QPR SUICIDE PREVENTION TRAINING: A CALIFORNIA STATE UNIVERSITY, STANISLAUS STUDENTS PERSPECTIVE

Transcription

1 QPR SUICIDE PREVENTION TRAINING: A CALIFORNIA STATE UNIVERSITY, STANISLAUS STUDENTS PERSPECTIVE A Thesis Presented to the Faculty of California State University, Stanislaus In Partial Fulfillment of the Requirements for the Degree of Master of Social Work By Sara Ray December 2014

2 CERTIFICATION OF APPROVAL QPR SUICIDE PREVENTION TRAINING: A CALIFORNIA STATE UNIVERSITY, STANISLAUS STUDENTS PERSPECTIVE by Sara Ray Signed Certification of Approval Page is on file with the University Library Shradha Tibrewal, Ph.D Professor of Social Work Date Jennifer Johnson, MSW, LCSW Lecturer of Social Work Date

3 2014 Sara Ray ALL RIGHTS RESERVED

4 DEDICATION I dedicate this thesis, and the entirety of my education to my family. To my husband, you encouraged me, wiped my tears, kept my coffee supply stocked, and worked so hard to make sure this dream was achieved. To my children, you three are the reason I began this journey, your hugs, kisses, and snuggles kept me going. I promise to give you the best life possible and to be truly present with you always. To my friends and extended family who were always there with words of encouragement, coffee, or a cocktail and a hug. Last, but certainly not least, to my mother, you stepped in and gave us everything you could to make sure this dream was achieved. Not only did you become caregiver to my family, you dealt with my rants and breakdowns with the love that only a mother could have for her child. I love you. With this degree the cycle has been broken and our family patterns have been changed forever. I love you all, a bushel and a peck. iv

5 ACKNOWLEDGEMENTS I would like to express my sincere gratitude to Dr. Shradha Tibrewal for her continued support, help, and encouragement in this process. It wasn t always fun, but because you pushed me, I have written a thesis that can potentially help people. This is more than just words on paper, or in this case, on a computer screen, it s research supporting suicide prevention. Thank you. To Jennifer Johnson, thank you for helping me EVERY step along the way. With your guidance and support I have found a new passion. I believe that I can actually make a difference in the world. This thesis wouldn t have come to fruition without you. You are truly a marble jar mentor. Thank you. And finally, to Megan Rowe, you have been so helpful with always making time to help me with the things I needed for this research. If it weren t for you becoming a QPR certified trainer, and conducting the trainings I wouldn t have had the data I needed for this research. Please keep your passion for suicide prevention alive. Thank you. v

6 TABLE OF CONTENTS PAGE Dedication... Acknowledgements... iv v List of Tables... viii List of Figures... Abstract... ix x CHAPTER I. Introduction... 1 Statement of the Problem... 1 Statement of Purpose... 8 Significance of Study... 9 II. Literature Review Suicide Among College Students A Brief Overview of Suicide Prevention Suicide Prevention Skills Suicide Prevention Actions Suicide Prevention Trainings Question, Persuade, Refer, and CSU, Stanislaus III. Methodology Overview Research Design Sampling Plan Instrumentation Data Collection Plan for Data Analysis Protection of Human Subjects IV. Analysis Demographics vi

7 Results Suicide Prevention Skills Suicide Prevention Actions Summary V. Discussion and Conclusions Findings as They Relate to Literature Limitations Implications for Social Work Practice Recommendations for Future Research References Appendix: Evaluation of California s Statewide Health Prevention and Early Intervention Initiatives vii

8 LIST OF TABLES TABLE PAGE 1. Students Total Skills Mean Scores Before and After QPR Training Accessing Mental Health Resources viii

9 LIST OF FIGURES FIGURE PAGE 1. Ability to encourage a fellow student experiencing mental health distress to get professional help Ability to encourage a fellow student experiencing mental health distress to talk to friends or parents Ability to provide guidance and advice to a fellow student experiencing mental health distress, about how to help themselves Ability to take a fellow student, experiencing mental health distress, to a hospital, mental health center, or counselor Ability to ask a fellow student experiencing mental health distress specific questions to assess the level of distress or seriousness of the problem ix

10 ABSTRACT Suicide is the second leading cause of death among college aged individuals in the United States (CDC, 2014). In an effort to reduce suicide, the Question, Persuade, Refer (QPR) suicide prevention training is being offered to the faculty, staff, and students on the California State University, Stanislaus campus. The purpose of this research was to evaluate whether the students are gaining suicide prevention skills and increasing their ability to take action after receiving the QPR training. This research examined the perspectives of the 74 CSU, Stanislaus graduate and undergraduate students who received the QPR training. Data were obtained from surveys that were completed and collected at the QPR trainings. Univariate and bivariate analysis were conducted to examine the changes in suicide prevention skills and actions reported before and after the QPR training. There were significant increases in self-reported suicide prevention skills and actions after students received the QPR training. The research supports continuing to offer QPR training to CSU, Stanislaus students contributes to the suicide prevention efforts being made on campus. Future research should include follow up surveys including open-ended questions to find what might be done to improve the QPR training. x

