Literature Review

Taking an Evidence-Based, Whole-Campus Approach to Mental Health Crisis Response

Post-secondary mental health centres are reporting an increase in the number of post-secondary students using campus mental health services and presenting with more severe mental health issues (Crozier & Willihnganz, 2006). A survey conducted by The Ontario University College Health Association (OUCHA) in 2009 reported that 6% of post-secondary students had contemplated suicide within the past year (OUCHA, 2009; as cited in Crozier & Willihnganz, 2006). More recent data suggests that this has increased to 16% of post-secondary-students (ACHA-NCHA, 2019). As the mental health needs of post-secondary students grow exponentially, campuses will need to work together and find effective resources to support students in crisis. However, there is currently no standard established to guide campuses on implementing interventions for mental health crisis response. Consider implementing the following evidence-based recommendations uncovered through our literature review as your institution works towards whole-campus approaches to supporting student mental health crises.

Establish comprehensive policies that address how mental health crises will be managed on campus

A recent survey looking at mental health policies across post-secondary institutions in Canada found that campuses are lacking in policies surrounding mental health crises on campus (Somma, Jaworska, Heck & MacQueen, 2017). The survey found that only 40% of schools had protocols in place to support students with severe mental illness and only 32% of schools had policies in place to assist students who have attempted or threatened to attempt suicide (Somma, Jaworska, Heck & MacQueen, 2017). This evidence suggests there is a clear need for comprehensive policies on campus that benefit mental health crisis response. However, there is little guidance on what constitutes best practice in mental health crisis response and how to effectively implement these practices. The existing literature on mental health crisis response on campus emphasizes community crisis intervention teams and community partnerships.

Identify internal and external stakeholders who contribute to supporting students experiencing a mental health crisis and determine if other relationships or capacity-building needs to be enhanced

Effective mental health crisis response in post-secondary institutions is multi-faceted and typically includes a range of internal and external stakeholders such as campus security, crisis teams, mental health services, local emergency departments and distress lines. One study that looked at crisis response at an Ontario post-secondary institution found that of the 311 reported incidents of student mental health crisis: 34.1% of students were transported to a hospital, 24% required emergency medical service, 21% used a mental health crisis team, 11.9% involved contacting the local police, and 39.5% used no external resources (Porter, 2018).

Some campuses also have crisis and behaviour response teams within the school. In 2005, the University of British Columbia established a crisis intervention team consisting of service providers from the counselling centre, disability services, health services, residence life, academic affairs
and campus security to ensure wrap-around support for students (Washburn & Mandrusiak, 2010). The University of Florida employs a crisis intervention team model in which select campus police officers are trained as part of a response team (Margolis & Shtull, 2012). These police officers receive specific training on recognizing signs of mental illness, mental health resources on- and off-campus, psychopharmacology, and crisis de-escalation (Margolis & Shtull, 2012).

Moreover, the goal for campus police when dealing with crisis situations is to safely connect the person in need with supports available either on campus or in the community (Margolis & Shtull, 2012). One study highlighted the need for adequate training and access to resources for campus police to support those in crisis (Margolis & Shtull, 2012). Suggestions to improve campus police response to mental health crises emphasized the importance of cultivating multidisciplinary approaches and prioritizing collaborative partnerships. For example, the campus can bring together various external and internal stakeholders to develop a training program that identifies the roles and responsibilities of the stakeholders and how to access these services during a crisis (Council of State Governments, 2002; Schwarzfield et al, 2008, as cited in Margolis & Shtull, 2010). Considering campus police are one of the first points of contact during a mental health crisis response, adequate mental health training and resources for campus police are crucial (Margolis & Shtull, 2010).

Create behavioural intervention response teams

Other crisis approaches that are prevalent across campuses in the United States include behavioural intervention/response teams/units. Behaviour response teams are comprised of an interdisciplinary group of campus personnel who evaluate cases involving students exhibiting concerning behaviours such as emotional distress, disturbed writing, and aggressive or suicidal remarks and behaviours. (Cornell, 2010, as cited in Golston, 2015; Frederick Community College, 2017). Mental health issues were the most commonly addressed concern by behaviour response teams (Golston, 2015; Mardis, Sullivan & Gamm, 2013, as cited in Self, 2017). One survey of over 800 universities and colleges found that 92% of campuses reported having some component of a behaviour intervention team, threat assessment team or students of concern team (Van Brunt et al., 2012).

