a case study in education abroad
Who is Playing Bach?: Managing Students in Crisis
Mental health, student behavior, and study abroad management
“Who is playing Bach in the middle of the night?” Louisa Knight, Resident Director of the Pendleton College Study Center in Eastern Europe thought. Glancing at the bedside clock displaying 3:00 a.m., she listened for a moment longer. She realized no one was playing Bach. It was her cell phone. She scrambled, expecting the worst. 3:00 a.m. calls were never good news. She fumbled the phone open and said “Hello?”
Louisa Knight had been Resident Director of the Pendleton College Study Center in Sofia for almost six years. Originally a teacher of languages with strong TEFL skills, she ended up living in Bulgaria when she married a Bulgarian physician. For several years, she had lectured at the local university. But teaching English—even literature at this level—simply didn’t motivate her. After a maternity leave seven years earlier, she decided to change careers and find something that would combine her education and her love of Eastern European history and languages with her extensive knowledge of all things American. As a U.S. citizen with a dual Bulgarian passport, working for a U.S. organization seemed like an ideal opportunity.
Pendleton, a small, Midwestern liberal arts college with 1,500 students, operates nine study centers of its own in a consortial arrangement with ten similar schools spread across the mid- and southwestern U.S. The school boasted a lovely setting, a long history of success, a mid-sized endowment, and a good reputation for a quality liberal arts education. More than half of Pendleton’s students moved on to graduate school, and its students consistently demonstrated a strong interest in study abroad. In a typical semester, Sofia has 15 to 20 students, mostly from Pendleton and other consortium members.
To make the numbers work, students from non-consortium schools with strong academic backgrounds were allowed to apply to Sofia. For those students, Pendleton served as the school of record, awarding transfer credit to qualified non-consortium students. Each semester, there were four or five such students. In Pendleton’s view, their participation was good for the program. The students typically performed well, and their tuition helped the program’s bottom line. These students contracted independently with the Pendleton study abroad office for admission and enrollment in the program, and the program arranged transfer credit with the Pendleton registrar, issuing transcripts to the students.
For students within the consortium, admission and enrollment protocols were similar—although students from consortium schools had clear preference for admission and worked primarily through their own schools’ study abroad offices.
Each school in the consortium took the lead role with one or two of the study centers operated by the group. In the case of Sofia, Pendleton was the lead college and Dean Elliott Thompson, Associate Dean of Academic Affairs and Faculty, provided oversight for the operation. As a practical matter, the head of Pendleton’s Eastern European languages department provided a good deal of the academic input. Budgets, management control, and problems, however, were managed by Dean Thompson’s office.
A Call for Help
As Louisa slowly awoke from her sleep, she recognized that the call was from a host family. Students in the Pendleton College Study Center were, whenever possible, housed with local families who provided a private room and two meals per day for a monthly fee. While the money was a motivator, in most cases the families had children and a desire to have an English-speaking college student living with them. The families were wonderful hosts and greatly enriched the value of the program for students; host family experience was consistently rated as a high point of the study abroad experience.
Half awake, it took Louisa a few moments to get her thoughts together to understand what was happening. As she listened to Mrs. Radaskin talk, she also tapped her husband awake. This was one of those times when it was good to be married to a doctor. Evidently, the student living with the Radaskins, Snowe McArthur had arrived home at about 11:00 p.m. In all ways, she seemed totally normal when entering the house and Mrs. Radaskin said she gave her little notice other than to say good night.
Tanya Radaskin was a delightful woman in her early forties, an accountant by training and, in Louisa’s opinion, one of the best host parents the program had found over the years. It was obvious as she listened to the call and stirred her husband that Mrs. Radaskin was visibly shaken. As near as she could piece together from listening, at some time after 2:30 a.m., Snowe McArthur had started to yell and scream so loudly that she had not only awakened the Radaskins and their two teenaged children, but also their neighbors on either side of their comfortable apartment—and those above and below as well. Mrs. Radaskin had entered Snowe’s room and tried to understand what was happening, but could make no headway in either getting information or quieting Snowe down. She was, as her atypical late night call emphasized, scared.
By that time, someone had called the police. They had arrived, and the whole building was awake. As is common in such circumstances, curious residents peered through hallway doors to investigate the commotion. The police had first tried to reason politely, but when Snowe struck out at one of them, they quickly pinned her to the floor, handcuffed her for their own protection, and called for help. The main police station, realizing that this might be as much a medical situation as anything else, had sent an ambulance. As Louisa and Mrs. Radaskin talked, Snowe was on the way to the hospital. The Radaskins spoke some English and the police spoke none, but all were convinced that Snowe was somehow disturbed, although no one knew exactly why.
By now, as she listened in one ear, Louisa had roused her husband so that he was awake. He listened carefully to one side of the conversation, nodding as if he was getting the gist of the situation. While Louisa had dealt with a variety of experiences over the years, this type of situation was totally new. Hurriedly dressing to go to the hospital where Snowe was being taken, she looked to her husband for quick medical input.