11 CHAPTER I INTRODUCTION Statement of the Problem Suicide is a non-discriminant killer, affecting people from all races, religions, and economic statuses. According to The American College Health Association National College Health Assessment s (ACHA-NCHA) spring 2013 survey report, 1.5% of the 123,078 students who completed the survey had attempted suicide within the last 12 months, and 7.4% had seriously considered suicide (American College Health Association [ACHA], 2013). Suicide is the third leading cause of death of individuals ages in the United States, and the second leading cause of death of individuals ages (Center for Disease Control and Prevention [CDC], 2014). The prevalence of death by suicide in the United States is evident, its effects are widespread, costly, and long lasting. Suicide is much like a virus, affecting most everyone who comes into contact with it. The individual who has committed or attempted suicide is not the only victim, the families, friends, and the communities left behind are also emotionally affected by the loss. According to a research study done by Mitchell, Kim, Prigerson, and Mortimer-Stephens, the surviving children, parents, and spouses of a suicide suffer from complicated grief (2004). The Center for Complicated Grief describes complicated grief as an intense and long-lasting form of grief that takes over a person s life (What is Complicated Grief, para. 1). Individuals who have lost a 1

12 2 loved one to suicide are at increased risk for not just complicated grief, but for posttraumatic stress disorder, major depression, suicide, experience a high level of stigma, and may require specialized health care (Tal Young et al., 2012; Mitchell et al., 2004). Additionally, financial consequences of suicide are serious. According to the CDC, the cost of suicide, calculated by lost work and medical expenses, is approximately 34.6 billion dollars per year (CDC, 2005). When the high suicide rates, psychological, and financial costs of suicide are considered together, the problem of suicide in the United States is noticeable. The effects of suicide are serious. Although this data does not isolate the effects on college students in particular, the seriousness of the effects of suicide in relation to college students can be made by considering the increased risk of the college population. In order to gain a better understanding of the attitudes about suicide and the particular perceptions of suicide on college campuses several studies have been conducted. Westfield et al., surveyed 1,865 university students in 2002 and 2003 on their perceptions of suicide (2005). Of the students surveyed, 24% had contemplated attempting suicide, 9% had threatened suicide, and 1% had attempted suicide (Westfield et al., 2005). When asked the reasons for attempting suicide the students in this survey indicated that contributing factors were; school related stress, relationship trouble, problems with family, depression hopelessness, anxiety, financial stress, feeling socially isolated, work problems, an exposure to trauma, drugs, alcohol, and other (Westfield et al., 2005). Additionally, the Diagnostic and

13 Statistical Manual of Mental Disorders-5, (American Psychiatric Association [APA], 2013), reports that: Suicidal behavior is seen in the context of a variety of mental disorders, most commonly bipolar disorder, major depressive disorder, schizophrenia, schizoaffective disorder, anxiety disorders (in particular, panic disorders associated with catastrophic content and PTSD flashbacks), substance use disorders (especially alcohol use disorders), borderline personality disorder, antisocial personality disorder, eating disorders, and adjustment disorders. (p. 803) 3 Although, age of onset of the above mentioned mental disorders varies, they commonly begin to manifest themselves in the early teens and through the late twenties, (APA, 2013). Moreover, the ACHA-NHCHA II survey data report that 45% of the students surveyed reported feeling hopeless, 79.1% exhausted, and 59.6% very sad, which are all symptoms used to diagnose major depressive, both bipolar I, and bipolar II disorders (ACHA, 2013; APA, 2013). This is not to say that all students who feel hopeless, exhausted, or sad will attempt suicide, however, it does support the assumption that many college students experience these feelings which correlate with an increased risk of suicide. Additionally, the developmental changes that college students often encounter can contribute to suicidal risk. A traditional college aged individual begins to experience a time of separation from family and social groups as well as psychological and existential transitions (Westfield et al., 2006). The age of onset of the mental disorders associated with suicidal behaviors, combined with feelings of hopelessness, exhaustion, sadness, and

14 4 the many changes being experienced at this time in life, provides support that college aged individuals may be at an increased risk for suicide. College students are at risk of contemplating or attempting suicide, but many do not seek help from suicide prevention resources, or even know that help is available to them. Westfield et al. report that only 26% of the 1,865 students surveyed were aware of suicide resources available to them (2005). A research study by Drum, Brownson, Denmark and Smith found that of 26,451 college students surveyed, 1,421 reported that in the previous 12 months they had seriously considered suicide (2009). Drum et al. found that 43% of the students reporting having seriously considered suicide told someone about their feelings, two thirds of them told a peer, and almost no undergraduates and not a single graduate student confided in a professor (2009, p.6). Of the students who did confide in a peer, only 52% were guided to seek professional help (Drum et al., 2009). The small percentage of students reporting knowledge of the available campus suicide prevention resources, coupled with the fairly large percentage of individuals confiding in peers exhibits a clear need to offer suicide prevention training to the entire campus community, including students. Although suicide prevention has begun to gain attention on college campuses in recent years, suicide prevention is not a new concept in the United States. Suicide prevention in the United States began with the opening of the first suicide prevention center in Los Angeles, California in 1958

