Undergraduate and Graduate Student Undergraduate and Graduate Student Coping with Stressful ExperiencesCoping with Stressful Experiences::

The Continuum of Distress, The Continuum of Distress, Suicidal Experiences and OutcomesSuicidal Experiences and Outcomes

Chris Brownson, PhDcbrownson@austin.utexas.edu

Elaine Hess, MAehess@utexas.edu

The University of Texas at Austin

Jennifer Kyle, PhD jkyle3@gmail.com

Queens College 1

Founded in 1991 at UT Austin6 completed studies to date

◦Will discuss data from our two most recent studies and campus-level data

Membership is determined study-by-studyResearch is an essential ingredient for

defining a subspecialty of college mental health (Penn State’s CSCMH, NCHA, Director’s Surveys, etc.)

2

National Suicide StatisticsNational 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 non-

clients◦ 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.

3Schwartz, 2006, 2011

Overview of PresentationOverview of Presentation1. Overview problem of college student suicide

◦ Consortium 2006 & 2011 structure/demographics◦ Problem of college student suicide◦ Key findings from Consortium studies

2. College Student Coping◦ Distal and proximal risk factors◦ Presentation of study details◦ Proximal risk factors◦ Protective factor: Coping

1. Help-seeking◦ Help-seeking patterns◦ Help-avoidance patterns◦ Implications of help-seeking/avoidance data

4

Overview of Current Overview of Current Study CharacteristicsStudy CharacteristicsWeb-based survey, anonymous, interventionOver 26,000 undergraduate and graduate

student responses (~101,000 surveys sent)~ 26% response rate

74 colleges and universities participatedRandom sample at each schoolGoal: Useful info for IHEs/CCs; both research

and “screening”

Demographics comparable to most recent NCHA survey

5

Structure of SurveyStructure of SurveyDemographicsHistory of help-seeking, risk and

protective factorsFocus 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

DemographicsDemographics

◦N = 26,430

◦Mean Age of 25.5 years(Range: 18 – 95 years)

◦63% Female

◦92% Heterosexual

7

Race/EthnicityRace/Ethnicity2011

Undergrad

N = 14,080

2011GradN =

12,094

African American, of African descent, African, of Caribbean descent, or

Black4.1% 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 HistoryMental Health History

Ever received MH services from:

UndergradN=14,113

GradN=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 Lifetime Suicidal Ideation for College Studentsfor College StudentsApproximately 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 SuicideFirst Considered SuicideUndergradN = 3,088

GradN = 2,182

When did you first seriously

consider attempting

suicide?

Before or while in middle

school28.7% 23.2%

While in high school

46.1% 33.9%

After high school but

before college3.9% 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 Recent Suicidal Ideation 5 to 6% seriously considered suicide

in past 12 months (Drum et al., 2009; ACHA-NCHA II, 2011)◦~1% actually attempted in past year

Episodes of ideation in past year described as brief, recurrent and intense (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 & Prevalence of Lifetime & Recent Suicide AttemptsRecent Suicide Attempts

2006Undergra

dN =

15,010

2006GradN =

11,441

2011Undergra

dN =

14,080

2011GradN =

12,094

Lifetime 7.6% 5.4% 7.2% 5.2%

Past 12 Months

0.85% 0.30% 0.81%* 0.22%*

During Stressful

Time Period

1.1% .40%

13

*NOTE: 2011 Past 12 Months item asked of those who endorsed one or more lifetime attempts; rates adjusted to

reflect entire sample

Intentions at Time of AttemptIntentions at Time of Attempt

For those who said “Yes” to having attempted suicide during their most stressful period.

Undergrad

N = 152

GradN = 43

Which of these statements

describe your intentions at the

time of the attempt(s)?

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 Role of Drugs & Alcohol in AttemptAttemptFor those who said “Yes” to having attempted suicide during their most

stressful period.

UndergradN = 155

GradN = 43

How would you describe the role of drugs or

alcohol in your most recent

suicide attempt?

