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College Student Suicide: A Call to Action

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Title: College Student Suicide: A Call to Action
Language: English
Authors: Westefeld, John S., Button, Christopher, Haley, James T.
Source: Death Studies. Dec 2006 30(10):931-956.
Availability: Routledge. Available from: Taylor & Francis, Ltd. 325 Chestnut Street Suite 800, Philadelphia, PA 19106. Tel: 800-354-1420; Fax: 215-625-2940; Web site: http://www.tandf.co.uk/journals/default.html
Peer Reviewed: Y
Page Count: 26
Publication Date: 2006
Document Type: Journal Articles
Reports - Evaluative
Education Level: Higher Education
Descriptors: Suicide, College Students, Risk, Legal Problems, Prevention, Intervention, Counselor Training, Counseling Services, Influences
ISSN: 0748-1187
Abstract: This article examines current issues related to the topic of college student suicide and why it continues to be an issue of major concern. The nature/extent of the problem, risk and protective factors, responses to college student suicide, legal issues, and training issues are discussed. The importance of addressing the issue of college student suicide and its prevention on college campuses is emphasized as is the importance of protective factors. Although more is being done to address this issue than has been done in the past, it remains a major concern, and it is an issue that requires a strong national response.
Abstractor: Author
Number of References: 68
Entry Date: 2007
Access URL: https://taylorandfrancis.metapress.com/link.asp?id=NX7XH712LQ041881
Accession Number: EJ753377
Database: ERIC
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  Value: <anid>AN0022493957;dea01dec.06;2019Mar28.13:32;v2.2.500</anid> <title id="AN0022493957-1">College Student Suicide: A Call To Action. </title> <p>This article examines current issues related to the topic of college student suicide and why it continues to be an issue of major concern. The nature/extent of the problem, risk and protective factors, responses to college student suicide, legal issues, and training issues are discussed. The importance of addressing the issue of college student suicide and its prevention on college campuses is emphasized as is the importance of protective factors. Although more is being done to address this issue than has been done in the past, it remains a major concern, and it is an issue that requires a strong national response.</p> <p>Suicide on college campuses in the United States has been an issue of great concern for many years. (e.g., Kraft, [<reflink idref="bib31" id="ref1">31</reflink>]; Westefeld & Furr, [<reflink idref="bib60" id="ref2">60</reflink>]; Westefeld et al., [<reflink idref="bib63" id="ref3">63</reflink>]; Westefeld, Whitchard, & Range, [<reflink idref="bib65" id="ref4">65</reflink>]). The death rate of suicide among college students has been found to range from 5.6/100,000 (Kraft, [<reflink idref="bib31" id="ref5">31</reflink>]) to 7.5/100,000 (M. M. Silverman, Meyer, Sloane, Raffel, & Pratt, [<reflink idref="bib53" id="ref6">53</reflink>]). This compares with an overall rate of 13.6/100,000 among 15–24 year olds in 1994 and 9.9/100,000 in 2002 (National Center for Health Statistics, n.d.). As far as attempts are concerned, the rate among college students has ranged from 1% (Furr, Westefeld, McConnell, & Jenkins, [<reflink idref="bib16" id="ref7">16</reflink>]) to 1.5% (CDC, [<reflink idref="bib10" id="ref8">10</reflink>]; Kisch, Leino, & Silverman, [<reflink idref="bib28" id="ref9">28</reflink>]) to 4% (Westefeld & Furr, [<reflink idref="bib60" id="ref10">60</reflink>]). Most recently, Westefeld et al. ([<reflink idref="bib61" id="ref11">61</reflink>]) found that 5% of a sample of 1,865 college students had attempted. Thus, in terms of attempts, the problem may be increasing. When suicidal ideation is examined, the rates range from about 9% of a sample thinking about committing suicide (Furr et al., [<reflink idref="bib16" id="ref12">16</reflink>]; Kisch et al., [<reflink idref="bib28" id="ref13">28</reflink>]) to 24% (Westefeld et al., [<reflink idref="bib61" id="ref14">61</reflink>]), to 32% (Westefeld & Furr, [<reflink idref="bib60" id="ref15">60</reflink>]).</p> <p>College student suicide is an issue of crtical importance, and though steps have been taken to address this issue, much more needs to be done. College students continue to take their own lives at an alarming rate. Westefeld et al.'s ([<reflink idref="bib61" id="ref16">61</reflink>]) finding that 24% of a sample of 1,865 college students had thought about attempting suicide and 5% had attempted is cause for concern. Given the devastating impact of this phenomenon, our central thesis is that colleges and universities across the country need to come together now and develop a national plan of action to address this issue.</p> <p>Although suicide is viewed by some as a relatively infrequent event, it is a devastating event. This review will examine a variety of critical issues that make up the complex topic of college student suicide. Specifically, the topics of risk/protective factors, responses to college suicide, legal issues, and training issues will be examined.</p> <hd id="AN0022493957-2">Risk Factors</hd> <p>Environmental and social factors unique to college students often serve to insulate these individuals from factors that increase the risk of suicide. However, other aspects of the college culture and the development of the college student may increase the risk of suicide. Notable developmental changes are present at many life-stage transitions. Traditional college age is a period of transition, where a late adolescent or young adult creates a degree of distance between her/his family or high school support group and establishes new avenues of support. The transition occurs on many levels including social, academic, psychological, and existential. The purpose or larger meaning of attending college may be a salient influence on the degree of experienced stress, depression, and potential suicidal risk. College may be seen as a refuge, proving ground, family requirement, coup de grace, sanctuary, social milieu, and place of experimentation (Rickgarn, [<reflink idref="bib46" id="ref17">46</reflink>]). The combination of college-age developmental changes and specific suicide risk factors is what may ultimately lead to college students taking their own life. This review now turns to specific risk factors.</p> <hd id="AN0022493957-3">History of Suicide Attempts</hd> <p>A history of attempting suicide in the past has been shown to raise the suicide risk level for both college students and the general population (Hawton & Sinclair, [<reflink idref="bib21" id="ref18">21</reflink>]; Westefeld et al., [<reflink idref="bib63" id="ref19">63</reflink>]). This has obvious implications for how colleges and universities treat risk level for enrolled students.</p> <hd id="AN0022493957-4">Substance/Alcohol Abuse</hd> <p>Substance/alcohol abuse have been identified as risk factors and this is an issue that colleges and universities have struggled with for many years. A variety of researchers have established a link between substance abuse and suicidal risk (Rogers, [<reflink idref="bib47" id="ref20">47</reflink>]; Shaffer et al., [<reflink idref="bib50" id="ref21">50</reflink>]) and alcohol use and suicidal risk (Windle, [<reflink idref="bib66" id="ref22">66</reflink>]).</p> <hd id="AN0022493957-5">History of Abuse</hd> <p>History of physical abuse and/or sexual abuse is a risk factor for suicide (Brent, Baugher, Bridge, Chen, & Chiappetta, [<reflink idref="bib6" id="ref23">6</reflink>]; Johnson et al., [<reflink idref="bib27" id="ref24">27</reflink>]; Silverman, Reinherz, & Gianconia, [<reflink idref="bib52" id="ref25">52</reflink>]). This risk factor is often in place prior to a student arriving at college. Thus, a comprehensive history and awareness of this factor are key implications for colleges and universities.