The Jed Foundation Framework: Developing Campus Protocols for the At-Risk Student

1. The Jed Foundation Framework: Developing Campus Protocols for the At-Risk Student Gregory T. Eells, Ph.D. Cornell University Dan Jones, Ph.D. Appalachian State University Jaquie Resnick, Ph.D. University of Florida Emil Rodolfa, Ph.D. University of California, Davis

2. The Jed Foundation Founded in 2000 by members of the Satow family after the loss of their son/brother Jed, a college sophomore Mission: To reduce the suicide rate among college students by focusing on the underlying causes of suicide and producing effective prevention, awareness, and intervention programs Our approach combines medical and public health models as you will see� Our approach combines medical and public health models as you will see�

3. The Jed Foundation ULifeline (www.ulifeline.org) Social marketing campaign with mtvU CampusCare Parent/Student Resource Guides focusing on the transition to college (in collaboration with the APF) Assessing and Managing Suicide Risk; involved in adapting AAS/SPRC training course for college mental health professionals and supporting regional trainings University Pilot Program to Promote Mental Health and Prevent Suicide I�m not going to talk about our programs in detail due to time constraints, but a summary of our current initiatives can be found in the handout. I�m not going to talk about our programs in detail due to time constraints, but a summary of our current initiatives can be found in the handout.

4. Concerns Expressed about the Jed Foundation Ties to the pharmaceutical industry Taking a top down approach-Phil Satow speaking with University presidents Not listening to the professionals who do the work.

5. Responses to Concerns Jed Foundation efforts to date have not involved any programs that advocate psychopharmacology in an inappropriate manner. The Framework is an example of the foundation�s shift to listening to the professionals who do the work and engaging in more grass roots involvement. Phil is an advocate for mental health services in his conversations with university presidents

6. Framework Framework for Developing Institutional Protocols for the Acutely Distressed or Suicidal College Student Background Development process Content Current status So the full title of the document that I will be talking about today is�. I am going to cover these five areas but most of our time today will be spent on the development process and content sections. In a nutshell, this document attempts to identify all of the issues that a college, regardless of its size and resources, would need to address when a potentially suicidal student has been identified. It is NOT a best-practice document; it IS designed to help colleges think through ALL of the key issues when revising or developing their protocols around managing at-risk students.So the full title of the document that I will be talking about today is�. I am going to cover these five areas but most of our time today will be spent on the development process and content sections. In a nutshell, this document attempts to identify all of the issues that a college, regardless of its size and resources, would need to address when a potentially suicidal student has been identified. It is NOT a best-practice document; it IS designed to help colleges think through ALL of the key issues when revising or developing their protocols around managing at-risk students.

7. Framework: Background 1,100 student suicides/year (3 per day) 1.5% of students report at least one attempt 90% of those who die by suicide (all ages) have a diagnosable mental illness Fewer than 20% of students who die by suicide have ever sought help at their counseling centers Counseling center directors report an increasing demand for crisis services I�d like to start with a little background about where this project came from and why it is so important. ACHA, 2005 Reducing suicide: A national imperative (Goldsmith, et al.) Gallagher Survey 2005 I�d like to start with a little background about where this project came from and why it is so important. ACHA, 2005 Reducing suicide: A national imperative (Goldsmith, et al.) Gallagher Survey 2005

8. Framework: Background Suicide is a public health issue Three parts to addressing suicide on a campus: Prevention Intervention Postvention In addition to being an issue, suicide is also a PH issue (I�ve also heard it called an environmental problem): �Public health is defined as the �science and practice of protecting and improving the health of a community�; this approach moves suicide from being an issue solely for MH professionals to manage (treatment-focused) to one of the entire college community (prevention-focused). The Framework focuses on intervention, although it certainly can be seen as prevention as well. For a more comprehensive look at these three parts, please refer back to the �Prescription for Prevention� Other prevention efforts could include: raising awareness among students, parents, and faculty about the signs and symptoms of mental illness and the risk factors for suicide; the establishment of a mental health task force to monitor students of concern; means restriction; offering programs aimed at strengthening life skills; and matching the mental health resources on campus to the demand for services. Postvention could include: promoting responsible reporting by the media, and ensuring that mental health resources are made available to those students, faculty, and staff affected by the suicide. In addition to being an issue, suicide is also a PH issue (I�ve also heard it called an environmental problem): �Public health is defined as the �science and practice of protecting and improving the health of a community�; this approach moves suicide from being an issue solely for MH professionals to manage (treatment-focused) to one of the entire college community (prevention-focused). The Framework focuses on intervention, although it certainly can be seen as prevention as well. For a more comprehensive look at these three parts, please refer back to the �Prescription for Prevention� Other prevention efforts could include: raising awareness among students, parents, and faculty about the signs and symptoms of mental illness and the risk factors for suicide; the establishment of a mental health task force to monitor students of concern; means restriction; offering programs aimed at strengthening life skills; and matching the mental health resources on campus to the demand for services. Postvention could include: promoting responsible reporting by the media, and ensuring that mental health resources are made available to those students, faculty, and staff affected by the suicide.

