This study focused on Suicide Risk Assessment (SRA) protocols completed by counsellors for 153 students who presented with suicidal ideation at a community college counselling centre during a five year period. This study sought to: determine the number of students presenting with suicidal ideation annually; identify the types of interventions used by counsellors; and assess the academic progress and retention rates of students who continued in their programs following intervention. Among the 122 individuals who continued in their studies, 73.8% met the criteria for retention and 42.1% achieved a GPA (Grade Point Average) of 3.0 or above.
The World Health Organization reports that mental illness affects 1 in 4 people worldwide (2001) and that nearly 2/3 of those affected never seek professional help as a result of discrimination, neglect, and stigma. In 2000-01, 7.1% of the Canadian population, 12 years of age and older, had experienced one major depressive episode in the preceding year, with the incidence of depression peaking at 9.6% among the 20 to 24 year age group (Statistics Canada, 2003). The Canadian Mental Health Association (2010) estimates that up to 20% of Canadian youth experience mental illness, and notes that suicide is a significant threat to the lives of young adults as the leading cause of death among 15-24 year olds.
Given these statistics, it is not surprising that community college counselling centres are well positioned to speak to mental health issues among this population. When the Directors of Canadian post-secondary counselling centres were asked about trends regarding client numbers and severity of issues, 77% indicated that they believed the number of students presenting with severe psychological issues had increased during the previous 5 years. Furthermore,79% responded that they believed the severity of issues presented by students had also increased during this time frame (Crozier & Willihnganz, 2005). Similarly, a national survey of counselling centre directors in the U.S. found that 93.4% of directors reported a tendency towards larger number of students on campus with severe psychological issues (Gallagher, 2009).
A longitudinal study of post-secondary counselling (Pledge, Lapan, Heppner, Kivlighan, & Roehlke, 1998) found that serious levels of distress among students were the norm and this remained consistent over the six year period studied. During this period students consistently required counselling assistance for serious levels of distress related to substance abuse, anxiety, depression, and suicidal ideation.
Another longitudinal study, which covered 13 years (from1988-2001), found an increase in the complexity of college counselling client issues, such that in more recent times, the usual relationship and developmental issues were often paired with more severe issues such as anxiety, depression, personality disorders, sexual assault, and suicidal ideation (Benton, Robertson, Tseng, Newton, & Benton, 2003). Over this time period, the number of students treated for depression doubled and the number of students reporting suicidal ideation tripled.
Thirty-two college counselling centres participated in a study, which looked at the severity and chronicity of psychological issues among college students seeking counselling in 1991, those seeking counselling in 1997, and those who did not seek counselling (Erdur-Baker, Aberson, Barrow and Draper, 2006). There was evidence that the severity of college students’ psychological issues increased over time, particularly in the areas of academic concerns, relationship and adjustment issues, romantic relationship concerns and depression. Also, both clinical samples reported significantly longer chronicity for issues than did students in the control group.
A 2008 survey of 80,121 students at 106 post-secondary institutions by the American College Health Association revealed that in the previous 12 month period: 62% of college students reported feeling hopeless; 43% reported feeling so depressed that they had difficulty functioning; and 9% reported that they had seriously considered suicide.
In view of the aforementioned statistics, community colleges can reasonably expect that 10-20% of the student population is at risk for the emergence or continuation of serious mental illness, which can significantly challenge or interfere with their ability to achieve academic success. One could also infer that an alarming number of students are at risk for suicide.
While previous studies have provided evidence that students who received counselling had a higher rate of academic retention than their non-counselled peers (Illovsky, 1997; Wilson, Mason, & Ewing, 1997; Turner & Berry, 2000), what has not been studied specifically is the academic progress and retention rate of a particular at-risk group, i.e. students who receive counselling for suicidal ideation.
The current study seeks to address this gap in the research by focusing on students who requested counselling assistance with regard to suicidal ideation and/or intentions during a five year period from September 1, 2004 to August 31, 2009. The purpose of this study was to: determine the number of students who presented to a college counselling centre with suicidal ideation during each academic year; obtain overall information about factors that contribute to each client’s risk of suicide; identify the types of interventions used by counsellors; and assess academic progress and retention rates for students who continued in their programs following intervention. For each client presenting to a counsellor with suicidal ideation, a Suicide Risk Assessment (SRA) protocol was completed. Counsellors used this protocol to assist in assessing risk, identifying deterrents, and recording interventions.
Based on previous findings of increasing student distress over time, it was expected that a trend of increasing numbers of suicide risk assessments would be evident over the five-year period studied. It was also expected that the majority of these clients would be retained (and continue into the next academic year) after they received the counselling supports and/or medical referrals required.