</p> <hd id="AN0022493957-6">Hopelessness and Helplessness</hd> <p>Hopelessness and helplessness are important risk factors for college student suicide (Furr et al., [<reflink idref="bib16" id="ref26">16</reflink>]; Kisch et al., [<reflink idref="bib28" id="ref27">28</reflink>]; Westefeld & Furr, [<reflink idref="bib60" id="ref28">60</reflink>]). When students feel they have little control over their lives, and when they feel that there is no hope, they are often overwhelmed and the risk for suicide increases.</p> <hd id="AN0022493957-7">Depression</hd> <p>Depression is a very important risk factor for suicide in college students as it is for people in general (e.g., Kisch et al., [<reflink idref="bib28" id="ref29">28</reflink>]). It is also of note that depressed college students may tend to view suicide as less morally wrong (Lester, [<reflink idref="bib33" id="ref30">33</reflink>]). Thus, not only is depression in and of itself a factor, but it is also the case that depression may lead to other attitudes that may increase the risk of suicide.</p> <hd id="AN0022493957-8">Creativity</hd> <p>Creativity in college students has been investigated as a suicidal risk factor. Domino ([<reflink idref="bib15" id="ref31">15</reflink>]) investigated differences in attitudes toward suicide between highly creative college students and their peers, with creative college students more likely to view suicide as an outcome of a mental illness and a more "normal" behavior. Highly creative college students also believed that suicide was less of a cry for help.</p> <hd id="AN0022493957-9">Protective Factors</hd> <p>Though research on suicidal risk has typically focused on factors that contribute to the likelihood that an individual will attempt and potentially complete suicide, less attention has been given to protective factors. It is our view that protective factors are a very important part of this equation, especially for college students. Protective factors were first researched empirically by Marsha Linehan in [<reflink idref="bib34" id="ref32">34</reflink>], when she published her "Reasons for Living Inventory" (Linehan, Goodstein, Nielsen, & Chiles, [<reflink idref="bib34" id="ref33">34</reflink>]). Linehan's conceptualization of this issue revolves around the question of what keeps people alive, even when they are thinking about suicide. Protective factors, then, are adaptive characteristics that may inhibit suicidal behavior (Hirsch & Ellis, [<reflink idref="bib23" id="ref34">23</reflink>]; Malone et al., [<reflink idref="bib35" id="ref35">35</reflink>]). These factors include the strategies implemented when coping with a stressful situation and the factors that contribute to an individual's ability to persevere during difficult periods in life (Morrison & Downey, [<reflink idref="bib40" id="ref36">40</reflink>]). The importance of examining protective factors has been demonstrated in several studies. Hirsch and Ellis ([<reflink idref="bib23" id="ref37">23</reflink>]) found that college students who possessed many adaptive characteristics tended to cite suicide as an option less often than those students with few adaptive characteristics. Malone et al. ([<reflink idref="bib35" id="ref38">35</reflink>]) suggested that identifying and using protective factors may help individuals feel a sense of hope during an otherwise difficult time. Thus, protective factors may increase hope and reduce suicidal risk. A number of specific protective factors have been identified for college students and these will now be discussed.</p> <hd id="AN0022493957-10">Reasons for Living</hd> <p>Reasons for Living, specifically, feelings of responsibility toward family, fear of social disapproval, moral objections to suicide, survival and coping skills, college- and future-related concerns, and a fear of suicide have all been identified as "reasons to live" and thus can be considered as protective factors under this general conceptual framework (Linehan et al., [<reflink idref="bib34" id="ref39">34</reflink>]; Westefeld, Cardin, & Deaton, [<reflink idref="bib59" id="ref40">59</reflink>]; Westefeld, Scheel, & Maples, [<reflink idref="bib64" id="ref41">64</reflink>]). Identifying reasons to live is more crucial in preventing suicide than the inability to identify reasons not to die for college students (Westefeld et al., [<reflink idref="bib59" id="ref42">59</reflink>]).</p> <hd id="AN0022493957-11">Social Support</hd> <p>Social support is one of the most important protective factors for college students. For college students, social support could be an emotional connection to family, college/university, and friends. There is strong evidence that having friends, being involved in extra-curricular activities, and having strong social connections are all important protective factors (Marion & Range, [<reflink idref="bib36" id="ref43">36</reflink>]; Maris, [<reflink idref="bib37" id="ref44">37</reflink>]; Westefeld et al., [<reflink idref="bib59" id="ref45">59</reflink>]; Zhang & Jin, [<reflink idref="bib67" id="ref46">67</reflink>]).</p> <hd id="AN0022493957-12">No-harm Contracts</hd> <p>No-harm contracts (i.e., agreeing not to kill oneself) are considered by many to be a protective factor. These are often used in therapy and many consider them a crucial tool (e.g. Westefeld et al., [<reflink idref="bib63" id="ref47">63</reflink>]).</p> <p>When risk and protective factors are taken together, a number of important conclusions emerge. Hopelessness, having prior attempts, having a history of abuse, being depressed, feeling helpless, lacking social support, abusing alcohol/substances, thinking about suicide, and lacking reasons for living contribute to increased risk. Having reasons to live and a positive/supportive college experience are pivotal protective factors for college students. The key to understanding and preventing college suicide may lie in the interaction between the many developmental tasks of college students and the generic risk/protective factors. A depressed, lonely, isolated college student who feels hopeless and helpless is at highest risk.</p> <hd id="AN0022493957-13">Prevention</hd> <p>Efforts to prevent suicide on college campuses have been widely discussed in the literature. Programs have been described that provide crisis-intervention, psychoeducational workshops, and training on such topics as depression (Grieger & Greene, [<reflink idref="bib18" id="ref48">18</reflink>]). This section will examine a number of potentially useful training models for preventing suicide on college campuses, as well as generic issues that relate to prevention. It should be noted that there is often significant overlap between prevention and intervention.</p> <p>Resident assistants (RAs) are often a first line of defense against suicide and should be well-educated about suicide. Grosz ([<reflink idref="bib19" id="ref49">19</reflink>]) described a valuable training model for RAs on college campuses that trains them to be able to recognize the verbal, behavioral, and affective warning signs with which the suicidal student may present.</p> <p>Because much continues to be written about the risk and protective factors for college student suicide, prevention programs can base screening for depression and suicide on these factors. For example, hopelessness and depression continue to be cited as key factors in suicidal risk among college students. (Furr et al., [<reflink idref="bib16" id="ref50">16</reflink>]). Asking students verbally through assessment interviews or paper–pencil screenings about hopelessness and depression during orientation can serve as an effective tool in identifying suicidal students and preventing suicide.