Suicide Prevention in College Students: A Collaborative Approach

Abstract

Described by Durkheim (1966) as the crudest expression of the social phenomena, suicide is of interest to clinicians, academics and researchers. Within the academic context, this issue has to be addressed and prevented. We are interested in sharing the process of participative action that led to the creation of a Suicide Prevention Program (SPP) for college students. Based on knowledge that was generated through a collaborative effort among all sectors of the academic community, we developed a prevention campaign that is culturally sensitive to our university’s environment. This campaign is directed towards overcoming the stigma of seeking help and is characterized by promoting a sense of wellbeing in a holistic manner, paying attention not only to the individual, but also to elements of their sociocultural environment.

Suicide, or the act of deliberately ending one’s own life, is considered a public health problem. The statitiscs shows that an average of 3,000 individuals commits suicide daily. For each effective occurrence, 20 or more individuals attempt it (World Health Organization. 2011). According to the Centers for Disease Control and Prevention, suicide is the third cause of death in the United States among individuals between 15 and 24 years, as cited by Appelbaum (2006). In Puerto Rico, according to statistics offered by the Heath Department, in 2008 there were 299 suicides, which represent a rate of 7.5 for every 100,000 Puerto Ricans. (Instituto de Estadísticas de PR, 2010)

Every year in the United States, approximately 1,100 college students between the ages of 18 and 24 commit suicide, and nearly 24,000 attempt it (Appelbaum, 2006). A four-year prospective study done in the United States with freshman college students revealed that 12% had suicidal ideation sometime during their years at college (Wilcox, Arria, Caldeira, et al., 2010).

Since the 80s, counseling center directors in the United States have been participating in an ongoing survey every two years. The survey is sponsored by the Association for University and College Counseling Center Directors. Since 2005, data from this survey reveals an increase of students that exhibit severe mental health problems and seek help through the counseling centers (Gallager, 2009).

Similarly, literature on the issue in Puerto Rico indicates that suicidal ideation and suicidal behavior are more frequently detected in students that seek help through the university counseling centers (Jiménez, 2009).

On the occurrence of behaviors associated with suicide, there are some studies that indicate that one out of every five suicides among college students occur the same day they are having a life crisis (Appelbaum, 2006). This finding points to the importance of not only investigating more deeply every aspect of the various behaviors associated with suicide, but also the way in which individuals think about this phenomenon.

Although suicide is an extremely important topic, its discussion in Puerto Rican society is very limited, particularly when it has to do with suicide among young persons. Campos, Padilla, and Valerio (2004) indicate that this is because individuals avoid and prefer not to face the fact that some young individuals think life is that painful and are killing themselves in a conscious and deliberate manner. This fact has an impact on and partially questions our social and family system.

Although research on mental health and behaviors associated with suicide among college students is scarce in Puerto Rico when compared to what has been published in the United States, a study done with the students of the University of Puerto Rico (UPR) indicated that 15.4% of surveyed students reported depressive symptomatology on a self-assessment scale (Reyes & Suárez, 2006). On the other hand, statistics from 2005 to 2009 at the Interdisciplinary Center for Student Development at the UPR-Cayey Campus (CEDE, for its acronym in Spanish) indicate that depressive symptoms were the most frequent problem among students serviced at the center through individual counseling.

Mental health research suggests the need to work on suicide prevention and intervention at universities, so that strategies can be developed to prevent suicide, fight against the stigma of seeking help, and promote wellbeing among college students. However, at the University of Puerto Rico (UPR) no systematic activities were in place to prevent suicide outside the clinical and therapeutic setting. This changed since 2006, when the Substance Abuse and Mental Health Services Administration (SAMHSA) awarded a grant to the UPR-Cayey Campus to develop a program on suicide prevention in the university context. Another 29 universities in the United States and a private university in Puerto Rico also received the SAMHSA grant to develop this type of program.

This paper presents and discusses the process of developing and implementing the Suicide Prevention Program among college students (SPP) that was developed at the University of Puerto Rico- Cayey Campus (UPR-Cayey) as a result of the collaboration with SAMHSA. The model we developed is collaborative in nature, which means that the aspect of prevention involves every sector of the university. As part of the experience, we implemented two key strategies to develop a successful collaborative model in the university setting: 1) Ask every sector to participate as advisors/collaborators in the development of prevention strategies; and 2) use culturally appropriate language to minimize the stigma associated with mental health problems. Below we will describe these strategies and the importance of using culturally sensitive models for suicide prevention among college students.

