Undergraduate and Graduate Student Coping with Stressful Experiences: The Continuum of Distress, Suicidal Experiences and Outcomes

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Undergraduate and Graduate Student Coping with
Stressful ExperiencesThe Continuum of
Distress, Suicidal Experiences and Outcomes

• Chris Brownson, PhD
• cbrownson_at_austin.utexas.edu
• Elaine Hess, MA
• ehess_at_utexas.edu
• The University of Texas at Austin
• Jennifer Kyle, PhD jkyle3_at_gmail.com
• Queens College

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• 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
  States CSCMH, NCHA, Directors Surveys, etc.)

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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
  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.

Schwartz, 2006, 2011
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Overview of Presentation

• Overview problem of college student suicide
• Consortium 2006 2011 structure/demographics
• Problem of college student suicide
• Key findings from Consortium studies
• College Student Coping
• Distal and proximal risk factors
• Presentation of study details
• Proximal risk factors
• Protective factor Coping
• Help-seeking
• Help-seeking patterns
• Help-avoidance patterns
• Implications of help-seeking/avoidance data

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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

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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

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Demographics

• N 26,430
• Mean Age of 25.5 years
• (Range 18 95 years)
• 63 Female
• 92 Heterosexual

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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
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Mental Health History
Ever received MH services from Undergrad N14,113 Grad N12,131
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
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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)

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First Considered Suicide
Undergrad N 3,088 Grad N 2,182
When did you first seriously consider attempting suicide? Before or while in middle school 28.7 23.2
When did you first seriously consider attempting suicide? While in high school 46.1 33.9
When did you first seriously consider attempting suicide? After high school but before college 3.9 3.9
When did you first seriously consider attempting suicide? While in college 18.3 18.7
When did you first seriously consider attempting suicide? After college but before graduate school .30 8.4
When did you first seriously consider attempting suicide? While in graduate school .10 7.9
When did you first seriously consider attempting suicide? Other 2.6 4.4
Of those who have considered suicide at some point in their life Of those who have considered suicide at some point in their life Of those who have considered suicide at some point in their life Of those who have considered suicide at some point in their life
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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)

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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
During Stressful Time Period 1.1 .40
NOTE 2011 Past 12 Months item asked of those who endorsed one or more lifetime attempts rates adjusted to reflect entire sample
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Intentions at Time of Attempt
For those who said Yes to having attempted suicide during their most stressful period. For those who said Yes to having attempted suicide during their most stressful period. For those who said Yes to having attempted suicide during their most stressful period. For those who said Yes to having attempted suicide during their most stressful period.
Undergrad N 152 Grad N 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
Which of these statements describe your intentions at the time of the attempt(s)? I tried to kill myself but knew I might survive 25.0 20.9
Which of these statements describe your intentions at the time of the attempt(s)? Was ambivalent and partly wanted to live 35.5 46.5
Which of these statements describe your intentions at the time of the attempt(s)? Mostly wanted to live but small part wanted to die 11.2 11.6
Which of these statements describe your intentions at the time of the attempt(s)? I did not intend to die 3.9 9.3
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Role of Drugs Alcohol in Attempt
For those who said Yes to having attempted suicide during their most stressful period. For those who said Yes to having attempted suicide during their most stressful period. For those who said Yes to having attempted suicide during their most stressful period. For those who said Yes to having attempted suicide during their most stressful period.
Undergrad N 155 Grad N 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
How would you describe the role of drugs or alcohol in your most recent suicide attempt? I intended to overdose with alcohol or drugs 30.3 27.9
How would you describe the role of drugs or alcohol in your most recent suicide attempt? I intended to use alcohol or drugs to reduce my inhibitions or fears about attempting suicide 11.6 9.3
How would you describe the role of drugs or alcohol in your most recent suicide attempt? My attempt was not planned in advance and may have happened because I was using alcohol or drugs 12.9 14.0
How would you describe the role of drugs or alcohol in your most recent suicide attempt? I was using alcohol or drugs but they were not related to my attempt 16.1 11.6
How would you describe the role of drugs or alcohol in your most recent suicide attempt? Addiction to alcohol or drugs was a reason for my attempt 5.8 2.3
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Thoughts During Stressful Period
Undergrad N 14,080 Grad N 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
During the stressful period, did you have any thoughts similar to the following? (Select all that apply) I wish this would all end 33.3 27.5
During the stressful period, did you have any thoughts similar to the following? (Select all that apply) I have to escape 20.1 17.1
During the stressful period, did you have any thoughts similar to the following? (Select all that apply) I wish I was dead 9.4 7.3
During the stressful period, did you have any thoughts similar to the following? (Select all that apply) I want to kill myself 5.7 3.6
During the stressful period, did you have any thoughts similar to the following? (Select all that apply) I might kill myself 3.1 1.9
During the stressful period, did you have any thoughts similar to the following? (Select all that apply) I will kill myself 1.0 .50
During the stressful period, did you have any thoughts similar to the following? (Select all that apply) I did not have any thoughts like these 37.5 42.8
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First experience STRESS
Most students who experience DISTRESS
Adapted from a presentation prepared by

Arizona State Universitys Wellness Health
Promotion Center
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The idea is to reach students here
so fewer end up here
Adapted from a presentation prepared by

Arizona State Universitys Wellness Health
Promotion Center
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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
  cant be solely responsible for this
• What successes and challenges have you had in
  collaborating with cross-campus partners?

