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

CERTIFICATION OF APPROVAL

QPR SUICIDE PREVENTION TRAINING: A CALIFORNIA

STATE UNIVERSITY, STANISLAUS

STUDENTS’ PERSPECTIVE

by

Sara Ray

Shradha Tibrewal, Ph.D

Professor of Social Work

Jennifer Johnson, MSW, LCSW

Lecturer of Social Work

Date

Date

Signed Certification of Approval Page is on file with the

University Library

© 2014

Sara Ray

ALL RIGHTS RESERVED

iv

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.

v

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.

vi

TABLE OF CONTENTS

PAGE

Dedication ............................................................................................................... iv

Acknowledgements ................................................................................................. v

List of Tables .......................................................................................................... viii

List of Figures ......................................................................................................... ix

Abstract ................................................................................................................... x

CHAPTER

I. Introduction ........................................................................................... 1

Statement of the Problem .......................................................... 1

Statement of Purpose ................................................................ 8

Significance of Study ................................................................ 9

II. Literature Review.................................................................................. 11

Suicide Among College Students ............................................. 11

A Brief Overview of Suicide Prevention .................................. 12

Suicide Prevention Skills .......................................................... 17

Suicide Prevention Actions ....................................................... 19

Suicide Prevention Trainings .................................................... 20

Question, Persuade, Refer, and CSU, Stanislaus ...................... 22

III. Methodology ......................................................................................... 27

Overview ................................................................................... 27

Research Design........................................................................ 27

Sampling Plan ........................................................................... 28

Instrumentation ......................................................................... 28

Data Collection ......................................................................... 30

Plan for Data Analysis .............................................................. 30

Protection of Human Subjects .................................................. 31

IV. Analysis................................................................................................. 33

Demographics ........................................................................... 34

vii

Results ....................................................................................... 35

Suicide Prevention Skills .......................................................... 35

Suicide Prevention Actions ....................................................... 37

Summary ................................................................................... 43

V. Discussion and Conclusions ................................................................. 44

Findings as They Relate to Literature ....................................... 44

Limitations ................................................................................ 49

Implications for Social Work Practice ...................................... 50

Recommendations for Future Research .................................... 52

References ............................................................................................................... 54

Appendix: Evaluation of California’s Statewide Health Prevention and Early

Intervention Initiatives. ...................................................................................... 63

viii

LIST OF TABLES

TABLE PAGE

1. Students’ Total Skills Mean Scores Before and After QPR Training .............. 36

2. Accessing Mental Health Resources ................................................................. 36

ix

LIST OF FIGURES

FIGURE PAGE

1. Ability to encourage a fellow student experiencing mental

health distress to get professional help ............................................................ 38

2. Ability to encourage a fellow student experiencing mental

health distress to talk to friends or parents........................................................ 39

3. Ability to provide guidance and advice to a fellow student

experiencing mental health distress, about how to help themselves ................. 40

4. Ability to take a fellow student, experiencing mental health

distress, to a hospital, mental health center, or counselor. ................................ 41

5. Ability to ask a fellow student experiencing mental health

distress specific questions to assess the level of distress or

seriousness of the problem. ............................................................................. 42

x

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.

1

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 15-24 in the United States, and the second leading cause of death of

individuals ages 25-35 (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

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

3

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)

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

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

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.

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

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 pre-

and 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

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 2013.

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.

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

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.

11

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

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

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).

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

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

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

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,

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

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

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

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 $6650.00 per year. This training is

offered online only, the college or university purchases the rights to the program, and

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 $495.00 per certification, which is significantly less than the

Kognito At-Risk for College students. After receiving the QPR trainer certification,

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,

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

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.

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

27

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

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.

29

The QPR training recipient’s ability to identify places or people in which to refer a

mentally distressed student; 2. Access to resources to learn about student mental

health; 3. Comfort with discussing issues of mental health with students; 4.

Confidence in ability to help students to address mental health issues, and 5. Mental

health warning signs and health distress (RAND, 2013). The actions being measured

in this research are separated into nine separate questions. The nine questions in the

actions category of the survey include the QPR training recipient’s self-reported

ability to do all of the following; 6. Encourage a person suffering with mental distress

to get professional help; 7. To call a crisis line with the individual suffering mental

distress; 8 Encourage the sufferer of mental distress to talk with family or friends; 9.

Provide the individual suffering mental distress with guidance and advice about how

to help ones-self ; 10. Take the individual suffering mental distress to get help; 11.

Give an individual suffering mental distress a phone number to call; 12. Ask an

individual suspected to be suffering from mental questions to assess the distress level

and seriousness of the issue; 13. To call someone to help to support the person in

distress; and, 14. Whether or not they feel it is their business to get involved with

another student’s personal life (RAND, 2013). The surveys analyzed were

specifically from QPR training, however, the survey was developed to evaluate

“California’s statewide mental health prevention and early intervention initiatives”

(RAND, 2013, p. 1). The implication is that the skills and actions being measured

can be considered suicide prevention skills and actions. Mental distress is not defined

in this survey.

