UNDERSTANDING VIOLENCE

1. UNDERSTANDING VIOLENCE Who are the predators we keep hearing about and what do they have in common? Very revealing are the first five indicators identified by the Safe School Initiative Final Report by the U.S. Secret Service and U.S. Department of Education: • Incidents of targeted violence at school rarely were sudden, impulsive acts. • Prior to most incidents, other people knew about the attacker’s idea and/or plan to attack. • Most attackers did not threaten their targets directly prior to advancing the attack. • There is no accurate or useful “profile” of students who engaged in targeted school violence. • Most attackers engaged in some behavior prior to the incident that caused others concern or indicated a need for help.

2. What do we know? • Roughly 80% of school violence perpetrators raised serious concerns about the potential for violence amongst friends, family, peers, or other community members prior to their acts • Roughly 80% of school shooters shared their plans, or parts of their plans, with others prior to their shootings. • Trust your instincts! Share what you hear!

3. Youth Risk Survey 2001 13,600 HS students • 28.3% sad or hopeless almost every day> 2 wks stopped some activity due to symptoms • 19 percent of students reported that they seriously considered attempting suicide • 14.8 percent had made a specific plan to attempt suicide. • 8.8 percent had attempted suicide in the previous year [Grunbaum et al 2002].

4. Recent Suicide Data • 1 FTE per 1700 students. Higher ratio smaller schools • 4 hours psychiatric consultation per week/ 1000 students, up from 2.1 in 2004 • 25% clients on meds • 366 schools 154 suicides, adjusted rate is 6.6/100,000 • 10% attempters die over 10 years • 45 of 76 suicides occurred during first week post hospitalization

5. On the lookout for Icebergs In 2001, a study by David Lisak, Ph.D., at the University of Massachusetts, Boston revealed: • 120 male students (of a surveyed population of 1,882) were responsible for 483 total acts of sexual violence (Lisak & Miller, 2002). • 76 of those 120 men were responsible for 439 of the acts of sexual aggression (6 acts each) (63% multiple perpetrators, 37% one-time perpetrators) • and 1,045 total acts of physical violence. • 76 men. 1,000+ crimes. 14 acts each. And, Lisak’s measures used very conservative definitions of crimes.

6. FULL AND CONTEXTUAL COMPLIANCE HIPAA FERPA COUNSELOR PRIVILEGE CLERY ACT TIMELY WARNING SECTION 504 OF THE REHABILITATION ACT LIABILITY IN NEGLIGENCE

7. HIPAA HOW DO YOU KNOW IF HIPAA APPLIES TO YOUR CAMPUS HEALTH OR COUNSELING SERVICE? You may be surprised by the answer…do a two-level analysis: 1) Does your counseling service or health service transmit electronic data about patients, such as health insurance or billing information? If not, HIPAA does not apply. If so, ask… 2) Does your counseling or health service treat students only, or other community members as well?

8. HIPAA If you treat only students, HIPAA does not apply. If you treat other community members, HIPAA will apply. Here’s why…if you only treat students, the Department of Education has stated that FERPA is the governing law for these records, not HIPAA. So, let’s talk FERPA next…

9. FERPA If FERPA is the governing law for counseling and/or health service records, we recognize the FERPA specifically exempts health and counseling records from the definition of educational records protected by the Act. Thus, while FERPA is the governing law, it is inapplicable, and the only law governing the privacy of these records is the state statute on privilege of health and mental health records, and the professional ethical requirements imposed by licensure.

10. MORE ON FERPA Who’s your dependent? FPCO relaxed its stance on proof of dependency, and will allow us to use an opt in/out form at registration For students who indicate they are dependents, additional verification via tax returns in unnecessary. Even if a student does not indicate they are a dependent, a parent may still show they are via the tax return method.

11. MORE ON FERPA What is the consequence of dependency? Colleges and universities MAY share ANY information from a student’s educational record with any parent/custodian claiming the student as a dependent: Tommy got a D in biology Beth is cutting Pak is in fact a College Republican

12. MORE ON FERPA Congress may liberalize the emergency health and safety exception to FERPA. Regardless, FERPA allows us to share information as necessary in a crisis, and that will apply to most cases where a student is a potential harm to themselves or others.

13. MORE ON FERPA What college administrators observe about students (not sourced from protected records) is not protected by FERPA. FERPA covers written records and recorded media. What you see or what someone says to you is not an educational record. Internally, officials can communicate to each other when they find there is a “legitimate educational need to know.”