“I’m a general surgeon, not a psychiatrist,” he said. “I don’t know what to tell you other than that she’ll be evaluated upon arrival. I’ll call the hospital to let them know you’re on the way and married to me so at least they might be polite when you get there. Whoever is attending will surely talk to you and provide more information when you get there. And, perhaps with your English you’ll be able to help out. Good luck,” he said, rolling over and quickly falling back to sleep, a trick most doctors acquired early in their medical training.
Facing the Unknown
Within 10 minutes Louisa was at the hospital emergency room. She identified herself, and after a little bureaucratic wrangling, was quickly led into a waiting room to see Snowe McArthur. “Thank God there is no HIPAA here,” she thought. Snowe was lying quietly on a cot in a small curtain-enclosed portion of the emergency room. She had wrist restraints on but they hardly seemed necessary. She appeared to be half asleep.
Louisa touched her arm and said hello, and while Snowe was definitely groggy, she did smile and respond politely. She hardly seemed the person that had been described on the telephone. Louisa did notice as she lay there that she had lost a lot of weight since arriving in Sofia. How much, she wasn’t sure, but clearly this young woman was a lot thinner than when she arrived, having gone from pudgy to gaunt. Louisa didn’t see all the students all the time and therefore hadn’t noticed. In the back of her mind, Louisa wondered why no one had mentioned it. She kept Snowe company while she waited for the attending physician to appear. The nurse had assured her the wait wouldn’t be long. He arrived in about an hour, apologizing for being behind schedule. He politely introduced himself, said a few nice words about her husband, and then summed up the situation.
“We’ve given her some very strong calming medication and she’s going to sleep through the night. There is nothing wrong with her physically that we’ve observed. My English is not all that good, but she was crying out that ‘nobody loved her and she couldn’t bear it anymore,’ whatever that means, when she arrived. We needed to calm her down. I think she’ll be fine for tonight. I’ve arranged for one of our psychiatrists to see her early in the morning. I would suggest that you check her medical records and come back about 8:00 a.m. She’ll rest until then and there’s nothing more you can do at this time.” Louisa thanked the physician, gave her cell number to the chief at the nurse station so they would have someone to call if they needed a contact, and headed over to the office to pick up Snowe’s records before returning home. As she walked out the door of the hospital, the first signs of the rising sun were in the sky.
Charting a Course on Unfamiliar Terrain
By the time Louisa had picked up Snowe’s records at the office, talked with her assistant about the situation to let him know she wouldn’t be in first thing, and arrived back home, it was time to get her daughter up and off to school. She also had time to reflect on the situation for a while and start to map out a course of action. As she sat at the kitchen table drinking strong coffee, she wrote on her pad:
- E-mail Dean Thompson to call Snowe’s home school, University of the West
- Call parents after seeing doctor
- Call Radaskins to let them know what is happening
- Check with Snowe’s best friend in program and see if she knows anything
Finally, after a few long moments, Louisa wrote “What next???,” summing up her uncertainty. She was sure there was more she should do, but she had no experience with such matters—much less guidance about how to handle them. She kissed her daughter and husband goodbye and headed out the door at 8:00 a.m. to return to the hospital. What was clear to her was that Snowe McArthur had problems. Her medical admissions form indicated that over the years she had struggled with eating and adjustment disorders. However, with medication, she seemed to function well and the signed paperwork indicated that she was medically capable of completing the program abroad without special treatment or concern. Louisa knew full well that many young men and women in the program had issues of this type and didn’t have problems of the magnitude of last night. This was so outside her experience that she wasn’t sure what to make of it. Maybe Snowe had just fallen off her meds and needed to get back on, she thought.
Arriving back at the hospital, an English-speaking psychiatrist was just arriving at Snowe’s room in the prisoner ward (there being no psychiatric wing, the hospital had admitted her to the most secure area they had available). Louisa explained her relationship to Snowe and the doctor asked Louisa to let him talk to Snowe alone after the two of them said good morning to the young woman. While looking tired and almost hung over, Snowe seemed otherwise fine. She said good morning as if nothing had happened and had a look on her face that said, “What am I doing here?” Louisa explained that she had been brought there by ambulance, having apparently lost some control at her host family’s apartment. Snowe seemed totally puzzled by this information and the doctor asked Louisa if he could speak to Snowe alone as planned. Louisa waited outside.
An hour later the Doctor emerged. “I don’t exactly know her situation. She says she’s never been diagnosed with bi-polar disorder, although the drugs she takes are clearly part of a treatment regimen for that pathology. She has a limited recollection of her behavior last night, although she knows she was upset and behaved inappropriately. She says she has been taking her medication.”
“Is she okay to leave?” Louisa asked.
“I see no reason to keep her for long. She’s totally rational right now. But that isn’t a guarantee she is going to stay that way. You clearly need to talk with her family and physician. Why don’t we keep her until later this afternoon so you can talk with them and then decide how to proceed?” Louisa agreed and said she would be back about 4:00 p.m. She set up a meeting with the doctor for that time.
She stopped in, said goodbye to Snowe, and said she would be back later with some clean clothes so Snowe could go back home. They chatted amicably, although she still seemed pretty “out of it” to Louisa. As Louisa left the hospital she wondered whether “back home” meant in Sofia or the U.S.
Is Anybody Out There?