It is recommended that behavioural intervention teams are comprised of 5 to 8 personnel who work closely with students (Van Brunt et al., 2012 Penven & Janosik, 2012, Goltson, 2015). Accordingly, most of the teams surveyed by Van Brunt et al. (2012) included primarily counselling staff, campus police/ security, deans of students, residence life staff, and academic affairs staff. Moreover, it is recommended that teams meet weekly to maintain communication and progress (Eells & Rockland-Miller, 2011; as cited in Golston, 2015). Van Brunt et al. (2012) also found that the majority of teams met on a weekly or bi-weekly basis, while others met monthly or as needed. Another relevant survey focused on the training of behavioural intervention team members found that most teams attended conferences, National Center for Higher Education Risk Management training, webinars and workshops with experts (Mardis, Sullivan & Gamm, 2013).

With the increasing demand for campus crisis response teams, there is need for a framework and guidance for colleges and universities to effectively develop these teams (Jed Foundation, 2013). In response, the Jed Foundation and the Higher Education Medical Health Alliance created a guide to help colleges and universities develop and improve campus teams. The guide focused on 5 components, including:

1. Team mission and purpose
2. Naming the team
3. Team composition, size, and leadership
4. Team functions
5. Common pitfalls and obstacles

The guide also provides key issues of consideration, as well as examples for implementation. It highlights several campus teams across the United States such as the University of North Texas CARE Team and Cornell University Alert Team. An example of a behaviour intervention team is the Behavioural Evaluation and Response Team (BERT) at Frederick Community College which consists of administrators from various college departments, a security supervisor, and a counsellor (Frederick Community College, 2017). The BERT investigates reported cases and follows up with the student to explore some strategies that might address the concerning behaviour (Frederick Community College, 2017). The BERT then continues to monitor the student’s behaviour and refers the student to appropriate resources such as the College Counselling Centre or recommends a leave of absence or withdrawal (Frederick Community College, 2017). In this way, behaviour intervention and response teams act as a proactive response to a potential crisis rather than an immediate crisis intervention. Frederick college encourages calling 911 or campus security in the instance of an immediate crisis. Despite the number of existing behavioural intervention teams and the framework, there is very limited literature on the efficacy and outcomes of these teams.

Integrate health and counselling services for a holistic and comprehensive approach to student care

Campuses must work to develop partnerships with community resources to ensure priority and timely support for students who present with concerns that are outside the scope of support available on campus (Lamberg, 2006). One method that colleges and universities can use to improve their current service offerings is integrating health and counselling services (American College Health Association, 2010). This integrated model results in a holistic and comprehensive approach to care for students. At the University of Texas at Austin, the Counseling and Mental Health Center (CMHC) and University Health Services (UHS) collaborated to create the Integrated Health Program (IHP) as a means to expand the psychological services offered to students (Tucker, Sloan, Vance & Brownson, 2008). The IHP consists of two psychologists and two clinical social workers who work in the UHS. They provide crisis intervention for any student experiencing a crisis.

Researchers are also suggesting an on-campus health/medical services model to reduce the need for student hospitalization (Porter, 2018). Considering the increasing rates of mental health crises, and responses often requiring hospitalization and inpatient psychiatry, it might be helpful for campuses to expand and prioritize psychiatric services and/or establish better links to psychiatric services in
the community. One survey found that 33.7% of psychiatric services are performed by a primary care physician/nurse practitioner and 23.9% of campuses do not provide any on-campus psychiatric services, instead referring students to community providers (American College Health Association, 2010). A survey of counselling centre directors in the United States reported that 30% of campuses have no psychiatric services available on campus, and in campuses with psychiatric services, 66% reported that the available services are inadequate (Barr, Krylowicz, Reetz, Mistler, Rando, 2011). In Canada, access to psychiatry services on campuses is fairly scarce. While 29% of medium-sized campuses and 57% or larger institutions have some internal access to psychiatry, there are no small campuses with internal access to psychiatric consultations (Jaworska et al., 2014).

