Psychiatric Rehabilitation Journal 2015, Vol. 38, No. 4, 342–348
© 2015 American Psychological Association 1095-158X/15/$12.00 http://dx.doi.org/10.1037/prj0000143
Faculty Perceptions of Accommodations, Strategies, and Psychiatric Advance Directives for University Students With Mental Illnesses Karin F. Brockelman and Anna M. Scheyett
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University of South Carolina Objective: Universities across the country struggle with the legal and ethical dilemmas of how to respond when a student shows symptoms of serious mental illness. This mixed-method study provides information on faculty knowledge of mental health problems in students, their use of available accommodations and strategies, and their willingness to accept psychiatric advance directives (PADs) as helpful interventions for managing student crises. Method: Participants were 168 faculty members at a large, public, Southern university. A web-based survey was used to collect quantitative self-report data as well as qualitative data in the form of open-ended questions. Quantitative data are presented with descriptive statistics. Qualitative data were analyzed using thematic analysis. Results: The majority of faculty surveyed have an overall supportive stance and are willing to provide accommodations to students with a mental illness. The most common advantage faculty see in a PAD is support of student autonomy and choice, and the primary concern voiced about PADs is that students with mental illness will have poor judgment regarding the contents of the PADs they create. Conclusions and Implications for Practice: PADs may be effective recovery tools to help university students with mental illnesses manage crises and attain stability and academic success. For PADs to be effective, university faculty and administration will need to understand mental illnesses, the strategies students need to manage mental health crises, and how PADs can play a role in supporting students. Keywords: psychiatric advance directives, college students, mental illness, crisis intervention
Psychiatric advance directives (PADs) are legal documents that allow individuals, when well, to document their wishes for treatment during times of psychiatric crisis when they are no longer capable of stating their needs or making competent decisions regarding their care (Joshi, 2003). PADs have been used with adults with mental illness in the public sector and have been well received (Swanson et al., 2006). Because of their functions as tools to empower consumer voice and choice, PADs are seen as ways to support and facilitate recovery (Scheyett, Kim, Swanson, & Swartz, 2007). However, to date, PADs have not been used in university settings. PADs have the potential of being a powerful intervention to support university students with mental illness. With PADs, students could identify and give permission for the university to communicate with care providers and relevant support people (family, partners, and friends). Students could identify their early warning signs of relapse, the interventions that are most helpful, and give advance permission for interventions or administration of specific medications they know are helpful to manage their symptoms. Universities would thus have the ability to gather the information they need, have guidance in crisis management, and could provide care before students decompensate to dangerousness (Scheyett & Rooks, 2012). PADs have been shown to be acceptable to students with mental illnesses (Scheyett & Rooks, 2012). However, for PADs to be part of an effective strategy to support students with mental illness, several other conditions are necessary. University faculty and administration must be familiar with mental illness in students, must be familiar with and use other existing strategies and accommodations for students with mental illness, and must also accept and be willing to use PADs. This study will provide us with
College is a time of significant psychological stress, with an estimated 15% of university students experiencing some sort of serious mental illness such as major depression or bipolar disorder (Blanco et al., 2008; Eisenberg, Hunt, & Speer, 2013). Students may manifest symptoms of mental illness for the first time during college, and students with existing but stable mental illness may have relapses into symptomatology. Universities across the country struggle with the legal and ethical dilemmas of how to respond when a student shows symptoms of mental illness. Confidentiality laws, in effect unless there is a significant risk of harm, bar university staff from contacting the student’s family members to share observations and gather information and bar them from communicating with the student’s mental health care providers. Symptomatology may prevent students from asking for help, giving permission to speak with care providers, or making sound decisions about their care (Collins, 2000). The university is thus unable to respond to de-escalate symptoms, and must wait until the situation deteriorates into dangerousness before it can intervene. By this time, it is often too late for effective intervention and a crisis, usually resulting in hospitalization and sometimes resulting in tragedy, occurs (Hartley, 2010).
This article was published Online First June 8, 2015. Karin F. Brockelman, PhD, Rehabilitation Counseling Program, University of South Carolina; Anna M. Scheyett, PhD, College of Social Work, University of South Carolina. Correspondence concerning this article should be addressed to Anna M. Scheyett, College of Social Work, DeSaussure College, University of South Carolina, Columbia, SC 29208. E-mail: [email protected] 342
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information on faculty knowledge of mental health problems in students, their use of available accommodations and strategies, and their willingness to accept PADs as helpful interventions for managing student crises. Our findings will inform future training for university faculty on mental illness as well as the potential for implementation of PADs in a university setting.
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Goals of the Project The overarching goals of this mixed-method study are (a) to assess faculty knowledge about students who have mental illness on the university campus, (b) to assess faculty knowledge and use of accommodations and strategies for university students with mental illness, and (c) to assess faculty acceptance of a novel crisis management intervention for university students with mental illnesses, PADs. The results of this study will be used to develop training and interventions for faculty in these areas and will inform the feasibility of using PADs in university settings.
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rate the effectiveness of the strategy on the following scale: not sure if it was effective, not effective, somewhat effective, or very effective. The strategies may have been implemented as a result of formal registration with the campus office of student disability services, through informal arrangements between the student and faculty member, or through universal design for instruction. Because of nonnormal distribution, a dichotomous variable was created from the responses “effective” (combining “very effective” and “somewhat effective”) or “effectiveness not supported.” Section D included detailed information about PADs and asked participants questions regarding their thoughts on using PADs with university students. This included 5-point Likert-type scale questions (1 ⫽ strongly disagree, 5 ⫽ strongly agree) regarding their views on PADs as well as three open-ended questions: (a) what do you see as the advantages of a PAD for students? (b) what do you see as the disadvantages of a PAD for students? and (c) why do you think a student might or might not want a PAD? Lastly, Section E requested demographic and employment information from participants.
Method Analyses Participants Participants were faculty members at a large, public Southern university. The researchers recruited participants by e-mailing a link to an online survey to all faculty members. Data were collected during a 1-month time frame. Researchers contacted faculty three times using the e-mails posted for faculty on the university website. The three e-mails included (a) the initial e-mail invitation to participate in the study, (b) a reminder e-mail 2 weeks later, and (c) a final reminder e-mail 10 days after the first reminder. Participants voluntarily self-selected to be in the study by completing the online consent form and questionnaire. The questionnaire took approximately 10 min to complete. Participants were able to complete the survey at any computer with Internet access.
