When around two dozen Eliot House students were facing academic problems last May, Eliot House Senior Tutor Oona Ceder ’90 sent an e-mail to Master Lino Pertile questioning the College’s treatment of students with mental health problems.

In the e-mail, which was circulated among a number of administrators and obtained by The Crimson, Ceder discusses the idea that the College allows students with mental health problems to remain in school for too long.

Ceder writes that the University should consider “whether we serve our students’ overall interests with the current UHS and Ad Board protocol for accommodations,” explaining that they allow students to hang on rather than getting the break and fresh start that they need.

In one e-mail, University President Lawrence H. Summers indicates that he is inclined to agree.

“Is Oona’s view on the need for earlier withdrawals as I suspect right[?]” he writes.

Summers now says that he was referring to “academic performance withdrawals,” not cases of students with mental health problems. And he adds that his comment was based on past suggestions to him that these students who are struggling academically would be better off leaving campus than remaining in school.

“A number of people had suggested to me at various points that we sometimes gave students a break and had them stay in situations where they would have been more likely to have improved their situation if they took a semester off,” he said last night.

Top administrators charged with overseeing mental health services echo the idea that time off can be the best option for students with severe mental illness—and assert that students should take this route more often.

But many students with serious mental health problems say that more than just presenting them with the option, College administrators often pressured them to leave Harvard and deal with their problems at home.

They say that Harvard is overly eager to get them off campus and is not committed enough to helping them navigate Harvard’s mental health resources while attending classes.

And as universities struggle to deal with the growing mental health problem, as well as a changing legal terrain, some students and experts say concerns about liability overly motivate administrators’ actions.

The Most Serious Case

While Harvard has not had to cope with three dramatic suicides this year as New York University did this fall, the University has in the past faced the thorny legal issues that surround serious student mental health issues and particularly suicide.

In 1998, a female undergraduate’s family sued the University after their daughter was stabbed to death by her Dunster House roommate, who committed suicide after the attack. The student’s family alleged that the College should have recognized the roommate’s instability when she missed three exams and began behaving erratically.

The case was settled out of court.

The Graduate School of Arts and Sciences also initiated major reforms to its program in 1998 after a spate of three suicides by graduate students was attributed to the school’s high-pressure atmosphere.

While these cases attracted national media attention, the prevalence of severe mental health problems often goes unnoticed until it surfaces in student suicide.

The suicide last December of Winthrop junior Marian H. Smith—a popular and lively figure in the Harvard social scene—served as the most recent reminder of how mental illness can lurk beneath the surface.

In the past 10 years, at least 15 Harvard undergraduates committed suicide.

Between 2000 and 2003, the Harvard University Police Department (HUPD) responded to 14 calls for service classified as attempted suicides.

In a recent Crimson poll, around 10 percent of respondents said they seriously considered attempting suicide in the past year and around 1 percent said they had attempted suicide in that time.

The University has developed a slew of mental health resources, including detailed guidelines for hospitalizing the most severe cases, but some students say the College’s liability concerns are driving its policy more than care for students.

As a result, some students say that Harvard’s main method of dealing with the problem is to avoid dealing with it altogether.

“[An assistant dean of freshmen] was pressuring me to take time off, and I felt like she was telling me, ‘It’s your own problem. We don’t want to have it on our hands,’” says a female 2002 graduate, who suffered from severe depression. “They love it when people take time off when having problems.”

A Leave of Absence

Director of University Health Services (UHS) Mental Health Services Dr. Richard D. Kadison estimates that more than 20 students take time off from school due to mental health problems each year.

Some students with mental health problems choose to take time off in order to recuperate.

But the College can also require that students with mental illnesses get counseling and, if necessary, leave campus.

Kadison says that the College will ask students to take time off when their mental health problems have disturbed their ability to be “functional enough in the community,” either academically or socially.

Several students who struggled with severe mental health problems say that administrators were overzealous in pushing them to voluntarily leave campus and that they felt alienated by the treatment.

The 2002 graduate, who suffered from depression and asked that her name not be used, says that her assistant freshman dean tried to convince her that leaving school was the best option, even before she had fully explored Harvard’s mental health services.

She says that even after she visited UHS and received a prescription for antidepressants, the assistant dean continued to try to convince her that she was making a mistake in staying in school.

“I was hopeful about the medicine working, and she was like, ‘What if it doesn’t work? What if you get a C on your transcript? You won’t get into law school,’” the graduate says. “She was giving me all these depressing things to think about that a depressed 18-year-old doesn’t need to hear right then.”

The 2002 graduate says that once the medicine began to work, her grades improved significantly and she finished the year with grades in the A and B range.