30

Data Collection

This researcher used existing data collected by the mental health professional

and the health educator. The surveys were completed by participants after receiving

the QPR training. The surveys were then delivered to the Peer Project on the CSU,

Stanislaus campus where they have been stored in a secure location. The researcher

was provided paper copies of the surveys completed by the students. The surveys

were distributed after the QPR training was completed, and asked pre-training and

post-training Likert scale questions. The students were asked to answer each of the

14 Likert scale questions from a “before I attended this training” and “after I attended

this training” perspective (RAND, 2013, p. 2-3). The surveys were only completed

by the students at the end of the training, where they, retrospectively, answered what

they thought their actions and skills were before the training and then simultaneously

assessed their actions and skills post training. The surveys were completed

anonymously, at various locations on the CSU, Stanislaus campus, after the QPR

training was received. Permission was given to the researcher to use the data

collected in the surveys, by the Chancellor’s office at California State University,

Long Beach and the RAND Corporation, after approval by the University IRB (J.

Johnson, personal communication, March 24, 2014; M. Woodbridge, personal

communication, April 8, 2014).

Plan for Data Analysis

Each of the 14 survey questions were addressed quantitatively in an effort to

answer the research questions. Univariate analyses were conducted on the questions

31

individually as well as the categories identified on the instrument, such as suicide

prevention skills, and suicide prevention actions. Four of the five questions

pertaining to skills (questions 1,3,4, & 5) were analyzed together to report any

changes in suicide prevention skills, one question, (question 2), was analyzed

separately The researcher did not feel that question number two, from the skills

section of the survey, specifically assessed skills. The nine questions pertaining to

actions were analyzed to report changes in suicide prevention actions, using

frequency measures. The researcher reported the mean and standard deviation for

suicide prevention skills and frequencies for suicide prevention actions. The

researcher examined the data to determine whether parametric assumptions were met

or not. Parametric assumptions were met, which allowed paired samples t-tests to be

conducted to examine the difference between pre-test and post-test scores of the

participants. The data were reported both numerically and in an interpretive written

summary.

Protection of Human Subjects

The surveys did not include any personal identifying information, therefore,

all data collection was done anonymously, to protect participant’s privacy. The

researcher was not present during the survey completion and collection. Therefore,

the researcher did not have access to any identifying information about the

participants. The surveys were stored in a secure location after collection. The

researcher stored the surveys in a secure location to protect the participant’s privacy.

32

Once the data were analyzed, the surveys were returned to the Peer Project on the

CSU, Stanislaus campus.

33

CHAPTER IV

ANALYSIS

The purpose of this research was to examine California State University,

Stanislaus students’ self-reported changes in suicide intervention skills, and ability to

take action, after receiving the Question, Persuade, Refer (QPR) suicide prevention

training. The QPR trainings were presented in a face-to-face model on the campus of

California State University (CSU), Stanislaus. The data were obtained from surveys

that were given to QPR participants after the training. This research was guided by

two main questions: 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? The assumption of the research is that the QPR training would improve

participants’ suicide prevention skills, and the actions they would take if confronted

with an individual they believed might be at risk of suicide.

The self-reported changes in suicide prevention skills and actions were

captured through a fourteen item survey. Although the surveys were only given to

the participants at the completion of the QPR training, each item asked the participant

to, first, consider a statement as if they had not received the QPR training, then to

reconsider the same statement after the QPR training. The items were all presented in

a Likert scale format. The first five items asked participant to rate the extent to which

they might agree with a statement on a scale of one through five; one representing

34

strongly disagree, two representing disagree, three representing neither agree or

disagree, four representing agree, and five representing strongly agree. The

remaining nine items asked the participants to rate the likelihood of performing a

specific action on a scale of one through four; one being not at all likely, two being

somewhat likely, three being likely, and four being very likely. Training participants

were students, faculty, or staff of California State University, Stanislaus and were

given a paper survey after participating in the QPR training. However, this research

focuses on CSU, Stanislaus students therefore, the data collected specifically from

that population was examined.

Demographics

This research was only interested in assessing California State University,

Stanislaus students who completed the QPR training. The sample included 74

participants, who received QPR training on the campus of California State University,

Stanislaus. Of the 74 participants; 23% were male, 77% were female. The majority

of the participants, 76.99%, were between the ages of nineteen and twenty-five, 22%

were between the ages of twenty-six and fifty-nine, and one student, 0.01%, was

between the ages of sixteen and eighteen. Additionally, 28% were undergraduate

students, 50% were graduate students, and 22% of the students did not report their

status as either graduate or undergraduate.

35

Results

A paired-samples t-test was conducted to compare the students’ suicide

prevention skills before and after QPR training. An alpha level of 0.01 (p ≤ 0.01) was

used in assessing for statistical significance. This research hopes to find an increase

in students’ mean scores for suicide prevention skills after participants received the

QPR training, when compared with the mean scores before the QPR training.