15 5 (Office of the Surgeon General (US); National Action Alliance for Suicide Prevention (US). [US Surgeon General et al.], 2012, p. 96). Nine years later, in 1968, the Center for Studies of Suicide Prevention was established by the National Institute of Mental Health, or NIMH (US Surgeon General et al., 2012, p. 94). In 1996 grassroots groups, following the guidelines of the United Nations, developed the National Strategy for Suicide Prevention (US Surgeon General et al., 2012, p. 95). This lead to Congress passing a resolution recognizing that suicide is a national problem, making suicide prevention a national priority. The recognition of suicide as a national problem prompted groups to begin to address this problem throughout the United States. The need to address the problem of suicide in the United States in turn prompted the need for guidelines and funding to be allotted to this particular field of research, therefore, federal and state acts begin to be enacted. Perhaps one of the most significant pieces of federal legislation, pertaining to suicide prevention on college campuses, to be enacted is the Garret Lee Smith Memorial Act (GLSMA). Passed in 2004, this act established a federal grant program intended for suicide prevention (US Surgeon General et al., 2012, p. 98). This Act is the result of a parent s need to make changes in the current understanding of suicide and the need for preventative measures. The GLSMA provides grant money to eligible institutions of higher education, states, tribes, and territories to fund suicide prevention efforts (US Surgeon General et al., 2012, p. 98). Nine GLSMA grants have been awarded to California colleges and universities.

16 6 The GLSMA federal grant comes on the heels of California Proposition (prop.) 63. California Prop. 63, also known as, the millionaire s tax, or the Mental Health Services Act, was passed in November 2004, became effective in 2005 and was perhaps the most influential piece of legislation to address mental health and suicide prevention in recent California history. The monies generated from this tax are allocated to county mental health programs and mental health prevention and early intervention programs (California Department of Health Care Services [CDHCS], 2014). These prevention and early intervention programs are dedicated to reduce mental health stigma and discrimination, as well as prevent mental health crises (CDHCS, 2014). The California State University system received a grant funded by Prop. 63 in the amount of 6.9 million dollars to be used on each CSU campus for: 1) curriculum development and training, 2) peer-to-peer support programs, and 3) suicide prevention (Smith, Quillian, Murillo, & Johnson, 2013, p. 3). California State University, Stanislaus currently receives funding under the CalMHSA grant and has used some of this funding to offer suicide prevention trainings (California State University Stanislaus Peer Project, ND; J. Johnson, personal communication April 1, 2014). One suicide prevention training being offered at California State University, Stanislaus is the Question, Persuade, Refer (QPR) training intervention, developed in 1995 by Dr. Paul Quinnett (Quinnett, 2012). This intervention trains individuals to recognize specific suicidal behaviors, question the individual in a productive way, and then, if the individual is suicidal, to refer the individual to an appropriate

17 7 resource. The training itself is approximately 60 to 90 minutes in length making it relatively brief to fit into busy schedules. QPR is being offered to individuals in various fields of work, but the focus has been on training gatekeepers. A gatekeeper is considered any person who may come into contact with a distressed individual and includes teachers, school personnel, clergy, police officers, primary health care providers, mental health care providers, correctional personnel, and emergency health care personnel (Quinnett, 2012, p. 3). QPR is considered an evidenced based practice by the National Registry of Evidence-based Practices and Policies (NREPP) (NREPP, nd). Several research studies have supported the efficacy of QPR training. One such study by Mitchell et al. examined the short and long term effects of the QPR training within a campus community (2013, p.6). In this particular study the participants completed the survey pre, post, and 3 to 6 month following the training and included students, staff, faculty, and other community members. (Mitchell et al., 2013). This study found that participants showed an increase in the knowledge of the warning signs of suicide, how to ask someone about suicide, persuading someone to get help, how to get help for someone, and local resources with suicide from preand post-test, and at the 3 to 6 month follow up (Mitchell et al., 2013, p.9). Additionally, after receiving the training, participants reported they would be more likely to ask someone if they were suicidal, help a person get help, refer a person to the proper resource, call a resource, or accompany a person to get help, than they were before receiving the training (Mitchell et al., 2013). However, this research study found that although knowledge of suicide facts increased at the post-test, there

18 8 was a significant decrease between post-test and the 3 to 6 month follow up (Mitchell et al., 2013). Several other research studies have supported the efficacy of QPR training for increasing suicide prevention skills and knowledge (Indelicato, Mirsu- Paun, & Griffin, 2011; Jacobson, Osteen, Shapre, & Pastoor, 2012; Tompkins & Witt, 2009). The brief nature of this training coupled with the evidence supporting the efficacy may be the reason QPR is gaining popularity. QPR is currently one of the suicide intervention training programs being utilized on the CSU, Stanislaus campus. The goal of this study was to examine the change in suicide intervention skills and actions of the students of CSU, Stanislaus who have received the QPR training. The information gathered in this research has the potential to support further QPR trainings on the CSU, Stanislaus campus. Statement of Purpose The purpose of this study was to assess the change in the suicide intervention skills and suicide intervention actions of CSU, Stanislaus students who received the QPR training. This descriptive research study examined quantitative data previously collected by QPR trainers, via surveys, from students who received the QPR training from a CSU, Stanislaus mental health professional and the health educator. The surveys were collected from trainings offered September through December These surveys were developed by the Rand Corporation for the California Mental Health Services Act (CalMHSA) to assess the changes in college students suicide intervention skills and actions in a pre-test, post-test comparison, using a post-test only survey.