9. Framework: Background Lack of consensus about what constitutes a comprehensive approach to responding to a student who may be at risk for suicide Crucial to develop protocols prior to a crisis Colleges differ in size, culture, and resources How do we develop a tool that will be useful to all colleges and universities? Through our ongoing work at the Foundation, we noticed that there was�.. Bullet #2: Advance preparation decreases ad hoc decision-making during high stress periods. Bullet #4:Protocols need to be broad enough to cover most potential situations allowing for case-by-case flexibility but narrow enough to remain meaningful. We really want to debunk the myth that in order for protocols to be flexible they must be informal and unwritten. Through our ongoing work at the Foundation, we noticed that there was�.. Bullet #2: Advance preparation decreases ad hoc decision-making during high stress periods. Bullet #4:Protocols need to be broad enough to cover most potential situations allowing for case-by-case flexibility but narrow enough to remain meaningful. We really want to debunk the myth that in order for protocols to be flexible they must be informal and unwritten.

10. Framework: Goals To encourage collaborative decision-making around mental health issues that focuses on the best interests of students. To promote cultural change toward strengthening the campus-wide mental health safety net for all college students. To motivate every college and university to develop, implement, and use comprehensive protocols. To promote the creation of exemplary protocols in addressing student mental health issues. To encourage discussion between schools about protocol content and development. Bullet#1: Students plural=student in question plus community Bullet #4: This is our hope after schools develop protocols based on the Framework. Now, I�m going to talk about the actual process of developing the Framework.Bullet#1: Students plural=student in question plus community Bullet #4: This is our hope after schools develop protocols based on the Framework. Now, I�m going to talk about the actual process of developing the Framework.

11. Framework: Process Collected and read policies, protocols, and procedures from 40 colleges Interviewed mental health professionals, student affairs personnel, legal experts Created draft document based on all sources of information Framework = detailed inventory of issues to consider when creating or revising protocols Bullet#3: Draft used as basis for the roundtable meeting I will discuss in a minute. Bullet #4: So, the format is a list of questions, and I will give you many examples in a few minutes of what the questions look like; this format was chosen because it will allow schools to draft protocols which are consistent with their philosophies and available resources. Some of the questions are complex, so additional information will be included in the Framework where appropriate in an effort to help colleges think through certain issues. One of the difficulties we face with this document is that so many decisions need to be made on a case by case basis, since each student�s circumstances will be different. But, there are only a finite number of possibilities for how to handle a particular student, so a school can develop a protocol for HOW these decisions get made in a crisis.Bullet#3: Draft used as basis for the roundtable meeting I will discuss in a minute. Bullet #4: So, the format is a list of questions, and I will give you many examples in a few minutes of what the questions look like; this format was chosen because it will allow schools to draft protocols which are consistent with their philosophies and available resources. Some of the questions are complex, so additional information will be included in the Framework where appropriate in an effort to help colleges think through certain issues. One of the difficulties we face with this document is that so many decisions need to be made on a case by case basis, since each student�s circumstances will be different. But, there are only a finite number of possibilities for how to handle a particular student, so a school can develop a protocol for HOW these decisions get made in a crisis.

12. Framework: Process Chose a collaborative process: Experts in higher education Professional organizations Organized a one-day roundtable with select number of participants who represented: Diversity of college types Personnel involved in student mental health Participants had all taken steps to address these issues at their own colleges By diversity of college types, I am referring to: rural vs. urban, East vs. West, North vs. South,large vs. small, public vs. private, residential vs. commuter, etc The participants were a mix of mental health professionals (psychologists/psychiatrists), student affairs personnel (vice-presidents for student affairs/deans of students or student life), and general counsels or other legal experts in higher education. They were selected based on previous work with The Jed Foundation, recommendations from existing participants, or affiliation with professional organizations. Of course, there are many other people on a campus who are involved in student mental health, as we will see in a later slide, but in order to have a workable group, we needed to restrict the number of participants; we decided that having several people with the same job title from different schools would be more useful than trying to have every potential campus player represented. By diversity of college types, I am referring to: rural vs. urban, East vs. West, North vs. South,large vs. small, public vs. private, residential vs. commuter, etc The participants were a mix of mental health professionals (psychologists/psychiatrists), student affairs personnel (vice-presidents for student affairs/deans of students or student life), and general counsels or other legal experts in higher education. They were selected based on previous work with The Jed Foundation, recommendations from existing participants, or affiliation with professional organizations. Of course, there are many other people on a campus who are involved in student mental health, as we will see in a later slide, but in order to have a workable group, we needed to restrict the number of participants; we decided that having several people with the same job title from different schools would be more useful than trying to have every potential campus player represented.