Instrument The questionnaire comprised six sections. Sections A, B, and C were adapted from the Mental Health and Illness Awareness Survey developed by Becker et al. (2002). Section D was adapted from the PAD Attitude Questionnaire developed by Swanson et al. (2006). Sections A through C asked participants about their observations of student behaviors and knowledge of mental illness and campus accommodations and strategies for students with mental illness. Section A listed 11 possible symptoms of mental illness and asked participants how often they observed these symptoms in their interactions with students. A Likert scale was provided for responses: never, once in my career, at least once per year, at least once per semester, at least once per month, and at least once per week. Because of nonnormal distribution, were collapsed into a dichotomous variable: at least once per year or more, or less than once per year. Section B listed seven mental health conditions and asks participants how familiar they were with the conditions. Response options were on a 3-point Likert scale: not at all familiar, somewhat familiar, very familiar. Section C asked about faculty use of 11 strategies for students with psychiatric disabilities. If the participant used a particular strategy, the participant was then asked to
The researchers used descriptive statistics including frequencies and measures of central tendency to report the quantitative findings of the survey. The data from the open-ended questionnaire items were examined using thematic analysis. Text from each open-ended question was coded and reviewed by both researchers. Codes were then collapsed into larger themes and theme frequency was determined.
Results Participants The survey link was e-mailed to 1,370 valid faculty e-mail addresses. One hundred sixty-eight faculty members participated in the online survey, yielding a response rate of 12.26%. The majority of participants identified as female (51%), White (75%), and married/cohabiting (65%). Average age was 47 years (SD ⫽ 9.7). Participants reported a mean of 14 years (SD ⫽ 8.7) of postsecondary teaching experience, were predominantly tenured (39%), and had a PhD (74%). Participants’ primary teaching loads were undergraduate (37%) or graduate (32%). See Table 1.
Familiarity With Mental Health When asked if they knew a student with a mental illness, 50% of respondents reported currently knowing a student on campus who was receiving mental health treatment. Researchers asked faculty members how often they saw certain common symptoms of mental illness. As shown in Table 2, faculty most frequently reported seeing the following at least once per year: excessive absences (80%), confused thinking (52%), and withdrawal or diminished friendliness (48%). Participants reported on their familiarity with certain mental health conditions. Faculty members were most familiar with depression; 48.8% marked they were very familiar with depression. More than half of participants were somewhat familiar with attention deficit (55.4%), anxiety (50.6%), and bipolar (53.0%) disor-
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344 Table 1 Participant Characteristics
Table 3 Familiarity With Mental Health Conditions (N ⫽ 168)
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% Gender Male Female No report Age Race/Ethnicity (can report ⬎1) White African American Asian Hispanic/Latino Other Marital status Married/Cohabitating Single, never married Separated/Divorced Widowed No report Years of postsecondary experience Academic appointment Tenured Tenure track Nontenure track No report Primary teaching load Undergraduate Graduate Both No report
Mean (SD)
33.3 51.2 14.9 47 (9.7) 75 5.4 5.4 0.6 0 65 11.3 7.7 0.6 14.9 14 (8.7) 39.3 22.6 23.2 14.9 36.9 32.1 15.5 14.9
der. Participants were least familiar with personality disorders (43.5%), schizophrenia (42.3%), and paranoia (41.7%). Faculty reported levels of familiarity with mental health conditions are listed in Table 3.
Use of Accommodations and Strategies Faculty members’ experience using particular accommodations and strategies was of interest in this study. Participant reported whether they ever used each of the accommodations and strategies; then they indicated the effectiveness of those accommodations and strategies they used. The numbers of participants who used each
Table 2 “Have You Seen These Potential Symptoms of Mental Illness in Students?” (N ⫽ 168) Symptom
% Responding “at least once per year or more”
Excessive absences Confused thinking Withdrawal/diminished friendliness Suspiciousness/grandiosity Rapid, pressured speech Marked personality changes Emotional outbursts Major change in appearance Odd/exaggerated gestures Student wrote/spoke of suicide
80 52 48 33 33 31 30 27 21 5.4
Attention deficit Anxiety disorder Bipolar disorder Depression Personality disorders Paranoia Schizophrenia
% Not familiar
% Somewhat familiar
% Very familiar
11.9 16.1 16.1 3.6 43.5 41.7 42.3
55.4 50.6 53.0 47.6 39.9 41.7 40.5
32.7 33.3 31.0 48.8 16.7 16.7 17.3
strategy or accommodation are listed in Table 4, along with their ratings of the effectiveness of those strategies or accommodations. Faculty most frequently reported the accommodation or strategy of extending a deadline for a student (69.6%) and discussing a student’s mental health problem with him/her (69.6%). Least used by faculty were exempting student from an exam (5.6%) and referring a student to counseling outside of the university (20.8%). The strategy seen as most effective by faculty who used them, with the highest percentage of ratings of somewhat effective or very effective, was consulting with the University of South Carolina Office of Disability Services or University of South Carolina Counseling regarding a student with a mental health problem (80.9%). Allowing a student extra time to complete an exam (75.6%), extending a deadline for a student (75.5%) and allowing a student to use a private testing location (70%) also received high effectiveness ratings. Participants who exempted a student with a mental health problem from an exam rated this accommodation as least effective; 33.3% rated it as not effective.
Psychiatric Advance Directives Participants responded to a set of questions regarding the utility of PADs for students with a mental illness in a university setting. The Likert scale provided ranged from 1.0 (strongly disagree) to 5.00 (strongly agree). Faculty agreed most strongly with the statement, “Students with a mental illness should talk with their doctor or therapist about what to write in a PAD.” Participants also agreed that, “Students with a mental illness should choose a family member or someone they trust and give them the right to make decisions about their treatment if they become ill.” Consistent with their other responses, participants disagreed with the statement, “Writing down a PAD will probably not do any good.” Table 5 lists the percentages of participants who responded “strongly disagree,” “disagree,” “neutral,” “agree,” and “strongly agree” to each statement.
Qualitative Findings What do you see as possible advantages of a PAD for a student with a mental illness? Faculty shared a number of possible advantages of a PAD for a student with a mental illness. The most popular theme was that of autonomy, control, and choice for the student. This theme was nearly twice as common as any other theme in response to this question. One participant emphasized student involvement and empowerment: “Students should be more involved and proactive in managing his or her mental health.
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Table 4 Use and Effectiveness of Strategies
For a student with a mental health problem, have you ever extended the deadline for a student? Have you ever discussed a student’s mental health issue with him/her? Have you ever referred a student to university Counseling Services? For a student with a mental health problem, have you ever given the student extra time to complete an exam? Have you ever referred a student to university Office of Disability Services? For a student with a mental health problem, have you ever allowed a student to use a private testing room or test center? Have you ever consulted with university Office of Disability Services or Counseling Services for a student with a mental health problem? For a student with a mental health problem, have you ever allowed the student to record lectures? Have you ever referred a student to counseling outside of the university? For a student with a mental health problem, have you ever exempted a student from an exam?