Additionally, this research measured the participants’ frequencies of reported

likelihood of performing specific actions to assist in suicide prevention. The

assumption of this research is that participants will experience an increase in the

likelihood of performing suicide prevention actions.

Suicide Prevention Skills

A paired-samples t-test was conducted to compare the sample’s (N = 74)

mean scores of suicide prevention skills before (M = 14.85) the QPR training and

after (M =18.54) the QPR training. The total skills being examined in this analysis

combined the following four survey items: I can identify the places or people where I

should refer other students with mental health needs/distress. I feel comfortable

discussing mental health issues with other students. I am confident in my ability to

help other students address mental health issues. I am aware of the warning signs of

mental health distress.

36

Table 1

Students’ Total Skills Mean Scores Before and After QPR Training

N M SD t P

Total Skills Before 74 14.85 3.17 -6.28 p < .001

Total Skills After 74 18.54 4.99

There was a statistically significant difference (p < .001) in the mean scores (t

= -6.28) of total suicide prevention skills after receiving QPR training. These results

suggest that students’ suicide prevention skills improve after receiving QPR training

when compared with before the training.

The following question asked participants’ to rate their ability to

access mental health resources. This question was included under the category of

suicide prevention skills in the survey. However, this researcher did not find that the

ability to access mental health resources reflected a skill, but did identify knowledge

of mental health resources.

Table 2

Accessing Mental Health Resources

N M SD t p

Ability to Access

Before

74 3.80 0.81 -8.42 p < .001

Ability to Access

After

74 4.55 0.55

The data demonstrated a statistically significant difference in the mean scores

for the ability to access mental health resources after QPR training; p < .001 when t =

37

-8.42. This result suggests that students’ reported ability to access mental health

resources improve after receiving QPR training, when compared with before the

training.

Suicide Prevention Actions

This research also measured the change in the mean scores for suicide

prevention actions before and after participants received the QPR training. The

examination of the actions data did not combine any of the survey items, but analyzed

each item separately. Each item asked the participants to rate on a Likert scale from 1

(not likely at all) to 4 (very likely). The participants were asked to rate each question

on how they felt before attending the training, and after the training. Each item

showed a significant difference in mean scores after participants received the QPR

training. The results suggest that participants reported a greater likelihood to take an

appropriate suicide prevention action, if a fellow student was experiencing mental

health distress.

Question one pertaining to suicide prevention actions asked participants to

report how likely they were to encourage a fellow student, experiencing mental health

distress, to get professional help from a hospital, mental health center, or counselor.

Before participating in the QPR training just over forty-percent (40.5%) of students

reported that they would be very likely to encourage a fellow student to get

professional help, compared with over eighty-percent (82.4%) after the QPR training.

Figure 1 demonstrates this information graphically.

38

Question two pertaining to suicide prevention actions asked participants to

report the likelihood of calling a crisis line with a student who was showing signs of

mental health distress. Before participating in the QPR training 10.8% reported they

were not at all likely, 25.7% reported somewhat likely, 35.1% reported likely, and

28.4% reported very likely. After receiving the QPR training the data show a

significant difference in the likelihood of calling a crisis line with the distressed

student present; 4.1% reported they were somewhat likely, 18.9% reported to be

likely, 77% reported very likely, and none reported they were not at all likely.

Participants reported a greater likelihood of calling a suicide prevention hotline with a

student suffering mental health distress after receiving the QPR training.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Not at all

likely

Somewhat

likely

Likely Very likely

S

t

u

d

e

n

t

s

Before

QPR

After QPR

Figure 1. Ability to encourage a fellow student experiencing mental health

distress to get professional help. This figure illustrates the frequency in

which each answer appeared.

39

The survey also asked participants to report how likely they would be to

encourage a student demonstrating mental health distress signs to speak with a friend

or parents about their problems. As demonstrated in Figure 2, before QPR training

41.9% reported that they were very likely to encourage a fellow student suffering

mental distress to speak with friends or parents. After receiving the QPR training a

larger percentage (79.7%) of participants reported they would very likely encourage a

mentally distressed student to speak to a friend or parent about their problems.

Before receiving the QPR training 44.5% of the participants reported they

were very likely to provide a mentally distressed student with advice or guidance

about how get help for themselves. After receiving the QPR training, a greater

percentage of participants reported being very likely (86.5%), or likely (13.5%) to

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

Not at alllikely

Somewhatlikely

Likely Very likely

S

t

u

d

e

n

t

s

BeforeQPRAfterQPR

Figure 2. Ability to encourage a fellow student experiencing mental

health distress to talk to friends or parents. This figure illustrates the

frequency that each answer appeared.

40

provide guidance or advice on how to get help to a fellow student showing signs of

mental health distress. Figure 3 shows a graphical representation for this action

question.

