing How College Students Deal With Mental Health, For Better Or Worse.” The Huffington Post, July 22, 2015. Accessed March 22, 2017, http://www.huffingtonpost.com/entry/social-media-college-mental-health_us_55ae6649e4b08f57d5d28845] 

Students surveyed were slightly more positive about social media (50 percent said it had a positive impact) but many (38 percent) still said it had a negative impact. The remaining students were not sure or did not think it had any impact. In discussing positive impact, students noted that social media can communicate favorable images of people with mental health challenges, raise awareness, and provide support. In discussing negative impact, many students reported that social media raises their anxiety, often through negative stories or because it is distracting.

Though social media may have some negative effects, colleges can harness its positive power in multiple ways. Universities are using social media to communicate with students and gather feedback on campus culture. Schools can use social media, email, and other platforms to reach students globally regarding available mental health services and supports and providing examples of success stories. Further, universities and students are using technology to reach “those who are struggling, from Facebook support groups and mental health apps to online therapy games.”[endnoteRef:133] [133:  Griffin, “Social Media Is Changing How College Students Deal With Mental Health, For Better Or Worse,” 2015. ] 

One respondent discussed a situation where a student attempted suicide, and the only way the college was able to identify the student was by the pictures the student posted on Facebook: “It’s very vivid for me because it’s very impactful and frightening. The awareness and the value of social media as a connector and investigative tool is important. From a preventative standpoint, you can figure out what’s going on and it’s valuable.”

In an example shared in an article on the Huffington Post,[endnoteRef:134] a student at the University of Michigan posted a suicide note on the anonymous social media app Yik Yak. Immediately afterward, many students posted their support and advice. The school’s social media director contacted campus police and located the student within 24 hours.  [134:  Griffin, “Social Media Is Changing How College Students Deal With Mental Health, For Better Or Worse,” 2015.] 

## Faculty and Staff Training

Both students and practitioners reported that training staff and faculty are key ways to address and reduce stigma. The assumption is that identifying students in need and referring them so that they receive the support they need, rather than reporting them so that they are penalized, would help provide more and earlier support. While faculty and staff can play important roles in supporting students, they must be adequately trained to identify students who may be experiencing distress, refer students, and provide reasonable accommodations. 

As part of the CalMHSA Evaluation of Statewide Prevention and Early Intervention Initiatives, RAND conducted surveys of California college and university faculty, staff, and students during the spring and fall of 2013. The study found that 53 percent of faculty and staff reported talking to students about mental health problems at least once in the six months before the survey. Prior to this survey, the California college system had launched campus-wide campaigns to train faculty and staff to support students with mental health problems. These trainings were offered throughout the academic year, at no cost, and in various locations. Eighteen percent of faculty and staff reported that they had participated in trainings in the preceding six months. While some faculty felt equipped to identify and refer students with mental health problems, less than 40 percent of faculty and staff believed they had the skills to directly help students with mental health problems.[endnoteRef:135] Some faculty are talking to students, but those faculty do not feel well trained to do so.  [135:  Sontag-Padilla, Lisa, Elizabeth Roth, Michelle W. Woodbridge, Courtney Ann Kase, Karen Chan Osilla, Elizabeth D’Amico, Lisa H. Jaycox, and Bradley D. Stein. “CalMHSA Student Mental Health Campus-Wide Survey.” Accessed March 22, 2017, http://www.cccstudentmentalhealth.org/docs/evaluation/CalMHSA_SMH_Campus_Wide_Survey_2013_Report.pdf] 

### Faculty and Staff Training to Identify and Provide Support to Students Who Have Mental Illnesses or Are Experiencing Extreme Emotional Distress

About an equal percentage of students interviewed believed that faculty and staff had received training (30 percent) as had not (28 percent). Other students noted that they thought some faculty had received some training (13 percent) and that faculty discussed mental health resources for students at the start of the semester (11 percent), which one student felt was likely part of training. The remaining 19 percent did not know. Even among students who reported that faculty were trained, some believed that faculty were resistant to training, noting, “I think they do [receive training], some are just stuck in their ways.”

One counseling center staff member interviewed noted that faculty and staff at her university understood that they are not prepared to help students, noting that “faculty are recognizing their own inadequacies and understanding how to reach out with compassion and sensitivity.” She noted that she is working closely with the faculty senate on how to help faculty become “more comfortable and competent in terms of helping students who are looking like they are having problems.”

Another counseling center staff member interviewed reported,

Oftentimes, what’s happening is that professors or faculty just send students to our CARE Team instead of talking to them and trying to figure out what’s going on. The CARE Team is really tied to the university’s prevention of school shootings. So, accommodations are being provided through a process that’s very clunky, not person-centered, and very “shamey.” We are moving in the right direction, though. We just trained all of the academic advisors [here]. There are also some faculty and staff who are self-disclosing and this disclosure starts a conversation that normalizes and takes away the classism of talking about mental health. —Counseling center staff member

However, the same counselor noted that some trainings are not effective and in fact contribute to stigma and fear:

I actually attended a training because I was going to teach a college success class focused on exactly where students are coming from. In the training I attended, they completely correlated mental health with “safety” and “reporting” of students—it was really terrible. —Counseling center staff member

The NSCCC survey found that 64 percent of counseling center directors reported spending more time training faculty and others on campus to respond to students in distress and to make more appropriate referrals. This was the highest response to the question of what actions the center has taken due to increased student demand. 

While gatekeeper training programs, which develop individuals' “knowledge, attitudes, and skills to identify [those] at risk, determine levels of risk, and make referrals when necessary,”[endnoteRef:136] seem to make a lot of sense, few such efforts have been empirically evaluated. Osilla et al.[endnoteRef:137] examined more than 250,000 teachers, students, and staff in California’s kindergartens, elementary schools, high schools, and colleges who had been trained to recognize students in distress and connect them to resources. They found preliminary evidence that such trainings were helpful in increasing participant confidence in their ability to intervene and refer. Although this study examined K–16, the authors note that this finding was consistent across the higher education system and across a diverse group of training participants. Programs such as Mental Health First Aid, Jed Program training, and QPR (Question, Persuade, Refer) have been found to be of great benefit. [136:  Gould, M. S., T. Greenberg, D. M. Velting, and D. Shaffer. (2003). “Youth Suicide Risk and Preventive Interventions: A Review of the Past 10 Years.” Journal of the American Academy of Child and Adolescent Psychiatry 42, no. 4 (2003): 386–405.]  [137:  Osilla, K. C., M. W. Woodbridge, R. Seelam, C. A. Kase, E. Roth, and B. D. Stein. Mental Health Trainings in California's Higher Education System Are Associated with Increased Confidence and Likelihood to Intervene with and Refer Students. Santa Monica, CA: RAND Corporation, 2015. http://www.rand.org/pubs/research_reports/RR954.html] 

### Faculty, Staff, and Academic Advisors

As noted, many students are not seeking help for fear of being stigmatized, and many do not feel an urgent need for help when in fact they may be under considerable distress. Gatekeeper training programs, which are proactive in identifying students in need of help and encouraging them, can assist in these cases. The training can also be integrated into what is already routine for students, such as meeting with academic advisors. Further, seeing the link between academic success and mental health wellness might encourage students to act.

In addition to training advisors who have a touchpoint with students, training faculty members to understand what to look for and how they can help is important. Faculty may see students multiple times each week, so helping faculty recognize key indicators (e.g., the students’ grades dropping, students missing classes) and make referrals is important. 

The AUCCCD Annual Survey collected more than 500 responses from counseling center administrators to understand the status of staffing, practice, services, and staffing trends and demographics.[endnoteRef:138] Only 58 percent of respondents indicated faculty and staff training as an area that represents an integral part of their counseling services’ missions.[endnoteRef:139] Beyond faculty and staff, training is needed at all levels of the university (e.g., resident assistants, administrators, and students). [138:  Reetz, Bershad, LeViness, and Whitlock. The Association for University and College Counseling Center Directors Annual Survey. (2016).]  [139:  Reetz, Bershad, LeViness, and Whitlock. The Association for University and College Counseling Center Directors Annual Survey. (2016).] 

### Faculty and Staff Training on Mental Health Issues and Reasonable Accommodations

Although faculty are required to provide reasonable accommodations by law, evidence that this occurs is mixed. Both practitioner and student interviewees noted that faculty members are sometimes resistant to providing accommodations. Research has found that some instructors are concerned that accommodations might compromise the academic integrity of their courses.[endnoteRef:140] Faculty members sometimes consider accommodations to be unfair advantages to students, rather than designed to provide equal opportunity. These mistaken beliefs reflect a lack of knowledge about disabilities and assistive technology.[endnoteRef:141] [140:  Nelson, R. J., J. M. Dodd, and D. J. Smith. (1990). “Faculty Willingness to Accommodate Students with Learning Disabilities: A Comparison among Academic Divisions.” Journal of Learning Disabilities 23, no. 3 (1990): 185–189.]  [141:  Yuker, H. “Variables That Influence Attitudes Toward People with Disabilities.” Psychosocial Perspectives on Disability 9, no. 5 (1994): 3–22.] 

Further, faculty have been found to be more willing to provide accommodations for students with physical and sensory impairments than those with invisible disabilities, such as psychiatric impairments.[endnoteRef:142] “Both faculty and students report that instructors and administrators need training to help them better understand their legal obligations to provide academic accommodations, strategies for communicating with and teaching students with disabilities, and resources to help them provide accommodations for their students with disabilities.”[endnoteRef:143] [142:  Lehmann, J., T. Davies, and K. Laurin. “Listening to Student Voices about Postsecondary Education.” Teaching Exceptional Children 32, no. 5 (2000): 60–65; Leyser, Y. “A Survey of Faculty Attitudes and Accommodations for Students with Disabilities.” Journal of Postsecondary Education and Disability 7, no. 3 & 4 (1989): 97–108; Leyser, Y., S. Vogel, S. Wyland, and A. Brulle. “Faculty Attitudes and Practices Regarding Students with Disabilities: Two Decades after Implementation of Section 504.” Journal of Postsecondary Education and Disability 13, no. 3 (1998): 5–19.]  [143:  Burgstahler and Doe, “Improving Postsecondary Outcomes for Students with Disabilities: Designing Professional Development for Faculty.” ] 

According to questionnaire respondents, “most faculty are flexible and willing to bend requirements. But there are a few who are very rigid, and for those individuals, intervention in the form of policy requirements are needed in the form of spelling out what they must do to accommodate those students.” In addition, some “faculty do not understand that mental health can (and does) get in the way of attending class and completing assignments. There needs to be a system or procedure for this that does not overly tax the disability administrators AND doesn't put the student in the middle position of negotiating their own accommodations in this area.” 

