This article was downloaded by: [University of Ulster Library] On: 26 February 2015, At: 07:17 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK
Journal of American College Health Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/vach20
Implementing an Early Intervention Program for Residential Students Who Present With Suicide Risk: A Case Study a
a
a
Estela M. Rivero PhD , M. Dolores Cimini PhD , Joseph E. Bernier PhD , Judith A. Stanley a
a
b
a
PhD , Andrea D. Murray MA , Drew A. Anderson PhD & Heidi R. Wright PsyD a
University Counseling Center, University at Albany, State University of New York, Albany, New York b
Department of Psychology, University at Albany, State University of New York, Albany, New York Accepted author version posted online: 14 Feb 2014.Published online: 08 May 2014.
Click for updates To cite this article: Estela M. Rivero PhD, M. Dolores Cimini PhD, Joseph E. Bernier PhD, Judith A. Stanley PhD, Andrea D. Murray MA, Drew A. Anderson PhD & Heidi R. Wright PsyD (2014) Implementing an Early Intervention Program for Residential Students Who Present With Suicide Risk: A Case Study, Journal of American College Health, 62:4, 285-291, DOI: 10.1080/07448481.2014.887574 To link to this article: http://dx.doi.org/10.1080/07448481.2014.887574
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
JOURNAL OF AMERICAN COLLEGE HEALTH, VOL. 62, NO. 4
Case Report
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Implementing an Early Intervention Program for Residential Students Who Present With Suicide Risk: A Case Study Estela M. Rivero, PhD; M. Dolores Cimini, PhD; Joseph E. Bernier, PhD; Judith A. Stanley, PhD; Andrea D. Murray, MA; Drew A. Anderson, PhD; Heidi R. Wright, PsyD
Abstract. Objective: This case study examined the effects of an early intervention program designed to respond to residential college students demonstrating risk for suicide. Participants: Participants were 108 undergraduates at a large northeastern public university referred to an early intervention program subsequent to presenting with risk factors for suicide between Fall 2004 and Spring 2011. Methods: Data were collected from archival records to examine quality of early intervention services, student retention, and grade point average (GPA) during the semesters prior to, during, and subsequent to the referral incident. Results: Program implementation was timely and responsive to student needs; students successfully completing the early intervention program remained in school and demonstrated small but significant rebounds in GPA the semester subsequent to the incident. Conclusions: There are benefits associated with the implementation of early intervention programs designed to respond to students manifesting risk for suicide, such as connecting the student to vital services and support networks.
lege students die by suicide each year, fewer than 20% of students reporting suicidal thoughts or a history of attempts were receiving mental health treatment.4–6 In fact, approximately 80% of students who died by suicide were not engaged in receiving mental health services. Not surprisingly, students who sought professional help were less likely to attempt suicide, and those in treatment were less likely to die by suicide than a comparable population not receiving treatment.5,7–9 In addition to a college student’s involvement in mental health treatment, the presence of a social support network (ie, family and friends) is also a potential protective factor associated with the prevention of suicide. Despite this, social support network members, including parents and peers, are often uninvolved in traditional individually oriented early interventions. Based on these findings, early intervention through the use of targeted programs that help articulate and strengthen support networks for students who present prior suicidal intent can provide an excellent opportunity to offer critical services in a timely and responsive manner. Such proactive and relevant interventions, in turn, may enhance the likelihood of a positive clinical outcome and related academic success, retention, and graduation from college. To address risk for suicide among college students through targeted early intervention strategies, the CARE Net (Consultation and Resource Evaluation) program was designed to provide a mechanism for staff members within the Counseling Center and Department of Residential Life at a large northeastern public university to intervene in a timely manner with students who either threaten or attempt suicide, as well as with their parents, and, as appropriate, their
Keywords: community health, counseling, mental health, prevention, suicide
It is widely known that approximately 90% of all individuals who die by suicide, whether or not they are matriculated college students, have a diagnosable psychiatric condition.1–3 Unfortunately, however, although approximately 1,100 colDr Rivero, Dr Cimini, Dr Bernier, Dr Stanley, Ms Murray, and Dr Wright are with the University Counseling Center at the University at Albany, State University of New York, in Albany, New York. Dr Anderson is with the Department of Psychology at the University at Albany, State University of New York in Albany, New York. Copyright © 2014 Taylor & Francis Group, LLC
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roommates or suitemates. Within this program, suicidal intent is defined as either a public suicide threat, tangible evidence that the student is making plans or preparing for suicide, or manifestations of serious self-inflicted injury. The Director of the Department of Residential Life refers students displaying the aforementioned indicators of suicidal intent to the Counseling Center. The referred student then participates in a 2-hour appointment (with follow-up appointment scheduled as indicated) with a licensed psychologist at the center. Essential components of the CARE Net protocol addressed with the student include (1) an assessment of current suicide risk; (2) an evaluation of the student’s willingness and ability to refrain from self-harm; (3) consultation regarding needed psychiatric, psychological, and supportive educational services; (4) inclusion of parents and or guardians who are informed of the incident that led to referral to the CARE Net program, the aims of the CARE Net program, and referral recommendations; and (5) provision of a supportive educational intervention that intends to minimize the disruption of normal functioning for roommates and suitemates in the residence community. The referred student collaborates with the psychologist in the development of a “CARE Plan” listing sources of support and healthy alternatives to risk behaviors engaged in prior to the intervention; copies of the CARE Plan are provided to the student, his/her treatment providers, and parents/legal guardians. In this way, the CARE Net program helps students identify the crisis, treatment, and educational services that are available on campus and in the larger community so they can begin to access vital assistance and may remain viable campus residents. Further, the program offers an avenue to mobilize parents and family members to provide support and assistance and to minimize the disruptive effects that suicide risk–related behaviors have on roommates and suitemates in the residence community. In cases in which the most appropriate option for a distressed student is to withdraw from the university for medical reasons, CARE Net clinicians offer assistance with this process. Active participation by the referred student in all phases of the program, including the student’s collaboration on the development of the CARE Plan, is required for successful program completion. A student’s referral to the CARE Net program augments and often immediately follows existing crisis intervention services such as emergency room visits, psychiatric hospitalizations, psychological treatment, and consultation services with Residential Life staff and students. The program is not designed to replace existing crisis intervention services, nor is it intended to undertake the psychological treatment of students referred to the program. In fact, in most cases the student has been evaluated in the crisis unit of the local psychiatric hospital, hospitalized when clinically indicated, and discharged prior to a referral to the program. The purpose of the present case study was to examine the impact of the CARE Net program, both in regard to process and quality assurance–related indices as well as the potential role of the program on subsequent student retention 286