It is recommended that behavioural intervention teams are comprised of 5 to 8 personnel who work closely with students (Van Brunt et al., 2012 Penven & Janosik, 2012, Goltson, 2015). Accordingly, most of the teams surveyed by Van Brunt et al. (2012) included primarily counselling staff, campus police/ security, deans of students, residence life staff, and academic affairs staff. Moreover, it is recommended that teams meet weekly to maintain communication and progress (Eells & Rockland-Miller, 2011; as cited in Golston, 2015). Van Brunt et al. (2012) also found that the majority of teams met on a weekly or bi-weekly basis, while others met monthly or as needed. Another relevant survey focused on the training of behavioural intervention team members found that most teams attended conferences, National Center for Higher Education Risk Management training, webinars and workshops with experts (Mardis, Sullivan & Gamm, 2013).

Create partnerships and agreements between post-secondary institutions and community resources

Effective management of mental health crisis collaboration between n-campus resources and off-campus resources is essential to ensure continuity of care (Jed Foundation, 2006; Suicide Prevention Resource Center, 2004; as cited in Washburn & Mandrusiak, 2010). Washburn & Mandrusiak (2010) recommend that for crisis response, university and college campuses must form partnerships with community resources such as mental health clinicians, hospital emergency departments and police departments. This is even more pertinent considering a national survey of counselling center directors in the United States reported that 9.4% of counselling center clients are referred to external off-campus resources for specialized or more intensive treatment (Gallagher, 2010). Moreover, a 2006 survey of American university and college counselling center directors reported that 2,069 post-secondary students were hospitalized for symptoms of mental illness, with an average of 8.6 students hospitalized per school over the course of a year (Gallgher, 2007). Despite frequent utilization of hospital resources for students, campus directors reported a lack of collaboration between the campus and local hospital and psychiatric services. As it relates to premature discharge, students often return to school without notification or an understanding on the part of hospital staff of the post-secondary environment (Rockland-Miller 2000, Rockland-Miller 2003, as cited in Rockland-Miller & Eells, 2008).

Rockkland-Miller & Eells (2008), highlights the need for partnership and agreements between post-secondary institutions and local hospitals to facilitate a safe hospitalization process. Once colleges and universities have determined that hospitalization is required, they should ask the student to sign a Release of Information (ROI) (Rockkland-Miller & Eells, 2008). Once the student has signed, the school clinician should call or have administrative staff contact the local hospital and connect with a touchpoint person who is determined by the partnership agreement and who can provide the student with the necessary information that they require (Rockkland-Miller & Eells, 2008). The transportation process is then dependent on the circumstances of the hospitalization. In the case of a voluntary admission, a friend or family member can be notified to accompany the student. In the case of involuntary hospitalization, transports would involve ambulance and campus police (Rockkland-Miller & Eells, 2008). Developing close partnerships, agreements and processes between campuses and local hospitals is one aspect post-secondary institutions should explore in regard to their crisis response.

While Rockland-Miller & Eells (2008), emphasize that the onus is largely on the college or university to facilitate and maintain partnerships with local hospitals, other researchers are exploring the role of hospitals and mental health service providers in supporting student mental health. McLeans Hospital in Belmont, Massachusetts introduced a College Mental Health Program (CMHP) that aimed to integrate the hospital and university/college system (Pinder-Amaker & Bell, 2012). Not only did the program provide direct clinical support for students, it also evaluated protocols and developed policies and standards to improve the hospital experience and processes for students (Pinder-Amaker & Bellm 2012). Within the program, 30% of students were on the Short-Term Inpatient Unit, as they were likely displaying acute symptoms (Pinder-Amaker & Bellm, 2012). Consequently, collaboration between the school and hospital system leads to improved mental health outcomes for college or university students (Pinder-Amaker & Bellm 2012).