A larger percentage of participants (79.7%) reported they would be very

likely to take a fellow student showing signs of mental health distress to a hospital,

mental health center, or counselor after receiving the QPR training as compared to

training (31.1%). Additionally, before the training a greater percentage (8.1%) of

participants reported they were not at all likely to take a mentally distressed student to

get help, 20.3% reported somewhat likely, and 40.5% reported likely. After receiving

the QPR training, none of the participants reported that they were not at all likely to

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Not at all

likely

Somewhat

likely

Likely Very likely

S

t

u

d

e

n

t

s

Before

QPR

After

QPR

Figure 3. Ability to provide guidance and advice to a fellow student

experiencing mental health distress, about how to help themselves. This

figure illustrates the frequencies in which each answer appeared.

41

take a mentally distressed student to get help. Please see Figure 4 for a complete

graphical representation.

If a fellow student showed signs of experiencing mental health distress, 32.4%

of participants reported they would be very likely to give that student a specific

number or person to call before they received the QPR training, in contrast to 82.4%

after receiving the training. Before receiving the QPR training 10.8% reported not at

all likely, 20.3% reported somewhat likely, and 36.5% reported likely. After

receiving the QPR training 1.4% reported not at all likely, 16.2% reported likely, and

none reported somewhat likely.

Figure 5 shows, graphically, the percentages of the answers to the suicide

prevention action pertaining to assessment of distress or seriousness of the problem.

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

Not at all

likely

Somewhat

likely

Likely Very likely

S

t

u

d

e

n

t

s

Before

QPR

After

QPR

Figure 4. Ability to take a fellow student, experiencing mental health distress, to a

hospital, mental health center, or counselor. This figure illustrates the frequencies

in which each answer appeared.

42

Participants also reported an increased percentage, 83.8%, of being very likely to ask

a fellow student, showing signs of mental health distress specific questions to assess

their level of distress or seriousness of the problem after receiving the QPR training.

Before receiving the QPR training only 27% of the participants reported they were

very likely to ask the same assessment questions.

Participants’ self-reported likelihood of calling security, administration, or a

counselor to support a fellow student showing signs of mental health distress also

increased after receiving the QPR training. Eighty-five percent of participants

reported being very likely to call administration, a counselor, or security after

receiving the training, 9.5% reported likely, 4.1% somewhat likely, and 1.4% not at

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

Not at all

likely

Somewhat

likely

Likely Very likely

S

t

u

d

e

n

t

s

Before

QPR

After

QPR

Figure 5. Ability to ask a fellow student experiencing mental

health distress specific questions to assess the level of distress or

seriousness of the problem. This figure illustrates the frequencies

in which each answer appeared.

43

all likely. Before receiving the QPR training 33.8% reported being very likely to call,

39.2% reported likely, 21.6% somewhat likely, and 5.4% not at all likely.

The final question pertaining to suicide prevention actions asked participants

to report the likelihood of feeling like it wasn’t their business to get involved in the

personal life of a student showing signs of experiencing mental health distress.

Before receiving the QPR training 47.3% reported it was not at all likely that they

would feel this way, 25.7% reported somewhat likely, 17.6% reported they would

likely feel this way, and 9.5% reported very likely. After receiving the QPR training

54.1% reported it would be not at all likely that they would feel like it wasn’t their

business to get involved in the personal life of a student showing signs of

experiencing mental health distress, 6.8% reported somewhat likely, 6.8% reported

likely, and 32.4% reported very likely.

Summary

The findings of this research demonstrate statistically significant increases in

the mean scores for suicide prevention skills. The mean scores for suicide prevention

skills are significantly lower before participants received the QPR. All of the suicide

prevention skills and actions mean scores increased after participants received the

QPR training. Additionally, the frequencies demonstrated that the participants

reported feeling more likely to take action after receiving the QPR training, than they

did before receiving the training. The findings of this study show that the QPR

training did increase the self-reported suicide prevention skills and actions within this

particular group of California State University, Stanislaus.

44

CHAPTER V

DISCUSSION AND CONCLUSIONS

The purpose of this study was to assess the change in the suicide intervention

skills and suicide intervention actions of California State University (CSU),

Stanislaus students who have received the QPR training. This study examined data

collected from surveys that were given to individuals after receiving face-to-face

QRP training. The goal of this study was to provide information regarding the

effectiveness of QPR training on suicide prevention and reduction on the CSU,

Stanislaus campus. The findings showed that students who received QPR training did

report an increase in their suicide prevention skills and ability to act after receiving

the training.

Findings as They Relate to the Literature

The two research questions guiding this research are; 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 purpose of

this study was to assess the change in the suicide intervention skills and suicide

intervention actions of CSU, Stanislaus students who have received the QPR training.

This research did find that the students who participated in the QPR training did

report an increase in suicide prevention skills and actions. The findings of this

research are consistent with the findings of previous QPR research.