and success in school. Using archival data collected over a 7-year time period, service-focused variables such as time from incident to referral to the CARE Net program, number of sessions to CARE Net program completion, and other time-related milestones were analyzed. Demographic and descriptive data, such as gender, race/ethnicity, class year, and severity of the incident that resulted in the CARE Net referral, were collected in order to better understand which students received services. Further, for all students who completed the CARE Net program, grade point averages and enrollment status were tracked for the semesters prior to, during, and subsequent to program involvement to assess the potential link between engagement in the program and student retention. METHODS Participants Participants in the present case study were 108 undergraduate students living in residence at a large public university in the northeastern United States who exhibited signs indicative of risk for suicide as defined by the following indices: (1) the student has threatened suicide verbally or in writing (eg, “I will kill myself if you break up with me,” “I’ve decided that life is not worth living,” “I would kill myself,if I had the chance,” “I’ve been thinking about how many pills it would take to kill myself,” or “I don’t have much to live for any more”), (2) the student has made overt plans and preparations for suicide (eg, has purchased a weapon or has been stockpiling/collecting pills, has been uncharacteristically engaging in reckless behaviors, has been giving away valued possessions—or saying “goodbye” to friends, has written a suicide note, has confided in another individual that “I’ve imagined how I’d kill myself” or “I’ve thought about what I’d say in a suicide note”), and (3) the student has engaged in serious self-injury (eg, cutting that required medical attention, overdosed on pills, or treated for alcohol poisoning associated with psychological distress). These indices of suicide risk were reported by Residential Life staff members using a paper-and-pencil checklist that was transmitted to the Director of Residential Life and to the Counseling Center. Procedures For each suicide risk–related incident that occurred in the university residence halls, the Director of the Department of Residential Life completed a CARE Net referral checklist outlining details regarding the referral incident. This document, along with the incident report, was faxed to the Counseling Center. Concurrent with the transmittal of this document, the Director of Residential Life met with each referred student, notified the student’s parent or legal guardian of the incident, and advised the parent or guardian of the referral to and purpose of the CARE Net program. During the same meeting with the student, the Director of Residential Life contacted the Counseling Center and made an appointment for the student (with the student present in the office) with JOURNAL OF AMERICAN COLLEGE HEALTH
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a CARE Net clinician to be completed within 5 business days. On arrival to the Counseling Center appointment, the referred student completed a demographic information form and read and signed an authorization form, and the CARE Net evaluation was completed. At the end of each semester, CARE Net data were compiled and analyzed as part of routine quality assurance activities, and both an annual report and multiyear cumulative CARE Net program data report were compiled to assess process and outcome variables and inform future program implementation. Prior to manuscript preparation, a request for release of archival data was submitted to and approved by the university Institutional Review Board. RESULTS Data for this case study were analyzed using the Statistical Package for the Social Sciences (SPSS), version 19 (IBM SPSS, Armonk, New York). This method offered ease of access to descriptive data and, when appropriate, allowed for the completion of repeated-measures analysis of variance (ANOVA). Demographic Characteristics of the Case Study Sample Participants were 108 undergraduate residential students from a large, public northeastern university referred to the CARE Net program between Fall 2004 and Spring 2011. Ninety-seven (90%) completed the CARE Net program, and 11 (10%) did not complete the program. Of the 11 students who did not complete the program, 1 requested a medical withdrawal from the university before a CARE Net appointment could take place, 1 moved off campus, thereby becoming exempt from residential policies, and the other 9 failed to comply with the program’s requirements and were referred by the Department of Residential Life to Judicial Affairs staff for university conduct code violation as outlined in the residence license. Forty-one percent of the students identified as male, and 59% identified as female. The majority of the students self-identified as Caucasian (42%), followed by black/African American (12%), Asian or Asian American (8%), Latino/Latina (7%), and multiracial (5%); information on race/ethnicity was unavailable for 26 cases (24%), as data on this demographic variable were not routinely collected until the third year of CARE Net program implementation. The majority of students referred to the CARE Net program were first-year students (36%), followed by sophomores (27%), juniors (21%), seniors (15%), and graduate students (1%). Service-Related Indices The time from the incident resulting in referral to the CARE Net program and the formal parental notification by the Director of the Department of Residential Life was made within 5.1 days on average; the referral to the CARE Net program was made on average within 6.2 days of the incident. The time span from the incident to the CARE Net appointment was 15.2 days on average, with a range of 3 to VOL 62, MAY/JUNE 2014
47 days. With this variable, as well as the date between incident and referral, a wide range was observed due to the need to accommodate for hospitalizations prior to the student’s return to campus and his or her availability for the CARE Net evaluation, as well as weekends and university holidays and breaks. Severity of Referral Incident Using the CARE Net program protocol guidelines as a metric, the severity of the referral incident for each student in the sample was categorized (see Figure 1). There was a wide range of severity levels. Of the 108 students in the sample, 67 (62%) were referred based on public expression of suicidal thoughts or feelings. Four students (4%) were referred subsequent to making overt plans for suicide. Thirtyseven students (34%) were referred after engaging in serious self-harm. Method of Self-harm Figure 2 displays the proportion of students referred to the CARE Net program exhibiting 5 categories of serious selfharm. Of the 37 students who were referred to the program after engaging in serious self-harm, 21 (57%) overdosed on a drug or medication, 9 (24%) engaged in cutting behavior with suicidal intent, 5 (13%) both overdosed and cut themselves, 1 (3%) was involved in an attempted drowning, and 1 (3%) attempted suicide by hanging. There was no relationship between the severity of the referral incident with variables such as completion and noncompletion of the CARE Net program or enrollment status or grade point average during the semester subsequent to the incident. Enrollment For the sample, the overall rate of retention in college was 66%, with retention rates of 51.3% for freshmen, 51.3% for sophomores, 69.6% for juniors, and 87.5% for seniors. Forty students were registered at the university for the semester subsequent to referral to the CARE Net program, and 26 students graduated from the university. Twelve students withdrew from the university for medical reasons, 7 were dismissed, and 23 students were not enrolled at the university (did not return but did not have a record of a formal leave of absence) during the semester subsequent to their involvement in the CARE Net program. Results indicated that 7 of the 11 students who did not successfully complete the CARE Net program (63.6%) were either not enrolled or had a grade point average of 0. Twentyfive of the 97 students successfully completing the CARE Net program (27.2%) were either not enrolled or had a grade point average of 0. Grade Point Average Data on grade point average were collected on students in the sample who participated in the CARE Net program. Specifically, the grade point averages of students the 287