Development of the Suicide Prevention Program (SPP)

The Suicide Prevention Program (SPP) implemented at the UPR-Cayey was the first federally funded initiative in the University of Puerto Rico system to address this problem. The UPR-Cayey is a public liberal arts institution that grants undergraduate degrees. It is located in the central part of the island of Puerto Rico and has approximately 3,300 students enrolled. It is also part of a system composed of eleven campuses with approximately 59,000 students.

Goals and Objectives of the SPP

At the campus, the main goals with the SPP were the development of a campaign directed at providing information and increasing awareness in the academic community about suicide and its prevention. In addition, our intention was to reduce the stigma associated with seeking help for mental health services. Our objectives were: a) to develop an emergency management and response plan; b) to prepare educational material; and c) to create a webpage about who could seek help, and when, where and how to seek it. During the Program’s planning and implementation process, it was important to start thinking about the particularities of our university’s students, faculty and staff, and our university’s culture. Various lessons and successful practices, which can be useful to other programs, were the product of this process of reflection. Following we present the process which led to the development of the SPP.

Initial Phase: Coordinate and offer training about the topic to students, faculty and staff

The first step in developing the campaign was to coordinate training sessions offered by local experts on the topic of suicide. These conferences were directed at mental health professionals working at the counseling centers (counselors and psychologists) from the eleven campuses of the UPR system. These trainings were extremely valuable for the eventual planning of prevention activities at the UPR-Cayey Campus.

During these meetings, we gathered information about everyone’s daily experiences working at the counseling centers. For example, we explored experiences related to intervention with students with mental health issues. Meeting participants also shared their experiences and interventions with suicidal crises. One important aspect identified was the fact that none of the centers had developed a crisis protocol, which was necessary. Another aspect was the importance of integrating every component of the academic community in the prevention of suicide. To accomplish this we needed to develop strategies because the main problem was that the academic community was not involved and only relied on professionals at the counseling center for suicide prevention. We were interested in learning how other colleague counselors in the UPR system perceived the role of other community members (faculty, staff, students) in promoting wellness and prevention.

It became quickly evident that we were confronting similar situations. For example, students’ participation in workshops was scarce. Typically, students do not attend activities that are not related to their courses, or their attendance is very limited. We needed to develop strategies that would stimulate student participation in the different activities.

Another common experience was the challenge of getting professors to refer students to the counseling centers. We knew that professors were probably the first ones to notice in students the need to receive counseling and that it was important for them to participate in our discussions. However, given their multiple and complex responsibilities, colleagues informed that getting them to coincide for a meeting or training was very difficult.

In addition to receiving training and sharing with other colleagues during this initial phase of the project, we also reviewed various training models available through the internet and aimed at lay persons on how to educate about suicide prevention. We chose the Question, Persuade and Refer model (QPR). This strategy was chosen because it is recognized as an evidence-based practice (Quinet, 2000). We would also be able to get a certification on the intervention by completing modules and taking online courses, and without having to travel outside the country. In addition, the reasonable cost of being trained as instructors would allow us to train and certify an unlimited amount of gatekeepers and it included various materials and books for us and for the gatekeepers. Another advantage was that the gatekeepers’ training could be offered with a certain amount of flexibility, making it culturally appropriate and completely adjustable to our population and to the availability of our participants.

Second Phase: Develop the Question, Persuade and Refer (QPR) Training

The QPR is based on the premise that talking about death at a personal and group level allows individuals to get more awareness of the signs that a persons woh is thinking about suicide shows and where to refer for help. (Quinnett, 2000). Using this model as a foundation, our team designed and adapted a one-and-a-half-hour workshop, which offers general information about the prevalence of suicidal behavior in our students and discusses some myths about the topic. We adapted the training according to participants’ time availability, but always including the key elements: talk and ask questions to the person at risk for suicide, persuade them to seek help and, if needed, refer the person to professional help.