“People are too often encouraged to take time off, and there’s just not enough listening of what students have to say,” she says.

Jeremy R. Jenkins ’97-’98, co-founder of the Mental Health Awareness and Advocacy Group, says he thinks a semester off is sometimes the best solution for struggling students—but he objects to the cold administrative tone the Administrative Board takes in the process.

Jenkins, who took time off to cope with his depression while he was an undergraduate, says his senior tutor was helpful to him, but that other administrators can make the Ad Board procedure painful for mentally ill students.

“There are people that get it, and there are others that just don’t. If you have someone, a senior tutor or someone, who doesn’t get it, they can be very adversarial and very confrontational,” he says.

Jenkins says that the effect of the process is to give students the impression that the College does not care about their problems and simply wants them gone.

“The idea that you are getting someone off campus, that you are shuffling them off on someone else, a lot of students have felt that way,” says Jenkins. “At the same time, sometimes [time off] is necessary. The difference is how that is presented to you, and the Ad Board does not do a good job explaining itself.”

The 2002 graduate and Jenkins say that they feel administrators and Ad Board members too often assume that students have family to lean on when they require students to take a leave of absence.

“There’s this general assumption that you can always go home and your parents will take care of you, but a lot of people really have problems with their families,” the 2002 graduate says.

Jenkins says the Ad Board must consider that the student’s situation at home may not be more conducive to recovery than the campus.

“There are issues about what environment you are going back to, and what access you are going to have to health care there. And this may not be feasible at all, to suddenly pack up and go,” Jenkins says.

Kristin M. Waller ’05, who has had bouts with depression since seventh grade and has cut herself periodically during her time at Harvard, says it was crucial to her mental health that the College did not force her to take a leave of absence.

She says if administrators had not helped her remain in school she would have had nowhere to go. Her parents are divorced and the parent she is closest with lives in a car, she says.

Waller says her freshman dean and senior tutor advocated strongly for her before the Ad Board and spoke to professors on her behalf to ensure that she could stay.

Kadison says he often speaks on behalf of students in therapy at UHS when they are called before the Ad Board, if they give him permission to do so.

Chief of MIT Medical’s Mental Health Service Alan E. Siegel says that MIT does not believe in encouraging mentally ill students to recuperate away from campus.

He says MIT administrators go to lengths to try to help students who want to continue their studies to stay on campus.

“It’s been my experience that MIT as an institution will really extend itself to try and help students remain on campus and live their lives as students participating in the university,” says Siegel. “People don’t have to be perfect they just have to be safe. The university will try to make it possible in whatever we do to help a student stay and be productive.”

But while Harvard students say that the College too often relies on leave of absence as a cure-all for mental health problems, administrators say more students should take this option.

Kadison says more students with mental health problems would benefit from taking time off.

“I think it’s not done often enough,” Kadison says. “There’s no shame to leave and come back in a much better frame of mind.”

University Provost Steven E. Hyman says students may be averse to taking time off because they consider it an admission of failure—and they should not.

“I think we all feel that if you take time off, it’s some terrifically negative mark on your record,” says Hyman, who is the former director of the National Institute of Mental Health. “If you had a dreadful physical illness and you were exhausted and couldn’t get out of bed, you would take time off. If you had an episode of mania, it might be really a good thing to take time off, re-collect yourself.”

Liability concerns

Some students who have dealt with severe mental illness at Harvard say the University is only acting in its one legal interest in promoting leaves of absence.

These students and legal and mental health experts suspect that the University is protecting its liability by attempting to push students with more serious mental health problems off campus.

Elizabeth A. Whitman ’05-’06, who has battled depression and an eating disorder, says that when she mentioned the possibility of taking time off, her senior tutor was eager to help her leave.

“As soon as I suggested I wanted to leave, she was like, ‘Go!’” Whitman says. “She didn’t give it a second thought…. I feel like they’re really fast to have you leave if you’re going to be a problem.”

Whitman says that clinicians at UHS encouraged her to take time off from school as well.

She attributes this attitude to a desire by UHS to protect Harvard’s liability in the event that she hurt herself.

“They have to keep Harvard’s liability in the back of their mind whenever they’re seeing you,” Whitman says. “I feel like they were quicker to encourage me to leave because I might have been a bigger liability to them if I did something to myself while I stayed.”

Peter F. Lake ’81, a professor of law at Stetson University in Florida who has published a book on university legal obligations, says that nudging students off campus is one way universities currently deal with the burgeoning mental health “crisis” on campuses.

“There’s a number of approaches to the first generation of the problem, and one thing is to push the problem off campus,” Lake says. “It may not be the best thing for them or the school, but it’s one solution to the campus issue.”