## Suicide Prevention

Suicide is a major concern on college campuses because it is the second leading cause of death of college students. Many campuses are engaging in suicide prevention efforts. Model Suicide Prevention Plans include those promoted by the JED Foundation,[endnoteRef:144] the Suicide Prevention Resource Center,[endnoteRef:145] Mental Health First Aid USA,[endnoteRef:146] and QPR.[endnoteRef:147] Some campuses are taking advantage of SAMHSA’s Garrett Lee Smith Campus Suicide Prevention Program, which provides limited funding to colleges to identify students who are at risk for suicide and suicide attempts, increase protective factors that promote mental health, and reduce risk factors for suicide. Eels et al. describe a public health approach to campus mental health promotion and suicide prevention, which also highlights the need to restrict access to the means of suicide.[endnoteRef:148] [144:  Jed Foundation and EDC, Inc. “A Guide to Campus Mental Health Action Planning.” 2011. Accessed March 22, 2017, https://www.jedfoundation.org/wp-content/uploads/2016/07/campus-mental-health-action-planning-jed-guide.pdf]  [145:  Suicide Prevention Resource Center, Promoting Mental Health and Preventing Suicide in College and University Settings, 2004. ]  [146:  See http://www.sprc.org/resources-programs/mental-health-first-aid-usa]  [147:  See https://www.qprinstitute.com/]  [148:  Eells, Gregory, T. C. Marchell, J. Corson-Rikert, and S. Dittman. “A Public Health Approach to Campus Mental Health Promotion and Suicide Prevention.” Harvard Health Policy Review 13 (2012). http://www.hcs.harvard.edu/~hhpr/wp-content/uploads/2012/04/features-1.pdf ] 

## Crisis Management Plan in Place

Practitioner interviewees noted that most colleges, motivated by safety concerns, had crisis management plans in place. After the Virginia Tech tragedy, colleges discovered that they were ill equipped to handle crisis events such as shootings. They then formed Behavioral Intervention Teams (BIT) for the assessment of threat of violence and Care and Concern Committees to address mental health concerns. Supplemental research is needed to measure the effectiveness of the current BIT structures and the overall functioning of the Care of Concern Committees. One important point is to ensure that colleges do not automatically label students with mental health disabilities as violent since these students tend to be withdrawn. 

The interviewed students either reported that there was a crisis management plan in place at their schools (57 percent), they were not sure (23 percent), or they did not think there was a plan in place (19 percent). Most students reported that the crisis management plan was a crisis or suicide hotline; only a handful mentioned that psychiatrists were available in the event of a crisis or that they had participated in an active shooter training session. Only two students reported that their college had a Student Behavior Team, which was responsible for crisis management and plans. These responses indicated that students were not very aware of their college’s plans.

### Behavioral Intervention Teams

The formal establishment of care teams and BITs that try to identify students who are struggling or pose some threat to themselves are a promising trend. A BIT is “a multidisciplinary group whose purpose is meeting regularly to support its target audience (students, employees, faculty, and staff) via an established protocol. The team tracks ‘red flags’ over time, detecting patterns, trends, and disturbances in individual or group behavior. The team receives reports (from coworkers, community members, friends, colleagues, etc.) of disruptive, problematic, or concerning behavior or misconduct and investigates, performs a threat assessment, and determines the best mechanisms for support, intervention, warning and notification, and response. The team then deploys its resources and coordinates follow-ups.”[endnoteRef:149]  [149:  From The National Behavioral Intervention Team Association (NaBITA) website. Accessed March 22, 2017, https://nabita.org/behavioral-intervention-teams/ ] 

The National Behavioral Intervention Team Association administered a survey which was completed by 313 colleges in 2016. It found that 97 percent of colleges had BITs, and that the BITs had been in existence for six years on average. 

Sokolow and Lewis[endnoteRef:150] laid out 12 best practices for second-generation BITs, as compared with first-generations BITs, which were short-term problem‐solvers. Second- generation BITs include a role nominally addressing threats but primarily supporting and providing resources to students, being guided by formal protocols and rubrics for assessment, training and educating the community on what and how to report, developing comprehensive databases that provide a longitudinal view of student behavior patterns and trends, focusing not only on student-based risks but also on faculty and staff, and intentionally integrating with campus risk-management programs and risk-mitigation strategies. [150:  Sokolow, B., and W. S. Lewis. “Second Generation Behavioral Intervention Best Practices.” URMIA Journal Reprint 2009. https://nabita.org/download/13Second%20Generation%20Behavioral%20INtervention%20Best%20Practices%20(URMIA%20Journal,%202009).pdf] 

Note that a Care and Concern Team is different from a BIT. BITs analyze and process threats while Care and Concern Teams respond to student mental health challenges. One responds to safety protocols and the other to mental health interventions.

## Pedagogy

### List Service Sites and Accommodation Policies on Class Syllabi

As another way to reduce stigma around mental health, all course syllabi could have a standard section that includes statements for students with physical or mental health disabilities, including why and where to seek support and the procedures to take time off. However, according to an interviewee, there is often pushback on such simple changes:

Every year I fight to get our faculty to include language in their syllabi, but our Academic Dean forwarded the email with “I have been asked by the Office of Disability Service to forward this to you.” Are we working as hard as we should to reduce stigma? No.

### Faculty Discusses Stress

Faculty talking openly about mental health issues is very important. One interviewer related, “I was impressed when we dropped our oldest daughter off at college a couple of months ago, and the head of the student body said, ‘You’re going to hear about how everyone is proud of you, but I’m going to talk to you about how hard it is.’ He normalized feeling overwhelmed, depressed, etc.—he put it out in the open. He made it normal to go see a therapist.”

### Integrate Stigma Reduction and Help-Seeking into Classes

Interviewees suggested incorporating mental health discussions into curricula to reduce stigma. Faculty should be able to easily integrate this type of material into their content areas. One respondent suggested creating a general education course requirement about mental health issues.

## Increased Access: Multiple Touchpoints

Interviewees argued for multiple ways for students to access services. For some students, going to a mental health office is very scary. Creating a safe venue where students with mental health disabilities can access services and not feel singled out is key. Services should be designed to provide students with multiple on-ramps to treatment—telephone, chat, in-person, online. The goal is to meet students where they are and get them into services as needed. Institutional levels of service availability need to be clearly articulated (everyone needs to know what is available) to allow students to make the right choices. 

### Anchor Adults

The inaugural Gallup-Purdue Index, a joint research effort with Purdue University and the Lumina Foundation to study the relationship between the college experience and college graduates’ lives, found,

The support and experiences in college had more of a relationship to long-term outcomes for these college graduates. For example, if graduates recalled having a professor who cared about them as a person, made them excited about learning, and encouraged them to pursue their dreams, their odds of being engaged at work more than doubled, as did their odds of thriving in all aspects of their well-being.[endnoteRef:151] [151:  Ray, Julie, and Stephanie Kafka. “Life in College Matters for Life After College.” GALLUP, Economy. May 6, 2014. http://www.gallup.com/poll/168848/life-college-matters-life-college.aspx] 

Respondents discussed the role of “anchor adult” in supporting students with mental health challenges. Respondents agreed that students need a sense of belonging and connection with someone on campus. Students who have a meaningful connection with at least one adult are more likely to graduate and be successful. This core element is found in most retention theories. Anchor adults can also proactively connect students to services and resources. This demand for an anchor adult suggests emphasizing training for college faculty and staff to serve effectively in this role. 

#### College Chaplain

The role of the chaplain was not discussed by respondents, but college and university chaplains do play a role in providing support to students. Studies with college students outside the United States have found that chaplains often meet with students suffering from depression or other mental health disabilities.[endnoteRef:152] College students often find comfort from a group where they can practice their faith, and groups can be a place to get counseling in conjunction with medical treatment for depression. Students can check with their schools’ chaplains or religious leaders to see if spiritual counseling is available. Further, college and university chaplains are likely to meet with students in the campus community who are grieving. They should serve on campus postvention[endnoteRef:153] committees, assisting with coordinating the appropriate messaging to the community. [152:  Hughes, P., and M. Sims. The Effectiveness of Chaplaincy: As Provided by the National School Chaplaincy Association to Government Schools in Australia. Perth: Edith Cowan University, 2009. http://schoolchaplaincy.org.au/files/2012/09/chaplaincyeffectiveness.pdf]  [153:  Postvention is counselling and other social care given after the experience of a traumatic event, especially to those directly affected by a suicide.] 

## Coordinated Support

It is important for the office for students with disabilities, the counseling center, academic departments, student support, and other groups to work together. Faculty, students, and the entities that support students, including the Greek system, need better training and communication. Currently, these offices do not typically communicate unless there is a crisis. Coordination among these entities would allow colleges to provide better outreach to at-risk students, offer a diverse group of service providers and supports, and offer wraparound services. If the groups met frequently, colleges could establish a student of concern network that would be able to address a broader spectrum of mental health issues.

### Case Management Approach

A new best practice is for colleges and universities to hire case managers to provide resources to students in distress, thus freeing up mental health counselors to provide treatment. The case management approach allows for much better oversight and follow-up with the student resource process. Case managers ensure that students have different touchpoints with college and university resources. They coordinate care and communication for students across the different services the colleges have available. They make sure there is no duplication in the use of resources. They can be liaisons for students who are on LOAs. In addition, case managers are community liaisons, maintaining relationships with community providers and keeping databases showing who is taking clients and who accepts student insurance. Further, case managers can serve on college-wide committees, including BITs. One student interviewed noted the need for “case managers at every school. We need people to be checking in on us and see how we’re doing. We have academic advisors—high risk students need emotional/mental ones too!”

### Parent and Family Programs

Respondents noted an expansion in parent and family programs over the last decade. Parents are often the strongest advocates for their own children in terms of access to services. Campuses now recognize that family members are an important part of students’ mental health and are trying to include them. For example, NAMI chapters host mental health awareness classes on many college campuses to teach family members how to best support their college-aged children.

## Telecounseling

Few colleges offer mental health services online. Only 10 percent of college directors reported that their colleges provide clinical services by telephone.[endnoteRef:154] However, this is up from just under seven percent in 2013–2014. Colleges are now using online and texting tools to make mental health services more accessible. While not intended to replace in-person counseling, the goal is to reach students who would not otherwise receive any counseling. For some, going to a mental health office is very scary—some students indicated that they want chat lines or texting lines. For others, “therapy via webcams is a great idea for people like me who physically have issues getting to therapy and sitting for a therapeutic hour.” [154:  Reetz, Bershad, LeViness, and Whitlock. The Association for University and College Counseling Center Directors Annual Survey, p. 68.] 

Research is still under way to determine the effectiveness and best uses for telecounseling. Respondents believe that it is a promising way to supplement in-person counseling and that it seems to be effective for treating anxiety. The key is to increase access, making it more likely students get the treatment they need. In this respect, telecounseling holds great promise, especially for rural areas and special populations, such as students with physical disabilities. Programs have included the following:

TAO Connect: The University of Florida’s Counseling and Wellness Center Therapist Assisted Online (TAO) program delivers therapy to students with anxiety disorders via a computer or smartphone. TAO is a seven-week program that “‘consists of several modules that teach students to observe their anxiety, live one day at a time, and face fears. Students also have weekly 10- to 12-minute video conferences with counselors as well as homework that they do via an app. They even get text message reminders to prompt them to complete their assignments,” says Sherry Benton, Ph.D., the former director of the University of Florida counseling center who led TAO’s development.[endnoteRef:155] [155:  Novotney, A. “Students under Pressure.” Monitor on Psychology 45, no. 8 (2014). http://www.apa.org/monitor/2014/09/cover-pressure.aspx] 

The University of Southern California TelehealthTM program is a completely virtual counseling and therapy clinic that uses online and video technologies to serve a diverse set of students. Students can connect with high-quality counseling and therapy providers from the comfort and security of their homes or other private locations. 

The National Technical Institute for the Deaf uses technological advances to help DHH students. Practices include video relay and video remote interpreting, which can support counseling sessions. Access to sign-fluent clinicians is made possible through computer screens. This is only newly available because of increases in bandwidth to accommodate motion and not just voices.