Participants were 153 students enrolled at a large community college (population 12, 128) for whom SRAs were completed by counsellors between September 1, 2004 and August 31, 2009. This included 99 (64.7%) females and 54 (35.3%) males. The mean age of clients was 23.7 years (SD = 5.99) with a range of 18-48 years.
Doctoral and Masters level counsellors and social workers, as well as supervised Masters level counselling psychology/social work interns, completed the SRA protocol with students and provided crisis, and possibly follow up, counselling services.
Data analysis was archival in nature and covered five academic years from 2004-2009. A list of students, for whom SRAs were completed during this period, was compiled from two separate counselling database systems. Paper SRA forms were pulled from individual files so that the following data could be coded and recorded: whether the student was reporting suicidal or suicidal and homicidal ideation; intensity of suicidal ideation (on a scale of 1-10); whether client had a previous experience of suicidal ideation and/or suicide attempt; if the client had a specific suicide plan in mind and if so, the availability of means to carry out that plan; and components of the intervention (i.e., safety plan, referral to hospital emergency room, referral to local Mental Health Crisis Service for assessment, referral to college health services, contact police and/or police Family Consultants, referral to family doctor, contacting family and/or friends to make them aware of situation, follow up counselling appointment). In order to assess the retention status of students, academic transcripts were obtained through the college’s academic records data system for the academic year of and following the students’ suicide risk assessments. Year over year retention was deemed to have occurred in cases where:
- A student successfully achieved their academic goal and graduated during the academic year being studied; or
- A student continued to be enrolled in full-time studies at the college during the following academic year (i.e., fall and/or winter semesters)
Student GPAs (Grade Point Average) during the academic year in which their SRA was completed (i.e. fall and/or winter terms), were also obtained via transcripts. Individual GPAs and client retention data were pooled across the time period studied.
Data was coded in such a way as to protect client confidentiality in final reports. This confidential data was viewed only by the researcher. Data was transferred to and analyzed via Excel and SPSS software programs.
During this five year period, counsellors completed 172 formal SRA protocols with 153 unique students. This worked out to an average of 34.4 assessments per year. Contrary to expectation, the number of assessments completed did not increase annually, but rather decreased over time with one inexplicable exception during the 2008-09 academic year. (See Figure 1).
Among the 153 students for whom SRAs were completed, 4 (2.6%) reported suicidal and homicidal ideation. On a scale of 1 to 10 (with 10 being the highest), mean intensity of suicidal ideation reported was 6.75 (SD = 2.56) with 54% (n = 73)1 of cases reporting an intensity score in the 7-10 range (See Figure 2). Intensity of suicidal ideation was not significantly related to retention (p = 0.34). Eighty per cent of SRAs (n = 137) recorded prior suicidal ideation, and 40% (n = 69) a prior suicide attempt by the student. Specific suicide plans were reported in 43% (n = 74) of SRAs, and availability of means to carry out suicide plans were recorded in 38.4% (n = 66) of the assessments. Intensity of suicidal ideation was significantly related to a prior suicide attempt (r = 0.20, p = .01), and to availability of means to complete suicidal plan (r = 0.23, p < .01).
Table 1 shows frequencies and percentages of specific counselling interventions utilized with students. Note that in some cases counsellors employed multiple interventions based on their assessment of client risk and potential deterrents.
Of these 153 individuals, 31 (20.3%) withdrew from their programs prior to the completion of their semester and deadline for withdrawing without academic penalty. (Thus no grades were recorded in their transcripts). Of the 122 students who chose to continue on with their studies, 33 graduated the same academic year in which they had been assessed, and 57 continued their studies into the academic year following their SRA. Focusing on the students who continued with their studies, 73.8% (n = 90) of this high risk group met the criteria for retention.
Among the 122 individuals who remained in their studies despite dealing with suicidal ideation, the mean Fall GPA = 2.66 (SD = 1.15), and mean Winter GPA = 2.70 (SD = 1.08). In this group 75.7% of students had GPA ≥ 2.0, and 42.1% had a GPA ≥ 3.0. (See Figure 3).
Contrary to the initial hypothesis, the number of suicide risk assessments completed over the 5 year did not increase markedly over time. In fact there appeared to be an annual decrease in SRAs completed until the fifth year during which, for some unknown reason, the numbers shot up by almost 100% over the previous year. This is different than the findings of Benton et al. (2003) who identified that reports of suicidal ideation tripled over a 13 year time period (1988-2001). More current research in this area, across a number of colleges, would be helpful in determining what the general trend is.