45

One major finding of this research was self-reported increase in suicide

prevention skills after participants received the QPR training. The suicide prevention

skills assessed included; the ability to identify suicide warning signs, the professional

resources available to refer a suicidal individual, comfort in discussing mental health

issues, and ability to help fellow students address mental health issues. These skills

are all important in suicide prevention. The ability to recognize suicide warning signs

and speak with an individual about them, then subsequently get the suicidal person

help is the theoretical underpinning of the QPR training (Quinnett, 2012). These

things are all part of the question, persuade, refer theory of QPR and are recognized

as important tools to have for suicide prevention by suicide prevention resources such

as: The National Strategy for Suicide Prevention (NSSP), and The American

Foundation for Suicide Prevention (AFSP) (US Surgeon General et al., 2012; AFSP,

2013). This finding is also consistent with findings from Cross et al.’s research which

found that participants’ gatekeeper skills increased after receiving the QPR training

(2010). The gatekeeper skills being referred to in Cross et al.’s research were, the

participant’s ability to appropriately question a person about suicide, to persuade a

person suffering mental health distress to get help, and finally, to refer the person to

the appropriate resource (Cross et al., 2010). The current research parallels previous

research, demonstrating that individuals receiving the QPR suicide prevention

training did report an increase in suicide prevention skills. The skill of identifying

suicide warning signs, ability to discuss mental health issues, and get a fellow student

46

to professional help can possibly prevent a completed suicide on the CSU, Stanislaus

campus.

This research found that the participants reported increased ability to assess

mental health distress, or seriousness of mental health problem, after receiving the

QPR training. The survey used for this research did not define mental health distress.

Identification of mental health distress is another guideline of the QPR training,

falling under the ‘question’ guideline (Quinnett, 2012). The aim of QPR in suicide

prevention is to be able to assess the level of distress a person is experiencing and

subsequently, to refer an actual suicidal person to a professional resource (Quinnett,

2010). The CSU, Stanislaus student participants reported feeling that their ability to

question a fellow student experiencing mental health distress to assess the level of

distress increased after receiving the QPR training. Exploring whether a fellow

student is actually experiencing suicidal thoughts through questions can be

challenging and anxiety provoking, but is necessary to decide if intervention is

appropriate (Feldman & Freedenthal, 2006). If a QPR trained student can identify a

fellow student suffering suicide ideation and subsequently get that person

professional help it may prevent a death by suicide on the CSU, Stanislaus campus.

Previous research indicates that just being able to talk about feelings of suicide

provides relief (Drum, et al., 2009). Many people, even trained social workers, fear

that talking about suicide with a suicidal person will actually increase the risk of

suicide (Sharpe, et al., 2014). Openly conversing with a possible suicidal individual

about their mental distress can provide relief and may actually prevent a suicide death

47

(Drum et al., 2009). An increased ability to assess the level of mental health distress

and, subsequently, refer a suicidal individual to a professional resource, after

receiving QPR is also consistent with the findings from Cross et al. (2010) and

Wyman et al. (2009), which also found an increased ability to assess level of distress.

After questioning to assess the level of distress the QPR also aims to train individuals

to be able to effectively persuade and refer a suicidal individual to an appropriate

resource (Quinnett, 2010; Tompkins et al., 2010).

This research also found a self-reported increase in the suicide prevention

actions after receiving the QPR training. Many of the action questions in the survey

relate to the ability to get an individual suffering mental health distress help, or refer.

The ability to refer a suicidal person to help is one of the components of the QPR

training, and is thought to be important for preventing suicide (Quinnett, 2012).

Some of the actions that were reported to increase were, the ability to provide

guidance about how to get help such as; encourage a person suffering mental health

distress to get professional help or talk to parents or friends about problems. One of

the things that student’s seriously considering a suicide attempt reported as being

helpful in preventing their attempt was talking to someone about their feelings (Drum

et al., 2009). Drum et al. also reported that suicidal ideation may be reduced by

developing positive, caring social support networks (2009). In addition to

encouraging a person suffering mental health distress to talk to someone, either a

professional, or family and friends, there was a reported increase in the ability to

actually accompany a suicidal person to get help, or call an appropriate resource.

48

This finding is also consistent with the findings from Cross et al. (2010). The ability

to encourage a suicidal individual to get professional help or to talk to friends or

family about their feelings can help decrease their suicidal feelings (Drum et al.,

2009).

The focus of the current research was on the students of CSU, Stanislaus, and

their reported suicide prevention skills and actions after receiving QPR training.

Training students in suicide prevention skills and actions is important because of the

number of suicidal individuals who first disclose their suicidal ideation to a peer

(Drum et al., 2009). The finding that after receiving QPR the student participants did,

in fact, report an increase in suicide prevention skills and actions is consistent with

findings from previous research. Tompkins and Witt found that the reported efficacy

to question a suspected suicidal individual, and either refer or take them to a

professional resource did increase among 240 student resident advisors after receiving

the QPR training (2009). Tompkins and Witt’s research is also consistent with

research done by Jacobson et al., and Sharpe et al., which found that master of social

work students reported increased ability to question and intervene with an individual

experiencing mental health distress (2012; 2014). Therefore, the current research is

consistent with previous research findings that students receiving the QPR training

also reported increased suicide prevention skills and actions. Giving college and

university students the opportunity to participate in QPR training and increase their

suicide prevention skills and actions, can be beneficial to reducing suicide deaths on

campus.

