Preventing mental health crises

This is the second in a four-part series on crisis response and mental health resources on campus. For part one, visit here.

Following the death of sophomore student-athlete Sam Wopat on March 25 and reports of several attempted suicides on campus this year, The Daily has undertaken a survey of existing campus resources and culture surrounding mental health.

On Monday, The Daily took a look at how the University responds to mental health crises. Today’s piece examines Stanford’s safety net to prevent mental health crises. Residential Education (ResEd) plays a large role in this net — from resident assistants (RAs), to resident fellows (RFs) and residence deans (RDs). The University has an RD on call to manage crises 24 hours a day, 365 days a year. Nearly every RA interviewed expressed satisfaction with the RA training process and said that while one can train for suicide risk reduction, it is nearly impossible for students to know what to expect and how to respond until they deal with a real attempt.

After exploring suicide risk reduction training for RAs, The Daily looked at Counseling and Psychological Services (CAPS) and The Bridge Peer Counseling Center protocol for addressing students who might be at risk of harming themselves. CAPS and The Bridge are each accessible to students via phone 24 hours a day.

Finally, this piece ends with some of the less obvious parts of the safety net — focusing on Undergraduate Advising and Research (UAR).
‘Significant increase’

At least four Stanford students have attempted suicide on campus this school year, with at least one case — that of sophomore student-athlete Samantha ‘Sam’ Wopat — resulting in a student’s death.

The Daily confirmed three instances of freshmen attempting suicide or making serious plans in three separate Wilbur Hall residences during this academic year.

The incidence of serious mental health issues in Wilbur Hall has increased significantly this year, said one Wilbur RA, who wished not to specify her dorm within Wilbur to protect the privacy of her residents. The RA cited numerous conversations with current student staffers, former student staffers and administrators in ResEd and UAR.

Wilbur RD John Giammalva declined to comment on whether Wilbur has experienced an increase in serious mental health issues this year.

“I value my relationships with students greatly, and it is important to me that they know when we talk about and are working through personal issues, I will not make those things public (even without using names),” Giammalva wrote to The Daily.

RA Training

This year’s group of RAs had just over three hours of training on issues related to mental health issues and suicide. According to CAPS director Ron Albucher, CAPS counselors led students in a two hour Question, Persuade, Refer (QPR) training session. The session included a presentation on how to identify a student who may have suicidal ideations and instructed RAs on how to address a student in crisis and refer them to the appropriate authorities and resources. The training session also featured a video from a suicide survivor and a role-playing segment at the end that allowed RAs to practice asking someone if they are entertaining thoughts of suicide.

In addition, representatives from CAPS and ResEd gave an hour and fifteen minute presentation on psychological distress. Another presentation focused more broadly on happiness, wellness and mental health.

CAPS began offering Question, Persuade, Refer (QPR) suicide risk reduction training to RAs and other ResEd staff, faculty, University staff and community members two years ago. Over 2,000 students, faculty and staff have participated in QPR training, according to CAPS.

According to the QPR Institute website, trained ‘gatekeepers’ will learn to “recognize the warning signs of suicide, know how to offer hope, [and] know how to get help and save a life.”

Albucher said that RA feedback about the program has been “pretty positive.”

“It’s been really well received — people think it was valuable, people felt like they were in a better position to know what questions to ask, and to have some practice,” Albucher said, citing feedback data.

Opinions on the quality of training differ among RAs who have dealt with suicide prevention or attempted suicide.

“I remember QPR being quite helpful,” wrote Suites RA Kiera O’Rourke ’13 to The Daily.

“I think that RA training for suicide prevention is terrible,” said RA Akshay Gopalan ’12, who is also a counselor at the Bridge Peer Counselor Center. “The way that the course is taught during RA training leaves a lot to be desired.”

While Gopalan said learning how to ask the questions is useful, he also said that other RAs who have had to deal with attempted suicides in their dorms have had a harder time than they expected.