14. PRIVILEGE Can be waived when Tarasoff applies, or when a direct threat is posed (in non-Tarasoff jurisdictions) Can be waived by the client Confidential information can be shared between counselors and health providers What are the peripheries of the privilege?

15. CLERY ACT TIMELY WARNING Was the Virginia Tech warning too little, too late? What should we do until the Department of Education decides? Use the standard law enforcement criteria for warning: Can we identify the nature of the threat? Can we identify the source of the threat? Can we give those being warned specific information about steps they can take to protect themselves from the threat posed?

16. NEGLIGENCE –DISCUSSION OF DUTY • Historical “no duty” rule • Present erosion of the no duty rule • Schieszler v. Ferrum College • Shin v. MIT • Why Jain v. Iowa may not be the leading case on college liability for student suicide • What is the Restatement (3rd) of Torts, and why should we care?

17. FEDERAL DISABILITY LAW: HOW BEST TO ADDRESS SUICIDAL STUDENTS • A Suicidal Student Has a Disability • Both the ADA and Section 504 Apply • Section 504 gives recourse to students who are discriminated against on the basis of a recognized disability. • The Americans with Disabilities Act (ADA) entitles students who are otherwise qualified to participate in the programs and activities of college to reasonable accommodations once they seek qualification with the campus disability services office. • Neither law requires that a suicidal student march into the disability services office to qualify as disabled.

18. THE LAW: HOW BEST TO ADDRESS SUICIDAL STUDENTS • Once suicidality is clear to college officials, our obligations under these laws are in effect. • We should explore whether the disability can be accommodated, and provide whatever support we can, within reason.

19. IT IS POSSIBLE, AND SOMETIMES DESIRABLE, TOSEPARATE A STUDENT FROM THE UNIVERSITY • Direct Threat Test • To rise to the level of a direct threat, there must be a high probability of substantial harm and not just a slightly increased, speculative, or remote risk; • In a direct threat situation, a college needs to make an individualized and objective assessment of the student's ability to safely participate in the college's program; • This assessment must based on a reasonable medical judgment relying on the most current medical knowledge or the best available objective (non-medical) evidence; • The assessment must determine; the nature, duration, and severity of the risk; the probability that the potentially threatening injury will actually occur; and whether reasonable modifications of policies, practices, or procedures will sufficiently mitigate the risk.

20. IDEATION, NON-SPECIFIC THREATS, GESTURES The direct threat test tells us that a student who is ideating, threatening or who is making non- specific gestures without a plan or means to carry though may not represent a high probably of substantial harm. • When George Washington University recently separated a student who reported suicidal thoughts at a hospital, it clearly overreacted. It did not make a finding that met the four elements of the direct threat test. • OCR is, by practice, deferential to our determination of direct threat, but they insist that we make one.

21. The direct threat test requires an assessment • This is not mandated to be a therapeutic assessment, but an overall assessment of a student’s ability to function effectively and safely in a campus environment. • A therapist’s conclusion under DSM-IV diagnostic criteria or other accepted evaluative instruments that a student is likely to be an imminent threat of harm to themselves or others • We are to use objective evidence, and if possible, the most current medical knowledge available

22. Mandated Assessment – The Legal Aspects • If the student will not share medical records from the hospital, and is not cooperative with your efforts to have him or her assessed, the law permits you to require the student to be assessed. • Who chooses the therapist? • Who pays? • Can we impose the condition that the student waive confidentiality, permitting you to communicate with the therapist about the student’s welfare?

23. What happens if the student does not attend required sessions? • If the student refuses, I recommend that you use your conduct code (or at least the threat of it). • We should all have and use policies addressing a student’s failure to comply with the directives of a college official. • If you then sanction, and even separate a student, it will not be on the basis of their disability, but on the basis of their conduct. • This approach is fraught with potential to push a fragile student over the edge, so I really entreat you to do everything you can first to ensure voluntary cooperation.

24. DISRUPTION AS PRETEXT • It can be easier for smaller or less affluent campuses to look to shift the burden elsewhere. They may be more likely to try to separate a suicidal student. • They often look to use their code of conduct to address behaviors, which has long been considered a best practice. A suicidal student may be disruptive, that is true. • But, today there are only limited circumstances in which OCR will find that our decision to separate a student for disruptive behavior is not a violation of Section 504.

25. Disruption as Pretext, con’t • The only instance I am aware of that might pass muster would be a decision to separate a student for disrupting the academic environment, made in an absence of knowledge that the student was suicidal. • Any other separation based on a disruption policy--where officials are aware of suicidality or the disruptive behavior occurs not in the classroom but in a residential setting--is highly likely to be seen by OCR as a pretext for discriminating against a student with a disability.