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FIGURE 1. Severity of suicidal intent.
semesters prior to, during, and subsequent to the CARE net intervention were examined. Data in Table 1 suggest that, as one would expect, the grade point average dropped significantly from baseline during the semester in which the suicidal incident occurred, t(43) = 2.55, p = .02. In addition, a significant rebound in grade point average was noted for students who completed the CARE Net program and were retained at the university for the semester subsequent
to the incident and CARE Net intervention, t(43) = 2.13, p = .04. For the data on grade point averages of students who successfully completed the CARE Net program, a repeatedmeasures ANOVA found an overall significant effect for time, F(2, 42) = 4.03, p = .03, and follow-up analyses suggested that grade point average went down significantly (from 2.92 to 2.59). There was a trend for grade point average to rebound
3% 3% Overdose 13%
24%
Cutting with Suicidal Intent Overdose & Cutting with Suicidal Intent Attempted Drowing 57% Hanging
FIGURE 2. Method of serious self-harm.
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TABLE 1. Comparison of Grade Point Average (GPA) for Semesters Prior, During, and Subsequent to CARE Net Program Intervention Preintervention semester
GPA
Intervention semester
Postintervention semester
M
SD
M
SD
M
SD
2.92
0.68
2.59
0.93
2.82
0.95
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Note. N = 44. The change from preintervention semester to intervention semester and intervention semester to postintervention semester were both significant (p < .05).
the semester after the CARE Net program referral (from 2.59 to 2.82). There was no significant difference between grade point average the semester before and grade point average the semester after the referral. Interestingly, there was a statistically significant difference in grade point average during the semester in which students were referred to the CARE Net program between those who completed and did not complete the program (2.66 vs 1.97, respectively, t(96) = 2.12, p = .04). COMMENT A review of quality assurance data collected over a 7-year time period indicates that the CARE Net program is being implemented with adherence to its specified aims and, more importantly, suggests that the program accomplishes the central goal of offering timely and vital services to students that support their viability within the university environment. Perhaps more importantly, data suggest that students who successfully completed the CARE Net program were able to remain in school the semester subsequent to the incident for which they were referred and demonstrated a small but nonetheless significant rebound in grade point average after experiencing a significant drop in grade point average during the semester in which the incident took place. Additionally, some students who successfully completed the CARE Net program achieved the milestone of graduation from college, a significant accomplishment in light of the serious stressors often associated with an incident involving suicide risk. Further, with regard to service-related measures, data indicate that responses by university officials and Counseling Center staff were both timely and responsive to the type and severity of behavioral risk incidents. An interesting finding was that more than half of freshmen and sophomores in the sample, students who are defined in the literature to be at particularly high risk for a number of health issues, including risk for suicide, alcohol and drug abuse, and other concerns,4,10–12 were retained at the university the semester subsequent to the CARE Net intervention. On the other hand, in cases in which students did not successfully complete the CARE Net program, the course of follow-up for each of these students was clear; that is, in
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cases in which students did not withdraw from the university for medical or other reasons, university officials took action to refer these students for conduct code violations per the parameters outlined in the residence license. In summary, data assessing the CARE Net program over a 7-year period suggest that the program adheres faithfully to its specified aims by providing critical services to students in a timely and comprehensive manner. The program also optimizes access to support services for students as a result of the documentation and communication processes inherent in its procedures, particularly through the collaborative development of the CARE Plan, and with the additional benefits that derive from providing parents/legal guardians and current or future treatment providers with the CARE Plan and informing them of the portfolio of supportive services the student might access. In essence, within the framework of the CARE Net program, the student is provided with a personalized prevention and intervention plan aimed to increase the availability of support services, thus enabling him or her to move forward in regard to academic success and retention in college. Clinical Implications The decision to implement a program that will permit a student to remain at a college or university subsequent to an incident involving risk for suicide has important clinical implications for professionals working in college health. During the 7-year period of time examined in this case study, there was clearly a wide range of levels of severity of risk displayed by the students referred to the CARE Net program, which allowed for a variety of outcomes (ie, graduating, withdrawal, etc). Therefore, each student’s circumstances and needs were considered on an individual basis; within these broad parameters, early intervention programs such as CARE Net can offer the necessary framework that, combined with clinical judgment, provides for a comprehensive assessment of a student’s support system and potential viability within the university setting. When formulating a campus response to students at risk for suicide, it is important to take into consideration the array of policies, programmatic infrastructures, and on-campus and
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off-campus mental health and other support resources that can be mobilized to respond to each student in a manner that is relevant to his or her needs. When responding to an incident involving suicide risk, many colleges and universities may choose to implement strategies such as involuntary medical withdrawal. However, this option does not afford the student the opportunity to benefit from referral to treatment or to avail himself or herself of the newly discovered strategies and resources that might be identified through the implementation of a post–critical incident assessment and evaluation during a time of crisis. In essence, programs such as CARE Net can offer the benefits of multidimensional assessment and referral after an incident involving suicide risk, as well as an opportunity to conduct a thorough evaluation of the student in regard to risk and protective factors and to thereby develop or enhance the student’s support network on and off campus.
