Web Exclusives: PawPlus

June 6, 2007:

After Virginia Tech

In the wake of shootings in April at Virginia Tech, PAW brought together four experts to discuss issues affecting Princeton and other universities. Here is the complete transcript of that discussion. (An abridged version of the meeting was published in the June 6, 2007, issue of PAW.)

PAW: When there’s evidence that a troubled Princeton student needs help, or if there’s concern that a student could cause harm to himself or herself or to others, what happens? What is in place?  

Dickerson: I would like to preface my answer to that question by saying that one of the great advantages that Princeton has is that we have a very taut network of deans, directors of study, upperclass deans, faculty advisors, and other administrators and staff members who are very observant. So we think that we are in a relatively good place as far as being a small-enough campus and an intimate-enough campus, so that students who are in trouble might be observed by people from any number of areas of the University.  

Another group that I should have mentioned is coaches, because they, too, are very much in touch with any changes in students’ behaviors. So, if something happens, what we’ve done is to encourage the student or the dean or coach or other faculty in the group who observed the student to be in touch with the student directly, first of all ­ if possible and if that’s appropriate ­ but then also be in touch with University health services through Counseling and Psychological services, which is headed by Dr. John Kolligian, or directly with Dr. Danny Silverman, who tends to be very effective in reaching out to observers and advisers or consultants [and] to the person who is concerned.

PAW: So does this happen informally, or are there very specific procedures that are in place that govern these steps?

Silverman: I think that’s an excellent question. In fact, I think that there’s a great deal of formal structure in place in that we have been developing over the past five years. There are a number of things that we have put in place. To begin with, we really felt that it was terribly important to identify our relationship at University Health Services and Counseling and Psychological Services with the Office of the Dean of Undergraduate Students and the Dean of Graduate students as a partnership, in that it meant there needed to be an open flow of information about what we refer to as students of concern.  

We have had numerous conversations with Peter, our general counsel, at many junctures in the last five years about what our role could and should be in identifying students whom we refer to as being at imminent risk of either harming themselves or others. And we have generally taken a University approach of being very proactive.  

Our first goal is to help the student, not necessarily meant to be disciplinary or intrusive, but it’s really about making sure that a student’s medical and mental health needs are being met. Dr. Kolligian, director of the Counseling and Psychological Services, actually shares a watch list of students of concern throughout the academic year, and those students are discussed in conference on a monthly basis with members of the deans and directors group, and [Associate Dean] Hilary Herbold, as well.  

So hopefully the students stay on our radar and they have been offered help. We also instituted a policy of so-called “Mandated Evaluation” so that any responsible adult on campus can initiate a request for formal evaluation of a student in distress. They generally flow through the Office of the Dean of Undergraduate Students, and less frequently through the graduate student office, but a faculty member, a coach, a public-safety officer, an administrator, or a dean can let the office of the dean of undergraduate or   graduate students know that there is a student that they are concerned about who may be in distress, and they can be formally asked to come for an evaluation. This is done literally scores of times throughout the academic year, and it helps us make a connection to a student and begin to assess the level of their risk.  

And then finally, we’ve implemented a number of programs and we are very pleased with their acceptance in the University community. The first one is something that we call P-DAP (because you’re not allowed to have a program at Princeton unless it has an acronym), the Princeton Depression Awareness Program. For the past two years, we have trained roughly 500 adult first-responders on campus, and this includes administrators, academic department managers, faculty members, coaches, public-safety officers, the entire University health-services staff, as well as students and residential college advisers, to recognize early signs and symptoms of depression and other forms of emotional stress in students at Princeton, to learn how to begin a conversation with the student, and to do everything they can if they have a high level of concern about a student to bring it to the attention of the appropriate responsible adult on campus.  

We analogize it to CPR of the mind: If you saw somebody who was in crisis medically on campus, you would certainly step in immediately to assist them. In the same way, if you see a student in emotional stress, we’re asking the same. It’s been intriguing, because one of the most interesting things we’ve learned from doing this training is that people are really asking for permission to have these conversations. There’s often a concern that somehow it would be a boundary violation if they addressed a student and asked is everything is OK. We’ve tried very hard to say that it’s not really just a question of OK; it’s actually a responsibility to do this as an adult first-responder on campus. The response to the program has been very positive.  

Finally, this past year we have been working with seven other colleges and universities to implement a first in the nation program which we refer to as the College Breakthrough Depression Care Collabroative Project, and we’re screening students with a validated depression screening tool when they come in for primary care medical visits. Again, the hope is that we’re finding additional ways to identify students at risk who might not self-refer to mental health services. I think one of the tragedies is that of the 1,500 students who take their own lives on a college campus each year, we know that 1,000 of them have never had a single visit to their university health service or their college counseling center. Those are the students that keep us up at night, because we don’t know about them. The students who are depressed, suicidal, or struggling with emotional distress who are in treatment with us generally make a good connection, and they are generally not likely to act upon such things.

PAW: When you mention the boundary question, Peter, can you talk at all about what the privacy issues are? As this is going on with the University, what is the parent/family role?

McDonough: Let’s take those one at a time. Just about 10 years ago, I spoke at a conference of student-life deans, and I went into my file before I came over today to remind myself of what I had termed my presentation topic. It was called, “Deans’ Offices, Health Services, and Institutional Attorneys Work for Peace.” It underscores two things, I think. One: this isn’t a new issue, or a new problem. Two: there’s always been and there’s always going to be attention.

