Dr. Bradley E. Cox

College Students in Crisis: Identification, Response Options, and Prevention for Resident Assistants

Canto, A. I., Swanbrow Becker, M., Cox, B. E., Hayden, S., Osborn, D. (2017). College students in crisis: Prevention, identification, and response options for campus housing professionals. Journal of College and University Student Housing, 43(2), 44-57.

ABSTRACT
Resident Assistants (RAs) are often faced with working and living among residents who are struggling, in distress, and, at times, in crisis. This article provides a primer on identifying residents in crisis as well as the tasks faced when working with students in transition and crisis. A discussion of the prevalence of distress reported by students is followed by a review of the unique stressors encountered by entering students. This article highlights the importance of, and challenges with, identifying residents in need, engaging them in supportive ways, and considering broader prevention efforts on campus. Implications for confidentiality, creating a supportive campus climate, and supporting RAs’ own mental health needs when working with residents in crisis are discussed.

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College Students in Crisis: Identification, Response Options, and Prevention for Resident Assistants

In the early morning hours of November 20, 2014, an alumnus of Florida State University (FSU) arrived on campus, armed and dangerous. That alumnus proceeded to the campus’s largest and main library where many students were studying for upcoming final exams. The gunman discharged several rounds wounding three individuals. Police arrived within three minutes, according to reports, and the assailant was shot and killed by police fire.
A campus shooting is one example among a myriad of complex crises that can occur on college campuses. The previously described incident is arguably not as severe in outcome as shootings at other campuses, such as Virginia Polytechnic Institute and State University on April 16, 2007, which left 32 individuals dead and 17 more injured. Indeed, the singular death that occurred in the FSU shooting was that of the assailant, however, many students, staff, and faculty were frightened and experienced considerable distress. Campus shootings are obvious crises for the campus at large and its students, faculty, and staff. However, this type of incident is not the only representation of student crises. Crises occur in many forms, often with delayed reactions including mental illness or debilitating distress. What, then, are other common student crises, how do they emerge, and what can RAs learn to help mitigate and possibly prevent the myriad of crises that may occur for students on college campuses?
The purpose of this paper is to raise awareness among RAs and their supervisors of the prevalence of resident distress, and provide strategies for identifying and engaging residents in crisis in supportive ways. Considerations of broader campus prevention efforts, and the need for RAs to engage in self-care and support with supervisors and allied staff are also presented. We first examine crises among residents as a continuum from stress, distress, to crisis and how that may be intensified with the transition to college and the unique stressors of college life. We then examine key elements of identifying and responding to residents in crisis and potential strategies to help prevent crisis among college students. We conclude with considerations for the mental health and well-being of residence life staff who are called to work with these students.
For some residents, the transition to college life can be challenging and is often exacerbated by the high stakes of choosing a major, meeting academic demands that are almost certainly higher than prior experiences, fitting in socially, and managing daily college life and class requirements (Baker, McNeil, & Siryk, 1985; Brougham, Zail, Mendoza, & Miller, 2009; Zajacova, Lynch, & Espenshade, 2005). For many residents, arrival on campus is a catalyst for a complex process of transitions that results in a change in relationships, routines, assumptions, and roles (Goodman, Schlossberg, & Anderson, 2006). Many RAs find themselves responsible for assisting transitioning students and intervening with residents in crisis while also being students themselves. While RAs live among residents, students still may not feel comfortable turning to RAs for help, possibly due to a fear of consequences (Burton Denmark, Hess, & Swanbrow Becker, 2012). Knowledge of key components associated with on-campus crises, i.e., the unique stressors that entering students may face, as well as the prevalence of crisis among college students, may provide RAs with a useful foundation upon which intervention strategies can be designed. For example, an RA may decide to design a program specific to managing the changes that first time students are experiencing. In the next section we describe stressors that are unique to those at the beginning of their postsecondary experience.

