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Legal/Ethical Considerations for
Accommodating Students with
Mental Health Diagnoses
CAPCSD 2016: San Antonio, TX
1
Disclosures
 Financial
 Florida State University: Employee
 CAPCSD: Complimentary conference
registration
 Non-financial
 Council of Academic Programs in
Communication Sciences and Disorders
(CAPCSD): President-Elect
 Personal bias: Mood disorders are prevalent in
my family
2
Mental Health on Campus
(From NAMI, 2014)
 At least 80% of college students report feeling
overwhelmed, with at least 45% of those
reporting they felt their situation was
hopeless
 “Mental Illness” describes a broad range of
mental and emotional conditions
 Symptoms can be temporary or long-lasting, vary
in consistency/person/episode
3
 75% of lifetime mental health cases
begin by age 24
 Incidence is estimated to be 25% for
adults between 18 & 24
 More than 25% of college students have
sought professional help for a mental
health condition in the past year
 Most frequent diagnosis is anxiety, with
depression occurring as the next most
frequent
4
 73% of students with a mental health
condition reported experiencing a
health crisis on campus, but 34% said
that no one at their college knew
 40% of students with a diagnosable
condition do not seek help, more than
half do not request accommodations
(NAMI, 2012)
5
 College mental health counseling
centers & offices of disability services
are experiencing ballooning caseloads
 Academic systems tend to rely on
students to self-advocate
 Implies that students are willing to disclose
 Accommodations offered do not always
correspond to needs of the student (McGuire,
Madaus, Litt, & Ramirez,1996)
6
Academic & Clinical
Implications Of Mental Illness
 Untreated severe depression can diminish prolonged
cognitive functioning
 Anxiety may make information retrieval difficult
 Post-traumatic stress disorder may make it difficult to
concentrate
 Malnourishment can lead to decreased cognitive functioning
 Reduced affect from the illness or its treatment can interfere
in clinical interactions
 Difficulty in mood regulation may lead to inconsistent
academic and clinical performance (Beckels & Wheeler, 2001)
7
CASE STUDY #1
8
Diagnoses & Symptomatology
9
Common Diagnoses
 Anxiety disorders
 Generalized Anxiety




Disorder = 3.7%
Obsessive-compulsive
disorder = 1.9%
Panic disorder = 0.6%
Phobias
Post-traumatic stress
disorder
 Mood disorders
 Dysthymia = 4.9%
 Depression = 4.0%
 Bipolar disorder = 2%
 Eating disorders
 Anorexia = 0.2%
 Bulimia = 2.5%
 Other
 Schizophrenia
 Borderline
personality
disorder
10
General Signs & Symptoms of Mental
Illness
 Marked personality change over time
 Confused thinking, strange or grandiose ideas
 Prolonged severe feelings of depression or
anxiety
 Feelings of extreme highs/lows
 Heightened anxieties, fears, anger or suspicion;
blaming others
11
 Social withdrawal, diminished friendliness,
increased self-centeredness
 Denial of obvious problems and a strong
resistance to offers of help
 Dramatic, persistent changes in
eating/sleeping habits
 Substance abuse
 Thinking or talking about suicide
(from Center for Psychiatric Rehabilitation)
12
Signs & Symptoms
In Class/Practicum
 Managing symptoms/tolerating stress
 Fatigue
 Negative side effects of medications
 Understanding areas of sensitivity as
presented by the disability
 Making excuses for missed deadlines/poor
quality work
13
 Being able to devote equal effort to classes
and clinic
 Being able to adjust to changes in demands
presented by different environments
 Recognizing when stress is increasing and
the associated implications
 Willingly asking for help/adjustments
when needed
 Disclosing the disability
14
 Solving problems/organizing work
 Recognizing a problem exists
 Identifying alternative solutions
 Being flexible with solutions
 Prioritizing tasks
 Meeting deadlines
 Following Code of Ethics, organizational
procedures
15
 Assessing own performance
 Recognizing areas in need of improvement
 Knowing when to ask for help
 Setting an agenda for supervisory/academic
meetings
 Interpreting others’ cues
 Maintaining stamina/pace
 Quickly transition from client to client, or clinic
to classroom
 Having energy to spend whole day on
campus/in clinic
 Combating drowsiness from medications
16
 Following schedule/attendance
 Handling time pressures and multiple tasks
 Being on time
 Consistent attendance
 Interacting with others
 Getting along/fitting in
 Interpreting social cues and work culture
 Being professional and accountable
 Responding to feedback
 Understanding/interpreting feedback or grades
 Knowing what to improve or how to initiate changes
17
 Responding to change
 Coping with unexpected changes
 In client needs, assignments, due dates, or instructors
 Initiating new activities
 Sustaining concentration
 Screening out environmental stimuli: sounds,




sights, odors
Restlessness
Shortened attention span
Easily distracted
Remembering verbal directions
18
 Learning essential skills
 Divided attention tasks, e.g., providing
stimulus & charting responses
 Responding to client verbal/nonverbal
behaviors
 Providing feedback appropriately
19
What Can We Do?