## Substance Use Recovery Center on Campus

SAMHSA’s 2012 National Survey on Drug Use and Health [endnoteRef:156] found the following: [156:  Substance Abuse and Mental Health Services Administration. Results from the 2012 National Survey on Drug Use and Health: Summary of National Findings. NSDUH Series H-46, HHS Publication No. (SMA) 13-4795. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2013. Accessed March 22, 2017, https://www.samhsa.gov/data/sites/default/files/NSDUHresults2012/NSDUHresults2012.pdf] 

College students aged 18 to 22 were more likely than their peers who were not enrolled full time (i.e., part-time college students and persons not currently enrolled in college) to report current, binge, or heavy drinking. Among full-time college students in 2012, 60 percent were current drinkers, 40 percent were binge drinkers, and 14 percent were heavy drinkers, compared with 52, 35, and 11 percent, respectively. This pattern has remained consistent since 2002.

In 2012, the rate of current use of illicit drugs was 22 percent among full-time college students aged 18 to 22. This rate was similar to that of other persons aged 18 to 22 (24.0 percent), including part-time college students, students in other grades or types of institutions, and nonstudents. 

According to one interviewee: 

We have a recovery program on our campus that is sort of a national trend. In 2015 we got a grant to start a collegiate recovery program. We hired some staff and we’ve started this. At the very top it’s SAMHSA. Funds were funneled through Governor’s office, then department of mental health and substance use. 

Sometimes, substance use results in charges or results in students having to leave the university. For some of these students, some of the most effective mental health care that they’ll ever have will be on this campus. Forcing students to leave school where they don’t have access to this is really doing the students a disservice. Substance use—seeing this as a particular person’s fault rather than as an illness is a stigma. —College counseling center staff member

Collegiate Recovery Programs are an emerging trend, designed to provide a peer and professional support network for students recovering from alcohol and other drug dependency.[endnoteRef:157] Many Collegiate Recovery Communities are currently participating in a survey, led by Texas Tech University, to create a national collegiate recovery database.[endnoteRef:158] [157:  Moore, Abigail. “A Bridge to Recovery.” January, 2012. Accessed March 22, 2017, http://www.nytimes.com/2012/01/22/education/edlife/a-bridge-to-recovery-on-campus.html; Collegiate Recovery Centers, Accessed March 22, 2017 http://collegiaterecovery.org/ ]  [158:  Accessed March 22, 2017, http://collegiaterecovery.org/research-data/ ] 

## Partnerships with Mental Health Providers in the Community

Colleges are becoming very good at recognizing when they do not have the capacity to support students and, when this is the case, developing partnerships with community providers. Colleges and universities generally provide short-term services to students and, if they have connections with community-based clinics, refer students for assistance with long-term needs. If there is a fee for service, it is helpful if colleges offer a voucher system for off-campus mental health services. In colleges that use the case-management model, case managers are often responsible for managing relationships with community-based providers. Case managers also help students transition to off-campus services, which is especially necessary for students who are not from the community and lack a way to determine which provider would be best for them. Fifty percent of the students interviewed reported that they were aware or thought that their colleges had some relationship with community mental health providers, 44 percent were not sure, and six percent did not think their colleges had these relationships.

In addition to providing services to students, community organizations have trained college faculty, staff, and students. For example, one respondent noted that community partners, such as New Avenues for Youth, come to the college to offer training and workshops on supporting youth with mental health challenges.

Colleges and universities have also developed partnerships with law enforcement and county mental health entities to streamline the mental health threat assessment process. A model practice is the L.A. County Department of Mental Health School Threat Assessment and Response Team. All California colleges and universities in L.A. County are eligible to participate.

Some colleges and universities, however, do not have local community resources to turn to; those resources focus on different demographic groups (the needs of a college student are different from those of a 12-year-old or a 40-year-old), organizations are unable to provide services, or transportation is not provided and students have difficulty reaching a local provider.

## Other Organizational Collaborations

### College Collaboration

As an African proverb cited by an interviewee states, “If you want to walk fast, walk alone. If you want to walk far, walk together.” In the face of increasing student mental health needs, interviewees highlighted the need for colleges to collaborate internally with on-campus student services and academic affairs programs to create a web of support as well as externally with community-based organizations, county organizations, and other colleges to work together toward common mental health support goals. Successful teamwork is essential if colleges are to fully meet the mental health needs of their students. 

One example of successful collaboration is the California Community College (CCC) Student Mental Health Program.[endnoteRef:159] The statewide program is funded by CalMHSA, developed when the state’s voters approved Proposition 63, which levied a one percent tax on millionaires to support mental health efforts in the state. A percentage of the CalMHSA revenue went to support campus-based mental health programs in California colleges. The CCC Student Mental Health Program works with colleges throughout the state to build strong collaborations within colleges, between colleges, and between community mental health departments. The program also developed a collaboration toolkit, which is available at the CCC Student Mental Health Program website.[endnoteRef:160] One collaboration was the Building Healthy Communities Initiative in Los Angeles, California, in which college and Department of Mental Health partners agreed on multiple strategies to support students. These strategies ranged from cross-participation on committees in each organization, population-specific mental health services for different populations, strategies for increased access to services, faculty and staff training, inclusion of student voice, and parity between physical and mental health budgets.[endnoteRef:161] [159:  See California Community Colleges Student Mental Health Program Website, http://www.cccstudentmentalhealth.org/]  [160:  See California Community Colleges Student Mental Health Program Website, http://www.cccstudentmentalhealth.org/]  [161:  See Los Angeles College Mental Health Consortium, http://www.lahc.edu/studentmentalhealth/Teambuilding-2.html] 

### College Collaborations with Other Organizations

Other successful collaborations include those between colleges and universities and NAMI and Active Minds. In 2011 NAMI conducted a survey[endnoteRef:162] to identify important mental health-related issues for students; an overwhelming majority of survey respondents said they were no longer in college (attendance stopped within the past five years) and were not attending college because of mental health-related reasons. They identified factors that would support students remaining in school, including: receiving accommodations (e.g., tutoring, books on tape, lower course loads, help with communicating their needs to professors or online classes); accessing mental health services and supports on campus; connecting with mental health providers earlier; availability of peer-run support groups; and assistance with medical bills and transportation.  [162:  Gruttadaro and Crudo, “College Students Speak: A Survey Report on Mental Health,” 2012. ] 

Respondents also shared that colleges could keep students with mental health challenges in school by doing the following: publicizing available accommodations, services, and supports on and off campus; encouraging students to get help before issues grow; sharing resources and strategies for addressing mental health issues and staying in school; proactively reaching out to students who are struggling; reducing burdensome paperwork needed to get help; not penalizing students or revoking financial aid because of mental health issues; encouraging peer support and clubs; and asking about and addressing barriers to getting help.

Respondents also shared tips on the following: disclosing disability; raising awareness, including pertinent information on college websites; improving accommodations; improving disabled student program services; improving campus mental health care on campus; reducing stigma; supporting students; and addressing and preventing crises.[endnoteRef:163] [163:  Gruttadaro and Crudo, “College Students Speak: A Survey Report on Mental Health,” 2012. ] 

Other important collaborations are between colleges and entities such as the Jed Foundation and the Clinton Health Matters initiative, which assist colleges and universities in creating more comprehensive solutions to help students maintain healthier and safer learning environments.

## Postvention

Regarding services provided to students, faculty, and staff following a traumatic event, respondents reported that policies vary widely across schools and that services are often inadequate. In the event of suicide, a “contagion effect” is likely among young people in contained communities such as college campuses.[endnoteRef:164] Thus, adequate postvention plans are critical to prevent further occurrences. While schools mostly have policies in place for specific traumatic events such as an active shooter, support services are typically only increased in the immediate aftermath of these events.  [164:  Haw, C., K. Hawton, C. Niedzwiedz, and S. Platt. “Suicide Clusters: A Review of Risk Factors and Mechanisms.” Suicide and Life-Threatening Behavior 43 (2013): 97–108. ] 

A best practice mentioned by multiple respondents was delivery of a coordinated crisis management response by pooling different resources across campus and creating a community support team,[endnoteRef:165] which can provide necessary support in the aftermath of a traumatic event when confusion is common and services are most needed. These teams often comprise diverse groups across the campus, including academic support staff, students, and mental health professionals, and create relationships with law enforcement and mental health units at local hospitals. These teams demonstrate that it is not always necessary to rely solely on trained mental health professionals, and that peer support groups of fellow students and staff can be helpful and cost-effective. The key to effective community support teams is training to ensure that teams understand the basic policies, procedures, and mental health concerns of their campuses. These community teams offer support and maintain stability for the campus community, mainly through meetings to share information and resources. [165:  http://www.hcs.harvard.edu/~hhpr/wp-content/uploads/2012/04/features-1.pdf] 

Finally, postvention plans must include opportunities for iterative evaluation and modification of the college’s assessment, prevention, and intervention policies.[endnoteRef:166]  [166:  https://www.jedfoundation.org/schools-institutions-need-to-have-a-postvention-plan/] 

## Considering the Needs of Diverse Populations 

Research highlights the unique stressors that impact a number of student populations, and colleges should ensure they consider the needs of these populations when developing and providing mental health services

### Students of Color

Some studies suggest that students of color face higher levels of mental health difficulties compared with White peers[endnoteRef:167] due to the impact of racial discrimination,[endnoteRef:168] stigma, the tendency for students of color not to engage in help-seeking behaviors as often as their White peers,[endnoteRef:169] and issues related to the lack of culturally relevant support services.[endnoteRef:170] Students of color are also more likely to discontinue mental health services prematurely.  [167:  Eisenberg, D., J. B. Hunt, and N. Speer. “Mental Health in American Colleges and Universities: Variation across Student Subgroups and across Campuses.” Journal of Nervous and Mental Disease 201, no. 1 (2013): 60–67.]  [168:  Neblett Jr., E. W., and S. O. Roberts. “Racial Identity and Autonomic Responses to Racial Discrimination.” Psychophysiology 50 (2013): 943–953; Ancis, J. R., W. E. Sedlacek, and J. J. Mohr. “Student Perceptions of Campus Cultural Climate by Race.” Journal of Counseling & Development 78 (2000): 180–185. doi:10.1002/j.1556- 6676.2000.tb02576.x; Pieterse, A. L., N. R. Todd, H. A. Neville, and R. T. Carter. “Perceived Racism and Mental Health Among Black American Adults: A Meta-Analytic Review.” Journal of Counseling Psychology 59, no. 1 (2012):1–9. doi: 10.1037/a0026208. pmid:22059427; Biasco, F., E. A. Goodwin, and K. Vitale. “College Students' Attitudes Towards Racial Discrimination.” College Student Journal 35 (2001): 523–528. ]  [169:  Masuda, A., P. L. Anderson, and J. Edmonds. “Help-seeking Attitudes, Mental Health Stigma, and Self-concealment among African American College Students.” Journal of Black Studies 43, no. 7 (2012): 773–786. doi:10.1177/0021934712445806.]  [170:  Thompson, V. L. S., A. Bazile, and M. Akbar. “African Americans’ Perceptions of Psychotherapy and Psychotherapists.” Professional Psychology: Research and Practice 35, no. 1 (2004): 19.] 