13. Framework: Process Meeting was held on November 18, 2005 in collaboration with: American College Health Association (ACHA) American College Personnel Association (ACPA) Association for University and College Counseling Center Directors (AUCCCD) National Association of Student Personnel Administrators (NASPA) Received unrestricted grant from the Aetna Foundation to fund meeting Draft document sent to participants prior to meeting as a basis for discussion , Blog set up for pre-meeting discussion where participants could post comments on document or others� comments. Now, I�d like to move away from the process and begin to address the content of the document. Draft document sent to participants prior to meeting as a basis for discussion , Blog set up for pre-meeting discussion where participants could post comments on document or others� comments. Now, I�d like to move away from the process and begin to address the content of the document.

14. Framework: Content Section Headings: Developing a safety protocol Developing an emergency contact notification protocol Developing a leave of absence and re-entry protocol Includes a number of vignettes to facilitate conversations about these issues

15. I. Safety Protocol Responding to the acutely distressed or suicidal student: How does your college prepare an administrator to identify and help the at-risk student? How does your college prepare a concerned other to identify and help the at-risk student? Have MOU been developed with local police or others who may be involved in a student crisis? Section I: Developing a safety protocol for the student who may be at risk for suicide. Obviously, I wasn�t able to list every question on these slides, so I have picked examples of the types of questions that are included in each section. Bullet#1: How does an administrator (e.g. dean of students, vice president for student affairs) decide if the student needs to be accompanied to the clinician�s office for an assessment or what information should be provided to the clinician about the student? Bullet#2: Same for concerned others. Bullet#3: It is suggested that some type of agreement be in place prior to a crisis situation.Section I: Developing a safety protocol for the student who may be at risk for suicide. Obviously, I wasn�t able to list every question on these slides, so I have picked examples of the types of questions that are included in each section. Bullet#1: How does an administrator (e.g. dean of students, vice president for student affairs) decide if the student needs to be accompanied to the clinician�s office for an assessment or what information should be provided to the clinician about the student? Bullet#2: Same for concerned others. Bullet#3: It is suggested that some type of agreement be in place prior to a crisis situation.

16. I. Safety Protocol Responding to the acutely distressed or suicidal student (cont.): What is the decision-making process at your school when the potentially at-risk student has been identified? What is the process by which the student�s risk for suicide is assessed by a mental health professional? How do you determine what to do when the student who needs help refuses it? Bullet#1: What are the roles of pertinent campus officials? How is the response to the acutely distressed or suicidal student affected by incident timing? Bullet#3: How do you balance the rights of the student with concerns for his/her safety?Bullet#1: What are the roles of pertinent campus officials? How is the response to the acutely distressed or suicidal student affected by incident timing? Bullet#3: How do you balance the rights of the student with concerns for his/her safety?

17. I. Safety Protocol Addressing issues around voluntary or involuntary psychiatric hospitalization: What is the decision-making process for determining whether hospitalization is in the best interests of the student? What options besides hospitalization have been explored for the student who may require close supervision? What issues must be addressed before the student can return to campus after discharge from the hospital? One of the issues raised was around a student who is sent to the ER for assessment but is not admitted and returns to campus without anyone knowing about it. Having an MOU � or simply discussions � with local hospitals ahead of time could be a first step in addressing this problem. Bullet#2: Such as intensive outpatient tx; can be a particular issue for schools in rural areas or when hospital decides not to admit the student. Bullet #3: This could include a plan for follow-up care, administrative meetings, discussions with roommates. Are the issues different if s/he lives in a college residence versus off-campus? If s/he is an undergraduate versus a graduate student? How do you decide whether it is in best interests of students and community for the student to remain enrolled or in campus housing?One of the issues raised was around a student who is sent to the ER for assessment but is not admitted and returns to campus without anyone knowing about it. Having an MOU � or simply discussions � with local hospitals ahead of time could be a first step in addressing this problem. Bullet#2: Such as intensive outpatient tx; can be a particular issue for schools in rural areas or when hospital decides not to admit the student. Bullet #3: This could include a plan for follow-up care, administrative meetings, discussions with roommates. Are the issues different if s/he lives in a college residence versus off-campus? If s/he is an undergraduate versus a graduate student? How do you decide whether it is in best interests of students and community for the student to remain enrolled or in campus housing?

18. I. Safety Protocol Developing a post-crisis follow-up plan with the student: What consequences could the student face for not complying with the follow-up plan? What should happen if the student begins to show signs of distress again? How do you identify and communicate with those who were involved with/affected by the at-risk student (e.g., friends, roommates, faculty, RAs)? Bullet #1: For example, can the student then be asked to take a medical leave? Bullet #2: In other words, what is the threshold for intervention? Bullet #3: What follow-up is provided to them? Bullet #1: For example, can the student then be asked to take a medical leave? Bullet #2: In other words, what is the threshold for intervention? Bullet #3: What follow-up is provided to them?