By 11:00 a.m. Sofia time, which was very early morning in the U.S., Louisa had spoken to the Radaskins, Dean Thompson at Pendleton—who was still waiting to hear from the study abroad office at University of the West—and to Snowe’s parents. Louisa wasn’t sure where to go from there. The Radaskins were obviously shaken and concerned about the welfare of their children and the reaction of the neighbors if they brought Snowe back to their apartment. They didn’t want to seem heartless but they did have other considerations. It wasn’t clear if they would take this young woman back into their home.
Dean Thompson was very sympathetic, but offered little advice about what to do. Pendleton didn’t seem to have any policy to address the situation. He was checking with Pendleton’s legal counsel to see what obligations the school might have. His sense was that Pendleton had no basis to dismiss Snowe from the program over a single incident unless the parents wanted her to return home. Yes, she was a problem, and yes, she might be difficult, but a single incident of a psychological nature was not grounds for program dismissal. He said he would e-mail information after talking to Pendleton’s general counsel.
Louisa was a little put off that Dean Thompson had very little specific advice about how to handle the practical realities of the situation. Louisa had also finally talked to the parents. They had expressed concern for their daughter and Louisa assumed that by now they had talked to her. They freely admitted that Snowe had some problems, but had always managed them well with the aid of drug therapy. They simply asked that Louisa keep an eye on her and to let them know if there was anything they could do to help. They seemed to ignore the fact that their daughter had to be restrained by police and drugged to calmness only 12 hours before. They didn’t see any reason to contact the family doctor listed on Snowe’s application form in spite of Louisa’s suggestion that it might be a good idea.
As Louisa headed back to the hospital, she was unclear about what to do next. This was not like teaching English, she thought. Her husband had put his phone in “do not disturb” mode. He was probably in surgery, so she couldn’t turn to him. Her staff rolled their eyes at what to do. For their money, they simply wanted to send Snowe home. They didn’t know how they were going to find housing for Snowe, much less take care of her. They were also checking on insurance. They were pretty sure there was some sort of psychiatric exclusion in the policy, but no one was sure. No one on staff had ever faced these issues before.
University of the West had not weighed in, but based on what Louisa suspected, they would probably say it was Pendleton’s issue to handle. They were a large university, and she suspected they wouldn’t get involved in the matter. Although Snowe was one of their students, and she was on the program with their permission, they had contracted with Pendleton, and she was now Pendleton’s responsibility. Nor were the Radaskins eager to welcome Snowe back—and placing her elsewhere after this incident was not going to be easy. Sofia had a small-town quality and host families talked. By now, the word would be out.
Just before leaving for the hospital, Louisa received an e-mail from Pendleton’s lawyer with a copy to Dean Thompson. The gist of the message was that the contract had no specific involuntary withdrawal clause for psychological disorders. There was a clause dealing with criminal behavior, drinking, and “other behaviors which might seriously impede the conduct of the program,” but he questioned whether, based on this single incident, they could remove Snowe McArthur from the program on legal grounds without opening themselves to risks.
With those thoughts on her mind, Louisa re-entered the hospital just before 4:00 p.m. While she had fresh clothes for Snowe, she wasn’t sure what to do, where to take her, and/or how to respond further to this incident. Her meeting with the psychiatrist didn’t help much either.
While Snowe was okay for the moment, he said, “There’s no way to know if and/or when the same kind of incident, or worse, might happen again. My experience is that usually when it happens once, it happens again, and often it’s a more severe break. But it doesn’t always happen that way. She’s a troubled young woman who needs treatment, but she should be able to function day-to-day. I’ve signed her discharge papers for you.” He wished her luck, asked to be remembered to her husband, and left.
Louisa was dumbfounded about what to do next.
COMMENTARY: Preparing for the Unexpected
Mark McLeod, Ph.D.
Director of the Emory University Student Counseling Center
Emory University
This is a familiar scenario that will likely become increasingly common in the future as more students with mental illness histories attend college and participate in study abroad programs. It is certainly not uncommon to find a well-trained faculty member or resident director with little or no formal training in mental health dealing with a potentially severe mental health problem of one of their students.
The scenario demonstrates two common themes: first, that the resident director often has little or no expertise in the area of mental health and consequently feels quite inadequate to deal with mental health related incidents. Second, that the resident director generally makes very good decisions regarding the care of her students, even when significant mental health issues are involved. For example, Louisa’s “to do” list that she develops after a night without sleep is a reasonably good one.
What is critical in these kinds of incidents and seems lacking in Louisa’s program are the established mechanisms necessary for the resident director to feel supported—including access to useful mental health expertise. These kinds of support mechanisms are very helpful in preparing for—and in some cases preventing—mental health emergencies. When effectively designed and realized, they should provide for proper treatment during the immediate crisis, for mechanisms to collect proper information from various resources able to help with intervention and follow up, for ways to deal with potential fallout with host families and fellow students, and for strategies to manage challenges that occur as the intervention plan is implemented.
Certainly in the current scenario there seem to be few clearly developed policies and procedures to deal with mental health emergencies. These kinds of procedures should be available to all front line and supervisory staff. They should also be part of ongoing staff orientation, annual training, and continuing education programs.