Gopalan said he does not blame RAs for having difficulty.

“RAs are capable, but I don’t think they’re being trained well enough to handle stuff like [attempted suicide],” Gopalan said.

O’Rourke said practicing skills in class is different than putting them to use in person.

“It’s one thing practicing role play and another having to deal with the issue, especially once it has already happened,” she said. “Maybe some attention can be given to that as well.”

Gopalan said that RAs were given 10 to 15 minutes to practice the skills they learn from the video, which he said is not enough time to determine if someone is suicidal. He reported spending six hours in a Bridge practice call while training to be a counselor there, and it took three hours for any signs of suicidal behavior to develop from his practice counselee.

According to Albucher, the University tries to strike a balance in preparing students for various situations without overwhelming them with information.

“I think it’s always a balancing act — trying to not overwhelm people with any one area,” Albucher said. “And [trying] to not have the RAs feel like they need to be clinicians, but [that they’re] getting enough training so that they know some early warning signs.”

Dean of ResEd Deborah Golder described a culminating segment of RA training called “Oh, The Places You’ll Go,” in which students are given the chance to practice responding to various crisis situations.

RAs in Suites and Wilbur said they found the simulations dealing with issues like schizophrenia, homophobia and sexual assault useful, but commented that none of the simulations in their training focused on suicide.

“Because the simulations were so realistic, I feel like if we had one about attempted suicide, it would have been helpful,” O’Rourke said.

Suites RA Jen Wylie ’13 said that a simulation on suicide might not work because the exercise focuses on responses to individuals during crises and not on responding to communities after crises.

Alejandro Martinez, senior associate director of CAPS, who manages the QPR training feedback, also said that student reception was mostly positive, but said he has also heard that students think more practice time would be valuable.

“It is valued, it is helpful, it is useful,” Martinez said participants reported, saying trainees most appreciated the opportunity to practice the skills they learn.

Martinez, who is also an instructor for the peer counseling courses that prepare students to work at The Bridge, said he agreed with Gopalan’s feedback that practice is key to training.

“You can’t just talk about it, you have to have the opportunity to actually practice,” Martinez said.

“We want to do more,” he added. Martinez said that the Bridge class offers “much more intensive training” than RAs receive.

“We provide the didactic material and we have sections where students have a much more intense opportunity to talk,” Martinez said.

The Bridge and crises

Gopalan said that while Bridge counseling sessions are usually driven by the counselee, The Bridge takes a more directive approach in a suicide-type counsel, in which they list instructions for the counselor to follow.

“We assess level of risk on a qualitative scale. [Our] response to that varies from ‘Let’s call the 24 hour CAPS number right now’ — that’s on the lower end [of the] scale,” Gopalan said. “On the higher risk scale, [we say] ‘Where are you? Tell me where you are,’ as far as ‘I will come over to take you to the hospital,’ or ‘Will you let me call the ambulance for you?’”

Gopalan said that Bridge counselors have gone directly to residences and waited until ambulances have arrived.

Before this step, Gopalan said, counselors get as much information as they can — if not a name, then whether the caller is an undergraduate or graduate, what department the caller works in — any identifying information to give to authorities.

The Bridge, which has four live-in counselors, works in two-person teams to respond to students at risk, Gopalan said.

“The minute we get a crisis call, we call down someone from upstairs,” he said, adding that the second counselor contacts CAPS immediately and 911, if necessary.

“It’s pretty comprehensive, and it works,” Gopalan said. “We’ve had very good success multiple times.”

Gopalan said this year has seen a relatively low number of suicide-related calls. He added that it is difficult to quantify the number of these calls. Overall, calls to the Bridge have increased in recent months.

“A lot of these calls don’t get quantified because of either extremely low risk — [suicide] comes up while talking about something else, and it’s not an issue,” Gopalan said. “A lot of the time, fixing the problem at hand will deal with those thoughts as well.”

