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Turning Violence Inward: Understanding and Preventing Campus Suicide

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Turning Violence Inward: Understanding and Preventing Campus Suicide Morton M. Silverman, M.D. Senior Advisor, Suicide Prevention Resource Center – PowerPoint PPT presentation

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Title: Turning Violence Inward: Understanding and Preventing Campus Suicide


1
Turning Violence Inward Understanding and
Preventing Campus Suicide
  • Morton M. Silverman, M.D.
  • Senior Advisor, Suicide Prevention Resource
    Center
  • Senior Medical Advisor, The Jed Foundation
  • Clinical Associate Professor of Psychiatry, The
    University of Chicago
  • Violence on Campus Prediction, Prevention, and
    Response
  • Columbia University Law School
  • New York, NY
  • April 4, 2008

2
THE BIG PICTURE
3
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4
Trends in Suicidal Behavior1990-1992 vs.
2001-2003National Comorbidity Survey and
Replication
  • 9708 respondents, face-to-face survey, aged 18-54
  • Queried about past 12 months
  • No significant changes

Kessler, et al., Trends in Suicide Ideation,
Plans, Gestures, and Attempts in the United
States, 1990-1992 to 2001-2003- JAMA May 25,
2005, Vol 293, No 20.
5
National Comorbidity Study(1990-92 15-54 yrs
5877 respondents)
  • LIFETIME IDEATION 13.5
  • LIFETIME PLAN 3.9
  • LIFETIME ATTEMPT 4.6
  • Kessler, et al. AGP 56 617-626, 1999

6
Median Age of Onset (percentiles) (Kessler, et
al., 2005)
7
Campus Suicide
  • Suicide is the 2nd leading cause of death among
    campus students
  • - more teenagers and young adults die from
    suicide than from all medical illnesses combined
  • 18 million enrolled students (over 9 million are
    ages 18 24)
  • Estimated 1,350 suicides annually (3 per day)

8
COLLEGE and GRADUATE STUDENTS SPEAK
9
ACHA-NCHA Findings
10
ACHA-NCHS Findings
Source American College Health Association
(2007)
11
ACHA-NCHA Survey Fall 2006
American College Health Association. American
College Health Association - National College
Health Assessment (ACHA-NCHA) Web Summary.
Updated August 2007. Available at
http//www.acha-ncha.org/data_highlights.html.
2007.
12
ACHA-NCHA Survey Fall 2006
American College Health Association. American
College Health Association - National College
Health Assessment (ACHA-NCHA) Web Summary.
Updated August 2007. Available at
http//www.acha-ncha.org/data_highlights.html.
2007.
13
ACHA-NCHA Survey Fall 2006
American College Health Association. American
College Health Association - National College
Health Assessment (ACHA-NCHA) Web Summary.
Updated August 2007. Available at
http//www.acha-ncha.org/data_highlights.html.
2007.
14
ACHA-NCHA Survey Fall 2006
American College Health Association. American
College Health Association - National College
Health Assessment (ACHA-NCHA) Web Summary.
Updated August 2007. Available at
http//www.acha-ncha.org/data_highlights.html.
2007.
15
UC Berkeley Graduate Student Survey - April, 2004
  • In the last 12 months
  • 45.3 experienced an emotional stress-related
    problem that significantly affected their
    well-being and/or academic performance
  • 67 felt overwhelmed 54 felt so depressed that
    it was difficult to function 9.9 seriously
    considered suicide
  • females were more likely to report feeling
    hopeless, exhausted, sad, or depressed

16
Why Dont Students in Need Seek Help?
  • gt 25 of depressed young adults express intent
    not to accept a diagnosis of depression due to
  • Negative beliefs and attitudes toward depression
    causation and treatment
  • Beliefs that depression should be hidden from
    family, friends, employers
  • Lack of past helpful treatment experiences
  • Van Voorhees et al., Annals of Family Medicine,
    2005

17
Selected Data from National Research Consortium
of Counseling Centers in Higher Educations Study
on The Nature of College Student Suicidal Crises
  • Chris Brownson, Ph.D.
  • cbrownson_at_mail.utexas.edu
  • The University of Texas at Austin
  • gt26,000 undergraduate and graduate students
  • 70 colleges universities
  • Web-based, anonymous, 25 response rate

