College student suicide: prevention and intervention

There is a lack of research on the literature concerning the policies and procedures higher education institutions and their employees utilize when responding to a student suicide attempt or suicide. Current research on college student suicide is limited for several reasons: (a) there are no federal, state, local, or institutional requirements for higher education institutions to report the number of attempts or suicides on campus; as a result, complete and accurate statistics on college student suicide are not available, (b) there are limited federal, state, local, or institutional directives that guide higher education protocols and procedures for students at risk, and (c) there are inadequate resources and information for evidenced-based practices and programs to prevent or intervene in the case of a suicide attempt or suicide. Consequently, higher education prevention and intervention strategies that specifically address the management and response to a student suicide attempt or suicide differ extensively from campus to campus.

COLLEGE STUDENT SUCIDE: PREVENTION AND INTERVENTION by Annie Nebeker Christensen A dissertation submitted to the faculty of The University of Utah in partial fulfillment of the requirements for the degree of Doctor of Philosophy College of Social Work The University of Utah August 2010 Copyright © Annie Nebeker Christensen 2010 All Rights Reserved The University of Utah Graduate School STATEMENT OF DISSERTATION APPROVAL The dissertation of has been approved by the following supervisory committee members: , Chair Date Approved , Member Date Approved , Member Date Approved , Member Date Approved , Member Date Approved and by , Chair of the Department of and by Charles A. Wight, Dean of The Graduate School. Annie Nebeker Christensen Larry L. Smith 1/25/10 Grafton H. Hull 1/25/10 Frederick V. Janzen 1/25/10 Stayner Landward 1/25/10 Lauren M. Weitzman 1/25/10 Jannah H. Mather Social Work ABSTRACT There is a lack of research on the literature concerning the policies and procedures higher education institutions and their employees utilize when responding to a student suicide attempt or suicide. Current research on college student suicide is limited for several reasons: (a) there are no federal, state, local, or institutional requirements for higher education institutions to report the number of attempts or suicides on campus; as a result, complete and accurate statistics on college student suicide are not available, (b) there are limited federal, state, local, or institutional directives that guide higher education protocols and procedures for students at risk, and (c) there are inadequate resources and information for evidenced-based practices and programs to prevent or intervene in the case of a suicide attempt or suicide. Consequently, higher education prevention and intervention strategies that specifically address the management and response to a student suicide attempt or suicide differ extensively from campus to campus. Given the fact that over 18 million students at higher education institutions could be impacted by student suicide prevention and intervention programs, research on prevention and interventions with students at risk for suicide is critical. This descriptive study utilized the Student Suicide Interview Questionnaire (SSIQ), a 35-item questionnaire that asked college and university supervisors and administrators a series of questions regarding: (1) professional and institutional demographics, (2) institutional suicide prevention efforts, (3) institutional response to a suicide attempt, (4) institutional response to a student suicide, and (5) additional resources campus professionals would like to provide to prevent and intervene with students at risk for suicide. Participants were a purposefully selected sample of 23 college and university officials from 20 institutions from across the U.S. The study identified several critical findings. Nearly all of the professionals were unable to accurately report the number of student suicide attempts or suicides on their campus while a small number of higher educational professionals identified 20-50 student suicide attempts during the past year. Consistent practices that campus professionals utilized to prevent suicide included on-line, mental health screening tools, gatekeeper training, and parent and family education and outreach. iv Love, like life, is much stranger and far more complicated than one is brought up to believe" - Kay Redfield Jamison TABLE OF CONTENTS ABSTRACT ..................................................................................................................... iii LIST OF TABLES ........................................................................................................... viii ACKNOWLEDGEMENTS…………………………………………………………… . ix CHAPTER 1. STATEMENT OF THE PROBLEM ..................................................................... 1 Purpose of the Study .............................................................................................. 7 Assumptions of the Study ...................................................................................... 7 Limitations of the Study ......................................................................................... 8 Definitions of Terms .............................................................................................. 8 Impact of the Study ................................................................................................ 10 2. REVIEW OF THE LITERATURE ....................................................................... 11 Introduction ............................................................................................................ 11 Research on Suicide Among College Students ...................................................... 11 The Current Threat of College Student Suicide ..................................................... 14 College Student Suicide .................................................................................. 14 Suicide in Utah ................................................................................................ 18 Youth Suicide in Utah ..................................................................................... 19 Suicide and Suicide Ideation at the University of Utah .................................. 20 Contemporary College Students ............................................................................. 20 Developmental Time Frames .......................................................................... 21 Millennial Students ......................................................................................... 21 Demographic Changes .................................................................................... 21 Technological Advances ................................................................................. 22 Current Challenges of College Life ................................................................ 22 Factors Increasing Mental Health Issues on Campus ............................................. 23 Sociocultural Changes ..................................................................................... 23 Cultural Shifts to Extrinsic Goals .................................................................... 23 True Prevalence of Mental Health Disorders .................................................. 24 Emergence of Mental Health Issues on Campus ............................................. 24 Current Mental Health Needs of Students .............................................................. 25 More Students with More Serious Mental Health Issues ................................ 25 Increased Need for Counseling Services on Campus ...................................... 26 The History of Preventing Suicide at Colleges and Universities ........................... 26 Higher Education Suicide Prevention Programs ............................................. 27 Mandated Psychological Assessment at the University of Illinois ........................ 31 The Suicide Prevention Team ......................................................................... 32 Landmark Lawsuits against Higher Education Institutions ................................... 34 Frentzel v. Ferrum College .............................................................................. 35 Jain v. State of Iowa ........................................................................................ 37 Shin v. Massachusetts of Technology ............................................................. 40 Current and Future Trends in Addressing Student Suicide .................................... 47 Conclusion .............................................................................................................. 49 3. METHODOLOGY ................................................................................................ 52 Introduction ............................................................................................................ 52 Design .............................................................................................................. 52 Population ........................................................................................................ 52 Sample ............................................................................................................. 53 Instrumentation ................................................................................................ 54 Data Collection ................................................................................................ 54 Data Analysis .................................................................................................. 54 Data Presentation ............................................................................................. 54 4. FINDINGS ............................................................................................................. 55 Introduction ............................................................................................................ 55 Location of Higher Education Experts and Their Campuses ................................. 56 vi Demographics of Higher Education Professionals ................................................. 57 Professions and Titles ...................................................................................... 57 Education Level ............................................................................................... 58 Professional Roles ........................................................................................... 59 Demographics of Higher Education Institutions ............................................. 61 Campus First Responders ................................................................................ 63 Number of Suicides and Suicide Attempts ..................................................... 64 Institutional Prevention Efforts .............................................................................. 64 Mental Health Screening ................................................................................. 65 Campus-Wide Educational Programs ............................................................. 68 Institutional Response to a Suicide Attempt ................................................... 72 Teams .............................................................................................................. 74 Institutional Response to a Suicide ................................................................. 81 Protective Factors ............................................................................................ 85 Risk Factors ..................................................................................................... 86 Services for At-Risk Students ......................................................................... 88 Additional Services ......................................................................................... 88 Recommendations for a Higher Education Suicide Prevention Program .............. 91 Interpersonal Psychological Theory of Suicide .............................................. 91 Thwarted Belongingness ................................................................................. 93 Belongingness and the Effect of "Pulling Together" ...................................... 94 Promoting Belongingness on Campus .................................................................. 95 Institutional Acculturation ............................................................................... 95 Increasing Institutional Engagement Opportunities ........................................ 97 Peer Mentoring Programs ................................................................................ 98 Service Learning Classes ................................................................................ 99 Teaching Life Skills ........................................................................................101 Implement Early Warning Systems .................................................................102 Encouraging the Use of New Technologies ....................................................104 Create Gathering Spaces on Campus ..............................................................105 Interventions for a Student Suicide Attempt ..........................................................107 Mandated Assessment .....................................................................................107 Notification of Parents ....................................................................................110 Interventions Targeted Belongingness ............................................................111 Monitoring a Student after a Suicide Attempt ................................................111 vii Postvention after a Student Suicide ........................................................................112 Postvention Policies and Procedures ...............................................................112 Psychological Autopsy ....................................................................................113 Communicating with Family and Friends .......................................................114 Campus Mental Health Interventions after Suicide ........................................117 The Aftermath of a Suicide .............................................................................120 Avoiding Media Contagion .............................................................................121 Ritual and Remembrance ................................................................................122 5. SUMMARY, CONCLUSIONS, AND RECOMMENDATIONS.........................125 Summary ................................................................................................................125 Findings and Conclusions ......................................................................................125 Demographics of the Professionals .................................................................125 Institutional Demographics .............................................................................126 Institutional Preventions Efforts ......................................................................127 Institutional Response to a Suicide Attempt ...................................................129 Institutional Responses to a Student Suicide ...................................................130 Recommendations ..................................................................................................132 Recommended Practices for a Suicide Prevention Program ...........................133 Institutional Practices after a Suicide Attempt ................................................134 Institutional Practices Following a Completed Suicide ..................................134 REFERENCES ................................................................................................................136 viii LIST OF TABLES 1. Location of Campuses .......................................................................................... 