Unique Stressors of Entering Students
Entering students face unique challenges and stressors, including changes in relationships, roles, and routines (Baker, McNeil, & Siryk, 1985; Upcraft, Gardner, Barefoot, & Associates, 2005; Wintre & Yaffe, 2000), which can occur simultaneously or in rapid succession. As a result of these challenges, it has been argued that today’s college students may be the most psychologically distressed generation to ever arrive on campus (Benton, Robertson, Tseng, Newton, & Benton, 2003; Twenge, Gentile, DeWall, Ma, Lacefield, & Schurtz, 2010). The experience of transitioning to college life can often complicate pre-existing psychological conditions or concurrent (non-college related) stressors (Sax, 1997). For the majority of first-year students, the resulting psychological states are temporary and healthy triggers for personal development (Brougham et al., 2009; Chickering & Reisser, 1993). For some residents, however, the transitions in and of themselves can instigate progression into a state of crisis – a maladaptive psychological response to these acute transitions can create intense, potentially chronic problems that warrant additional attention or intervention (Pancer, Hunsberger, Pratt, & Alisat, 2000). Additional crises above and beyond transitions can further complicate adjustment for many students.
Unfortunately, despite their distress, students on college campuses tend to underutilize professional help (Drum, Brownson, Burton Denmark, & Smith, 2009). With respect to suicidal ideation, researchers (Burton Denmark, Hess & Swanbrow Becker, 2012) identified the top reasons students do not share these thoughts: believing the thoughts would go away on their own; not wanting to burden others; not thinking others could be helpful; concern about stigma; and fear of repercussions. Of suicide completers, nearly 80% of students who completed suicide never received services at their campus counseling center (Kisch, Leino, &Silverman, 2005).
Studies on college students experiencing suicidal thoughts indicate that if they disclose their suicidal ideation, they rely more on peers than others on campus, such as professional counselors or professors (Drum et al., 2009; Wyman et al., 2008). In fact, the absence of reaching out for support from peers can be a warning sign that a student is experiencing difficulty (Pierson & Canto, 2012).

Prevalence of Crisis in College Students
A crisis can be defined as an event that significantly interferes with an individual’s ability to meet needs, disrupts typical problem-solving skills, and incites a state of disorganization for the individual (James & Gilliland, 2013). Results of the American College Health Association’s National College Health Assessment (ACHA-NCHA, 2015) of 93,034 students across 108 institutions portrayed considerable distress currently exists among college students. Over one-third (35%) of responding students reported that over the past 12 months they felt so depressed it was difficult to function and 57% indicated experiencing overwhelming anxiety. In addition, a disturbing proportion of students endorsed feeling overwhelmed (86%), exhausted although not from physical activity (82%), very sad (64%), very lonely (59%), and hopeless (48%). Six percent of surveyed students in that study indicated engaging in self-harm, such as intentionally cutting, burning, or bruising the body within the past 12 months. Additionally, many students reported experiencing violence and abuse: 17% said they had experienced a verbal threat, 8% were in emotionally abusive relationships, 5% were stalked, 3% had been physically assaulted, and 2% experienced sexual penetration without their consent. Only 26% of female students in that study reported feeling very safe on their campus at night and only 14% felt very safe in their surrounding community at night.
These findings paint a picture of emotional distress as appearing common among college students. College students report a range of contributors to their stress, including academics, finances, relationships, life transition, emotional and physical health, substance use and interpersonal violence (Brownson, Drum, Swanbrow Becker, Saathoff, & Hentschel, in press), and, the statistics reported indicate that a large proportion of college students experience distress at some point in their postsecondary endeavors. Due to the reported outcomes for some of these students, (e.g., depression impairing function) distress can quickly lead to crisis for many students.