While this specific situation may be novel to Louisa, she should have had at least some training to identify and deal with mental health emergencies. At the very least, she should clearly know who to call for help with a student who is having a mental health problem. These procedures should include clear guidelines allowing for communication with supervisors, home institutions, parents, mental health professionals and consultants, and others as deemed necessary for the safety of a troubled student. Such protocols also play a vital role in maintaining the continuity and integrity of the program, no matter what circumstances may arise.
In the present situation, mechanisms should have been in place to allow officials from consortium members, as well as from individual non-member institutions that may have students participating, to speak with each other easily during an emergency. In situations involving mental health related emergencies, the issue of communication and confidentiality can be complicated. The ability to seek advice from a mental health consultant or lawyer who specializes in mental health issues is more than useful. It’s absolutely critical.
In addition to procedures to minimize the likelihood and impact of mental health emergencies, programs should have clear procedures for determining the circumstances in which students could be sent home against their will. These procedures should take care to focus on behavioral requirements (e.g.: students who are disruptive to program operation, refuse an evaluation, or hurt themselves) and not mental health diagnostic criteria which would likely violate ADA rules.
In this scenario, for example, Snowe’s behavior had not yet reached the level necessitating her termination from the program, despite the feelings of some of the staff. However, if she refused treatment, if her behavior worsened, if she attempted suicide or constantly talked about suicide, or if her friends began reporting concerns about her eating habits, she might satisfy behavioral criteria suggesting the need for elevated concern. That elevated concern, backed by documented observations, could then be objectively evaluated to arrive at an informed decision to terminate Snowe’s participation in the program.
These decisions must not be spurious or subjective, and are best made by a team of people, preferably including at least one member with mental health expertise. When considering the decision, team members would have to recognize the need to balance the student’s right to participate in the program with the sponsoring institution’s duty to ensure the safety of its students—and the need to maintain safe, open relationships with hosts and other community members.
It is also important to remember that many students with histories of mental illness attend study abroad programs and complete them successfully, either with or without additional support and oversight by the sponsoring institution. Most study abroad staff with whom I have worked tended to try everything possible to support students with special needs so that those students can have positive, successful experiences. The student grows and matures as a result, and staff feels fulfilled to have made significant, positive impacts on those students’ lives.
In addition to highlighting the importance of having established policies and procedures for mental health emergencies—including procedures for training staff—the scenario demonstrates some other important points related to dealing with mental health issues abroad. For example, the kinds of medications and treatment modalities employed abroad may be quite different from those in the U.S. In some cases, these differences may be quite confusing to a troubled student. Therefore, it would be to the resident director’s advantage to identify ahead of time therapists in the area who speak English and who use Western therapy models. Similarly, it would be helpful for foreign students studying in the U.S. to have access to culturally syntonic mental health care when needed.
The scenario also illustrates the importance of identifying and becoming familiar with students—both before and after their arrival—by checking medical records and making personal contact. This simple step can elevate awareness among program support staff of those students with health concerns, both mental and otherwise. That duty should continue throughout the program, with regular staff contact, thus limiting the risk that profound changes in student health might go unnoticed. Certainly there were many red flags in Snowe’s file that would have allowed Louisa to be aware of her special needs, monitor her more closely, and perhaps prepare the host family in some way; all of which might have averted the middle of the night emergency—or at least provided some useful context.
In closing, colleges and universities across the country are experiencing more mental health challenges than ever before. It is only natural that the experience of study abroad programs would mirror this increase both in the numbers of students with mental health concerns and in the severity of the students’ problems. Colleges and universities that sponsor such programs must have mechanisms established to deal with this increasing challenge. In many instances, the best place to start is with the personnel at their respective counseling centers.
Mark McLeod, Ph.D. is a clinical psychologist and Director of the Emory University Student Counseling Center where he has worked for over 25 years. Dr. McLeod works closely with Emory’s Center for International Programs Abroad as a mental health consultant and has been a consultant for CIEE for the past 4 years. Dr. McLeod has taught study abroad programs through the Emory University Psychology Department which has led to an interest in examining more systematically the phrase so often heard from participants... “It was the best experience of my life!”
COMMENTARY: What To Do When You Don’t Know What to Do
Rodney E. Gould, Esq.
Rubin, Hay & Gould, P.C.
Framingham, MA
Louisa Knight, Resident Director of the Pendleton College Study Center, is obviously knowledgeable about all things Bulgarian, but has no medical degree or knowledge concerning psychiatric disorders. Not surprisingly, Louisa doesn’t have the first clue what to do next with regard to Snowe McArthur.
She does know she has four primary options which will be discussed later in the commentary: (1) pack Snowe up and send her home on the first plane; (2) plead with the Radaskins to take her back; (3) try to place her in another home and; (4) in conjunction with options two or three, arrange for counseling and frequent monitoring of her condition.
Before deciding amongst her options, she must identify the people who have some interest in the events which have transpired and which likely could transpire over the remainder of Snowe’s time in Sofia. These constituent interests include Pendleton, (of which Louisa is a part), Snowe, Snowe’s parents, the Radaskins, any potential substitute host parents, and the University of the West.