### ***Foster Youth***

Foster youth are twice as likely as nonfoster youth to have contemplated suicide in the past 12 months and almost four times as likely to have attempted it.[endnoteRef:171] Eighty-five percent of foster youth live with serious mental health challenges,[endnoteRef:172] more so than nonfoster peers.[endnoteRef:173] These mental health problems may interfere with the ability of former foster youth to succeed in school, particularly if the treatment they received while in care is discontinued after emancipation—a common occurrence.[endnoteRef:174]  [171:  Pilowsky D. J., and L. T. Wu. “Psychiatric Symptoms and Substance Use Disorders in a Nationally Representative Sample of American Adolescents Involved with Foster Care.” Journal of Adolescent Health 38 (2006): 351–358. doi:10.1016/j.jadohealth.2005.06.014.]  [172:  Substance Abuse and Mental Health Services Administration. “National Survey on Drug Use and Health.” In Results from the 2005 National Survey on Drug Use and Health: National Findings. Rockville, MD: Office of Applied Studies, NSDUH Series H-30, DHHS Publication No. SMA 06-4194, 2005. http://archive.samhsa.gov/data/NSDUH/2k5nsduh/2k5results.pdf]  [173:  McMillen, Zima, Scott Jr., Auslander, Munson, Olie, and Spitznagel, “Prevalence of Psychiatric Disorders among Older Youths in the Foster Care System,” 88–95; Shin, “Need for and Actual Use of Mental Health Service by Adolescents in the Child Welfare System,” 1071–1083.]  [174:  Courtney, M., A. Dworsky, G. Ruth, T. Keller, J. Havlicek, and N. Bost. Midwest Evaluation of the Adult Functioning of Former Foster Youth: Outcomes at Age 19. Chicago: Chapin Hall Center for Children at the University of Chicago, 2005; McMillen, J. C., and R. Raghavan. “Pediatric to Adult Mental Health Service Use of Young People Leaving the Foster Care System.” Journal of Adolescent Health 44, no. 1 (2009): 7–13.] 

### International Students

The number of international students studying at U.S. colleges and universities has grown steadily since the 1950s. While all students experience academic and personal pressures, international students face unique academic and social challenges that increase the potential for stress.[endnoteRef:175] Stressors include language barriers, financial pressures, and isolation from family and friends. Since the stigma of mental illness is greater in many countries than it is in the United States, culture may be an added barrier to students accessing mental health services.[endnoteRef:176] Hyun et al. analyzed 551 surveys from international graduate students at one university asking about the prevalence of mental health needs, students’ knowledge of mental health services, and students’ use of on- and off-campus counseling services. They found that 44 percent of international graduate students reported experiencing a stress- or emotion-related problem affecting their health and well-being.[endnoteRef:177]  [175:  Suicide Prevention Resource Center. “A Comprehensive Approach to Suicide Prevention.” (nd). Accessed March 22, 2017, http://www.sprc.org/effective-prevention/comprehensive-approach]  [176:  Yi, J. K., J. G. Lin, and Y. Kishimoto. “Utilization of Counseling Services by International Students.” Journal of Instructional Psychology 30, no. 4 (2003): 333–342.]  [177:  Hyun, J., B. Quinn, T. Madon, and S. Lustig. “Mental Health Need, Awareness, and Use of Counseling Services Among International Graduate Students.” Journal of American College Health 56, no. 2 (2007): 109–118.] 

### ***Veterans***

Colleges are seeing the largest number of student veterans since World War II because of the financial support provided by the post-9/11 GI Bill. Veterans may come to colleges and universities with serious mental health challenges or traumatic brain injuries. Veterans commonly report problems associated with academic demands, socialization with peers, and limited access to services in postsecondary institutions.[endnoteRef:178] Veterans also face stressors such as transitioning to a new environment and feeling out of sync with fellow students due to age and experience. Research cites that current veterans face dropout rates as high as 88 percent.[endnoteRef:179] It is fairly common for student veterans to experience cognitive impairments such as disruption in attention or verbal memory or challenges with new learning.[endnoteRef:180] More than 50 percent of veterans believe their deployments increased their personal stress levels, 32 percent believe their combat experience changed the way they learned, and 11 percent marked “my combat experiences now interfere with my participation in education”[endnoteRef:181] on the survey. Furthermore, according to an interview with Student Veterans of America, underreporting of disabilities is common among veterans, and testing for learning disabilities is costly and often difficult to receive.  [178:  DiRamio, D., R. Ackerman, and R. Mitchell. “From Combat to Campus: Voices of Student-Veterans.” NASPA Journal 45, no. 1 (2008): 73–102.]  [179:  Wood, D. “Veterans' College Drop-out Rate Soars.” Huffington Post, October 25, 2012. Retrieved from http://www.huffingtonpost.com/2012/10/25/veterans-college-drop-out_n_2016926.html]  [180:  Sinski, J. B. “Classroom Strategies for Teaching Veterans with Post-Traumatic Stress Disorder and Traumatic Brain Injury.” Journal of Postsecondary Education and Disability 25, no. 1 (2012): 87–95.]  [181:  Ostovary, F., and J. Dapprich. “Challenges and opportunities of Operation Enduring Freedom/Operation Iraqi Freedom veterans with disabilities transitioning into learning and workplace environments.” New Directions for Adult and Continuing Education (2011): 63–73. doi: 10.1002/ace.432] 

### Sexual Orientation and Sexual Identity

Since 2000, the number of college students who identify as LGBTQ has roughly doubled.[endnoteRef:182] These students have higher risks and stressors when compared with traditional students. In a recent survey of 10,000 youth, LGBTQ youth were nearly twice as likely as non‐LGBTQ youth to report having been excluded by peers at school, twice as likely to have been verbally harassed at school, three times as likely to feel that they do not fit in, and one‐third less likely to report having an adult they can turn to for help.[endnoteRef:183] The 2015 Cooperative Institutional Research Program (CIRP) Freshman Survey reported on 141,189 freshmen entering 199 four-year U.S. colleges and universities.[endnoteRef:184] They found that students who identify as lesbian, gay, bisexual, queer, or “other” (LGBQ/other) more frequently have felt overwhelmed and depressed in the past year compared to their heterosexual/straight classmates. Students identifying as queer were the most likely to have felt overwhelmed (64 percent) and depressed (46 percent) in the past year. Further, while more than half (53 percent) of heterosexual/straight students rate their emotional health as either “above average” or in the “highest 10 percent,” just 25 percent of LGBQ/other students reported the same.[endnoteRef:185] Further, compared to heterosexual students, sexual minority students had higher rates of psychological distress (26 percent versus 18 percent), were more likely to report academic impairment related to mental health problems (17 percent versus 11 percent), and reported higher overall levels of stress over the past month (63 percent versus 55 percent).[endnoteRef:186] [182:  UC Office of the President. Promoting Student Mental Health. (2016). http://sja.ucdavis.edu/files/PSMH-guide.pdf; citing national data from American College Health Association (ACHA) nationwide survey, which was collected across multiple survey administrations.]  [183:  Human Rights Campaign. 2012. Accessed March 22, 2017, https://www.hrc.org/videos/videos-hrc-2012-unprecedented-mobilization-for-equality]  [184:  Human Rights Campaign. http://www.hrc.org/files/assets/resources/Growing-Up-LGBT-in-America_Report.pdf]  [185:  Eagan, K., E. B. Stolzenberg, A. K. Bates, M. C. Aragon, M. R. Suchard, and C. Rios-Aguilar. (2015). The American Freshman: National Norms Fall 2015. Los Angeles: Higher Education Research Institute, UCLA, 2015. Retrieved from https://www.heri.ucla.edu/monographs/TheAmericanFreshman2015.pdf]  [186:  Sontag-Padilla, Lisa, Elizabeth Roth, Michelle W. Woodbridge, Courtney Ann Kase, Karen Chan Osilla, Elizabeth D’Amico, Lisa H. Jaycox, and Bradley D. Stein. CalMHSA Student Mental Health Campus-Wide Survey. Accessed March 22, 2017, http://www.cccstudentmentalhealth.org/docs/evaluation/CalMHSA_SMH_Campus_Wide_Survey_2013_Report.pdf] 

Finally, transgender university and college students are at a significantly higher risk for suicide attempts when their campus experience includes being denied access to bathrooms and gender-appropriate campus housing. Using data from the National Transgender Discrimination Survey (NTDS), the largest survey of transgender individuals conducted in the United States, Seelman found that 47 percent of transgender individuals participating in this study had a history of attempted suicide, and that rate was even higher for those who had been denied access to bathrooms (61 percent) or gender-appropriate campus housing (61 percent).[endnoteRef:187]  [187:  Seelman, Kristie L. “Transgender Adults’ Access to College Bathrooms and Housing and the Relationship to Suicidality.” Journal of Homosexuality 63, No. 10 (2016): 1378–1399. Retrieved from http://www.tandfonline.com/doi/full/10.1080/00918369.2016.1157998] 

Because there are an increasing number of students who identify as LGBTQ on college campuses, and they have unique mental health stressors, this requires a corresponding increase in the availability of mental health services to support them. 

### Students with Disabilities

In the last two decades, the number of students with disabilities on college campuses has doubled.[endnoteRef:188] Students with physical, mental, and learning disabilities are at higher risk for mental health problems than those without such disabilities and typically have higher rates of depression and more thoughts and attempts of suicide.[endnoteRef:189] Additionally, students’ risk for suicidal behavior has been shown to be higher if the disability is less visible.  [188:  Hadley, W. M. “College Students with Disabilities: A Student Development Perspective.” New Directions for Higher Education 154 (2011): 77–81.]  [189:  Center for Disease Control, 2016. Accessed March 22, 2017, https://www.cdc.gov/ncbddd/disabilityandhealth/relatedconditions.html] 

Students with disabilities face similar problems to those experienced by other students, except their problems are often compounded by unique factors that cause additional stress, such as lack of access to accommodations and/or modifications that allow them to have equal access and participate on equal footing with students without disabilities; prejudice and discrimination; and the daily challenges of a disability. 

### Graduate Students

Graduate students face unique stress and challenges compared with undergraduate students, including an increased risk for social isolation and consequences of stigma when working closely with faculty whose recommendations are crucial for career advancement.[endnoteRef:190] In one study at a large university, nearly half of the graduate students surveyed (45 percent) reported having an emotional or stress-related problem in the past year, and over half of the respondents (58 percent) reported a colleague with a similar problem.[endnoteRef:191] A survey of law students across 15 law schools found that 17 percent of law students screened positive for depression, 23 percent screened positive for mild to moderate anxiety, and 14 percent screened positive for severe anxiety.[endnoteRef:192]  [190:  The Provost’s Committee on Student Mental Health. “The State of Student Mental Health on College and University Campuses with a Specific Assessment of the University of Minnesota, Twin Cities Campus.” 2016. Accessed March 22, 2017,http://www.mentalhealth.umn.edu/download/Provost_s_Committee_on_Student_Mental_Health_White_Paper_Final.pdf]  [191:  Hyun, J. K., B. C. Quinn, T. Madon, and S. Lustig. “Graduate Student Mental Health: Needs Assessment and Utilization of Counseling Services.” Journal of College Student Development 47, no. 3 (2006): 247–266.]  [192:  Organ, J. M., D. B. Jaffe, and K. M. Bender. “Helping Law Students get the Help They Need: an Analysis of Data Regarding Law Students Reluctance to Seek Help and Policy Recommendations for a Variety of Stakeholders.” The Bar Examiner 84, no. 4 (2015): 9–17. https://ssrn.com/abstract=2815513.] 

### Community College Students

CalMHSA and RAND Corporation research found that CCC students, compared with their four-year state school counterparts, had higher rates of impaired academic performance due to mental health issues; received less information from their campuses about mental health and wellness; received and used half the number of mental health referrals; and most often had to be referred to community mental health resources due to the lack of on-campus resources. 