57 2. Educational Level ................................................................................................ 58 3. Professional Responsibilities in the Event of a Suicide Attempt or Suicide ....... 60 4. Public or Private Higher Educational Institution ................................................. 62 5. Number of Undergraduate Students as a Percentage of Institution Size ............. 62 6. Campus First Responders .................................................................................... 63 7. Parent Education and Training ............................................................................. 71 8. Institutions Mandating Assessment ..................................................................... 75 9. Institutional Counseling Services in the Event of a Student Suicide ................... 84 ACKNOWLEGMENTS I express my profound thanks to my committee members without whom this dissertation would not have been possible. Dr. Larry L. Smith, dissertation chairperson, dedicated his energy, time, and patience to the completion of this project. He persevered with me in the design, framework, organization, and writing of the study and compassionately and persistently guided and motivated me. Dr. J. Stayner Landward, former Dean of Students, has mentored and counseled professionally and personally. For over a decade, I have had the benefit of calling Stayner my friend, advisor, and supervisor. Dr. Grafton Hull graciously offered his literary expertise and analytical instruction. I was honored to have him as a member of my committee and recognize his prominence in the field and lightheartedness in the classroom. Dr. Fred V. Janzen taught me statistics with persistence and wit. His criticisms were candid, constructive, and thoughtful. His contributions to my research were selfless and significant. Dr. Lauren Weitzman has supported me by being a superior researcher, clinician, and administrator. For many years, Lauren has been my professional colleague and confidante. Her determined and graceful example has encouraged me intellectually and professionally. Ms. Candace Minchey kindly offered outstanding recommendations and knowledgeable wisdom throughout my tenure as a graduate student. My utmost gratitude is expressed to the 23 Student Affairs professionals across the country that made this research possible by sharing their expertise, insight, and personal and institutional prevention and intervention efforts. A special thank you is due to Dr. Martha M. Dore, Dr. Robin M. Roberts, Dr. Hank Leise, and Dr. Jannah Mather, who challenged my scientific thinking and academic resourcefulness. To Lori McDonald, I express profound appreciation for her logic, calmness, and work ethic that permitted to complete my program. Dr Kari Ellingson provided objective feedback on the conceptualization of the study and helped me find the lighter side of academia and administration. To Stacy, Jay, Brenda, and Allison, I extend my acknowledgment of their support, acceptance, and a tolerance of my mood variations. Thank you for your optimism. I recognize the tremendous influence of Dr. Barbara H. Snyder, Vice-President of Student Affairs. I am indebted to her for her belief in my academic and professional abilities. And finally to my family, I express my profound love and gratitude. The completion of this dissertation would not have been possible without the Nebeker and Christensen families. xi Orson and Kevin supplied amusement and hopefulness. Jeanne, Mary, and Stephen provided assurance, empathy, and humor. To my mother, June W. Nebeker, thank you for your intellectual curiosity and your life-long example of compassion and social justice. To my father, Stephen B. Nebeker, thank you for helping me find joy in my work for being a father who is not only devoted to his children but to reasonableness and generosity. I dedicate this dissertation to Gary M. Christensen for his enduing encouragement, loyalty, and love. I know that for the last four years you have coped with an absent, stressed, and preoccupied spouse. You have sustained me with countless moments of delight, tenderness, and affection. I love you. xii CHAPTER 1 STATEMENT OF THE PROBLEM The third suicide at New York University (NYU) in less than 40 days was greeted with sadness, shock, and concern across college campuses nationwide. Over six years ago, three students leaped to their deaths from the sixth, ninth, and tenth floor balconies at the New York University library (Scelfo, 2003). In a memo to all parents of NYU students dated October, 25, 2003, NYU President John Saxton stated that access to the internal balconies at the Elmer Bobst Library would be restricted and extra security guards would be posted to keep people away while glass panels were installed to prevent future suicide attempts (Lipton, 2003). On the NYU campus, sorrow was mixed with futility. How do universities put enough precautions and safeguards in place for college students at risk for suicide? In the last 50 years, suicide rates for the general population in the United States have been fairly stable (Kachur, Potter, James, & Powell, 1995). In contrast, suicide rates for college students in the U.S. tripled (Peters, Kochanek, & Murphy, 1996). Suicide is now the second leading cause of death for American college students next to automobile accidents (Jamison, 1999; Silverman, 1993). Because college suicide rates are not officially tracked on a national or state level, the current knowledge base on suicide and suicidal behaviors among this population is based on the studies of selected universities, surveys of university officials, and surveys of college students themselves. 2 Schwartz (2006) studied college suicide during 1991-2004 using reports from the National Survey of Counseling Center Directors and reported that there were 1404 student suicides and an estimated at risk population of 33,412,350 students. This translated into a rate of 6.5 student suicides per 100,000 students per year. With 8 million students currently attending college between the ages of 18-24, this translates into approximately 935 student suicides each year (Schwartz, 2006). Research on college student suicide has shown that 1 in 12 college students make a suicide plan and 18-24 year-olds think about suicide more often than any other age group (The Jed Foundation, 2002). While the rates of suicide for young adults are a serious concern, most of the literature suggests that college students are less likely to kill themselves than are their nonstudent peers (Silverman, Meyer, Sloane, Raffel, & Pratt, 1997). Researchers attribute this lower rate of suicide to more low or no-cost mental health treatment services that are available to students on campus, a more supportive peer and advising environment than is found in the general population, university policies that prohibit firearms on campus, a stricter monitoring of alcohol use, and a clearer sense of purpose among college students as opposed to their nonattending peers (Hass, Hendin, & Mann, 2003). Other research indicates that college itself is a risk factor and that the college environment may exacerbate the problem of student suicide (Hirsh & Ellis, 1997; Seiden, 1971). These studies suggest that parental pressure to succeed academically, fear of failure, economic demands to successfully complete a college degree, and lack of a familiar social support systems may prove to be overwhelming for some college students, 3 particularly if that student has a less developed ability to resolve stressful life events (Hirsh & Ellis, 1997). The 2008 National College Health Assessment, conducted by the American College Health Association (2009) found that 6.3% of college students had seriously considered attempting suicide during the last year and 1.3% of college students nationwide had actually attempted suicide. Forty-seven percent of student reported feeling hopeless at times and nearly 31% of students reported that they were depressed to the point of having difficulty functioning. Other trends regarding student suicide are also alarming. A study published in the Journal of American College Health (Barrios, Everett, Simon, & Brener, 2000) indicated that suicide ideation runs along a continuum and can be linked to unintentional injury and homicide, which are the first and second leading cause of death among the college-age students. Specifically, the authors' state: Suicide has been described as the end point of a continuum that begins with suicide ideation (consideration of suicide), followed by planning and preparation for suicide and finally by threatening, attempting, and completing suicide. Although some young people make impulsive suicide attempts, many experience thoughts and engage in behaviors along this continuum. (Barrios et al., 2000, p.229) The study further reported that students with suicidal ideation were more likely to …carry a weapon, engage in a physical fight, boat or swim after drinking alcohol, ride with a driver who had been drinking alcohol, drive after drinking alcohol, and rarely or never used seat belts. (Barrios et al., 2000, p.229) The three leading causes of death for young adults age 15 to 24 are all injury related and include unintentional injury, suicide, and homicide. The literature describes suicide as a cluster injury-related risk that tends to correlate with other high-risk 4 behaviors. Increased risks for all three of these causes of deaths have been associated with suicide ideation (Cheng, Wright, & Fields, 1999). In the effort for campus officials to manage dangerous behaviors among college students, it is essential to pay attention to suicide because it is so closely correlated with other dangerous behaviors that threaten the health and well-being of college students. Mental health problems are presently at an all time high on college and university campuses. A recent study by a psychologist at Kansas State University (Benton et al., 2003) examined trends among college students seeking mental health counseling from 1988 to 2001 and found that the percentage of students seen with depression doubled. The number of students seen with suicidal ideation tripled. The 13 year study reported that four times as many college students were seeking counseling due to a sexual assault. Six percent of college students reported serious problems with substance abuse or an eating disorder and the proportion of students taking psychotropic medication rose from 10% to 25% (Benton, et al., 2003). Despite nearly 1000 college student suicides each year, institutions of higher education have made few systematic efforts to either record or respond to campus suicide (Schwartz, 2006). There are several reasons for this inaction. First, many colleges and universities do not feel that promoting the emotional development and well-being of students is part of their academic mission. As a result, campus responses to common college student problems such as substance abuse, eating disorders, and depression have been at the least slow and sporadic at best. With more and more college students at risk and decreasing higher education budgets, many college counseling centers have not had 5 the financial ability to increase the number of their professional staff to cope with the rising mental health needs of students (Kadison & Di Geronimo, 2004). Second, institutions of higher education are not required to report student suicides, subsequently, complete statistics on campus suicide or suicide attempts are not always available or do not exist (Goldberg, 2003). Third, institutions do not have a national governmental or educational clearinghouse to direct protocols or programming requirements to prevent or intervene in the case of student suicide (Joffe, 2002). Therefore, policies and procedures that address the institutional management of a suicidal student or student suicide death vary extensively from campus to campus. Fourth, until recently, the courts have viewed colleges and universities as having no-duty-to-prevent student suicide with limited exceptions (Lake & Tribbensee, 2002). Such legal protection has created the sad reality that many institutions of higher education have not placed a significant priority on the issue of college student suicide (Lake & Tribbensee, 2002). Fifth, colleges and universities have been reluctant to disclose that a student is depressed or has attempted suicide to a parent or guardian because they fear litigation resulting from the violation of student confidentiality regulations required by the Family Educational Rights and Privacy Act (FERPA). This federal law prohibits the release of student educational records to anyone other than the student. Consequently, all records of non-minor students including academic, behavioral, and financial are deemed completely private by federal and state laws. Furthermore, counseling or medical records of non-minor students are protected by legal and ethical obligations of confidentiality that arise in the context of professional relationships such as with a therapist, psychiatrist, or physician (Baker, 2004). 6 The distressing reality of the above factors demonstrate that if a student is experiencing depression, loneliness, anxiety, academic concerns, or homesickness, a college or university may not be aware of the student's situation or may not know how to intervene appropriately. In short, with little or no campus intervention or prevention programs, college students have been expected to shoulder the burdens and stressors of the transitions to the college environment by themselves, even if those burdens are very high and at times become unbearable. According to the National Center for Educational Statistics, in the fall of 2009, there were 18.2 million students enrolled in colleges and universities in the U.S. and outlying areas (National Center for Educational Statistics, 2009). Of those, 85% were enrolled in undergraduate programs, 13 % were enrolled in graduate programs, and 1.9% were enrolled in first-professional programs. Accordingly, a large proportion of individuals could be reached through college-based suicide prevention and intervention programs. Suicide among college students is a serious public health concerns at higher education institutions in the United States today. A death of a college student by suicide represents a devastating loss that affects many different individuals from the student's family, friends, witnesses, roommates, faculty members, campus personnel, and professional staff. Today's college climate demands that higher education officials establish comprehensive and collaborative programs that educate the campus about mental illnesses and injury-related risk behaviors. Suicide prevention programs that promote student safety, understand and engage potential risks, and use community and campus 7 resources to address mental health issues and injury related behaviors need to be developed, implemented, and evaluated. Purpose of the Study The purpose of the study is threefold. The study will first review the literature to examine the dynamics of today's mental health crisis on college and university campuses. Additionally, the literature review will analyze prevention strategies and intervention protocols university professionals can use to identify students at risk. Using a snowball sampling procedure, the researcher will also conduct in-depth interviews with key higher education administrators using a Student Suicide Interview Questionnaire (SSIQ) to assess how their institution addresses and responds to student suicide attempts and completed suicides. Finally, the study will develop recommended practices for campuses that suggest specific prevention and intervention policies and practices to address college student suicide. Assumptions of the Study The first assumption of the study is that the Student Suicide Interview Questionnaire (SSIQ) completed by college and university officials is valid and reliable in accurately assessing each institution's specific protocols and responses to attempted and completed student suicides. The second assumption of the study is that college and university officials and administrators are being truthful and forthright discussing their institution's policies and procedures. 