Because of privacy concerns—HIPAA aside—it is not at all clear with whom Louisa can discuss the situation. Likely she can legally discuss it with Dean Thompson of Pendleton and related Pendleton officials because it is a Pendleton program and Pendleton has a right to knowledge concerning all aspects of its program, including any problems which occur. Without question Louisa has an absolute right to discuss the situation with Snowe, to go over the ramifications of her conduct, and inquire as to whether medications were not taken, etc. Equally obvious, some inquiry could be made to the Radaskins inasmuch as they were contractees of Pendleton and were the ones who made the 3:00 a.m. call to Louisa. Louisa is entitled to probe and try to determine what happened and to the extent possible why it happened, so as to be able to determine what should be done going forward.
But what is less clear, legally, is the propriety of the call to the parents. Snowe is almost surely an adult (over 18) and unless Snowe in her application specifically agreed that medical or other conditions could be reported and discussed with her parents, it may well be that there is no legal right to involve the parents. On the other hand, the manifest necessity of telling the parents of an incident of this magnitude and of the comments made by the psychiatrist are so overwhelming that one would be surprised if very many Resident Directors did not do as Louisa did. The involvement of the University of the West is more attenuated. It is not its program; its integrity is not on the line. While its student was attending the program, that hardly elevates the University’s right to know of her medical problems.
We assume in discussing the following options that Louisa discusses the various options with Snowe, and that Snowe assures her that she will continue to take whatever medications are required. We assume also that Snowe does not voluntarily wish to go home, and to the contrary, wishes to remain on the program.
Option 1
Pendleton’s lawyer does not produce very positive news as to the right, much less the wisdom, of throwing Snowe off the program. Snowe does appear to suffer from a psychological disorder which could recur, and which could become more serious. On the other hand, there is utterly no specificity as to how much more serious the next episode might be. Is she at risk of hurting herself or simply waking up more of the neighborhood? Is there a meaningful risk that instead of trying to push a police officer, she might throw something at somebody and cause meaningful injury? Can her condition in fact be controlled by additional or alternative medication?
Given this uncertainty, the decision to expel her could be deferred for a short period pending a discussion with Louisa and a follow-up with the parents after insisting that Snowe authorize Pendleton to discuss her condition directly with them and her stateside psychiatrist. Assuming that consent is given and the stateside psychiatrist believes she is stable enough to remain on the program, and that adequate medication is prescribed, the next question is whether either Option 2 or Option is viable. If not, there may be no choice but to send her home notwithstanding her psychiatrist’s beliefs.
Options 2 and 3
These options present no shortage of problems. The Radaskins do not want Snowe back and Pendleton is hardly in a position to force her back on them. Of course, finding an alternative home would be difficult if for no other reason than the gossip surrounding the incident. Moreover, the risk of more significant injury than having the police come into an apartment at 3:00 a.m. exists. While we do not know for sure, it surely seems possible that Snowe’s next episode could escalate into violent conduct directed to the first person who comes into her room which likely would be a host parent. Obviously any future host parent would have to be advised of this risk and agree to assume it.
Assuming Louisa can find acceptable host parents, Pendleton might be able to utilize Options 2 and if all components of Option are satisfied.
Option 4
This option would require the following to take place:
- Snowe’s U.S. psychiatrist must sign off on her continued stay in Sofia, and be comfortable with her medication regimen.
- Louisa must be satisfied that Snowe has her medications, knows how to refill them, and is comfortable in believing that Snowe is in fact taking the medicines as indicated.
- Given the weight loss issue, which no one called to Louisa’s attention, probably some kind of required frequent meetings with Snowe would be necessary. These need not be long nor intense, but they should give a Pendleton representative an opportunity to get a sense of Snowe’s continued well-being.
- If Snowe agrees, a note to Snowe’s parents outlining these conditions should be sent. It is not imperative that it be sent, but it is highly desirable. Some pressure should be put on Snowe to authorize the communication. [We assume the absence of a contractual provision giving Pendleton the right to do so regardless of Snowe’s wishes. Inserting such a provision in the original contract would be highly desirable]. But in any event Snowe herself must agree to these conditions in writing.
Finally, if these conditions cannot be satisfied, her psychological disorder might very well constitute “other behavior which might seriously impede the conduct of the program.” Legally the better course, in that event, might well be to send her home.
Rodney E. Gould is a partner at Rubin, Hay & Gould, P.C., Framingham, Massachusetts, where he specializes in litigation and counseling to members of the travel and tourist industry. He is a Magna Cum Laude graduate of Columbia Law School where he was an editor of the Law Review. He received his Bachelor of Arts from Colby College where he was a member of Phi Beta Kappa.
COMMENTARY: It Was Only A Matter Of Time
Martha Johnson
Associate Director of the Learning Abroad Center
University of Minnesota
Minneapolis, MN
Louisa’s situation is indicative of the increasingly complex nature of managing education abroad programs on-site. She is the archetypical American expatriate educator with local connections found managing programs around the world. Louisa’s educational and cultural qualifications, her commitment to the students, and willingness to problem solve are to her credit. However, she does not have adequate background or training in several vital areas of student services, and Pendleton has not accommodated for this by providing her with appropriate resources.
Conversely, Pendleton’s management of its program in Sofia is illustrative of the laissez-faire attitude institutions sometimes take to managing study abroad program sites. The acceptance of students from other institutions to “make numbers work” may benefit Pendleton’s bottom line, but if appropriate policies and procedures for managing the student experience are not part of the program’s infrastructure, Pendleton may quickly find this route is not the easy solution it had sought.