</p> <p>Students' perception about how college-age suicide can be prevented is also an important component of this issue. In a study of 278 students, 28% indicated that universities needed to make students more aware of suicide prevention services available to them, 20% reported that their institution should make services more accessible, 10% indicated that students needed to become more educated about depression, and 6% wanted institutions to provide students with more supportive activities (Furr et al., [<reflink idref="bib16" id="ref51">16</reflink>]). A sizeable minority of college students view their institution as weak in suicide prevention.</p> <p>The University of Illinois Urbana-Champaign's (UIUC's) prevention program (Joffe, [<reflink idref="bib26" id="ref52">26</reflink>]) has received extensive attention in the literature (e.g., Haas, Hendin, & Mann, [<reflink idref="bib20" id="ref53">20</reflink>]), and is an exemplary program. The university website includes a suicide prevention brochure on why students kill themselves, warning signs, myths about suicide, and detailed information about how to help a student who is suicidal (UIUC, [<reflink idref="bib57" id="ref54">57</reflink>]). The brochure stresses that people often attempt suicide because they believe it is the only way to deal with overwhelming feelings and it notes that a situation that may appear relatively minor to one person may be overwhelming to another. UIUC's ([<reflink idref="bib56" id="ref55">56</reflink>]) online brochure states that the type of response given to the person in crisis can prevent suicides. It suggests the following steps for those encountering a suicidal person: (a) remain calm and listen to what the person is saying; (b) be willing to talk directly about the topic of suicide; (c) encourage the individual to make well thought-out decisions, because they are likely not thinking clearly; and (d) break confidentiality if necessary to get help from professional resources who will be able to offer additional assistance. This approach exemplifies a program that actively can potentially prevent suicide.</p> <p>There are a few researchers who have studied prevention strategies empirically. These studies make an important contribution to the literature. Kralik and Danforth ([<reflink idref="bib32" id="ref56">32</reflink>]) examined college students who self-identified as having no past suicidal ideation, mild ideation, severe ideation, or suicide attempts, to identify what beneficial coping strategies college students used to decrease suicidality. On the Coping Strategies Questionnaire (CSQ), students first listed all possible reasons for staying alive if they were to be suicidal at that point in their life and then listed all possible coping strategies they could use to deal with such suicidal thoughts. A larger group of students then rated the original reasons given on the CSQ for purposes of content and factor analyses. Engaging in problem-solving and thinking about coping, seeking support from family and friends, and relying on religious convictions/spirituality was more common among mild than serious ideators, and having social attachments was more common among serious ideators than attemptors. Thus, Kralik and Danforth ([<reflink idref="bib32" id="ref57">32</reflink>]) argued that both cognitive and behavioral coping skills were significant in helping students deal with suicidality. This research is important because it indicates that "reasons for living" made a difference in suicidality and suggests that a strategy that strengthens reasons for living might help to prevent suicide.</p> <p>Recently, research on suicide prevention and intervention has included more diverse samples, thus making the findings more externally valid. Studies that examine specific groups continue to be important to understanding the difference in effective suicide prevention strategies. Among gay/lesbian/bisexual (GLB) college students, although suicide rates are higher than heterosexual populations, mediating factors often are prejudice, loneliness, and isolation rather than sexual orientation per se (Westefeld, Maples, Buford, & Taylor, [<reflink idref="bib62" id="ref58">62</reflink>]) and most suicide attempts take place before the adults reach age 21 (Hirsch & Ellis, [<reflink idref="bib23" id="ref59">23</reflink>]). Gay men and lesbians identified fewer reasons for living than their heterosexual counterparts, but about the same levels of self-efficacy and hope (Hirsch & Ellis, [<reflink idref="bib23" id="ref60">23</reflink>]). Among 54 Mexican American early and late immigrant students who had not previously been exposed to suicide prevention programs, acculturative stress contributed to depression and suicidal ideation (Hovey, [<reflink idref="bib24" id="ref61">24</reflink>]). Among African American college students, fewer reasons for living was associated with higher suicidal risk. In particular, total reasons, survival and coping beliefs, and college- and future-related concerns on the College Student Reasons for Living Inventory (CSRLI; Westefeld, Badura, Kiel, & Scheel, [<reflink idref="bib58" id="ref62">58</reflink>]; Westefeld et al., [<reflink idref="bib59" id="ref63">59</reflink>]) most accurately differentiate between high- and low-suicide risk levels in African American college students (Westefeld et al., [<reflink idref="bib58" id="ref64">58</reflink>]). All of these studies reinforce the notion that not all college students are the same, be it related to suicide or anything else.</p> <p>Likewise, all colleges are not the same. One study indicated that the size and residency of the student population were important in determining the most effective suicide prevention program for a particular campus, with students at larger universities more likely to have experienced depression since beginning college and believing that academic stress was a major contributor to their depression (Furr et al., [<reflink idref="bib16" id="ref65">16</reflink>]). In the same study, students at institutions with large commuter populations endorsed money problems as the greatest contributing factor to their depression. Prevention programs have been suggested to be most beneficial when they are designed to be institution-specific.</p> <p>Regardless of the campus however, the key components of an effective prevention program are educating participants about warning signs, what action to take, and how to access local resources (Furr et al., [<reflink idref="bib16" id="ref66">16</reflink>]). The key is to both take into account the uniqueness of a given campus and its student body as well as to use what have generically been found to be crucial components of an effective suicide prevention program. Assisting college students with successfully negotiating their many development tasks is of central importance, as is dealing with risk/protective factors. Thus, for example, workshops in social skills training, can have value in reducing college suicide risk as well as workshops that focus specifically on "suicide prevention".</p> <hd id="AN0022493957-14">Intervention</hd> <p>We now turn to the issue of intervention, that is, what to do when we have a student who is potentially or actually suicidal. A variety of strategies will be reviewed, including psychotherapy, mandated assessment, university-wide systemic responses, and contracting.</p> <p>Mental health professionals believe that psychotherapy is a helpful intervention for college students contemplating suicide (Westefeld et al., [<reflink idref="bib63" id="ref67">63</reflink>]), if they will use it. However, in one survey, only 17% of college students who had experienced depression sought counseling (Furr et al., [<reflink idref="bib16" id="ref68">16</reflink>]). On the Coping Strategies Questionnaire college students did not highly endorse the item, "I would seek some type of psychological counseling" as a helpful coping strategy thus not fitting within the final factor structure of this scale (Kralik & Danforth, [<reflink idref="bib32" id="ref69">32</reflink>]). Likewise, in a sample of 15,977 students, less than 20% reporting ideation or attempts received any kind of treatment (Kisch et al., [<reflink idref="bib28" id="ref70">28</reflink>]). Thus, the key is to get students to take advantage of counseling opportunities on their campus.