Total number used
Effectiveness not supported
Effective
117 (69.6%) 117 (69.6%) 107 (63.7%)
31 (26.5%) 46 (39.3%) 63 (58.9%)
86 (73.5%) 71 60.7%) 44 (41.1%)
102 (62.2%) 91 (54.2%)
27 (26.5%) 46 (50.5%)
75 (73.5%) 45 (49.5%)
71 (43.6%)
21 (29.6%)
49 (69%)
68 (42.5%)
13 (19.1%)
55 (80.9%)
60 (35.7%) 35 (20.8%) 9 (5.6%)
39 (65%) 22 (62.9%) 5 (55.6%)
21 (35%) 13 (37.1%) 4 (44.4%)
They should be empowered to assert their own wishes when they are well.” Two other frequent themes were helping others know what to do in a crisis and receiving better, needed, or more consistent care. A faculty member highlighted the safety benefits for those interacting with the student in the moment of crisis:
It has been my experience that when a person with a mental illness is doing well, could be when they are in most danger of deciding to discontinue their medications so I am a bit conflicted about a student writing what meds they want to be given (should their condition deteriorate) while they are feeling good because that is when many decide they do not really need meds any longer.
Increasingly, we are seeing that policing organizations are being trained to “taze first and ask questions later” when dealing with mental health crisis. A PAD could contain critical information for those acting in a liaison capacity with officers and for officers themselves to lower the risk of injury or harm to a person in crisis or others.
The second most common disadvantage of a PAD pointed out by participants was concern for confidentiality or privacy. Logistical problems getting PAD information when needed was also a frequently mentioned disadvantage. Several points were expressed by one faculty member:
Table 6 lists the themes found among faculty members’ perceived advantages of a PAD for a student with a mental illness. What do you see as possible disadvantages of a PAD for a student with a mental illness? Faculty gave thought-provoking responses to this question. Most commonly, faculty wrote that students with mental illness do not have good judgment or students with mental illness will not use PADs appropriately. One participant gave a specific example:
The document can be inflexible to the conditions of an actual crisis, and is only good if it is frequently updated. Additionally, the PAD may could potentially run counter to the advice of qualified health professionals. So, in the event of conflict how does that get resolved?
Table 7 lists the themes of disadvantages of a PAD for a student with a mental illness.
Table 5 PADs for Students With a Mental Illness
Students with a mental illness should talk with their doctor or therapist about what to write in a PAD Students with a mental illness should, when they are feeling well, write down what kind of medicine or other treatment they want in the future if they become ill Students with a mental illness should choose a family member or someone they trust and give them the right to make decisions about their treatment if they become ill Students with a mental illness should have a PAD because it will give them more control over their own lives and what happens to them in the future Students with a mental illness should have a PAD otherwise they might go without treatment they need to get well Students with a mental illness should have a PAD otherwise they might be put in the hospital against their will or be given medicine they do not want PADs will help students with a mental illness stay well Doctors and hospitals should pay a legal penalty if they fail to follow a PAD Writing down a PAD will probably not do any good Note.
PAD ⫽ psychiatric advance directive.
% Strongly disagree
% Disagree
% Neutral
% Agree
% Strongly agree
3.4
0.0
4.1
32.4
60.0
4.1
1.4
9.0
42.8
42.8
4.1
2.1
11.7
44.1
37.9
3.4
2.1
17.2
45.5
31.7
4.1
7.6
23.4
40.7
24.1
4.8 5.5 7.6 22.1
4.1 11.0 22.1 51.7
35.2 41.4 36.6 21.4
36.6 29.0 24.8 2.8
19.3 13.1 9.0 2.1
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346 Table 6 Advantage of a PAD
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Theme
N
PADs promote student self-determination and overall autonomy PADs tell others what to do to help the student PADs increase likelihood of student receiving better/needed/consistent care PADs are established ahead of time while student healthy PADs facilitate rapid response in times of crisis as well as crisis prevention Don’t know if PADs are helpful No advantages PADs promote student elf-reflection/awareness PADs enable students to get help when vulnerable PADs include documentation/information that is needed by others in order to help the student Clear information in PADs promotes safety for the student, helpers, and those responding to crisis PADs give student an advocate Other Note.
%
47 29.75 23 14.56 20 12.66 15 9.49 14 8.86 7 4.43 7 4.43 6 3.80 5 3.16 5 3.16 4 2.53 3 1.90 2 1.27
PAD ⫽ psychiatric advance directive.
Why might a student want or not want a PAD? The number one reason participant thought a student might not want a PAD was the stigma of mental illness. A participant explained that stigma may not only be a concern for the student’s time at the university, “Fear of the stigma of mental illness might cause a student to worry that the document could affect eventual employability.” The second most common reason faculty said a student might not want a PAD was denial: denial of his or her mental illness, denial of the need for treatment, or denial of the need for crisis planning. One participant spoke from personal experience: They may not think it is applicable. Mental illness often develops or matures when students are in college. This happened to my sister who suffers from bipolar disorder. As a family, we never knew she had a significant problem until she had a full crash.
Less frequently mentioned themes were mistrust of others making decisions for them, concerns about coercion or misuse of a
PAD, not fully understanding a PAD, and not having others to support them in implementing a PAD. Participants mentioned few reasons for why a student might want a PAD. The most common theme was to prevent getting unwanted care, as shared by one faculty member: “[A student might want a PAD] for the greatest likelihood of their wishes being respected and followed” Table 8 lists the themes among faculty responses to why a student might want or not want a PAD.
Discussion Faculty Familiarity With Mental Illness and Accommodations or Strategies Despite the high rates of mental health issues among university students (estimated 15% of students), this survey of university
Table 7 Possible Disadvantages of a PAD Theme
N
%
Students with mental illness won’t have good judgment/use PAD appropriately Confidentiality/Privacy may be compromised by using PAD Logistical problems getting PAD info to those who need to follow or implement Restricts care options when the student’s needs change, desired options are not available, or new options become available; must be regularly updated Don’t know disadvantages of PADs Stigma/Embarrassment Not enforceable or legally binding University uses for coercion or monitoring or liability Creates confusion for helpers or slows process of getting needed care Providers don’t know about the PAD or resist using it when it does not match their professional recommendations Hard to predict what is needed in advance Other None Student loses current control PAD will be ineffective Unclear how to determine when student is capable/incapable and PAD should be implemented General legal issues Can’t be rescinded Students become dependent/use as excuse
18 15 13
12.41 10.34 8.97
12 10 10 9 7 7 6 6 6 5 4 4 4 4 3 2
8.28 6.90 6.90 6.21 4.83 4.83 4.14 4.14 4.14 3.45 2.76 2.76 2.76 2.76 2.07 1.38
Note.
PAD ⫽ psychiatric advance directive.
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Table 8 Why Might a Student Want/Not Want a PAD?
Why not want Stigma Denial of mental illness/need for treatment/need for crisis planning Confidentiality/privacy may be compromised Don’t know May lose choice in the moment with a PAD Mistrust of others making decisions for them Concern about coercion or misuse of a PAD Problems with time, convenience, ease Other Students don’t fully understand a PAD PAD may not be current at time of crisis May not have others to support Why want Keep from getting unwanted care To express wishes and be part of care Independence through a PAD Other Note.