Despite the challenges among students at community colleges, a 2012 American College Counseling Association (ACCA) study involving 294 community college counselors found that fewer than 13 percent of community colleges provided psychiatric services for students.[endnoteRef:193] By contrast, 56 percent of four-year colleges and universities offered on-campus psychiatric services.[endnoteRef:194] The lack of psychiatric care was a concern because many community college students were at an increased risk for mental health problems compared with their traditional university student counterparts.[endnoteRef:195]  [193:  American College Counseling Association – Community College Task Force Survey of Community/2 Year College Counseling Services 2012-2013. https://www.insidehighered.com/sites/default/server_files/files/ACCA%20CCTF%202012-2013%20Survey%20FINAL.PDF ]  [194:  Similar numbers to our findings from the AUCCCD survey, which found that 61 percent of IHEs have psychiatrists on campus, while according to the NSCCC survey, only 7 percent of community colleges have access to on campus psychiatrists.]  [195:  American Psychological Association. “Mental Health Services Remain Scarce at Community Colleges.” Monitor on Psychology 43, no. 4 (2012). Retrieved from http://www.apa.org/monitor/2012/04/community-colleges.aspx] 

### Student Athletes

Student athletes face many of the same challenges as their nonathlete peers; however, they are exposed to an additional set of risk factors, including less time to focus on schoolwork, pressures to perform at the highest level in their sport, and a culture that encourages risk behaviors and discourages help-seeking.[endnoteRef:196] Student athletes, coaches, and staff tend to minimize mental disorders or mental stress because of expectations of strength, stability, and “mental toughness” inherent in the sports culture. Thus, student athletes often do not disclose mental health concerns for fear of being perceived negatively by teammates or coaches.  [196:  Brown G. T. (ed.) Mind, Body and Sport: Understanding and Supporting Student-Athlete Mental Wellness.” Indianapolis, IN: National Collegiate Athletic Association, 2014. http://www.ncaapublications.com/productdownloads/MindBodySport.pdf ] 

# Chapter 8. Full Findings and Recommendations

The findings of this study demonstrate that student mental health services are needed to support the mental well-being of students and important for academic success and retention—but resources are lacking and barriers are prevalent. It is vital that Congress make additional resources available to colleges and universities to support their mental health services and supports. The policy recommendations that follow are aimed at ensuring student success by removing barriers that prevent college students with mental health disabilities from participating and succeeding in college and, consequently, employment.

## Recommendations to Congress 

Lack of financial resources are a major barrier to colleges in meeting the mental health needs of their students. NCD commends Congress for passage of the 21st Century Cures Act, which broadens the criteria by which institutions of higher education may receive grants for mental and behavioral health services, and authorizes an increased appropriation of $2,000,000 per year for fiscal years 2018–2012. The allowable uses of grant funds correspond very closely with the findings and recommendations in this report, including the need for training of students, faculty, and staff; increasing mental health prevention and treatment services; outreach to students about mental health services; linking college mental health services to community mental health providers; and hiring appropriately trained mental health staff. 

**Recommendation:**Congress should fully fund Section 9031 of the 21st Century Cures Act (mental health and substance use disorder services on campus) to assist colleges in addressing the increased need for mental health services and supports for students.[endnoteRef:197] [197:  114 P.L. 255 (2016). See Section 9031: Mental Health and Substance Use Disorder Services on Campus] 

**Recommendation:**Congress should make federal financial assistance to colleges contingent on colleges implementing a mental health program, just as federal law makes federal financial assistance contingent on a college’s implementation of a program to prevent student use/abuse of illicit drugs and alcohol.[endnoteRef:198]**** [198:  20 USC §2011i.] 

**Recommendation:**Congress should increase funding for the Garrett Lee Smith Campus Suicide Prevention Program.

**Finding 1: Multiple restrictions in the provision of federal and college financial aid negatively impact the ability of students with mental health disabilities to complete their postsecondary education.**

Practitioners and students noted that multiple restrictions in the provision of financial aid negatively impact the ability of students with mental health disabilities to succeed in school. 

Many students with mental health disabilities are unable to complete full-time course loads and are much more successful taking one or two courses at a time. Students with lightened course loads are at risk of not completing their education within the 12-semester limit of Pell Grants and are therefore in danger of losing financial aid. Further, colleges are held accountable to students completing degrees within this time frame, so the pressure falls on students with mental health disabilities to take full loads**even though it is not in their best interest to do so.

Students are required to maintain a certain GPA or lose their scholarships or financial aid. Students with mental health disabilities who are unable to uphold their GPAs because of their disabilities, or who are on medical leave due to their disabilities, are at risk of losing scholarships and must begin loan repayments if their LOA is longer than the grace period to begin paying their loan.

Borrowers do not have to begin repaying most federal student loans until a semester or a year after graduation when they have had time to get financially settled, determine expected income and expenses, and select a repayment plan. However, the unemployment rate of many individuals with mental disabilities is high at graduation and beyond, and the loan amounts are also high because of longer degree completion time frames. Thus, loan repayment is very burdensome for individuals with mental disabilities.

**Recommendation:** Congress should amend the Higher Education Act to extend the length of time a student with a disability is eligible for federal financial aid when, due to the disability, a student needs more time to complete degree requirements than is allowed under federal financial aid time parameters. 

**Recommendation:** Congress should amend the Higher Education Act to allow students whose disabilities cause them to require additional semesters of financial aid to retain their eligibility for Pell Grants beyond 12 semesters.[endnoteRef:199] [199:  20 U.S.C. § 1070a(c).] 

**Recommendation:** Because college students with disabilities may require a medical LOA that extends past six months while they are pursuing a degree, Congress should amend the Higher Education Act requirement that loan repayments begin 6 months after leaving college,[endnoteRef:200] to allow a time extension as a disability-related accommodation.  [200:  20 U.S.C. § 1078(b)(7).] 

**Recommendation:**Congress****should substantially increase Pell Grants to provide opportunities to students with disabilities who are disproportionately low-income to attend and achieve higher education. 

## Recommendations to ED

**Finding 2: The U.S. Department of Education has not provided guidance to colleges on how to respond to students that pose a threat to themselves.**

The regulations under Title I of ADA expressly recognize that *employers* need not accommodate employees who pose a “direct threat” to the health or safety of themselves or others, and provide a framework for assessing whether an employee poses such a threat.[endnoteRef:201] In the absence of a Title II regulation that provided colleges with a framework that applied to students, many colleges adopted the Title I framework and developed policies and procedures, including those related to medical withdrawal and involuntary withdrawal, to respond to students who posed a direct threat to the health or safety of themselves or others. Colleges anticipated that the 2011 Title II regulations would include “direct threat” provisions applying to students, but the regulations did not. Colleges have not received guidance from OCR or DOJ on how they can properly respond to students at risk of self-harm or harm while maintaining compliance with disability laws. According to interviewees, this places colleges in an unfair position as they have little guidance on what to do, what works, and what is lawful. Students who are forced to withdraw or take medical LOA because they report feeling suicidal, for example, are also burdened by the lack of guidance to colleges. [201:  29 C.F.R. § 1630.15(b)(2); 29 C.F.R. § 1630.2(r) (Direct Threat means a significant risk of substantial harm to the health or safety of the individual or others that cannot be eliminated or reduced by reasonable accommodation. The determination that an individual poses a “direct threat” shall be based on an individualized assessment of the individual's present ability to safely perform the essential functions of the job. This assessment shall be based on a reasonable medical judgment that relies on the most current medical knowledge and/or on the best available objective evidence. In determining whether an individual would pose a direct threat, the factors to be considered include: (1) The duration of the risk; (2) The nature and severity of the potential harm; (3) The likelihood that the potential harm will occur; and (4) The imminence of the potential harm. ] 

**Recommendation:** ED/OCR should provide colleges with best practices for responding to students who exhibit or threaten self-harming behavior.

**Recommendation:**ED/OCR should provide colleges with best practices for providing legally required modifications and accommodations for students with mental health disabilities. 

**Finding 3: The FAFSA does not contain fields in which an applicant may include disability-related expenses.**

Despite references to including disability-related expenses in calculating Pell Grants and the Cost of Attendance, FAFSA does not provide an option for students to disclose disability-related expenses. The lack of an easy option to disclose disability-related expenses is a barrier to students with disabilities.

**Recommendation:**Modify the FAFSA to allow students to directly input disability related expenses.

**Finding 4: More financial support is necessary for students with mental health disabilities to achieve academic success.**

As noted, students with mental health disabilities incur greater costs related to their disabilities and have more difficulty in repaying loans.

**Recommendation:** Substantially increase financial aid for students with mental health disabilities who are disproportionately low-income to improve their higher education opportunities. Expansion of the federal Pell Grant would be most beneficial and is highly recommended.

**Finding 5: There is a perception among colleges that they cannot use federal Student Support Services funds to provide mental health counseling and other psychoeducational support services to eligible students.**

Some interviewees were told, during the grant competition period, that their application would be scored lower if the use of mental health counseling was part of their application because it was not explicitly stated in the allowable services. However, Student Support Services regulations do allow for counselors.[endnoteRef:202] According to one interviewee, they assumed that this can refer to licensed counselors who conduct actual psychological sessions, to aid with the student's retention.  [202:  20 U.S.C. 1070a–14(b)(2)] 

**Recommendation:** ED should clarify that Student Support Services funding can be used to provide mental health counseling. Further, ED should direct technical assistance providers for Student Support Services projects to stress the importance of the mental health counseling. Additionally, during grant competitions, ED should direct technical assistance providers conducting workshops to inform applicants that mental health counseling is a permissible service.

## Recommendations to HHS/SAMHSA 

**Recommendation:**SAMHSA****should****take actions to increase the awareness of colleges about mental health grant-funding opportunities, including funds available under the 21st Century Cures Act.

**Recommendation:**SAMHSA should****require colleges that apply for mental health-related grant funding to hire mental health staff, describe how they will recruit and hire culturally competent and diverse counselors, and have a system in place to ensure that colleges that receive grant funds comply with these requirements. 

**Recommendation:**SAMHSA should****require colleges that apply for mental health-related grant funding to provide, as part of each application, their policies on providing reasonable modifications, reasonable accommodations, and auxiliary aids for students with disabilities. SAMHSA should also require colleges to post these policies on their websites, at their DSS offices, and in their counseling centers.

**Recommendation:** SAMHSA should require colleges that apply for mental health-related grant funding to describe, as part of each application, how they will collaborate with community mental health service providers to meet student needs, as currently required from applicants under the Garret Lee Smith Campus Suicide Prevention program.

**Recommendation:**SAMHSA should give mental health****grant-funding priority to colleges that will use the funds for direct services that are proven best practices in providing mental health services to college students.

**Recommendation:**SAMHSA should liberally approve waivers to the matching funds requirement for mental health grant funding to colleges that do not have the financial capacity to provide campus mental health services without federal grant funds, and that show that they have high populations of at-risk students and students with multiple disabilities. 

## Recommendations to Colleges

**Finding 6: College policies do not reward help-seeking behavior from students.**

Colleges should develop policies that put students first. Because students are a captive audience, colleges offer a unique opportunity to engage students and connect them to an array of services. As one interviewee said, “College may be the place they receive the best medical care.” 