49

Limitations

Even though the study shows promising results with regard to the QPR

training increasing suicide prevention skills and actions, there are some limitations to

the study. The manner in which the surveys were distributed to participants was a

limiting factor. These surveys asked participants to report their suicide prevention

skills and actions before and after the QPR training, however, the surveys were only

distributed after the training. In order to get a true account of participants’ suicide

prevention skills and actions the surveys needed to be distributed before and again

after receiving the training. Asking participants to answer questions as if they had not

received the training when, in fact, they had could possibly influence their answers.

Another limitation to the study was the lack of a clear definition of suicide

prevention skills and actions within the survey. The survey did separate questions

into either suicide prevention skills or suicide prevention actions, but it did not clearly

define what suicide prevention skills or actions are. This survey was not developed

for use with QPR training specifically, but for other mental health trainings as well.

Development and utilization of surveys to assess the effectiveness of the QPR

training itself might allow for better outcome data specific to the guidelines of QPR,

and eliminate the vagueness on the terminology.

Finally, this researcher was unable to find out what type of quality control

assessments this particular survey was subjected to. Although this survey was

developed by the RAND Corporation which is known for developing quality data

50

collection resources, the process was not made available to this researcher. This

researcher can only speculate the reasons this information not obtainable, however, it

does provide more support for a QPR specific survey to be developed and

implemented.

Implications for Social Work Practice

This research demonstrated that the QPR training does increase the ability to

recognize suicide warning signs, therefore, it would benefit social workers to

participate in the training. The ability to recognize suicide warning signs among

students, coupled with the communication skills already being taught in the master of

social work program at CSU, Stanislaus, could possibly make social work students

even more effective in suicide prevention. In order to be effective in suicide

prevention social workers should also feel comfortable assessing the level of distress

and referring a suicidal student to a professional mental health resource.

Although, many CSU, Stanislaus social work students will be pursuing careers

as mental health professionals, while completing their education they may not be the

best referral source to prevent suicide. This research found that individuals

participating in the QPR training reported feeling more able to assess the level of

distress of an individual suffering mental distress after completion of the training.

The ability to assess the level of mental distress is important to discover if the

individual is suicidal. Once the skill of assessing level of distress is learned, the

social worker can begin to persuade a suicidal individual to get professional help.

This researcher suggests that students, including social worker students, who

51

participate in the QPR training, will feel more able to assess the level of distress and

subsequently refer to a professional, if needed.

This research found that students who received the QPR training reported an

increase in the ability to take action when confronted with a suicidal individual. This

researcher suggests that by receiving QPR training students will be better equipped to

take action to prevent suicide if necessary. This is important for social work students

in the role as student, but also in the field as interns. The QPR training is not a

targeted training, meaning it does not teach suicide prevention only as they apply to

college students. The suicide prevention skills and actions taught by the QPR training

are meant to be applicable to the general population, as well as within college

students. The skills and actions that are learned in QPR training can be valuable

when encountering a mentally distressed student, friend, colleague, or client which

can make a social work student even more effective to suicide prevention.

Finally, this researcher suggests that continuing to offer the QPR suicide

prevention training on the CSU, Stanislaus campus can strengthen the suicide

prevention efforts within the campus community, as well as, within the communities

in which the participants live and interact. Additionally, the individuals participating

in the QPR training can apply the suicide prevention skills and actions learned to

experiences off campus contributing to suicide prevention within their communities

as well. Suicide prevention is important to everyone, as implied by Regina M.

Benjamin, MD, MBA, VADM, U.S. Public Health Service Surgeon General (2012),

52

“No matter where we live or what we do every day, each of us has a role in

preventing suicide” (US Surgeon General et al., 2012, p.4).

Recommendations for Future Research

Future research should include follow up surveys given at specific time

intervals after receiving the QPR training asking specific questions about application

of training. Assessing suicide prevention skills and actions over time, as well as,

finding out whether participants have actually used the skills and actions they have

learned to make a referral could provide information about the support durability and

effectiveness of QPR. Follow up surveys would also provide valuable information

about the durability of the QPR training. Understanding the durability of the QPR

training over time would give information about the need, or lack of need, for follow

up trainings. The culmination of understanding durability over time, as well as

application of QPR training can be valuable to the future of suicide prevention

training.

Finally, future research should include a qualitative component should ask

open-ended questions to assess the participant’s viewpoint on what they feel would

increase their suicide prevention skills. If in fact, participants are not using the

knowledge they have gained it is important to find out the things that might be

hindering them. This information would allow for growth in developing more

effective suicide prevention trainings for the future.