N
%
31 25 22 12 9 4 4 4 3 3 2 2
21.53 17.36 15.28 8.33 6.25 2.78 2.78 2.78 2.08 2.08 1.39 1.39
12 6 4 1
8.33 4.17 2.78 0.69
PAD ⫽ psychiatric advance directive.
faculty revealed the surprising fact that common symptoms of mental illnesses were not noted even once per year by a substantial proportion of respondents (e.g., about 50% did not see withdrawal, a common symptom of depression, even once a year). Faculty may not be recognizing warning signs and symptoms of mental illness in students, making it difficult for them to provide students with support and assistance. Faculty reported being familiar with some of the mental health conditions experienced by students; however, over 40% reported lack of familiarity with personality disorders, paranoia, and schizophrenia. Given that schizophrenia most commonly has an age of onset during adolescence and young adulthood (McGrath, Saha, Chant, & Welham, 2008), this finding is of some concern. In addition, these high rates of self-reported familiarity with disorders are not consistent with the low frequency with which faculty report noting symptoms of mental disorders in students. Faculty may not be aware of deficits in their knowledge; this is an area that warrants further study. Our findings indicated that the vast majority of faculty surveyed have an overall supportive stance and are willing to provide accommodations to students with a mental illness. This can be seen by the large proportion who reported providing students with extra time, extended deadlines, and separate testing locations. Our findings were strikingly similar to those of Becker et al. (2002) and Brockelman (2011) regarding the most commonly used strategies and accommodations. In all three studies, extended a deadline for a student and discussed a student’s mental health issue with him/her were the most commonly used. In addition, faculty are willing to discuss mental health issues with a student and to refer them to counseling, again indicating a supportive stance. Faculty also demonstrated an openness to receiving information from “experts” when working with students with mental illness, as nearly all faculty who consulted with the Office of Disability Services or University Counseling Center reported it to be an effective action.
Faculty Views of PAD Utility for University Students Faculty respondents were, overall, supportive of the idea of PADs as an intervention to help students with a mental illness, with an average score of 4 (agree) for the statement, “Students with a mental illness should, when they are feeling well, write down what kind of medicine or treatment they want in the future if they get ill.” However, faculty most highly endorsed statements that said students should consult with a doctor or therapist when creating a PAD (average score 4.46) and that students should choose a trusted person as health care proxy (average score 4.19). This could indicate faculty member’s ambivalence about students’ ability to make autonomous decisions about their mental health care without guidance from an expert or mature adult. This is reflected in the qualitative data as well, where the most common advantage faculty see in a PAD is support of student autonomy and choice, and the primary concern voiced about PADs is that students with mental illness will have poor judgment and not use a PAD appropriately. Thus it would seem that faculty are cautiously optimistic about the utility of PADs in university students with mental illnesses.
Study Limitations As an exploratory study, this research has a number of limitations. First, because it was limited to one university, results may not be generalizable. Second, because the survey was voluntary and participants self-selected, respondent bias is possible. In addition, there is a likelihood of some social desirability bias in responses; given the heightened discussions about mental illness in university settings, faculty may be reluctant to admit a lack of knowledge, or may feel they are “familiar” with mental illnesses simply from hearing the topic mentioned repeatedly. Finally, because many faculty were not familiar with PADs prior to the survey, there is the chance that a one-page written description of PADs is not sufficient for them to fully grasp the intervention,
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which would result in responses different from ones they might have given if they had more understanding of PAD and time to think about its implications. Despite these limitations, our findings provide a foundation for future research on PADs in university settings and can begin to inform training for faculty on student mental illnesses and ways in which faculty can support these students.
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Future Actions
concerns about student judgment in creating and using PADs. In addition, our findings suggest that faculty may have limited ability to recognize mental illness symptoms in students, which would limit their ability to support student with PADs and other accommodations and strategies. Additional feasibility research and faculty training are necessary to inform utilization of PADs in university settings.
References
Assessing the knowledge and needs of faculty regarding interacting with students with mental illness is an important step in the process of preparing our faculty and students for success. In addition, faculty willingness to accept PADs is an important prerequisite for PAD implementation on a university campus. Findings from our study thus suggest actions in two areas. First, our results indicate that faculty could be supportive of PADs for students with mental illness. This is promising, as there is now evidence that both faculty and students could be accepting of PADs. With these findings we are encouraged to begin research to examine the actual feasibility of using PADs in university settings. Feasibility research will need to address a number of ethical questions. For example, how can PADs be effectively implemented on a college campus while protecting students’ private health information? Traditional college students are in a developmental stage in which they change relationships, goals, and living arrangements often. How can the faculty and staff of the college be sure the PAD is current for a particular student? Could the information in a PAD be used against a student in a disciplinary situation? Must a PAD be registered with the office of student disability services? Could a PAD be used to circumvent campus policies and procedures regarding disability-related accommodations, disciplinary procedures, or student housing? A second set of actions indicated by these finding involve additional training for faculty. Training is needed to increase faculty familiarity with mental illnesses and ability to recognize symptoms of mental illnesses in students. Faculty could also benefit from education and encouragement to use a wide range of accommodations and strategies for students. Additional research to design and test educational interventions for faculty, identifying interventions that are acceptable and effective, is needed.
