Undergraduate and Graduate Student Coping with Stressful Experiences: The Continuum of Distress, Suicidal Experiences and Outcomes Chris Brownson, PhD cbrownson@austin.utexas.edu Elaine Hess, MA ehess@utexas.edu The University of Texas at Austin Jennifer Kyle, PhD jkyle3@gmail.com Queens College 1 Founded in 1991 at UT Austin 6 completed studies to date ◦ Will discuss data from our two most recent studies and campus-level data Membership is determined study-by-study Research is an essential ingredient for defining a subspecialty of college mental health (Penn State’s CSCMH, NCHA, Director’s Surveys, etc.) 2 National Suicide Statistics 2nd leading cause of death on college campuses National suicide rates for college students range from 6.5 to 7.5 per 100,000 ◦ Compared to 16 per 100,000 in age-matched peers Roughly 25% of campus suicides are counseling center clients, nationally ◦ Suicides in CC clients are 3.3 times greater than nonclients ◦ When taking into consideration the 4 most significant risk factors (previous attempts, psychiatric illness, gender, and firearms), you would expect clients of CCs to commit suicide 20 times more than non-clients. Schwartz, 2006, 2011 3 Overview of Presentation Overview problem of college student suicide 1. ◦ ◦ ◦ Consortium 2006 & 2011 structure/demographics Problem of college student suicide Key findings from Consortium studies College Student Coping 2. ◦ ◦ ◦ ◦ Distal and proximal risk factors Presentation of study details Proximal risk factors Protective factor: Coping Help-seeking 1. ◦ ◦ ◦ Help-seeking patterns Help-avoidance patterns Implications of help-seeking/avoidance data 4 Overview of Current Study Characteristics Web-based survey, anonymous, intervention Over 26,000 undergraduate and graduate student responses (~101,000 surveys sent) ~ 26% response rate 74 colleges and universities participated Random sample at each school Goal: Useful info for IHEs/CCs; both research and “screening” Demographics comparable to most recent NCHA survey 5 Structure of Survey Demographics History of help-seeking, risk and protective factors Focus in on recent stressful period ◦ ◦ ◦ ◦ Characteristics of stressor Level of distress during worst point Coping approaches Outcomes (e.g., suicidal ideation) Resolution ◦ Resilience and factors impacted ability to cope 6 Demographics ◦ N = 26,430 ◦ Mean Age of 25.5 years (Range: 18 – 95 years) ◦ 63% Female ◦ 92% Heterosexual 7 Race/Ethnicity 2011 Undergrad N = 14,080 2011 Grad N = 12,094 African American, of African descent, African, of Caribbean descent, or Black 4.1% 4.5% Asian or Asian American 8.1% 12.6% Caucasian,White, of European descent, or European 71.4% 67.9% Hispanic, Latino, or Latina 6.5% 4.9% Middle Eastern or East Indian 1.5% 3.0% Native American or Alaskan Native 0.3% 0.3% Native Hawaiian or other Pacific Islander 0.2% 0.2% Other 1.4% 2.0% Multiracial 6.3% 4.4% 8 Mental Health History Ever received MH services from: Undergrad N=14,113 Grad N=12,131 Counselor 37.4% 44.4% Psychiatrist 12.0% 14.1% Clergy 6.1% 10.4% Other medical provider 10.2% 10.2% Alternative medical provider 4.2% 4.9% Other 1.4% 1.7% Never 53.7% 46.8% Ever received counseling from college counseling center: 17.1% 22.6% Taken medication for mental health concern: 16.1% 22.8% Been hospitalized for mental health concern: 3.2% 3.0% 9 Lifetime Suicidal Ideation for College Students Approximately half endorsed some form of suicidal thoughts in lifetime (Drum, Brownson, Burton Denmark & Smith, 2009) Approximately 20% endorsed seriously considering suicide in lifetime (Drum et al., 2009) Female students more likely to report lifetime ideation and attempts (Brownson, Drum, Smith & Burton Denmark, 2011) 10 First Considered Suicide When did you first seriously consider attempting suicide? Undergrad N = 3,088 Grad N = 2,182 Before or while in middle school 28.7% 23.2% While in high school 46.1% 33.9% After high school but before college 3.9% 3.9% While in college 18.3% 18.7% After college but