Colleges must be committed to finding ways to retain students and reward help-seeking behavior. Interviewees described effective college policies and practices as those where the college creates a culture that allows students to seek help and supports those who do. They believed that colleges have tried in recent years to take a public health approach[endnoteRef:203] to behavioral health issues in general. [203:  A model that addresses health or social problems in a comprehensive way. It considers human factors, characteristics of the source of harm, and the environment, identifies causes and suggests possible interventions. The public health model takes a population approach to health promotion and disease prevention. https://www.slideshare.net/drswaroopsoumya/public-health-model] 

When students know schools are putting them first, they are more likely to seek out the services they need. The academic affairs office should coordinate with the counseling/student support office to make decisions that are flexible enough to work on an individual, case-by-case basis. 

Interviewees argued that colleges should have parity between the provision of physical and mental health services and that they should be funded to do so. One respondent stated, “You would never identify a student with strep throat and give them half a prescription. If you’re going to treat the student, you need to provide full treatment up to specialty referrals.” The same goes for mental health services. If colleges have no limits on the amount of physical medicine clinic visits, they should not have limits on mental health counseling visits. Further, as with physical ailments, referrals to off-campus doctors or counselors should be made only when the staff on campus does not have the expertise to provide appropriate treatment.

**Finding 7: Lack of financial resources are a major barrier to colleges in meeting the mental health needs of their students.**

**Recommendation:** Colleges should work with their own shared governance structures to access funds for mental health services and supports through existing on-campus programs and services. The shared governance structures usually include college administrators, faculty and staff, advisory committee members, and students.

**Recommendation:** Colleges should examine the service structure within campus health centers to ensure that parity exists between mental and physical health services. Policies should be adjusted to adhere to parity regulations if needed.

**Recommendation:** Colleges should collaborate with local Department of Mental Health, veteran support, and Department of Rehabilitation entities to develop supplemental mental health services and supports on campuses.

**Recommendation:**Community colleges should work with their governance structure to raise the college student health fees if they are not at approved state levels so they are equipped to offer more comprehensive mental and physical health care services.

**Recommendation:** Colleges should examine the benefits and use of master’s- and doctoral-level psychology internship programs in serving students with mental health disabilities to cover more students in a cost-effective manner.

**Recommendation:** Colleges should explore the use of web-based counseling applications for outreach and to serve more students in a cost-effective manner.

**Recommendation:** Colleges should work with state legislators to develop legislation that funds supplemental mental health services and supports for colleges and universities. An example of successful legislation is California’s Proposition 63, which established mental health funding from an ongoing one-percent tax on millionaires. The current level of funding is insufficient for the state’s college mental health needs, but it is adequately building a state infrastructure of support.

**Recommendation:** States should develop an infrastructure that supports increased capacity building for mental health services and supports within colleges. An example is California’s CalMHSA service structure for colleges, state universities, and University of California campuses.[endnoteRef:204]  [204:  See http://calmhsa.org/.] 

**Finding 8: College faculty, staff, and administrators need more training to identify and support students with mental health disabilities.**

**Finding 9: College faculty, staff, and administrators need training in disability-related accommodations.**

Most institutions lack the resources for faculty/staff/student mental health awareness training and suicide prevention training, which would support efforts to identify and refer at-risk students. Lack of training was highlighted as a key barrier for students to receive the services they need to be academically successful.

**Recommendation:** Provide mandatory mental health sensitivity and awareness training for faculty, staff, and administrators, including streamlined identification and referral protocols and reasonable accommodation suggestions for students who have mental health disabilities. 

**Recommendation:** Provide mandatory faculty training on ADA and Section 504 regulations so that colleges comply with federal law and faculty understand their obligations. Encourage faculty to team with programs for college students with disabilities. 

**Recommendation:** Professional associations of student aid administrators, including the National Association of Student Financial Aid Administrators, should provide enhanced training to improve their members’ understanding of the special problems and circumstances facing low-income students with mental health disabilities. These organizations should evaluate the extent to which their members’ understanding of the time demands and the financial burdens faced by those with mental health disabilities impacts their guidance to these students and the provision of financial support. In addition, student aid administrators should understand the inappropriateness of applying standard packaging rules to students with mental health disabilities. 

**Finding 10: Institutions can have extensive paperwork requirements for students to complete before receiving mental health services, and students often experience long waits for college mental health services because of appointment backlogs.** Students may also experience a long wait for professional mental health disability assessments because of appointment backlogs.****This process is extremely problematic for crisis-ridden students who need immediate assistance and follow-up care. 

**Recommendation:** Colleges and universities should work with their own shared governance structures to ensure that students have immediate access to crisis services by developing and implementing streamlined intake processes.

**Finding 11: Colleges can better serve today’s student population by employing counselors that adequately reflect the student populations they serve.**Additionally, interviewees stressed the importance of professional organizations and mental health licensure professionals conducting outreach and inclusion activities to support the integration of more professionals of color into the field.

**Recommendation:**To encourage more mental health practitioners of color, forgive student loans of professionals committed to working with students with mental health disabilities in college.

**Finding 12: Colleges are struggling with the goal of supporting students with mental health disabilities. In addition to financial barriers that impact colleges’ ability to provide adequate services, colleges also need support and training in the implementation of best practices.**

**Recommendation:**Colleges should implement the best practices identified in this report. Several organizations and community entities, such as the Jed Foundation (Campus Mental Health Action Plan), California Community College Student Mental Health Program (CCC SMHP), NAMI on Campus, and Active Minds offer abundant information on best practice implementation. 

**Recommendation:**Each state should develop a website that captures materials, training videos, public service announcements, and best practice programming to support students with mental health disabilities, such as developed by the CCC Chancellor’s Office Mental Health program.[endnoteRef:205] [205:  See California Community Colleges Student Mental Health Program Website http://www.cccstudentmentalhealth.org/. This website provides cost-free training, webinars, and resources to build capacity to implement and sustain prevention and early intervention strategies that will allow campuses to better identify and address the mental health needs of students. And, ultimately to promote sustainable student mental health systems and policies. ] 

**Finding 13: This report identified the following best policies for colleges.**

**Recommendation:**Leave of Absence and Student Code of Conduct

It is critical that colleges and universities provide a time-sensitive assessment to determine whether a discipline situation is occurring or a mental health crisis is occurring. The pathways to successful outcomes for either of these situations depends on it. Colleges too often use punitive rather than supportive measures when students are presumed to be “acting out” or presenting some form of disruption that is out of the norm. Such punitive measures, however, discourage students—not just the penalized student but all others—from seeking help. They isolate students from social and professional supports—friends and understanding counselors and teachers—at a time of crisis, increasing the risk of harm. These punitive measures may also result in loss of insurance coverage for mental health care.

Implementation of college LOA and code of conduct policies should put students first. This includes looking at student behaviors to determine whether a situation is one of violence or a mental health crisis. All student disruptions should not be considered in breach of the student code of conduct. Once it is determined that students are undergoing mental health episodes that necessitate intervention, colleges should not apply disciplinary policies and punish behavior. Instead, they should provide due process and take student experiences into consideration, including appropriate interventions, such as whether students have a supportive home life if they were to be suspended or expelled from school. When students know they are first and know that their schools are not solely relying on punitive measures, they are more likely to seek out the services they need during times of crisis.

Following are best practices around LOA and student code of conduct policies:

Coordination between the academic affairs office and counseling/student support office to make decisions that are flexible enough to appropriately respond to student needs on a case-by-case basis. Immediately dismissing students from campus because of a mental health episode helps neither the students nor the schools. The students’ chances of returning and matriculating are slim. 

Clear communication to students contemplating LOAs of the impact of the LOA on their grades when they leave school, and their re-entry options. 

Elimination of mandatory**LOAs for students with mental health issues (e.g., students who have eating disorders, are cutting themselves, or have suicidal thoughts—regardless of whether they are suicidal or pose a significant risk).

· Consider flexible academic policies for leave, reduced course load, and other accommodations to help students work through mental health issues and maintain active student status.

Georgetown University has a policy of “freshmen forgiveness”—grades can be forgiven in recognition of the difficult transition from high school to college. While not currently used for students with mental health challenges, this policy could be an appropriate accommodation.

Removal of withdrawals from student transcripts in cases of mental health disabilities.

Provision of a school contact or liaison (see Case Management Approach section) for students taking LOAs. 

Policies that allow administrations to report crisis incidents so students, faculty, and staff receive fact-based communication, not just word of mouth.

**Recommendation:** Revise scholarship rules that require a certain GPA to accommodate students who can show that the drop in grades was clearly related to either mental disabilities or unaccommodated disabilities.

**Finding 14: This report identified as a best practice stigma reduction, education, and outreach.**

**Recommendation:** Best practices include the following:

Orientation for students can help set up a culture where mental health is not viewed as a disease or permanent state, and the complete normativeness of anxiety and other mental health concerns is acknowledged. Orientation could include a simple mental health assessment, with resource listings, that is self-scored by students. Students can be supported in developing skills that will help avoid mental health problems, such as time management, decision making, resilience, and coping. Orientation should allow opportunities for preenrollment in support service programs at freshman orientation, as it provides an easy, confidential manner for students to identify themselves.

Greater transparency of mental health services and supports through campus websites, with clear guidance on campus policies governing student LOAs and ADA mandates for accommodations.

· College students must know about the services available to them. Colleges report that they provide mental health services, but they need to better articulate exactly what services they provide and publish information on the Internet to encourage students to get help. Colleges should disseminate information on websites and social media that is clearly articulated to encourage students to come forward to get help. 

The campus community should be informed that mental health conditions are common and getting help is important (signage such as suicide prevention magnets and stickers in dorms and around campus are helpful). The link between mental health and academic success should be presented.

Open conversation on campus among faculty and staff about mental health issues should be an ongoing practice.

Creation of a broad-based committee on campus mental health that would include a racially diverse group of students with disabilities, LGTBQ students, foster students, and veterans as well as faculty, staff, and counseling center staff. The committee would discuss campus mental health needs and hold the college leadership accountable for addressing identified needs.

Co-location of mental and physical health services is a prime example of how colleges can place these two at the same level. Co-locating services signals to students that mental health is as important as physical health and reduces the stigma attached to seeking help.

Spotlighting of students, faculty, and staff who have achieved success living with a mental health condition to fight stigma and offer hope.

Hosting of on-campus educational activities and campaigns that combat stigma.

Faculty openly discussing mental health challenges normalizes the issue.

Assembly of celebrity speakers on mental health.

**Finding 15: This report identified as a best practice increasing student voice.**

**Recommendation:** Best practices include the following:

Train student leaders or reach out to NAMI or Active Minds to identify potential peer-to-peer workers to counsel classmates, as some students may not feel comfortable meeting with a counselor or resident advisor and may not seek support.

Encourage student-led organizations to get involved in campus mental health discussions and participate in efforts to destigmatize mental illness.

Participation in a Broad-Based Committee on Campus Mental Health, which integrates the voice of all constituency groups.

**Finding 16: This report identified multiple best practices in pedagogy.**

**Recommendation:** Best practices include the following:

Faculty talking openly about mental health issues.

Discussions of mental health challenges and resolutions can be incorporated into curricula to reduce stigma and normalize the process of embracing mental health wellness.

Requirement of all course syllabi to have a standard section that includes statements for students with physical or mental health disabilities, including why and where to seek support.