</p> <p>When students do seek counseling, it is often helpful. The majority of the students (68%) in Furr et al. ([<reflink idref="bib16" id="ref71">16</reflink>]) found counseling helpful. Students endorsed the following reasons for its helpfulness: gave them someone to talk to (24%), received medication (18%), helped to explore their options (16%), and gave them new ways to look at things (13%). In the same study, of the 20% who reported experiencing suicidal ideation, 48% of that group indicated that it was helpful. These students endorsed similar reasons to the depressed students for therapy's helpfulness including that it gave them someone to talk to (27%), they felt empowered (13%), it gave them new ways to look at things (13%), and it helped them to sort through things (13%). Although relatively few students experiencing depression or suicidal thoughts seek psychotherapy, about half who do find it helpful. Thus, mechanisms need to be identified to increase utilization rates on our campuses.</p> <p>Therapist factors make a difference in suicide intervention on college campuses. College students, suicide hotline volunteers, and graduate student therapists in training were studied and compared as nonprofessionals, paraprofessionals, and professionals, respectively (Neimeyer, Fortner, & Melby, [<reflink idref="bib43" id="ref72">43</reflink>]). Participants completed demographic questionnaires, the Death Attitude Profile Revised, the Suicidal Behaviors Questionnaire, the Suicide Opinion Questionnaire, and the Suicide Intervention Response Inventory. Individuals who held more accepting attitudes toward ending one's life responded less appropriately to suicidal threats made by others, thus suggesting that personal attitudes toward suicide impact ability to deliver suicide prevention services effectively. Also, even well-trained professionals, who had experienced or were currently struggling with suicidal ideation, did not respond appropriately to potentially suicidal clients. This finding indicates that personal history or experience with suicidality can interfere with a counselor's ability to deliver appropriate crisis intervention for suicidal clients (Neimeyer et al., [<reflink idref="bib43" id="ref73">43</reflink>]).</p> <p>Some university programs, such as the one at UIUC, have tailored suicide intervention programs to a model that includes very direct strategies and action (Haas et al., [<reflink idref="bib20" id="ref74">20</reflink>]). The UIUC website outlines the university's mandated assessment program for students following a suicide threat or attempt (UIUC, [<reflink idref="bib56" id="ref75">56</reflink>]). Any student who has threatened or attempted suicide is required to attend four sessions of professional assessment to better help the student meet the university standard of maintaining reasonable concern for their own care. This program details a procedure that includes an assessment session within one week of the incident or release from the hospital, with following sessions to occur optimally one week apart. The assessment sessions are mandated to be related only to the student's past and current suicidality, and as a result students are informed that they are not required to participate in psychotherapy. However, students have the option during assessment sessions to broaden the focus of the meetings to become more therapeutic in nature. Students who do not comply with the university policy are referred to the Dean of Students and may incur penalties such as disciplinary action, suspension, or withdrawal. Studies on the effectiveness of UIUC's program have found that the campus suicide rate decreased 54% during the program's 18-year tenure and that none of the 1,500 students participating in the intervention program have committed suicide (Joffe, [<reflink idref="bib26" id="ref76">26</reflink>]). This program is one of the very few nationwide with empirical data to document effectiveness.</p> <p>Additional intervention plans have been documented in the literature. Bost and Ballou ([<reflink idref="bib5" id="ref77">5</reflink>]) described the prevention, intervention, and postvention steps taken by a small university in Texas—a model based on strong decisive intervention. In this program, when a student attempts suicide, the student is typically required to be temporarily hospitalized and undergo an off-campus evaluation. The Dean of Students decides if the student should return to campus. This decision is based on the evaluators' recommendations, the student's readiness to engage in academic work, and the student's level of danger to self or others.</p> <p>Contracting with suicidal students continues to be a suicide intervention strategy for college students (Buelow & Range, [<reflink idref="bib8" id="ref78">8</reflink>]; Descant & Range, [<reflink idref="bib13" id="ref79">13</reflink>]), though there is some difference of opinion about the value of this strategy. It also could be argued that contracting is more of a prevention strategy. We consider it intervention-based because it is often—though not always—used after a student begins psychotherapy. Contracting usually involves an agreement that the client will not engage in self-harm for a specific period of time and a list of steps for the client to take if unable to comply with the promise to do no harm (Buelow & Range, [<reflink idref="bib8" id="ref80">8</reflink>]).</p> <p>No-suicide contracts can remove a feeling of immediate danger from the client and assist them in feeling that they can delay self-harm (Descant & Range, [<reflink idref="bib13" id="ref81">13</reflink>]). Most of 145 undergraduate psychology students said that they would be very likely to sign a no-suicide contract, and believed that contracting shows care for the client, strengthens the therapeutic alliance, and gives both parties a sense of control. However, students were neutral about whether no-suicide contracts would actually stop suicidal thoughts but believed contracts were helpful in reducing suicide attempts, getting through a suicidal crisis, assisting the client to develop focus on the future, and reducing the therapist's anxiety (Descant & Range, [<reflink idref="bib13" id="ref82">13</reflink>]). In a study comparing different lengths and specificity of no-suicide contracts, college students, regardless of gender, ethnicity, prior counseling experience, or prior suicidal thoughts, preferred a more detailed and specific contract to a more simplistic one (Buelow & Range, [<reflink idref="bib8" id="ref83">8</reflink>]). Interestingly, although 82% of the students reported that they would recommend no-suicide agreements for suicidal students, when given a list of factors that would lead to decreased suicidal ideation, students rated no-suicide contracts as least effective in helping. Instead, they endorsed factors such as gaining stronger coping skills, improving their living situation, and fear of death as most effective in decreasing ideation (Buelow & Range, [<reflink idref="bib8" id="ref84">8</reflink>]). It is possible that students believe no-suicide contracts to be helpful for immediate self-protection, but view them as only a temporary remedy, whereas change in other factors could lead to more long-term situational change. Contracts are most effective when they are part of a strong, caring relationship between suicidal student and therapist.