Limitations In a comprehensive review of the effectiveness of the CARE Net program, several limitations need to be considered. First, the review of archival data does not allow conclusions about cause and effect to be made or to identify which portions of the CARE Net intervention were most effective. Second, students who did not engage in or did not complete successfully the CARE Net program were not contacted for follow-up assessments, although the number of students who did not complete the program was very small. Third, longer-term follow-up data collection for more than one semester post CARE Net intervention was not conducted, limiting access to longitudinal data on the functioning of students engaged in the intervention program. Finally, data were collected from only one university, which limits the generalizability of the findings. Despite these limitations, the use of case study methodology allows the opportunity for both researchers and practitioners to understand more fully the successes and challenges associated with a university’s decision to implement a program to respond to incidents of suicide risk in the context of a large public university and busy campus mental health service agency faced with multiple administrative and service demands.
Summary and Future Directions The development and implementation of a campus-based consultative assessment, resource evaluation, and referral program for students who have displayed risk for suicide may be an effective means of retaining the student within the college environment and supporting future academic success. It is recommended that future research utilize longitudinal designs that examine the effects of such early intervention programs over time, as well as to examine the procedural, programmatic, and policy implications for colleges or universities associated with the implementation of such programs.
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ACKNOWLEDGMENTS
The authors offer special thanks to Laurie M. Garafola and the Department of Residential Life, University at Albany, State University of New York, for their support and collaboration on this project. FUNDING This program was developed in part under grant number SM57502 from the Substance Abuse and Mental Health Administration (SAMHSA), US Department of Health and Human Services (HHS). The views, politics and opinions expressed are those of the authors and do not necessarily reflect those of SAMHSA or HHS. CONFLICT OF INTEREST DISCLOSURE The authors have no conflicts of interest to report. The authors confirm that the research presented in this article met the ethical guidelines, including adherence to the legal requirements, of the United States and received approval from the Institutional Review Board of the University at Albany, State University of New York. NOTE For comments and further information, address correspondence to Estela M. Rivero, University Counseling Center, University at Albany, State University of New York, 400 Patroon Creek Boulevard, Suite 104, Albany, NY 12206, USA (e-mail: [email protected]). REFERENCES 1. Kim CD, Lesage AD, Seguin M, et al. Seasonal differences in psychopathology of male suicide completers. Compr Psychiatry. 2004;45:333–339. 2. Konick L, Gutierrez PM. Testing a model of suicide ideation in college students. Suicide Life-Threat Behav. 2005;35:181–192. 3. Renaud J, Berlim MT, McGirr A, Tousignant M, Turecki G. Current psychiatric morbidity, aggression/impulsivity and personality dimensions in child and adolescent suicide: a case-control project. J Affect Disord. 2008;105:221–228. 4. Haas A, Koestner B, Rosenberg J, et al. An interactive webbased method of outreach to college students at risk for suicide. J Am Coll Health. 2008;57:15–22. 5. Kisch J, Leino EV, Silverman MM. Aspects of suicidal behavior, depression and treatment in college students: results from the Spring 2000 National College Health Assessment Survey. Suicide Life-Threat Behav. 2005;35:3–13. 6. Lamberg L. Experts work to prevent college suicides. JAMA. 2006;296:502–504. 7. Drum DJ, Brownson C, Adryon BD, Smith SE. New data on the nature of suicidal crises in college students: shifting the paradigm. Prof Psychol Res Pract. 2009;40:213–222. 8. Gallagher RP. National Survey of Counseling Centers, 2004. Arlington, VA: The International Association of Counseling Services; 2005. 9. Schwartz AJ. College student suicide in the United States: 1990–1991 through 2003–2004. J Am Coll Health. 2006;54:341–352.
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Early Suicide Intervention Program for Residential Students 12. Wilcox HC, Arria AM, Caldeira KM, Vincent KB, Pinchevsky GM, O’Grady KE. Prevalence and predictors of persistent suicide ideation, plans, and attempts during college. J Affect Disord. 2010;127:287–294.doi: 10.1016/j.jad.2010.04.017. Received: 1 October 2013 Accepted: 19 January 2014
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10. Garlow SJ, Rosenberg J, Moore JD, et al. Depression, desperation, and suicidal ideation in college students: results from the American Foundation for Suicide Prevention College Screening Project at Emory University. Depress Anxiety. 2008;25:482–488. 11. Beghi M, Rosenbaum JF. Risk factors for fatal and nonfatal repetition of suicide attempt: a critical appraisal. Curr Opin Psychiatry. 2010;23:349–355.