before graduate school .30% 8.4% While in graduate school .10% 7.9% Other 2.6% 4.4% * Of those who have considered suicide at some point in their life 11 Recent Suicidal Ideation 5 to 6% seriously considered suicide in past 12 Episodes of ideation in past year described as brief, recurrent and intense months (Drum et al., 2009; ACHA-NCHA II, 2011) ◦ ~1% actually attempted in past year (Drum et al., 2009) Female students appear to be at greater risk for recent suicidal ideation and attempts (Brownson et al., 2011) 12 Prevalence of Lifetime & Recent Suicide Attempts 2006 Undergrad N = 15,010 2006 Grad N = 11,441 2011 Undergrad N = 14,080 2011 Grad N = 12,094 Lifetime 7.6% 5.4% 7.2% 5.2% Past 12 Months 0.85% 0.30% 0.81%* 0.22%* 1.1% .40% During Stressful Time Period *NOTE: 2011 Past 12 Months item asked of those who endorsed one or more lifetime attempts; rates adjusted to reflect entire sample 13 Intentions at Time of Attempt For those who said “Yes” to having attempted suicide during their most stressful period. Which of these statements describe your intentions at the time of the attempt(s)? Undergra d N = 152 Grad N = 43 I made a serious attempt to kill myself and intended to die 24.3% 11.6% I tried to kill myself but knew I might survive 25.0% 20.9% Was ambivalent and partly wanted to live 35.5% 46.5% Mostly wanted to live but small part wanted to die 11.2% 11.6% I did not intend to die 3.9% 9.3% 14 Role of Drugs & Alcohol in Attempt For those who said “Yes” to having attempted suicide during their most stressful period. How would you describe the role of drugs or alcohol in your most recent suicide attempt? Undergrad N = 155 Grad N = 43 I was not using alcohol or drugs before or during my attempt 44.5% 53.5% I intended to overdose with alcohol or drugs 30.3% 27.9% I intended to use alcohol or drugs to reduce my inhibitions or fears about attempting suicide 11.6% 9.3% My attempt was not planned in advance and may have happened because I was using alcohol or drugs 12.9% 14.0% I was using alcohol or drugs but they were not related to my attempt 16.1% 11.6% Addiction to alcohol or drugs was a reason for my attempt 5.8% 2.3% 15 Thoughts During Stressful Period During the stressful period, did you have any thoughts similar to the following? (Select all that apply) Undergrad N = 14,080 Grad N = 12,094 This is all just to much 51.2% 44.5% I wish this would all end 33.3% 27.5% I have to escape 20.1% 17.1% I wish I was dead 9.4% 7.3% I want to kill myself 5.7% 3.6% I might kill myself 3.1% 1.9% I will kill myself 1.0% .50% I did not have any thoughts like these 37.5% 42.8% 16 During the stressful period, did you have any thoughts similar to the following? 30000 25000 20000 15000 10000 Those endorsing "yes" to these thoughts First experience Most students STRESS who experience DISTRESS 5000 0 Entire sample This is all just too much I wish this would all end I have I wish I to was escape dead I want to kill myself I might I will kill kill myself myself Adapted from a presentation prepared by Arizona State University’s Wellness & Health Promotion Center 17 During the stressful period, did you have any thoughts similar to the following? 30000 25000 20000 15000 The idea is to reach students here… 10000 Those endorsing "yes" to these thoughts …so fewer end up here 5000 0 Entire This is sample all just too much I wish this would all end I have I wish I I want to was to kill escape dead myself I might I will kill kill myself myself Adapted from a presentation prepared by Arizona State University’s Wellness & Health Promotion Center 18 Discussion Questions What are your campuses doing to try to shift the curve (i.e., prevention & fostering well-being of entire population)? What are some of the challenges with tying suicide prevention to broader prevention initiatives on campus? Counseling Centers and Health Education Centers can’t be solely responsible for this ◦ What successes and challenges have you had in collaborating with cross-campus partners? 