Conclusions College is a time of growth and transition to independence, opportunity, and responsibility. PADs may be effective recovery tools to help university students with mental illnesses manage crises and attain stability and academic success. For PADs to be effective, university faculty and administration will need to understand mental illnesses, the strategies students need to manage mental health crises, and how PADs can play a role in supporting students. Our research indicates that faculty members are in general supportive of PADs and students’ self-determination but have
Becker, M., Martin, L., Wajeeh, E., Ward, J., & Shern, D. (2002). Students with mental illnesses in a university setting: Faculty and student altitudes, beliefs, knowledge, and experiences. Psychiatric Rehabilitation Journal, 25, 359 –368. http://dx.doi.org/10.1037/h0095001 Blanco, C., Okuda, M., Wright, C., Hasin, D. S., Grant, B. F., Liu, S. M., & Olfson, M. (2008). Mental health of college students and their non-college-attending peers: Results from the National Epidemiologic Study on Alcohol and Related Conditions. Archives of General Psychiatry, 65, 1429 –1437. http://dx.doi.org/10.1001/archpsyc.65.12.1429 Brockelman, K. F. (2011). Faculty members’ ratings of the effectiveness of academic strategies for university students with psychiatric disabilities. Journal of Postsecondary Education & Disability, 24, 41–50. Collins, K. D. (2000). Coordination of rehabilitation services in higher education for students with psychiatric disabilities. Journal of Applied Rehabilitation Counseling, 31, 36 –39. Eisenberg, D., Hunt, J., & Speer, N. (2013). Mental health in American colleges and universities: Variation across student subgroups and across campuses. Journal of Nervous and Mental Disease, 201, 60 – 67. http:// dx.doi.org/10.1097/NMD.0b013e31827ab077 Hartley, M. (2010). Increasing resilience: Strategies for reducing dropout rates for college students with psychiatric disabilities. American Journal of Psychiatric Rehabilitation, 13, 295–315. http://dx.doi.org/10.1080/ 15487768.2010.523372 Joshi, K. G. (2003). Psychiatric advance directives. Journal of Psychiatric Practice, 9, 303–306. http://dx.doi.org/10.1097/00131746-20030700000005 McGrath, J., Saha, S., Chant, D., & Welham, J. (2008). Schizophrenia: A concise overview of incidence, prevalence, and mortality. Epidemiologic Reviews, 30, 67–76. http://dx.doi.org/10.1093/epirev/mxn001 Scheyett, A. M., Kim, M. M., Swanson, J. W., & Swartz, M. S. (2007). Psychiatric advance directives: A tool for consumer empowerment and recovery. Psychiatric Rehabilitation Journal, 31, 70 –75. http://dx.doi .org/10.2975/31.1.2007.70.75 Scheyett, A. M., & Rooks, A. (2012). University students’ views on the utility of psychiatric advance directives. Journal of American College Health, 60, 90 –93. http://dx.doi.org/10.1080/07448481.2011.572326 Swanson, J. W., Swartz, M. S., Elbogen, E. B., Van Dorn, R. A., Ferron, J., Wagner, H. R., . . . Kim, M. (2006). Facilitated psychiatric advance directives: A randomized trial of an intervention to foster advance treatment planning among persons with severe mental illness. The American Journal of Psychiatry, 163, 1943–1951. http://dx.doi.org/10.1176/ ajp.2006.163.11.1943
Received July 16, 2014 Revision received March 27, 2015 Accepted March 30, 2015 䡲
© 2015 American Psychological Association 1095-158X/15/$12.00 http://dx.doi.org/10.1037/prj0000143
Faculty Perceptions of Accommodations, Strategies, and Psychiatric Advance Directives for University Students With Mental Illnesses Karin F. Brockelman and Anna M. Scheyett
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University of South Carolina Objective: Universities across the country struggle with the legal and ethical dilemmas of how to respond when a student shows symptoms of serious mental illness. This mixed-method study provides information on faculty knowledge of mental health problems in students, their use of available accommodations and strategies, and their willingness to accept psychiatric advance directives (PADs) as helpful interventions for managing student crises. Method: Participants were 168 faculty members at a large, public, Southern university. A web-based survey was used to collect quantitative self-report data as well as qualitative data in the form of open-ended questions. Quantitative data are presented with descriptive statistics. Qualitative data were analyzed using thematic analysis. Results: The majority of faculty surveyed have an overall supportive stance and are willing to provide accommodations to students with a mental illness. The most common advantage faculty see in a PAD is support of student autonomy and choice, and the primary concern voiced about PADs is that students with mental illness will have poor judgment regarding the contents of the PADs they create. Conclusions and Implications for Practice: PADs may be effective recovery tools to help university students with mental illnesses manage crises and attain stability and academic success. For PADs to be effective, university faculty and administration will need to understand mental illnesses, the strategies students need to manage mental health crises, and how PADs can play a role in supporting students. Keywords: psychiatric advance directives, college students, mental illness, crisis intervention
Psychiatric advance directives (PADs) are legal documents that allow individuals, when well, to document their wishes for treatment during times of psychiatric crisis when they are no longer capable of stating their needs or making competent decisions regarding their care (Joshi, 2003). PADs have been used with adults with mental illness in the public sector and have been well received (Swanson et al., 2006). Because of their functions as tools to empower consumer voice and choice, PADs are seen as ways to support and facilitate recovery (Scheyett, Kim, Swanson, & Swartz, 2007). However, to date, PADs have not been used in university settings. PADs have the potential of being a powerful intervention to support university students with mental illness. With PADs, students could identify and give permission for the university to communicate with care providers and relevant support people (family, partners, and friends). Students could identify their early warning signs of relapse, the interventions that are most helpful, and give advance permission for interventions or administration of specific medications they know are helpful to manage their symptoms. Universities would thus have the ability to gather the information they need, have guidance in crisis management, and could provide care before students decompensate to dangerousness (Scheyett & Rooks, 2012). PADs have been shown to be acceptable to students with mental illnesses (Scheyett & Rooks, 2012). However, for PADs to be part of an effective strategy to support students with mental illness, several other conditions are necessary. University faculty and administration must be familiar with mental illness in students, must be familiar with and use other existing strategies and accommodations for students with mental illness, and must also accept and be willing to use PADs. This study will provide us with
College is a time of significant psychological stress, with an estimated 15% of university students experiencing some sort of serious mental illness such as major depression or bipolar disorder (Blanco et al., 2008; Eisenberg, Hunt, & Speer, 2013). Students may manifest symptoms of mental illness for the first time during college, and students with existing but stable mental illness may have relapses into symptomatology. Universities across the country struggle with the legal and ethical dilemmas of how to respond when a student shows symptoms of mental illness. Confidentiality laws, in effect unless there is a significant risk of harm, bar university staff from contacting the student’s family members to share observations and gather information and bar them from communicating with the student’s mental health care providers. Symptomatology may prevent students from asking for help, giving permission to speak with care providers, or making sound decisions about their care (Collins, 2000). The university is thus unable to respond to de-escalate symptoms, and must wait until the situation deteriorates into dangerousness before it can intervene. By this time, it is often too late for effective intervention and a crisis, usually resulting in hospitalization and sometimes resulting in tragedy, occurs (Hartley, 2010).
This article was published Online First June 8, 2015. Karin F. Brockelman, PhD, Rehabilitation Counseling Program, University of South Carolina; Anna M. Scheyett, PhD, College of Social Work, University of South Carolina. Correspondence concerning this article should be addressed to Anna M. Scheyett, College of Social Work, DeSaussure College, University of South Carolina, Columbia, SC 29208. E-mail: [email protected] 342
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information on faculty knowledge of mental health problems in students, their use of available accommodations and strategies, and their willingness to accept PADs as helpful interventions for managing student crises. Our findings will inform future training for university faculty on mental illness as well as the potential for implementation of PADs in a university setting.
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Goals of the Project The overarching goals of this mixed-method study are (a) to assess faculty knowledge about students who have mental illness on the university campus, (b) to assess faculty knowledge and use of accommodations and strategies for university students with mental illness, and (c) to assess faculty acceptance of a novel crisis management intervention for university students with mental illnesses, PADs. The results of this study will be used to develop training and interventions for faculty in these areas and will inform the feasibility of using PADs in university settings.
343
rate the effectiveness of the strategy on the following scale: not sure if it was effective, not effective, somewhat effective, or very effective. The strategies may have been implemented as a result of formal registration with the campus office of student disability services, through informal arrangements between the student and faculty member, or through universal design for instruction. Because of nonnormal distribution, a dichotomous variable was created from the responses “effective” (combining “very effective” and “somewhat effective”) or “effectiveness not supported.” Section D included detailed information about PADs and asked participants questions regarding their thoughts on using PADs with university students. This included 5-point Likert-type scale questions (1 ⫽ strongly disagree, 5 ⫽ strongly agree) regarding their views on PADs as well as three open-ended questions: (a) what do you see as the advantages of a PAD for students? (b) what do you see as the disadvantages of a PAD for students? and (c) why do you think a student might or might not want a PAD? Lastly, Section E requested demographic and employment information from participants.