</p> <p>Studying the effectiveness of college suicide prevention and intervention programs will continue to be a challenge. As Haas et al. ([<reflink idref="bib20" id="ref85">20</reflink>]) noted, it is difficult to determine the significance of a program when there are low suicide base rates before and after implementation of such programs. The program at the University of Illinois represents the best example of a prevention/intervention model, and there is evidence to document the effectiveness of this program. It is crucial that colleges and universities screen for suicidal risk, conduct prevention workshops, and have counseling services available for those students in need. There services need to be well-publicized and readily accessible. Low utilization remains a major concern.</p> <hd id="AN0022493957-15">Postvention</hd> <p>Postvention as a component of a comprehensive suicide prevention program encourages healthy adjustment in a community following a suicide (Celotta, [<reflink idref="bib9" id="ref86">9</reflink>]). It involves responding to the needs of people close to someone who commits suicide. Postvention has been considered an important component of university plans to address suicide because (a) prolonged or severe consequences to peers' psychological/emotional adjustment may be prevented (Petretic-Jackson, Pitman, & Jackson, [<reflink idref="bib44" id="ref87">44</reflink>]) and (b) those who are closely affected by a suicide are more likely to commit suicide (Hiegel & Hipple, [<reflink idref="bib22" id="ref88">22</reflink>]).</p> <p>One aspect of postvention is preventing attribution of heroism to the person who committed suicide. Portrayals of heroism can sometimes lead to copycat suicide (Clark, [<reflink idref="bib12" id="ref89">12</reflink>]). There are often a very wide range of responses following a suicide. Differences in responses may be related to a survivor's proximity to the victim or their own personal history with death or suicidality (Stone, [<reflink idref="bib54" id="ref90">54</reflink>]).</p> <p>Another aspect of postvention is the psychological autopsy. A psychological autopsy in a university setting assesses the psychological profile of the individual who has completed or attempted suicide by reviewing student records and interviewing the campus community, friends, or family who might know about the suicidal individual's thoughts, feelings, problems, or behaviors (Grieger & Greene, [<reflink idref="bib18" id="ref91">18</reflink>]). A psychological autopsy on campus should include a review team, which could consist of the director of the counseling center and other professions involved in the crisis management such as campus security, student health, and student affairs professionals (Grieger & Greene, [<reflink idref="bib18" id="ref92">18</reflink>]). The review team creates a document that organizes information gathered in interviews and identifies recommendations for various team members. The goals of the psychological autopsy include developing an understanding of the events leading up to the suicidal behavior and response, as well as assessing the campus crisis response (Grieger & Greene, [<reflink idref="bib18" id="ref93">18</reflink>]).</p> <p>Still another aspect of postvention is a detailed crisis plan. Such plans are helpful in responding to a campus suicide in a way that prevents further suicides. Stone ([<reflink idref="bib54" id="ref94">54</reflink>]) recommended each campus have a widely circulated written emergency plan that describes an emergency response team, psychological services available to those in need, a media liaison, and a community relations liaison. Mental health professionals serving as suicide postvention specialists are not advised to also serve as the media liaison (Petretic-Jackson et al., [<reflink idref="bib44" id="ref95">44</reflink>]). Stone's writings on this issue are particularly useful.</p> <p>University staff charged with implementing suicide postvention plans can also benefit from Petretic-Jackson et al's ([<reflink idref="bib44" id="ref96">44</reflink>]) recommendations for how to best interact with various university groups. A suicide postvention plan should be organized in advance with specific campus groups. Staff must then focus on developing rapport and a working relationship with the affected university group. It is important for staff to be able to provide accurate information about suicide in general, anticipated psychological responses to the crisis, and the specific circumstances surrounding the campus suicide. Staff must also be willing to help those in the university community cope with their feelings and refer those who are significantly affected for individual or group counseling. Staff providing postvention services to a campus community should be prepared to provide ongoing consultation and follow-up (Petretic-Jackson et al., [<reflink idref="bib44" id="ref97">44</reflink>]).</p> <p>Smaller colleges may be able to respond to those associated with a suicidal student in a more direct manner than larger universities. Bost and Ballou ([<reflink idref="bib5" id="ref98">5</reflink>]) noted that a postvention plan at a small liberal arts university they studied focuses on university counseling staff making quick personal contact with those in the campus community who were most closely associated with the suicidal student.</p> <p>In addition to comprehensive postvention plans, studies have suggested additional issues to address with those affected by a campus suicide. First, helping survivors of the deceased to move on from the question of why the student committed suicide can prevent them from feeling trapped in their grief (Clark, [<reflink idref="bib12" id="ref99">12</reflink>]). Second, survivors need to be helped to normalize the feelings they have toward the deceased. Specifically, some survivors might feel anger toward the victim whereas others who have experienced the long-term depression of the victim might feel a sense of relief when finality is reached (Clark, [<reflink idref="bib12" id="ref100">12</reflink>]). Third, bereavement support groups can be effective in coping with the suicide (Clark, [<reflink idref="bib12" id="ref101">12</reflink>]). Such support groups could be especially helpful for residence halls, college sports teams, sororities/fraternities, or any large student group that has been impacted by a suicide. Staff should also look for survivors to talk openly about the positive and negative attributes of the deceased or the loss, as a sign that they are appropriately working through their feelings (Petretic-Jackson et al., [<reflink idref="bib44" id="ref102">44</reflink>]).</p> <p>In developing healthy postvention responses to suicide, campuses should take advantage of technological advances. For example, the university website or campus-wide email can be used to provide students and the community with information about self-care after a campus suicide. Clark ([<reflink idref="bib12" id="ref103">12</reflink>]) noted that online bereavement support groups can be especially helpful for those affected by suicide in a geographically isolated area or for those who prefer to address personal grief issues in a private and anonymous manner.</p> <p>Overall, postvention programs are vital to campus communities because they can help in preventing copycat suicides, returning affected campus members to pre-suicide levels of functioning, and providing models of how to regroup after a significant tragedy (Petretic-Jackson et al., [<reflink idref="bib44" id="ref104">44</reflink>]). It is important to develop a postvention plan specific to a particular campus, and to have a plan in place prior to the crisis.