19 Overview of Presentation Overview problem of college student suicide 1. ◦ ◦ ◦ Consortium 2006 & 2011 structure/demographics Problem of college student suicide Key findings from Consortium studies College Student Protective Factors and Coping 2. ◦ ◦ ◦ ◦ Distal and proximal risk factors Presentation of study details Proximal risk factors Protective factor: Coping Help-seeking 1. ◦ ◦ ◦ Help-seeking patterns Help-avoidance patterns Implications of help-seeking/avoidance data 20 Distal vs. Proximal Risk Factors ◦ Suicide results from a complex interaction of distal and proximal risk factors While having a lack of protective factors such as coping skills, family cohesion, adequate social support and access to mental health services Proximal Risk factors: Stressful life events, Intoxication, Hopelessness Moscicki, 2001 21 Distal vs. Proximal Risk Distal Risk Factors e.g., vulnerability Proximal Risk Factors e.g., Stressful Life Events Suicide Crisis Protective Factors such as coping, spiritual faith influence the progression 22 Queens College Part of the City University of New York, the nation's largest urban public university. Established in 1937 to offer a liberal arts education. Enrollment of 20,000 students, including 16,000 undergraduate students. Students come from nearly 170 different countries and speak over 110 different languages. One of the “Best Public UniversitiesMaster’s” institutions in U.S. News and World Report’s America’s Best Colleges. Historically, a commuter school, however, in 2011, Queens College opened the first residential facility. • 23 National vs. Campus Level Data National Queens College Sample Size 26,430 78 Age M = 25.5 Range: 18 - 95 M = 29.82 Range: 18 - 64 Gender Female = 63% Female = 70.5% Sexual Orientation Heterosexual = 92% Heterosexual = 87.2% Housing Parents or family = 51.3% Partner or spouse = 16.7% Alone = 15.4% 24 Demographics: Race/Ethnicity African American, of African descent, African, of Caribbean descent, or Black 5.2% 14% Asian or Asian American 11.6% 10.3% Caucasian,White, of European descent, or European 74.2% 41% Hispanic, Latino, or Latina 7.8% 20.5% Middle Eastern or East Indian 2.9% 2.6% Native American or Alaskan Native 1.5% -- Native Hawaiian or other Pacific Islander .5% -- Other 2.3% 5.1% 25 Religious Preference Christian = 46.2% Catholic = 29.5% How important are your Jewish = 16.7% beliefs? Buddhist = 3.8% • Very important = 37.2% Hindu = 3.8% • Moderately important = Agnostic = 10.3% 35.9% Atheist = 5.1% • Not at all = 25.6% 26 Connection with Friends & Family Do you consider your relationship with people you spend most of your time with to be: Overall Sample N = 26,297 M = 4.09 Queens College N = 78 M = 4.00 1 - 2 (Not at all close) 4.7% 7.7% 3 (Moderately close) 23% 47.4% 4 - 5 (Very close) 71.8% 44.9% On average, how close is your relationship with your family? N = 26,304 M = 4.16 N = 78 M = 3.96 1 – 2 (Not at all close) 6.5% 3.8% 3 (Moderately close) 18.7% 30.8% 4 - 5 (Very close) 74.3% 65.4% 27 Past History of Suicide Ever consider attempting suicide: ◦ Yes = 19 (24%) ◦ No = 59 (75.6%) When did you first consider suicide? ◦ Prior to college = 16 (20.5%) ◦ While in College/Other = 3 (3.9%) Therefore, 84% of those having ever thought about suicide had done so prior to attending college. 28 Proximal Risk: Stress What sources of stress did students report? Academics Financial problems Family problems Emotional health problems Problems at work Friendship problems And during that time, what was their level of distress? 