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Journal of American College Health Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/vach20
Implementing an Early Intervention Program for Residential Students Who Present With Suicide Risk: A Case Study a
a
a
Estela M. Rivero PhD , M. Dolores Cimini PhD , Joseph E. Bernier PhD , Judith A. Stanley a
a
b
a
PhD , Andrea D. Murray MA , Drew A. Anderson PhD & Heidi R. Wright PsyD a
University Counseling Center, University at Albany, State University of New York, Albany, New York b
Department of Psychology, University at Albany, State University of New York, Albany, New York Accepted author version posted online: 14 Feb 2014.Published online: 08 May 2014.
Click for updates To cite this article: Estela M. Rivero PhD, M. Dolores Cimini PhD, Joseph E. Bernier PhD, Judith A. Stanley PhD, Andrea D. Murray MA, Drew A. Anderson PhD & Heidi R. Wright PsyD (2014) Implementing an Early Intervention Program for Residential Students Who Present With Suicide Risk: A Case Study, Journal of American College Health, 62:4, 285-291, DOI: 10.1080/07448481.2014.887574 To link to this article: http://dx.doi.org/10.1080/07448481.2014.887574
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
JOURNAL OF AMERICAN COLLEGE HEALTH, VOL. 62, NO. 4
Case Report
Downloaded by [University of Ulster Library] at 07:17 26 February 2015
Implementing an Early Intervention Program for Residential Students Who Present With Suicide Risk: A Case Study Estela M. Rivero, PhD; M. Dolores Cimini, PhD; Joseph E. Bernier, PhD; Judith A. Stanley, PhD; Andrea D. Murray, MA; Drew A. Anderson, PhD; Heidi R. Wright, PsyD
Abstract. Objective: This case study examined the effects of an early intervention program designed to respond to residential college students demonstrating risk for suicide. Participants: Participants were 108 undergraduates at a large northeastern public university referred to an early intervention program subsequent to presenting with risk factors for suicide between Fall 2004 and Spring 2011. Methods: Data were collected from archival records to examine quality of early intervention services, student retention, and grade point average (GPA) during the semesters prior to, during, and subsequent to the referral incident. Results: Program implementation was timely and responsive to student needs; students successfully completing the early intervention program remained in school and demonstrated small but significant rebounds in GPA the semester subsequent to the incident. Conclusions: There are benefits associated with the implementation of early intervention programs designed to respond to students manifesting risk for suicide, such as connecting the student to vital services and support networks.
lege students die by suicide each year, fewer than 20% of students reporting suicidal thoughts or a history of attempts were receiving mental health treatment.4–6 In fact, approximately 80% of students who died by suicide were not engaged in receiving mental health services. Not surprisingly, students who sought professional help were less likely to attempt suicide, and those in treatment were less likely to die by suicide than a comparable population not receiving treatment.5,7–9 In addition to a college student’s involvement in mental health treatment, the presence of a social support network (ie, family and friends) is also a potential protective factor associated with the prevention of suicide. Despite this, social support network members, including parents and peers, are often uninvolved in traditional individually oriented early interventions. Based on these findings, early intervention through the use of targeted programs that help articulate and strengthen support networks for students who present prior suicidal intent can provide an excellent opportunity to offer critical services in a timely and responsive manner. Such proactive and relevant interventions, in turn, may enhance the likelihood of a positive clinical outcome and related academic success, retention, and graduation from college. To address risk for suicide among college students through targeted early intervention strategies, the CARE Net (Consultation and Resource Evaluation) program was designed to provide a mechanism for staff members within the Counseling Center and Department of Residential Life at a large northeastern public university to intervene in a timely manner with students who either threaten or attempt suicide, as well as with their parents, and, as appropriate, their
Keywords: community health, counseling, mental health, prevention, suicide
It is widely known that approximately 90% of all individuals who die by suicide, whether or not they are matriculated college students, have a diagnosable psychiatric condition.1–3 Unfortunately, however, although approximately 1,100 colDr Rivero, Dr Cimini, Dr Bernier, Dr Stanley, Ms Murray, and Dr Wright are with the University Counseling Center at the University at Albany, State University of New York, in Albany, New York. Dr Anderson is with the Department of Psychology at the University at Albany, State University of New York in Albany, New York. Copyright © 2014 Taylor & Francis Group, LLC
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roommates or suitemates. Within this program, suicidal intent is defined as either a public suicide threat, tangible evidence that the student is making plans or preparing for suicide, or manifestations of serious self-inflicted injury. The Director of the Department of Residential Life refers students displaying the aforementioned indicators of suicidal intent to the Counseling Center. The referred student then participates in a 2-hour appointment (with follow-up appointment scheduled as indicated) with a licensed psychologist at the center. Essential components of the CARE Net protocol addressed with the student include (1) an assessment of current suicide risk; (2) an evaluation of the student’s willingness and ability to refrain from self-harm; (3) consultation regarding needed psychiatric, psychological, and supportive educational services; (4) inclusion of parents and or guardians who are informed of the incident that led to referral to the CARE Net program, the aims of the CARE Net program, and referral recommendations; and (5) provision of a supportive educational intervention that intends to minimize the disruption of normal functioning for roommates and suitemates in the residence community. The referred student collaborates with the psychologist in the development of a “CARE Plan” listing sources of support and healthy alternatives to risk behaviors engaged in prior to the intervention; copies of the CARE Plan are provided to the student, his/her treatment providers, and parents/legal guardians. In this way, the CARE Net program helps students identify the crisis, treatment, and educational services that are available on campus and in the larger community so they can begin to access vital assistance and may remain viable campus residents. Further, the program offers an avenue to mobilize parents and family members to provide support and assistance and to minimize the disruptive effects that suicide risk–related behaviors have on roommates and suitemates in the residence community. In cases in which the most appropriate option for a distressed student is to withdraw from the university for medical reasons, CARE Net clinicians offer assistance with this process. Active participation by the referred student in all phases of the program, including the student’s collaboration on the development of the CARE Plan, is required for successful program completion. A student’s referral to the CARE Net program augments and often immediately follows existing crisis intervention services such as emergency room visits, psychiatric hospitalizations, psychological treatment, and consultation services with Residential Life staff and students. The program is not designed to replace existing crisis intervention services, nor is it intended to undertake the psychological treatment of students referred to the program. In fact, in most cases the student has been evaluated in the crisis unit of the local psychiatric hospital, hospitalized when clinically indicated, and discharged prior to a referral to the program. The purpose of the present case study was to examine the impact of the CARE Net program, both in regard to process and quality assurance–related indices as well as the potential role of the program on subsequent student retention 286
