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Chapter 5: Handling Emergencies Abroad

Mental health concerns create some of the greatest challenges and frustrations for on-site staff who are responsible for study abroad students. You will face these challenges whether you are a faculty or staff member of a university outside the United States, a faculty member leading U.S. students in education abroad programs, a resident director, or an on-site staff member of a U.S.-based provider of study abroad programs.

One of the reasons that mental health emergencies can present significant challenges to problem solving is that the person who needs treatment is not necessarily capable of responding in his or her own best interests. While you must develop policies to address these issues, keep in mind that each case must be assessed and treated individually. Your readiness to manage on-site mental health crises depends on the thoroughness with which you have planned your program—regardless of the length of your program. Students with mental health issues can and do select programs of varying durations: semester-long, year-long, or short-term. If you are a member of a university based outside the United States and are attracting students to your university directly, you need to consider how you might address a wide range of concerns at your institution.

The following activities are options for minimizing risk both to students and to your program:

Identify the local resources for handling mental health crises.
Analyze whether Western treatment practices exist locally.
Obtain the cost and availability of existing psychological treatment.
In a foreign language setting, does the U.S. consulate or embassy have a list of English-speaking specialists to recommend? If so, visit a few and speak with them about the needs of your U.S. student population.
If no psychological counseling is available, you must provide this information to students up front. In some cases, students may need to select another program.
In predeparture settings, ensure that students will be advised about counseling options and availability of psychotropic medications abroad.
Create budget allocations for handling potential mental health crises.
Make sure you have emergency contact information for every student and the student’s written permission to use it in case of a crisis. Obtaining student permission is particularly important if the student is an independent adult.

U.S. Campus Resources

Assistance is readily available for crisis planning on U.S. campuses. Get to know on-campus colleagues with expertise in crisis management, including risk managers, counseling center staff, the student affairs staff, legal counsel, residential life, and campus police—the list is virtually endless. These professionals can help you identify resources on your campus that can be helpful if a mental health crisis occurs abroad. If applicable, plan ahead so that the student who is abroad can consult with a campus-based counselor if resources are not available at the study abroad location.

Invite your counseling and health center colleagues to speak to students at predeparture orientations (see Chapter 3). The more they learn about your study abroad programs, the more they can help students develop appropriate treatment plans when abroad. Identify individual on-campus professionals who can assist you with making difficult decisions about an individual student.

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Student Program Contract

In setting up the program, ensure that you have rules of participation indicating what happens if a student becomes a danger to him- or herself or to others. Sometimes an additional behavioral contract can be drafted (either before departure or on site) in which a student acknowledges the advice provided about using resources on site (see Chapter 2). Under a behavioral contract, you can insist that the student continue with treatment while abroad as a condition of remaining in the program. Specific language in the contract will help when making difficult decisions. Clear contracts also allow you to spend more time focusing on assisting the student and less time worrying about your legal liability. The safety of your student group—as well as the individual student—should be foremost.

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On-site Orientation Programs

It is vital that on-site orientation programs include a health section that provides students with a sense of personal responsibility for their well-being. Encourage students to stay on their prescribed medications—even if they feel better and believe that they no longer need them. Advise students always to seek a medical opinion before changing the dosage of their medication or discontinuing it. Some people suffer relapses when they go off their medications.

Provide all students with specific physical and psychological resource information during orientation presentations. This information should be in writing and on the Web so that students can reference it in private.

In addition, provide students with a confidential or anonymous method of reporting concerning behavior of other students. As mentioned throughout this document, students often are the first to notice signs of emotional and mental distress in their peers, and giving them the means of reporting this information confidentially could help education abroad professionals intervene before a problem reaches a crisis stage.

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On-site Staff Methods for Checking on Student Well-Being Peers

Peers

Other students participating in an education abroad program may notice unusual behavior and become concerned about a particular student. They may then ask on-site staff for intervention. Staff should listen to these students—they have their radar up and are good gauges about “normal” versus “abnormal” behavior. To protect the student’s privacy, do not share information with the reporting student.