</p> <hd id="AN0022493957-16">Legal Issues</hd> <p>An area of increasing importance to faculty, staff, and administrators on college campuses who deal with suicide is the frequent legal questions/phenomena that can arise around college student suicide. Understanding the legal issues surrounding campus suicide is very complex, for a number of reasons. First, the legal rulings vary by state, because tort law is state-specific. Second, case findings may have minute differences that can impact precedent and how colleges and universities choose to act. Third, legal and psychological variables may be thrown into conflict in specific situations, making decision-making difficult. Nevertheless, it is important to briefly review the pivotal cases that relate to college suicide.</p> <p>There have been a variety of cases adjudicated that relate to the issue of a university's responsibility vis a- vis suicide. One of the most important issues is whether or not a special relationship exists between the college/university and the student who attempts/completes suicide. There are three cases that are especially relevant to this question.</p> <p>In <emph>Jain v. State of Iowa</emph>, the key finding was that a housing contract does not create a special relationship. In this case, a University of Iowa student killed himself in his residence hall room. His father sued the university, claiming that the university failed to act in way(s) that could have prevented this suicide. In terms of the specifics of the case, the student's girlfriend indicated to RAs that the student was trying to kill himself using carbon monoxide poisoning by running a moped in his room. The hall director was informed of these allegations, and encouraged the student to notify her if he felt self-harm was going to occur, and also encouraged him to seek counseling. The hall director then reported this to her supervisor. Two weeks later the student killed himself via carbon monoxide poisoning. The court basically found for the university. Thus, in this case the court ruled that the university was not liable for failing to intervene to prevent a suicide and that there was not a special relationship involved. An implication of this case is that university administrators who are not psychotherapists do not have a duty of care to prevent suicide.</p> <p>In <emph>Schieszler v. Ferrum College</emph> ([<reflink idref="bib49" id="ref105">49</reflink>]), the courts ruled differently in response to a somewhat similar case. The Schieszler case once again involved a college student who lived in a residence hall. He notified his girlfriend in a note that he was planning to kill himself. Police got the note and visited the student in his room. Police found the student alive but with self-inflicted injuries. Police then informed the Dean of Students who required the student to sign a no-harm contract. However, the student did commit suicide. In this case, the court ruled that a special relationship existed and the college officials had a duty of care. Thus, in two similar circumstances, one court ruled that colleges have a special relationship and therefore a duty to protect students against suicide, and another court ruled just the opposite.</p> <p>In <emph>Shinn v. Massachusetts Institute of Technology</emph> (MIT, [<reflink idref="bib51" id="ref106">51</reflink>]), Elizabeth Shinn lit herself on fire and died. She was in treatment by mental health professionals and in contact with university administrators. The parents, who brought the lawsuit, alleged that the death was a suicide and preventable. The university considered the death an accident. In initial rulings, the courts cleared MIT, but suits were also filed against several staff. In April 2006, this case was settled (MIT News Release, April 3, [<reflink idref="bib39" id="ref107">39</reflink>]). The parents agreed to a settlement, not to be made public.</p> <p>Each situation needs to obviously be judged on its own merit. However, colleges and universities need to act decisively when there is risk of suicide. The first priority is to keep the student alive and weather the crisis. The chief legal officer, chief student affairs officer, and chief mental health person on a campus must work closely together when students reveal suicidal thoughts or plans.</p> <p>The issue of if/when to notify parents concerning a college student's potential for suicide—another major legal issue—is fraught with complexity. On the one hand, mental health professionals are bound by the laws and the ethics of confidentiality. On the other hand, confidentiality can be broken to "protect the client/patient ... from harm" (American Psychological Association, [<reflink idref="bib1" id="ref108">1</reflink>]).</p> <p>Student affairs professionals typically are not bound by legal/ethical confidentiality concerning suicide risk, and therefore their response to a potentially suicidal student may be different from that of a mental health professional. The Family Educational Rights and Privacy Act (FERPA) is also relevant. Though FERPA essentially mandates that confidential information concerning college student not be released to parents, suicide situations pose some relevant exceptions. A subsection of FERPA speaks to emergencies and allows school officials to disclose information if it protects the well being of the student. Under 34 C.F.R. 99.36, a college/university may disclose information in an emergency. Thus based on FERPA, the APA Code of Ethics, and sound clinical practice with the goal of preventing a suicide, university officials must contact parents when they are concerned that a student is suicidal.</p> <p>The University of Iowa has a comprehensive policy on parental notification in the event of a suicide attempt (see Baker, [<reflink idref="bib2" id="ref109">2</reflink>], for a detailed description). Essentially, the major goal of this policy is to "protect the student's safety, enhance the quality of life on campus, and improve the likelihood of student success in college" (Baker, [<reflink idref="bib2" id="ref110">2</reflink>], p. 15).</p> <p>Note that the Iowa policy covers an actual attempt. Of greater complexity is when a student affairs staff member or a therapist is concerned that a student is at high risk but has not attempted. What then? Student affairs professionals who are concerned about suicide should work through their own administrative chain. Then, someone should contact the lead mental health person/office on campus and the university's general counsel and consult. Parents may or may not be notified at this point. Mental health professionals who are concerned about suicide should follow their ethical guidelines.</p> <p>If in the judgment of the college/university a student is clearly suicidal, then university officials should contact the parents. Though there is some legal risk, contacting the parents may also prevent a suicide. A final issue of concern relates to mandatory leave vis á vis suicidal risk among college students. In what may be a precedent-setting case, Jordan Nott is suing George Washington University. He alleges that he was unfairly dismissed. The university maintains that he engaged in "endangering behavior", so based on the university's policy of "psychological distress" he was dismissed. The case needs to be watched closely for its potential implications for college and university officials.</p> <hd id="AN0022493957-17">Training</hd> <p>The final issue to be addressed in this review is training. Specifically, we will examine the importance of training human services graduate students about suicide and how to effectively accomplish such training. This is a very important issue, because it is the key to dealing with suicide intervention at colleges and universities.