The designation of the Associate Dean of Academic Affairs and Faculty indicates that the program oversight and development has been grounded in the academic components and curriculum. While Dean Thompson may be well suited to oversee the academics and administration of the program, student affairs issues are not likely to be his forte. And what a shame that Pendleton has not taken advantage of the many resources available right on its campus. Residence life and counseling offices undoubtedly offer basic training to resident advisors and housing personnel that would have better prepared Louisa. Established relationships with these offices would allow Louisa to access advice and act according to established protocols for incidents on campus. Louisa laments in mid-crisis that she has “no experience or guidance about how to handle such matters.” No experience is less problematic, as these skills tend to be gained on the job. No guidance clearly indicates that Pendleton has not provided her with a plan or protocol for crisis management.
Should Louisa have seen this coming? Hindsight tends towards 20/20. However, several systematic checks and balances could have provided a hint or offered a better chance to anticipate the crisis at hand. In cases such as these, a lack of clear ownership can result in a problem for which no one wants responsibility. Pendleton sought to admit students with “strong academic backgrounds” and while academic preparation is crucial to success in study abroad, it is not the only factor to be considered. As the University of the West is not in their consortium, Pendleton may not have required any sort of endorsement from the home school. The University of the West may have approved her participation in the program, but she is likely on a leave of absence or special status. The lack of a nomination process removes the opportunity for the home institution to alert the program of student issues.
To Snowe’s credit, she did disclose her medical history. The anxiety of a new situation and culture is often a trigger for conditions that are successfully under control in the U.S., where resources are widely available and students have greater control over their environment. The disclosure on the form was a squandered opportunity to begin a dialogue with Snowe about her medications and needs before her arrival. A safety net of resources (local counselors and specialists) could have been made available, and the host family advised to assist in assuring her successful adjustment. A proactive approach can also remove the shame a student may feel about mental health issues and lay the foundation for a healthy, continuous dialogue about needs. The on-site staff’s ignorance of the health insurance’s coverage for psychiatric care reveals general lack of awareness regarding mental health issues for their students.
Certainly Louisa’s admission that she “didn’t see all of the students all of the time” is concerning. As resident director of a relatively small program, Louisa should be checking in with participants is some sort of formalized way. While the timeline is not exactly clear, if Snowe had time to lose considerable weight and deteriorate, we can assume enough time has passed to warrant a higher level of personal contact with participants.
At this point, Louisa and the local community have done an acceptable job of handling the situation with a few exceptions. Of special positive note are the Radaskins quick communication of the situation to Louisa, the police’s good judgment in bringing Snowe to the hospital instead of to jail, and the hospital’s identification of an English-speaking psychiatrist who requested privacy when meeting with Snowe. All of these elements prevented further complications that could easily have exacerbated the situation. Louisa seems to be remaining calm, and is communicating with Pendleton for guidance.
But Louisa’s disregard for Snowe’s privacy is alarming. It would appear Louisa has shared private student information with her husband, Dean Thompson, the Radaskins, Snowe’s parents, Snowe’s best friend on the program, the other program staff, and the staff of the University of the West. While many of these stakeholders would certainly merit exclusion from FERPA restrictions, some would not. Her reflection of relief regarding “no HIPAA” demonstrates a disregard for privacy laws as well as ignorance to how they may or may not apply to U.S. students on a U.S. accredited program. Snowe has not been advised of Louisa’s desire or need to inform various individuals, which will likely result in a more extreme reaction from Snowe later. Even when a student is in a fragile state, some level of responsibility in the situation as it unfolds can be crucial to successful resolution. While Louisa’s desire to work around Snowe and inform potentially impacted parties is understandable, it is not appropriate or beneficial to Snowe in the long term.
Other than the e-mail and the list Louisa made over coffee, it would appear that Louisa is not documenting many of her conversations and updates. In complicated cases where contact with health professionals, law enforcement, various institutions, families, etc. all garner separate pieces of relevant information, it is crucial that staff document and verify details. A case like this is likely to be scrutinized in some way in the future, and it will be to Louisa’s and Pendleton’s benefit to have clear documentation to illustrate actions, timelines, and communication.
But of course all reflection on what could and should have been done is somewhat immaterial in the here and now. Louisa needs to quickly formulate a plan of action and make some decisions regarding Snowe’s participation in the program. While the policies for student conduct and behavior for Pendleton students should be fully applicable in this case, the extent to which they apply to Snowe are not clear. Dean Thompson’s reticence to clearly advise Louisa on a plan is again indicative of the very difficult position on-site staff can find themselves in. His sympathy is nice but not terribly useful. His primary investigation has been with general counsel. The Dean’s concerns regarding litigation are obvious, his regard for student welfare somewhat absent.
While much discussion seems to be taking place about “obligations” and whether or not “a single incident of a psychological nature was not grounds for program dismissal,” the central question of what will be best for Snowe has not been addressed. And in fact, Louisa has not asked Snowe what she wants to do. Sometimes in the frenzy to fix the situation, we forget these students are, in fact, legal adults with responsibility for their own decisions. Snowe’s ranting, particularly the statements the she “can’t bear it,” indicate she could be a risk to herself. Her drastic weight loss and general disorientation seem to show some sort of condition past an isolated incident. Louisa needs to engage in a frank dialogue with Snowe offering a few clear options, as well as outlining Snowe’s responsibilities in relation to her choices.