I’ve been here at Princeton for 16 years, and for all 16 years of my time here, I’ve been periodically over at the McCosh health center talking to the counseling people about what would we rather deal with: a contention or claim of a privacy violation, or a death? And that answer is very easy to arrive at in the abstract. It gets harder when the folks in the counseling center present a continuum: The anorexic student who is on her way to a real problematic physical place, but even physicians can disagree about how far along on that continuum she is. So at what stage do we “act”?  

There’s no right or wrong answer about these things, so frankly. I think it is easier in our environment, for the reasons that Janet and Danny have suggested, than at a larger institution, to figure out how to manage these things. That’s a first cut at tension, and we can talk more about the tension. Another level of slicing is that we always talk, from the lawyers’ standpoint, about the institution responding to conduct, not conditions, from a disciplinary standpoint. When you start to change somebody’s status or rights and responsibilities, particularly as a student but certainly as an employee, it becomes even more challenging to responding to conduct, not condition.

I’m gathering that I’m going to hear from the other panelists here ­ and Danny has sort of suggested it ­ that either there is a pre-existing conduct in situations that can prove worrisome that you can react to. There might not even be “known conditions” that somebody is going to say we have a record of. So what do you do there? That is an issue.

PAW: That is a tricky question. As an attorney, what would you do?

McDonough: As I said, respond to conduct, not condition ­ that is the framework that we are in. But do it in a nuanced way, as Danny has suggested, and as the environment allows, so that hopefully you are supportive in recognition of the condition and not imposing discipline or restrictions or adjustments to rights and responsibilities, but bringing someone as close to voluntarily as possible to that place.

It’s been reported in the Virginia Tech aftermath that FERPA [Federal Education Rights and Privacy Act] really inhibits a lot of institutions because it creates a barrier ­ a practical barrier, if not a legal barrier for some larger institutions in particular ­ regarding sharing information with parents. We followed here our same set of guideposts about balancing concerns about privacy with concerns about the individual. I think it’s fair to say that being as respectful as we possibly can to the various laws, whether they be statutory and impacting medical professionals or statutory and impacting educational institutions, at the end of the day, we’re going to try to preserve life.

PAW: How specific is FERPA when it comes to things like notifying parents? There was a piece in The Wall Street Journal recently that suggested that, in fact, universities and colleges have been very wary about that, but the law does give them more leeway.

McDonough: There are many ways to manage the FERPA obligations. There are also huge practical inhibitions against managing it when the institution becomes larger and larger. I think it’s frankly easier for a small institution that has resources, can institute protocols, and is centralized to manage it. It’s harder when the institution is smaller and doesn’t have resources, or when the institution’s management structure isn’t centralized. And then it’s very hard at the other end, when the institution is extremely large with tens of thousands of students.  

PAW: Professor Newman, given your research, how do you react to hearing about these programs and this approach on campus?

Newman: I have two reactions ­ one as a faculty member and the other as a researcher. As a faculty member, I am very well aware that we have an abundant set of resources for helping our students, and I think that’s what makes Princeton such a special place to work. But it’s not always clear, at least to those of us who are relatively new to the campus, that we actually know how to activate these resources. I actually think there is some productive work that we can do to raise awareness and to be cognizant of the many things that faculty have in their minds and so what they will hold and they won’t home in their brains. I say this as someone deeply involved in teaching and grading right now.

First and foremost, I think it would be very helpful if our undergraduate representatives in each department were very aware of these resources, because my first call most of the time, if I get a student who is of concern to me, is going to be to my colleague who is responsible for the undergraduate program. Because I actually don’t know anything about their [students’] residential life ­ I know they have one, but with any given student, I don’t know where they are or who their residential-life dean is. I know they have one, but not how to find them.  

Fortunately, I’ve had enough contact with Janet that she would be the next person that I would call, but not everybody has. So I think that it would be very helpful, and I’m speaking now as a faculty member, to be sure that part of the purview of our undergraduate representatives is to know where the department should turn so that faculty feed to them and they in turn connect to the appropriate institution, because the likelihood that I’m going to keep this on my desk and remember that you’re the person I should call is slim, I think.  

As a researcher, again I’m aware of the enormous resources we have and how beneficial that is, and actually my hat is off to my colleagues at Virginia Tech, because I think they made use of every resource they could get their hands on. The most frightening thing about the Virginia Tech case is that it didn’t work, but it wasn’t because they didn’t make every effort.

I’m not even sure that we’ll have to wait for the investigation that it was because the resources weren’t there. It’s going to take a long time for us to understand why certain things were not done ­ why someone who was declared a danger to himself and others was not handed over to his parents or involuntarily committed or a whole bunch of other things that potentially, I imagine, could have been done. I don’t think any of us know why those things didn’t happen.  

I am very reassured to hear my colleagues say two things: first, that protecting a student’s life is very important, and protecting the safety of students and faculty around them is critical, because in my mind that should be really quite paramount. Everything else ­ being sued, being hauled in front of a regulatory board ­ all of that pales by comparison to those two objectives.  

As a researcher I am aware of the extraordinary tension that students in this age group are under. I do worry about that. I do think, especially here at Princeton, we have an extremely gifted student body; they come to us as hyper-competitive people who are accustomed to being at the top of their game, and then they’re thrown into a cauldron in which everyone else is also at the top of their game. As someone who has taught freshman seminars and seen them when they first arrive here, there is a bit of a shock that comes with the readjustment of the pecking order and the recognition that what comes after they leave Princeton is an incredible cauldron of competition that they must find their way through.  

And this does produce quite extraordinary tensions, even if we’re not talking about someone who’s psychologically in trouble or feeling overwhelmed for other reasons. So I think it behooves all of us to recognize that this is a stressful period as much as it is also a lot of fun, and it can produce in some people extreme vulnerability. I do hear my students, because I know them well, talking to me about kids who are cutting themselves or kids who have eating disorders or panic attacks. I hope they are getting treatment; if they were my own students, I would call somebody, but they’re talking about friends of theirs who are worrying them because they’re involved in behaviors connected to depression.  