</p> <p>There is clearly a need for increased training in regard to suicide, given that approximately 97–99% of all psychology interns will work with a suicidal client (Dexter-Mazza & Freeman, [<reflink idref="bib14" id="ref111">14</reflink>]; Kleepsies, Penk, & Forsyth, [<reflink idref="bib29" id="ref112">29</reflink>]) and between 5% and 24% of trainees and professional psychologists will experience a client death by suicide (Dexter-Mazza & Freeman, [<reflink idref="bib14" id="ref113">14</reflink>]; Kleepsies et al., [<reflink idref="bib29" id="ref114">29</reflink>]; Kleepsies, Smith, & Becker, [<reflink idref="bib30" id="ref115">30</reflink>]; McAdams & Foster, [<reflink idref="bib38" id="ref116">38</reflink>]). Training in suicide must be a high priority for university administrators and faculty.</p> <p>The greatest need for more extensive training in suicide comes from the ethical responsibility to competently serve clients. For example, the APA's ([<reflink idref="bib1" id="ref117">1</reflink>]) Ethical Principles of Psychologists and Code of Conduct states, "Psychologists provide services, teach, and conduct research with populations and in areas only within the boundaries of their competence, based on their education, training, supervised experience, consultation, study, or professional experience" (p. 4, code, 2.01).</p> <p>With the rising trend of severe mental health problems among the college student population and the increasing number of students seeking counseling services (Gilbert, [<reflink idref="bib17" id="ref118">17</reflink>]; Haas et al., [<reflink idref="bib20" id="ref119">20</reflink>]), some college/university counseling centers may be ill-suited to accept clients presenting with severe psychopathology (Pledge, Lapan, Heppner, Kivlighan, & Roehlke, [<reflink idref="bib45" id="ref120">45</reflink>]). Given the strong link that exists between severe psychopathology and suicide (Bret & Perper, [<reflink idref="bib7" id="ref121">7</reflink>]; Tanney, [<reflink idref="bib55" id="ref122">55</reflink>]), more training is clearly needed in this area. What is needed specifically is training concerning the link between psychopathology and suicide.</p> <p>Two factors that have challenged college mental health care providers in the treatment of suicidal individuals on college campuses are a reduction in resources for health care professionals and an increased severity of college students' presenting problems. Most counseling centers provide short-term therapy, which can be ineffective for some severe disorders (Gilbert, [<reflink idref="bib17" id="ref123">17</reflink>]), particularly when clients are in need of psychopharmacological and psychiatric interventions. Mental health professionals at college counseling centers need training in psychopathology, suicide, and the link between the two.</p> <p>In 1991, Bongar and Harmatz challenged psychology to set the standard in suicide training and education for all core mental health service providers. They made this challenge upon the discovery that, of the clinical psychology graduate programs they sampled, only 40% offered formal training in the study of suicide. Despite several calls for increased training, a review of the literature indicates that as a profession there is still a lack of adequate training (Dexter-Mazza & Freeman, [<reflink idref="bib14" id="ref124">14</reflink>]). In one survey, only about half of psychology interns reported that they had training in suicide (Dexter-Mazza & Freeman, [<reflink idref="bib14" id="ref125">14</reflink>]; Kleepsies et al., [<reflink idref="bib29" id="ref126">29</reflink>]). This amount of training is inadequate.</p> <p>Given that more and better training is needed, what form should this training take? In our view it needs to be both pragmatic and comprehensive. Mental health trainees should be trained in prevention, intervention, and postvention. The training that does exist incorporates relatively few of the aforementioned components. As Neimeyer ([<reflink idref="bib42" id="ref127">42</reflink>]) stated, "When such training is offered, it is typically limited to a recitation of risk factors and a cursory discussion of "no harm" contracts, coupled with the ethical necessity to report and prevent client self injury" (p. 551). Suicide as a topic was generally incorporated into other courses or practica (Bongar & Harmatz, [<reflink idref="bib4" id="ref128">4</reflink>]; Dexter-Mazza & Freeman, [<reflink idref="bib14" id="ref129">14</reflink>]; Neimeyer, [<reflink idref="bib42" id="ref130">42</reflink>]). Although empirically supported suicide prevention programs exist on college campuses (e.g., Joffe, [<reflink idref="bib26" id="ref131">26</reflink>]), to date there is little information reported in the literature regarding the training and education of professionals who participate in these programs. Also, there appears to be little literature to empirically support the training and education of non-mental health professionals on college campuses such as RAs, residence life staff, faculty, advisors, and other college personnel. Rosenberg ([<reflink idref="bib48" id="ref132">48</reflink>]) noted that there is not a formalized comprehensive training model for experienced or inexperienced clinicians designed to assess skills and to treat clients' suicidal thoughts and feelings. Although the suicide literature has many suicide training models, protocols, policies, and general recommendations, the research has failed to clearly recognize a comprehensive empirically supported suicide training model.</p> <p>However, some aspects of training are effective in educating professionals/paraprofessionals in identifying and treating clients displaying suicidal symptomology. Three important overall factors that a training model should focus on are expertise and cognitive psychology principles, training in assessment skills, and affective or feeling-based intervention strategies (Rosenberg, [<reflink idref="bib48" id="ref133">48</reflink>]). In addition, it is important to have a well-defined protocol for trainees. This protocol should include helping the client identify other means to address the situation, de-escalating the crisis, and signing a no-suicide agreement. Furthermore, formal and informal training should begin early in trainees' careers and continue throughout their career.</p> <p>Campus groups can be diverse in the way they present with suicidal behavior and ideation, making the assessment and treatment methods campus counselors espouse extremely important. Not all individuals self-disclose suicidal thoughts, feelings, and actions (Morrison & Downey, [<reflink idref="bib40" id="ref134">40</reflink>]). For example, Asian American female college students come from a background that stresses group affiliation and acceptance, so they may benefit from support groups to cope with suicidal issues (Chung, [<reflink idref="bib11" id="ref135">11</reflink>]). Training that focuses on educating counselors regarding how different populations deal with life stressors (that may or may not lead to suicide or suicidal behaviors) should be an important feature in counseling center programming and graduate training.</p> <p>It appears that training in suicide is minimal at best in many mental health graduate training programs. What is needed for all trainees is didactic coursework, practicum experiences, and internship experiences that teach trainees about risk factors, assessment, intervention, and postvention in a comprehensive and practical manner.</p> <hd id="AN0022493957-18">Summary and Implications</hd> <p>Identification of risk/protective factors has important implications for how to prevent and respond to suicide. Substance/alcohol abuse, having attempted suicide previously, a history of physical/sexual abuse, a diagnosis of depression, relationship problems, hopelessness, and lack of social support have all been identified as risk factors for college students. For some of these factors the risk is already in place when the student arrives at college. It is therefore important that colleges and universities obtain a comprehensive health history on all entering students. For other factors (e.g., social support), educational programming is paramount. In planning for suicidal students, colleges and universities need to establish a strong mental health delivery system that collaborates with strong student development services.