Students in crisis sometimes will turn to another caring student as a confidante and sole support. If you become aware of such a situation, take an active role to support both students. The second student may be taking on too much responsibility and might even be jeopardizing his or her own academic success. After you have connected the student in crisis to a mental health professional, give permission to the student who has been helping to stop taking care of his or her peer and return to his or her own work and enjoyment.

On-Site Staff

All on-site staff should have a mechanism for following up with students who have been in crisis. This may seem like an odd request to university staff outside of the United States. (After all, these students are adults, aren’t they?) U.S. undergraduates—in broad terms—are used to a certain level of involvement by administrators and staff. Creating a check-in program can help. Require students to stop by the office or check in with a faculty member on a weekly or at least monthly basis. Actively seek out any students who do not seem to respond to these efforts.

Be on the lookout for the following symptoms of mental illness:

Depressed mood most of the day.
Markedly diminished interest in almost all activities.
Significant weight loss when not dieting, weight gain, or decrease or increase in appetite.
Insomnia or increased sleeping.
Restlessness or slowing down of body movements.
Fatigue or loss of energy.
Feelings of worthlessness or excessive or inappropriate guilt.
Diminished ability to think or concentrate, or indecisiveness.
Recurrent thoughts of death (not just fear of dying), recurrent thoughts of suicide, or a suicide attempt.

Substance abuse (alcohol or drug or both) can also be a sign of an underlying condition as students try to alter or mask symptoms they have detected but have not addressed with a counselor.

Diagnosis

Unless you are a mental health professional, do not attempt to diagnose a student. If you detect symptoms of mental illness or if a student brings these concerns directly to you, refer the student to a trusted professional in the mental health field.

While you may have concerns about signs of trouble, not all signs imply a mental health concern. Many of us in the field of education abroad see students out of context; they are new to us and we have trouble seeing them as they were a semester ago (or earlier). It can be difficult to ascertain whether what students are experiencing now is new and different—and significant.

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Cultural Differences with Mental Health Treatment

You may find yourself in a culture that does not accept the existence of a psychological basis for illness. Similarly, a student with a mental health condition may not be open to treatment due to cultural or religious values. If this is the case, you will not have traditional Western treatment resources available to assist the student. If the symptoms are severe, you may be faced with the difficult decision of whether to end the student’s program. If the symptoms are not life-threatening but he or she needs counseling, there are options.

Review the online resources listed at the end of this document. Gather feedback from mental health professionals at a campus-counseling center to see which online resources, if any, they would recommend for a particular type of scenario.

When online resources are inadequate, telephone the student’s program in the United States to inform staff of the student’s situation. The U.S. program will work with its counseling resources to determine an appropriate response. It may be possible to arrange for the student to have a private consultation. Decide how you will pay for the phone consultation and how you will protect the student’s privacy while the call is in progress. Ask the student to sign an authorization for the release of medical information so you can talk with the mental health practitioner and ask for an evaluation and suggestions for how you can best help the student. Ask whether the student can reasonably remain in the program—with or without support from the United States. If telephone counseling is advised, you will have to determine who will pay for the calls and the method of payment.

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When Things Go Wrong

Self-Disclosure

It is important for your institution to encourage self-disclosure of mental health concerns. (For a more detailed discussion, see “Encouraging Disclosure” in Chapter 4.) You should have a confidentiality policy and an established record of keeping issues in confidence.

If you have a mechanism for documenting students’ preexisting mental health conditions, you can help the student put in place an appropriate treatment plan while abroad. For example, when a student has disclosed a history of depression, anxiety, or bipolar disorder, you can be proactive and help the student arrange on-site treatment before the student departs on the program. This avoids any interruption in treatment and allows medication management to continue without change. Students who have successfully transferred their treatment to providers abroad are more likely to succeed. What’s more, when your program has documentation of students’ specific mental health concerns, you can more effectively manage any related crises that may surface later on. Such information might be critical to quickly mobilizing appropriate resources and interventions when a student’s safety is at risk.

