NEWS

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November 14, 2003

Student's return postponed after suicide attempt

Editor's note: One student in the College was granted anonymity to discuss her attempted suicide and the University's response to it. She is referred to in this article as Julie.

With suicide on her mind, Julie's life was in the balance. She needed help.

Over the weekend at the beginning of spring quarter 2003, Julie's calls for help went unanswered. Julie's request to speak with her psychiatrist had been met with the response that she should save it until her scheduled session—next Thursday.

The University's therapist-on-call hotline did not provide support either. Julie said that after five minutes of discussion, the therapist began to berate her, telling her, "This is not a therapy session." When Julie telephoned the dean-on-call hotline, no one picked up the phone, she said.

After another failed attempt to get help from her psychiatrist on Monday, Julie was overwhelmed by her personal crisis. Julie, in her dorm room on Monday, swallowed a cocktail of pills and passed out.

Found several hours later by one of her roommates, Julie was taken to the hospital by her resident head and the UCPD. After her hospitalization, Julie returned home to her family.

Julie took the quarter off and spent the time re-cuperating with her family. She expected to return to the University—perhaps as early as the summer term—to take up her studies and continue to put her life in order. Saying that the University misled her, Julie believed that she would be able to juggle her classes and catch up on the work she had missed during the spring.

Julie's depression had been bad—so bad it had almost claimed her life. As the shock of her suicide attempt wore off, Julie began to think that recovery would be found within the idyllic gates of the University.

But the administration didn't agree. Julie has been placed on academic leave for the school year and will not be reconsidered for re-admittance into the College until next fall term. Julie is currently living in Hyde Park, working part time, attending therapy sessions, and, she said, reading a lot.

The University's response to Julie's attempt to take her life spotlights a facet of the administration normally shrouded in darkness and splintered with complications. With Julie's eagerness to attack the University matched by the administration's inability to discuss specific cases—it is bounded by issues of confidentiality—clear answers are difficult to pinpoint.

But this difficulty makes the policy on suicide attempts no less important. It is an issue faced by the administration at every university and has drawn increased attention since the three heavily publicized suicides at New York University earlier this fall.

The University's decision to put Julie on leave brings into question the administration's practices for addressing mental health issues. It questions the degree of confidentiality that students actually enjoy when they visit University therapists—often the central qualm for students in need of help but afraid of the consequences.

Most broadly, Julie's experience reveals profoundly different visions of the University community and divergent understandings of the responsibility of the University to its students.

Focused Interest

The University has no set policy in response to suicide, according to Steve Klass, dean of students in the University. He described the need for flexibility to evaluate each situation on its own terms.

"From an administrative standpoint, the cases of attempted suicide are so highly variable that no one policy could guide all cases," Klass said. "There's just no way you can sit down and say ‘if this, then that.'"

He added that in suicide attempts, the University is not only concerned with the student's well being. "We are a very tight-knit community," Klass said.

"Someone who is really hurting and threatening to take their life has a terribly negative emotional impact on the community."

Klass, who has never dealt closely with an attempted suicide case, would not say if the University community's interests ever outweigh those of specific suicidal students. He made it clear, however, that weighing the countervailing forces—of the need to maintain an insular community while ensuring the best circumstances for the suicidal student—is a difficult task.

He added that the University has an array of mechanisms in place to monitor the mental health of students, such as the house system and the advisers.

"There's just no black and white on this," Klass said. "It takes a lot of focused interest—we want to make sure to give the student every opportunity to heal. But the additional element is that the impact on the community is traumatic."

"Not Acceptable"

While refraining from stating a clear-cut policy, Klass said that health care officials need to have the authority to monitor potentially suicidal students.

"First and foremost the student needs help—and that has to do with not spending time in an academic setting," Klass said. "You need to protect their integrity and information. You want them to get better and back to work."

Klass refrained from giving almost any specifics, but on September 11, 2003, the University made its policy clear in a letter to Julie explaining why she was put on leave for the year.

"Suicide attempts are not acceptable at the University, even if they stem from mental illness or emotional problems," reads a copy of a letter sent to Julie's attorney. "Suicidal conduct renders a student unqualified to study at the University and live in a dormitory, as any violent or seriously disruptive conduct would render an employee unqualified."

The letter's author, Patricia Bergeson of the University's Office of Legal Counsel, no longer works for the University, and the office refused to comment on this case. A representative from the office, Russ Herron, also declined to elaborate on the University's suicide policy.

The letter lays out a clear distinction between the act of suicide—which it says is dangerous and therefore punishable by removal—and possible emotional or mental problems.

"The issue here is not your client's psychiatric history but her on-campus conduct," the letter explains.

It also demanded that Julie's medical records be turned over to the University.