IDENTIFICATION OF COLLEGE STUDENTS IN CRISIS
Distinguishing Between Normal and Pathological Stress Reactions
While many residents experience adjustment difficulties following their transition to college or during crisis events, not all reactions are considered pathological. Typical (safe) crisis reactions differ from pathological (problematic) crisis reactions in a number of ways; thus, distinguishing typical responding from maladaptive responding is important (Pierson & Canto, 2012). Pierson and Canto specifically define a pathological response as “one that (a) while intended to relieve symptoms, fails to alleviate immediate symptoms of distress; (b) reduces the ability of the individual or organization to manage the crisis; or (c) places the individual at increased risk for danger” (p. 632). Evaluating the student’s reaction in light of what is known about the student and the particular crisis event is also important to appropriately contextualize the response. While diagnosis of post-traumatic stress disorder is the purview of mental health professionals, RAs play a key role in helping to characterize the student’s stress reaction in light of the absence, persistence, and/or intensity of the student’s reaction and as a front line responder to student distress (Pierson & Canto, 2012). Unique characteristics of the student that may put him or her at increased risk for a maladaptive response are discussed next.
Factors both internal and external to the student can increase the risk of a maladaptive or pathological stress reaction (Brock, 2002). While physical proximity (i.e., geographical closeness) to a crisis event appears to be the greatest risk factor for a pathological response to the situation, emotional proximity (e.g., knowing an affected individual) is another strong risk factor for developing a pathological response (Brock, 2002). There are also several student-level factors that appear to increase a student’s risk of developing a pathological response; for example, students’ limited access to previously utilized resources (e.g., social connections, financial support), a history of prior traumatization, developmental immaturity, an avoidant style of coping, or poor emotional regulation can all increase one’s risk of developing a pathological response (Brock, 2002; Pierson & Canto, 2012). Furthermore, students with a history of mental illness may experience an increased intensity of symptoms during adjustments or crisis situations (Brock, 2002). Students who use or abuse substances often increase their substance use when they are distressed, as a means of coping or self-medication (Brock, 2002).
Despite the presence or absence of the aforementioned risk factors, it should be noted that anyone can develop a pathological response to crisis (Pierson & Canto, 2012). The following warning signs are indicators for RAs that a resident may be experiencing significant distress: intrusiveness of the event (e.g., intrusive memories, prolonged distress); persistent avoidance (e.g., avoiding persons or places associated with the crisis); pronounced and persistent negative changes in thoughts or emotions (e.g., inability to recall key details, self-blame, disruption in ability to experience positive mood or emotions); or increased disruptions in arousal or reactivity (e.g., aggression, recklessness) (American Psychiatric Association, 2013). Specifically, withdrawal from social activities, depressed mood/tearfulness, missing classes, not attending mealtimes, recent isolation from peers, excessive anger outbursts, persistent somatic complaints, or taking excessive precautions are often observable clues to a student’s distress (Brock, 2002). Any one of these behaviors or emotions in isolation may not be problematic, but when a student is presenting several at once, the student may benefit from intervention (Pierson & Canto, 2012). Lastly, any indication by the student of risk of harm to self or others is a distinct warning sign that intervention and referral for mental health services is needed immediately. Regardless of the presence of risk factors, if a student is exhibiting one or more of the warning signs described above, referral for mental health services is advised (Pierson & Canto, 2012).
In contrast to the pathological stress reaction described above, residents can also demonstrate a healthy response to stress. Students experience a healthy response to stress when the stressful situation energizes them toward positive action to reduce the stress. For instance, residents feeling stressed about an upcoming exam might channel their efforts into studying. Likewise, residents upset about a relationship issue might take action to talk more openly about their feelings and state their needs more clearly. For RAs, becoming adept at helping residents identify when they are engaging in a pathological versus a healthy stress reaction is a core developmental skill, essential for knowing how to best intervene with their residents.

The Issue of Student Privacy
When a resident expresses an intent to harm him or herself or others, campus authorities must be contacted. However, it is less clear when to refer a resident for additional support when other mental health concerns become apparent, such as self-injury (cutting behaviors), erratic behavior, tumultuous romantic breakups, and substance use and abuse. When a resident shares a mental health concern with an RA, does that student have the right to expect confidentiality? Should a parent or guardian be called if a resident is intoxicated or engaging in cutting behaviors?
When in doubt, referral to campus mental health services is recommended. With regard to confidentiality of that referral and the outcome, the Health Insurance Portability & Accountability Act of 1996 (HIPAA) and the Family Educational Rights and Privacy Act (FERPA) provide some guidance on these issues. The Privacy Rule of HIPAA addresses issues of disclosure of an individual’s health information. The most pertinent rule is that unless a student signs a release of information and specifies information that can be shared and to whom, a mental health professional will not be able to share information about that student, even one who was referred by the RA.
The FERPA legislation protects students’ educational records and also allows parents and guardians access to a minor student’s educational records. This does not, however, include observations or conversations about students, although institutions may have policies that address these forms of communication. A 1998 amendment to FERPA also allows (but does not require) disclosure to a parent or guardian if a student under 21 or a student over 21 who is a “dependent student” violates campus rules or laws specific to alcohol or controlled substance possession or consumption. Disclosure in this example is left to the discretion of university personnel. Release of information about specific student mental health concerns is not currently covered by FERPA. Given that knowledge of a student’s mental health status may be useful in crisis prevention and recovery, some professionals (Graham, Hall, & Gilmer, 2008) are calling for universities to take another look at FERPA and eliminate university policies and restrictions that are not required by law. According to Graham and colleagues, universities may tend to lean toward over-restrictive policies in favor of student rights to privacy, a decision that may ultimately lead to tragedy. For example, in the case of the Virginia Tech campus shooting, various campus entities had concerns about the perpetrator, information that was unfortunately in most cases isolated to those entities and not communicated broadly until the aftermath of the event (Virginia Tech Review Panel, 2007) Many campuses have since created a university or college-wide committee that reviews concerns about the safety of students and includes personnel such as law enforcement, student affairs, and mental health professionals.
With these mandates and guidelines in mind, as well as state-specific mandatory reporting laws, RAs are specifically encouraged to follow their university’s reporting structure and to seek additional supervision as often as needed to engage in responsible practices. For example, it is important to share with students that RAs are required to report the content of some types of conversations to supervisors. To assist in detangling the nuances of students’ rights to privacy and confidentiality, residence life staff are encouraged to work closely with campus counseling professionals to determine what information should be shared, with whom, and under what circumstances. For example, at Florida State University, the campus counseling center is involved in training RAs specifically to identify and respond to a range of mental health issues faced by students (M. Swanbrow Becker, personal communication, October 23, 2015). This is accomplished through discussions and through interactive role-plays prior to the start of the fall semester. The counseling center then continues to consult with residence life staff throughout the year to help RAs support students in distress while respecting privacy. Preparing RAs to identify residents in need of support, intervene with them, and effectively address resident concerns would appear to be important training goals (Drum et al., 2009; Lewis & Lewis, 1996; Westefeld, Button, Haley, Kettmann, MacConnell, Sandil, & Tallman, 2006).