No Previous Diagnosis or Non–Self Disclosure

The greatest difficulties arise with students who have no previous history of mental illness or treatment. Some of the most significant psychological disorders, such as schizophrenia or bipolar disorder, present in late adolescence or the early 20s. Additionally, students who have a prior diagnosis but fail to disclose may experience a serious relapse. These students may attempt to cope in their own way with psychological changes that are frightening and make them feel out of control. In these cases, as an education abroad professional, you may have to deal with the student’s resistance to any treatment. This can delay critical care for common but sometimes serious mental health conditions.

Nonadherence to Medications Abroad

Adherence to medication or the extent to which a student follows medical directions while abroad poses an additional difficulty. As they do on their home campuses, students sometimes stop taking their medication while abroad when they think they feel better or when they find alternate coping methods. Other times, students decide to stop taking medication because it loses its potency, needs to be adjusted, or has unacceptable side effects. Students might not anticipate that their problems could reemerge—sometimes with greater intensity. Another complication is ensuring the availability of adequate medication. Ultimately, it is the student’s responsibility to verify the availability of required medications abroad and to work with his or her education abroad adviser to make sure that the medication is available abroad and determine a course of action if it is not. Keep in mind that students travel with a limited amount of medication for a variety of reasons. Some plan to have the medication shipped to them, not realizing that laws in certain countries do not allow this and that certain FDA-approved medications—including commonly prescribed medications for depression and Attention Deficient Disorder (ADD)—are not widely available or even legal abroad.

Determining that a Student Needs Help

Knowing when a student is in trouble is highly subjective. Experience and judgment combine to make the best decisions. Some students function well coping with major difficulties, while other students have difficulty with seemingly minor issues. In the education abroad setting, which requires an ability to change and adapt and where students do not have as much support, events that may not have bothered students at home may be overwhelming.

When a student’s behavior begins to interfere with his or her ability to attend class, to complete assignments, or to adapt culturally—or when he or she exhibits any of the symptoms listed earlier in this chapter, call the student in for a discussion.

More obvious signs that students need help include engaging in risky behavior, becoming delusional, or attempting suicide.

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Psychological Evaluation

When you determine that a student needs psychological treatment, work with the student’s U.S. program and insist that, as a condition of remaining in the program (see program contract above), the student obtain a psychological evaluation. This action is vital if you believe that the student’s behavior is life threatening (e.g., threatening harm to self or others, suicidal thoughts, anorexia, severe bulimia, or schizophrenia).

Suicide attempts, no matter how ineffective, should never be taken lightly and must be considered a little differently than other behaviors. Without intensive professional help, the student may feel worse and you will not know if or when he or she is likely to make another attempt. It is usually best for the student and the program to send the student home.

If on-site mental health resources are available, consult with a specialist and have the student evaluated. The purpose of the evaluation is to determine the feasibility of the student staying in the program. Ask the student to sign an authorization to release medical records so you can obtain the student’s diagnosis and learn what treatment plan is recommended.

As the program official responsible for the well-being of the students, you must then consult the student’s home institution and collaborate on a decision about the future of the student in the program.

Example: A female student in Costa Rica begins to faint on a regular basis. Her U.S-based education abroad program provider arranges for its overseas staff to take her to see a physician, where she is diagnosed with bulimia and anorexia. The student has severe electrolyte imbalances that result in her fainting. Her host family volunteers the information that she is vomiting after meals.

She is taken to a psychiatrist, who recommends that she may stay in the program as long as she is able to follow a closely monitored medically devised plan.

Her education abroad program provider creates a behavior plan so the student can remain on the program and put it in writing to her, citing the “danger to self” clause in her originally signed contract agreement. She must continue with psychiatric treatment through the duration of the program (five weeks) or until medical/psychiatric treatment is no longer considered necessary. The student is required to sign and date the behavioral document agreeing to the contract or return home.

The student agrees to the conditions of remaining on the program and the psychiatrist provides updates every few weeks. The student returns home having successfully completed her coursework and adhering to the program requirements.

This arrangement was not stress-free. The student was not cured overnight, suffered two setbacks in treatment, and was not particularly happy with the arrangement. (Note that if the student in this example had not been participating in an education abroad program organized by a program provider, the consultation would have taken place between the student’s U.S. university and colleagues at the host university abroad.)