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 Thoughts During Stressful PeriodPeriod

Undergrad

N = 14,080

GradN =

12,094

During the stressful

period, did you have any

thoughts similar to the

following? (Select all that apply)

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

Most students who experience

DISTRESS

First experience STRESS

Adapted from a presentation prepared by Arizona State University’s

Wellness & Health Promotion Center17

…so fewer end up here

The idea is to reach students

here…

Adapted from a presentation prepared by Arizona State University’s

Wellness & Health Promotion Center18

Discussion QuestionsDiscussion QuestionsWhat 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 PresentationOverview of Presentation1. Overview problem of college student suicide

◦ Consortium 2006 & 2011 structure/demographics◦ Problem of college student suicide◦ Key findings from Consortium studies

2. College Student Protective Factors and Coping◦ Distal and proximal risk factors◦ Presentation of study details◦ Proximal risk factors◦ Protective factor: Coping

1. Help-seeking◦ 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

21

Moscicki, 2001

Distal vs. Proximal RiskDistal vs. Proximal Risk

22

Protective Factors such as coping, spiritual faith influence the progression

Queens College

23

• 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 Universities-Master’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.

National vs. Campus Level DataNational vs. Campus Level DataNational Queens College

Sample Size 26,430 78

Age M = 25.5Range: 18 - 95

M = 29.82Range: 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/EthnicityDemographics: Race/Ethnicity

25

African American, of African descent, African, of Caribbean

descent, or Black5.2% 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%

Religious PreferenceReligious PreferenceChristian =

46.2%Catholic = 29.5%Jewish = 16.7%Buddhist = 3.8%Hindu = 3.8%Agnostic =

10.3%Atheist = 5.1%

How important are your beliefs?

• Very important = 37.2%

• Moderately important = 35.9%

• Not at all = 25.6%

26

Connection with Friends & FamilyConnection with Friends & Family

27

Do you consider your relationship with people you spend most of your

time with to be:

Overall Sample

N = 26,297M = 4.09

Queens CollegeN = 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 = 26,304M = 4.16

N = 78M = 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%

Past History of SuicidePast History of SuicideEver 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: StressProximal Risk: StressWhat sources of stress did students report?

And during that time, what was their level of distress?

Academics 64.1%

moderately to very much (56.4%)

Financial problems 35.9%

moderately to very much (33.3%)

Family problems 32.1%

moderately to very much (26.9%)

Emotional health problems

23.1%moderately to very much (21.8%)

Problems at work 21.8%

moderately to very much (20.5%)

Friendship problems

16.7%moderately to very much (12.8%) 29

Comparison of Students with History Comparison of Students with History of SI: Stress Managementof 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

…how motivated are you to manage

your daily challenges?

M = 3.11 M = 4.02

t (23.506) = -2.630, p < .05

…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 Proximal Risk: Stress & Its Impact on Social Connectedness and BelongingnessSocial Connectedness and Belongingness

Baseline

Stressful Period

How much do you feel you are a burden on others?

M = 2.24

M = 2.59

t (73) = -2.680, p < .01

Increase in feeling a burden

How understood by others do you feel?

M = 3.03

M = 2.94 NS

How cared for by others do you feel?

M = 3.77

M = 3.31t (73) = 3.676, p < .01

Decrease in feeling cared for

How much do you feel that you can count on others?

M = 3.01

M = 3.01 NS

How comfortable do you feel making new connections with others?

M = 3.33

M = 2.71t (72) = 4.275, p < .01

Decrease in feeling

comfortable in making new connections

31

Protective Factor: CopingProtective 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 much (34.6 %)

Emotion-focused Coping

Creating a plan

41.0%moderately to very much (32%)

Problem-focused Coping

Distracting myself

38.5%moderately to very much (32%)

Avoidance Coping

Prayer 21.8%moderately to very much (19.3%)

Faith-based Coping

32

Coping: It’s Impact on StressCoping: It’s Impact on Stress

How the following impacted your ability to cope?