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Overview of Presentation

• Overview problem of college student suicide
• Consortium 2006 2011 structure/demographics
• Problem of college student suicide
• Key findings from Consortium studies
• College Student Protective Factors and Coping
• Distal and proximal risk factors
• Presentation of study details
• Proximal risk factors
• Protective factor Coping
• Help-seeking
• Help-seeking patterns
• Help-avoidance patterns
• Implications of help-seeking/avoidance data

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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
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Distal vs. Proximal Risk
Protective Factors such as coping, spiritual
faith influence the progression
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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 Universities-Masters
  institutions in U.S. News and World Reports
  Americas Best Colleges.
• Historically, a commuter school, however, in
  2011, Queens College opened the first residential
  facility.

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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
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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
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Religious Preference

• Christian 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

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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
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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.

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Proximal Risk Stress
What 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)
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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
how motivated are you to manage your daily challenges? M 3.11 M 4.02 t (23.506) -2.630, p lt .05
how meaningful do you view your life to be? M 3.00 M 4.10 t (24.382) -2.984, p lt .01
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Proximal Risk Stress Its Impact on Social
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 lt .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 3.31 t (73) 3.676, p lt .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 2.71 t (72) 4.275, p lt .01 Decrease in feeling comfortable in making new connections
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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 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
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Coping Its 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)
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Protective Factor Coping 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.

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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)

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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.

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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

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Protective Factors Study

• Examining protective factors in a sample of
  diverse college youth as a means of predicting
  passive ideation
• Instruments
• Suicide (Outcome Variable)
• Harkavy Asnis Suicide Scale (HASS)
• Protective Factors (Predictor Variables)
• College Student-Reasons for Living Inventory
  (RFL-CS)
• Young Adult Social Support Inventory (YA-SSI)
• Spiritual Well- Being Scale (SWBS)

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Dependent Variable Suicide Data
Harkavy Asnis Suicide Scale (HASS Demo) N ()
History of Suicide Ideation 78 (32.1) Beginning at age 8 Mode 14 years old 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)
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Student Distress Passive Ideation
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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 ß
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 lt .05 p lt .01 p lt .000 R2 .137, F (5,163) 5.034, p lt.000, R squared change .115, F change (3, 158) 7.013, p lt.000
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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?

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Overview of Presentation

• Overview problem of college student suicide
• Consortium 2006 2011 structure/demographics
• Problem of college student suicide
• Key findings from Consortium studies
• College Student Coping
• Distal and proximal risk factors
• Presentation of study details
• Proximal risk factors
• Protective factor Coping
• Help-seeking
• Help-seeking patterns
• Help-avoidance patterns
• Implications of help-seeking/avoidance data

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Methods Used to Connect to Others
How important is the following? Likert Scale 1 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
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Disclosing Suicidal Thoughts2006 study Asked of
those who had seriously considered attempting
suicide (N1,321)

• 54 told one or more people
• 46 told no one

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Racial / Ethnic Identity Help-Seeking
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
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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
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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
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Reasons for Choosing Help Sources2011 Study
Asked of those who turned to someone for help
during stressful period
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Reasons for Concealment2006 study Asked of
those who seriously considered suicide and did
not tell anyone (N769)
Concealment Category Percentage Example of Category
Low Risk 18 The chances of me going through with it wasnt extremely unlikelyeven though I wanted to
Solicitude 16 I didnt want to bother anyone with my problems
Privacy 15 Because its something I dont feel comfortable sharing with others
Pointless 13 Didnt think anyone would care, or that they wouldnt take me seriously
Stigma 13 Didnt 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 didnt want anyone to talk me out of doing it
Perceived Lack of Confidants 3 There wasnt anyone I felt I could turn to
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Reasons For Not Seeking Help2011 Study Asked of
those who indicated seeking help from no one
during stressful period
52
Future Help-Seeking Referral of Others to
Counseling Center ServicesUndergraduate sample,
N 13,960, M 2.54
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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?

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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 Nat
ional Director Chris Brownson, PhD Email
cbrownson_at_austin.utexas.edu
55
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. Journal of College Student
Psychotherapy, 25(4), 277294. 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.   Moscicki, E. K. (2001). Epidemiology
of completed and attempted suicide toward a
framework for prevention. Clinical Neuroscience
Research, 1(5), 310323.   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.