26. THE CONDUCT CODE APPROACH • I have similar concerns for using a conduct code provision on “threat of harm to self or others” as the basis for separating a student. • Certainly, it can be used for an interim suspension, because an interim suspension is not subject to the direct threat test. • The problem with the “threat of harm to self” policy is that it is not usually backed up by the four elements of a direct threat finding. • If it were, I think it would satisfy OCR.

27. THE CONDUCT CODE APPROACH, con’t • I recommend instead that you develop and utilize a medical withdrawal procedure, with both voluntary and involuntary options. • I read recently that some commentators fear that involuntary medical withdrawal policies have been abused by some campuses, and so as I recommend this, it is with these assumptions: • that you would have already exhausted accommodation options, • that you will use the direct threat test as the standard for your medical withdrawal policy, • that you would have in place a requirement that you do not separate a student unless you have a plan for where they will go when they are separated, and have made appropriate efforts to see that support mechanisms are in place for that student.

28. HEIGHTENED DUE PROCESS • Another reason for preferring a medical withdrawal policy is because disabled students are entitled to heightened due process rights--according to OCR--and we fear that our conduct processes may not meet those requirements. • For example, OCR states that a student who is being withdrawn for medical reasons is entitled to an appeal. Our conduct procedures may cover that, but may not. • A student is also entitled to present medical evidence countering the finding of a direct threat. Our conduct procedures may not permit that.

29. Mandated Assessment • The process of requiring that a student be evaluated by a mental health professional. • Often an assessment will be completed over 2-4 personal counseling sessions. • Assessment can be provided by an on-campus resource or an off-campus therapist. • Trusting the source of evaluative findings is important, especially if they indicate a student is a direct threat.

30. Mandated Assessment • What is the purpose? • Objective findings of whether a student poses a risk of harm to him/herself or others • To “coerce” a student into a therapeutic relationship in the hope that s/he will feel comfortable there with time, and will maintain a personal counseling relationship voluntarily once the assessment is completed.

31. Mandated Assessment • Isn’t mandated assessment just a palatable way of selling counselors on mandated counseling? • Evaluation and assessment are counseling functions. They are provided to a client in a counseling relationship. • Calling it assessment may make it more palatable to those who believe that counseling is optimized when it is voluntary. • But, for determining harm to self/others, administrators need objective evaluative results.

32. Mandated Assessment • Virginia Tech was the 9/11 for colleges and universities. • It gave us wake up call to a previously unanticipated threat. • We have to ask what did we learn from tragedy? • What needs to change? • We need to be willing to mandate assessment. • College counseling centers need to provide assessments, or we need to find outside providers who will.

33. Mandated Assessment • Criticisms • Some people believe that a mandated assessment-based suicide prevention program, such as the UIUC model, may identify students who pose a remote risk of suicide. • But, critics suggest such approaches may drive the truly suicidal underground for fear they will be caught up in a net if they ideate, cut, or otherwise tip administrators to their potential suicidality.

34. Mandated Assessment • We must focus holistically on “red flag” behavior, not just on indicators of suicidality. • The NCHERM CUBIT draws from a greater base of threat indicators, and may enable intervention through mental health screening, enhanced monitoring of excessive absenteeism, and alcohol screening.

35. WHAT IS A RED FLAG? • Distress-level behavior rarely results in violence • Disturbed behavior, especially when repeated or rapidly escalating, can be a red flag. • Dysregulated behavior is a red flag. • A suicidal student may be a homicidal student • A suicidal student may be willing to risk other lives to accomplish his or her mission

36. WHAT IS A RED FLAG? • Alarming behavior that may show a lack of control by the actor (stereotype) • More often, flat affect and calm planning are indicative. • The “thousand-yard stare” shows a level of detachment from self that is concerning • Suicidal threats or gestures • “I don’t need my hard drive any more” • “No one cares about me”

37. WHAT IS A RED FLAG? • In addition to suicidality, there is a correlation between violence and a history of the actor being subject to extreme bullying. • Look for patterns in writing, class discussion or class interaction. • Themes of revenge • Themes of annihilation • Themes of “outsider” exclusion

38. REPORTING THESE BEHVIORS • Faculty have been reluctant to report disruptive activities in the classroom. In Coping With Disruptive College Students (1994), Gerald Amada identified four possible (and typical) reasons: • Faculty hope for a spontaneous resolution • Faculty fear that they will not be supported by the administration • Faculty fear that reporting will be viewed as a reflection of inadequacy as an educator • Faculty fear retaliation.