“The genius of good communication is to be at the
same time as honest and kind as possible.”
(Center for Psychiatric Rehabilitation)
20
Disability Law & Mental Health
 Section 504 of the Rehabilitation Act of 1973
 “No otherwise qualified person due to disability may
be
 denied participation in,
 denied the benefits of, or
 subjected to discrimination
(29 U.S.C. § 794 (a))
 Americans with Disabilities Act of 1990
 Title II: Prohibits public entities from denying qualified
persons with disabilities right to
 participate in,
 benefit from services/programs/activities
(42 U.S.C. § 12132)
21
 Otherwise qualified
 Person must be able to meet the essential
eligibility requirements of the program
 An individual is qualified for the program if he/she can
meet admission, academic & technical standards
 Administrators may take into account the functional
limitations arising from the disability, provided
limitations are relevant to the reasonable qualifications
 Duty to Investigate
 The program must assess each student’s ability
to succeed given new learning strategies and
adjustments
 Assessment can’t be based on stereotypes
 Courts have deferred to faculty judgment
22
 Fundamental Alteration
 Occurs when requirements of the program of study are
substantially altered or reduced
 Requirements must be reasonable & essential to the program
 If the program believes a requested accommodation is a
fundamental alteration
 Alternative adjustments should be explored
 Reasons the accommodation would be a fundamental alteration
should be documented
 Programs are not obligated to provide the accommodation in
cases of fundamental alteration
 Reasonable accommodation
 Adjustments should match the individual need of the student
 Student should be able to meet core requirements without the
adjustment
 Adjustments should not affect grading standards
23
CASE STUDY #2
24
Why Is It So Hard To
Know What To Do?
We try to make decisions that end up
being led by
our morals vs. our Code of Ethics
Common Ethical/Moral Conflicts
When It Comes to SMI
 Holding welfare of someone else
paramount
 Whose welfare? Client’s or student’s?
 Competence in practice
 Scope of practice
 Dual relationships
 Having both a professional and personal
relationship with someone
Ethical Values
 Autonomy
 Commitment to respect an individual’s
independent actions & choices
 Beneficence
 Obligation to convey benefits and help others
further their legitimate interests
 Harm avoidance (nonmaleficence)
 Obligation not to inflict harm, risk of harm or
evil on others
 Justice
 Equal distribution of burdens, benefits, and
scarce resources
 Professional responsibility
 Obligation to observe rules of professional
conduct with patients, colleagues, students,
community at large
 Truth
 Disclosure of all pertinent information, even if
it may reflect poorly on the informer
28
Morals
 Definitions based on the individual
 Moral judgments are typically subjective
rather than obvious or consistent across
societies or belief organizations.
 Often decided intuitively because of deep
emotional convictions.
 Moral judgments are value judgments that
are made in real time situations (Broidy)
Differences between
Ethics and Morals
 Definitions often overlap




Based on emotions
Can be subjective
Provide guidance/structure to interactions
Occur in real-time
 Many theorists use terms interchangeably
 Both are emotionally-laden constructs
ASHA Code of Ethics
 Definitions
 Diminished decision-making ability: Any condition that
renders a person unable to form the specific intent
necessary to determine a reasonable course of action.