and success in school. Using archival data collected over a 7-year time period, service-focused variables such as time from incident to referral to the CARE Net program, number of sessions to CARE Net program completion, and other time-related milestones were analyzed. Demographic and descriptive data, such as gender, race/ethnicity, class year, and severity of the incident that resulted in the CARE Net referral, were collected in order to better understand which students received services. Further, for all students who completed the CARE Net program, grade point averages and enrollment status were tracked for the semesters prior to, during, and subsequent to program involvement to assess the potential link between engagement in the program and student retention. METHODS Participants Participants in the present case study were 108 undergraduate students living in residence at a large public university in the northeastern United States who exhibited signs indicative of risk for suicide as defined by the following indices: (1) the student has threatened suicide verbally or in writing (eg, “I will kill myself if you break up with me,” “I’ve decided that life is not worth living,” “I would kill myself,if I had the chance,” “I’ve been thinking about how many pills it would take to kill myself,” or “I don’t have much to live for any more”), (2) the student has made overt plans and preparations for suicide (eg, has purchased a weapon or has been stockpiling/collecting pills, has been uncharacteristically engaging in reckless behaviors, has been giving away valued possessions—or saying “goodbye” to friends, has written a suicide note, has confided in another individual that “I’ve imagined how I’d kill myself” or “I’ve thought about what I’d say in a suicide note”), and (3) the student has engaged in serious self-injury (eg, cutting that required medical attention, overdosed on pills, or treated for alcohol poisoning associated with psychological distress). These indices of suicide risk were reported by Residential Life staff members using a paper-and-pencil checklist that was transmitted to the Director of Residential Life and to the Counseling Center. Procedures For each suicide risk–related incident that occurred in the university residence halls, the Director of the Department of Residential Life completed a CARE Net referral checklist outlining details regarding the referral incident. This document, along with the incident report, was faxed to the Counseling Center. Concurrent with the transmittal of this document, the Director of Residential Life met with each referred student, notified the student’s parent or legal guardian of the incident, and advised the parent or guardian of the referral to and purpose of the CARE Net program. During the same meeting with the student, the Director of Residential Life contacted the Counseling Center and made an appointment for the student (with the student present in the office) with JOURNAL OF AMERICAN COLLEGE HEALTH
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a CARE Net clinician to be completed within 5 business days. On arrival to the Counseling Center appointment, the referred student completed a demographic information form and read and signed an authorization form, and the CARE Net evaluation was completed. At the end of each semester, CARE Net data were compiled and analyzed as part of routine quality assurance activities, and both an annual report and multiyear cumulative CARE Net program data report were compiled to assess process and outcome variables and inform future program implementation. Prior to manuscript preparation, a request for release of archival data was submitted to and approved by the university Institutional Review Board. RESULTS Data for this case study were analyzed using the Statistical Package for the Social Sciences (SPSS), version 19 (IBM SPSS, Armonk, New York). This method offered ease of access to descriptive data and, when appropriate, allowed for the completion of repeated-measures analysis of variance (ANOVA). Demographic Characteristics of the Case Study Sample Participants were 108 undergraduate residential students from a large, public northeastern university referred to the CARE Net program between Fall 2004 and Spring 2011. Ninety-seven (90%) completed the CARE Net program, and 11 (10%) did not complete the program. Of the 11 students who did not complete the program, 1 requested a medical withdrawal from the university before a CARE Net appointment could take place, 1 moved off campus, thereby becoming exempt from residential policies, and the other 9 failed to comply with the program’s requirements and were referred by the Department of Residential Life to Judicial Affairs staff for university conduct code violation as outlined in the residence license. Forty-one percent of the students identified as male, and 59% identified as female. The majority of the students self-identified as Caucasian (42%), followed by black/African American (12%), Asian or Asian American (8%), Latino/Latina (7%), and multiracial (5%); information on race/ethnicity was unavailable for 26 cases (24%), as data on this demographic variable were not routinely collected until the third year of CARE Net program implementation. The majority of students referred to the CARE Net program were first-year students (36%), followed by sophomores (27%), juniors (21%), seniors (15%), and graduate students (1%). Service-Related Indices The time from the incident resulting in referral to the CARE Net program and the formal parental notification by the Director of the Department of Residential Life was made within 5.1 days on average; the referral to the CARE Net program was made on average within 6.2 days of the incident. The time span from the incident to the CARE Net appointment was 15.2 days on average, with a range of 3 to VOL 62, MAY/JUNE 2014
47 days. With this variable, as well as the date between incident and referral, a wide range was observed due to the need to accommodate for hospitalizations prior to the student’s return to campus and his or her availability for the CARE Net evaluation, as well as weekends and university holidays and breaks. Severity of Referral Incident Using the CARE Net program protocol guidelines as a metric, the severity of the referral incident for each student in the sample was categorized (see Figure 1). There was a wide range of severity levels. Of the 108 students in the sample, 67 (62%) were referred based on public expression of suicidal thoughts or feelings. Four students (4%) were referred subsequent to making overt plans for suicide. Thirtyseven students (34%) were referred after engaging in serious self-harm. Method of Self-harm Figure 2 displays the proportion of students referred to the CARE Net program exhibiting 5 categories of serious selfharm. Of the 37 students who were referred to the program after engaging in serious self-harm, 21 (57%) overdosed on a drug or medication, 9 (24%) engaged in cutting behavior with suicidal intent, 5 (13%) both overdosed and cut themselves, 1 (3%) was involved in an attempted drowning, and 1 (3%) attempted suicide by hanging. There was no relationship between the severity of the referral incident with variables such as completion and noncompletion of the CARE Net program or enrollment status or grade point average during the semester subsequent to the incident. Enrollment For the sample, the overall rate of retention in college was 66%, with retention rates of 51.3% for freshmen, 51.3% for sophomores, 69.6% for juniors, and 87.5% for seniors. Forty students were registered at the university for the semester subsequent to referral to the CARE Net program, and 26 students graduated from the university. Twelve students withdrew from the university for medical reasons, 7 were dismissed, and 23 students were not enrolled at the university (did not return but did not have a record of a formal leave of absence) during the semester subsequent to their involvement in the CARE Net program. Results indicated that 7 of the 11 students who did not successfully complete the CARE Net program (63.6%) were either not enrolled or had a grade point average of 0. Twentyfive of the 97 students successfully completing the CARE Net program (27.2%) were either not enrolled or had a grade point average of 0. Grade Point Average Data on grade point average were collected on students in the sample who participated in the CARE Net program. Specifically, the grade point averages of students the 287