INTERVENTION RESPONSE OPTIONS
Residents in crisis need support and the RAs are often the first to encounter them. Developing awareness of available supports once a student in crisis is identified, is critical to facilitate the connection of students to available resources. Students in distress are more likely to reach out to someone with whom they have a pre-existing relationship (Wyman et al., 2008). As such, RAs can foster relationships with their residents early by initiating one-on-one introductory meetings, sharing information about the RAs role, and addressing any questions residents might have regarding ways the RA might help the resident, including information on the limits of confidentiality. Attending to clues that students may be in distress can help identify those individuals needing additional support. Such clues may come in the form of what residents say (e.g., “I can’t take this anymore”), what they do (e.g., missing class, substance abuse, absence of personal hygiene), or events that happen to them (e.g., failing an exam, relationship breakup). Given the prevalence of psychological concerns among college students and the complex nature of the indications of distress, it is important that RAs possess a sophisticated understanding of the differences between contextually appropriate stress reactions and those pointing to significant concerns in need of support. Thus, the need for information on how to accurately identify students in crisis and provide resources to these students becomes imperative for successful residence life programs.
Within a university setting, campus counseling centers are the primary resource for residents in crisis – campus counseling centers consist of trained helping professionals who are knowledgeable of appropriate interventions in which to assist a student in crisis (Ellingson, Kochenour, & Weitzman, 1999). In addition to the campus counseling center, campus resources for mental health services may include the campus medical clinic, the career counseling center (if a separate entity), Dean of Students personnel, campus police, and alcohol and drug educators.
There are also times when community resources are accessed instead of campus resources, due to the complexity of the issue or limited availability of campus resources (Lacour & Carter, 2002). Community and national crisis hotlines such as the National Suicide Prevention Lifeline (800-273-8255) are generally free, confidential and accessible at all times. Local hospital emergency rooms are also a resource when residents pose imminent harm to themselves. Additionally, residents can receive services by accessing local police and primary care physicians. Making information about counseling services readily available to RAs can enhance the capability for them to refer residents to appropriate resources (Taub & Servaty-Seib, 2010).
Building Relationships (http://reslife.net/building-relationships-two-departments-one-goal/) is another example of a collaborative program between residence life and the campus counseling center at Gwynedd-Mercy College in Pennsylvania. Within this program, the two departments collaborated and developed response protocols for several trauma scenarios. This training program aimed at residence life professional staff, RAs, and counseling staff was judged by their agencies as a positive proactive response to educating staff and working with students in crisis.
RAs should view referrals for mental health services as a joint endeavor whereby residents are active participants in the decision to seek counseling. Thus, residents have the opportunity to express concerns, fears, and reservations about engagement in counseling (Sharkin, 2006). Evidence in other settings suggest that preparing individuals for what to expect from counseling and setting the stage for following up with a mental health referral often increases the likelihood of their engagement (e.g., McKay, McCadam, Gonzales, 1996). RAs can improve the effectiveness of their referral of residents to mental health services by becoming more familiar with on and off-campus resources and engaging students in a non-threatening, non-authoritative way. Some suggestions include: host an event during training where representatives from campus support groups can make brief presentations; create a quick reference guide that includes a synopsis of these sites as well as information regarding common resident concerns they serve, contact information, hours of operation, and preferred referral steps. Lastly, it is recommended that RAs physically visit these support centers and develop individual relationships with key personnel and to be able to more fully describe the facility and available services to residents.