19 9 The two questions guiding this survey were: 1) Are there any changes in suicide prevention skills and knowledge after a college student receives QPR training? 2) Do college students feel better equipped to take action if there is a perceived mental health distress after receiving the QPR training? The assumption of this study is that students who have received QPR training will feel that they have gained suicide intervention skills, and they will feel more prepared to take action if they perceive an individual may be at risk of suicide. Significance of Study The research can potentially provide support that individuals who take the QPR training are gaining suicide prevention and intervention knowledge and skills. This study hopes to provide research to support continued suicide prevention and awareness trainings on the CSU, Stanislaus campus. Offering QPR training can assist in increasing suicide and mental health awareness (Indelicato et al., 2011; Jacobson et al., 2012; Mitchell et al., 2013; Tompkins & Witt, 2009). At this point, QPR is being offered to CSU, Stanislaus campus community and the effectiveness, in relation to this specific community is not known. This research aimed to identify the effectiveness of the QPR training and address the ways to increase suicide prevention in the most effective way. The goal of this research is to support suicide prevention efforts on the CSU, Stanislaus campus by continuing to offer the QPR training to the student population, as well as, faculty and staff. By providing research supporting the effectiveness of QPR training this research may be helpful in accessing funding to continue offering QPR training on this campus. Furthermore, if this research

20 10 indicates that QPR is effective in increasing suicide prevention skills and actions, it would be beneficial for the Master of Social Work (MSW) program to offer this training to all of the students in this program. Because MSW students work within the community, they should be prepared to intervene with suicidal individuals. Therefore, this training, if effective, should be offered as a part of the MSW program. This can increase suicide awareness and prevention on the CSU, Stanislaus campus and in the community as well. It is also important to consider that as more individuals become trained in recognizing potentially suicidal behaviors, the greater the chance of decreasing death from suicide, not just in educational institutions but in the entire community.

21 CHAPTER II LITERATURE REVIEW College campuses and universities in the United States have recognized suicide among the student population is a problem. Research is discovering the extent of this problem, some of the factors that may be contributing to suicide among college students, and the important role that peers can play in the reduction and prevention of suicide. It is essential to fully understand, not only the extent of the problem of suicide among college students, but the evolution of suicide prevention in the United States, and how, what, and who to train in order to develop strong suicide prevention efforts among college and university campuses. This literature review will present some of the literature that describes suicide rates among college students, the evolution of suicide trainings to include college students, the important role of student peers in suicide prevention efforts, the skills and actions that need to be learned to assist in preventing suicide, and the trainings that teach these skills and actions. Suicide Among College Students Data on the college aged population report that suicide is the second leading cause of death of individuals between the ages of 10 and 24 years (CDC, 2014). The average age of college students is between 18 and 24 years (American College Health Association-National College Health Assessment [ACHA-NCHA], 2013). Westfiled et al., surveyed 1,865 students at four large United States universities and found that 11

22 12 42% either agreed or strongly agreed that suicide was a problem on their college campus (2005). This research also found that 40% of the sample had known someone who had attempted suicide. 28% had known someone who had completed suicide. 4% had thought about attempting suicide. 9% had made a suicidal threat. 5% had attempted suicide. (Westfield et al., 2005, p.3) Similar research by Drum et al. randomly selected and surveyed 26,451 graduate and undergraduate students from 70 participating college and university campuses (2012). This research found that six-percent of undergraduates and four-percent of graduate students reported that they had seriously considered suicide within the past 12 months, and 37% of undergraduate and 28% graduate students had gone so far as to make preparations to take their own lives (Drum et al., 2012). The culmination of the data suggests that college students may be at particular risk for attempting or completing suicide. The research by Drum et al., Westfield et al., along with the statistics from the CDC and ACHA-NCHA may be what has spurred college university campuses to begin to develop and implement suicide prevention programs (Drum et al., 2012; Westfield et al., 2005, CDC, 2014, ACHA-NCHA, 2013). A Brief Overview of Suicide Prevention The initial and driving force behind suicide prevention did not begin specifically targeting college students. In fact, the United States began to recognize suicide as a problem in 1958 with the first suicide prevention center opening in Los Angeles, California in 1958 (US Surgeon General et al., 2012, p.10). With little funding and support, grassroots organizations, many consisting of survivors of