39. DISRUPTION UNPACKED • Distressed • Emotionally troubled • Individuals impacted by situational stressors and traumatic events • Psychiatrically symptomatic • Disturbed • Behaviorally disruptive, unusual, and/or bizarrely acting • Destructive, apparently harmful to others • Substance abusing • Dysregulated • Suicidal • Parasuicidal (self-injurious, eating disordered) • Individuals engaging in risk-taking behaviors (e.g., substance abusing) • Hostile, aggressive, relationally abusive • Individuals deficient in skills that regulate emotion, cognition, self, behavior, and relationships

40. CLASSIFYING THE RISK • USE THE NCHERM CUBIT MODEL RUBRIC TO CLASSIFY THE RISK OF EACH OF THE FOLLOWING SCENARIOS: • MILD • MODERATE • ELEVATED • SEVERE • EXTREME

41. SCENARIO #1 • June and Ryan dated for several months, until he broke up with her for being “nuts” • After they broke up, June created a fan web site “Everybody Loves Ryan” and posted pictures, intimate details of their relationship, and a daily blog in which she chronicle her belief that Ryan represented male perfection personified. • Several months after, June found out that Ryan had begun dating Ho. She made liberal use of the obvious pun in her blog, e.g. “Ryan is now dating a huge Ho” and seemed to obsess.

42. SCENARIO #1 • By email, Ryan asked June to stop writing about him. • In early May, June went to Ryan’s room, armed with a machete. She threatened Ryan and Ho with it, telling them she had a right to write anything she wanted. • On her way out the door, June buried the blade in Ryan’s door and left it behind.

43. SCENARIO #2 • Paul is in your Contemporary Authors class. His writing is brilliant, thought-provoking and evinces an authorial style quite reminiscent of Henry James. • Unfortunately, Paul never writes on the given assignment. His essays are handed in whenever an assignment is due, but tend to be screeds on whatever catches his attention.

44. SCENARIO # 2 • Recent topics have included the plight of disabled veterans, trace elements of prescription drugs in drinking water, $4.00 gallon gas and the $17 billion in excess profits declared by the oil companies, how wrong Michael Moore was about health insurance, how the frat boys on campus get special treatment, and his theory that the head football coach is “banging the President’s wife.”

45. SCENARIO # 2a • What if Paul’s essays covered the following topics, instead: • The poison found in Cheerios • The conspiracy to require Bill Clinton to be called the First Philanderer • His belief that small microchips detect whether you are speeding and email the police directly from your car to report you • His belief that the housekeeper in his residence hall is a slave who is chained in the basement at night

46. SCENARIO # 3 • Student Karol informs you that she is aware that two of her friends, fellow students Bela and Yuri, hacked into the student information system just for fun, but discovered a page that gave access to anyone’s social security numbers. • She doesn’t know what, if anything, they may have copied down, but she overheard them talking about it in the cafeteria. • Simultaneously, the reporting database indicates an increasing trend of students experiencing identity theft, with one reported in September, two in November and four in December.

47. SCENARIO # 4 • Kevin joins a Facebook group called “Bush Sucks.” In it, he gleefully trumpets each of the President’s misstatements, lies, verbal flubs and pictures depicting blank expressions published by various media outlets. • He often posts about how much better the world would be without Bush, whom he calls Shrub. • He fantasizes about what the world would be like without Bush, and starts a contest with his fellow group members “The Top Ten Ways to Trim the Bush” in which they compete for the best ways to kill the President.

48. SCENARIO # 4 • Some propose arsenic, others hypoatremia, while others suggest allowing him to be “questioned” at Gitmo. Some suggest sending him personally to find Bin Laden. • Kevin proposes that instead of Mission Accomplished, he will offer the President a Final Solution. A bomb that will blow up the Rose Garden when the President endorses a successor. Two with one blow, Kevin calls it.

49. SCENARIO # 4 • Simultaneously, one of Kevin’s professors reports to your team that he has a student who has been asking alarming questions about bomb-making in his Chemistry class. • Another student reports anonymously that he observed a student fitting Kevin’s description downloading “how to make your own bomb” recipes from the Internet on a library study carrel computer.

50. SCENARIO # 5 • Nadia calls the Dean of Students to report that her boyfriend, Sig, made a casual reference to killing himself last night on MySpace. • He told her he is bi-polar, and she knows this because she saw Prozac in his medicine cabinet. • She asked him if he was serious, and he said if he intended to kill himself, she would be the first to know.