The emphasis of this workshop was on the importance of having the participation of the entire academic community in suicide prevention among college students. The student in need decides who he talks to about this (for example, it could be another student, a professor, or a staff person). This is why it was so important to train the entire academic community. When designing the workshop for professors, for example, we emphasized the fact that, in addition to the idea of dying, there could be indicators of anguish and hopelessness. Another objective for the professors’ training was to share information about how to identifify students who might be considering the idea of taking their lives. We also presented and modeled strategies to persuade an individual to seek help and offered information about referral resources.

Once the QPR workshop was adapted, the team was challenged with the task of implementing it to train every sector of the academic community.

Strategies to Educate and Disseminate Information About the Issue

We identify two key elements to educate and disseminate information about the important facts about suicide and about actions that can be taken in those cases. The first key element is to recruit every part of the academi community to become consultants. The second key elemnt is to use culturally adequate language to reduce the impact of stigma on students. In the next section we elaborate about these elements.

Key Element #1: To Recruit Every Part of the Academic Community to Become Consultants

Talking about students’ mental health is typically seen as a matter pertaining exclusively to the counseling centers and we wanted to initiate a dialogue about this topic with every sector. To increase participation, we had to come up with diverse alternatives.

Counselors and Psychologists

One of the most significant contributions of this experience was to include this group as consultants and collaborators. Although we work for the same system, as a professional group we have very limited opportunities to meet and share our experiences working in an academic context. Response from this group was excellent, 95% of those invited came to the meeting.

The participation of the counselors and psychologists who work at the UPR-Cayey was a key element to this project. We were the first ones to meet and participate in formal training on the topic, including the certification as QPR instructors. The Program covered the cost of the certification. It also paid stipends so that the staff could participate in meetings for brainstorming and strategy development in the areas we wanted to develop to address the issue of suicidal behavior. First, the need to promote services and the process of referral and intervention in at-risk cases was identified as an area to improve. As a product of these meetings, this group of colleagues came up with a slogan to promote the Counseling Center (CEDE) within the academic community. This slogan had to be attractive for students, which are our clientele. The slogan was: “Your challenges are not only academic. When it gets tough, let us help you”. It was included in posters and the CEDE promotional materials and this is how the CEDE promotional campaign started. The staff also collaborated in developing the intervention protocol for individuals at risk of suicide and the initial screening of referred students. In addition, the Center started a registry of the suicide risk cases addressed. The experience of pairing the Center’s goals with the goals of the Suicide Prevention Program was a key element in establishing practices that are still being implemented even after federal funding has ended. The fact that the promotional strategies and the intervention protocols were a product of the group working at the CEDE and were not adopted from an external entity contributed to their rapid implementation at the CEDE and contributed to the dissemination and permanence of the campaign at the university.

Students

We met with the presidents of every student organization and asked for their collaboration in getting the students to participate in the SPP. We did this because we knew that it was easier for a student to talk about his/her worries with another student than with an adult, even if it is a mental health specialist. We decided to train every member of the student organizations free of charge to become collaborators or gatekeepers in suicide prevention. These students took the training and obtained a certification as gatekeepers. Their role was to collaborate with the program in detecting signs of suicidal risk in other students and knowing how to persuade them to seek help and refer them. When presenting this proposal to them, we emphasized their abilities and leadership skills. In addition, we asked them for ideas to develop strategies for suicide prevention in addition to the ones presented during the training or before receiving the training. We made emphasis on the fact that, as peers, they could be key elements in identifying at-risk students.

As a result, some student organizations developed activities in which they combined preventive action with academic content. For example, a student from the undergraduate math program decided to write a paper for her Statistics course where she explained various concepts using suicidal behavior rates by age and gender and compared them by geographical region. These groups also had the idea of holding a suicide prevention day. One of the activities during the day was that students asked their professor to use 5 minutes in class to read facts about the topic of suicide and promote among students the use of counseling services when they had difficult challenges to deal with. Another student organization prepared a mural with the slogan “Laugh, Live and Love”, to promote among students expressions of their reasons to be alive. Through these and other strategies, we had an impact on 90% of the students participating in student organizations.