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FIGURE 1. Severity of suicidal intent.
semesters prior to, during, and subsequent to the CARE net intervention were examined. Data in Table 1 suggest that, as one would expect, the grade point average dropped significantly from baseline during the semester in which the suicidal incident occurred, t(43) = 2.55, p = .02. In addition, a significant rebound in grade point average was noted for students who completed the CARE Net program and were retained at the university for the semester subsequent
to the incident and CARE Net intervention, t(43) = 2.13, p = .04. For the data on grade point averages of students who successfully completed the CARE Net program, a repeatedmeasures ANOVA found an overall significant effect for time, F(2, 42) = 4.03, p = .03, and follow-up analyses suggested that grade point average went down significantly (from 2.92 to 2.59). There was a trend for grade point average to rebound
3% 3% Overdose 13%
24%
Cutting with Suicidal Intent Overdose & Cutting with Suicidal Intent Attempted Drowing 57% Hanging
FIGURE 2. Method of serious self-harm.
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TABLE 1. Comparison of Grade Point Average (GPA) for Semesters Prior, During, and Subsequent to CARE Net Program Intervention Preintervention semester
GPA
Intervention semester
Postintervention semester
M
SD
M
SD
M
SD
2.92
0.68
2.59
0.93
2.82
0.95
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Note. N = 44. The change from preintervention semester to intervention semester and intervention semester to postintervention semester were both significant (p < .05).
the semester after the CARE Net program referral (from 2.59 to 2.82). There was no significant difference between grade point average the semester before and grade point average the semester after the referral. Interestingly, there was a statistically significant difference in grade point average during the semester in which students were referred to the CARE Net program between those who completed and did not complete the program (2.66 vs 1.97, respectively, t(96) = 2.12, p = .04). COMMENT A review of quality assurance data collected over a 7-year time period indicates that the CARE Net program is being implemented with adherence to its specified aims and, more importantly, suggests that the program accomplishes the central goal of offering timely and vital services to students that support their viability within the university environment. Perhaps more importantly, data suggest that students who successfully completed the CARE Net program were able to remain in school the semester subsequent to the incident for which they were referred and demonstrated a small but nonetheless significant rebound in grade point average after experiencing a significant drop in grade point average during the semester in which the incident took place. Additionally, some students who successfully completed the CARE Net program achieved the milestone of graduation from college, a significant accomplishment in light of the serious stressors often associated with an incident involving suicide risk. Further, with regard to service-related measures, data indicate that responses by university officials and Counseling Center staff were both timely and responsive to the type and severity of behavioral risk incidents. An interesting finding was that more than half of freshmen and sophomores in the sample, students who are defined in the literature to be at particularly high risk for a number of health issues, including risk for suicide, alcohol and drug abuse, and other concerns,4,10–12 were retained at the university the semester subsequent to the CARE Net intervention. On the other hand, in cases in which students did not successfully complete the CARE Net program, the course of follow-up for each of these students was clear; that is, in
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cases in which students did not withdraw from the university for medical or other reasons, university officials took action to refer these students for conduct code violations per the parameters outlined in the residence license. In summary, data assessing the CARE Net program over a 7-year period suggest that the program adheres faithfully to its specified aims by providing critical services to students in a timely and comprehensive manner. The program also optimizes access to support services for students as a result of the documentation and communication processes inherent in its procedures, particularly through the collaborative development of the CARE Plan, and with the additional benefits that derive from providing parents/legal guardians and current or future treatment providers with the CARE Plan and informing them of the portfolio of supportive services the student might access. In essence, within the framework of the CARE Net program, the student is provided with a personalized prevention and intervention plan aimed to increase the availability of support services, thus enabling him or her to move forward in regard to academic success and retention in college. Clinical Implications The decision to implement a program that will permit a student to remain at a college or university subsequent to an incident involving risk for suicide has important clinical implications for professionals working in college health. During the 7-year period of time examined in this case study, there was clearly a wide range of levels of severity of risk displayed by the students referred to the CARE Net program, which allowed for a variety of outcomes (ie, graduating, withdrawal, etc). Therefore, each student’s circumstances and needs were considered on an individual basis; within these broad parameters, early intervention programs such as CARE Net can offer the necessary framework that, combined with clinical judgment, provides for a comprehensive assessment of a student’s support system and potential viability within the university setting. When formulating a campus response to students at risk for suicide, it is important to take into consideration the array of policies, programmatic infrastructures, and on-campus and
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off-campus mental health and other support resources that can be mobilized to respond to each student in a manner that is relevant to his or her needs. When responding to an incident involving suicide risk, many colleges and universities may choose to implement strategies such as involuntary medical withdrawal. However, this option does not afford the student the opportunity to benefit from referral to treatment or to avail himself or herself of the newly discovered strategies and resources that might be identified through the implementation of a post–critical incident assessment and evaluation during a time of crisis. In essence, programs such as CARE Net can offer the benefits of multidimensional assessment and referral after an incident involving suicide risk, as well as an opportunity to conduct a thorough evaluation of the student in regard to risk and protective factors and to thereby develop or enhance the student’s support network on and off campus.