**Finding 17: This report identified as a best practice the creation of a coordinated support system.**

**Recommendation:** Best practices include the following:

Encourage the office for students with disabilities, the counseling center, academic departments, and student support groups, among others, to work together. Better training and communication is needed among faculty, students, and the entities that support students, including the Greek system. Currently, these offices do not communicate often enough unless there is a crisis.

Train faculty, staff, administrators, resident advisors, and students to recognize symptoms of mental health disorders and act appropriately to refer students. Training can be integrated into what is already routine for students, such as meeting with faculty and academic advisors, or it can be a web-based or college event training.

Identify faculty and staff who can be anchor adults. Students need a sense of belonging and connection with someone on campus. Students who have a meaningful connection with at least one adult are more likely to graduate and be successful.

Establish BITs and Care Teams that identify students who are struggling and need help or pose some threat.

Hire case managers to oversee the provision of resources for students in distress. By adopting this practice, colleges and universities can dedicate their mental health counselors to provision of treatment. The case management approach allows for much better oversight and follow-up with the student resource process.

Have a case manager in the counseling center, as well as one in the Dean of Students office, to coordinate between the two offices.

Create parent/family programs. Parents are often the strongest advocates of their own children in terms of access to services. Campuses can become more proactive in involving family members, including providing easier pathways for parents in terms of guiding institutions in terms of what services need to be provided.

Integrate mental health promotion into what is already routine for students, such as meetings with academic advisors. Determining students’ academic goals with their mental health concerns in mind may help them to help themselves.

**Finding 18: This report identified as a best practice creating collaboration and partnerships with community-based organizations and other colleges.**

**Recommendation:** Best practices include the following:

Connections with community-based organizations help address long-term mental health needs. Campuses that cannot provide all services can establish relationships with local providers to assist in supporting their needs. A case manager often is responsible for managing relationships with community-based organizations and helps students transition to those off campus services.

Colleges should collaborate with one another, especially those within the same region, to share best practices and available local resources, such as information about adequate off campus referrals. An example of a successful collaboration is the California Community College Student Mental Health Program.[endnoteRef:206]  [206:  http://www.cccstudentmentalhealth.org/. ] 

**Finding 19: This report identified as a best practice multiple ways to increase access to care.**

**Recommendation:** Best practices include the following:

Increase the size and diversity of the counseling and health center staff by using master’s- and doctoral-level psychology interns who work with an expanded number of students under the supervision of licensed mental health professionals. This approach has proven to be student-friendly and cost-effective.

Ensure that all counselors have cultural competency. Provide professional development in understanding the cultural considerations of students of color and other vulnerable student groups, if necessary. It is important to have a mental health counseling staff that is as diverse as the student body they serve.

Offer multiple types of services, including after-hours access to counseling, helplines, streamlined referral network to outside agencies, and telecounseling (especially helpful in rural areas).

Use technology, from Facebook support groups and mental health apps to online therapy games, to reach those who are struggling. 

**Finding 20: This report identified as best practices multiple ways to prevent suicide.**

**Recommendation:** Best practices include the following:

The Suicide Prevention Resource Center’s guidebook to promoting mental health and preventing suicide in college and university settings argues that college campuses with a comprehensive wellness system in place to assist in early intervention have a greater chance at reducing student suicide rates.[endnoteRef:207] [207:  Suicide Prevention Resource Center, Promoting Mental Health and Preventing Suicide in College and University Settings, 2004 ; The Suicide Prevention Resource Center, “A Comprehensive Approach to Suicide Prevention.” ] 

The Jed Foundation provides a thorough suicide prevention strategic planning guide. The purpose of this guide is to assist campuses in the development of suicide prevention protocols, including suggestions for developing leadership capacity on college campuses.[endnoteRef:208] [208:  Jed Foundation and EDC, Inc. “A Guide to Campus Mental Health Action Planning.” 2011. Accessed March 22, 2017, https://www.jedfoundation.org/wp-content/uploads/2016/07/campus-mental-health-action-planning-jed-guide.pdf] 

The National Suicide Prevention Lifeline offers connection with live responders at any time. They can be reached at 1-800-273-TALK. 

The American Foundation for Suicide Prevention and the Suicide Prevention Resource Center have collaborated to produce a toolkit to assist schools in the aftermath of a suicide. Although written for high schools, much of the information and many of the tools are applicable to the community college context as well.[endnoteRef:209]  [209:  See http://www.sprc.org/sites/sprc.org/files/library/AfteraSuicideToolkitforSchools.pdf] 

Colleges must use a comprehensive approach that includes promoting social networks and connectedness, identifying and assisting those who may be at risk, improving access to mental health services, and being prepared to respond when an incident occurs.

Suicide rates were cut in half when a college instituted a policy requiring students who threatened or attempted suicide to attend four sessions of professional assessment.[endnoteRef:210] [210:  Joffe, P. “An Empirically Supported Program to Prevent Suicide in a College Student Population.” Suicide and Life-Threatening Behavior 38, no. 1 (2008): 87–103.] 

Rather than requiring students to leave school because of mental health concerns, offering personalized interventions with college staff can address underlying problems with substance use, mental health, or other personal issues.

Reduction of access to means of suicide: prevent people from obtaining lethal methods of self-harm by educating families of those in crisis about safely storing medications and firearms; provide environmental deterrents to means of suicide by installing barriers on bridges and parking garages.

Offering life skills and resilience classes as part of a comprehensive health promotion effort along with the integration of mental health curricula in regular classes.

**Finding 21: This report identified as a best practice multiple ways to prevent violence.**

**Recommendation:** Best practices include the following:

Use threat assessment teams and increase staffing levels, services, and training across the mental health continuum of care.

Address attitudes, beliefs, perceptions, and skills that contribute to violence through education, skill building, curriculum infusion, and other efforts.

Support healthy group norms and promote bystander intervention during times of crisis.

Convey clear expectations for conduct among students, faculty, staff, and visitors.

Create and disseminate comprehensive policies and procedures addressing each type of violent behavior, and institute training programs to ensure that policies are followed and enforced.

Provide a range of support services for students, including mental health services, crisis management, and comprehensive and compassionate services for victims and bystanders who may have witnessed traumatic events.

Help students avoid harm by offering escort services and self-defense classes.

Develop, implement, and enhance comprehensive alcohol and other drug prevention programs as per financial aid regulations.

**Finding 22: This report identified as a best practice bereavement and postvention approaches.**

**Recommendation:** Best practices include the following:

A plan should be in place to help the community respond to an incident and reduce the risk to other vulnerable people, both in the short- and long-term.

Delivery of a coordinated crisis management response by pooling different resources across campus and creating a community support team. These teams often comprise diverse groups across the campus, including academic support staff, students, mental health professionals, along with mental health units at local hospitals.

Numerous states have issued reports identifying policy recommendations for preventing and responding to campus violence. These recommendations acknowledged the need for stronger mental health services and supports, and proposed that states and colleges find ways to increase the funding dedicated to campus mental health and wellness. Less than one year after the Virginia Tech shooting, the Virginia legislature improved the emergency evaluation process, modified the criteria for involuntary commitment, tightened procedures for mandatory outpatient treatment, and increased state funding for community mental health services.

**Finding 23: This report identified as a best practice multiple ways to support students of color with mental health disabilities.**

**Recommendation:** Best practices include the following:

Acknowledge and validate the unique experiences of students of color on campus, both at the individual and institutional level, by providing physical and social spaces for people of color to caucus within their own communities, with other communities of color, and with the larger campus community.

Provide messages that highlight mental health as a universal concern and decrease stigma; provide access to financial support for at-risk students.

Promote trust between mental health professionals and students of color (e.g., by making students of color stakeholders in decision making processes regarding the availability of mental health services on college campuses).

Increase the number of professionals and peer leaders of color and ensure that they have adequate training.

Offer professional development to understand the cultural considerations of students of color and provide general cultural sensitivity and awareness training that addresses the issue of microaggression.

Increase nonprofessional support, such as informal networking groups of students, staff, and faculty of color.

**Finding 24: This report identified as a best practice multiple ways to support foster youth with mental health disabilities.**

**Recommendation:** Best practices include the following:

Lift limits on the number of mental health sessions available to foster youth.

Provide free life skills training and tutoring to foster youth to learn employment and job readiness skills, financial literacy and management, and home and living skills.

Extend eligibility for services and financial resources to students older than 21, since many foster youth are not ready to begin postsecondary education at age 18. 

Create a Transitional Independent Living Plan, a document that provides the basis for all the financial benefits and services, such as housing, college financial aid, and tutoring, to help foster youth succeed in a college environment.

**Finding 25: This report identified as a best practice multiple ways to support veterans with mental health disabilities.**

**Recommendation:** Best practices include the following:

Identify and reach out to veterans before they arrive on campus to answer questions about housing and benefits, among others.

Provide drop-in hours for counseling services, telecounseling outside of regular business hours, and an overall willingness and ability to respond rapidly when veteran students are in need of assistance.

Provide coordinated support by assisting veterans in accessing local resources, such as the local Veterans Affairs medical center if one exists, student-run veterans groups, and campus mental health providers.

Provide counselors with similar backgrounds who have at least a basic understanding of where veterans are coming from and, therefore, are better equipped to assist with mental health services.

**Finding 26: This report identified as a best practice multiple ways to support LGBTQ students with mental health disabilities.**

**Recommendation:** Best practices include:

Provide a welcoming environment for LGBTQ students across the entire campus community, such as offering visual cues in office spaces or in providers’ verbal and nonverbal communication.

Provide anti‐bullying education.

Provide Safe Zone programs to educate peers, faculty, and staff.

Develop and implement specific policies that take into account nondiscrimination and confidentiality for LGBTQ youth.

**Finding 27: This report identified as a best practice multiple ways to support students with disabilities who also have mental health disabilities.**

**Recommendation:** Best practices include the following:

Ensure that policies and practices comply with ADA, Sections 504 and 508, and the Fair Housing Act.

Provide physical and programmatic access to services and programs, making sure counseling services are in physically accessible buildings and that sign language interpreters are available for DHH students.

Provide college faculty and staff with disability sensitivity and awareness training.

Provide DSS office staff and other student programs with mental health sensitivity and awareness training.

Provide access to technological advances that allow students with disabilities to participate on equal footing with students without disabilities (e.g., video remote interpreting for DHH students and other assistive technology).

Provide telecounseling as an alternative for students who may have difficulty getting to campus counseling offices.

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# Appendix A: List of Interviewees

Table A-1: List of practitioner and expert interviewees

### 

## Interviewee Questions

National Council on Disability Interview Questions

POLICY

1. What policies and reforms at colleges and universities address barrier removal for full access to mental health services and accommodations as mandated by federal law? 

2. What policy and system reforms affecting students with mental health disabilities in postsecondary settings are needed? 

3. Stigma and discrimination are often experienced by students with mental health challenges. What gaps, weaknesses, and discriminatory policies and/or practices have you observed? 

ACCESS

4. What can be done to enhance the inclusion, retention, and graduation of students with mental health disabilities in higher education? 

5. What barriers prevent colleges or universities from providing accessible mental health services for students that are required by law? 

6. Are students who disclose mental health disabilities provided reasonable accommodations to remain in school? Please describe a sampling of any accommodations that you are aware of. 

PRACTICE

7. What services do colleges and universities provide for students with mental health challenges and/or disabilities? Are the services adequately available? 

8. Do most colleges and universities maintain relationships with community mental health providers? 

9. Do colleges and universities provide mental health services to all students regardless of physical or sensory disabilities? 