I do have to say that there is a difference between people who are experiencing garden-variety or even quite-serious forms of depression and people who are going to take it to the level that we saw at Virginia Tech. What we saw at Virginia Tech and all the other school rampage shootings that I studied are people who are really in extreme mental distress. They are, in the cases of the youngest adolescents, entering what will later (if they survive) be diagnosed almost certainly as extreme mental illness. They are not just depressed; they are really in trouble, and they are subsequently diagnosed as schizotypal personality disorders or full-blown schizophrenics, and they are at the early end of that symptomology.

We will not be dealing with people like this on the whole; those are young children ­ they are 11 to 14 years old.   It’s difficult to identify ­ I’m sure the doctors on the board will back me up on this ­ it’s much harder to recognize and classify their symptoms.   By the time they get to be the age our students are, we’re coming closer to what our diagnostic manuals help us understand, so in some ways we’re better off with an age group like the one we deal with, because it’s coming closer to where medical science can really help us diagnose people. But if they get this far, we are talking about people who are really psychotic or schizophrenic, and that’s not your ordinary, garden-variety depression.

The second point I would make is for our students in general and for faculty as well. The research that I have done shows very clearly that people who are headed down the path that [Seung-Hui] Cho was headed down give off warning signals. It’s not always easy to interpret what those warning signals are, and he may have been particularly secretive ­ we need to learn a lot more about him ­ but the shooters that I’ve studied have a particular goal in mind. They are problem-solving, as horrible as that may sound, through shooting. The problem they’re trying to solve is to change the image that other people have of them. And that is not generally something done through a spontaneous explosion; the groundwork for that is laid over a fairly long period of time ­ a period of time in which they’re hinting. They’re threatening, in so many words, because they’re trying to gain the attention of others, and just a final explosion won’t do that.  

How much people could possibly have seen in Cho’s case is really very hard to say, but he didn’t invent the cultural imagery that we see on those videos ­ the sort of Rambo imagery, or the kung-fu imagery. My guess is that, if we find out enough about him, we will discover that it wasn’t the very first time he had made that clear somehow. It took me two years of research to ferret this kind of information out among the shooters that I studied very closely; it’s going to take someone about that long to understand how Cho unfolded.  

But in the cases I studied, there were lots of warning signals. They were difficult to interpret, though, because unless you have in your mind a shooting like this could happen, what you hear are vague hints and comments that don’t necessarily add up, and they’re often coming from someone who is known to make comments like this all the time. So that could be just one more crazy thing that Johnny said, and Johnny is known for saying things that gain attention because his purpose is to try to change the way we think about him through a notorious, dangerous act that makes him look like an alluring male figure instead of the incompetent social creature he feels himself to be.

PAW: Dr. Silverman, on this issue of warning signals, not just for mass shootings but for other potentially harmful situations, you’ve been quoted as saying that at Princeton, more than 50 percent of the students report getting severely depressed every year. If that’s now the norm, how do you distinguish between serious warning signals that require intervention and not-so-serious ones?

Silverman: I’m just marveling at all the points that the professor made, and trying to address myself to some of them. I’d certainly agree with her first point about not talking about garden-variety psychopathology in the people who pick up automatic weapons and create havoc. It’s interesting. Again, I think it’s very early to try to interpret what little we know about what happened at Virginia Tech, although I would certainly agree that there were many warning signs. One of the ones, and this pertains to the question, that would have concerned me is the content of some of his creative writing. And I will apologize to Professor Newman: We haven’t done a good-enough job if we didn’t let you know how to find us, but one of the reasons we’ve been doing these presentations to the faculty is in fact to get our faces in front of people and to say we are here and we are available.  

Newman: I might have just been at the wrong place…

Silverman: Well, please invite us to your program to do the presentations; we’re delighted to do them, and they’re very well received by the faculty. And a major goal was to say, “You have a friend at Chase Manhattan, and call us night or day,” and it really was to raise people’s consciousness about how to make these connections.

On the issue of the warning signs and the severity of it, it is a fact that the students here are under inordinate stress. I think a couple myths exist, though. One is that this is somehow peculiar and particular to elite institutions. We find that this is true across the United States at most college and university settings. As special as we are at Princeton, we’re not that different in this regard.  

The fact should also be stated that the vast majority of people, even with serious mental health problems, do not act out violently. I think that’s another misconception, and once we begin to talk about schizotypical personalities and schizophrenics, we’re now suddenly raising the specter of people who are likely to behave violently. It’s a very rare event, even in those people who are floridly psychotic or suffer from chronic schizophrenia, schizoaffective disorder, or whatever it may be. So again, we’re talking about a very small proportion, thankfully.

Not to tread on Professor Newman’s research, but this type of tragedy is obviously hard to study in itself because there are not, thankfully, huge numbers of events like this. The one point that should be made, and many people have heard me mention this at Princeton, is that we’ve been struck by a dramatic increase in students arriving as freshmen with serious vulnerabilities or mental health problems. There is a subpopulation of vulnerable students at Princeton and all other colleges and universities. And we know this for a variety of reasons.

It’s been estimated that the number of students arriving who have been appropriately diagnosed and treated with a psychotropic medication has grown tenfold in the last 10 to 20 years. One can earnestly ask why this is the case, and I have my own theories. It’s not been well-studied, but I believe that, first of all, we do a better job of diagnosing children in middle school and high school with depression, anxiety disorders, OCD, attention deficit. While there may be a risk of over diagnosing and over treating, many of the students we see were appropriately picked up and in fact got such good treatment. They came from families of privilege where they could access good mental health care, so they were on medication and sometimes had psychotherapeutic intervention for years, and they were literally able to start college on time with their own cohort.  