PREVENTION
In addition to identification and intervention, fostering a stigma-free help-seeking climate among residents can be a powerful preventive measure to increase the use of support for students in distress. At an ecological level, campuses can work to promote a culture of inclusion and openness to support-seeking among its members (Downs & Eisenberg, 2012). An example of this is found at The University of Texas at Austin, where the “Be That One” suicide prevention program encourages all campus members to “be that one” who responds to others in distress (The University of Texas at Austin, 2013), thereby spreading the responsibility to intervene to all campus members. Similarly, Cornell University (2013) has created the Cornell Caring Community where campus members “reach out to each other in times of need and work together to build a better place.” RAs serve as an essential part of such programs as they may be the first to notice residents experiencing difficulties. Additionally, building a sense of teamwork and collective responsibility among RAs may help them tap into a variety of ideas and share responsibility for residents in crisis.
Strategies for prevention might also include collaborative efforts with on or off campus resources to provide workshops for managing stress, depression, loneliness, and other concerns specific to the residents in a particular residence hall. Publicizing other support services such as group counseling is another way to help students preemptively address issues before they turn into crises. The success of these approaches is likely associated with the degree to which they meet the needs of residents. Strategies such as including residents in the assessment of what peers need in terms of support, planning and promoting events, tapping in to residents’ creativity to address topics of interest, facilitating student testimonials to help make the material more relevant, and using social media to engage students would likely increase the effectiveness of programs. The best attended events are often those where the residents themselves encourage their peers to participate. Additionally, it is helpful for RAs to anticipate that certain events such as holidays, mid-terms, parent weekends, and fraternity and sorority life recruitment weeks may trigger stress reactions among students. This anticipation allows for planning briefer interventions, such as leaving messages to residents (e.g., actual messages, tokens, cartoons, and the like) of hope and ways to manage stress.
Crisis management extends beyond the management at the individual (or resident) level of the system. As previously mentioned, university level committees that incorporate participants from various campus and sometimes community agencies to promote safety, planning and management of crises have gained in number. Two additional resources in developing and implementing campus wide crisis management programs include the following: Campus Crisis Management: A Comprehensive Guide to Planning, Prevention, Response and Recovery (Zdziarski, Dunkel, & Rollo, et al., 2007) and Enough is Enough: A Student Affairs Perspective on Preparedness and Response to a Campus Shooting (Hemphill & La Banc, 2010). These seminal works have been used by many college personnel in initiating or refining their crisis management protocols and to teach future student affairs professionals.

AVOIDING BURNOUT OR VICARIOUS TRAUMATIZATION
In addition to residents needing assistance, RAs working with students in crisis can also find themselves experiencing challenges to their well-being. Intervening with students in crisis is at times emotional and RAs need support to perform this function while also maintaining their own mental health. Campus residence life professionals are also charged with encouraging RAs to maintain their self-care through exercise, sleep, hygiene, and eating well. Increasing social connectivity between RAs and residence life professionals may also help RAs feel supported and part of a larger community.
Over time, working with individuals with adjustment difficulties and those in crisis can induce burnout (Cacciatore, Carlson, Michaelis, Klimek, & Steffan, 2011; Jenkins & Baird, 2002; Voss Horrell, Holohn, Sision, & Vance, 2011). In addition to working with residents facing these issues, RAs may be exposed to a variety of student experiences that can, in and of themselves, be vicariously traumatizing to the RA. In either case, it is equally important that RAs and other residence life professionals seek consultation, supervision, and even professional mental health services to maintain their well-being. It is recommended that consultation between RAs and their supervisors occur regularly to ascertain when RAs may be at risk for developing maladaptive symptoms or styles of coping. RAs often pride themselves on how well they care for their residents; but they must not forget to take care of themselves along the way. Some ways that RAs can care for themselves include seeking support at the counseling center to help process their experiences, developing their own ways to relax and manage stress (including mindfulness practices and learning to take breaks when needed) and reaching out for support from their peers and supervisors when working with difficult residents.

CONCLUSION
Working with residents on college campuses who are in crisis can be challenging. Frequent contact with residents to discuss, normalize, and validate feelings of distress can be critical components of preventing maladaptive or pathological responses of residents and lays the groundwork for collaborative relationships. As these relationships develop, RAs have an opportunity to identify and intervene with residents in crisis and refer to campus and community resources as needed. Lastly, maintaining the health and well-being of RAs should also be monitored and managed via collaboration, supervision, and perhaps counseling as well.

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