64.1% moderately to very much (56.4%) 35.9% moderately to very much (33.3%) 32.1% moderately to very much (26.9%) 23.1% moderately to very much (21.8%) 21.8% moderately to very much (20.5%) 16.7% moderately to very much (12.8%) 29 Comparison of Students with History of SI: Stress Management When approaching the challenges of daily life: History of Suicide Ideation Yes (n = 19) History of Suicide Ideation No (n = 59) ..how critical are you of yourself? M = 3.58 M = 3.46 NS …how capable are you of managing your daily challenges? M = 3.89 M = 4.08 NS t (23.506) = -2.630, p < .05 …how motivated are you to manage your daily challenges? M = 3.11 M = 4.02 …how meaningful do you view your life to be? M = 3.00 M = 4.10 t (24.382) = -2.984, p < .01 30 Proximal Risk: Stress & Its Impact on Social Connectedness and Belongingness Baseline How much do you feel you are a burden on others? How understood by others do you feel? How cared for by others do you feel? How much do you feel that you can count on others? How comfortable do you feel making new connections Stressful Period t (73) = 2.680, p < .01 M = 2.24 M = 2.59 M = 3.03 M = 2.94 NS M = 3.77 M = 3.31 t (73) = 3.676, p < .01 M = 3.01 M = 3.01 NS M = 2.71 t (72) = 4.275, M = 3.33 Increase in feeling a burden Decrease in feeling cared for Decrease in feeling comfortable in making new 31 Protective Factor: Coping During the stressful period… Methods of Student Coping How helpful was this method of coping? Type of Coping Acknowledging emotions 44.9% moderately to very Emotion-focused much (34.6 %) Coping Creating a plan 41.0% moderately to very Problem-focused much (32%) Coping Distracting myself 38.5% moderately to very Avoidance Coping much (32%) Prayer 21.8% moderately to very Faith-based Coping much (19.3%) 32 Coping: It’s Impact on Stress How the following impacted your ability to cope? Improved my ability to cope Connection with your friends 59.0% Connection with your family 51.3% Having experienced a similar situation before 47.4% Connection to religion, spirituality or a higher power 32.0% Connection with a mental health professional 14.1% The strength of faith-based coping is its ability to find meaning that allows one to overcome adversity and maintain greater psychological and physical well being (Wachholtz & Sambamoorthi, 2011) 33 Protective Factor: Coping & Spiritual Faith Faith-based coping faith- 1) Helps develop personal meaning around a particular stressful event, and regulate the associated affective experience 2) facilitates the use of social support, e.g., based gatherings. Youth with spiritual beliefs were more likely to use and favorably evaluate social support received from a variety of sources, e.g., parents, siblings, friends and church groups and were less at risk. 34 Proximal Risk: Stress to Distress And for some students, their distress manifested as overwhelming thoughts: This is all just too much = 36 (46.2%) I wish this all would end = 29 (37.2%) I have to escape = 15 (19.2%) I wish I was dead = 6 (7.7%) I want to kill myself = 6 (7.7%) I might kill myself = 2 (2.6%) I will kill myself = 1 (1.3%) 35 Stress – Distress Continuum Key finding on suicide crisis in college students reported that suicidal thoughts are common but most importantly that crises are often brief, intense and can be recurrent (Drum, Brownson, Burton Denmark & Smith, 2009). ◦ Therefore understanding the role that individual and environmental protective factors play in the students progression from just being merely stressed to distressed and contemplating suicide becomes paramount. 36 Protective Factors Protective factors are varied and can include an individual's attitudinal and behavioral characteristics, as well as attributes of the environment and culture. Examples: Strong connections to family and community support Skills in problem solving and coping Easy access to a variety of clinical interventions and support for help-seeking Cultural and religious beliefs that discourage suicide 37 Protective Factors Study ◦ ◦ Examining protective factors in a sample of diverse college youth as a means of predicting passive ideation Instruments Suicide (Outcome Variable): 1. Harkavy Asnis Suicide Scale (HASS) Protective Factors (Predictor Variables) : 1. College Student-Reasons for Living Inventory (RFL-CS) 2. Young Adult Social Support Inventory (YA-SSI) 3. Spiritual Well- Being Scale (SWBS) 38 Dependent Variable: Suicide Data Harkavy Asnis