</p> <p>In responding to suicide (prevention, intervention, and postvention) colleges and universities need to deliver suicide prevention workshops to a variety of constituencies on a regular basis. The workshops should be targeted to sororities/fraternities, students in residence halls, RA staff, faculty, and academic advisors. These workshops should include information on suicide warning signs, actions to take if concerned about someone, and a listing/directory of local resources. A comprehensive action-oriented model such as the one at The University of Illinois Urbana-Champaign (Joffe, [<reflink idref="bib26" id="ref136">26</reflink>]) is highly recommended.</p> <p>Postvention has grown dramatically over the past 20 years. Now, on most campuses, when a suicide occurs, there is a postvention response. Campuses need to have postvention teams/procedures in place in advance of a crisis. The postvention response needs to be tailored to the particular campus, but typically includes psychoeducation, group work, referral information, and opportunities for affective processing.</p> <p>Perhaps no issue generates as much debate as the legal issues surrounding suicide. (See Baker, [<reflink idref="bib2" id="ref137">2</reflink>][<reflink idref="bib3" id="ref138">3</reflink>], for an excellent discussion of many of these issues.) Staff at colleges and universities often fear lawsuits around the issue of suicide. Evidence indicates that lawsuits do happen, but it is imperative that campus officials educate themselves about the true risks of such lawsuits.</p> <p>In terms of training, graduate programs in psychology, social work, and counseling that prepare those who work in college and university counseling centers, and psychology internship training programs located in college and university counseling centers need to do much more. Didactic courses, guided supervision, and discussion of available resources need to be included in training programs. We also advocate that a required unit on suicide be included in practicum and internship training.</p> <p>For colleges and universities, the key steps that need to be taken are:</p> <p></p> <ulist> <item> developing a unified, national mandate to address the issue of suicide;</item> <p></p> <item> providing prevention programming, focusing both on generic risk/protective factors as well as coping with college transitions;</item> <p></p> <item> encouraging student affairs staffs, mental health staffs, and university general counsel officers to work closely together on this issue;</item> <p></p> <item> offering training in graduate human services programs on the topic of suicide; and</item> <p></p> <item> highlighting reasons for living.</item> </ulist> <p>In 1990—over 15 years ago—Westefeld et al. stated about the problem of college student suicide "what is being called for is to take additional action both reactively and proactively" (p. 473).</p> <p>Today, in 2006, the need for action remains.</p> <hd id="AN0022493957-19">Acknowledgments</hd> <p>Appreciatio is expressed to Thomas Baker, J.D., for his helpful comments concerning this manuscript.</p> <ref id="AN0022493957-20"> <title> References </title> <blist> <bibl id="bib1" idref="ref108" type="bt">1</bibl> <bibtext> American Psychological Association. 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Items – Name: Title
  Label: Title
  Group: Ti
  Data: College Student Suicide: A Call to Action
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  Data: <searchLink fieldCode="AR" term="%22Westefeld%2C+John+S%2E%22">Westefeld, John S.</searchLink><br /><searchLink fieldCode="AR" term="%22Button%2C+Christopher%22">Button, Christopher</searchLink><br /><searchLink fieldCode="AR" term="%22Haley%2C+James+T%2E%22">Haley, James T.</searchLink>
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  Data: <searchLink fieldCode="SO" term="%22Death+Studies%22"><i>Death Studies</i></searchLink>. Dec 2006 30(10):931-956.
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  Data: Routledge. Available from: Taylor & Francis, Ltd. 325 Chestnut Street Suite 800, Philadelphia, PA 19106. Tel: 800-354-1420; Fax: 215-625-2940; Web site: http://www.tandf.co.uk/journals/default.html
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– Name: Pages
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  Data: 26
– Name: DatePubCY
  Label: Publication Date
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  Data: 2006
– Name: TypeDocument
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  Data: Journal Articles<br />Reports - Evaluative
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  Label: Education Level
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  Data: <searchLink fieldCode="EL" term="%22Higher+Education%22">Higher Education</searchLink>
– Name: Subject
  Label: Descriptors
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  Data: <searchLink fieldCode="DE" term="%22Suicide%22">Suicide</searchLink><br /><searchLink fieldCode="DE" term="%22College+Students%22">College Students</searchLink><br /><searchLink fieldCode="DE" term="%22Risk%22">Risk</searchLink><br /><searchLink fieldCode="DE" term="%22Legal+Problems%22">Legal Problems</searchLink><br /><searchLink fieldCode="DE" term="%22Prevention%22">Prevention</searchLink><br /><searchLink fieldCode="DE" term="%22Intervention%22">Intervention</searchLink><br /><searchLink fieldCode="DE" term="%22Counselor+Training%22">Counselor Training</searchLink><br /><searchLink fieldCode="DE" term="%22Counseling+Services%22">Counseling Services</searchLink><br /><searchLink fieldCode="DE" term="%22Influences%22">Influences</searchLink>
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  Data: 0748-1187
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  Data: This article examines current issues related to the topic of college student suicide and why it continues to be an issue of major concern. The nature/extent of the problem, risk and protective factors, responses to college student suicide, legal issues, and training issues are discussed. The importance of addressing the issue of college student suicide and its prevention on college campuses is emphasized as is the importance of protective factors. Although more is being done to address this issue than has been done in the past, it remains a major concern, and it is an issue that requires a strong national response.
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  Data: 2007
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  Data: <link linkTarget="URL" linkTerm="https://taylorandfrancis.metapress.com/link.asp?id=NX7XH712LQ041881" linkWindow="_blank">http://taylorandfrancis.metapress.com/link.asp?id=NX7XH712LQ041881</link>
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      – SubjectFull: Suicide
        Type: general
      – SubjectFull: College Students
        Type: general
      – SubjectFull: Risk
        Type: general
      – SubjectFull: Legal Problems
        Type: general
      – SubjectFull: Prevention
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      – SubjectFull: Intervention
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      – SubjectFull: Counselor Training
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      – SubjectFull: Counseling Services
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      – SubjectFull: Influences
        Type: general
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      – TitleFull: College Student Suicide: A Call to Action
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            NameFull: Haley, James T.
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