Staff

Coordinating staff assistance for the training sessions was one of the most successful. It was coordinated for security officers and secretaries. In both cases, we presented them with the possibility of a workshop and emphasized on how their role as part of the academic community allowed them to identify special situations among students early on. We think that the emphasis we made on their vantage point for detecting and referring contributed to a greater participation in the workshops. Security officers explained that because they are always present on campus, they observe students in their daily interactions and can identify mood states, sometimes way before counseling professionals who are in their offices. In addition, secretaries pointed out that because they have daily contact with many students who come to ask questions and seek help with academic issues, sometimes they got students who talked with them about daily worries and problems. Both security officers and secretaries felt that their role allowed them to identify and refer students that needed additional help. The Human Resources office included the topic of suicide prevention among the topics offered periodically to employees for professional development.

Another group that was included as consultant and that was especially productive was the Graphic Arts division and its personnel. This division was a key player in designing the local campaign’s creative concept. One of the suggestions they made was to develop posters with short messages, complemented with images or photos. They also contributed by using individuals from the academic community as models, which attracted attention towards the posters and, of course, towards the campaign.

Teaching personnel

With the professors, we were successful in getting some time during a faculty meeting, where we indicated that we wanted to get their opinions and recommendations about the strategies we had developed in the prevention campaign. We were not able to get a time allocated for offering a workshop or training. It was extremely useful to get professors involved as consultants, given their experience with students and their particular competencies. This strategy increased interest in the issue of suicidal conduct. Professors’ contribution to the process was to approve the strategies we were using. The opportunity of talking with professors about our interest in suicide prevention and letting them know that everyone in the academic community could contribute was aimed at stimulating them to collaborate in identifying students who could be at-risk and refer them or guide them to seek help. We started to receive referrals from professors and we even had professors who personally brought students to the Center.

The dialogues with the various sectors of the academic community helped discover ways in which everyone could contribute, participate or generate strategies for suicide prevention. Counselors contributed their experience and a strategy to promote the Counseling Center’s services was developed with them. The strategy included a slogan for the Counseling Center, a web page and an emergency protocol. The slogan and the promotional messages were developed taking into account suggestions students had given, including to use messages related to stress generating situations in academic life and to avoid pathologizing jargon. Our campaign was characterized by using culturally appropriate language for college students. When we talked about this with professors and staff, they indicated that given the type of scenarios in which they offer their services, this would facilitate interaction with the students and help detect indicators that a student might need help. In the next section, we will explain these consultation processes in detail.

Findings of the Consultation Process

Discussion groups held with colleague counselors and students took place at the University. We invited counselors to come to a meeting that was held in a non-working day with the purpose of brainstorming to produce strategies for suicide prevention. We provided a stipend for participating. With students, we coordinated meetings with theater students and with the leaders of the student organizations to present the Suicide Prevention Program and ask for ideas on how they thought the campaign could be more effective. In both cases, an open question format was used. The questions were designed to explore the main problems affecting students’ wellbeing. These discussion groups developed from the Project Director’s interest in working in a collaborative manner and developing culturally appropriate and relevant products.

A very interesting aspect of these dialogues was that participants perceived the university as a scenario that stimulates competence and goal attainment, which consciously or unconsciously inhibits people from showing their vulnerabilities. Students informed that this culture of competition could generate excessive stress and anxiety. Our University has high admission standards. For this reason, some students find it difficult to let others see them as vulnerable or incapable of meeting academic demands. In addition, there was consensus among participating academic community members on the fact that in Puerto Rico there is prejudice against persons who visit a mental health professional.

Some students reported being preoccupied with being identified as a mentally sick person as a result of visiting a mental health professional. Studies indicate that mental health has a stigma in society (Mateu & Cuadra, 2007). In Puerto Rico there has also been some research done on the stigma associated with prejudice against individuals who visit a psychologist or other mental health professionals (Varas & Cintrón, 2007). For us it was evident, particularly when exploring students’ perspective, that we needed to overcome the clinical paradigm of suicide prevention as an individual matter that only pertains the individual with suicidal behavior and in which only the mental health professional intervenes.

From our experience at the CEDE and from the dialogues held with other colleagues, we knew that the general attitude in the academic community was to delegate suicide prevention and intervention exclusively to the University’s mental health professionals. In order to recruit every sector of the academic community, this perception had to be changed. In addition, a collaborative approach that included every member of the academic community in the efforts made to prevent suicide had to be implemented. That is to say, far from assuming the clinical construction of what mental health problems are, we wanted to examine which were the typical problems that students faced and if their lack of skills to manage them could increase the risk of suicidal behavior.