19. I. Safety Protocol Documenting encounters with the acutely distressed or at-risk student: What specifically about the encounters should be documented? Where are the records kept? How is compliance with your documentation policy enforced?

20. I. Safety Protocol Addressing other pertinent issues relating to the acutely distressed or suicidal student: Are there special considerations relating to the international student (e.g., language barriers during assessment)? Have translators or a translation service been identified in advance of a crisis involving the student for whom English is a second language?

21. II. Notification How do you prepare for the need to notify an emergency contact? What guidance do you provide about whom the student should choose as an emergency contact? Where is emergency contact information maintained? How are those personnel involved in notification educated about how to do this?

22. II. Notification What factors might give rise to exceptions to normal notification practices? How do you engage the emergency contact who may be in denial about the seriousness of the student�s mental health issues? How can discussions be navigated with the emergency contact if s/he initially brought the student�s distress to the attention of the college and wants to be kept �in the loop�?

23. III. Leave of Absence What are the potential repercussions for the student taking a leave of absence for mental health reasons? Do details about why the student has taken a leave become part of his/her �academic record�? What are the ramifications of taking leave for the student who receives financial aid?

24. III. Leave of Absence What is the structure of your leave of absence process? If the student needs to be on leave but is unable to go home, what are the other options? If there are multiple types of leave on your campus, who determines what type of leave the student can take for mental health reasons?

25. III. Leave of Absence In determining whether involuntary leave is in the best interests of the students, how do you balance a desire to stay in school with what services and support your college is able to provide? What is the decision-making process? Does the student have the right to appeal the decision?

26. III. Leave of Absence What is the structure of your re-entry process? How do you determine the requirements for the student to return from leave? Prior to the student returning from leave, what communication takes place between college personnel and the student, parents/significant other, and �home� mental health practitioner? How is re-entry coordinated among college personnel?

27. III. Leave of Absence How do you communicate with the student and other campus personnel about a leave of absence? How do you let the student know what is required prior to starting a leave and prior to returning from one (e.g. by providing a checklist)? How is the student�s leave communicated to relevant campus personnel?

28. Implementation Allocate sufficient funds/resources to allow for the development, implementation, use, and review of the protocols. Consider the ethnic, racial, cultural, and spiritual diversity of your student body and create protocols that reflect and support these differences. Refer to the mission/vision statement of your institution to identify its stated or implied role in managing student mental health.

29. Implementation Select the process by which protocol development will take place at your college. Define the relevant stakeholders in protocol development, implementation, and use, as well as what is expected of them. Establish an ongoing dialogue with community entities who could potentially be involved in caring for a student at risk.

30. Implementation Select and define the terminology you will use in your protocols. Develop a plan for reviewing the protocols after they have been implemented, including how often they will be reviewed and by whom. Define the circumstances under which the protocols could be set in motion. To this end, it may be helpful to create a �job description� for what it means to be a student at your institution.

31. Implementation Be transparent with students and parents about the content of the protocols and the circumstances under which they could be invoked. Identify a �point person� for individuals both inside and outside of the college community to contact with questions about the protocols, including those relating to legal issues.

32. Implementation Consider using your protocols to create (or augment) a procedural �Crisis Checklist� that provides all those involved in student crises with a way to ensure that all appropriate actions have been taken. Engage in regular table-top exercises to �practice� your crisis protocols.

33. Campus Context Ensure that protocol development takes place as part of a campus-wide suicide prevention and mental health promotion strategic planning process. Create an environment that encourages help-seeking for emotional issues. Determine whether the process used to address disruptive student behaviors promotes the identification and treatment of emotional disorders.

34. Campus Context Ensure that campus-wide protocols are consistent with intra-school protocols. Consider establishing a case management committee to monitor students who are of concern as a result of mental health issues. Establish a comprehensive postvention protocol that includes identifying and offering services to those affected by the crisis

35. Campus Context Advocate for student health insurance that provides adequate mental health coverage. To this end, it may be helpful for members of the counseling and/or health centers to be involved in insurance-related decisions.

36. Framework: Current status Availability was announced through listservs of professional organizations. No cost. Can be found and printed at : www.jedfoundation.org/framework.php Plan to conduct process and outcome evaluations.

37. Conclusion The framework is a useful document to stimulate conversations and examine issues on each of our campuses. It is a starting point for each of us as we think about systemic ways to deal with very difficult student issues.

38. Contact Information Joanna Locke, MD, MPH Program Director, The Jed Foundation 583 Broadway, Suite 8B New York, NY 10012 212.647.7544 jlocke@jedfoundation.org www.jedfoundation.org