18
Which of the following occurred before seriously
considering a suicide attempt in the past 12
months
19
Events rated as having a large impact on
seriously considering suicide in the past 12
months
20
WHAT THE EXPERTS SAY
21
2006 AUCCCD Survey (367 campuses)
  • 9 of enrolled students seen
  • 25 are on psychiatric medications (17 in 2000
    9 in 1994)
  • 40.1 of clients had severe psychological
    problems, 8.3 have impairments so severe that
    they cant remain in school or can only do so
    with extensive psychological help
  • 2,368 hospitalizations for psychological reasons
  • 142 suicides - only 10 current/former clients

22
2007 AUCCCD Survey(272 campuses)
  • 8.5 of enrolled students seek counseling
  • 91.5 believe greater of students with severe
    psychological problems
  • 49 of clients have severe psychological problems
  • 1,981 hospitalizations for psychological
    problems
  • 105 suicides - 21.8 were former/current clients
  • Post VTU 30.5 report policy revisions re
    communicating with parents about students in
    crisis

23
Mental Illness on Campus
  • Contributing Factors to Increased Demand for
    Services
  • early diagnosis better treatment
  • overall lessening of social stigma re mental
    illness
  • greater adjustment stress of diverse student
    population
  • limited access to off-campus services (high cost
    of private care insufficient insurance)
  • increased stress associated with the 24/7 pace of
    campus life (academic, social, etc.)
  • adjusting to a world of terrorism economic
    uncertainty political instability

24
Campus Suicide
  • Suicide is the 2nd leading cause of death among
    college students
  • Majority of students who die by suicide (80)
    have never been seen by the counseling service
  • Only 14 of students report receiving suicide
    prevention information from their colleges
  • Students at risk
  • - Those with pre-existing mental illness
  • - Those that develop mental illnesses
    while in college
  • - Those who lack coping and other life
    skills (or stop their treatments while away from
    home)

25
Foreign Students
  • May be at increased risk if
  • - shy
  • - lacking social skills
  • - lacking a support network
  • - having language/communication problems
  • - having financial/academic difficulties

26
Student Challenges - Summary
  • Finances - living expenses health insurance
  • Social Life - dating partnerships
  • Marital Life - spousal job postponing children?
  • Race/Ethnicity/Gender Issues - inequalities
    glass ceiling
  • Developmental Issues - separation individuation
    ethical moral principles commitments being
    self-reliant working alone
  • Social/Coping Skills - working closely with
    faculty peers
  • Dissertation Woes
  • Transitioning Into/Out of School - support
    identity
  • Career Identity - academia vs. real world
  • Getting a Job
  • Acculturation/Assimilation - international
    students language
  • Psychiatric Illnesses - including substance use
    and abuse

27
WAIT A MINUTE! ARE CAMPUSES TOXIC?
28
Suicidal ideation and behavior among high school
students by category and sex,U. S., 2005
Source CDC Youth Risk Behavior Survey During
the 12 months preceding the surveyOne or more
times
29
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30
What is the greatest precipitating factor among
youth suicide?
  • Among all 18-24 year olds who died by suicide
  • Almost 50 were due to intimate partner problems
  • Other reasons included
  • legal/criminal (20),
  • financial (12),
  • relationship problem with friend or family (13)
  • Important to attend to youth who have had a
    recent life event (relationship problem), who are
    depressed, and a tendency towards impulsiveness,
    especially within 2 weeks of life event

Source Harvard NVISS Pilot 2001
31
What do we know about impulsiveness of youth
suicide?
  • Among all 18-24 year olds who died by suicide
  • 1 in 5 occurred on the same day as an acute life
    crisis
  • 1 in 4 occurred within 2 weeks
  • Approx. 46 occurred either on the same day or
    within 2 weeks of a life crisis
  • Important because impulsiveness of suicide
  • Crucial to provide immediate help
  • Develop means for students in crisis to cope,
    provide safe haven, ensure support system in place

Source Harvard NVISS Pilot 2001
32
Truisms
  • Campuses are not therapeutic communities
  • therefore must acknowledge limits on services and
    resources
  • You cant treat a public health problem out of
    existence
  • - therefore solution is not just to increase
    counseling center staff and campus police force
    ad infinitum