The implication of this institutional connection is that the Student Counseling and Resource Service (SCRS) works for the University—not the student—according to Julie's Lawyer, Karen Ward.

Ward is the senior counsel of Equip for Equality, a nonprofit group created to safeguard the rights of people with physical and mental disabilities.

She blasted the University's suicide policy, vis-a-vis this letter, as absurd.

"They flip-flop between the issue of conduct and illness," Ward said, explaining that if a student had gotten into a fistfight on campus—an example of misconduct—he or she would be entitled to a hearing.

"I don't know if they can switch from one to the other, but it's really terrible policy—so punitive to the student," Ward added.

The letter also claims that Julie's on-campus suicide attempt was not the only instance in which she tried to kill herself. "She has since told the dean [Susan Art] that she tried to commit suicide a second time while hospitalized after the dorm attempt," the letter reads.

Julie denies telling Dean of Students in the College Susan Art that she attempted to commit suicide while in the hospital, and she refused further comment.

Felt for Months

Art, who made the decision to keep Julie from returning this fall, defended the University's practices.

It is University policy that when any student takes a leave of absence—either voluntary or forced—re-admittance is overseen by a specific dean, in this case Art.

Because of confidentiality issues, she could not comment on the case directly, but in general terms repudiated criticism of the University's administrative practices.

Art focused much of her discussion on the negative impact that suicide attempts have on the University community, and she highlighted the administration's role in comforting those left behind. Art said that the need to protect the health of the "whole community" compels the administration to "step in decisively" when a student attempts suicide.

"Often the reverberations are felt for months, and those who are already struggling with depression—even though they may not know the deceased student-—can be very badly affected," she wrote in an e-mail interview.

Offering help, according to Art, is a way the University can ensure that a student does not try to take his or her life again.

"Usually—but not always—this involves time away from the College in order to seek treatment," she wrote.

Art said that before allowing a student to return, the student's doctors are asked to speak with SCRS director Tom Kramer to ensure ongoing treatment and stability.

"We have followed these practices carefully and consistently over a number of years," she added.

Blurring the Lines

Art's reliance on Kramer's assessment, while making sense from the standpoint of a worried administrator, raises concerns about the confidentiality of students who visit the SCRS.

According to the State of Illinois Mental Health Code, the SCRS cannot reveal details of a therapy session without written consent.

"Other than authorized SCRS staff, no one will have access to your mental health records without your signed consent," reads the SCRS webpage. "They will not become a part of your academic file, and even the fact that you have come to the SCRS will not be divulged to anyone inside or outside the University without your permission."

Whatever message the website might convey, the degree to which the SCRS honors confidentiality is limited. Before beginning therapy at the SRCS, students must sign a confidentiality form, which states that therapists are allowed to consult with supervisors and colleagues to improve "his or her skills and provide you with the highest quality services possible."

"An exception to confidentiality would be a situation in which you were assessed to be a danger to yourself or others," reads a copy of the confidentiality document. "Even in these cases, you would be informed if possible and no more information than necessary would be released."

The statement makes clear that students expressing suicidal sentiments should expect their confidentiality to be breached. It isn't clear, however, that the confidentiality document allows the SCRS to discuss a patient's dangerous episode weeks or months after a situation—or discuss the situation with an administrator in the position to make an academic decision about the troubled student.

Yes or No

After Julie's attempted suicide, Kramer said he would send Art a one-word evaluation of her recovery. Julie claimed that this was done without her permission.

"All I tell Dean Art is a simple yes or no—from what I heard—[whether] you are ready to return or not," reads the e-mail Kramer sent to Julie on April 15.

It is unclear exactly what Kramer told Art, but it appears that Kramer may have overstepped a one-word answer, according to Ward.

Art, in an October 13 letter explaining her decision to delay Julie's re-entry into the University, implied that their conversation might have gone beyond a simple yes or no answer.

"Dr. Kramer has talked with your doctor and your therapist, and has in general terms discussed these conversations with me," the letter reads. "Based on Dr. Kramer's assessment and after consideration of the entire situation, I must deny your request to return to the College until you have demonstrated sufficient stability to withstand the rigors and demands of the program."

According to Ward, the "lines were blurred" between Kramer and Art, breaking Julie's confidentiality.

"It would appear that there was communication—and that needs to be defined a lot more clearly," Ward said in a telephone interview. "The patient needs to absolutely know what the information is being used for when they go into a doctor's office."

SCRS

While the SCRS comes under attack, there is a strong case to be made in its defense. It is considered an outstanding mental health center—administrators cited it as the best in the nation—and administrators believe that Kramer's expertise is essential in overseeing the treatment of students who have attempted suicide.

Kramer became director of the SCRS, which is located on University Avenue adjacent to the main quads, in January and immediately recognized that segments of the University were unaware of his organization. He started a campaign to increase the SCRS's presence on campus.