Method Analyses Participants Participants were faculty members at a large, public Southern university. The researchers recruited participants by e-mailing a link to an online survey to all faculty members. Data were collected during a 1-month time frame. Researchers contacted faculty three times using the e-mails posted for faculty on the university website. The three e-mails included (a) the initial e-mail invitation to participate in the study, (b) a reminder e-mail 2 weeks later, and (c) a final reminder e-mail 10 days after the first reminder. Participants voluntarily self-selected to be in the study by completing the online consent form and questionnaire. The questionnaire took approximately 10 min to complete. Participants were able to complete the survey at any computer with Internet access.
Instrument The questionnaire comprised six sections. Sections A, B, and C were adapted from the Mental Health and Illness Awareness Survey developed by Becker et al. (2002). Section D was adapted from the PAD Attitude Questionnaire developed by Swanson et al. (2006). Sections A through C asked participants about their observations of student behaviors and knowledge of mental illness and campus accommodations and strategies for students with mental illness. Section A listed 11 possible symptoms of mental illness and asked participants how often they observed these symptoms in their interactions with students. A Likert scale was provided for responses: never, once in my career, at least once per year, at least once per semester, at least once per month, and at least once per week. Because of nonnormal distribution, were collapsed into a dichotomous variable: at least once per year or more, or less than once per year. Section B listed seven mental health conditions and asks participants how familiar they were with the conditions. Response options were on a 3-point Likert scale: not at all familiar, somewhat familiar, very familiar. Section C asked about faculty use of 11 strategies for students with psychiatric disabilities. If the participant used a particular strategy, the participant was then asked to
The researchers used descriptive statistics including frequencies and measures of central tendency to report the quantitative findings of the survey. The data from the open-ended questionnaire items were examined using thematic analysis. Text from each open-ended question was coded and reviewed by both researchers. Codes were then collapsed into larger themes and theme frequency was determined.
Results Participants The survey link was e-mailed to 1,370 valid faculty e-mail addresses. One hundred sixty-eight faculty members participated in the online survey, yielding a response rate of 12.26%. The majority of participants identified as female (51%), White (75%), and married/cohabiting (65%). Average age was 47 years (SD ⫽ 9.7). Participants reported a mean of 14 years (SD ⫽ 8.7) of postsecondary teaching experience, were predominantly tenured (39%), and had a PhD (74%). Participants’ primary teaching loads were undergraduate (37%) or graduate (32%). See Table 1.
Familiarity With Mental Health When asked if they knew a student with a mental illness, 50% of respondents reported currently knowing a student on campus who was receiving mental health treatment. Researchers asked faculty members how often they saw certain common symptoms of mental illness. As shown in Table 2, faculty most frequently reported seeing the following at least once per year: excessive absences (80%), confused thinking (52%), and withdrawal or diminished friendliness (48%). Participants reported on their familiarity with certain mental health conditions. Faculty members were most familiar with depression; 48.8% marked they were very familiar with depression. More than half of participants were somewhat familiar with attention deficit (55.4%), anxiety (50.6%), and bipolar (53.0%) disor-
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344 Table 1 Participant Characteristics
Table 3 Familiarity With Mental Health Conditions (N ⫽ 168)
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% Gender Male Female No report Age Race/Ethnicity (can report ⬎1) White African American Asian Hispanic/Latino Other Marital status Married/Cohabitating Single, never married Separated/Divorced Widowed No report Years of postsecondary experience Academic appointment Tenured Tenure track Nontenure track No report Primary teaching load Undergraduate Graduate Both No report
Mean (SD)
33.3 51.2 14.9 47 (9.7) 75 5.4 5.4 0.6 0 65 11.3 7.7 0.6 14.9 14 (8.7) 39.3 22.6 23.2 14.9 36.9 32.1 15.5 14.9
der. Participants were least familiar with personality disorders (43.5%), schizophrenia (42.3%), and paranoia (41.7%). Faculty reported levels of familiarity with mental health conditions are listed in Table 3.
Use of Accommodations and Strategies Faculty members’ experience using particular accommodations and strategies was of interest in this study. Participant reported whether they ever used each of the accommodations and strategies; then they indicated the effectiveness of those accommodations and strategies they used. The numbers of participants who used each
Table 2 “Have You Seen These Potential Symptoms of Mental Illness in Students?” (N ⫽ 168) Symptom
% Responding “at least once per year or more”
Excessive absences Confused thinking Withdrawal/diminished friendliness Suspiciousness/grandiosity Rapid, pressured speech Marked personality changes Emotional outbursts Major change in appearance Odd/exaggerated gestures Student wrote/spoke of suicide
80 52 48 33 33 31 30 27 21 5.4
Attention deficit Anxiety disorder Bipolar disorder Depression Personality disorders Paranoia Schizophrenia
% Not familiar
% Somewhat familiar
% Very familiar
11.9 16.1 16.1 3.6 43.5 41.7 42.3
55.4 50.6 53.0 47.6 39.9 41.7 40.5
32.7 33.3 31.0 48.8 16.7 16.7 17.3
strategy or accommodation are listed in Table 4, along with their ratings of the effectiveness of those strategies or accommodations. Faculty most frequently reported the accommodation or strategy of extending a deadline for a student (69.6%) and discussing a student’s mental health problem with him/her (69.6%). Least used by faculty were exempting student from an exam (5.6%) and referring a student to counseling outside of the university (20.8%). The strategy seen as most effective by faculty who used them, with the highest percentage of ratings of somewhat effective or very effective, was consulting with the University of South Carolina Office of Disability Services or University of South Carolina Counseling regarding a student with a mental health problem (80.9%). Allowing a student extra time to complete an exam (75.6%), extending a deadline for a student (75.5%) and allowing a student to use a private testing location (70%) also received high effectiveness ratings. Participants who exempted a student with a mental health problem from an exam rated this accommodation as least effective; 33.3% rated it as not effective.
Psychiatric Advance Directives Participants responded to a set of questions regarding the utility of PADs for students with a mental illness in a university setting. The Likert scale provided ranged from 1.0 (strongly disagree) to 5.00 (strongly agree). Faculty agreed most strongly with the statement, “Students with a mental illness should talk with their doctor or therapist about what to write in a PAD.” Participants also agreed that, “Students with a mental illness should choose a family member or someone they trust and give them the right to make decisions about their treatment if they become ill.” Consistent with their other responses, participants disagreed with the statement, “Writing down a PAD will probably not do any good.” Table 5 lists the percentages of participants who responded “strongly disagree,” “disagree,” “neutral,” “agree,” and “strongly agree” to each statement.