8 Limitations of the Study One possible limitation of the study is that the sample of college and university administrators is purposive. A purposive sample was used in order to maximize the understanding of college student suicide by interviewing higher education experts who formulate and administer college campus prevention and intervention policies and programs used to respond to college student suicide and suicide attempts. Purposive sampling was used in this study to provide in-depth analysis and meaning to the protocol and interview data. There are limitations to this sampling strategy. One limitation of purposive sampling is that the investigation is limited to a selection of higher education experts and is not representative of a greater population of such officials, thus, there is a potential for selection bias. A second limitation of the study is that the data collected from the interviews from the college and university administrators and officials consisted entirely of self-reports. While every effort was made to ensure the confidentiality and truthfulness in interview responses, the reliability of these self-reports may not be established. Definitions of Terms The definitions and conceptualization of terms in this study were developed from the review of college student suicide literature. For the purposes of the study, key terms are defined as follows: 1. Student: Any individual who was registered in either the graduate or undergraduate program either full or part-time at any college or university in the United States during an academic year. 9 2. Student Suicide Attempt: A student suicide attempt will be defined as concrete and observable self-injurious behaviors. Qualifying behaviors include a preparation of means (e.g., purchasing pills), practicing the means (e.g., holding knife over one's wrist), public statements, and other attempts. The duration of these actions may be mere seconds (e.g., putting pills in one's mouth and immediately spitting them out), and still constitute a crossing of the threshold of a suicide attempt. Methods for the suicide attempt may include, but are not limited to, drug and/or alcohol overdose, self-laceration, hanging, ingestion of other toxic chemicals, carbon monoxide poisoning, other forms of self-mutilation, and the use of firearms. 3. Student Suicide: Any self-inflicted injury resulting in a student's death. 4. Suicide Incident Report Form: A suicide incident report form is any document that a college or university uses to record that a student has threatened, attempted, or completed suicide. This document is most often used in on-campus student residential facilities and college counseling centers and is subsequently used by higher education institutions to administratively track and monitor at-risk students while they are enrolled at the higher education institution. 5. Suicide Prevention Team: The suicide prevention team is a collection of college and university administrators and mental health professionals who administer the policies and procedures concerning student suicide attempts and suicides of a specific college or university. These teams often function as quasi-conduct and discipline officials with authority from the office of the dean of students. These teams often review student suicide attempts and recommend necessary treatment 10 plans and interventions. They also use the University or College Student Code of Rights and Responsibilities to encourage and sanction students who do not comply with university policies and procedures and the Suicide Prevention Team treatment plans. Impact of the Study For many young adults the college years are the best times of their lives, but too often these critical years of adjustment are undermined by mental health issues that can lead to suicide. First, a review of the literature adds to the body of knowledge by identifying the causes of the current mental health crisis on campus. The review of the literature further adds to the knowledge by carefully analyzing current protocols, procedures, programs, and trends that colleges and universities use when there is an attempted or completed suicide. Second, by using a purposive sample, the study seeks to locate relevant information from higher education experts around the country on the subject of higher education institutions' responses to student suicide by using personal interviews. Finally, the study recommends a model program that contains specific prevention and intervention policies, protocols, and interventions for campus officials to utilize in the case of student suicide attempts and completed suicides. CHAPTER 2 REVIEW OF THE LITERATURE Introduction The review of the literature on college and university suicide was organized into nine areas. The first area focused on the history of research on university and college suicide. The second area concentrated on the current threat of college and university suicide and the third section addressed the issues of suicide in the state of Utah and at the University of Utah. The fifth area discussed factors increasing the mental health needs of college students and current mental health needs. The sixth area discussed higher education suicide prevention and intervention strategies while the seventh section described landmark lawsuits involving higher educational institutions and student suicide. The final area contemplated future developments concerning student suicide. Research on Suicide among College Students Despite significant attention to the problem of college student suicide over the past several decades, research on the extent of the college student suicide problem has largely been problematic. Early studies examining student suicide used different measurements and definitions in their research, severely limiting the comparability of their methodologies. Some studies examined student suicides that occurred on campus, while other studies included suicides that occurred while a student was enrolled, 12 regardless of location. Differences in student characteristics and campus environments were largely unaccounted for in the research, further complicating the matter (Lipschitz, 1990). Attempts by investigators to understand, predict, and prevent the suicide of college students have resulted in an extensive literature, but very little systematic research. As a result, data on college student suicide on issues ranging from incidence to causation have been largely inconclusive and unclear (Haas, Hendin, & Mann, 2003). For the first half of the twentieth century, suicide among adolescents and young adults in the U.S. received little attention because the suicide rate for young people was relatively low (Haas, et al., 2003). Professor Arthur L. Beeley of the University of Utah published the first study of suicide on the American campus in 1932. Dr. Beeley examined suicide in U.S. colleges and universities from an epidemiological perspective. Whereas Beeley could not establish suicides rates of college students that were higher than the general population, he encouraged American institutions of higher education to be more attentive to "the mental needs of the student" (p. 67, 1932). Raphael, Power, and Berridge (1937) examined suicide for 5 years at the University of Michigan focusing on a psychological and sociological perspective. The researchers found that suicide accounted for over half of the deaths of students attending the university. Over 10% of the student population seen at the mental health clinic reported suicidal feelings or suicidal ideation. The authors concluded that suicide was a part of university life and "…must be realized and undramatically accepted as a matter of fact and so planned for and managed" (p. 14, Raphael et al., 1937). During and after World War II, there was a lull in the study of suicide due to the war-time focus on the new diagnosis of combat fatigue. In the 1950s, the expansion of 13 higher education and the influx of veterans into U.S colleges and universities led to a renewed interest in studying youth suicide. From the 1950s to the 1980s, the U.S. suicide rate for young people aged 15-24 tripled for men and doubled for women (Haas et al., 2003). The earliest studies of college student suicide in the U.S. were conducted at elite higher education institutions such as Yale, Harvard, the University of California at Berkeley, and the University of Pennsylvania (Haas, et al., 2003). These studies generally reported higher suicide rates among university students compared to the general population and attributed the higher rate of suicide to the intense academic pressures at these exclusive institutions. Later research questioned whether the academic environment of these schools was responsible for student's suicidal behavior or whether these institutions attracted students more emotionally at risk (Berkovitz, 1985; Seiden, 1971). Students at these elite institutions often attributed their emotional difficulties to academic pressures at school. However, researchers found that these students experienced difficulties because they were clinically depressed, not because they were involved in more rigorous educational environments (Hendin, 1975a, 1975b). In a 1990 review of the literature, Lipschitz found considerable differences in the estimated rate of suicide ranging from 5 to 50 suicides per 100,000 college students. Discrepancies in his research were due to small, unrepresentative samples with differences in student populations such as: age range, socioeconomic status, ethnicity, geographical location of institution, drug and alcohol use, and social supports. In light of these inconsistencies, Lipschitz (1990) found it impossible to identify any suicide study that was representative of the national collegiate population 14 The Current Threat of College Student Suicide Recent statistics from the Center for Disease Control and Prevention (CDC, 2006) indicate that suicide is the second leading cause of death among 25-34 year old and the third leading cause of death among 15-24 year olds. Among 15-24 year olds, there are approximately 100-200 attempts for every completed suicide in the general population, and suicide accounts for 12 % of all deaths annually. College Student Suicide The Big Ten Student Suicide Study (Silverman, Meyer, Sloane, Raffel, & Pratt, 1997) has been considered by many researchers to be the most methodologically sound analysis of the incidence of suicide in undergraduate and graduate school populations (Haas et al., 2003). This study collected correlational and demographic information on 350,000 students over a 10-year period and analyzed 261 suicides of registered students at 12 schools affiliated with the Big Ten University Athletic Association. In an effort to comprehensively examine the rate of suicide, the Big Ten study examined suicides that occurred within six months of the student having last enrolled at a university (Silverman et al., 1997). The study's most significant finding was that the average rate of suicide for college students was 7.5 per 100,000. The overall suicide rates were 5.8 for those under 25, and 10.7 for those students over 25. The Big Ten study established that the suicide rate of 7.5 student suicides per 100,000 was half of the national suicide rate of 15 suicides per 100,000 of the general population when matched by age, gender, and race. Schwartz (2006) also found comparable rates of suicide. His study determined the relative rate of suicide for college students was 52% of the rate for the general U.S population aged 20-24 years, when matched for sex. 15 The Big Ten study found 9% of female and 14% of male suicides occurred in the 17-19 age category. In the 20-24 age category, suicide rates was more proportional, accounting for 49% of female suicides and 45% of male suicides. Overall suicide rates were 5.8 for student under 25, and 10.7 for students. Women's rates were roughly half those of men throughout the undergraduate years. Female graduate students' suicide rates were not significantly different from their male counterparts, 9.1 suicides per 100,000 women and 11.6 suicides per 100,000 men. Compared to overall rates of the general population, students under 25 had suicide rates significantly lower when aged-matched to national controls. Rates for students over 25 did not differ significantly from controls (Silverman et al., 1997). According to the Big Ten study, graduate students had the highest rates of suicide with female graduate students most at risk (Silverman et al., 1997). In a 2004 article, Silverman attributed the increased risk to the unique stressors that confront graduate students as they pursue advanced degrees. Silverman stated that graduate students often take deliberate time-outs from the workforce to return to school which increases their financial debt. He argued that mounting financial pressures may contribute to more stress for graduate students and reported that graduate students often have additional responsibilities other than being a student and carrying out adult roles with intimate relationships where they may be responsible for children and aging parents. Silverman (2004) hypothesized that graduate students who experience difficulties in important relationships, their academic pursuits, or employment are more likely to be weighed down by setbacks and the consequences that the difficulties will have on their relationships and families, their academic responsibilities, and their future employment. 