Maybe the burden of illness 20, 30, or 40 years ago would have prevented someone with these problems from either entering college in the first place or certainly starting it on time. They are actually coming in droves to us.   We know that there are many more students arriving on our doorstep this way, and in fact if you graph our curves, the demand for mental health services at Princeton is quite phenomenal.

I think we're blessed that we have so many resources. But we see something like 16 to 18 percent of students for a mental health visit on this campus, which is way above the national numbers of the penetration of any general population into mental health. So the students are seeking us out, and it is kind of good news/bad news story, but also we are providing I think help to a lot of students.  

The data that you cited was from the National College Health Assessment, which we participated in most recently in 2006. It was alarming to see the number of students who say that between one and 10 times a year I feel so profoundly depressed I can barely function, that I feel hopeless at times ­ which is hard to imagine that somebody with the smarts to get into Princeton and the kind of future that lies before them to feel hopeless about things, not a normal response.  

And the number of students who, even though they don’t act on it, would seriously consider suicide is somewhere between 7 and 8 percent of our students and nationally, similarly, 7 to 8 percent. One and a half percent of students tell us they actually have attempted it, which may be a minor swallowing of pills or cutting themselves.  

I don’t know if the professor knows, but we did do the largest study of a “normal” college population on self-injurious behavior with Cornell last year. It was in the Journal of Pediatrics in 2006. And it was alarming, again. We found that the lifetime prevalence of this behavior in Princeton and Cornell students was 17 percent, and about evenly divided between did it before I got to Princeton and currently doing it, so around 8 percent of our students say that they have self-injured at least one or more times.

All of this is sort of in the background, and when you do add, I think, the enormous stress of being a student at Princeton, it’s a potentially volatile mix. I completely agree with what the professor was saying ­ I like to say that each of the students at Princeton was the American Idol of their own reality-TV show before they get here. They were stars, but they suddenly find themselves in a constellation or galaxy of stars. And that is very shocking, developmentally, to a lot of the students, to go from ­ in their minds ­ best to last. Of course that is not in fact the case, but that is their perspective.

PAW: Janet and Danny, you talked about the training that you’re doing. Are you finding that students are in fact reporting to an adult that “Hey, my friend is having a lot of trouble here”? What are you finding in the dorms? How is it translating to what you’re actually hearing and then can act upon it?

Dickerson: I’ll speak briefly. I know that you [Silverman] have more direct information about the referrals. I think that our RCAs [residential college advisers] are very well-trained, They are quite observant and are willing, in appropriate ways, to express concerns either to their deans or directly to someone in Health Services in a confidential way. We have peer educators in other areas as well.  

I think that students are quite alert to signs and symptoms and really do find ways to report these issues. They are cautious about it, but they do report. I’d also say that, as I understand it, we’ve had some good intuitions from parents who may have some concerns. One of the interesting things about students in this generation is that they often view their parents as their heroes and their closest friends, and they tell us as parents more than we want to know sometimes. But the good news is that a parent might pick up some indication that a student is staying in her room, not following through in ways that she should, or not taking her medication. They have ways of getting their messages through. I will occasionally hear from a parent or a student who wants to make a referral because they’re concerned about their student.

Silverman: I agree with everything you said, Janet. I get lots of calls from parents saying, “Go check on my child.” As recently as this morning, I attended a conference with Dr. Kolligian and Dean Herbold about a student of grave concern who came to our attention because her best friend “turned her in.”  

And there are things that still have to be sorted out. We have something that we officially call “third-party contacts.” We also encourage students to contact us anonymously if they’re concerned enough about a student. They don’t have to identify themselves and they don’t have to necessarily identify the student initially to get a consultation from us as to how to help them. We are concerned: The students here are fantastic, and very often they will try to sustain and pump up a friend, a roommate, or a teammate for far too long. And we try to convey the idea that we don’t want you to be psychotherapists or psychiatrists here. We think your responsibility is to get the student to professional help.  

But some of the stories have just amazed me ­ chronically suicidal students whose best friends have sort of stayed around, in one case, a young woman for three years. And finally, by their senior year, they were just exhausted and came as a group to see us and ask for help. Our job was to give them permission to say “Let’s turn this over to the professionals.”

Newman: Can I add one thing to this? Here’s where I really feel like college campuses are very fortunate compared to high schools. It’s in high schools that kids will refrain from coming forward because they’re worried about being adult identified, and they’re worried about betraying their friends. They’re in a period of life in which separating from the adult world is essential to their identities. By the time they come to us, they’re ­ I would imagine ­ through that, and to be more adult-identified is fine. So in some ways I think we’re advantaged by the age group that we deal with. I really don’t think that we need to worry very much about this particular problem compared to what the high schools I studied have to worry about.

McDonough: Let me try to combine a couple of thoughts there, because one of the things that we haven’t talked about yet directly is the really wonderful set of protections for what we would term disabled people. And I use that word only because of the commonly known Americans with Disabilities Act, and we have a New Jersey equivalent.

It’s always seemed to me that one of the challenges on a college campus, whether we want to talk about our employee base (which I include faculty in) or our student group, is that in many ways we almost celebrate eccentricities and we have an extremely high tolerance for differences of conduct. We, I think, would have folks who can very accurately use data to explain why we should even come to expect levels of what medically what would be described as a disability in some context where we have extraordinary intellects. So, we’re different than a workplace in the corporate world, and we’re also different than those secondary and primary schools where there are fairly regimented expectations for those students.