 Impaired practitioner: An individual whose professional
practice is adversely affected by addiction, substance
abuse, or health-related and/or mental health–related
conditions.
31
 Principle I, Rule R: Individuals whose professional practice is adversely
affected by substance abuse, addiction, or other health-related
conditions are impaired practitioners and shall seek professional
assistance and, where appropriate, withdraw from the affected areas
of practice.
 Principle I, Rule S: Individuals who have knowledge that a colleague
is unable to provide professional services with reasonable skill
and safety shall report this information to the appropriate authority,
internally if a mechanism exists and, otherwise, externally.
 Principle I, Rule T: Individuals shall provide reasonable notice and
information about alternatives for obtaining care in the event that
they can no longer provide professional services.
 Principle IV, Rule D: Individuals shall not engage in any form of
conduct that adversely reflects on the professions or on the
individual's fitness to serve persons professionally.
32
 Principle IV, Rule I: Individuals shall not knowingly allow
anyone under their supervision to engage in any practice
that violates the Code of Ethics.
 Principle IV, Rule L: Individuals shall not discriminate in their
relationships with colleagues, assistants, students, support
personnel, and members of other professions and disciplines on
the basis of race, ethnicity, sex, gender identity/gender
expression, sexual orientation, age, religion, national origin,
disability, culture, language, dialect, or socioeconomic status.
 Principle IV, Rule N: Individuals shall report members of
other professions who they know have violated standards
of care to the appropriate professional licensing authority or
board, other professional regulatory body, or professional
association when such violation compromises the welfare of
persons served and/or research participants.
33
AAA Code of Ethics
 Principle 2, Rule 2f: Individuals shall maintain
professional competence, including participation in
continuing education.
 Principle 6, Rule 6a: Individuals shall not
misrepresent their educational degrees, training,
credentials, or competence. Only degrees earned from
regionally accredited institutions in which training was
obtained in audiology, or a directly related discipline,
may be used in public statements concerning
professional services.
34
What Programs Can Do:
Before Students Are On Site
 Clearly state in admissions information and program
policy documents (e.g. program handbooks for
students)…
 Information about disability services on campus and how to
become identified
 Information about mental health services
 The options that exist for students who are unable to meet
program standards
 Due process within the organization
 Non-clinical track
 Dismissal can occur
 Expectations for performance and program policies that
might lead to a student’s dismissal
35
Examples of Policy Language
 “Demonstrate the emotional health necessary to apply knowledge
effectively and to exercise appropriate judgment.”
 Must be “flexible and creative in order to adapt to professional and
technical change and function in new and stressful environments.”
 “The faculty/clinical staff reserve the right to request the withdrawal
of any student whose conduct, health, or performance demonstrates
lack of fitness for continuance.”
 “Demonstrate interpersonal skills appropriate for the profession.”
Based on the professional judgment of faculty through regular reviews
of student progress.
 “Students must possess the emotional stability to enable them to
develop therapeutic relationships and successfully communicate with
individuals….”
 “Students should be emotionally able to handle demanding workloads
and to function effectively under stress.”
 In a definition of “unprofessional conduct”, list “mental or physical
incompetence.”
36
Before students enter cont. …
 Faculty should develop awareness of campus
resources such as mental health and
disability services
 The program should have written
documentation of functional skills needed for
successful program completion
 Consider what reasonable accommodations might
be for these skills
 Implement a student review mechanism for
ALL students
37
What Programs Can Do:
Once Students Are Attending/On Site
 Understand potential implications of
accommodating students informally
 Slightly different than “academic freedom”
 Confusing to the student
 May create an environment where the student
learns to manipulate the system
 May create a potential legal problem down the
road
38
 Privacy
 The student does not have to disclose specifics
about the disability to the
instructor/supervisor/department
 The program CANNOT disclose information to
 Off-site supervisors unless
 The affiliation agreement specifies that the student is there
for an academic (clinical) experience – be very careful about
this
 The student authorizes release of information
 Other school officials (e.g., even department
colleagues) unless there is a “legitimate educational
interest”
 Parents if the student is > 18 unless the student is a
dependent for income tax purposes
39
 CAN disclose information
To law enforcement agencies
In connection with an emergency
40
Possible Accommodations for SMI
 In the classroom









Use preferential seating
Assign accompanier/classmate/volunteer assistant
Permit beverages
Schedule pre-arranged breaks
Increase frequency of grading opportunities
Allow delay for assignment due dates
Use flexibility in determining full-time status
Allow “stop-out” vs. “drop-out”
Assign incompletes vs. “F” or “W”
(Center for Psychiatric Rehabilitation)
41
 When considering accommodations for
clinical settings…
 What is expected of all students at this stage of
clinical development?