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Determining Whether or Not a Student Should Return Home

The following items should be considered when determining whether or not a study abroad student should return home:

Level of disruption of behavior to the program (e.g., peers, classroom structure, and host family, if applicable).
Danger to self or others.
Length of return flight; number of airport transfers to get home.
Timing: crises often do not occur during business hours. Make sure that U.S. and overseas education abroad professionals know how to contact each other and additional colleagues upon whom they rely for advice, 24 hours a day, seven days a week.
Overseas-based education abroad professionals need to be aware that the brunt of the burden of dealing with a student in crisis may fall on them after business hours or on the weekend.
Some of the most serious psychological illnesses present in late adolescence or the early 20s. These illnesses include schizophrenia and bipolar disorder.

Hospitalization

Some conditions will be severe enough to warrant hospitalization, which can occur voluntarily or involuntarily. If the student is deemed to be a danger to him- or herself or others, or is in a delusional state, the police and emergency services can be contacted for assistance in hospitalization. This is also known as committing or sectioning.

Contacting the police or emergency services to evaluate the student for possible hospitalization is a distressing decision for an on-site education abroad professional to have to make. This decision should almost never be made alone, but rather in consultation with the student’s home institution. The student’s home institution will contact the student’s family. You can make this decision when the student’s life is in danger, when the student is so disabled as to be unable to care for him- or herself, or when the student is threatening to harm others. The safety of the student and of others is the most important consideration.

Once a student is hospitalized, the staff must decide when he or she must leave the program and how he or she will return home. Review the following questions to determine how to get the student home.

Under what conditions will the hospital release the student? And to whom?
Does the student’s insurance coverage include medical evacuation?
If not, how will the student get home? Does the student already have a ticket?
If not, how will you pay for the ticket?
Will medical personnel need to accompany the student? How will you identify such a person?
If yes to the above, who will pay for someone to accompany the student?
Will the student need to be medicated?
How long is the international flight?
How many airport transfers will there be?
Will the student need to be transferred to a medical facility once he or she lands or can he or she go home?
Who will pack the student’s belongings and send them to the home address?

Having a person committed to a mental health institution instead of a general hospital overseas may differ depending on the country. Find out ahead of time what conditions are like in these institutions, and whether the treatment meets human rights standards and protections. Visit Mental Disability Rights International on the Web at http://www.mdri.org for additional information.

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What to Do When a Suicide Occurs Abroad

Suicide is the most tragic result of a mental health crisis in study abroad. (For a more detailed discussion, see “Suicide” in Chapter 2.) If a suicide occurs abroad, the police will be called in to determine the cause of death. Work with the appropriate police department to secure the room or apartment and student’s personal property. Contact the bank to seal the student’s account until further notice and request information about procedures for his or her family to access the account. The U.S. Bureau of Consular Affairs follows established procedures to handle the death of a U.S. citizen. It will contact the U.S.-based family and work with you and the student’s insurance carrier to take over the case. For non–U.S. citizens on a U.S. education abroad program, check with a representative from the country of origin as well as the family.

In partnership with the student’s U.S. university, you will need to follow established procedures to contact the next of kin, legal guardian, or parent of the deceased. The body will be repatriated. Insurance companies often have services in place to take over this arrangement (once a claim is filed). Part of your risk management planning should include a review of the insurance policies of the student group. If a tragedy occurs abroad, you will need to implement the insurance that the student, the parents, or the degree-granting university has provided.

The family will need to receive death certificates for repatriation and other purposes. Foreign death certificates are issued by the local registrar of deaths or similar local authority. The certificates are written in the language of the foreign country and prepared in accordance with the laws of the foreign country. Although one can obtain authenticated copies of the foreign death certificate, since the documents are written in the language of the foreign country, they are sometimes unacceptable in the United States for insurance and estate purposes. In the United States, a “Report of Death of an American Citizen Abroad” issued by the U.S. consular officer is generally used as proof of death in lieu of a foreign death certificate.

You will need to arrange for trauma counseling for other students in the education abroad program and possibly for yourself and other staff members. You may also want to provide other program participants with a list of various religious resources.