Now what do we do as lawyers when we’re trying to help advise Janet and her folks and the rest of the campus? Well here’s the framework that the law applies. The law says that if someone as an employee or a student can perform the essential functions that are expected of them ­ and remember that our faculty, because of academic freedom and some other very good reasons, would hesitate to define too precisely the essential functions of every single class and the essential expectations for conduct and work product ­ but if someone can perform the essential functions with reasonable accommodations, then they’re otherwise qualified to be a student and an employee. It makes it very hard to deal with that person, even when you’re talking about conduct, because we have wide tolerance for conduct. It’s very hard for us to say, “Geez, this person has acted strangely.” In a lot of our departments, somebody would say, “Yeah, and what’s the point?” And that’s just the reality, right? So that’s the challenge for the law, for the lawyers, and for the folks who have to play within the framework of the law.

Newman: Can I add something else? Two things. One, I think that knowing that makes faculty and other employees very hesitant about how aggressively they should bring forward conduct that makes them nervous. But my rule of thumb is if it makes you nervous, you should tell someone, because your instincts are telling you something that someone else can help you calibrate.

I think it’s also very important to recognize that ­ and we don’t like to talk about this very much ­ we are involved in inherently tension-creating situations. I grade people every semester. I know that the grades I give them have an impact on what kind of future they can expect to have. We are a part of a stratifying institution, or a stratifying machine, and the students are aware of it and we are aware of it. That is not something where everyone always comes out happy, so you will see these tensions develop.

In the aftermath of the Virginia Tech situation, I can tell you that dozens of faculty members have felt anxious about how far can this tension go before you should be worried about the student who’s upset about their grade or who’s worried about whether they’ll get into law school to follow in your footsteps. There are real-life consequences to what we do, and that is unavoidable in the way we conduct our business at the University. We should simply recognize that this isn’t always about a happy community of common intellectual achievement and celebration; it’s also about where people are going to end up and who stacks up where. There is a tension inherent in that, and it is conflictual at times.  

PAW: Given these tensions and given the law, is there ever a point at which Princeton says, “We’re so concerned about you that if you don’t get treatment ­ even though you’re getting straight A’s ­ you have to leave this campus; you can’t be here if you’re not getting treatment”?

McDonough: Let me just frame the answer and fill it in with detail this way. And this might be a luxury that Princeton has for all of the reasons that we’ve been talking about today. In this and other contexts, so often the discussions that I’ve been in have started with, “OK, let’s figure out what the right thing to do is.” And on this one, that’s where the conversation tends to begin. I’ve heard ­ and I frankly don’t hear it from my lawyer colleagues elsewhere in the country very often ­ that it’s fear of liability that drives some responses on college campuses. I think that’s the perception of the non-lawyers on those campuses. I don’t have the data or even the anecdotal evidence to offer a view as to why that is, but when I sit with my colleagues from those campuses, that’s not what I’m hearing. I’m hearing, “We tend to start with what’s the right thing to do in this circumstance.” Now, what do we actually do?

Silverman: I can give you so many examples, and you’ve been involved in some of these conversations. The one that comes to mind is one that you’ve already alluded to, and that is the student with a severe eating disorder that is beginning to cross over the line into medical emergency and urgency ­ a situation in which there is irreversible bone density loss, and yet the student is still passing all of her courses. And we’ve had this exact case.  

You ask the parents to come in, and the parents say that she would do so much worse at home, because there is so much more structure here, and she loves her courses. Of course she’s dealing with her courses the way she’s dealing with her body, which is in a terribly perfectionist, driven, and hyper-vigilant style of coping. And at the end, when asked the question of what’s the right thing to do, we say that we’re a residential college, not a residential treatment center. And in fact, we think that your current health behaviors are putting your long-term health and wellbeing at grave risk.

And we’ve had parents who have said that you entered into a contract to educate my daughter, and under the Americans with Disabilities Act, she’s meeting her academic requirements, and if she’s harming anyone, she’s harming herself. Although students with severe emotional distress often create an enormous stress and tension for what I refer to as the “surround.” They are having an impact on the residential life of the University, so we’re always balancing what’s in the best interest of the individual student and what’s in the best interest of creating and sustaining a healthy environment for the entire campus.  

And I can remember a number of occasions that Pete said to me, “Danny, I’ll go with you to court and we will explain to the judge that we’re trying to be better parents than perhaps the parents were who insisted upon keeping the student at school when we felt it was endangering her life and well-being.” It’s a little bit easier sometimes to make the case in depression and suicidality; it’s a little bit subtler with an eating disorder because at what point ­ as Pete mentioned ­ do you say it has crossed the line? You can make fairly concrete decisions about the loss of body mass and body weight and various other kinds of electrolyte disturbances, and physiological measurements can tell us when we are getting to a point of no return. Anorexia nervosa can be a life-threatening illness.

Dickerson: I really love Danny’s providing the context for the kind of decisions that are made. There is a range of responses that we can provide, from requiring a student to live off campus, to requiring a student to go home for a year and get medical treatment or psychiatric or psychological treatment before returning. Pete’s comment about our response to conduct, not condition, is very important here. But if there’s evidence of bad behavior, we can expel a student from school. So we try to be responsive to the needs of the individual, and I think that we do have a wonderful and collaborative team of people who work very closely with families to make sure that decisions are made in a way that really is responsive to the particular needs of the individual student.

PAW: Do parents have a realistic expectation of what the University can and cannot do when their students come to Princeton?