33
Best Practices for Campus Prevention Programs
34
What Are We Trying to Do?
  • Disease Prevention
  • prevent self-injurious behaviors
  • Health Promotion
  • promote resiliency
  • promote life-enhancing skills
  • promote health maintenance
  • DIFFERENT GOALS REQUIRE DIFFERENT APPROACHES

35
Suicide is an outcome that requires several
things to go wrong all at once
Immediate Triggers
Proximal Factors
Predisposing Factors
Biological Factors
Familial Risk
Major Psychiatric Syndromes
Hopelessness
Public Humiliation Shame
Substance Use/Abuse
Access To Weapons
Serotonergic Function
Intoxication
Impulsiveness Aggressiveness
Severe Defeat
Personality Profile
Neurochemical Regulators
Abuse Syndromes
Negative Expectancy
Major Loss
Demographics
Severe Chronic Pain
Severe Medical/ Neurological Illness
Worsening Prognosis
Pathophysiology
36
Evidence-based Interventions
  • Community education/awareness
  • Safety is an issue
  • Community collaboration around suicide prevention
  • Social marketing
  • Destigmatizing help-seeking for mental health
    problems
  • Increasing social support
  • Strengthening social networks
  • Honor and support responsible help-seeking

Guild PA, Freeman VA, Shanahan E. Promising
Practices to Prevent Adolescent Suicide What We
Can Learn From New Jersey. Cecil G Sheps Center
For Health Services Research. Univeristy of North
Carolina at Chapel Hill. 2004.
Knox, K, et al., Risk of Suicide and related
adverse outcomes after exposure to a suicide
programme in the US Air Forcecohort study.
British Medical Journal, December 13, 2003.
37
Evidence-based Interventions
  • Gatekeeper training
  • Peer helper programs
  • Resiliency/coping/problem solving skill building
    programs
  • Juvenile justice
  • Homeless youth

Guild PA, Freeman VA, Shanahan E. Promising
Practices to Prevent Adolescent Suicide What We
Can Learn From New Jersey. Cecil G Sheps
CenterFor Health Services Research. Univeristy
of North Carolina at Chapel Hill. 2004.
38
Evidence-based Interventions
  • Restricting availability of means
  • Improved surveillance
  • Postvention for the bereaved
  • Domestic violence prevention
  • Training the media

Guild PA, Freeman VA, Shanahan E. Promising
Practices to Prevent Adolescent Suicide What We
Can Learn From New Jersey. Cecil G Sheps
CenterFor Health Services Research. Univeristy
of North Carolina at Chapel Hill. 2004.
39
Evidence-based Interventions
  • Access to effective treatment of mental health
    problems
  • Training for primary care providers
  • Training for mental health providers
  • Increased availability of mental health treatment
  • Increased affordability of mental health
    treatment
  • Linking suicide prevention programs with
    treatment services
  • Appropriate follow-up after ED treatment
  • Alcohol and substance abuse programs

Guild PA, Freeman VA, Shanahan E. Promising
Practices to Prevent Adolescent Suicide What We
Can Learn From New Jersey. Cecil G Sheps Center
for Health Services Research. Univeristy of North
Carolina at Chapel Hill. 2004.
Knox, K, et al., Risk of Suicide and related
adverse outcomes after exposure to a suicide
programme in the US Air Forcecohort study.
British Medical Journal, December 13, 2003.
40
What Changes Need to Happen on Campus to Protect
and Save Lives?
41
  • Five minutes before the party is not the time to
    learn to dance!
  • Snoopy 1964

42
Major Barriers To Progress
  • Lack of awareness and support among senior
    administrators
  • Stigma (lack of help-seeking culture)
  • No single person in charge of wellness
  • Departmental and programmatic silo effect
  • Lack of urgency in dealing with highest risk
    students
  • Legal blurs - FERPA HIPAA
  • Fears around liability
  • Insurance policy weaknesses (lack of parity
    discrepancies inadequacies)