He reached out to faculty, students, and staff. He oversaw the SCRS's redesigned website. Currently, he is piecing together a panel of students from varied disciplines to improve the breadth of the SCRS.

Though Kramer works to improve the reach of SCRS, he said that the service is only intended for short-term treatment. He also made plain his connection to Art; as her "clinical consultant," he informs her in making decisions about whether or not students can return.

He added that the SCRS offers students individualized care, tailored to students' specific mental health concerns.

"Our goal for students with all illnesses, medical or, in the case of the ones that I evaluate, psychiatric, is to make sure that someone is healthy enough to return to school with a minimum of risk of causing damage to themselves or the community," he wrote in an e-mail interview.

HIPAA and Beyond

Kramer's disclosure to Art may have violated the Health Insurance Portability and Accountability Act (HIPAA), a new federal law safeguarding patients' privacy. Passed in April, the law prohibits almost all sharing of medical information.

According to Klass, HIPAA has complicated discourse among University officials about mental health issues. "You'd think that there should be more open discussion," he said. "But the legal landscape is getting very difficult to manage."

Julie said that she is in the process of filing a HIPAA claim against the University.

But to Dr. Kevin Kelly, a practicing psychiatrist, HIPAA has only codified responsible psychiatrists' longstanding practices. Kelly, a Clinical Associate Professor of Psychiatry in the Weill Medical College of Cornell University and a graduate of the U of C Divinity School (M.A. '75), said that real effect of HIPAA is to give the insurance industry access to personal medical records.

"That understanding is a misnomer," Kelly said. "It doesn't impose any new burdens on psychiatrists that haven't been practiced by sensible doctors for ages."

Now unaffiliated with the University, Kelly was able to discuss freely the administrative situation. Kelly emphasized that he was not intimately familiar with the University's practices.

Kelly, who has dealt with issues of confidentiality among medical and postgraduate students, said that the SCRS should remain entirely confidential if its patients are adults, both in their years and maturity.

Otherwise, he said, the caregiver must make a judgment call.

"The doctor has to decide: At what point does the institution preventing harm outweigh protecting confidentiality?" Kelly said. "The point of overriding confidence will come sooner the younger the patient is."

Full Disclosure

In the aftermath of Julie's attempted suicide, the University demanded that a full disclosure of her treatment information be evaluated by the SCRS.

Following this demand, Julie's therapist—affiliated with the University Hospital's psychotherapy program—told Kramer that she was mentally fit and should "return to structured activity such as her full time college courses."

But Kramer continued to demand a full disclosure—a move that effectively disregarded the professional's opinion, according to Ward.

"I find it alienating that he's talking about sensitive, personal information, and he just passes it on to administrators for me to be evaluated on," Julie said of Kramer.

The demand that the SCRS oversee medical files is suspect, according to Ward, who argued that the organization's claim to confidentiality is compromised by its institutional connection to the dean's office.

"A counseling service can't provide information to the school when placed in a doctor-patient relationship," Ward said. "It has to be with the knowledge and consent of the individual."

Interoffice communication was not the only target of criticism. Julie said that information was shared improperly among members of the SCRS. Citing an e-mail in her medical file that was written by a member of the SCRS, Julie said she was described in condescending terms.

The effect, for Julie, was to feel that the SCRC did not sincerely care for her and that the organization was abusing her confidentiality.

Response

If widely known, the University's policy would deter students with thoughts of suicide from seeking help—particularly from the SCRS, according to Ward. It would also make them think twice about confiding in anyone who might communicate with University officials, she said.

"Those who may attempt suicide, but have a change of heart, would be deterred from admitting themselves to a hospital, and friends of students would be loathe to ‘interfere' to seek help for a student if the result would be expulsion of their friend for ‘unacceptable conduct,'" Ward wrote in an official letter, dated September 12.

"Finally, the depression and feelings of hopelessness that often lead to suicidal thoughts or conduct would likely be worsened by the knowledge that the University would deem a student unfit if it knew of her problem," Ward added.

What has been most painful for Julie has been the lack of a coherent policy—what Klass heralded as an essential "freedom" for administrators.

Julie feels the University misled her, switching its position from one in which she understood that she could return "whenever she was ready" to its decision to place her on leave for the year.

"All of a sudden they changed their message," Julie said. "They didn't give me specific or valid reasons."

By not knowing what is expected of her, Julie feels that the University is making it even more difficult for her to prove that she is able to return.

"If I know I'm being evaluated on how I act, that just puts even more pressure on me," Julie said. "It feels strange to be here but not a student. I'm half excluded, half included. I feel ready to return to classes. I felt ready to return for a while. It's a lot more stressful to be in this limbo than classes ever were."