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Traditionally, health professionals and gatekeepers have responded to disclosures of suicidality by conducting risk assessment and risk management or mitigation. This article reviews the problems with this approach for students, health professionals, and society. It describes what is, as far as we are aware, the world’s first needs and person-based approach to suicide prevention, Care • Collaborate • Connect, and provides examples of how universities can implement person-centred policies and practices.

Actuarial risk approaches – approaches that try to calculate the probability of a negative adverse event in the future – are characterised by anxiety about the future, rather than needs in the present.¹ A number of problems have been identified with the risk approach to suicide prevention.² These include:

• Risk is a relatively poor predictor of suicide. Students who are misclassified as high risk when they are not, are frequently traumatised, and students who are misclassified as low risk sometimes die by suicide, despite having asked for help.
• The risk approach ignores the needs of the person asking for help. No one discloses suicidality to be managed. They ask for help because they trust that the person can help them feel better.
• It teaches students how to get help – if you want to be hospitalised, you need to say you are thinking of suicide; never mention the word suicide if you do not want to be managed or detained.
• It ignores the existing strengths of the student, including that they asked for help.
• Safety planning keeps students’ attention on suicide, both through its name – safety plan – and by encouraging students to be hypervigilant for warning signs of suicidal crises.
• Despite this well-established practice of risk approach and significant attention and investment, the incidences of deaths by suicide have not reduced significantly over time.

Suicide prevention within a biopsychosocial framework

Suicide prevention can be reframed from stopping a person dying by suicide in a given moment to ensuring health and wellbeing, and reducing the likelihood that an individual will feel there is no other option than suicide to reduce their distress. The biopsychosocial context of health and wellbeing comprises healthy environments (physical, social, cultural and economic), responsive parenting, a sense of belonging, healthy behaviours (sleep, nutrition, exercise, study), healthy coping, resilience (an outcome of healthy coping) and early interventions for illnesses (physical and psychological).² The first four components are preventative and reduce the likelihood of a person experiencing overwhelming distress. Universities do not cause suicide. University study, however, can sometimes be challenging and stressful. For students with pre-existing biopsychosocial problems, inadequate healthy coping strategies, or poor access to community treatment services, the added stress associated with studying may be the straw that breaks the camel’s back and may result in suicidality. Universities, as education institutions, are just one, often small, part of students’ lives and can, therefore, never prevent suicide in isolation. They can, however, play a role in suicide prevention by attending to the biopsychosocial components of health and wellbeing within their sphere of influence and promoting health and wellbeing.

How universities can contribute to suicide prevention

1. Healthy environments

These include the physical, social, cultural, and economic environments students inhabit and the learning environment of the university. Curriculum design, affordable, comfortable housing, inclusive, respectful university communities, and responsiveness to needs of first-in-family students, are some of the areas where universities can contribute to developing a healthy environment for students.

2. Responsive parenting

Adult learners come to university with experiences of diverse parenting during their childhoods. Students who experienced abuse, neglect, or overprotective parenting may have significant problems with identity formation, emotional and behavioural regulation, interpersonal skills, and problem-solving skills – all of which are crucial for university study and graduate employment. While universities have no influence over what happened in the past, being aware of the impact of poor parenting on students’ skills and behaviours may inform policies and strategies about how to best support these students.

3. A sense of belonging

Everyone needs to feel respected and that they are a valued member of their communities – family, neighbourhood or university. Students come to university with different needs and expectations about the role it will play in their lives and with different levels of interpersonal skills. With increasing moves towards blended and online learning, and many students balancing work and other commitments with their learning, students have fewer opportunities to develop a sense of being part of their university, their discipline and their cohort. All levels of the university have the challenge of creating a community and implementing strategies to help the most vulnerable students in particular feel part of it.

4. Healthy behaviours

Sleep, nutrition, and exercise are essential for emotional regulation and the prevention of psychiatric disorders. Sleep, in particular, is paramount, given that it is when material learnt during the day is consolidated into memory. Unhealthy behaviours are highly prevalent among university students, with many students not getting the recommended seven to nine hours of sleep each night, good nutrition, or adequate exercise.^3,4 As students become stressed with assignments and exams, these are also the biological needs that may be neglected. Universities can play a significant role in psychoeducation, health promotion, prioritising affordability and nutrition for on-campus food and in designing, promoting and normalising incidental exercise. University health and counselling centres could also be proactive in assessing and promoting these lifestyle factors.

5. Coping

Unpleasant emotions are a normal human experience, as is the attempt to reduce them. The health theory of coping posits that all coping strategies may initially be effective in reducing distress.² However, they can be categorised as healthy or unhealthy, depending on the likelihood of unwanted adverse consequences. Healthy coping categories are self-soothing, relaxing and distracting activities, social support and professional support. Unhealthy coping categories include behaviours such as negative self-talk, harmful activities (aggression, alcohol, drugs, eating, self-harm), social withdrawal, and suicidality. Within this coping framework, suicidality is destigmatised by being included on the continuum of coping rather than being perceived as a separate dichotomous strategy. Suicide is caused by the absence of alternative strategies to reduce distress.⁷

Universities can promote healthy coping, for example, through psychoeducation and by actively encouraging students to make a coping plan – perhaps by delivering a mandatory seminar in their first term. In this way, institutions can offer something which is effective in reducing distress and improving wellbeing.⁵

Care • Collaborate • Connect is a strengths and needs-focused approach to suicide prevention.^2,6 This approach prioritises Care (listening and empathy) as the priority intervention for acute distress. Collaborate involves finding out what strategies the student currently uses to cope and, if necessary, helping them to identify one or two new healthy coping strategies they could use before turning to unhealthy coping strategies in the future, such as taking a few deep breaths, walking around the block or calling a helpline. Collaborate also involves working with the student to identify any need for additional professional support and, if so, whether their needs are moderate or high. Connect involves linking the student with more intensive professional support when needed. The key here, of course, is having good connections with local support services (NHS, charities, GPs and so on). Professional and academic staff can also use Care • Collaborate • Connect steps when supporting students who need additional administrative, educational, or counselling support with relevant services within the university. Used consistently across the university, students, particularly those with help-seeking difficulties, learn that people care about them and will support them.