23 13 suicide, continued to push for the problem of suicide to be recognized on the national agenda (US Surgeon General et al., 2012, p. 96). The hard work and motivation of these grassroots organizations paid off in 2001 with the first National Strategy for Suicide Prevention (US Surgeon General et al., 2012, p. 96). While national recognition was the goal, many of these efforts contributed to additional grassroots organizations gaining attention, rallying for changes in legislature, or for new legislature to be passed. The recognition of suicide as a national problem may have allowed some of the grassroots organizations to focus their attention on college and university campuses specifically. In 2012, the National Strategy for Suicide Prevention was revised to include 13 updated goals and 60 updated objectives to create more opportunities for suicide prevention (US Surgeon General et al., 2012, p. 17). One of the developments, and the one most pertinent to suicide reduction on college campuses, is to provide Increased knowledge of the types of interventions that may be most effective for suicide prevention; and an increased recognition of the importance of implementing suicide prevention efforts in a comprehensive and coordinated way (US Surgeon General et al., 2012, p.11). The comprehensive way the National Strategy for Suicide Prevention is approaching suicide prevention recognizes the importance of training more than just mental health, and medical providers on suicide prevention techniques and specifically includes educational institutions. The revised National Strategy for Suicide Prevention includes community, educational institutions, family, friends, and more as key players in the effort to prevent suicide (US Surgeon General et al., 2012, p. 11).

24 14 The Role of Peer Students in Suicide Prevention Efforts The importance of providing suicide prevention training to peer students becomes evident when examining research identifying the individuals to whom a suicidal student might disclose this information. Drum et al. s study on the suicidal crises among college students found compelling data supporting the need to train peers (2009). This research found that, of the six percent of undergraduate and four percent of graduate students who reported having suicidal thoughts or serious ideation within the past 12 months, 52% told another person about these thoughts (Drum et al., 2009). Interestingly, of the college students who did disclose suicidal ideation, two thirds first disclosed to a peer (Drum et al., 2009). Statistically, over half of the college students who disclose suicidal ideation are disclosing to a peer, supporting the idea that student peers are a critical population on whom to focus suicide preventions efforts (Drum et al., 2009). Not only are suicidal individuals more likely to disclose to peers, but peers may have a clearer understanding of the current pressures and stresses of college life. Additionally, the support individuals either do or do not receive from peers can play an important role in either contributing to or deterring their suicidal thoughts (Bertera, 2007). Positive peer support can contribute to a reduction in suicide among college students (Bertera, 2007). The transition into college can be exceptionally difficult, the college student may be leaving family and high school support groups leading to feelings of loneliness, stress, and isolation (Westfield et al., 2006). The intention of the transition to college life is to create new avenues of support and for the individual

25 15 to begin to demonstrate more independence (Westfield et al., 2006). However, this demonstration of independence does not always go as smoothly as expected, which may result in the student feeling more isolated than independent. The importance of gaining positive support from peers, in this challenging transitional time of a person s life, is connected to a reduction in suicidal ideation and attempts. Bertera s research, on adolescents ages 15-19, found that suicidal ideation was lower in adolescents with positive social support than those experiencing negative social interactions (2007). Similarly, Westfield et al. found that one of the most important factors protecting against suicide among college students is social support (2006). The role of peers and positive peer interactions is important in reducing suicide on college campuses. The literature is indicating that college students most often disclose suicidal thoughts to peers, and that positive peer support can reduce suicide. The peer receiving the information needs to know what to do in a situation where a friend is disclosing suicidal thoughts, or intentions. Westfield et al. (2005) surveyed 1,865 students from four universities located in the Midwest, southeast, and south central United States. The survey questions were open-ended and multiple choice. Participants were of varied religions, cultures, and college majors; 68% were male, and 32% female (Westfield et al., 2005). Westfield et al. s, research found that of the 1,865 college students surveyed, only 26% knew about suicide prevention resources available to them. Cerel, Bolin, and Moore (2013) surveyed 1,000, randomly selected, students from the University of Kentucky and found that 51% of the 1,000 students surveyed strongly agreed, (on a Likert scaled question), that they would

26 16 likely use a crisis hotline to seek help. In their study, Cerel et al. (2013), found that of the students surveyed 33% strongly agreed that they would know if a friend was experiencing suicidal ideation, and 73% strongly agreed they would be likely to seek help from other friends. Students in both studies have reported that they are aware of the problem of suicide, but did not feel it was a problem on their specific college campus (Cerel et al., 2013; Westfield et al., 2005). While the research is indicating that students most often seek help form peers, their peers may not know how to get them the help that they need, using campus resources. Following the recommendations from the 2012 National Strategy for Suicide Prevention suicide prevention, efforts include providing supportive environments in the community and schools, as well as fostering a feeling of connectedness to individuals, communities, and social institutions (US Surgeon General et al., 2012, pg. 15). The National Strategy for Suicide Prevention, reports that if the community receives suicide prevention training, it can reduce prejudice about suicide and mental health disorders; which can allow the individual suffering to feel more comfortable disclosing suicidal ideation to others (US Surgeon General et al., 2012, p. 12). The community, in respect to college campuses includes students, or peers, as well as, faculty and staff. While Drum s 2009 research showed that fifty-two percent of the individuals reporting they had seriously considered suicide had disclosed their feelings to a peer, forty-eight percent did not disclose their feelings (p.218). According to the 2012 National Strategy for Suicide Prevention positive relationship building and general health promotion efforts are important in suicide prevention (US