16 For younger, undergraduate students, Silverman stated there will always be new relationships and opportunities to be found. While this may be true for the older students, it is not always the perception of students pursuing advanced degrees. As a result, Silverman (2004) reasoned that older students may approach setbacks from a different perspective that may have an effect on their coping skills. The Big Ten study (Silverman, et al, 1997) is a significant addition to the literature. Nevertheless, the study has limitations inherent in the design. To encourage participation in the study, only the total data set was examined. By doing this, discrepancies in the 10-year average suicide rates reported by 12 institutions were largely unexplored. Suicide rates of the 12 campuses varied from 3.1 suicides per 100,000 students to 16.3 per 100,000 students. These disparities led to speculation that the rate of suicide may have been correlated with institutional characteristics such as the presence or availability of counseling services on campus although these variables were not examined in this study. It is conceivable that institutions with minimal or no counseling services identified fewer student suicides in the study (Haas et al., 2003). In addition, the study did not distinguish between full-time and part-time student status. It is likely that the same factors cited by the author as supporting lower suicide rates might impact part-time college students to a lesser degree. This led to the expectation that suicide rates may be higher at institutions such as community colleges having a larger number of part-time students (Haas et al., 2003). The Silverman study (1997) also restricted the definition of suicide by limiting the timeframe of a student suicide. He used the "6-month rule," examining suicides that occurred within 6 months of a student being enrolled. This measure of time was 17 considerably shorter than the range used in previous student suicide research (Schwartz, 2006). Silverman noted that his definition excluded a "disturbingly large" number of former students who committed suicide but did not explain this finding (Haas et al., 2003). Even without Silverman's explanation, the elevated rate of suicide among college dropouts has long been recognized. A longitudinal study of 50,000 students from the University of Pennsylvania and Harvard found that students who failed to graduate had a 50% greater risk of suicide than their graduating peers (Paffenberger & Asnes, 1966; Paffenberger, King, & Wing, 1969). Arnstein's study (1986) found an inverse relationship between student suicide and drop-out rates, supporting the conclusion that students may drop out of college before committing suicide. Silverman's failure to include the number of suicides that occurred after a student dropped out of college artificially lowered the "student rate" of suicide as compared with the suicide rate for the age group as a whole. From 1990-1991 through 2003-2004, Schwartz (2006) studied college student suicide by examining data from the National Survey of College Counseling Center Directors. The counseling center directors' survey has been in existence since 1981 and has an average of 309 institutions responding each year. Schwartz (2006) reported 1,404 student suicides over a 14-year period and an adjusted suicide rate of 6.5 per 100,000 students, about half the rate of 12.6 per 100,000 during the same period for the general US population when matched for gender and age. Schwartz further reported the rate of suicide for students who had been previously or were currently clients at campus counseling centers was three times the rates of students who had not been clients. He 18 indicated that student clients had 18 times the risk of suicide for students in the general student population. Schwartz (2006) argued the advantage of his methodology was the large number of observed suicides and the associate minimal error of the estimate. There were several limitations of his research. First, the national directors' survey is administered only to 4 year universities or colleges and the degree to which the responding institutions are representative of the population of 4 year colleges and universities in the U.S is unknown. In addition, the survey did not report data on the number of suicides by sex and undergraduate or graduate status which have been factors significantly associated with the rates of death by suicide. Suicide in Utah From 2004-2008, Utah's age-adjusted rate of suicide was 15.2 per 100,000 persons. Utah has one of the highest suicide rates in the U.S. with an average of 366 suicides per year. Suicide is the leading cause of death for Utahns aged 35-44 years old and the second leading cause of death for Utah's age 15-34 (Utah Department of Health, 2009) According to a 2009 study, 7.2% of Utah high school students attempted suicide one or more times and 3.2% of these students suffered an injury, poisoning, or an overdose that had to be treated by a doctor or nurse during the past 12 months (Utah Department of Health, 2009). In 2008, the Utah age-adjusted suicide rate was 14.8 per 100,000 population. Since 2004, males had a significantly higher suicide rate than females (24.7 per 100,000 versus 6.1 per 100,000 population) (Utah, Department of Health, 2009). According to the 19 2005-2007 study of the Utah Violent Death Reporting System, non-Hispanic and Latino persons had a significantly higher age adjusted suicide rate than Hispanic and Latino persons (12.7 and 7.5 per 100,000 respectively). Black/African American, Hispanic, and Latino person had significantly lower age-adjusted suicide rates than the state rate (Utah Department of Health, 2009). Youth Suicide In Utah In a 2002 study of youth suicide in Utah, 89% of suicides were male, 93% were Caucasian, 74% killed themselves at home, 63% had contact with the criminal justice system, and 50% of these individuals had minor referrals to the police for alcohol or drug use, abuse, or possession (Gray, Achilles, & Leller, 2002). Only 3% of young adults who took their lives were on psychotropic medication when they died and only 2% were actively seeking mental health treatment (Gray et al., 2002). The etiology of youth suicide is multifactorial. The developmental tasks of adolescents and young people are unique and necessitate special consideration when suicide risk factors are studied. Specific risk factors for youth suicide in Utah include major depressive disorders, anxiety disorders, substance abuse disorders, and conduct disorders. A distinctive characteristic of youth suicide is that it is often precipitated by a recent loss, rejection, or a disciplinary crisis. Unfortunately, these events are common occurrences in the lives of many young adults attending college (Zamekin, Alter, & Yemini, 2001). 20 Suicide and Suicide Ideation at the University of Utah During the fall semester of 2004, the University of Utah implemented a randomized electronic survey assessing the student body's health status in several areas (Gilman, Han, Kim, Alder, & Durrant, 2006). Because of the unique demographics of the state of Utah, the student population at the University of Utah has distinctly different demographics from student populations at similar universities. For example, at the University of Utah, the mean age of students is 25 years of age, 60% of students work more than 20 hours a week, 74% live off campus, and 35% are married. The authors compared 88 respondents who reported that they had seriously considered suicide in the previous 12 months with the remaining 954 respondents to identify discriminating variables. Students who considered suicide more seriously tended to reside off campus, reported they had been emotionally abused, assaulted, and experienced assault, unwanted sexual touching in the last twelve months. Students who seriously considered suicide tended to be unemployed and not heterosexual (Gilman, et al., 2006). Contemporary College Students In order to understand college student suicide, it is essential to understand the current climate of higher education. Today's college students are extremely different than their counterparts from previous generations. These differences are related to changes in developmental time frames, millennial students, demographic changes, technological advances, and the current challenges of college life. 21 Developmental Time Frames Young adults attending college in the U.S. today experience a distinctive and extended time frame occurring from the late teens to the late 20's. Arnett (2000) described this period as ‘emerging adulthood" and referred to these young people as volatile, experimental, and emotional. During emerging adulthood, instability and high risk behaviors are normative and developmental process emphasize exploration and change. Millennial Students Students from the millennial generation are different from previous generations attending college. Millennial students have experienced the most supervised and protected childhoods in history (Howe & Strauss, 2002). Higher education professionals have experienced these student and their parents as having high expectations. Millennial students are characterized by their intensity, competitiveness, and perfectionistic (Hollingsworth, Dumke, & Douce 2009). Demographic Changes Another contextual change in student life has included significant demographics changes on campus. Higher education institutions in the United States now have students with multiple ethnic, racial, and international identities. In 2007, Baruth and Manning reported that students of color will comprise the majority of students attending college by 2050. Nontraditional students including veterans and women are also increasing in numbers in higher education (Hollingsworth et al., 2009). Whereas college was once a 22 place of homogeneity and privilege, college students today are more representative of our increasingly multicultural population. Technological Advances Technological advances have also influenced students and they had experienced instant access to graphic media reports of local, national and international catastrophes and traumas throughout the critical years of their development. This instant access to technology has given students an immediate contact with vast educational and social networks yet has appeared to reduce their ability to problem solve in age appropriate ways. (Hollingshead et al., 2009). Current Challenges of College Life In addition, life on campus is very different than before. Students face many challenges as they come to college including the "hook-up culture," high rates of alcohol use, increased freedoms and peer pressure, and greater academic stresses which have created high risk student behaviors in increasing numbers. Consequently, it is not surprising to learn that 90% of college student reported feeling stressed and 40% reported being so distressed that it interfered with their academic and social functioning. Nearly 10% of college students reported seriously contemplating suicide in the last year (American College Health Association-National College Health Assessment, 2008). 23 Factors Increasing Mental Health Issues on Campus Sociocultural Changes Sociocultural changes have been major factor that has contributed to the increase of psychological difficulties on campus. Larger numbers of student have experienced trauma in their lives. Student affairs professional are familiar with students who have directly experienced violence in their homes, through distant wars, terrorist attacks, and natural calamities. Students have also come to campus without a supportive or stable family base. Divorce, disordered interpersonal attachments, and inadequate parenting skills have led to greater instability in the psychological lives of students (Gallagher, 2004). Hollingshead (2009) adds that student have relatives who are directly affected by current world events that may seem remote to other students on campus. Current students have also grown up in homes where individuals have been in various stages of acculturation and come from socioeconomic classes that have confronted increased adversity and hardship in the U.S (Hollingshead 2009) Cultural Shifts to Extrinsic Goals At a basic level, generational changes demonstrate the effects of the current culture on the individual. Twenge et al. (2010) have reported that current college student experience greater rates of psychopathology than previous generations because American culture is much more focused on the extrinsic goals of materialism, good looks, wealth, and status than on the satisfying intrinsic goals of affiliation, community, meaning in life, and close relationships. 24 Surveys of high school students and entering college freshmen have demonstrated significant increases in materialistic values between 1970 and the present. Twenge and Campbell (2008) studied the value of college students and found that that "having a lot of money" was important to as students as was "being well off financially. is important. Higher education professionals have observed college students and their significantly high expectations for job and educational attainment which are often labeled as unrealistic as these expectations are far higher than expected outcomes (Twenge & Campbell, 2008). Unfortunately, the cultural shift towards extrinsic values has resulted in the current generation of college student suffering from greater mental health issues including poor relationships and antisocial behavior (Twenge, et al., 2010). True Prevalence of Mental Health Disorders With better treatment and earlier diagnosis, psychological disorders are finally showing their true prevalence on campus. While serious mental health conditions have always been present, 20 years ago students affected with these disorders were rarely diagnosed and treated making it difficult for them to attend college. Medical technology has provided new psychotropic medications with fewer side effects. The stigma of mental illness has lessened and seeing a therapist or psychiatrist is more common and acceptable. Emergence of Mental Health Issues on Campus Another reason for the increase in student mental health issues is the fact that a student's first experience with a mental illness is likely to occur during the college years. Epidemiological studies indicated that the rate of mental illness is highest (39%) for 25 youth in the age category of 15-21 years old, corresponding to the traditional aged college student (Mowbray, et al., 2006). As a result, student affairs professionals are very familiar with the fact that many students have experienced their first psychiatric episode during their college years with behavioral indicators seen in the classroom, the residence halls, or at a campus event. Current Mental Health Needs of Students More Students with More Serious Mental Health Issues In 2009, Gallagher reported that 93% of college counseling center directors reported that the recent trend of a greater number of students with serious psychological problems continues to be true on their campus. The same study found that that 16% of all student clients were referred for psychiatric evaluation and 25% were on psychiatric medications. This latter number is up from 20% in 2003, 17% in 2000, and 9% in 1994. Ninety-one percent of directors indicated that there were an increased number of students coming to campus already on psychiatric medication up from 87% in 2007. As for the demands on campus counseling centers, the Directors Study (Gallagher 2009) reported that 48% of student clients had severe psychological problems, 7% experienced psychological impairment so serious that they could not remain in school or could only do so with extensive psychiatric/psychological help, and 41% of clients had significant mental health difficulties but could be treated successfully with available treatment modalities. 26 Increased Need for Counseling Services on Campus The prevalence and severity of mental illness on campus has resulted in staggering increases in the demand for mental health services on college campuses. Consequently, the number of students who have needed counseling services has grown faster than the number of new staff hires on many campuses. In 2006, the University Of California's Mental Health Committee found that the average provider-to-student ratio was one professional staff member to 2300 students, (University of California Office of the President, 2006). The number was significantly higher than the national average ratio of one staff person to 1,527 students at college counseling centers (Gallagher, 2009). In a 2010 article, Gallagher stated that students hat counseling centers were busier and seeing students with mental health problems were more complex and demanding. He added that a few weeks into a new semester, many counseling centers were forced to put students on waiting lists that were in need of services (Jashkic, 2010). The History of Preventing Suicide at Colleges and Universities While many researchers have made specific recommendations for the prevention of college suicide, the majority of literature on this topic has concentrated on demographic and psychological profiles of student who have committed suicide. Haas reported that the majority of suicide prevention programs that exist on college campuses tend to be educational in nature with the aim of making students more informed about stress, self-destructive behaviors, and suicide (Funderburk, 1989; Haas et al., 2003). Joffe (2003) reported that there have only been six reports of systematic programs to prevent suicide on college campuses (Dashef, 1984; Funderburk, 1989; The Jed Foundation, 2002; Meilman, Pattis, & Krause-Zeilman, 1994; Ottens; 1984,). 