Suicide Scale (HASS Demo) History of Suicide Ideation N (%) Beginning at age 8 78 Mode: 14 years old (32.1%) 16 (21%) reported having a plan History of Suicide Attempts 6 (3%) Most reporting only one attempt; 2 subjects reported 5 or more Beginning at age 8 Mode: 13 years old Current Suicide Ideation (Past 2 weeks) 1.6% (4) 3 subjects denied plan or intent 1 was brought to Counseling Center Better off dead (Within Past 2 weeks) 95 (39%) Once: 82 (33.7%) 2 – 4 times/week: 13 (5.3%) 39 Student Distress: Passive Ideation HASS I: Passive Ideation Low 29% Moderate High 38% 33% 40 Protective Factors as Predictors of Passive Ideation Summary of Hierarchical Regression Analysis Predicting Passive Ideation Using Social Support, Spiritual Well-Being, Reasons For Living, Gender And Religious Affiliation Variables (N = 243) Variable B SE B β Gender .470 .438 .085 Religious Affiliation .144 .083 .137 Gender .686 .423 .123 Religious Affiliation .109 .079 .104 YA-SSI -.935 .243 -.326*** CS-RFLI -.265 .241 -.091 SWBS -.617 .260 -.192* Step 1 Step 2 Note: * p < .05; ** p < .01; ***p < .000 R2 = .137, F (5,163) = 5.034, p <.000, R squared change = .115, F change (3, 158) = 7.013, p <.000 41 Discussion Questions Do we need to target students differently based on distal versus proximal risk factors? How can we foster better coping skills among students, such as using freshman seminars? How has your campus used existing programs or outreach efforts to foster better coping among students? How can we increase social connectedness on college campuses? And would we need differential strategies for commuter versus residential universities? As college counselors, how can we support students’ faith-based coping? 42 Overview of Presentation Overview problem of college student suicide 1. ◦ ◦ ◦ Consortium 2006 & 2011 structure/demographics Problem of college student suicide Key findings from Consortium studies College Student Coping 2. ◦ ◦ ◦ ◦ Distal and proximal risk factors Presentation of study details Proximal risk factors Protective factor: Coping Help-seeking 1. ◦ ◦ ◦ Help-seeking patterns Help-avoidance patterns Implications of help-seeking/avoidance data 43 Methods Used to Connect to Others How important is the following? Baseline (Mean) During Stressful Period (Mean) Attempters (Mean) In person contact 4.41 4.20 3.71 Phone 3.77 3.46 2.91 Video chat 2.16 1.60 1.53 Email 3.61 1.96 1.68 Social networking (e.g., Facebook) 3.35 2.10 2.04 Text message 3.71 2.70 2.79 Gaming connections 1.48 1.19 1.31 Blogging 1.40 1.17 1.33 Other 1.39 1.20 1.22 Likert Scale 1 Not at all important – 5 Very important 44 Disclosing Suicidal Thoughts 2006 study: Asked of those who had seriously considered attempting suicide (N=1,321) 54% told one or more people First person told: 16% 14% 3% Romantic partner Peer Family 33% Professional 34% Other (e.g. clergy, professor, RA) 46% told no one 45 Racial / Ethnic Identity Help-Seeking Students Advised Seek Professional Help N = 596 Students Advised Seek Help Who Did N = 331 Caucasian 61% 72% Multi-Ethnic 52% 36% Latino/a 45% 50% Asian American 40% 80% Alaska Native / American Indian 40% 50% International Student 29% 50% African American 27% 43% Average 56% 69% Racial/Ethnic Identity Help-Seeking Disparities for Racial and Ethnic Minority Students Alaska Native / American Indian, Asian American, and Multiethnic students had more distressed thinking or suicidal ideation than others Caucasian students more likely to be advised to seek professional help from confidant Asian American students utilize professional help at lower rates than other students ◦ Of those disclosing suicidal ideation, not frequently encouraged to seek help from confidants ◦ In contrast, large proportion of those advised to seek help do follow through Brownson, Swanbrow Becker, Shadick, & Smith, in press 47 Help Seeking During a Stressful Period 2011 study: Comparison of sources of support sought by students who did and did not seriously consider suicide during the