6. Resilience

Resilience is the bouncing back after coping with adversity. It is an outcome rather than something that can be taught. Everyone has been resilient since conception. Early life examples include learning to self-soothe when our cries were not always responded to immediately as an infant or getting back up to try again when we fell while learning to walk. People who have experienced significant biopsychosocial adversities have perhaps been more resilient than most, getting back up many times, even after experiencing overwhelming distress. Most people who have died by suicide had long track records of being resilient.² Death by suicide is the one time they could not reduce their distress using alternative strategies and bounce back.

7. Treatment of illness

Early interventions for physical and psychiatric illnesses may decrease the impact of the illness on the person and those around them. Universities can contribute to treatment by establishing strong links with community health providers, supporting students with illness-related disabilities by exploring the bidirectional impact of study requirements and illness (stress may exacerbate mental illness and mental illness may make academic work challenging, and so on), developing and implementing realistic support plans, and providing flexible learning arrangements where practical.

Evidence base

Care • Collaborate • Connect was developed from more current research in the fields of neuroscience, health and wellbeing, coping and suicide prevention. A mixed-methods evaluation of the Care • Collaborate • Connect: Suicide Prevention training with health professionals and students in health disciplines found significant improvements in knowledge, attitudes, confidence and self-care pre to post training with moderate to very large effect sizes.⁶ There were no significant differences in outcomes between those who had and had not had previous training or experience working with people expressing suicidality. Qualitative feedback showed almost universal support for the person- and strengths-focused approach of supporting people with suicidality, and participants noted that it fitted well with their organisations’ values and priorities.

A clinical trial of the My Coping Plan app⁸ with university students found that, at one-month follow-up, participants reported significantly lower psychological distress, improved wellbeing and improved healthy coping strategies compared with the control condition.5 There were similar results with an online student version of the programme that included healthy behaviours and coping: Care • Collaborate • Connect: Student Success.⁷

Summary

University study is challenging and sometimes stressful. In an ideal world, students would have healthy environments, developmental competences, a sense of belonging, healthy behaviours to minimise emotional reactivity and healthy coping strategies to reduce distress, when it occurs. For many students, though, this is not their reality, and they may experience overwhelming distress during their time at university. Universities can play a role in suicide prevention through the creation of healthy environments, taking action to promote a sense of belonging and by promoting healthy activities and coping. Care • Collaborate • Connect is an approach to support anyone who is upset, rather than waiting until someone has suicidal ideation before intervening. A consistent Care • Collaborate • Connect approach to distressed students has the potential to reduce suicide by teaching students they are cared about and that they will be supported when they ask for help. While these strategies will help students during their time at university, they may also contribute to lifelong health and wellbeing and have broader suicide prevention effects that are not measurable.

A comparison of needs-based and risk-based approaches to disclosures of suicidality.

Dr Helen Stallman is an award-winning clinical psychologist, Director of the International Association for University Health and Wellbeing, and Associate Professor – Clinical Psychology at the University of the Sunshine Coast. Dr Stallman is a specialist in the development, evaluation and dissemination of interventions to optimise health and wellbeing.

References

1. Stallman HM, Ohan JL. The alignment of law, practice and need in suicide prevention. BJPsych Bulletin 2018; 42(2): 51–53. doi:10.1192/bjb.2017.3
2. Stallman HM. Coping planning: a patient– and strengthsfocused approach to suicide prevention training. Australasian Psychiatry 201; 26(2): 141–144. doi:http://dx.doi. org/10.1177/1039856217732471
3. Haase A, Steptoe A, Sallis JF, Wardle J. Leisure-time physical activity in university students from 23 countries: associations with health beliefs, risk awareness, and national economic development. Preventative Medicine 2004; 39(1): 182–190. doi:10.1016/j.ypmed.2004.01.028
4. Lund HG, Reider BD, Whiting AB, Prichard JR. Sleep patterns and predictors of disturbed sleep in a large population of college students. Journal of Adolescent Health 2010; 46(2): 124–132. doi:10.1016/j.jadohealth.2009.06.016
5. Stallman HM. Efficacy of the My Coping Plan mobile application in reducing distress: a randomized controlled trial. Clinical Psychologist, Advance online 2019. doi: https://doi. org/10.1111/cp.12185
6. Stallman HM. Online needs-based and strengths-focused suicide prevention training: Evaluation of Care • Collaborate • Connect. Australian Psychologist, Advance online 2019. doi:https://doi.org/10.1111/ap.12419
7. Stallman HM, Ohan JL, Chiera B. Reducing distress in university students: a randomized control trial of two online interventions. Australian Psychologist 2019; 54(2): 125-131. doi:https://doi.org/10.1111/ap.12375

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