First, Louisa should prepare explicit details for each option to address Snowe’s likely questions as best as possible. For instance, if she chooses to go home, how will Pendleton work with her on her transcript? Can she complete her coursework? What would her financial responsibilities be? A clearly laid out plan that assuages many of her immediate concerns will also reinforce that this option is supported and not viewed by Pendleton as a failure. And the more Pendleton can do to be flexible within reason, the better. A well-supported “escape-hatch,” that removes the stigma of an obvious withdrawal, is often a relief to a student in an anxiety-ridden situation.
If Snowe expresses a desire to stay, Pendleton should immediately create some sort of contract or policy statement that addresses some of the gaps previously identified. It is not unreasonable, given the impact of the previous incident on the homestay and local community, to require Snowe to commit to appropriate terms upon which the program agrees to allow her to complete her studies. These should include an established plan for monitoring her health through updated diagnosis and communication with her family physician, as well as the use of local counselors and doctors. Snowe should also be asked to commit to use of her prescribed medication. The terms should require a system of checking in with Louisa and/or her staff on a regular basis. If Snowe wants to explore such options, Louisa’s biggest challenge is likely to be finding appropriate housing.
Given the recent incident, a new homestay with a family well-apprised in advance of some of Snowe’s history and needs who are willing to partner in her success would be highly desirable and allow Snowe a fresh start.
The case study indicates that most students live in homestays. If a suitable homestay is not available, they may need to explore other options. However Snowe’s fragility necessitates some level of supervision, making more independent options less suitable. In any case, Snowe must agree to the terms of the new arrangement, and the contract should clearly state that her failure to comply is grounds for dismissal.
Neither Dean Thompson nor the general counsel seem to have explored what the policy would be for an incident of this nature on the Pendleton home campus. Given the rise in mental health issues on college campuses in general, they may be overlooking an easily modifiable policy and protocol for an incident of this nature collecting dust across campus. Study abroad programs and the administrators who oversee them sometimes “reinvent the wheel” for the foreign-made model. In the absence of a specific policy (the ideal), at least an existing American-made policy would have provided Louisa with the guidance and plan she desperately needed and deserved when the crisis arose. After all, it was only a matter of time.
Martha Johnson is Associate Director of the Learning Abroad Center at the University of Minnesota. She has worked in education abroad since 1991, including on-site in Ireland, four years based in England, and institutional relations management for several program providers. Martha has been at the University of Minnesota since 2001. She holds a BA from St Mary’s University in Minnesota with a double major in Literature and Theatre Arts and an MA in Literature from the University of St. Thomas with an emphasis in multicultural and travel literature, and post-colonial theory.
COMMENTARY: No Easy Solutions
John Lucas, Ph.D.
Associate Vice President of Academic Programs and Dean for Barcelona, Vienna, and Berlin
IES
Like most resident directors, Louisa Knight is an academic. Her excellent teaching skills, enthusiasm, and cross-cultural background landed her an exciting and challenging position with Pendleton College in Sofia. And like most resident directors, nothing in Louisa Knight’s training has prepared her to deal effectively with the type of mental health concerns that the current generation of college students brings with them as they step off the plane. Louisa has at least three options available to her, none of which are particularly appealing:
Do nothing.
This is the most tempting decision since Louisa lacks information about Snowe’s illness, and the psychiatrist at the hospital said that Snowe should be able to function with medication. However, in the same breath, the doctor cautioned that these episodes frequently reappear. Louisa does not have much going for her in the way of institutional support either. Dean Thompson is reluctant to dismiss Snowe since she has only experienced one psychological crisis, and the College’s polices lack definition and clarity. The fact that Pendleton is in a consortial arrangement with the College of the West only makes matters worse. Perhaps Louisa should just observe Snowe and hope for the best. But what if something worse happens?
Remove Snowe from the program.
At first blush, it seems that this would be the best solution for Louisa. Her staff has no idea how to proceed with Snowe, and the homestay family is naturally wary to have a potentially sick student staying in their home. Who knows what might happen next time? The Dean is not tremendously supportive, but Louisa’s husband is a doctor. Perhaps he could write a strongly-worded letter, with the help of a psychiatrist, recommending that they send Snowe home. However, this means Louisa will have to fight a battle on many fronts. The Dean is not going to be pleased to get involved in a struggle over the dismissal of a student from another consortium university. Furthermore, Snowe’s parents seem unaware of the severity of the incident. What if they refuse to take Snowe home? Louisa probably wonders if her job is at stake in the event the family takes legal action.
Seek further information.
Louisa does not seem to know where to turn. Her husband, a doctor, has already recommended that she speak to someone at the local hospital. Sofia is a mid-sized Bulgarian city, but where else should she go for help? Another psychiatrist? A psychologist? The American Embassy?