During group discussion with students, we explored the typical problems and life events that can affect their performance and sense of wellbeing, driving them to consider suicidal behavior. They informed various difficult events that can generate distress in college students, such as: (a) romantic breakups; (b) rejection because of sexual orientation; (c) problems at home; (d) stress related to studying and working at the same time; (e) being a parent; and (f) depressed mood. We validated this knowledge, which was based on their experiences. This was particularly relevant because there is local and international research that supports the relationship between suicidal ideation and negative life events (Adams & Adams, 1996; Rosello & Berrios, 2004;). There is research that identifies romantic breakups as the most important cause of suicidal behavior in young persons (Drum, Brownson, Burton, & Smith, 2009). Similarly, research on the topic indicates that difficulties related to feeling discriminated or rejected due to sexual orientation can also be a risk factor for suicide (Silenzio, Pena, Duberstein, Cerel, & Knox, 2007).

The dialogues and collaborative experiences with the various groups of collaborators from the academic community were extremely productive in generating ideas and strategies, mainly because they helped us to broaden our information with a cultural perspective. That is to say, if our program was aimed at young college students at the undergraduate level, most of them raised in the central part of the Island, it was important to try to know and understand their particularities. Similarly, we wanted to understand their worldview and to see how it differed from our own. This was especially important because we are professional adults and come from a different cultural group. We recommend that the visual materials take into consideration culturally relevant symbols and metaphors, actors and models.

Key Element #2: Use Culturally Adequate Language to Reduce the Impact of Stigma on Students

Following we present some of the ways we implemented the findings obtained through discussion groups, workshops and dialogues.

Slogan

We decided that the Suicide Prevention Program campaign should use non-biased language that did not contribute to stigma-generating conceptions. This required us to focus on difficulties inherent to the academic experience and the developmental stage where most part of the students were, as well as on the challenges they must deal with. Taking this into account, one of the first actions that this strategy generated was the development of a slogan to promote among students the practice of seeking help. The slogan selected was: “Your challenges are not only academic. When it gets tough, let us help you.” This slogan was culturally appropriate and did not use pathologizing or stigma-generating language. This was achieved by framing students’ problems as challenges; which empowers the student. This slogan states that academic life is much more than acquiring academic competences or skills. It is a time in life in which the individual is also facing other personal, economic, family and relational matters, which can produce stress and are potentially dangerous for the person’s stability and wellbeing. In this slogan, we invite the person to visit the mental health specialists at the Counseling Center, which emphasizes help and support instead of diagnosis and treatment of a particular condition.

Posters

With the information we had about the typical problems students face, we prepared posters representing the situations described by them. The models used for the posters were students, employees and a professor from our University.

One of the contributions of the collaborative approach to the development of the prevention campaign was the language used to name the typical problems students face, without using traditional DSM IV categories. For example, in one of the posters, the image of a visibly sad young man is accompanied by the word “rocheao”. In English, the meaning of this word would be similar to that of “bummed out”. Young people use this word to describe a sad or anguished emotional state. This type of word is common among young Puerto Rican’s language. Including this word intended to connect with them. On the other hand, including members of the academic community in the posters resulted in a very effective element for bringing attention to the posters and to the message.

Webpage

Student’s perspective on the topic also contributed to the development of a webpage for the Counseling Center (which was part of the objectives of the PPS). During the process of designing the webpage, a very talented freshman reviewed the pages of prevention programs in other universities. As a result, she decided that in building our page she should focus on the challenges students face and not on the deficits. According to this student, in her review, she found that some pages included instruments to screen for depression, panic attacks and eating disorders, among others. In addition, in her judgment, the language used was too clinical and appealed to a student diagnosed with some mental health disorder. The student suggested that we should not use this kind of language so that the page would be more appealing to students with problems or challenges, instead of sick students.