At an average of 34.4 SRAs completed per year, the counselling centre saw approximately 3 clients per month who were reporting suicidal ideation. Taking into account that the American College Health Association (2009) found that 9% of college students surveyed reported seriously considering suicide within the preceding year. The fact that the student population of the college studied is approximately 13,000, it would appear that the counselling office is potentially not connecting with almost 1000 students who are at risk. This is a source of concern. Why are we only seeing a small fraction of these at risk students? Future research in this area should focus on the general college population, and not only ask the question as to whether students have seriously considered suicide in the past year, but should also ask what deterred them from acting on these thoughts, whether they obtained professional assistance, and if not, why.
In over half of the cases, students reported a high intensity of suicidal ideation (i.e., rated between 7 and 10 on a scale of 1-10). Intensity of suicidal ideation was significantly related to whether a student had a prior suicide attempt. Similarly, Schwartz (2006) found that prior attempted suicide was the single most powerful predictor of completed suicide in that it increased chances of completed suicide for women sixtyfold and for men fortyfold. It seems to be the case, in a suicide risk assessment, that past behaviour is a good predictor of future behaviour. Information on prior suicide attempts appears to continue to be an essential question in assessing current risk.
The current study also found that intensity of suicidal ideation was significantly related to availability of means to complete a suicide plan. In these cases clients had given serious consideration not only to planning how to end their life, but also to ensuring that their plan was practical and that they had access to the means to carry out their plan. This amount of preplanning may well be a reflection of the level of pain and desperation experienced by clients, which is then reflected in the high levels of self-reported intensity/distress associated with suicidal ideation.
The two aforementioned factors (i.e., prior attempt and availability of means) may also thus be helpful predictors of suicide risk in those cases where students are unable or unwilling to quantify the intensity of their suicidal ideation, which in this study occurred in 21% of cases.
In terms of counsellor interventions, there were no predetermined plans of action. Counsellors assessed individual student risk and deterrents, checked into wait times for mental health crisis assessments/physician appointments, and set up interventions based on individual willingness to comply with referrals (in cases that weren’t imminent). In a few cases where the student was perceived to be at imminent risk of suicide, or suicide and homicide, and the student refused to go to hospital, police were contacted and intervened. Fortunately these were rare cases in which the threat to human life outweighed client confidentiality. In cases where risk was high but not imminent, a student could refuse to go to hospital. Instead the counsellor would work with the student to look at other feasible intervention options. Students might agree to see their family doctor or a campus physician, or to being assessed by the local mental health crisis service. In these cases, it sometimes took days or weeks to obtain an appointment. Depending on students’ relational dynamics, counsellors would often try to obtain informed consent to notify family and/or significant others of the student’s emotional state and need for additional support. In most cases, counsellors offered follow up counselling to students, so they could continue to provide them with professional support and information, as well as assisting them in developing coping strategies to get through the difficult times. Using the SRA process, counsellors sought not only to assess risk, but also to begin working with students to create a network of support to help them to get through.
One of the more hopeful aspects of the data is the number of students in this high risk client group who decided to continue their studies and were in fact quite successful, despite the challenges of suicidal ideation. Nearly 74% of those who chose to stay in school and deal with their issues medically and/or with counselling, either graduated that year or continued to be active in their studies into the next academic year. This group had GPAs that averaged above 2.6. This success rate appears to attest to the effectiveness of the protocol being used. Moreover, the fact that 47% of these students, who despite very serious personal challenges, achieved GPAs of 3.0 or above, speaks to the tremendous resiliency of this population when provided with the appropriate professional supports.
This current study is limited by the fact that it speaks to the experience of only one college counselling centre, and only involves students who presented with suicidal ideation. One wonders if it is possible that more of our clients experienced suicidal ideation, but because we may have neglected to ask, they did not tell us. It would also have been helpful to have spoken to a sample from the non-client student population, to find out what the prevalence of suicidal ideation was in that group and why they did not come to counselling.
At a time when mental illness seems to be at a chronically severe level among college students, there is something that colleges can do to help our most at-risk students to cope, heal, and rise above their challenges. Offering timely professional counselling services is vital, as is access to emergency mental health medical resources. With the current economic pressures, it is vital that these services not be decimated. With the appropriate interventions and supports, even highly suicidal students can move past their crises and achieve personal and academic successes.
At the same time, it appears that counselling services are only being accessed by a small number of at-risk students. We need to do a better job of making our services attractive and accessible to these students by reducing the stigma attached to mental illness, dispelling the myths of what counselling entails, and educating them regarding the practical and measurable benefits of using these services.
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Shirley Porter, is a registered social worker and a counsellor at Fanshawe College, London, Ontario. Her main areas of research interest include student mental health counselling, and trauma counselling for emergency responders. She may be contacted firstname.lastname@example.org