The best place to start our analysis of this case study is on the home campus. Unfortunately, Louisa is the victim of poor planning, lack of training, and inadequate support structures. Dean Thompson runs nine study abroad programs along with his consortium and, as such, should have negotiated clear emergency guidelines for resident directors dealing with mental or physical health crises abroad. These procedures should include a chain-of-command, precise action steps, and contact numbers on campus.
The consortium should have hammered out clear guidelines regarding responsibility when two or more universities are involved in a crisis, and incorporated these into their bylaws. Pendleton should also have invested in the proper training for Louisa. Every college in the consortium no doubt has at least one psychologist on staff that could write a handbook or be contracted to conduct mental health training.
Finally, the college should have involved legal counsel, campus mental health services, and study abroad in drafting the code of conduct and conditions for participation that students sign. The procedures are too unclear to be useful in a crisis, and there are gaps here that study abroad and campus mental health could have helped the college legal counsel to fill in. No matter what decision Louisa makes, these documents are her best hope of explaining and defending her decision if called upon to do so.
In this case, the student was forthcoming on her medical form and has volunteered information about her illness to Pendleton. She has been honest with the College and decided to go on the program assuming that she was capable. After all, her doctor signed the medical form, and Pendleton accepted her. Why did the admissions office not follow up and ask Snowe about her problems and her needs while abroad? Pendleton has failed its resident director in this case, and it has done the student an enormous disservice as well.
Louisa is not entirely without fault. She could have prepared herself for this and other emergencies by making a short directory of services available in the city including, at minimum, the name and contact details a psychiatrist, a psychologist, a general physician, a dentist, and a gynecologist.
Dean Thompson needs to take some responsibility. He is duty-bound to provide better leadership and direction to the Pendleton College Consortium of study abroad programs.
As things stand, Louisa cannot afford option one. No matter what the nature of Snowe’s illness, it is clearly a serious matter. Snowe has been diagnosed with something and is currently taking medication. Consider a few possibilities. Bi-polar disorder is becoming more common on campuses, and a resident director would be unwise to take it lightly. Suicide rates for untreated bi-polar disorder can be up to 15%. Bi-polar disorder involves the abnormal shift in moods between two polar opposites: depression and mania. Severely depressed students feel helpless and hopeless. There is a strong statistical relationship between depression and suicide. Eating disorders, such as anorexia, often bring a host of other medical side effects due to poor nutrition.
The medical form, while helpful in this instance, may not be as reliable—or complete—as Louisa might hope. Just because a physician signed off that Snowe is capable of attending the program is not a reason to disregard further risks. Campuses often have a disparate array of physical and mental health services. Given the nature of U.S. privacy laws, these departments rarely speak with one another. Some students will find a doctor off campus or someone whom they do not know to sign their form. In the course of a brief medical exam, it is unlikely that a physician will be able to detect many of the mental illnesses listed above.
Given the legal concerns and the lack of information, it is probably also too early and somewhat rash to adopt option two, and send Snowe home immediately. However, simply seeking more information by itself is not enough. The first thing Louisa needs to write down on her list is to create a file on her computer and to document everything that has occurred and each of the actions she takes. If the situation escalates, Louisa will be too exhausted and anxious to remember the details or to be able to explain her course of action clearly.
Secondly, Louisa should have an open and honest conversation with Snowe. She should tell Snowe exactly what has occurred while she blacked out, if the student does not remember. Snowe is doubtless scared and alone. Being admitted to a hospital is a frightening experience for anyone. Louisa should demonstrate genuine concern for Snowe, and ask Snowe to help her by sharing the nature of her illness. In some cases, giving the student permission to talk about what is troubling opens a dialogue. Many college students suffer in silence and are waiting for the opportunity to share. It is perfectly fine for Louisa to talk to Snowe about suicide and ask her if she has had thoughts about this. It is a common myth that one can “put the idea of suicide into a student’s head.” This is not, however, the case. Most psychologists recommend talking openly with students about suicide.
After writing down everything Snowe reveals, she should contact the campus mental health services unit at Pendleton and/or The University of the West. No doubt, there is a trained professional there who can interpret the information the doctors and Snowe have provided.
Louisa may not have time immediately to get a second opinion in Sofia. However, while she is busy talking to Snowe, Louisa might ask her assistant to contact the American Embassy for the number of an English-speaking psychiatrist or try to locate one locally. The more information that Louisa can gather, the better. If she has a U.S. and a local perspective, she will be better prepared to make a good decision.
Armed with this information, Louisa should contact Dean Thompson by telephone and share the information she has gathered. Most importantly, Louisa should involve Dean Thompson in the decision making process. It is unfair for the resident director to assume the burden for making this decision by herself. She can, however, provide Dean Thompson with information to support the course of action she prefers to take based upon the advice she receives. If the medical advice is to allow Snowe to remain on the program, Louisa and Dean Thompson may want to require that Snowe follow-up with a psychiatrist as a condition to remain with Pendleton College in Sofia.
Dr. John Lucas was formerly the Resident Director of the CIEE Study Centers in Barcelona and Alicante, Spain. He also holds a Master’s degree in international education, including coursework in cross-cultural counseling. He has over ten years of experience directing international programs, teaching Spanish, and advising students on cultural adjustment. He has published in the fields of mental health and study abroad, intercultural communication, and Spanish linguistics. He frequently appears at international conferences and seminars on these topics.