Dickerson: It all depends. We have what we have been commonly calling “helicopter parents.” You name whatever the fastest, fiercest, most hovering helicopter is ­ we’ve   got those kinds of parents here at Princeton. I think some people understand, and others really want the University to deal with the problems or challenges that they feel they can’t deal with at home. And that’s when I think a lot of the work that the deans and the folks at Health Services end up doing has to do with really advising and counseling parents.

We’ve tried to help the broad group of parents understand some of these issues through the programs that are provided in our parent and family weekend events and activities. Dr. Silverman now runs a session at the very beginning of freshman year for those parents who are interested in attending, because we do have students with demonstrated concerns and needs, and we try to be responsive to them, but we recognize that for many parents this is their first actual opportunity to deal with something that they may have been in denial about or have been reluctant to confront.  

Silverman: I think it raises such an interesting observation, if I derive from what Peter is saying. I really do think that certainly in the area of university health and mental health, the pendulum of in local parentis concept has really swung back to the feeling that these are partially formed adults who still need a great deal from us. The social contract really implies that we are here to do more than just provide a classroom, a professor, and a syllabus, and we really see all of these issues as being part of the greater educational enterprise.

I think those of us in health care who choose to be on a college campus do it because we see ourselves as educators as well as health care providers, and hopefully there are issues being dealt with here that will help people lead healthier lives for the rest of their adulthoods. I think I’ve had a great deal of support from the administration in terms of our being proactive and trying to do exactly the right thing. We’ve done some fairly amazing things with keeping students in school as well by providing intensive treatment.  

But there’s a certain point, clinically, where if these problems are so severe that the level of clinical intensity that is needed to treat the student makes it impossible to be a fully engaged student at Princeton. That’s when we generally talk to the deans or talk to Vice President Dickerson and say our strong recommendation is that this student’s first job is to go home and get healthy and come back, because we don’t want students just to survive at Princeton, we want them to thrive here.  

And very often that year off is very helpful. We often send them home with a very detailed bill of particulars of what is expected in terms of treatment, counseling, medication, exercise, support, and we also ask and receive written permission from the students and the parents to let us talk to their caregivers so that we follow them during the time that they’re away from Princeton. And we’ve had enormously successful returns of students to this campus. We always say that Princeton will likely be here when you’re ready.

McDonough: I want to emphasize that 99 percent of those times, it’s through a process of collaborative and voluntary conversations. For the reasons that I alluded to before concerning how one treats conditions versus conduct and the disability laws, it is extremely hard for this or any other institution to mandate those types of protocols when they aren’t tied necessarily to the essential functions that this person is unable to accomplish without doing that while away.

Newman: And I would imagine that we’re going to discover that this was important in why Virginia Tech couldn’t do more than they did. I wouldn’t be surprised, anyway.

McDonough: Since there’s been a reference a couple of times to cuttings, I was intrigued by the concluding couple of sentences in Professor Newman’s piece in The Chronicle [of Higher Education]. I just want to offer a perspective from a real case involving NYU that you may know about.  

In The Chronicle recently, Professor Newman said that part of the story lies in the unwillingness of our society to lock up people who have committed no illegal acts. It is not a crime to be depressed, or even scary, as this young man was. And for those civil liberties, we have paid a heavy price. The price will be debated for years to come. And I think that’s right ­ it is really civil liberties of which the rights of the “disabled” are central here, versus the concerns that we have.

There was a case a number of years ago involving NYU. In 1977, the medical school had denied readmission to a woman who had been admitted without the school’s knowledge of a long history of serious psychological disorders. She sued NYU after NYU took action, and the action was to not readmit her after the first few years in her graduate medical school program. But here’s the conduct: She attempted suicide by drinking potassium cyanide; she severed an artery in her elbow with a razor blade; she cut her wrists with a broken light bulb; she cut a vein in her left arm; she pulled sutures out of her wound; she bit a hospital worker; she cut her foot and resisted police custody; she kicked a doctor in the groin; she cut her arm again; she bit a psychiatrist, kicked him in the groin and attempted to stab him; she fought with staff members at a psychiatric hospital; and then she escaped with her husband’s help out the hospital window.

She wasn’t readmitted, and she sued NYU. It took years ­ I think four or five years of intense litigation, including appellate litigation ­ for NYU to ultimately prevail. By the way, while she was on her leave of absence from NYU, before she sought readmission, she applied to Harvard School of Public Health and was accepted there.

So what we took from this case was again emphasis on the conduct not the condition, but showing the tolerance of the laws and society to look at conduct and say “OK, so why doesn’t that fit the environment?” I would have thought it’s a no-brainer for this level of conduct to not fit what we imagine from a physician at the completion of medical school, but it took four years of litigation for the court to agree.

PAW: That was in 1977, you said?

McDonough: No, that was in the ’80s. The case began in ’77 and concluded in the early ’80s.

PAW:   Have there been recent cases where in fact they were no-brainers, or is it still problematic?

McDonough: It’s a challenge; each case is on its facts, and usually at the beginning of the case is an “it depends” answer that a lawyer will give when, in real time, trying to advise the folks.

Newman: But I think this is an excellent case in which our understanding is that we have lawyers because we might need you to go to court to protect us because the University is going to have to take someone like this out. And maybe they’re going to get sued as a result, and the University will respond as NYU did, because otherwise this becomes an untenable work environment.

I could imagine a faculty member who was faced with this claiming that this was a hostile work environment ­ to have contend with someone who is that dangerous and   to be exposed to these conditions is to expose us to untenable risks. And there you have a clashing of different legal principles.