27 Unfortunately, these six programs have been short lived or have gathered little empirical evidence that would allow an investigation of their effectiveness. Higher Education Suicide Prevention Programs The majority of suicide prevention programs at higher education institutions described in the literature can be grouped into four categories: (1) cultivation of a community of caring, (2) identification and referral of at-risk students at the higher education institution, (3) intervention strategies following a completed suicide, and (4) reduction of academic stress. Cultivation of a community of caring. The University of Florida started the most comprehensive of all of the community of caring prevention programs. This 1986 program was designed to educate the university community about self-destructive behaviors and suicide. The focus of the program was on early intervention and included identification of ways that students cope with problems. This suicide prevention project clarified effective and ineffective coping strategies and encouraged students to recognize signs of distress in themselves and their peers. The core objective of the project was to encourage the campus community to play a more active role in helping students cope with and confront problems before suicide became an option. Carrying the theme of "This Campus Cares" the program continued for 10 years and gathered little empirical evidence to assess its impact on the university's suicide rate (Joffe, 2003). Identification and referral of at-risk students. A second kind of suicide prevention approach has been to lesson barriers to professional treatment and increase the likelihood that suicidal students will receive appropriate assistance. After four suicides took place at Cornell University in 1977-78, the university began a program to avert future tragedies 28 (Ottens, 1984). A pilot crisis intervention training program aimed at residence hall coordinators, key faculty and staff members who occupied "front line" campus positions was created and was so successful that Cornell Psychological Services decided to make this program available to the campus at large. From 1979 to 1983, more than 200 students, faculty, and staff participated in the free, noncredit course entitled "Life-Threatening Emotional Crisis: Assessment and Response" (Ottens, 1984). The crisis course was intended to augment the skills of problem identification and referral for nonclinical professionals. Ottens (1984) hypothesized that perhaps as a result of Cornell's efforts at outreach, campus consultation, and crisis programming was that no successful student suicide occurred at Cornell for 2 years after the program's implementation. After six suicides in 1969, Dashef (1984) reported on a multi-faceted project at the University of Massachusetts at Amherst. Particularly disturbing in this rash of student suicides was the fact that three deaths were the result of students jumping to their deaths from high-rise dormitory buildings on campus. This prevention effort included an expansion of treatment resources, educational outreach about warning signs, closer collaboration with community hospitals and mental health agencies, and a more immediate approach to intervene with disturbed students and their families. After this program was implemented, the university went 15 months without a student suicide. Dashef (1984) theorized that students involved in this preventative effort benefited from direct treatment or were able to leave school in a compassionate noninjurious manner. The College of William and Mary Suicide Prevention Policy. Because of a long-standing university policy that mandated an immediate mental health evaluation for any 29 student who is thought to be suicidal, the counseling center at the College of William and Mary has been able to examine almost all situations where a student was suicidal or was believed to be suicidal. The William and Mary policy required all university officials, including residence hall staff, to inform the dean of students' office if a student attempts or threatens suicide or if there is other cause to believe that a student is suicidal. Subsequently, the dean of students' office required that the student report to the college health service for an evaluation by the medical and counseling center staff and an outside psychiatric consultant if needed. Once the student was evaluated, a crisis intervention plan was instituted. Once the crisis had passed, the counselor, dean and a physician from student health services and perhaps the student's parents, participated in a meeting to determine the steps necessary to maintain the student safely in school. If the student refused to go for the evaluation, the vice-president of student affairs had the power to suspend the student. As a result, student compliance with this suicide protocol was almost guaranteed. The University's goal was to reduce the possibility that students will take their own lives and to direct them to sources of help on campus. Meilman (1994) reported that for a twenty five year period, the College of William and Mary reported two suicides, a number that is far below the epidemiological expectations for a campus of that size. Interventions following a student suicide. A third strategy to prevent campus suicide have been clinical intervention programs subsequent to a student suicide. A suicide on campus affects not only the family, friends, faculty members, peers, and roommates but a myriad of other individuals on campus. Today, most college institutions campus have a variety of intervention models that assist the college and university 30 community members with the grief process, identify and refer those individuals who may be at greatest risk for depression, anxiety, and suicidal behavior. Generally, initiatives for clinical intervention plans rest with college counseling centers in coordination with the dean of students or other chief student affairs officers with crisis management experience. There are several models of clinical interventions following a student suicide. Webb's (1986) intervention model presented a range mental health services for campuses in the event of a student suicide. Clark's (2001) model included assisting survivors with finding some meaning in the suicide victim's life. Brock (2002) described a very specific protocol for primary and secondary schools after a student had taken their life. Advocates of the interventions following the suicide of a student report that programs should include school-community collaboration, development of written protocols, training of intervention teams, procedures for notifying family and friends, the establishment of communication guidelines, and educational processes that address the stages of crisis (Webb, 1986; Gould & Kramer, 2001). While the number of intervention strategies following a student suicide has increased significantly in recent years, there is very little research in this area (Brock, 2006). The evaluation of school-based clinical interventions after a student's suicide is further limited (Gould & Kramer, 2001). Decrease academic pressure. A fourth kind of suicide prevention effort called for lessening stressors on college students, especially academic pressure which Knott (1973) believed predisposed a student to commit suicide. Knott called for a lessening of academic stressors on campus in an attempt to decrease student suicide (Joffe, 2003). 31 Perhaps the most comprehensive endeavor of this strategy has been The Jed Foundation (2002). The Jed Foundation is a nonprofit organization committed to reducing the rate of suicide among young adults. Since 2000, The Jed Foundation has been working with higher education institutions to insure that they meet essential standards for college students at risk for suicide. Among one of its recommendations was a more student friendly medical leave policy for students at risk (Joffe, 2003). Mandated Psychological Assessment at the University of Illinois Perhaps the most well-known and empirically validated of all college student suicide prevention efforts is the Suicide Prevention Program at the University of Illinois at Champaign (Joffe, 2003). In 1983, in cooperation with the Champaign Coroner's office, the Counseling Center at the University of Illinois examined the records of all students who had committed suicide between the academic years of 1976 and 1983. Results of the psychological autopsies found that 95% of these students had committed suicide without seeing a therapist. The records further indicated that 68% of these students had given tangible indications of their suicidal intent in the form of a public threat or attempt prior to their suicide. In the fall of 1984 and based on the Coroner's Report, the University of Illinois Counseling Center started the suicide prevention program. At the core of the program was a policy that required any student who threatened or attempted suicide to attend four sessions of professional assessment with a licensed clinical social worker or psychologist. If a student failed to comply with this mandate, they faced university disciplinary 32 sanctions including academic encumbrance, disciplinary suspension, and or involuntary psychiatric withdrawal based on the university's Student Code of Conduct. While the four assessment sessions were the core of this prevention effort, this requirement was only the first in a multilayered approach. At each step of the program, students were assessed for their ability and willingness to adhere to the standard of self-welfare. In cases that involved entrenched behaviors such as substance abuse, eating disorders, self-mutilation, and other defiant behaviors, the program adapted to the student and addressed their noncompliance with increasing firmness. The Suicide Prevention Team The Suicide Prevention Team (SPT) was created to administer and monitor student compliance with the mandated assessment policy. The team consists of four professionals, two psychologists, a social worker, and administrative specialist. These professionals are responsible for a central university registry that tracks information about student threats of suicide and suicide attempts. The team adjudicates disputes over what constitutes a valid report specifically deciding whether there was a suicide threat or a suicide attempt. The SPT also adjudicates over what constitutes a valid assessment. Suicide incident report from. The SPT utilizes a Suicide Incident Report Form to gather their data. The vice-chancellor for student affairs had previously required all Student Affairs staff to submit a suicide report form whenever they had credible evidence that a student had threatened or attempted suicide. The form is not a current or future assessment of risk but a report that documents when a student had crossed the line from passive thoughts of suicide to concrete and observable actions of self-harm any point in the last three months. Qualifying behaviors for the report include: a preparation of the 33 means of self-harm (such as buying pills), practicing the means of self-harm (such as holding a knife over one's wrist), public statements, and actual attempts. Once the threshold from thoughts to actions occurs, no other distinctions of actions are made. For example, if a suicidal student buys a bottle of Tylenol or overdoses on a bottle of Tylenol, the same policy of mandated assessment applies. The program's strategy is to avoid second-guessing the significance and seriousness of a student's self-destructive acts which is often problematic for mental health professionals. The program theorized that a student who has shifted from thoughts of suicide to tangible actions is at increased risk for suicide. Imminent risk versus proximal risk. In the initial phase of the program, the professionals addressed a shortcoming that existed within the prevailing standard-of-response for suicide that relied on the presence of imminent risk of harm to self. The team drew a distinction between imminent and proximal risk. The SPT defined imminent risk as risk posed by current suicide intent associated with a ready access to means of self-harm. They defined proximal as an increased risk of suicide associated with displays of a wide range of suicide intent in the year following that display. After nineteen years of the program being in effect, the SPT has evolved into a quasi-conduct and discipline office reporting directly to the dean of students (Joffe, 2003). Theoretical foundations of the program. The University of Illinois program is based on several theoretical premises that are vastly different from traditional approaches to suicide prevention. First, suicide is viewed by the institution not as a "cry for help" but an act of self-directed violence in which the same person is the victim and perpetrator. The Illinois program disciplined suicidal behavior by attaching standardized, 34 mandated consequences to its occurrence. Second, based on empirical evidence, the program recognized that the majority of individuals who die by suicide have previously displayed suicidal intent and that the presence of suicide intent is the single most powerful predictor of an eventual suicide (Joffe, 2003). Similarly, the program presumed that individuals who are suicidal have entrenched resistance and are strongly opposed to seeking professional help when left to their own devices. Therapeutically, the program reasoned that the most effective intervention for suicidal students was weekly assessment appointments with a mental health professional spread out over 1 month. Lastly, to maintain institutional consistency, effective and timely institutional interventions must have administrative authority and controls on the student at risk and the mental health professional treating the student. In the 19 years the program has been in effect, there were 1670 reports on suicide incidents submitted to the Suicide Prevention Team. Prior to the program starting, the rate of suicide at locations within Champaign was 6.91 per 100,000 enrolled students. After 19 years of the suicide prevention program, the suicide rate dropped to 2.90 per 100,000 enrolled students, representing a 58% reduction in student suicide. The program also reported that only one student was administratively withdrawn for a three month period during the programs existence and she returned to the university 18 months later. In addition to preventing suicide, anecdotal evidence has suggested that the University of Illinois program has led to greater student retention (Joffe, 2003). Landmark Lawsuits Against Higher Education Institutions With few exceptions, the courts have protected colleges and universities from liability for student suicide in a broad range of cases. Suicide has been considered an 35 illegal, deliberate, and intentional act that was an intervening proximate cause that precluded liability (McLaughlin v. Sullivan, 1983). As the Supreme Court of New Hampshire observed: In recent years, however, tort actions seeking damages for the suicide of another have been recognized under two exceptions to the general rule, namely, where the defendant is found to have actually caused the suicide, or where the defendant is found to have had a duty to prevent the suicide from occurring. (p.124) An individual or entity may