Improvedmy 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%

33

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)

Protective Factor: Protective Factor: Coping & Spiritual FaithCoping & Spiritual Faith

Faith-based coping 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., faith-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 DistressProximal 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 ContinuumStress – Distress ContinuumKey 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 FactorsProtective 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 StudyProtective 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 Dependent Variable: Suicide DataData

Harkavy Asnis Suicide Scale (HASS Demo)

N (%)

History of Suicide Ideation

78 (32.1%)

Beginning at age 8Mode: 14 years old16 (21%) reported having a plan

History of Suicide Attempts

6(3%)

Most reporting only one attempt; 2 subjects reported 5 or moreBeginning at age 8Mode: 13 years old

Current Suicide Ideation(Past 2 weeks)

1.6%(4)

3 subjects denied plan or intent1 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 IdeationStudent Distress: Passive Ideation

40

Protective Factors as Predictors of Passive Ideation 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)

41

Variable B SE B β

Step 1      

Gender .470 .438 .085

Religious Affiliation

.144 .083 .137

Step 2      

Gender .686 .423 .123

Religious Affiliation

.109 .079 .104

YA-SSI -.935 .243 -.326***

CS-RFLI -.265 .241 -.091

SWBS -.617 .260 -.192*

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

Discussion QuestionsDiscussion QuestionsDo 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 PresentationOverview of Presentation1. Overview problem of college student suicide

◦ Consortium 2006 & 2011 structure/demographics◦ Problem of college student suicide◦ Key findings from Consortium studies

2. College Student Coping◦ Distal and proximal risk factors◦ Presentation of study details◦ Proximal risk factors◦ Protective factor: Coping

1. Help-seeking◦ Help-seeking patterns◦ Help-avoidance patterns◦ Implications of help-seeking/avoidance data

43

Methods Used to Connect to OthersMethods Used to Connect to Others

44

How important is the following?

Likert Scale1 Not at all important – 5 Very

important

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

Disclosing Suicidal ThoughtsDisclosing Suicidal Thoughts2006 study: Asked of those who had seriously considered attempting suicide 2006 study: Asked of those who had seriously considered attempting suicide (N=1,321)(N=1,321)

54% told one or more people

46% told no one45

Racial/Ethnic Identity

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

Help-Seeking Disparities for Racial and Help-Seeking Disparities for Racial and Ethnic Minority StudentsEthnic 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

47Brownson, Swanbrow Becker, Shadick, & Smith, in press

Help Seeking During a Stressful PeriodHelp Seeking During a Stressful Period

48

2011 study: Comparison of sources of support sought by students who did and did not seriously consider suicide during the stressful period

Reasons for Choosing Help SourcesReasons for Choosing Help Sources2011 Study: Asked of those who turned to someone for help during stressful period2011 Study: Asked of those who turned to someone for help during stressful period

49

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”

Reasons for ConcealmentReasons for Concealment2006 study: Asked of those who seriously considered suicide and did not tell anyone 2006 study: Asked of those who seriously considered suicide and did not tell anyone (N=769)(N=769)

50

Reasons For Not Seeking HelpReasons For Not Seeking Help2011 Study: Asked of those who indicated seeking help from no one during stressful 2011 Study: Asked of those who indicated seeking help from no one during stressful period period

51

Future Help-Seeking & Referral of Others Future Help-Seeking & Referral of Others to Counseling Center Servicesto Counseling Center ServicesUndergraduate sample, Undergraduate sample, N = 13,960, M = 2.54N = 13,960, M = 2.54

52

Discussion QuestionsDiscussion QuestionsKnowing 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 ToSpecial 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!!

54

http://cmhc.utexas.edu/researchconsortium.html

National Director: Chris Brownson, PhDEmail: cbrownson@austin.utexas.edu

ReferencesReferences

55

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. Journal of College Student

Psychotherapy, 25(4), 277–294.

Brownson, C., Swanbrow Becker, M., Shadick, R., & Smith, S. (in press). Suicidal behavior and help seeking among diverse clients. Journal of College Counseling. Drum, D. J., Brownson, C., Burton Denmark, A., & Smith, S. E. (2009). New data on the nature of

suicidal crises in college students: Shifting the paradigm. Professional Psychology: Research and

Practice, 40(3), 213-222. Mościcki, E. K. (2001). Epidemiology of completed and attempted suicide: toward a framework for

prevention. Clinical Neuroscience Research, 1(5), 310–323.  Schwartz, A. J. (2006). College Student Suicide in the United States: 1990-1991 Through 2003-2004. Journal of American College Health, 54(6), 341-352. Schwartz, A. J. (2011). Rate, relative risk, and method of suicide by students at 4-year colleges and universities in the United States, 2004-2005 through 2008-2009. Suicide and Life-Threatening Behavior, 41(4), 353-371.