27 17 Surgeon General et al., 2012, p. 21). Suicide prevention is everyone s business (US Surgeon General et al., 2012, p. 21), including student peers on college campuses. In order to provide suicide prevention training to peer students we need to understand what to teach. Suicide Prevention Skills Identifying the risk factors, or factors contributing to suicide contemplation, is a skill helpful to suicide prevention. Although the factors contributing to an individual seriously considering suicide are unique to them, there are warning signs that some suicidal individuals may display (US Surgeon General et al., 2012, p. 12; "Suicide Warning Signs," 2014; "Suicide: A Major, Preventable Health Problem Factsheet," n.d; "Know the Warning Signs of Suicide," 2014). Some of the contributing factors were mentioned earlier in this review of the literature, such as; the difficult transition period of going to college and negative peer support. Drum et al., found that for the college students reporting that they had seriously considered suicide, the following events impacted their suicidal thoughts; (listed in order from most reported to least) emotional or physical pain, romantic relationship problems, impact of wanting to end life, school, friend, family, and financial problems, showing others the extent of their pain, punishing others, alcohol and drug problems, sexual assault, and relationship violence (2009). Students reporting a suicide attempt indicated the following as contributing to their attempt; stress related to school, trouble with relationships, family problems, depression, hopelessness, anxiety, financial stress, feelings of social isolation, problems with work, exposure to trauma,

28 18 involvement with drugs, alcohol and other (not specified) (Westfield et al., 2005). The problems identified as contributing to an individual s suicide attempt or ideation are issues that many college students report they are having. In fact, the American College Health Association National College Health Assessment s (ACHA-NCHA) Spring, 2013 report found that 45% of the students surveyed reported feeling hopeless over the previous 12 months; 55.9% felt very lonely, 59.6% felt very sad, 31.3% had difficulty functioning because they felt so depressed, 41.7% felt more than average stress, and 10.3% reported that they felt stress tremendously (ACHA-NCHA, 2013). Additionally, 7.3% reported financial and 9.7% relationship difficulties significant enough to impact academic performance (ACHA-NCHA, 2013). College students also reported what could be perceived as a traumatic event, either physically or sexually, with 57.6% reporting a variety of emotional assaults, physical and sexual assaults, or attempted physical or sexual assaults (ACHA-NCHA, 2013). The things that college students reported to contribute to their suicide attempt or contemplation are important to recognize as possible warning signs, or risk factors. The skills for suicide prevention include recognizing that a peer is exhibiting some warning signs or has some of the risk factors associated with suicide contemplation or attempt (Quinnett, 2012). Suicide risk factors or warning signs include, but are not limited to, the following; talking about killing one s self, feeling hopeless, withdrawal, increased substance use, depression, anxiety, recklessness, feeling purposeless, previous suicide attempt, isolation, mood swings, and family history of suicide. The recognition of the warning signs of suicide is an important

29 19 suicide prevention skill (US Surgeon General et al., 2012, p. 12; "Suicide Warning Signs," 2014; "Suicide: A Major, Preventable Health Problem Factsheet," nd; "Know the Warning Signs of Suicide," 2014). In addition to recognizing suicide warning signs or risk factors, the individual involved in the suicide prevention effort should have access to and be able to identify mental health resources (US Surgeon General et al., 2012, p. 15). Suicide Prevention Actions Training students to identify suicidal behaviors is helpful, but training peers on how to assist them in getting a suicidal individual to the proper treatment resource should be provided (Quinnett, 2012). The suicide prevention actions, for the purpose of this research, is the action of getting a suicidal individual to a treatment resource. Getting a suicidal individual to accept help or to go to a mental health care practitioner or facility may require persuasion (Quinnett, 2012). Effective suicide prevention according to research done by Schwartz-Lifshitz, Zalsman, Gliner, and Oquendo, should include not only identification methods, but treatment as well (2012). This means that college students who are being trained to recognize suicide risk warning signs, also need to be trained on the treatment facilities available on their campuses and within their communities, as well as some effective persuasion methods (Quinnett, 2012). This treatment includes psychotherapy, which is available on most college campuses in the form of counseling services (Schwartz-Lifshitz et al., 2012). The implication is that college and university campuses should be