Limitations In a comprehensive review of the effectiveness of the CARE Net program, several limitations need to be considered. First, the review of archival data does not allow conclusions about cause and effect to be made or to identify which portions of the CARE Net intervention were most effective. Second, students who did not engage in or did not complete successfully the CARE Net program were not contacted for follow-up assessments, although the number of students who did not complete the program was very small. Third, longer-term follow-up data collection for more than one semester post CARE Net intervention was not conducted, limiting access to longitudinal data on the functioning of students engaged in the intervention program. Finally, data were collected from only one university, which limits the generalizability of the findings. Despite these limitations, the use of case study methodology allows the opportunity for both researchers and practitioners to understand more fully the successes and challenges associated with a university’s decision to implement a program to respond to incidents of suicide risk in the context of a large public university and busy campus mental health service agency faced with multiple administrative and service demands.
Summary and Future Directions The development and implementation of a campus-based consultative assessment, resource evaluation, and referral program for students who have displayed risk for suicide may be an effective means of retaining the student within the college environment and supporting future academic success. It is recommended that future research utilize longitudinal designs that examine the effects of such early intervention programs over time, as well as to examine the procedural, programmatic, and policy implications for colleges or universities associated with the implementation of such programs.
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ACKNOWLEDGMENTS
The authors offer special thanks to Laurie M. Garafola and the Department of Residential Life, University at Albany, State University of New York, for their support and collaboration on this project. FUNDING This program was developed in part under grant number SM57502 from the Substance Abuse and Mental Health Administration (SAMHSA), US Department of Health and Human Services (HHS). The views, politics and opinions expressed are those of the authors and do not necessarily reflect those of SAMHSA or HHS. CONFLICT OF INTEREST DISCLOSURE The authors have no conflicts of interest to report. The authors confirm that the research presented in this article met the ethical guidelines, including adherence to the legal requirements, of the United States and received approval from the Institutional Review Board of the University at Albany, State University of New York. NOTE For comments and further information, address correspondence to Estela M. Rivero, University Counseling Center, University at Albany, State University of New York, 400 Patroon Creek Boulevard, Suite 104, Albany, NY 12206, USA (e-mail: [email protected]). REFERENCES 1. Kim CD, Lesage AD, Seguin M, et al. Seasonal differences in psychopathology of male suicide completers. Compr Psychiatry. 2004;45:333–339. 2. Konick L, Gutierrez PM. Testing a model of suicide ideation in college students. Suicide Life-Threat Behav. 2005;35:181–192. 3. Renaud J, Berlim MT, McGirr A, Tousignant M, Turecki G. Current psychiatric morbidity, aggression/impulsivity and personality dimensions in child and adolescent suicide: a case-control project. J Affect Disord. 2008;105:221–228. 4. Haas A, Koestner B, Rosenberg J, et al. An interactive webbased method of outreach to college students at risk for suicide. J Am Coll Health. 2008;57:15–22. 5. Kisch J, Leino EV, Silverman MM. Aspects of suicidal behavior, depression and treatment in college students: results from the Spring 2000 National College Health Assessment Survey. Suicide Life-Threat Behav. 2005;35:3–13. 6. Lamberg L. Experts work to prevent college suicides. JAMA. 2006;296:502–504. 7. Drum DJ, Brownson C, Adryon BD, Smith SE. New data on the nature of suicidal crises in college students: shifting the paradigm. Prof Psychol Res Pract. 2009;40:213–222. 8. Gallagher RP. National Survey of Counseling Centers, 2004. Arlington, VA: The International Association of Counseling Services; 2005. 9. Schwartz AJ. College student suicide in the United States: 1990–1991 through 2003–2004. J Am Coll Health. 2006;54:341–352.
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Early Suicide Intervention Program for Residential Students 12. Wilcox HC, Arria AM, Caldeira KM, Vincent KB, Pinchevsky GM, O’Grady KE. Prevalence and predictors of persistent suicide ideation, plans, and attempts during college. J Affect Disord. 2010;127:287–294.doi: 10.1016/j.jad.2010.04.017. Received: 1 October 2013 Accepted: 19 January 2014
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10. Garlow SJ, Rosenberg J, Moore JD, et al. Depression, desperation, and suicidal ideation in college students: results from the American Foundation for Suicide Prevention College Screening Project at Emory University. Depress Anxiety. 2008;25:482–488. 11. Beghi M, Rosenbaum JF. Risk factors for fatal and nonfatal repetition of suicide attempt: a critical appraisal. Curr Opin Psychiatry. 2010;23:349–355.
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