10. What efforts do colleges or universities employ to reduce stigma and discrimination? 

11. Have faculty and staff received adequate training to identify, refer, and support students who have mental health disabilities or who are experiencing emotional distress? 

12. Are there adequate crisis management plans in place for students, faculty, and staff to deal with suicide, acts of violence, or traumatic events? Please describe. 

13. What are promising best practices and emerging trends? 

# Appendix B: Student Interviews

Colleges and universities where student interviews were conducted:

University of Texas–San Antonio (2)

Columbia University 

Texas Southern University

University of Maine

Los Angeles Harbor College

University of California–Berkeley

Central New Mexico Community College

## Student Interview Questions

National Council on Disability Interview Questions

STUDENT GROUPS:

1. What types of changes affecting students with mental health disabilities in your college (or other colleges that you’ve heard about) are needed? **Clarification:** E.g., additional policies or programs needed?

2. Are students who disclose mental health disabilities provided reasonable accommodations to remain in school? Please describe a sampling of the accommodations provided on your campus. **Clarification:** Examples may include: access to adequate counseling services, extended time on tests, leave of absence, 24-hour hotlines, etc.

3. What services does your college or university provide for students with mental health challenges and/or disabilities? Are the services adequately available? **Clarification:** See examples above to jog your thinking

4. Do you know if your college or university maintains relationships with community mental health providers? **Clarification:** If so, which providers? Do you know if these organizations are helpful?

5. Do you know if your college or university provides mental health services to all students regardless of physical or sensory disabilities? **Clarification:** Are there any limitations on mental health services based on the type of disability that a student has?

6. What efforts does your college or university employ to reduce stigma and discrimination? **Clarification:** E.g., awareness events, your school’s disciplinary process for students with mental health problems. Does your college president or other administrators routinely discuss student mental health?

7. Have faculty and staff received adequate training to identify, refer, and support students who have mental health disabilities or who are experiencing emotional distress? **Clarification:**Do college faculty or staff ever discuss with students any mental health services that are available? Do they note mental health services on class syllabi?

8. Is there an adequate crisis management plan in place for students, faculty, and staff to deal with suicide, acts of violence, or traumatic events? Please describe. **Clarification:** What resources does your campus provide after traumatic events?

9. What are promising best practices and emerging trends? **Clarification:** How do you see the discussion of mental health on college campuses evolving?

# Appendix C: Questionnaires

## Practitioner/Expert Questionnaire

**POLICY**

1. What policies and reforms at your college or university address barrier removal for full access to mental health services and accommodations as mandated by federal law?

2. What policy and system reforms affecting students with mental health disabilities in postsecondary settings are needed? 

**ACCESS**

3. What can be done to enhance the inclusion, retention, and graduation of students with mental health disabilities in higher education? 

4. What barriers prevent your college or university from providing accessible mental health services for students that are required by law? 

**PRACTICE**

5. What services does your college or university provide for students with mental health challenges and/or disabilities? Are the services adequately available? (This may include crisis management, relationships with community mental health providers, faculty and staff training.)

6. What efforts does your college or university employ to reduce stigma and discrimination? 

7. What are promising best practices and emerging trends that you are aware of nationwide?

**Student**Questionnaire

**PRACTICE**

1. What services does your college or university provide for students with mental health challenges and/or disabilities? Are the services adequately available? (This may include crisis management, relationships with community mental health providers, faculty and staff training.)

2. What efforts does your college or university employ to reduce stigma and discrimination? 

3. What are promising best practices and emerging trends that you are aware of nationwide?

4. In what ways does social media positively or negatively impact your campus’ culture surrounding mental health? Does social media have any effect on your own mental health?

**ACCESS**

5. What can be done to enhance the inclusion, retention, and graduation of students with mental health disabilities in higher education? 

6. What barriers prevent your college or university from providing accessible mental health services for students that are required by law? 

**POLICY**

7. What policies and reforms at your college or university address barrier removal for full access to mental health services and accommodations as mandated by federal law?

8. What policy and system reforms affecting students with mental health disabilities in postsecondary settings are needed? 

# Appendix D: Twitter Chat Questions

Q1. Why are Mental Health services and supports needed on college campuses?

Q2. What are some specific ways that campuses are offering support for a student’s #mentalhealth needs? 

Q3. Are campuses providing support for all populations? (veterans, grad students, LGBTQ, etc.). What is working? What can be improved?

Q4. What are colleges doing to reduce stigma about receiving mental health services?

Q5. What type of training do faculty, staff, & students receive to support students with #mentalhealth challenges? What are the best practices?

Q6. In what ways can colleges and universities improve access to #mentalhealth services?

Q7. If you had to pick only one, what piece of advice would you give to students who think they may want or need mental health supports or services?

Appendix E: Sample Screening and Assessment Tools

# Columbia-Suicide Severity Rating Scale (C-SSRS)

An evidence-supported, low-burden screening tool developed by a team of investigators from Columbia University, the University of Pennsylvania, and the University of Pittsburgh, with support from the National Institute of Mental Health. This questionnaire for suicide prevention was adopted by the Centers for Disease Control and Prevention, to be delivered by all gatekeepers, enabling blanket coverage and linking of systems (e.g., campus counseling, security, corrections, hospitals/behavioral health, crisis assessment), and fostering prevention. www.cssrs.columbia.edu

# Interactive Screening Program (ISP) (American Foundation for Suicide Prevention)

ISP provides a safe and confidential way for individuals to take a brief screening for stress, depression, and other mental health conditions, and receive a personalized response from a caring mental health counselor. ISP is being used by college and university counseling centers, medical and professional degree schools, hospital networks, corporation, and Employee Assistance Programs, connecting thousands of people to help. 

https://afsp.org/our-work/interactive-screening-program/

# National Institute on Drug Abuse—Modified Alcohol, Smoking, and Substance Involvement Screening Tool (ASSIST)

This guide is designed to assist clinicians serving adult patients in screening for drug use.www.drugabuse.gov/sites/default/files/pdf/nmassist.pdf

# Suicide Assessment 5-Step Evaluation and Triage

Assessment tool for mental health providers that measures the risk of suicidality through the lens of risk and protective factors.www.integration.samhsa.gov/images/res/SAFE_T.pdf

# The Suicide Behavior Questionnaire

Screening tool for suicide prevention that includes a brief questionnaire and scoring instructions to assess for risk of suicide.www.integration.samhsa.gov/images/res/SBQ.pdf

# Suicide Prevention Training

Kognito is an award-winning developer of role-playing training simulations and games in the areas of health and behavioral health. Through online and mobile simulations, users learn effective communication tactics for managing challenging conversations by practicing speaking with intelligent, fully animated, and emotionally responsive avatars that act and respond like real humans. The simulations promote behavioral change, early intervention, prevention, and treatment adherence.www.kognito.com

Other tools are listed below:

The Jed Foundation Campus Program: www.thecampusprogram.org

California Community Colleges Student Mental Health Program: www.cccstudentmentalhealth.org/

Los Angeles College Mental Health Consortium: www.lahc.edu/studentmentalhealth

Half of Us: http://www.halfofus.com/

Lifeline: http://www.ulifeline.org/

Each Mind Matters: http://www.eachmindmatters.org/

My Life Project: http://www.pdx.edu/profile/my-life

Bazelon Campus Mental Health Know Your Rights Guide: http://www.bazelon.org/Portals/0/pdf/YourMind-YourRights.pdf

# Appendix F: Common Modifications

# Accommodations Commonly Recognized as Effective

Reduced course load

Notetakers

Taking exams in a quiet space or isolation

Extended time for assignments

Extended time for exams or refresh time

# Accommodations Recognized as Effective but Not Easy to Get or to Implement

Flexibility in dropping courses

Flexibility in rescheduling exams when symptoms cycle on

Flexibility in excusing absences when symptoms cycle on

Flexibility in withdrawal, including retroactive withdrawal

# Accommodations for Traumatic Brain Injury and Post-Traumatic Stress Disorder (PTSD)

Recommended by the U.S. Department of Veterans Affairs (VA) and other sources

· Safe parking

· Safe classroom location

· Service, companion, and assistance animals

· Place of refuge

· Vets’ center

· Reduction of triggers:

· Noise and distraction reduction (e.g., construction)

· Group assignments

· Crowded classrooms

· Class assignments and lectures related to war

· Timed tests

· Drug, suicide, and marital counseling services 

# What Works

An effective counseling center

Students know what counseling services are available

· Provide services in a nonstigmatized setting with good physical features, respecting anonymity

· Electronic scheduling through an accessible website

· Electronic record-keeping

· Center staff connected to student health services, psychiatric services, local hospitals, the VA, etc.

· Solid coordination with DSS office

Counsel center policies

Do not discourage students from seeking treatment, such as forced medical leave for sharing suicidal ideation, treatment, or attempts

Demonstrate a respect for confidentiality

Have students identify who they wish to be contacted in case of a psychiatric or medical emergency

Always be clear whether you are acting in a treatment relationship or on behalf of the university

An effective DSS office

Insight into the attitudes that face students with disabilities in higher education, such as association with violence

Ability to get functional limitation information, including differences when limitations cycle on and off

Ability to convert functional limitations to workable accommodations

Ability to advocate directly with faculty for accommodations rather than rely on a self-advocacy model

An effective DSS office continued:

Knowledge of and relationships with community service providers

· Family

· Mental health care providers

· Vocational rehabilitation

Knowledge of and relationships with rest of campus

· Student health services

· Counseling

· Student affairs

· Academic affairs

· Residential life

· Veterans center

· Campus staff members who can be “natural supports”

· Financial aid

· Security services

· Threat assessment team

· Disciplinary officers

An effective threat assessment team:

Postsecondary teaching is the second safest profession in America!

	However, three percent of counseling center students report they fear that they may lose control and act in a violent manner.[endnoteRef:211]  [211:  Ben Locke. Center for the Study of Collegiate Mental Health (CSCMH) 2009 Pilot Study (2010). Center for Counseling & Psychological Services; Eells, Marchell, Corson-Rikert, and Dittman, “A Public Health Approach to Campus Mental Health Promotion and Suicide Prevention,” p. 47. ] 

Violence on campus does occur (e.g., Virginia Tech)

Threat assessment team functions

While balancing *privacy, autonomy,*and*safety,* identify individuals of interest 

Prevent premature inquiries into direct threat

Identify appropriate times for such inquiries

Assign someone to commence the direct threat determination process and monitor it to completion, assuring procedures that comply with FERPA, HIPAA, Section 504, and the ADA

Help evaluate the effectiveness of current level of counseling, student health, and intervention services including alcohol, drug, and suicide programs, BUT DO NOT assign this committee a leading role in developing mental health policies or emergency response planning— too much stigma

Threat assessment team continued:

· Multidisciplinary team

· Membership should vary consistent with need for confidentiality balanced against the degree of the threat

· Core: 

· House counsel particularly for guidance of FERPA and HIPAA

· Counseling center

· Student health services

· Variable

· DSS

· Security/EMT services

· Veterans’ affairs

· Student affairs

· Student housing

· Dean, faculty, staff witnessing concerning conduct, events, or statements

Threat assessment team limits

· Profiling is a danger

· “There is no useful profile in terms of gender, SES, or ethnic background.” 

· There is a debate among experts if there are*any*predictive indicia

· “Most individuals who engage in targeted violence are suicidal with no escape plan” Eells at p. 47.

· Drug and alcohol abuse

· Access to tools of violent

· Breach of confidentiality is a danger: FERPA, HIPAA, State Law

# Endnotes

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