Gopalan said he was not at liberty to quantify the number of response cases this year, but says The Bridge has “between a couple and seven or eight” per year.

CAPS and potential crises

CAPS also uses a team-based approach for phone calls to assess whether a student is at immediate risk and to simultaneously contact authorities like RDs or the police. RDs are particularly useful because they have exclusive access to information on past incidents, as well as master keys to residences.

Albucher described CAPS protocol for assessing whether a student that is called in or calls the 24 hour CAPS hotline himself is at-risk of suicide. Albucher said this response is tailored to the individual situation.

“The scenario could play out in many different ways,” Albucher said.  “It’s hard to give a set response.”

Albucher said that if CAPS can speak to the student directly, on-call counselors will get information about what kinds of thoughts, plans and steps the student has taken to harm himself. On-call counselors will also look into prior history of attempts and mental health concerns, learn about substance use and medical problems, and ask how the student is going to keep himself safe.

Counselors work in teams to talk with students and RDs or other authorities at the same time, Albucher said.

If the counselor determines that the student requires hospitalization, Albucher said, he or she will discuss with the student why such a move makes sense and will get the on-call RD involved, contact the Stanford Police to provide the escort into the hospital, and call ahead to the hospital to alert the psychiatry resident on call who will evaluate the student.

During the clinical evaluation, Albucher said, counselors pose a series of questions to determine whether a student has thought his or her actions through, whether the student intended to take his own life or whether he meant to distract himself from other forms of pain or suffering.

Once the crisis is over, the hospital may discharge the student to an outpatient center or to CAPS.

Albucher said that under different circumstances, ResEd has walked students over to CAPS for evaluations in the past.

Golder said that for ResEd, deciding whether a student’s actions constituted a suicide attempt is dangerous, citing the need to help students regardless of cause or intention.

“If anything is showing up where someone could be harming themselves we’re going to try to get them the appropriate help they need,” Golder said.

Dean of Student Affairs Chris Griffith remarked that when attempted suicides do occur, the University crafts long term responses individually, saying that some options include voluntary and involuntary leaves of absence.

“Decisions about leave for a student who attempts suicide are complicated and require us to review the student’s circumstances from a broader perspective including the continued safety of the student and the impact on others in the community,” Griffith wrote in an email to The Daily. “It is important to remember that every student’s circumstances are different — that is why the individualized assessment is so critical.”

The wider net

For depressed or struggling students who have not reached the point of attempting suicide, several administrators described a safety net in which departments across the University — from resident assistants and resident deans to Undergraduate Advising and Research (UAR) and CAPS. Student residential staff members who spoke with The Daily said that the safety net works.

“Students may not be aware of how many people are looking out for them and caring for them,” said Koren Bakkegard, associate director of UAR.

Bakkegard and Golder said that faculty and staff frequently report potentially troubled students.

“It’s really common for us to get a call from an IHUM fellow, saying, ‘Someone doesn’t quite seem themselves in section lately,’” Bakkegard said.

“It might be a custodian in a residence hall, it might be someone who’s at the dining hall, noticing someone’s eating pattern changing,” Golder said.

Bakkegard said that UAR asks residence deans and resident fellows to check on students through RAs.

“We follow up on every lead that we get that there might be something that is not quite right with a student,” she said.

A former freshman RA currently staffing in an upperclass house confirmed this system, saying she had once been asked by an IHUM teaching assistant to check up on a student who had not been to section regularly.

The RA added that in addition to University faculty and staff “flagging” students, RAs in different dorms and houses communicate with one another.

“Both as a freshman RA and an upperclass RA, it is not uncommon for me to get calls from other RAs with concerns about one of my residents,” she said. “Often a student will go to their RA with a concern about their friend in another dorm and that RA will contact the RA of the friend.”

This was the second in a four-part series on crisis response and mental health resources on campus. Part three will explore broader mental health issues on campus and highlight student experiences with campus services.