Hyman says that liability is always a concern for medical institutions because of the number of lawsuits filed by patients.

“Of course everyone in the world of medicine thinks about being sued because it’s just part of the ethos that makes people defensive,” Hyman says. “But if you practice really good clinical care, I think that’s all that can be asked of you.”

While Kadison says he thinks administrators sometimes worry about the liability of the College if troubled students hurt other students, he says concern over liability is never a major factor when the College asks a student with mental health problems to take a leave of absence.

“There are some concerns about liability in dorms here, but I can’t think of a time that students [have] had to leave because people are afraid they’re going to hurt themselves,” Kadison says.

Lake says it is fairly common for universities to push mentally ill students off campus in order to avoid murky legal issues.

While Siegel says liability should not be a top concern for universities, he says he thinks some universities probably do try to push students with mental health problems off campus to avoid lawsuits.

“There are so many opportunities to be sued,” he says.

According to former Dean of the College Harry R. Lewis ’68, the College should be concerned about another type of liability if administrators want to take a more aggressive line in removing students with mental illness who are struggling academically.

“As for whether we should be less accommodating to mental illnesses and allow students to flunk out instead of just hanging on, I should think you would want to consult legal counsel before heading in that direction, mental illnesses being something for which we are required by law to provide accommodations, under [the Americans with Disabilities Act],” Lewis wrote in an e-mail response to Ceder’s and Summers’ discussion.

But University General Counsel Robert W. Iuliano ’83 says that no law prevents Harvard from urging mentally ill students who are not doing well to leave.

“There’s nothing in the law that prohibits an educational institution from encouraging any student to take a leave of absence,” he writes. “In many instances this may be exactly the right piece of advice for a student who for whatever reason is not effectively participating in the academic and extracurricular activities of the school.”

The Shin Case

In less than one year, one court case—Shin v. MIT—may redefine universities’ liability in cases of students with mental health problems.

In 2000, MIT undergraduate Elizabeth Shin fatally set herself on fire after spending a year in treatment with campus mental health clinicians.

Her parents are suing MIT in Massachusetts Superior Court for breach of contract, medical malpractice and negligence, claiming that MIT did not provide Shin with adequate, coordinated mental health care, and that the school should have informed them when Shin had threatened and attempted to commit suicide before.

Lake says the case the Shin case holds “major national significance” for universities’ legal responsibilities for mentally ill students.

“Everybody is watching this case—it’s an incident that’s leading to a revolution,” Lake says. “We all expect this case to be the kind of litigation with long-term significance.”

David A. Deluca, the attorney who represents Shin’s parents, says that the confidentiality rule that prevented MIT from telling the Shins about their daughter’s problems is one policy that may be reinterpreted by this case’s decision. “You can’t hide behind the wrongly-held belief that anything having to do with the health care of a student is going to be privileged and not communicated,” Deluca says. “There’s a huge exception to that—when the [it] reaches an emergency situation, that goes out the window.”

Currently privacy laws like the 1974 Family Educational Rights and Privacy Act bar schools from releasing most information to parents about a student—from grades to medical information—without the student’s permission.

The rule provides for confidentiality to be broken only when the student is in imminent danger, but this categorization can be hazy.

Lake says that the case has garnered so much attention because higher education institutions have long been been able to avoid legal responsibility for student health.

“Higher education for decades was basically immune from most legal responsibility,” Lake says. “That has changed, but the mentality is still there, that you don’t change until the court tells you to.”

Deluca says that universities have a legal obligation to “move aggressively to intervene” if administrators discover a student is suicidal.

Universities are not just watching and waiting until the decision is handed down. Lately, many schools—including Harvard—have begun examining their mental health care systems.

Harvard, in addition to Columbia, MIT and Yale, recently began a collaborative effort with the Jed Foundation, a group dedicated to suicide prevention, to look into developing more successful campus suicide prevention frameworks.

Kadison says he doesn’t think the Shin case will change how Harvard deals with mentally ill students, unless the law is significantly reinterpreted.

He cites Harvard’s dedication to carefully coordinating care—a major issue in the Shin case—as evidence that the case’s outcome will not markedly change Harvard policies.

Iuliano writes in an e-mail that it is “awfully hard” to predict how the Shin case will effect Harvard.

And Hyman says the case is not a serious factor in shaping mental health policy for Harvard.

“We’re not going to be driven by the Shin case,” he says. “We’re going to be driven by taking the best possible care of our students.”

–Staff writer Katharine A. Kaplan can be reached at kkaplan@fas.harvard.edu.