stressful period No one Resident adviser Alternative medical provider Coach Psychiatrist Considered Suicide (N=1,167) Clergy Medical provider Did Not Consider Suicide (N=25,030) Instructor (e.g. professor, TA) Academic adviser Psychologist, counselor or SW Romantic partner Family member Friend, peer or roommate 0 10 20 30 40 50 60 70 48 Reasons for Choosing Help Sources 2011 Study: Asked of those who turned to someone for help during stressful period Referred to them Didn't know where else to turn They had expertise They had gone through experience before Considered Suicide (N=959) Appeared safe to confide in Did Not Consider Suicide (N=21,892) They were easily accessible Had received help from them before Thought they would empathize 0 10 20 30 40 50 60 70 80 49 Reasons for Concealment 2006 study: Asked of those who seriously considered suicide and did not tell anyone (N=769) Concealment Category Percentage Example of Category Low Risk 18% “The chances of me going through with it wasn’t extremely unlikely…even though I wanted to” Solicitude 16% “I didn’t want to bother anyone with my problems” Privacy 15% “Because it’s something I don’t feel comfortable sharing with others” Pointless 13% “Didn’t think anyone would care, or that they wouldn’t take me seriously” Stigma 13% “Didn’t want to appear weak, out of control, crazy” Shame 7% “I was ashamed to admit that I had these thoughts” Repercussions 7% “Because they would make me go to the doctor or tell on me” Interference 7% “I didn’t want anyone to talk me out of doing it” Perceived Lack of Confidants 3% “There wasn’t anyone I felt I could turn to” 50 Reasons For Not Seeking Help 2011 Study: Asked of those who indicated seeking help from no one during stressful period Had a prior negative experience seeking help (Pointless) Thought there could be negative consequences (Repercussions) Other Worried would be judged or thought of differently (Stigma) Did not want anyone to interfere or help (Interference) Considered Suicide (N= 199) Felt ashamed or embarrassed (Shame) Did Not Consider Suicide (N=2,904) Did not feel there was anyone to talk to (Perceived lack of confidants) Did not want to burden others (Solicitude) Did not think I needed help (Low Risk) Typically do not share concerns (Privacy) Did not think it would be helpful (Pointless) 0% 10% 20% 30% 40% 50% 60% 51 Future Help-Seeking & Referral of Others to Counseling Center Services Undergraduate sample, N = 13,960, M = 2.54 4-5 (Very likely) After going through this stressful period, how likely would you be to seek help through your campus counseling center for future stressful experiences? 3 (Neither more nor less likely) If you had a friend who was going through a similarly stressful experiences, how likely would you be to refer her or him to the campus counseling center? 1 (Not at all Likely)-2 0% 10% 20% 30% 40% 50% 52 Discussion Questions Knowing that students are the most important gatekeepers but the hardest to train, what can we do? What are ways that IHEs can create a greater sense of connectedness and belongingness among students? Knowing how students connect to others generally and when in stress, how do we best use social media for creating meaningful connections? 53 Special Thanks To The 26,000 Student Research Participants The 74 Research Consortium Participating Institutions and Counseling Center Directors David Drum, Ph.D. Adryon Burton Denmark, Ph.D. The entire Research Consortium Team!! http://cmhc.utexas.edu/researchconsortium.html National Director: Chris Brownson, PhD Email: cbrownson@austin.utexas.edu 54 References American College Health Association-National College Health Assessment II [ACHA-NCHA II]: Reference Group Data Report Spring 2011. Baltimore: American College Health Association; 2011. Brownson, C., Drum, D. J., Smith, S. E., & Denmark, A. B. (2011). Differences in suicidal experiences of male and female undergraduate and graduate students. 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