Establish discharge protocols in partnership with local hospitals that include follow-up with campus services

Discharge planning and follow-up are important for student outcomes after hospitalization. One study looked at college students who received psychiatric evaluation at a Comprehensive Psychiatric Emergency Program (CPEP) after experiencing a crisis. College students represented 8% of all patients between the ages of 18-40 at the CPEP (Mitchell, Kader, Haggerty, Bakhai & Warren, 2013). The average hospital stay for students was 2.38 days; however, 77% of students were discharged the same day as they were admitted (Mitchell, Kader, Haggerty, Bakhai & Warren, 2013). Considering that the majority of students were not admitted to the program, discharge and follow-up care is necessary to support students. In particular, students admitted to the inpatient psychiatry unit stayed for an average of 8.93 days (Mitchell, Kader, Haggerty, Bakhai & Warren, 2013). Once students were discharged, 79% were referred for outpatient mental health services, 14% were referred to a campus counselling centre, and 7% were not given a referral (Mitchell, Kader, Haggerty, Bakhai & Warren, 2013). Before discharge, approximately 50% of the students received a referral for an actual appointment with a community service provider (Mitchell, Kader, Haggerty, Bakhai & Warren, 2013).

Moreover, having an appointment prior to discharge increased the likelihood of students successfully connecting with supports after discharge (Mitchell, Kader, Haggerty, Bakhai & Warren, 2013). This is an important aspect of crisis postvention plans that can lead to improved mental health outcomes for students. As such, when exploring mental health crisis response, postvention processes such as discharge planning and follow-up should also be considered. Furthermore, discharge planners from the hospital should follow up with the students to ensure they are receiving the recommended treatment (Mitchell, Kader, Haggerty, Bakhai & Warren, 2013). Considering the major role of the discharge planner in the mental health outcomes of students, both hospitals and campuses would benefit from partnership to ensure effective coordination of care for students (see the example in the appendix).

Improve ease of navigation and raise awareness of crisis counselling services that are accessible 24/7 worldwide

It is also important to note the change in student mental health and crisis protocols and policies within the context of the COVID-19 pandemic. During this time, most universities and colleges are operating through remote and distance learning. Over the last few years, CICMH’s need’s assessment has identified this as a barrier for students seeking supports in a timely manner. The pandemic has exacerbated the mental health issues students were experiencing due to academic uncertainty, social isolation, difficulty concentrating, loss of routine, concerns over personal and family health, and financial difficulties. (Son, Hegde, Smith, Wang, Sasangohar, 2020; Grubic, Badovinac & Johri, 2020). Campuses also have international students who may be studying in their home countries, far away from their campuses.

As a result of remote learning, access and structures of mental health supports have changed. For example, most schools have moved to providing online mental health supports and counselling services (Conrad, Rayala, Menon, Vora K, 2020). Many universities in North America are encouraging students in crisis to use school and community crisis lines to access support. Despite available online supports, one study found that most students were utilizing self- management strategies to cope with the anxiety and stress of the pandemic, with 23% of students using maladaptive coping strategies (Son, Hegde, Smith, Wang, Sasangohar, 2020). Another study reported that 55% of college students surveyed did not know how to access mental health supports during a crisis (Active Minds, 2020). Moreover, students were having difficulties accessing general mental health supports (Redden, 2020). A study looking at the mental health information available on counselling centre websites found that only 50% of the web pages provided information on remote counselling and community resources such as 24/7 hotlines (Siedel, Mohlman, Basch, Fera, Cosgrove & Ethan, 2020). More concerningly, only about 30% of schools provided information on how to access mental health crisis services (Siedel, Mohlman, Basch, Fera, Cosgrove & Ethan, 2020). Providing students with easily accessible knowledge and information is essential in helping reduce barriers to service access.

Investigate reasons for the underutilization of counselling services

Other studies have reported that students are not utilizing counselling services offered by their university. Reasons for underutilization included not feeling that their issues were severe enough for support, discomfort seeking help from unfamiliar counsellors, and distrust of counselling services (Son, Hegde, Smith, Wang, Sasangohar, 2020). Recommendations to reduce barriers to access include providing “walk-in” appointments for virtual care options (Liu, Pinder-Amaker, Hahm & Chen, 2020). Drop-in appointments for counselling might present a timely and accessible option for students in crisis to get connected to initial support. Additional recommendations include monitoring and connecting with vulnerable students such as international students, Black students, Queer students, Indigenous students, and those with pre-existing mental health issues or financial stressors (Liu, Pinder-Amaker, Hahm & Chen, 2020). Proactively reaching out to vulnerable students can work to mitigate the risk of a mental health crisis. For more information on how to better engage with equity-deserving students, see CICMH’s Anti-Oppressive Practice toolkit.