REFERENCES

54

REFERENCES

American College Health Association. (2013). National College Health Assessment

II: Refrence Group Executive Summary Spring 2013. Hanover, MD: American

College Health Association. Retrieved from

http://www.achancha.org/reports_ACHA-NCHAII.html

American Foundation for Suicide Prevention. (2013). S.740 the Garrett Lee Smith

memorial act reauthorization of 2013. Retrieved from

http://www.afsp.org/advocacy-public-policy/federal-policy/garrett-lee-smith-

memorial-act-programs

American Psychiatric Association. (2013). Diagnostic and statistical manual of

mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

Bertera, E. M. (2007). The role of positive and negative social exchanges between

adolescents, their peers and family as predictors of suicide ideation. Child and

Adolescent Social Work Journal, 24(6), 523-538. doi:1 0.1007/s10560-007-

0104-y

California Department of Health Care Services. (2014). Mental health services act

(Proposition 63). Retrieved from

http://www.dmh.ca.gov/Prop_63/MHSA/default.asp

55

California State University, Stanislaus Peer Project. (n.d.). Our mission. Retrieved

from http://www.csustan.edu/PEERProject/

Center for Disease Control and Prevention. (2014). 10 leading causes of death by age

group, United States – 2010. Retrieved from

http://www.cdc.gov/injury/wisqars/LeadingCauses.html

Center for Disease Control and Prevention. (2005). Data & Statistics (WISQARS™):

Cost of Injury Reports. Retrieved from

http://wisqars.cdc.gov:8080/costT/cost_Part1_Finished.jsp

Cerel, J., Chandler Bolin, M., & Moore, M. M. (2013). Suicide exposure and attitudes

in college students. Advances in Mental Health. 12(1), 46-53. doi:

10.5172/jamh.2013.12.1.46

Cross, W. F., Seaburn, D., Gibbs, D., Schmeelk-Cone, K., White, A. M., & Caine, E.

D. (2011). Does practice make perfect? A randomized control trial of

behavioral rehersal on suicide prevention gatekeeper skills. Journal of

Primary Prevention. 32(3-4), 195-211. doi:10.1007/s10935-011-0250-z.

Drum, D. J., & Denmark, A. B. (2012). Campus suicide prevention: Bridging

paradigms and forging partnerships. Harvard Review of Psychiatry, 20(4),

209-221. doi:10.3109/10673229.2012.712841

Drum, D. J., Brownson, C., Denmark, A. B., & Smith, S. E. (2009). New data on the

nature of suicidal crises in college students: Shifting the paradigm.

56

Professional Psychology: Research and Practice. 40(3), 213–222. doi:

10.1037/a0014465.

Feldman, B.N., & Freedenthall, S. (2006). Social work education in suicide

intervention and prevention: An unmet need. Suicide and Life Threatening

Behavior, 36, 467-480. doi:10.1521/suli.2006.36.4.467

H.R. 2734-113th Congress: Garrett Lee Smith memorial act reauthorization of 2013.

(2013). Retrieved from http://www.govtrack.us/congress/bills/113/hr2734

Indelicato, N.A., Mirsu-Paun, A., & Griffin, W.A., (2011). Outcomes of a suicide

prevention gatekeeper training on a university campus. Journal of College

Student Development, 52, pp 350-361. Retrieved from

http://muse.jhu.edu/journals/csd/summary/v052/52.3.indelicato.html

Jacobson, J.M., Osteen, P.J., Sharpe, T.L., & Pastoor, J.B. (2012). Randomized trial of

suicide gatekeeper training for social work students. Research on Social Work

Prractice, 22(3), 270-281. doi: 10.1177/1049731511436015

Know the Warning Signs of Suicide. (2014). Retrieved from

http://www.suicidology.org/resources/warning-signs

Mitchell, A., Kim, Y., Prigerson, H., & Mortimer-Stephens, M. (2004). Complicated

grief in survivors of suicide. Crisis: The Journal of Crisis Intervention and

Suicide Prevention. 25(1), 12-18. doi: 10.1027/0227-5910.25.1.12

57

Mitchell, S., Kader, M., Darrow, S., Haggerty, M., & Keating, N. (2013). Evaluating,

question persuade, refer (QPR) suicide prevention training in a college setting.

Journal of College Student Psychotherapy. 27(2).

doi:10.1080/87568225.2013.766109

Office of the Surgeon General (US); National Action Alliance for Suicide Prevention

(US). 2012 National strategy for suicide prevention: Goals and objectives for

action: A report of the U.S. surgeon general and of the National action

alliance for suicide prevention. Washington (DC): US Department of Health

& Human Services (US). Retrieved from

http://www.ncbi.nlm.nih.gov/books/NBK109917/

Quinnett, P. (2012). QPR gatekeeper training for suicide prevention the model, theory,

and research. Retrieved from http://www.qprinstitute.com/theory.html

RAND CalMHSA. (2013). Evaluation of California’s statewide mental health

prevention and early intervention initiatives. [College student post-only

survey]. Unpublished survey.

Rubin, A., & Babbie, E. (2010). Research methods for social work (7th ed.). Belmont,

CA: Brooks/Cole.