 Is the student “otherwise qualified?”
 What are the essential/nonessential functions
of the practicum assignment?
 How will you evaluate the functional
limitations of the student in this assignment?
42
 In clinical settings
 Assign a co-clinician
 Permit beverages
 Allow pre-arranged breaks
 Adjust clinic/internship schedule
 Change supervision model
43
If You Have GENERAL Concerns
About A Student
 Be open and honest
 State that you are concerned
 Make specific observations
 I’ve noticed that …
 In the past, other students I’ve known who …
 I’m wondering whether this might be true for you?
 Ask questions
 Are you eating
 Are you sleeping
 Does anyone else know you’re feeling a bit stressed right
now?
 Has this ever happened before?
44
 Offer some options
 Talking with advisor
 Contacting on-campus resources
 University counseling center
 University health center
 Psychology department?
 Crisis lines
 Suggesting the student talk to his/her physician or
religious advisor
 Document that your observations, the
interaction, and any steps discussed/taken
45
If You Have Concerns About
An ACUTE Situation
 Recognize signs of decompensation
 Extreme emotion
 Physical symptoms – shaking, sweating, changes in
respiration, noticeable lack of cleanliness/neatness
 Cognitive symptoms -- Not processing/distracted,
inappropriate responses in conversation or in writing
 Other symptoms: Unusual behavior or speech that you’ve
not observed before
 Be open and honest
 I am very concerned
 I need you to be very honest with me right now
46
 Make specific observations
 I’m noticing that …
 Ask questions
Can you tell me what’s going on?
Are you sleeping? How much/how often?
Are you eating?
Are you taking anything?
Are you seeing a doctor?
Does anyone else know you’re struggling right
now?
 Have you had any thoughts about hurting
yourself?
47






 Take action
 I am not comfortable with you leaving my office
until I know you are going to be cared for by
somebody
 Would you like me to call or would you like to
make the call from my phone?
 State to the service provider that it is an
emergency and the student needs to be seen
immediately
 Counseling center, health center, student’s
physician, university police
 Is there anyone else we need to call (e.g., parents)
48
Document your observations, the
interaction, and the steps taken
49
CASE STUDY #3
50
When Is Dismissal Appropriate?
 When a student fails to meet grade or other
academic requirements
 Cannot require that a student attend therapy or
take medication as a disciplinary measure
 Can determine that “fund of knowledge” is
insufficient
 Faculty has right to use “professional, academic
judgment that a student cannot meet the
school’s academic requirements”
 Clinical experiences are considered academic
requirements
51
 To dismiss a SMI
 In general, wrongdoing/insufficient
performance must be carefully
documented
 All students must be subjected to same
policies and procedures
 Appropriate due process must be
provided
52
Dismissal Is Appropriate When…
 The student is failing in spite of accommodations
 Is there a flow from probation to dismissal?
 Are there clear criteria for dismissal?
 Has due process been followed?
 Documentation of functional limitations and
accommodations attempted
 Honest discussions with student
 Advance warning
 Have alternate steps been explored?
 Changes in accommodations?
53
 Dismissal
 Can be dismissed for disciplinary reasons when there
are violations of
 Criminal laws
 University code of conduct
 Program code of conduct
 Office of Civil Rights emphasizes that prior to dismissing
a SMI for failure to meet essential function standards,
the university must provide the student
 Reasonable notice of the standards
 The basis for the belief that the student is not meeting
the standards
 A reasonable opportunity to modify the behavior or
engage in counseling
54