30 20 implementing trainings that incorporate teaching the students to identify warning signs and effectively assist in obtaining treatment for the suicidal individual. Suicide Prevention Trainings Many suicide prevention trainings have been developed. In fact, according to The Suicide Prevention Resource Center, there are 23 suicide prevention trainings that are considered evidence based, and 94 that are included in their best practice registry (Suicide Prevention Resource Center [SPRC], 2012). The evidence based listing means that the training has met the Substance Abuse Mental Health Services Administration s (SAMHSA) National Registry for Evidence-based Programs and Practice s (NREPP) guidelines to be considered an evidence-based program or practice (SPRC, 2012). In order to be considered evidence based the practice must have gone through rigorous evaluation for effectiveness (SPRC, 2012). Additionally, the listing under SPRC s best practice registry means that the training was evaluated to meet criteria stating that this practice is based on the best research and expertise available (SPRC, 2012). Many of these SPRC endorsed suicide prevention trainings are specifically developed for targeted populations such as; American Indians, adolescents, high school, middle school, military, emergency room, elderly, families, and college populations (SPRC, 2012). Only one of these suicide prevention trainings, the Kognito At-Risk for College Students, targets college students specifically. Kognito Interactive has developed several suicide prevention training models, one of which has been developed specifically to educate college students. The

31 21 Kognito At-Risk for College Students is a gatekeeper training offered online, providing 30 minute simulations using avatars (Kognito, 2013). The National Strategy for Suicide Prevention defines a key gatekeeper as people who regularly come into contact with individuals or families in distress.key gatekeepers interact with people in environments of work, play and natural community settings and have the opportunity to interact in other than medical settings (US Surgeon General et al., 2012, p. 78). During the simulation the individual receiving the suicide prevention training participates interactively with an avatar who demonstrates suicidal ideation (Kognito, 2013). The participant is trained to recognize the suicidal warning signs, learns appropriate trust building skills, and effective means of referral (Kognito, 2013). Kognito At-Risk for College Students was developed in 2012, and by May, 2013, had been implemented in 250 colleges in the United Stated, the United Kingdom, Canada, and Australia (Kognito, 2013). In California, the Kognito At-Risk for College Students has been adopted by 112 community colleges, and seven California State Universities (B. Rigoli, personal communication, August 26, 2014). While the Kognito At-Risk for College Students suicide prevention training does provide suicide prevention skills, such as identifying the individual as having suicidal thoughts or intentions, and referring the individual to the appropriate resource to get help, it s audience is specific to only college students. Additionally, this training is costly, Brandon Rigoli from Kognito Interactive quoted the cost for an institution with a student body of six to eight thousand to be $ per year. This training is offered online only, the college or university purchases the rights to the program, and

32 22 the students have access to the account to participate in the training with a code that is given to the institution (B. Rigoli, personal communication, August 26, 2014). There is a training available for faculty and staff through Kognito, however, the training module and cost is separate from the student version (B. Rigoli, personal communication, August 26, 2014). The Kognito At-Risk for College Students is an effective suicide prevention training, but California State University, Stanislaus has chosen not to use this specific training (J. Johnson, personal communication, August 28, 2014). Question, Persuade, Refer and CSU, Stanislaus An additional suicide prevention training that has been endorsed by the SPRC is the Question, Persuade, Refer or QPR (SPRC, 2012). QPR is a training that has been developed to train individuals on the ways to recognize that an individual may be at risk of suicide through questioning and or effective listening, and to assist in getting a suicidal individual the help they need (Quintette, 2012). The goal of QPR is to enhance the probability that a potentially suicidal person is identified and referred for assessment and care before an adverse event occurs (Quinnett, 2012, p. 3). QPR is available as a 60 to 90 minute face-to-face training, or institutions may purchase an online version (QPRinstitute, 2011). An individual may become a certified trainer through the QPR institute, then they can teach the training to any number of individuals who would like to participate (QPRinstitute, 2011). The cost to become a certified QPR trainer is $ per certification, which is significantly less than the Kognito At-Risk for College students. After receiving the QPR trainer certification,

33 23 the trainer is free to present the material to any population interested in attending (K. White, personal communication, August 27, 2014). The QPR training is not specifically for college students, but designed to be effective in most populations (QPRinstitue, 2011). This makes the face-to-face version of the QPR training cost effective as well as accessible. The online version of the training works differently, the institution purchases a determined number of codes at a cost per code, the cost is determined by the number purchased (K. White, personal communication, August 27, 2014). QPR is supported by the SPRC s best practice registry, SMAHSA s National Registry for Evidence-based Programs and Practices (NREPP), and it also meets the National Strategy for Suicide Prevention s (NSSP) 2012, goals and objectives for actions (US Surgeon General et al., 2012). The support of the NREPP and SPRC s best practice registry indicates that QPR training has been researched and proven to be an effective, evidence supported suicide prevention training. In research evaluating QPR among 10 high schools and 6 middle schools, Wyman et al. (2008) found that QPR training had a positive impact on the staff s perception of and ability to perform the role of a gatekeeper. QPR training was also found to increase participants ability to identify risk factors and warning signs of suicide (Wyman et al., 2008). Additionally, Wyman et al. s research found that the staff questioned more students about possible suicide ideation after receiving the QPR training (2008). Wyman et al. conducted this research with a randomized control sample, the intervention group did receive the QPR training and the control group did not (2008). The intervention group included 112 participants consisting of, teachers,