43
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44
Duty and Liability
Far Side by Gary Larson
45
Issues to Consider Relevant to Effective
Prevention
  • Knowledge of Effective Prevention Programs
  • Comprehensive Needs Assessment
  • Community Readiness and Support
  • Resources for implementation
  • Investment in current practice
  • Population needs and access issues
  • Fear of Evaluation
  • Sustainability

46
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47
Building an Effective Safety Net
  • Create a new, senior-level administrative
    position to oversee student health and well-being
  • Ensure coordination and communication across
    various departments and organizations on campus
  • Prioritize mental health promotion and suicide
    prevention when allocating resources

48
Building an Effective Safety Net II
  • Organize a cross-institutional mental health task
    force or committee, which includes students, to
    examine mental health issues and services
  • Survey all students to understand the landscape
    of mental health issues on campus, including
    students knowledge and perception of campus
    mental health services (needs assessment)
  • Ensure that policies and procedures emphasize the
    best interests of the students

49
Building an Effective Safety Net III
  • Clarify and/or institute transparent policies
    regarding parental notification and leave of
    absence/re-entry
  • Ensure appropriate training regarding exceptions
    to confidentiality
  • Address perceived legal barriers that may affect
    how to approach students with emotional issues
  • Encourage the creation and involvement of a
    student mental health advocacy group

50
Policy Implications
  • Judicial Removal for serious suicidal ideation
    be prepared to remove a lot of people.
  • Importance of academics Recent academic problems
    is second most likely event to precede SI,
    school problems ranked 4th in contributing to
    SI.
  • Therefore, provide motivation to follow
    through on treatment in exchange for
    continuing/returning to school.
  • Need to find a way to help students without
    punishing them academically.

51
Take Home Messages
  • Suicidal ideation is not uncommon.
  • Develop educational campaigns to encourage
    help-seeking for those with mental health issues
    and suicidal thinking.
  • Educate peers in addition to others on campus
    about how to respond to those with mental
    disorders and suicidal ideation.
  • Professional services must get word out that they
    are helpful and available and confidential.
  • Focus on life skills and community
    responsibilities.

52
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53
Comprehensive Prevention Approach
54
Jed Foundation/SPRCComprehensive Approach
55
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56
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57
National Suicide Prevention Lifeline
  • National toll free number 1-800-273-TALK
  • Calls routed automatically to the closest of 125
    networked crisis centers
  • Partners with NASMHPD, Rutgers Columbia
    Universities
  • Evaluation studies published June, 2007 in
    Suicide and Life-Threatening Behavior

58
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59
THANK YOU
  • msilverman_at_edc.org

60
Another Truism
  • Suicide Prevention is Violence Prevention

61
Jed Foundation/EDCComprehensive Approach
62
Promote Social Networks
  • Goal To promote relationship-building between
    students and a sense of community on campus

63
Promote Social Networks
  • Reduce student isolation and promote feeling of
    belonging
  • Encourage the development of smaller groups
    within the larger campus community

64
Develop Life Skills
  • Goal To promote the development of skills that
    will assist students as they face various
    challenges in both school and in life

65
Develop Life Skills
  • Improve students management of the rigors of
    college life
  • Equip students with tools to recognize and manage
    triggers and stressors

66
Increase Help-Seeking Behaviors
  • Goal To educate students about mental health
    and wellness, encourage seeking appropriate
    treatment for emotional issues, and reduce the
    stigma surrounding mental illness and seeking
    help for suicidal thoughts and behaviors

67
Increase Help-Seeking Behaviors
  • Stimulate campus-wide cultural change that
    de-stigmatizes mental health problems and removes
    barriers to getting help
  • Enhance accessibility of mental health services
  • Educate students about the signs and symptoms of
    suicide and mental illness and where to go to get
    help
  • Provide online self-assessment tools

68
Groundbreaking pro-social campaign with mtvU
launched in November 2006 Seeks to reduce stigma
and increase help-seeking through on-air, online
and on-campus components Campaign built on
original quantitative and qualitative research
commissioned by The Jed Foundation and mtvU
69
Identify Students At Risk
  • Goal To identify those students who may be at
    risk for suicide through the use of outreach
    efforts, screening, and other means

70
Identify Students At Risk
  • Include questions about mental health on medical
    history form
  • Provide gatekeeper training to recognize/refer
    distressed or distressing students
  • Create interface between disciplinary process and
    mental health service
  • Screen to identify high-risk or potentially
    high-risk students
  • Establish cross-department case management
    committee