But in the end, I take heart from, and I believe that Virginia Tech probably would have taken a similar point of view, probably with fewer resources, we might have to go ahead and get sued. We start with the question what is the right thing to do, and we have a gut instinct or a medical instinct for where that’s necessary, and if the chips fall where they fell in the NYU case, that’s what we have lawyers to help us with, because we can’t let this stand as a recipe for how much we need to tolerate, I don’t think.

Silverman: I think it’s very early to try to assess the facts in the Virginia Tech situation, but the red flags that stood out for me were a couple of things. One is that, I think ­ at least if the facts as they have been reported in the media are correct ­ that the young man had a history of stalking two women students on campus, in addition to the reports of numerous faculty members who seemed to feel literally unsafe being in his presence. It created a rather amazing system of backups and alerts and so on and so forth that any mental health institution can be proud to have developed.

And I was struck by the irony that we’ve been here trying to urge professors to come forward and talk to us when they’re concerned about a student, and in fact here, several faculty members had spontaneously approached the university and mental health practitioners on campus and said this is a terribly alarming, terribly outlying kind of experience with a student.

And I would hope in my heart, I believe that had this taken place at Princeton, that we probably would have removed this student from his active status. On the other hand, that doesn’t offer any ultimate protection; he could have stewed in his release and come back if he’s determined to do what he is going to do. But all I’m suggesting is that this is exactly what our systems are set up to do, which is to identify a student like this and then as Pete says, collaboratively and really with a great deal of deliberation, decide does it make sense to let the student stay on campus or to ask them to leave.

PAW:   So one of the points in that case, of course, was the violent and disturbing imagery in his creative writings. Professor Newman, can you just touch on that? How does a faculty member evaluate whether it’s just imagination or whether there really is something going on there?

Newman: It’s very difficult, I’m sure, in creative writing because in creative writing you’re asking someone to sort of run away with their imagination. I will say that in the book that I wrote, I reprint in its entirety a story that was submitted by one of the shooters to his high school English teacher in his freshman year, because I wanted the readers to judge for themselves: What would you do if you were presented with an essay like this?  

Would you look at this and say, I really ought to bring this to someone’s attention, or would you say to yourself, as this particular teacher did, well boys are always writing about mayhem ­ that’s what boys write about in creative writing? In that particular instance, the kid had come to the teacher and asked permission to use the real names of other students in this essay. The writing is extremely florid and very violent ideation. It is not actually the normal form of boys’ recreational writing about Rambo. But it’s a very curious judgment call.

My own view is that faculty should learn, and we do know, to go with our instincts. You have a sixth sense for something that is out of bounds. You might in err in one direction or another ­ that is always a possibility. But I think that trusting your instincts and getting another opinion ­ consulting with our colleagues who know medical conditions better than we do. Those few occasions when I had to deal with students who really were seriously psychologically imbalanced, it was very clear to me the difference between my training and your training. I’m not a psychiatrist; I don’t know how to deal with people who are really in deep psychological trouble. I might have some sense as to recognize who they are, but when it comes to their treatment, that is a specialty that even a reasonable sensible social scientist is not equipped to deal with, and they need to turn it over to people who do.   So I say, you know, trust your instincts. …

I must have done 15 television programs and 20 radio interviews based on the research that I’ve done in the last few weeks, because people all over the country are thinking about this and worrying about this. And yes, many of my colleagues, knowing that I’ve worked on this subject, have raised this with me, not because they were worried, but because they were concerned or interested and want to know what this research has to say about what they or anyone should do. And we do talk about the fact that we are involved in conflict situations, and we’re aware that this is a tension we have to live with to fulfill our responsibilities, and Princeton is not unique in this respect, but perhaps it’s switched up a little bit by the high quality of the students we get here and by their high ambitions and the ambitions their families have for them. And the difficulty is piling through late adolescence in the society in which we live. So we do talk about these things.

PAW: Is Princeton undergoing any type of review of its procedures in the wake of Virginia Tech? A lot of campuses are, but is there anything that you’ve addressed?

Dickerson: I will just say, briefly, we have an environmental safety and risk-management committee. I know that you’re going to be interviewing [public safety director] Steve Healy, and he can talk in much more detail about the kind of discussions that are going on. Garth Walters [director of environmental health and safety] is also a person who would be a very important source.

Newman: I’ve talked at length with Steve, and I’m scheduling another lunch with him, too. He’s extremely proactive, very thoughtful, up on all the latest research, very in tune with his compatriots around the country who have equivalent responsibilities to his. I’m really very impressed with our campus police force and their understanding of the complexity of these issues. I really feel like we’re very lucky.  

That said, when I compare university environments to high school environments that I’ve studied, universities are harder. We have hundreds of buildings, hundreds of entrances. It’s not like a high school where you can set up a single space to filter through. And the age groups that are appropriately here are everything from 18 to 70. In a high school environment, you might be able to spot someone who doesn’t belong more easily than you can here, because everybody belongs here. So I think it’s a very challenging physical environment in which to work on the security side of things. And that’s why the social signals are so much more important.

To be perfectly honest, we can’t get to high school campuses fast enough to stop these things from happening when they’re on the way ­ that’s actually too late. So the proactive encouragement of getting kids to come forward, which I think we don’t really have a problem with here, the ability to treat what comes over the transom in the way of mental health issues is about as much as we can reasonably expect. I think we’re fortunate to have those resources.  

We should remember how very rare these incidences are. I have to go back to 1966 ­ the Texas tower incident ­ to find anything on a university campus was even remotely like what Cho did. That’s a 40-year period in which nothing of the kind happened. That doesn’t mean that there aren’t shootings on campus; there are disputes between known antagonists that happen, but that’s different from these random shooting incidents, and honestly it’s been roughly 40 years since anything like that has happened on a college campus.