34 24 administrators, social service, health service, and support staff (Wyman et al., 2008). Cross et al. s observational research involving 50 university employees results were similar to that of Wyman et al. s 2008 findings (2010). This research included participants from five different Universities, and concluded that participants increased their ability in asking about suicide ideation, increased their ability to persuade a suicidal individual to get assistance, and made an efficient referral to a helpful resource after receiving the QPR training (2010). Additional research supports that brief gatekeeper training programs improve suicide knowledge and attitudes with school personnel and parents (Cross et al., 2011; Tompkins, Witt, & Abraibesh, 2010). While offering QPR to school personnel improves their suicide knowledge, this research is interested in the effectiveness of the QPR training among college and university students. Research including college students did find that the QPR suicide prevention training had a positive impact on suicide prevention knowledge (Sharpe, Jacobson- Frey, & Osteen, 2014; Jacobson et al., 2012; Tompkins & Witt, 2009). Jacobson et al. s research among Master of Social Work Students from University of Maryland s, Baltimore School of Social Work found that the 38 students who received the QPR training showed greater improvement in suicide prevention knowledge including, ability to recognize suicide warning signs, and ability to intervene (2012). In follow up research, eight social work students were asked open-ended questions about their perspectives of the QPR training (Sharpe et al., 2014). Sharpe et al. s research found that the eight master of social work students whom they interviewed reported that the

35 25 QPR training not only helped them to increase their ability to recognize and intervene with suicidal individuals, but also increased their confidence to identify and work with suicidal individuals (Sharpe et al., 2014). Additionally, Sharpe et al. s research found that the QPR trained social work students had used the skills that they gained from QPR to intervene with suicidal clients (Sharpe et al., 2014). The research with the social work students paralleled research done with 204 resident advisors, indicating that after the QPR training, the ability to identify suicide warning signs, question a suicidal individual about suicide, and persuade a suicidal individual to seek help increased after the training. The research among social work students and resident advisors demonstrates that students also report increased suicide prevention knowledge, and ability to intervene after receiving the QPR training. With evidentiary support, QPR has been adopted by 264 institutions of higher education in the United States and Canada (K. White, electronic communication, August 27, 2014). California State University, Stanislaus has adopted the QPR training and does have certified trainers offering this training on the campus. According to the program coordinator of the Peer Project of California State University, Stanislaus, Jennifer Johnson, LCSW, the reason QPR training was chosen over other suicide prevention trainings was based on the length of the training, and the status of evidence-based practice (J. Johnson, electronic communication, August 15, 2014). Offering QPR training allows California State University, Stanislaus to provide any student, staff or faculty member to participate in the training, and become prepared to handle a situation in which an individual is presenting suicidal risk signs.

36 26 Offering suicide prevention trainings on college and university campuses can help to not only possibly save the life of a student, but can help with mental health and suicide stigma reduction providing a healthier college or university community. Therefore, this research examined the self-reported changes in suicide intervention skills and ability to take action of individuals who participated in the QPR training on the CSU, Stanislaus campus

37 CHAPTER III METHODOLOGY Overview The purpose of this quantitative research was to examine the self-reported changes in suicide intervention skills and ability to take action from pre-training to post-training of a Suicide Prevention program. This study examined surveys completed by students who received QPR training through California State University, Stanislaus. The overarching research questions guiding this study were: 1) Are there any changes in suicide prevention skills after a college student receives QPR training? 2) Do college students feel better equipped to take action if there is a perceived mental health distress after receiving the QPR training? Research Design This quantitative, descriptive, research design examined surveys that were given to students after receiving the QPR training from a mental health professional and the health educator at California State University, Stanislaus. The research design is considered descriptive because it refers to the characteristics of a population; it is based on quantitative data obtained from a sample of people that is thought to be representative of that population (Rubin & Babbie, 2011, p. 134). Specifically, this study describes the suicide prevention knowledge and suicide prevention skills among students who received the QPR training and subsequently filled out the surveys. The students who received the QPR training were recruited 27

38 28 either via general invitation for the entire CSU, Stanislaus division of enrollment and student affairs, or invited as a resident advisor. Additionally, a class of master of social work students also received the training. The survey included 14 Likert scale questions, supporting the quantitative nature of the design. Sampling Plan In this study a non-probability, convenience sample was utilized. This type of sample was chosen due to the availability of the data. In this case, the sample population refers to students who received the QPR training from a mental health professional and the health educator and promoter September through December of 2013, at California State University, Stanislaus, and subsequently filled out the survey. The students who completed the QPR training and survey were graduate and undergraduate students from CSU, Stanislaus. The surveys did not contain any personal identifying information, but include the student s graduate or undergraduate status. Convenience sampling or availability sampling is defined by Rubin and Babbie (2011) is A sampling method that selects elements simply because of their ready availability and convenience (p. 617). The sample size was 74 completed surveys. The researcher obtained permission from the California State University Chancellor s office to use the surveys for the purpose of research. Instrumentation The survey used for this data collection was designed by the RAND Corporation. The skills being measured in this research are separated into five questions on the survey. The five questions in the skills category are as follows: 1.