71
Transition Years
  • Partnering with the American Psychiatric
    Foundation (philanthropic arm of the American
    Psychiatric Association)
  • Outreach project to high school seniors, college
    freshmen, and their parents
  • Promote the smooth, safe, and healthy transition
    from high school to college
  • Key components will include a literature review,
    survey of parents, media campaign, parents
    resource guide, and student survival guide

72
Provide Mental Health Services
  • Goal To accurately diagnose and appropriately
    treat students with emotional problems, including
    assessing and managing suicide risk

73
Provide Mental Health Services
  • Utilize internal university resources to
    complement existing services
  • Engage in prevention/outreach
  • Create linkages to community resources
  • Train mental health providers to identify/treat
    suicidal risk
  • Refer cases as appropriate
  • Institute policies and procedures
  • Train personnel on confidentiality, notification,
    and other legal issues

74
UDBD
  • Understanding Depressive and Bipolar Disorders
    (www.UDBD.org)
  • Free Web site designed to help college counseling
    and other healthcare professionals learn to
    better distinguish between unipolar depression
    and bipolar disorder
  • Provides information about these disorders and
    the key questions to ask when evaluating students
  • Includes useful tools such as tips for
    differentiating among types of depression and
    case studies

75
Clinical Training Workshops
  • Assessing and Managing Suicide Risk tailored for
    college mental health professionals
  • Originally developed by AAS and SPRC
  • One-day training includes in-depth discussion,
    journal writing, video clips, and small group
    exercises participants also assigned
    pre-workshop reading
  • Delivered by an expert trainer
  • Hundreds of college mental health professionals
    have been trained so far
  • Currently undergoing formal evaluation

76
Crisis Management Procedures
  • Goal To develop policies that promote the
    safety of distressed or suicidal students and
    respond to crises, including suicidal acts, using
    institutionalized processes.

77
Crisis Management Procedures
  • Establish and follow policies (e.g., parental
    notification, medical leave/re-entry) and
    protocols that respond to suicide attempts and
    other high-risk behavior
  • Respond with a comprehensive postvention program

78
Framework
  • Document guides the process
  • of creating campus-wide
  • protocols that address
  • Safety for at-risk students
  • Emergency contact notification
  • Leave of absence/re-entry
  • www.jedfoundation.org/framework.php

79
Restrict Access to Lethal Means
  • Goal To limit access to potential sites,
    weapons, and other agents that may facilitate
    dying by suicide

80
Restrict Access to Lethal Means
  • Limit access and/or erect fences on roofs of
    buildings
  • Replace windows or restrict size of window
    openings
  • Restrict access to chemicals
  • Prohibit guns on campus
  • Control access to alcohol and other drugs

81
Legal Roundtable
  • Fear of liability is affecting decision-making
    around students in distress or at risk for
    suicide
  • Need for a clear, concise resource for college
    health/mental health professionals,
    administrators, and legal counsels
  • One-day roundtable held in Spring 2007 brought
    together leading experts in higher education law,
    as well as campus personnel, to discuss issues of
    law and liability as they relate to mental health

82
Building Campus Safety Net
Decrease Emotional Distress Reduce Suicidal
Behavior
Promote Help-Seeking ULifeline ? mtvU
Pro-Social Campaign APA Collaboration
Raise Awareness Decrease Stigma ULifeline ?
mtvU Pro-Social Campaign APA Collaboration ?
Outreach
Strengthen Campus Services ULifeline ?
Framework ? CampusCare Clinical Workshop ?
UDBD.org
Increase Evidence Base Pilot Program ? Framework
? ULifeline Clinical Workshop
TJF
83
Comprehensive Framework Mental Health and
Suicide Prevention
Program and Policy Levels (social ecological
framework)
Adapted from Potter et al, 2004 and DeJong
Langford, 2002
84
Contact Information
  • Joanna Locke, MD, MPH
  • Program Director, The Jed Foundation
  • 583 Broadway, Suite 8B
  • New York, NY 10012
  • 212.647.7544
  • jlocke_at_jedfoundation.org
  • www.jedfoundation.org
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