fall within the first exception of causing the suicide, in a number of limited circumstances. For example, when an individual causes severe physical injury to another, leading that individual to a state of mental incapacity that results in suicide, the individual causing the physical injury may be held responsible for the resulting suicide (Orcutt v. Spokane County, 1961). In addition, if a defendant causes severe mental injury through serious physical abuse, torture, abuse of process, or improper confinement, that defendant may be also responsible for causing an uncontrollable impulse to commit suicide that prevented the individual from realizing the wrongful and serious nature of the suicidal act. As the McLaughlin court observed, an exception based on causing the suicide: …involves cases where a tortuous act is found to have caused a mental condition in the decedent that proximately resulted in an uncontrollable impulse to commit suicide, or prevented the decedent from realizing the nature of his act…Such cases typically involve the infliction of severe physical injury, or in rare cases, the intentional infliction of severe mental or emotional injury through wrongful accusation, false arrest, or torture. (McLaughlin v. Sullivan, 1983, p. 124) Frentzel v. Ferrum College While higher education institutions have most commonly been viewed as having no-duty-to prevent suicide, these protections are eroding (Lake & Tribbensee, 2002). In a 36 2002 landmark case involving Ferrum College, the court upheld a claim involving an alleged duty to prevent suicide. Michael Frentzel initially experienced disciplinary problems during his first semester at Ferrum College. As a result, disciplinary staff required Frentzel to attend anger management classes. Early in his second semester, campus police and residential staff were summoned to an incident in Frentzel's dormitory where Frentzel had written a note to his girlfriend threatening to hang himself with his belt. The campus police noticed bruises on Frentzel's head which he reported were self-inflicted and informed the dean of students. The dean of students responded to Frentzel's behavior by requiring him to sign a statement that he would not harm himself. Within the next 2 days, Frentzel wrote several desperate communications to his girlfriend which she forwarded to campus officials. The dean of students and residential staff took no further action to assist Frentzel and prohibited the girlfriend from visiting his dorm room. The last note from Frentzel stated that only God could help him, which again the girlfriend pursued with college officials. Three days after the initial incident, when residential staff visited Frentzel's room, they found that he had hung himself with his belt. Representatives from Frentzel's estate sued the college for $10 million claiming that it owed a duty to Frentzel to prevent the suicide. Ferrum College moved to dismiss the complaint, stating that there was no such duty owed. The courts refused to dismiss the action arguing that Frentzel's suicide was foreseeable due to the fact that there was an "imminent probability" of harm and the college officials had notice of this specific harm. Because the dean of students required Frentzel to sign a no-harm agreement, it was clear that college officials were aware of the possibility that Frentzel might hurt himself. 37 While there is usually no affirmative duty to aid others "absent unusual circumstances" the court determined that a "special relationship" existed sufficient to impose a duty of aid (Schieszler v. Ferrum College, 2000). In other words, because campus officials had knowledge that Frentzel was a risk to himself, they had legal responsibility to try to prevent him from harming himself (Schieszler v. Ferrum College, 2000). Three years after the student's death, Ferrum College settled with Frentzel's guardian and admitted that it shared responsibility for his suicide. The college also established an $85,000 scholarship in the name of Michael Frentzel and agreed to modify its policies and procedures for students in crisis. Jain v. State of Iowa Traditional tort rules regarding the duty to prevent suicide focus upon the actual physical responsibility to prevent the suicide. For example, a defendant could be liable for a suicide if it either provided the actual means of destruction or, in the case of custodial care, failed to use reasonable care to monitor individuals under its care. Recent litigation has raised new issues that relate to the duty to prevent suicide, notably the responsibility of higher educational institutions to notify parents and share information about a student. The question of whether traditional-aged college students should be seen as full adults or as young people within a special transition period--in need of greater supervision--was settled by the Iowa State Supreme Court in 2000 (Jain v. State of Iowa). Sanjay Jain was 18 years old when he enrolled at the University of Iowa and moved into an off-campus dormitory. Jain had enjoyed a successful academic career in high school and planned to major in biomedical engineering. This course of study was 38 difficult for him and by mid-semester his personal and academic life were showing the strain. Jain became moody and skipped class and experimented with drugs and alcohol. Shortly thereafter, a residential staff coordinator placed Jain on disciplinary probation for smoking marijuana in his room and ordered him to attend a series of alcohol and drug education courses. Because university policies call for privacy in respect to the university's relationship with adult students, Jain's parents were not notified about his recent behavioral difficulties. Later that semester, resident assistants were summoned to Jain's room to resolve a dispute between him and his girlfriend over the keys to his Moped. Jain had moved the motorized scooter into his dormitory room and reported that he was trying to kill himself with the exhaust fumes. Jain admitted to the residential staff that he was trying to take his life but after an hour of discussion, he agreed to seek counseling the next day. The following day, the resident coordinator asked if she could contact Jain's parents but he refused. Staff encouraged Jain to seek help at the university counseling center and further stipulated that he remove his Moped from his room. The resident coordinator gave Jain her home phone number and urged him to call if he thought he was going to harm himself. Jain agreed and claimed that he was looking forward to talking with his family during Thanksgiving break which would start the next day. Jain spent Thanksgiving break with his family but did not share the recent turmoil in his life and his family did not notice anything amiss about his behavior. The first day of his return from the break, the residential coordinator ran into Jain and inquired about his condition and he reported that he was doing fine. The next morning, resident staff found Sanjay Jain unconscious in his room with his Moped running. After emergency 39 personnel evacuated the dormitory, Jain was pronounced dead of self-inflicted carbon monoxide poisoning. The University of Iowa had an unwritten policy that permitted the dean of students to notify parents in the case of a suicide attempt. However, residential staff did not communicate relevant information to the dean until after the student's death. Unlike the previous lawsuit, the Iowa Supreme Court refused to find a special relationship between Jain and the university sufficient to raise a duty to notify the parents of the impending danger. The court elaborated: No affirmative action by the defendant's employees, however, increased that risk of self-harm. To the contrary, it is undisputed that the [resident assistants] appropriately intervened in an emotionally charged situation, offered Sanjay support and encouragement, and referred him to counseling. [A residential coordinator] likewise counseled Sanjay to talk things through with his parents, seek professional help and call her anytime. She sought Sanjay's permission to call his parents but he refused. In short, no action by university personnel prevented Sanjay from taking advantage of the help and encouragement offered, nor did they do anything to prevent him from seeking help on his own. (Jain v. State of Iowa, 2000, p. 617) The court found no conclusive proof that Sanjay Jain relied, to his detriment, on the services gratuitously offered by the same personnel. To the contrary, by all reports, Jain failed to follow-up on recommended counseling or to seek the guidance of his parents, as he assured the staff he would do (Jain v. State of Iowa, 2000). While the court found that the university did not owe a duty of care as a matter of law, the court relied on evidence demonstrating that residential staff performed their duties with reasonable care. The court placed little weight on the university's failure to follow its unwritten policy and viewed Jain as a bystander to the university, one to whom 40 no duty was owed because the University had neither assumed a duty to protect him nor increased his risk of injury. To some degree, the rationale of the court is distressing because those individuals who are at risk for suicide most often refuse to seek help (Joffe, 2003). It is troubling to think that those students who are seriously contemplating suicide and refuse help, isolate themselves, or deny their condition will be allowed the least amount of care in the State of Iowa (Lake & Tribbensee, 2002). Shin v. Massachusetts of Technology In a case that has riveted college administrators nationwide; the parents of Elizabeth Shin filed a wrongful death suit for $27 million against the Massachusetts Institute of Technology (MIT) for their daughter's death in April 2000. The Shins allege that MIT, overly concerned with protecting their daughter's confidentiality, failed to inform them of their daughter's deteriorating psychiatric condition in the month before her suicide. By all accounts, Elizabeth Shin was a precocious, intelligent, 19 year-old who enrolled at MIT in 1998. She first experienced psychiatric problems on campus the winter of her freshmen year. In February 1999, Elizabeth had a panic attack about failing her physics course and subsequently overdosed on 15 Tylenol with codeine. When she was released to her parents, according to MIT, the Shins immediately escorted Elizabeth from the hospital to her dorm room (Sontag, 2002). The next academic year, Elizabeth reported that she had gotten into the habit of cutting herself superficially (Sontag, 2002). Later that spring, Elizabeth threatened to kill herself with a knife and was taken to the infirmary for observation and released the next 41 day to her father who was aware that his daughter had been treated at the infirmary but did not know why she was being treated and did not pursue the matter. Elizabeth continued to do poorly and another MIT Health Center physician put her on antidepressants. However, there seemed to be little sense of urgency or concern about her condition on the part of the medical staff. The professionals treating Elizabeth noted that she had a chameleon-like ability to hide her feelings from adults while showing acute distress to her friends. This pattern of behavior made it very difficult for the health professionals to accurately evaluate the seriousness of Elizabeth's condition. It was also very disruptive for her friends and residents of her dormitory who were repeatedly exposed to Elizabeth's threats of suicide. The evening before Elizabeth's death, she made another suicide threat and reported that she wanted to kill herself by sticking a knife in her chest but could not bring herself to do it. Elizabeth was taken to the health center by her friends and spoke on the phone with the psychiatrist on call. The psychiatrist was aware that Elizabeth had expressed suicidal intentions and that her medical history included depression and a previous suicide attempt. The psychiatrist determined that it was safe for her to return to her dorm room and she was released from the health center. On the evening of April 10, 2000, students in Elizabeth's residence halls notified an administrator that Elizabeth said she planned to kill herself with a "cocktail of alcohol and Tylenol" (Sontag, 2002, p.11). The administrator contacted the MIT mental health center and spoke with a psychiatrist who had worked with Elizabeth. The psychiatrist was not as alarmed as the administrator and directed the administrator to check on Elizabeth but not to bring her to the medial center because he had received assurances 42 from Elizabeth that she was fine and he determined that she was not the type of patient that should be involuntarily committed. The administrator found Elizabeth sleeping at approximately 6:30 a.m. and later had a conversation with her prior to 10:00 a.m. The administrator reported that the conversation was disturbing and accusatory and the administrator contacted yet another psychiatrist regarding Elizabeth (Lake, 2008). The decision was made to allow Elizabeth to continue sleeping but to contact campus administrators later that morning. There was a previously scheduled meeting between the mental health professionals and deans that occurred on the morning of April 10. The attendees of the meeting reviewed Elizabeth's situation and an appointment was made for Elizabeth to receive further treatment. Elizabeth was informed of this appointment by a message left on her answering machine. Reportedly, no one made direct contact with her that day. Just before 9:00 p.m. that evening, Elizabeth locked her door and lighted some candles. A short time later, a student reported smelling smoke and hearing a smoke detector alarm coming from Elizabeth's room. The student called the campus police and reported that Room 421 was on fire and that its resident was suicidal. When the campus police kicked in the door, they found Elizabeth flailing around in room engulfed in flames. The officers blasted her room with fire extinguishers, poured gallons of water from the dorm bathroom on her, and performed CPR. Elizabeth suffered third degree burns over 65% of her body and died several days later (Sontag, 2002). A medical examiner determined that the cause of death was thermal burns that were self-inflicted (Hoover, 2006). A fire department investigator reported that it could not be determined if the fire was deliberately set or merely an accident. 