Qualitative Findings What do you see as possible advantages of a PAD for a student with a mental illness? Faculty shared a number of possible advantages of a PAD for a student with a mental illness. The most popular theme was that of autonomy, control, and choice for the student. This theme was nearly twice as common as any other theme in response to this question. One participant emphasized student involvement and empowerment: “Students should be more involved and proactive in managing his or her mental health.
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Table 4 Use and Effectiveness of Strategies
For a student with a mental health problem, have you ever extended the deadline for a student? Have you ever discussed a student’s mental health issue with him/her? Have you ever referred a student to university Counseling Services? For a student with a mental health problem, have you ever given the student extra time to complete an exam? Have you ever referred a student to university Office of Disability Services? For a student with a mental health problem, have you ever allowed a student to use a private testing room or test center? Have you ever consulted with university Office of Disability Services or Counseling Services for a student with a mental health problem? For a student with a mental health problem, have you ever allowed the student to record lectures? Have you ever referred a student to counseling outside of the university? For a student with a mental health problem, have you ever exempted a student from an exam?
Total number used
Effectiveness not supported
Effective
117 (69.6%) 117 (69.6%) 107 (63.7%)
31 (26.5%) 46 (39.3%) 63 (58.9%)
86 (73.5%) 71 60.7%) 44 (41.1%)
102 (62.2%) 91 (54.2%)
27 (26.5%) 46 (50.5%)
75 (73.5%) 45 (49.5%)
71 (43.6%)
21 (29.6%)
49 (69%)
68 (42.5%)
13 (19.1%)
55 (80.9%)
60 (35.7%) 35 (20.8%) 9 (5.6%)
39 (65%) 22 (62.9%) 5 (55.6%)
21 (35%) 13 (37.1%) 4 (44.4%)
They should be empowered to assert their own wishes when they are well.” Two other frequent themes were helping others know what to do in a crisis and receiving better, needed, or more consistent care. A faculty member highlighted the safety benefits for those interacting with the student in the moment of crisis:
It has been my experience that when a person with a mental illness is doing well, could be when they are in most danger of deciding to discontinue their medications so I am a bit conflicted about a student writing what meds they want to be given (should their condition deteriorate) while they are feeling good because that is when many decide they do not really need meds any longer.
Increasingly, we are seeing that policing organizations are being trained to “taze first and ask questions later” when dealing with mental health crisis. A PAD could contain critical information for those acting in a liaison capacity with officers and for officers themselves to lower the risk of injury or harm to a person in crisis or others.
The second most common disadvantage of a PAD pointed out by participants was concern for confidentiality or privacy. Logistical problems getting PAD information when needed was also a frequently mentioned disadvantage. Several points were expressed by one faculty member:
Table 6 lists the themes found among faculty members’ perceived advantages of a PAD for a student with a mental illness. What do you see as possible disadvantages of a PAD for a student with a mental illness? Faculty gave thought-provoking responses to this question. Most commonly, faculty wrote that students with mental illness do not have good judgment or students with mental illness will not use PADs appropriately. One participant gave a specific example:
The document can be inflexible to the conditions of an actual crisis, and is only good if it is frequently updated. Additionally, the PAD may could potentially run counter to the advice of qualified health professionals. So, in the event of conflict how does that get resolved?
Table 7 lists the themes of disadvantages of a PAD for a student with a mental illness.
Table 5 PADs for Students With a Mental Illness
Students with a mental illness should talk with their doctor or therapist about what to write in a PAD Students with a mental illness should, when they are feeling well, write down what kind of medicine or other treatment they want in the future if they become ill Students with a mental illness should choose a family member or someone they trust and give them the right to make decisions about their treatment if they become ill Students with a mental illness should have a PAD because it will give them more control over their own lives and what happens to them in the future Students with a mental illness should have a PAD otherwise they might go without treatment they need to get well Students with a mental illness should have a PAD otherwise they might be put in the hospital against their will or be given medicine they do not want PADs will help students with a mental illness stay well Doctors and hospitals should pay a legal penalty if they fail to follow a PAD Writing down a PAD will probably not do any good Note.
PAD ⫽ psychiatric advance directive.
% Strongly disagree
% Disagree
% Neutral
% Agree
% Strongly agree
3.4
0.0
4.1
32.4
60.0
4.1
1.4
9.0
42.8
42.8
4.1
2.1
11.7
44.1
37.9
3.4
2.1
17.2
45.5
31.7
4.1
7.6
23.4
40.7
24.1
4.8 5.5 7.6 22.1
4.1 11.0 22.1 51.7
35.2 41.4 36.6 21.4
36.6 29.0 24.8 2.8
19.3 13.1 9.0 2.1
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346 Table 6 Advantage of a PAD
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Theme
N
PADs promote student self-determination and overall autonomy PADs tell others what to do to help the student PADs increase likelihood of student receiving better/needed/consistent care PADs are established ahead of time while student healthy PADs facilitate rapid response in times of crisis as well as crisis prevention Don’t know if PADs are helpful No advantages PADs promote student elf-reflection/awareness PADs enable students to get help when vulnerable PADs include documentation/information that is needed by others in order to help the student Clear information in PADs promotes safety for the student, helpers, and those responding to crisis PADs give student an advocate Other Note.
%
47 29.75 23 14.56 20 12.66 15 9.49 14 8.86 7 4.43 7 4.43 6 3.80 5 3.16 5 3.16 4 2.53 3 1.90 2 1.27
PAD ⫽ psychiatric advance directive.
Why might a student want or not want a PAD? The number one reason participant thought a student might not want a PAD was the stigma of mental illness. A participant explained that stigma may not only be a concern for the student’s time at the university, “Fear of the stigma of mental illness might cause a student to worry that the document could affect eventual employability.” The second most common reason faculty said a student might not want a PAD was denial: denial of his or her mental illness, denial of the need for treatment, or denial of the need for crisis planning. One participant spoke from personal experience: They may not think it is applicable. Mental illness often develops or matures when students are in college. This happened to my sister who suffers from bipolar disorder. As a family, we never knew she had a significant problem until she had a full crash.
Less frequently mentioned themes were mistrust of others making decisions for them, concerns about coercion or misuse of a
PAD, not fully understanding a PAD, and not having others to support them in implementing a PAD. Participants mentioned few reasons for why a student might want a PAD. The most common theme was to prevent getting unwanted care, as shared by one faculty member: “[A student might want a PAD] for the greatest likelihood of their wishes being respected and followed” Table 8 lists the themes among faculty responses to why a student might want or not want a PAD.