I just feel like, from that point of view, we don’t need to push many more alarm buttons but being vigilant and aware because, given that a shooter may be very rare, dealing with people who are depressed or who are about to hurt themselves, that’s far more common, and in a way, if you can get to that, you’re going to get to most of the people who might end up in the more extreme end of things.

Silverman: Did you agree with the media’s decision to show the tapes?

Newman: The media issues are so complicated, and my view is this: There’s huge research value to being on tape. I don’t know that I would have shown them right now, this minute, because the situation was so inflamed and the sensitivities of the families who lost their children should really be paramount in all of this. By the way, I’ve written a great deal about the aftermath of these events, which is as least as important as why they happen.

I think the public needs to see at some point that this is someone who really was very far out on the psychiatric edge, because otherwise they will think that this could happen everywhere to everybody, and it’s not, it’s a very extreme case. The other thing we need to understand is that people come forward when they know something could happen. If the media did not tell us these things happen, we would not know that there was something to come forward about.

And in fact, you can see the incidence of these shootings is at a very low level through the 1970s and the 1980s and then it starts to climb up in the 1990s. It’s still very rare, but it starts to climb up. And then we have Columbine. And what happens after Columbine is that it plummets to zero. The actual number of completed shootings plummets to zero, but the number of near miss cases ­ that is, the cases that were on their way and discovered by the police ­ continues to rise.  

Why does that happen? It happens because people start reporting. If the media didn’t tell us what happened and why, they wouldn’t do that and we would have seen this rapid [word unintelligible on tape]. So it’s a very double-edged sword. People who are looking for attention realize that they can get it when the media starts paying all of this attention, but if we didn’t have this template, nobody would come forward.

PAW: What’s important for parents to know about these issues as their kids go off to college?

Newman: I think parents have to learn to trust their children and trust their instincts and understand that the launching of the child into the world is always something that is going to be accompanied by a certain amount of anxiety. At the other end is a fully formed adult human being, which is what we’re all looking for colleges to help us produce. Ninety-nine-point-nine-nine-nine percent of the time that will be exactly what the outcome is.

I think they can be very confident that Princeton, among other places, is an excellent place for them to turn into that fully-fledged human being, and that there are very strong support services for those kids that are having trouble with the process, and that they should learn how to let their kids go, which doesn’t mean never seeing them, never speaking to them, or having anything else to do with their lives. They will continue to be part of their lives forever, and that’s the greatest joy of raising a child and sending them off to become the human beings that they are.

I don’t really think, to be perfectly honest, that our parents have very much to worry about with respect to the students’ safety. When a case like this happens, everyone feels shaken. Everyone feels like they can’t judge how safe an environment is. And it takes time for us to equilibrate and recognize that it’s been 40 years since something like this happened. That doesn’t mean we take no lessons from it, but it should not mean that we overreact to it and see a shooter around every corner, because they are not there.

Dickerson: I was going to say most of what Professor Newman said. First of all, having communications with one’s student is very important, because if you are an observant parent and listen and are open to hearing what students have to say and are trustworthy, the parent can usually find out or know what is going on. And the other that I would offer is that most campuses are very safe environments, but no place is completely safe. So for parents to have realistic expectations about what the community will be like is a very important thing.

Silverman: I think that I’ll just follow up on one point that Professor Newman made and that is that more mundane or less dramatic problems like depression and stress are much more common in college age populations, and dramatic events like the Virginia Tech situation creates a great deal of uneasiness among us all, but it’s not the most pressing kind of thing.

The message I would like them to share with their children is to not be afraid to ask for help at Princeton. It takes a strong person to ask for or use help; it’s not a sign of failure or weakness or moral failure to look to the adults and various kinds of support services and programs that are here for the very reason that people need them.

Finally, encouraging students to understand that there is so much more that goes into a Princeton education than simply what goes on in the classroom. There are many opportunities to grow and learn by forming and sustaining important interpersonal relationships and that time spent building those relationships and enjoying those relationships should not be viewed as coming at the expense of one’s educational experience but really something that enhances and broadens it. My hope is that students not only come out with a great front of knowledge after being at Princeton, but also a great deal of experiential enrichment.

McDonough: I think for me, it would be for parents to recognize that the most challenging of situations that develop with their child on campus or that their child is experiencing because of another student on campus are also the most challenging for the campuses to figure out how to manage. Understanding that there are complexities, even if a parent doesn’t understand the complexities themselves, is very important so that there is not a major reaction because a parent believes that the situation is black and white and only one approach should be obvious to the folks that are involved. These are really hard, hard situations, and fact intensive, and there isn’t often what one would call precedent for dealing with the next one the way you dealt with the previous one.  

PAW: As a lawyer, if you could rewrite a law so that Princeton and every other university can do everything they think is necessary, is there anything you would change to get more flexibility in the law?

McDonough: Because there is not only one law, I actually think we’ve got it about right in terms of how these laws are [word unintelligible on tape], whether we talk about privacy of medical records, or privacy of educational records, or civil-rights protection for people, or protection for people with disabilities, I think that we’ve got it about right.  

Where we get off track is with the transactional cost of involvement and time, and with the emotional upheaval that comes with all that. When you have to work through how it all played out. We play it out in internal disciplinary processes or we play it out in employee reviews or to the next level in courtrooms. So we revisit what we did over and over again, and sometimes over a period of years.

And if we could just figure out how to shortcut that to have a faster disposition of the lawsuit, to have a faster disposition of the internal administrative review process ­   that would probably be the best bet. But saying that the laws are wrong or the focus is off…Professor Newman, about paying a heavy price for civil liberties, she’s right, but I’m not sure I’d change that sentence around.