Results from the merging of these elements

We achieved the goal of getting the members of the academic community that we wanted to impact to become actors in knowledge-building and to participate with us in the analysis of the object of study (suicide among students and the stigma related to seeking help). They participated in identifying the necessary elements to prevent and address suicide in students. Similarly, they participated in the development and designing of a preventive campaign with effective messages and images to be used in the academic setting taking into consideration our particular cultural context.

Concretely, as a result of the Suicide Prevention Program the university’s Counseling Center’s visibility and presence in the campus increased, a webpage was developed and cases referred to the Center were better documented. In addition, intervention protocols were developed and distributed to the entire academic community.

Conclusion

The development of a program for preventing a social phenomenon has to take into consideration the particular characteristics of the cultural context in which the conduct shows up or is manifested (Goldstein, Davis, Whitbeck, Murakami, Zayas, & Nagayama, 2008). Culture influences the way in which mental sickness is perceived and the uneasiness a person might feel when diagnosed as mentally sick. This is why we consider it important to acknowledge that studying suicide is not complete if we limit ourselves to the information specialists have about the topic. This is why it was important not to limit ourselves to receiving formal education on the theorical aspects of suicide, but also to explore with the academic community their knowledge about the topic. Such measures allowed us to explore conceptions, myths and, in general, the social imaginaries about suicide, its definition and how to address it.

The intellectual product of science has an impact in society’s material and symbolic life. So exploring the ways stigma manifests itself was important for the SPP. The traditional view individuals hold about mental health professionals addressing pathologies or individuals with mental disorders can affect students’ decision of seeking help, as we found out in the discussion groups we held with counselors and psychologists, students and other members of the academic community.

We agree with Ratts cited in Greenleaf and Williams (2009) in that the approaches that place the causes of problems on the individual and those focused on deficit and pathology can perpetuate forms of social injustice and cultural oppression within counseling. We believe that sometimes, symptoms are a product of the stress experienced by individuals with little power or living a reality that is different from what they want (Fernández, 2006).

Suicide is certainly an act that is committed individually most of the time, but when we look at it in terms of process, it is a conceptual action. That is to say, it originates from the ideas derived from the different norms and symbols that form culture and society. From this perspective, suicide is a social act. It is not dictated as an inevitable destiny. Self-destructive behavior is often accompanied by myths related to the values, beliefs and norms of the human groups. Social researchers have the task of analyzing the construction of these myths about suicide, where destiny and the inevitable play a central role. We should not forget that suicide can be prevented.

Research on the different issues associated with suicide contributes valuable elements to understanding this behavior. When these elements are strategically disseminated, they become important aspects of community prevention. This could be a good example of the social impact that academic knowledge has in society. Understanding suicide through the lens of the academic community reveals those aspects the community has to address. Suicide is a multi-factor problem, where diverse social, cultural, psychological, educational and economic dynamics converge. Being such a complex phenomenon, its study requires an interdisciplinary perspective that allows for a broad understanding of self-destructive behavior at the personal and group level. Studying and researching suicide requires multisector actions that have profound interactions with the environment. In that sense, a program designed with this in mind will not only be flexible, but will also be a space where components of the academic community interested in research can converge.

We know that the collaborative strategy is useful in generating change and facilitates the understanding of the area where we want to intervene. The Suicide Prevention Program of the UPR-Cayey allowed us to develop a different methodology for doing things. Sometimes we faced indifference, due particularly to the reductionist idea of seeing suicide as a problem that only pertains to the individual in crisis, and not as a social problem. This individualistic view hinders active participation in the process of reflection and discussion of alternatives that contribute to the prevention and reduction of suicide rates.

In our prevention program, we had clear goals and objectives for suicide prevention. However, we opened a space for the rest of the academic community to contribute on how to reach these goals and objectives. The results obtained are the product of a dynamic process that values human life and dignity, where members of every sector of the academic community participated through discussion and action.

We want to share this experience not only to describe the development of a participative action process, but also to emphasize its value and contribution to promoting hope and wellbeing among our college students. We agree with Betancourt (2006), who also has a suicide prevention program at a university setting:

And while statistics provide us with indifferent or detached numbers to which we are used to, as if dead human beings were lost marbles, we know that every number has a face, a face that looked at itself in other faces, maybe in yours, maybe in mine, and for that face, for that name, we are working.

We consider suicide among students as a matter pertaining to everybody, because everybody can do something about it.