Discussion Faculty Familiarity With Mental Illness and Accommodations or Strategies Despite the high rates of mental health issues among university students (estimated 15% of students), this survey of university
Table 7 Possible Disadvantages of a PAD Theme
N
%
Students with mental illness won’t have good judgment/use PAD appropriately Confidentiality/Privacy may be compromised by using PAD Logistical problems getting PAD info to those who need to follow or implement Restricts care options when the student’s needs change, desired options are not available, or new options become available; must be regularly updated Don’t know disadvantages of PADs Stigma/Embarrassment Not enforceable or legally binding University uses for coercion or monitoring or liability Creates confusion for helpers or slows process of getting needed care Providers don’t know about the PAD or resist using it when it does not match their professional recommendations Hard to predict what is needed in advance Other None Student loses current control PAD will be ineffective Unclear how to determine when student is capable/incapable and PAD should be implemented General legal issues Can’t be rescinded Students become dependent/use as excuse
18 15 13
12.41 10.34 8.97
12 10 10 9 7 7 6 6 6 5 4 4 4 4 3 2
8.28 6.90 6.90 6.21 4.83 4.83 4.14 4.14 4.14 3.45 2.76 2.76 2.76 2.76 2.07 1.38
Note.
PAD ⫽ psychiatric advance directive.
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Table 8 Why Might a Student Want/Not Want a PAD?
Why not want Stigma Denial of mental illness/need for treatment/need for crisis planning Confidentiality/privacy may be compromised Don’t know May lose choice in the moment with a PAD Mistrust of others making decisions for them Concern about coercion or misuse of a PAD Problems with time, convenience, ease Other Students don’t fully understand a PAD PAD may not be current at time of crisis May not have others to support Why want Keep from getting unwanted care To express wishes and be part of care Independence through a PAD Other Note.
N
%
31 25 22 12 9 4 4 4 3 3 2 2
21.53 17.36 15.28 8.33 6.25 2.78 2.78 2.78 2.08 2.08 1.39 1.39
12 6 4 1
8.33 4.17 2.78 0.69
PAD ⫽ psychiatric advance directive.
faculty revealed the surprising fact that common symptoms of mental illnesses were not noted even once per year by a substantial proportion of respondents (e.g., about 50% did not see withdrawal, a common symptom of depression, even once a year). Faculty may not be recognizing warning signs and symptoms of mental illness in students, making it difficult for them to provide students with support and assistance. Faculty reported being familiar with some of the mental health conditions experienced by students; however, over 40% reported lack of familiarity with personality disorders, paranoia, and schizophrenia. Given that schizophrenia most commonly has an age of onset during adolescence and young adulthood (McGrath, Saha, Chant, & Welham, 2008), this finding is of some concern. In addition, these high rates of self-reported familiarity with disorders are not consistent with the low frequency with which faculty report noting symptoms of mental disorders in students. Faculty may not be aware of deficits in their knowledge; this is an area that warrants further study. Our findings indicated that the vast majority of faculty surveyed have an overall supportive stance and are willing to provide accommodations to students with a mental illness. This can be seen by the large proportion who reported providing students with extra time, extended deadlines, and separate testing locations. Our findings were strikingly similar to those of Becker et al. (2002) and Brockelman (2011) regarding the most commonly used strategies and accommodations. In all three studies, extended a deadline for a student and discussed a student’s mental health issue with him/her were the most commonly used. In addition, faculty are willing to discuss mental health issues with a student and to refer them to counseling, again indicating a supportive stance. Faculty also demonstrated an openness to receiving information from “experts” when working with students with mental illness, as nearly all faculty who consulted with the Office of Disability Services or University Counseling Center reported it to be an effective action.
Faculty Views of PAD Utility for University Students Faculty respondents were, overall, supportive of the idea of PADs as an intervention to help students with a mental illness, with an average score of 4 (agree) for the statement, “Students with a mental illness should, when they are feeling well, write down what kind of medicine or treatment they want in the future if they get ill.” However, faculty most highly endorsed statements that said students should consult with a doctor or therapist when creating a PAD (average score 4.46) and that students should choose a trusted person as health care proxy (average score 4.19). This could indicate faculty member’s ambivalence about students’ ability to make autonomous decisions about their mental health care without guidance from an expert or mature adult. This is reflected in the qualitative data as well, where the most common advantage faculty see in a PAD is support of student autonomy and choice, and the primary concern voiced about PADs is that students with mental illness will have poor judgment and not use a PAD appropriately. Thus it would seem that faculty are cautiously optimistic about the utility of PADs in university students with mental illnesses.
Study Limitations As an exploratory study, this research has a number of limitations. First, because it was limited to one university, results may not be generalizable. Second, because the survey was voluntary and participants self-selected, respondent bias is possible. In addition, there is a likelihood of some social desirability bias in responses; given the heightened discussions about mental illness in university settings, faculty may be reluctant to admit a lack of knowledge, or may feel they are “familiar” with mental illnesses simply from hearing the topic mentioned repeatedly. Finally, because many faculty were not familiar with PADs prior to the survey, there is the chance that a one-page written description of PADs is not sufficient for them to fully grasp the intervention,
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which would result in responses different from ones they might have given if they had more understanding of PAD and time to think about its implications. Despite these limitations, our findings provide a foundation for future research on PADs in university settings and can begin to inform training for faculty on student mental illnesses and ways in which faculty can support these students.
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Future Actions
concerns about student judgment in creating and using PADs. In addition, our findings suggest that faculty may have limited ability to recognize mental illness symptoms in students, which would limit their ability to support student with PADs and other accommodations and strategies. Additional feasibility research and faculty training are necessary to inform utilization of PADs in university settings.
References
Assessing the knowledge and needs of faculty regarding interacting with students with mental illness is an important step in the process of preparing our faculty and students for success. In addition, faculty willingness to accept PADs is an important prerequisite for PAD implementation on a university campus. Findings from our study thus suggest actions in two areas. First, our results indicate that faculty could be supportive of PADs for students with mental illness. This is promising, as there is now evidence that both faculty and students could be accepting of PADs. With these findings we are encouraged to begin research to examine the actual feasibility of using PADs in university settings. Feasibility research will need to address a number of ethical questions. For example, how can PADs be effectively implemented on a college campus while protecting students’ private health information? Traditional college students are in a developmental stage in which they change relationships, goals, and living arrangements often. How can the faculty and staff of the college be sure the PAD is current for a particular student? Could the information in a PAD be used against a student in a disciplinary situation? Must a PAD be registered with the office of student disability services? Could a PAD be used to circumvent campus policies and procedures regarding disability-related accommodations, disciplinary procedures, or student housing? A second set of actions indicated by these finding involve additional training for faculty. Training is needed to increase faculty familiarity with mental illnesses and ability to recognize symptoms of mental illnesses in students. Faculty could also benefit from education and encouragement to use a wide range of accommodations and strategies for students. Additional research to design and test educational interventions for faculty, identifying interventions that are acceptable and effective, is needed.
Conclusions College is a time of growth and transition to independence, opportunity, and responsibility. PADs may be effective recovery tools to help university students with mental illnesses manage crises and attain stability and academic success. For PADs to be effective, university faculty and administration will need to understand mental illnesses, the strategies students need to manage mental health crises, and how PADs can play a role in supporting students. Our research indicates that faculty members are in general supportive of PADs and students’ self-determination but have
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Received July 16, 2014 Revision received March 27, 2015 Accepted March 30, 2015 䡲