43 The Shin family sued MIT, four of its psychiatrists, an associate dean and a dormitory staff member for $27 million. Among other arguments, the Shins claimed that MIT had violated the "health and safety exception" of FERPA, because they were not notified of Elizabeth's self-destructive behaviors. The Shin's claims against MIT were dismissed by a Superior Court in June 2005. Nevertheless, the Court allowed the Shins to pursue damages from individual staff members at MIT finding that they had "failed to secure Elizabeth's short-term safety…by not formulating an immediate plan" in response to her threats the day that she died (Hoover, 2005). As the court stated: The Plaintiffs argue that the MIT medical professionals individually and collectively failed to coordinate Elizabeth's care. As a "treatment team," the professionals failed to secure Elizabeth's short-term safety in response to Elizabeth's suicide plan in the morning hours of April 10. During the "deans and psychs" meeting on the morning of April 10, plans to assist Elizabeth were discussed; however, an immediate response to Elizabeth's escalating threats to commit suicide was not formulated. By not formulating and enacting an immediate plan to respond to Elizabeth's escalating threats to commit suicide, the Plaintiffs have put forth sufficient evidence of a genuine issue of material fact as to whether the MIT Medical Professionals were grossly negligent in their treatment of Elizabeth. (Shin, WL 1869101, at *8, 2005) What is remarkable about this case is the fact that the court allowed non health care administrators to be brought to trial for this participation in a treatment planning process. Peter Lake, a higher educational legal expert stated: Although this was not explicitly contained in the decision and may not be true, Shin leaves the distinct impression that by participating in an intervention planning process involving mental health care, administrators may be brought into some form of hybrid malpractice responsibility. Indeed it is hard to avoid the comparison to hospital administrators in cases involving medical negligence. But, even if administrators do not actively participate in an intervention planning, the Shin court held that an affirmative duty to act on behalf of the students may still exist. (Lake, 2008, p.274) 44 While the Shin decision had limited precedential value because it was an intermediate appellate court decision, Lake reports that the court focused heavily upon intervention responses; Shin may have needed more immediate care. Lake continued that this lawsuit offers some insight in that institutional intervention processes should be customized to meet present needs and dangers. Higher education can have preference for regularly scheduled meetings and student crises can be anything but routine. Even as at MIT where there was a weekly "deans and psychs" meeting, that meeting should not be the one and only opportunity for intervention teams to collaborate and formulate a plan especially when a students may be in danger or harming themselves (Lake, 2008). In February of 2006, when it appeared that the case would likely go to a trial, the American Council on Education filed a friend-of the-court brief. The brief argued that by allowing the case to go forward, the Superior Court found that nonclinical university employees are obliged to prevent suicide based on a ‘special relationship' purportedly created by the ‘foreseeability' of the student's act. The brief contended that this decision had engendered the opposite of its intended effect. By imposing a legal duty on non-clinical university personnel to detect and prevent student suicides, it had fostered perverse incentives for members of campus communities to disengage from troubled students lives. In a surprising twist on April 3, 2006, MIT and the Shins settled the case and agreed that the young woman's death was probably an accident not a suicide. David DeLuca, the Shin's lawyer, confirmed toxicology results that indicated that Elizabeth had overdosed on nonprescription medications. While the overdose was not lethal, this overdose may have caused Elizabeth's unresponsiveness when the candles in her room 45 sparked a fire. By settling with MIT, the Shin's agreed to withdraw their lawsuit, ending a case that was set to go to trial in May of 2006. Based on the most compelling precedent in the appellate courts, nonclinical college administrators have no general duty to prevent suicide. Gary Pavela (2006), director of judicial programs at the University of Maryland at College Park reported that the Shin settlement provided college administrators with some "breathing room to achieve two fundamental and highly compatible goals: Give students at risk of suicide the help they need while helping them stay in school. Pavela elaborated stating that mandatory medical withdrawal policies based on "risk management" strategies devised after the preliminary ruling in the Shin case should now be reconsidered. To this date, there has not been a single court ruling that has challenged the release of information to parents and family members or imposed a legal duty to notify parents. In the three lawsuits described, all of the families filed "failure-to-notify" claims against the higher education institution. Family members contend that their personal intervention following the notification about their student's behavior from university officials would have prevented the student's suicide. In Schieszler v. Ferrum College (2002), and Jain v. State of Iowa (2000), student affairs staff were well aware of the student's suicidal behaviors yet chose not to share the information with a parent or guardian. The Schieszler case (2002) found a "special relationship" sufficient to impose a duty of Ferrum College officials to aid Michael Frentzel. In the Jain case, the court ruled that the university did not owe a duty of care and concluded that university personnel performed their duties with reasonable care (2000). The Shin case further obscured matters because the case was settled resulting in the court never having an 46 occasion to rule on the issue of student suicide and parental notification. While the court's rulings are confusing in their inconsistency, it is clear that the failure to notify family members about a student's precarious situation increases the likelihood of a lawsuit (Pavela, 2006). Understanding recent court rulings about a college's liability for a student suicide is complicated. The issue of liability is made difficult by the small number of published court opinions, the nonstatutory nature of tort law, variations in law from state to state, and the lack of definitions in laws governing student educational and medical records. While the courts have remained generally protective of higher education institutions in cases of student suicide, the nature of duty and liability for universities and colleges to provide a safe learning environment are being reconceptualized and redefined by the courts. The argument that a university has no duty or limited duty to protect students from certain risks has fallen into disfavor across the nation. Recent court rulings have embraced the position that higher education institutions have a "special relationship" with students that requires them to exercise shared responsibility for student safety and student behavior. While it is not possible for universities to place the general student population in custodial control sufficient to prevent suicide, universities and colleges can not afford to be bystanders to students at risk. Recent litigation has raised the specter of potential liability for America's higher education institutions and their administrators. In reviewing this litigation three themes emerge from case law. First, as events at Northern Illinois and Virginia Tech prove, a student's suicidal behavior puts others at risk and can dramatically disrupt the academic environment. Suicide is not longer just an individual's problem. Secondly, suicide and violence often go together and therefore suicide 47 prevention is violence prevention. Thirdly, college administrators must now consider the legal ramifications of how they respond to emotionally disturbed students (Hoover, 2006). Interventions that are information-based, holistic and environmental will help create reasonably safe learning environments supportive of students with mental health issues. At no other point in time has a Higher Education Administrator professional borne such responsibility and yet have such opportunity to prevent harm by sharing what they see, hear and think. With the events of recent years, it is clear that students, staff, faculty and administrators have become empowered to be agents of safety at American colleges and universities (Lake, 2008). Current and Future Trends in Addressing Student Suicide Due to a number of highly publicized suicides on campuses across the country, higher education institutions have made increased efforts to educate students about mental illness and provide treatment. In the wake of the Shin case, MIT formed a committee to review policies and improve their mental health services. These recommendations resulted in a budget increase of $838,000 and involved several improvements including extended appointment hours for clients, additional mental health staff fluent in languages other than English to assist with a diverse student body, and 100% insurance coverage for off-campus counseling services. MIT now conducts screening and outreach programs to encourage troubled students to seek counseling and provide more timely and accessible services (Healy, 2002). At Johns Hopkins, every student who visits the counseling center answers a battery of questions designed to identify those students who should be placed at the center's "suicide tracking" list. In a recent year, 170 of the center's 756 clients were on 48 the list. The John Hopkins counseling staff, which includes seven psychologists and three consulting psychiatrists, meets once a week to review the status of these students (Kadison & DiGeronimo, 2004). In an effort to decrease academic stress and encourage intellectual curiosity, the University of Rochester now omits first-year grades from transcripts. The university also assigns volunteer faculty members to groups of 20-40 students to demystify the faculty. Faculty members meet with the students informally and have outings that encourage faculty and student interaction and connection (Kadison & DiGeronimo, 2004). In a similar vein, New York University, Columbia, and Cornell now place counselors in their residence halls to assist students with the stressors of college life. According to Kadison (2004), the University of Maryland offers credit courses to freshman in order to help them deal with the challenges of college life including stress and time management. The University has found that 86% of the students who took the course returned their sophomore year, compared with 69% of a comparable group that did not take the course. Such courses are now offered by about two-thirds of the nation's schools. In 2002, the American Foundation for Suicide Prevention developed an anonymous online mental health questionnaire and program to guide troubled students to counseling. In this program, the Student Health Questionnaire identifies students for risk of suicide and is accessible to them on-line through a secured web site. Students are asked about symptoms of depressions, suicidal ideation and attempts, and other psychological difficulties. A counselor reviews each questionnaire and sends an individual assessment back to the students. Those students whose responses suggest 49 psychological problems are invited to come in for a face-to-face evaluation. Currently, Emory and the University of North Carolina are piloting the survey (Capriciso, 2006). Conclusion It is understandable that litigation arising from college student suicides have many campus officials approaching the issue of student suicide as a risk management issue. In the wake of high profile litigation, college administrators wonder what the legal risks are for notifying or not notifying parents. Campus officials question whether it is safer to have mandatory withdrawal policies for students who have mental health problems or to assist these students with getting appropriate treatment? Unfortunately, the risk-management approach to college student suicide has resulted in disturbing and problematic outcomes for students and institutions. Whereas some college administrators erred on the side of not notifying parents, assessing the student at risk, and hospitalizing a student, the risk management approach overreacts and may penalize a student for seeking help. For example, Jordan Nott was a 21-year- old, 4.0 student attending George Washington University (GWU) when he became depressed over a close friend's recent suicide. Jordan became concerned about his own depression, sought emergency care and voluntarily admitted himself to a local hospital. When the university learned of Nott's hospitalization, GWU officials charged him with violating the school code of conduct by "endangering behavior." Subsequently, campus administrators suspended Jordan, evicted him from his dorm, and threatened him with arrest for trespassing if he set foot on university property (Applebaum, 2006). 50 These disturbing events have occurred on campuses across the county and several students who have been suspended or withdrawn as a result of seeking treatment are fighting back in the courts and through the Department of Education's Office for Civil Rights. These students argue that federal and state disability laws protect their right to stay on campus. Campus legal experts warn that these institutions may be creating greater ethical questions and legal risks for themselves by barring students with mental illness rather than helping them recover from their conditions (Pavela, 2006). Equally troubling is the controversial policy of "counseling waivers" used at many institutions including GWU. These waivers permit information about students who seek services at a university counseling center to be shared with campus administrators. Stephen Bennie, the Director of ethics at the American Psychological Association, says that such measures are very troubling because they forfeit a student's right to confidentiality. Bennie added that there are already exceptions to confidentiality in order to address emergent situations, such as a risk of harm to self or others (Capriccioso, 2006). Many mental health experts have expressed concern that such practices discourage students from seeking help and abandon students when they are at their most vulnerable (Capriccioso, 2006). While higher education officials have often defined their obligations to students from a legal and risk management perspective, they have neglected at times to approach the issue of student suicide educationally. The right educational policies and the best risk management policies is to ensure that students who threaten or attempt suicide obtain immediate and professional help even if this means that assessment or treatment has to be required, mandated, or enforced by the campus discipline system. This is best done by a 51 team of mental-health professionals who will assist in finding ways to keep the student enrolled. Campus administrators who create policies that encourage students to get appropriate and urgent care are more compassionate and judicious to students and, in the end, more protective of their higher education institution. CHAPTER 3 METHODOLOGY Introduction The methodology section included the following areas: (1) design, (2) population, (3) sample, (4) instrumentation, (5) data collection, (6) data analysis, and (7) data presentation. Design The study utilized a descriptive design that focused on three areas: (1) a comprehensive review of the literature regarding college and university suicide; (2) an in-depth phone or face-to-face interview with college and university administrators regarding their suicide prevention and intervention programs and protocols; and (3) the development of recommended practices and policies when addressing student suicide at colleges and universities. Population The population included select colleges and universities in the United States with evidenced-based programs designed to address serious young adult distress and to prevent suicide. The criteria for inclusion in the study came from the National Mental Health Association and the Jed Foundation (2002) list of essential services for addressing 53 suicide behaviors on campus. Requirements for inclusion of the institution in the study included three criterions: (1) a functional operating structure within the institution that had authority, funding, responsibility and accountability for suicide prevention; (2) institutional data collection and evaluation systems to track information on suicide attempts and completed suicides; and (3) institutions of higher education that were identified in the literature and by many experts to have model suicide prevention and intervention programs or policies. Sample The in-depth phone interviews were conducted with a nonprobability sampling procedure. The participants were a purposefully selected sample of 23 college and universities officials who had recognized prevention and response programs. In order to be considered in the sample, the university administrator had to be one of the most experienced or involved professionals in working with student crises. These individuals also were required to be members or consultants to either their institution's suicide response team or Crisis Intervention Response Team. Key supervisors and administrators were contacted and asked to participate in a lengthy interview regarding their suicide prevention and response policies and procedures. Many of these interviews were conducted with college and university supervisors and administrators who the researcher had known professionally prior to the study. All of the in-depth interviews were recorded. Each interview was transcribed. 