If needed—and if possible—designate space at the host institution or program offices for “safe rooms” where students, teachers, and staff can receive comfort and counseling and talk about events during the crisis. Another approach is to quickly identify the students, faculty, and staff who knew the deceased, call them together, and provide them with a structured time to receive accurate information and be able to express their feelings. If possible, it is best to have a mental health professional present. It is important not to glorify the person who died in order to avoid copycat behavior.

Be alert for other students at risk. Bereavement after suicide is a profoundly difficult experience. The stigma of suicide, as well as the painful emotions it engenders, often leaves survivors feeling isolated at a time in their lives when they are most in need of support. Be especially watchful about suicide contagion. Health and counseling professionals must be alert to any warning signs (e.g., verbalizations about committing suicide; mood changes such as becoming despondent) that a survivor himself/herself is experiencing suicidal ideation or intent. Such persons must be referred to a health professional qualified in suicide prevention.

Another important role is to quell rumors and to ensure that information is factual and sympathetic in nature. Documentation must be thorough and factual. If the death draws media attention, do not speak with a representative of the media without first contacting the student’s U.S. university. Collect memories of the student from other students—any photos or mementos will be helpful to the grieving family left behind. Practical matters will include packing up the deceased student’s belongings, supporting the deceased’s roommate (if applicable), credit and grade resolution, and program fee questions.

Finally, arranging a memorial service can be a healing process for the community. The student’s home university and/or host university abroad may support this and may already have a plan in place to provide services in accordance with the deceased family’s wishes.

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Managing Communication When a Crisis Occurs

Document, Document, Document

When dealing with a crisis, it is important to document who, what, when, where, and how the crisis happened and what your crisis response has been. If there are limited staff resources available during the actual crisis, record your data into a voice recorder or devise a shorthand system so you can create a full report after the crisis has passed.

Informing University Officials

This publication is addressed to several different audiences. Each of these audiences will have institutional rules for privacy. Follow your own privacy policy with regard to notification of family, university officials, and local officials. Make sure your policy is in writing and that you have it handy in the face of an emergency.

In the United States, follow the “need-to-know” rule. Be careful to advise only those people who need to know about this particular incident. This could include next of kin as well as educational administrators (registrar, dean, etc.) or faculty members from the host and degree-granting universities. Notifying program officials whether in your country or in the United States is essential. U.S. faculty or staff members leading a group should have a list of U.S. campus officials sponsoring the program to contact in the event of an emergency. Update these contacts regularly. Written documentation, as described above, should occur after the crisis is over.

Parents

Most U.S. degree-granting universities have included parents of this generation of students in much of the university planning. Many study abroad providers also write to parents as part of their communication system. Parents see themselves as customers and they expect to be included. Given that there are several U.S. laws that govern the release of student information to a third party, refer parent inquiries back to the student’s U.S. university when in doubt.

Avoiding parents during a crisis does not make sense. If the student has already self-disclosed, it is likely you have already spoken to the parent about the student’s potential problems abroad. If the diagnosis is new and the student has signed a release, contact the parents directly. In some cases, it may become necessary for a guardian or parent to fly to the host city. Often they may feel more comfortable if they can be there.

If the student is in danger and is still a dependent, notifying the parents or next of kin of this emergency does not violate their privacy. Check with your legal counsel to obtain his or her interpretation of this point. Some university/college attorneys advise that, in the face of potential death or extreme suffering of a student, they would rather defend the decision of violating the student’s privacy than defend why the parents were not contacted.

Credits and Grades

Tying up the loose ends of credit and grades can be a vital part of this process. Having a stated policy for providing credit and grades following a crisis can relieve part of a student’s overall anxiety. Make sure your policy includes a provision for when you are able to guarantee credit, when the student can continue his/her studies from home, or whether the student’s condition is severe enough that credit and grades cannot be granted.

Refund Policies

Have a stated policy available for the student regarding his or her costs for discontinuing the program or for interrupting the program while seeking treatment.

Staff Support

After a crisis has occurred abroad, it is important that any students and staff who became involved are permitted to speak with a counselor at no additional cost to themselves. Individual crises can have a profound and lasting effect on those left behind. One group session can be an enormous help to the program.

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