Wadsworth/Thompson Learning, IncSAMHSA’s National Registry of Evidence-based

Programs and Practices. (2014). QPR gatekeeper intervention for suicide

prevention. Intervention Summary. Retrieved from

http://nrepp.samhsa.gov/ViewIntervention.aspx?id=299

58

Schwartz-Lifshitz, M., Zalsman, G., Giner, L, Oquendo, M.A. (2012). Can we really

prevent suicide?. Current Psychiatry Report. 14, 624-633.

doi:10.1007s/11920-012-0318-3

Shavelson, R. J. (1988). Statistical reasoning for the behavioral sciences (2nd ed.).

Needham Heights, MA: Allyn and Bacon, Inc.

Sharpe, T.L., Jacobson-Frey, J., & Osteen, P. J. (2014). Perspectives and

appropriateness of suicide prevention gatekeeper training for MSW students.

Social Work in Mental Health. 12, 117-131.

doi:10.1080/15332985.2013.848831

Smith, E.P., Quillian, B.F., Murillo, R., & Johnson, N. (2013). The California State

University Committee on Educational Policy Meeting Minutes, from January

22- 23. Systemwide and campus-wide student mental health services. Long

Beach, California. Retrieved from

http://google.calstate.edu/search?q=cache:6YtodgQafNAJ:www.calstate.edu/

BOT/Agendas/Jan13/EdPol.pdf+calMHSA&output=xml_no_dtd&client=csu_

frontend&proxystylesheet=csu_frontend&ie=UTF-

8&site=calstate_edu&access=p&oe=UTF-8

Suicide: A Major, Preventable Health Problem Factsheet. (n.d.). Retrieved from

http://www.nimh.nih.gov/health/publications/suicide-a-major-preventable-

mental-health-problem-fact-sheet/index.shtml

59

Suicide Prevention Resource Center. Grantees. Retrieved from

http://www.sprc.org/grantees

Suicide Prevention Resource Center. (2012). Section I: Evidence-based programs.

Best Practices Registry. Retrieved from http://www.sprc.org./bpr/section-i-

evidence-based-programs

Suicide Prevention Resource Center. (2012). Using the BRP. Best Practices Registry.

Retrieved from http://www.sprc.org./bpr/using-bpr

Suicide Warning Signs. (2014). Retrieved from http://www.afsp.org/preventing-

suicide/suicide-warning-signs

Tal Young, I., Iglewicz, A., Glorioso, D., Lanouette, N., Seay, K., Ilapakurti, M., &

Zisook, S. (2012). Suicide bereavement and complicated grief. Dialogues in

Clinical Neuroscience, 14(2), 177-186. Retrieved from

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3384446/

The Center for Complicated Grief. (nd). What is complicated grief? Columbia

University School of Social Work. Retrieved from

http://www.complicatedgrief.org/bereavement/

Tompkins, T.L. & Witt, J. (2009). The short-term effectiveness of a suicide prevention

gatekeeper training program in a college setting with residence life advisers.

Journal of Primary Prevention, 30, 131-149. doi:10.1007/s10935-009-0171-2

60

Tompkins, T. L., Witt, J., & Abraibesh, N. (2010). Does a gatekeeper suicide

prevention program work in a school setting? Evaluating training outcome and

moderators of effectiveness. Suicide and Life-Threatening Behavior, 40(5),

506-515. Retrieved from

http://ezproxy.lib.csustan.edu:2048/login?url=http://search.proquest.com.ezpr

oxy.lib.csustan.edu:2048/docview/822518480?accountid=10364

United States, Health and Human Services, Office of the Surgeon General and

National Action Alliance for Suicide Prevention. (2012, September). National

Strategy for Suicide Prevention; Goals and Objectives for Action. Washington,

DC: HHS. Retrieved from www.surgeongeneral.gov/library/reports/national-

strategy-suicide-prevention/index.html

Westfield, J. S., Button, C., Haley, Jr, J. T., Jenks Kettmann, J., Macconnell, J.,

Sandil, R., & Tallman, B. (2006). College student suicide: A call to action.

Death Studies, 30, 931-956. doi:10.1080/07481180600887130

Westfiled, J., Hoffman, B., Spotts, J., Furr, S., Range, L., & Werth, Jr., J. (2005).

Perceptions concerning college student suicide: Data from four universities.

Suicide & Life-threatening Behavior, 35(6), 640-645. Retrieved from

http://library.csustan.edu/

What is QPR? (2011). Retrieved from http://www.qprinstitute.com

61

Wyman, P. A., Brown, H., Inman, J., Cross, W., Schmeelk-Cone, K., Guo, J., & Pena,

J. P. (2008). Randomized trial of a gatekeeper program for suicide prevention:

1-year impact on secondary school staff. Journal of cosult clinical psychology,

76(1), 104-115. doi:10.1037/0022-006X.76.1.104

APPENDIX

63

APPENDIX

EVALUATION OF CALIFONIA’S STATEWIDE MENTAL HEALTH

PREVENTION AND EARLY INTERVENTION INITIATIVES.

64

65