54 Instrumentation The instrument used in the study, the Student Suicide Interview Questionnaire (SSIQ) was a thirty item questionnaire that asked college and university supervisors and administrators a series of questions regarding the threat of suicide on their campus, what their response was to suicide, and whether or not they have had initiated any suicide prevention programs. Data Collection The in-depth face-to-face interviews were conducted February 1, 2008, to January 15, 2009. Each in-depth interview lasted between 45-90 minutes. Each phone interview followed the Student Suicide Interview Questionnaire. Data Analysis The data were analyzed using frequencies, percentages, median, and mean scores. Where appropriate, a Chi-square analysis was obtained from cross tabulations to examine critical areas of the investigation. Data Presentation The data presentation in Chapter 4 is organized according to the purposes of the study: (1) demographics of participants and their college or university; (2) institutional suicide prevention efforts; (3) institutional interventions and practices when a student attempts suicide; (4) institutional practices and policies when a student dies from suicide; and (5) additional services or resources higher education institutions would like to 55 provide to prevent, intervene, and respond to suicide attempts and suicides. Graphs, charts, and other visual aids were used to highlight the findings of the study. CHAPTER 4 FINDINGS Introduction As mentioned earlier in Chapter 3, the Student Suicide Interview Questionnaire was developed by several higher education experts to assess how colleges and universities are attempting to prevent suicide and respond to suicide attempts and completed suicides. The researcher interviewed 23 higher education professionals from November 1, 2007 to January 15, 2009. Five of the interviews took place in person and 18 interviews occurred over the phone. The researcher also interviewed three additional people from three higher education institutions. These extra interviews were based upon the recommendation of the first interviewee who believed that they could not answer every question in the SSIQ. Each interview lasted from 45-90 minutes and was audio taped and later transcribed. Each transcript was read and reread several times by the researcher and answers were then coded. Many interviewees directed the researcher to a campus website that explained their institution's suicide prevention efforts and services. The researcher also carefully reviewed the Substance Abuse and Mental Health Services grant awards and other pertinent information regarding the institution's suicide prevention efforts. 57 Fifteen of the 20 institutions selected for the study were chosen because they were recipients of federal grants from the Substance Abuse and Mental Health Services Administration (SAMHSA) Suicide Prevention grants. The purpose of these campus suicide prevention grants was to provide funding to higher educational institutions to improve services for students with mental health issues such as depression, bipolar disorder, substance abuse, and suicide attempts, all of which can lead to failure in school and decreased student retention. The additional five institutions that participated in the study were selected based on the review of the literature and the recommendation of higher education experts in the field who suggested specific colleges and universities because they had model suicide prevention programs and policies. Location of Higher Education Experts and Their Campuses Table 1 shows the location of the institutions where the higher education experts were interviewed. Over 50% of experts interviewed were from the western part of the U.S. Twenty-five percent were from campuses in the Midwest, and the rest of the experts came from institutions in the southern and northeast parts of the country. Demographics of Higher Education Professionals Professions and Titles Twenty-three higher educational professionals were interviewed representing 20 higher education institutions. Five of the 23 professionals were deans or assistant deans of students. Five respondents were the directors of their university's or college's counseling center. Three higher educations professionals were student conduct 58 Table 1 Location of Campuses ________________________________________________________________________ ________________________________________________________________________ professionals and three were assistant or associate vice-presidents of student affairs. One chief student affairs officer was interviewed as were two health center directors, two counseling center staff psychologists, and two directors of other student affairs agencies. The length of employment at their current college or university for the higher education ranged from 1 year to 39 years. The average length of time the professionals had been employed at their college or university was over 14 years. Educational Level Table 2 illustrates the educational level of the participants. The majority of professionals had doctorate degrees. A quarter of the professionals had master's degrees. Variable Frequency Percent Northeast (CT, ME,MA, NH, NJ, NY, PA, RI, VT) 3 15% Midwest (IL, IN, IA, KS, MI, MN, MO,NE, ND, OH, SD,WI) 5 25% South (AL, AR, DE, DC ,FL, GA, KY, LA, MD, NC, OK, SC, TN, TX, VA,WV, 3 15% West (AK, AZ, CA,CO, HI, ID, MT, NV, NM, OR, UT, WA, WY) 9 55% 59 Table 2 Educational Level ________________________________________________________________________ ________________________________________________________________________ Professional Roles The higher education professionals had specific responsibilities in the event of a student suicide attempt or completed suicide. The roles of the professionals were divided into three categories. First responders were individuals who supervised a crisis team or were core team members who formulated and managed a crisis plan for the campus in the event of an attempt or suicide. Secondary clinical responders were directed by the crisis team to provide clinical assessment, evaluation, or counseling services to the student attempter or those individuals most immediately impacted by the crisis. Secondary responders also provided intervention services to the campus community. Secondary conduct responders were professionals who investigated the attempt or suicide to understand what factors contributed to the student's death such as a hazing, family issues, a break-up of a significant relationship, or an academic or career setback. These investigations addressed violations of the student code of conduct by other students or student organizations that may or may not have been associated with the student's attempt or suicide. Variable Frequency Percent PhD/PsyD Psychologists 12 52% Masters Degree 6 26% Jurist Doctorate 2 9% PhD In Higher Education 2 9% EdD in Educational Leadership 1 4% 60 Table 3 indicates that 10 of the 23 professionals reported that they had secondary consulting roles in the event of a student suicide. As consultants, these professional were directed by the campus crisis team to provide a range of clinical and counseling services to the campus community. These services included: (1) assessing and evaluating the student attempter for risk to themselves or others; (2) intervention following a student suicide such as clinical debriefings and other psychological first aid services; and (3) on-going counseling to those individuals who were most profoundly impacted by the attempt or suicide. Individuals involved in consultation efforts saw their role as reducing the contagion of attempts or completed suicides, decreasing excessive levels of emotionality in the community, and supporting the campus community members in regaining equilibrium in the event of a student attempt or death. Table 3 Professional Responsibilities in the Event of a Suicide Attempt or Suicide ________________________________________________________________________ ______________________________________________________________________________________ Variable Frequency Percent First Responders 8 35% Secondary Clinical Responders 10 43% Secondary Conduct Responders 3 13% Notify Student Advocacy Office 2 9% 61 Three higher education professionals indicated that their primary responsibility in the event of a student suicide was to investigate the circumstances surrounding the suicide attempt or death to determine if there was a prior indication of imminent threat to the student or community. These professionals could remove a student from campus through an administrative or immediate suspension by means of the college's student code, had the administrative ability to encourage or mandate a psychological assessment or evaluation of a student at risk, and investigated what factors contributed to the student's crisis. One professional said: …ordinarily, we would look at the surrounding circumstances to make sure that there were no student factors that contributed to it. For example, a hazing situation, a roommate situation, or a relationship that went bad (personal communication, June 12, 2008). Two of the professionals indicated that their key responsibility was to notify the central campus's student advocacy office where a formalized protocol of services was administered by the professionals in this office. The student advocacy office communicated with the Crisis and Consultation office which activated the crisis plan, coordinated the communication of the crisis or tragedy to the appropriate law enforcement officials and medical and media professionals, and worked directly with parents, guardians, and university officials. Demographics of Higher Education Institutions Table 4 shows that of the 23 institutions that participated in the study, most were public colleges or universities and seven were private institutions. Of the seven private institutions, two institutions were religiously affiliated. 62 Table 4 Public or Private Higher Education Institution ________________________________________________________________________ Variable Frequency Percent Public College or University 16 70% Private College or University 7 30% ________________________________________________________________________ Table 5 Number of Undergraduate Students as a Percentage of Institution Size ________________________________________________________________________ ______________________________________________________________________________________ Variable Frequency Percent 100% 1 4% Over 90% 3 13% Between 76-90% 11 48% Between 51-75% 7 31% 50% 1 4% 63 The enrollment figures of the colleges and universities varied widely. The largest enrollment was 50,995 students and the smallest was 953. The average enrollment of the 23 institutions was 20,870 students. The graduate and undergraduate student populations varied as shown in Table 5. One university had only undergraduate students and another institution had only half of its student population classified as undergraduate students. Over half of the schools had 76%-90% of their total enrollment listed as undergraduates. The number of students who lived on campus varied widely. One institution did not offer on-campus housing and one institution had 97% of their students living on campus. Eight institutions had 10-20% of their students living on campus. Eight schools, or about a third, had 20-40% of their students living on campus and five institutions had over 40% of their students residing on campus. Campus First Responders Question eight on the SSIQ asked the participants what campus agency or department would first respond to a threat of suicide on campus. (See Table 6.) Each of the respondents indicated that the first responder varied depending on which campus office first received the information. Seven of the respondents reported that the local campus police would first respond to a suicide threat on campus. Six schools indicated that personnel from the Office of the Dean of Students would first respond and six professionals stated that that their campus counseling center staff members would respond first. One school reported the first responder would be the Vice-Chancellor or Vice- President of Student Affairs and two professionals explained that their health center personnel would initially respond. One institution reported that the first responder for a 64 Table 6 Campus First Responders ______________________________________________________________________________________ ______________________________________________________________________________________ student suicide attempt would be mental health professionals from a mobile psychological crisis unit from their local county jurisdiction. Number of Suicides and Suicide Attempts Two professionals surveyed did not know how many students from their institution committed suicide in the last year. Fourteen reported that there were 0 to 1 student suicides at their institution during the past academic year. Six professionals reported that there were 2-5 suicides and one reported that they had 6-10 suicides on their campus in the past 12 months. Seven of the respondents did not know how many students from their institution had attempted suicide and nine professionals reported that 0-5 students had attempted suicide. Ten schools reported that they had 5-10 students attempt suicide and one professional reported that they had 11-20 students attempt suicide. Three professionals reported that they had between 20-50 suicide attempts in the past year. Variable Frequency Percent Vice-President of Student Affairs 1 4% Police or Public Safety 7 30% Counseling Center 6 26% Dean of Students 6 26% Health Center 2 10% County Mental Health Mobile Team 1 4 65 Institutional Prevention Efforts Prevention practices and policies for suicide varied and were largely dependent upon a school's size, public or private status, religious affiliation, financial and human resources, campus culture, student population, and number of students living on campus. While prevention efforts varied, results from the study indicated that some prevention tools were being utilized at the majority of the institutions that participated in the study. This section highlights college suicide prevention efforts including (1) mental health screening, (2) campus wide educational programs, and (3) populations being targeted for intervention. Mental Health Screening Some higher educational institutions have started to use mental health screening assessments or questionnaires for incoming students to be better prepared for students who may have preexisting mental health conditions. In this study, higher education experts were asked if they screened incoming students for mental health issues. Four of those surveyed reported that after a student had been accepted to thei