After a Suicide, What Colleges Can Do to Protect the Public Health

In just one year at Appalachian State University, nine students died, at least four of them by suicide. Administrators wondered whether they were doing something wrong, or could do something better.

Campus leaders that year didn’t see any direct connections among the deaths, but they sought expert help in examining their procedures. How a university responds to a suicide can be a matter of public health, especially as rates of depression and anxiety grow among college students.

“When there are a lot of deaths on the college campus, it probably makes things seem even darker for somebody who’s already in a dark place,” says Dan Jones, who was the university’s counseling-center director in 2014-15, when the 18,000-student campus experienced the series of deaths.

He and other administrators turned to experts in what’s known as postvention: best practices for handling communication, counseling, mourning, memorialization, and other matters following a suicide. Appalachian State adopted a 16-page protocol, in sync with a similar guide published by the Higher Education Mental Health Alliance, making it among the first colleges to customize broad recommendations to the practicalities and culture of its campus.

Preventing Suicide Contagion

No college wants to plan for the aftermath of a student’s suicide, but not to, experts say, is reckless and dangerous. “Postvention” guidelines on how best to notify students, handle mourning and memorials, and offer counseling might play a crucial role in averting suicide clusters.

• A Postvention Primer
• Resources for Handling Suicide’s Aftermath
• What to Say After a Student Dies

About 1,100 college students die by suicide each year. Having a plan in place for the possibility of a student’s suicide might help prevent subsequent deaths that could occur through a contagion effect. Postvention practices aim to counter contagion through a combination of counseling and other interventions, carefully tailored notification and news-media strategies, and discouragement of memorial events. It is part of a comprehensive public-health approach to suicide that also involves tracking data to discover particular vulnerability in certain student demographics and restricting access to dangerous places, materials, and situations. Postvention is viewed with particular urgency as national suicide rates tick up and Generation Z students arrive on campus with their own set of challenges and susceptibilities.

The statistics are especially grim for young men, who die by suicide about four times as often as young women in the 15-to-19 age group, says Greg Eells, director of counseling and psychological services for Cornell University’s health services. At Cornell, he says, citing data going back to the 1980s, about 90 percent of student suicides have been men.

Suicide “amplifies all the vulnerabilities that were there, individually and systemically, so having a good postvention plan in place is really a key element in preventing a secondary death,” says Jane Wiggins, director of the Campus Suicide Prevention Center of Virginia, which offers training and guidance to 72 colleges in the state.

From a liability standpoint, too, colleges that haven’t designed postvention plans would be wise to, says Gary Pavela, an expert on law and higher-education policy. Imagine that you’re the general counsel representing a college in a negligence suit over a suicide cluster. You’d be mighty uncomfortable facing the judge if that college didn’t have postvention practices and suicide data tracking in place.

Yet fewer than half of colleges are aware of or have instituted postvention protocols, estimates Nance Roy, an assistant clinical professor of psychiatry at Yale University and clinical director of the Jed Foundation, which promotes mental health and suicide prevention among teens and young adults.

General postvention guidelines need to be tailored to each campus and backed by its top leaders, says Ms. Roy. Just as important, she says, postvention procedures can’t just be on paper. Those responsible for various tasks need to regularly meet, review, and rehearse their roles.

Among the major components of how colleges should plan to respond to suicide are questions of memorializing the student who died and communicating about the death.

After its series of campus deaths, Appalachian State put in writing that it would not recognize memorials that the university could not control. In a tradition that dates back decades, the names of students who have died while attending the university since 1990 are read aloud yearly in a ceremony of remembrance. This is the only memorial service that the university will support. The guideline treats all deaths the same out of a sense of fairness but also to avoid sponsoring ceremonies that might unintentionally glorify a suicide.

Appalachian State changed, too, how it handles announcements of suicides and other deaths. The protocol dictates that student deaths are announced to the campus at large only if the death could be part of a wider threat to campus safety.

J.J. Brown, dean of students, explains that the wide notifications, once thought to be helpful, were reconsidered after students became distressed by them. At the large university, many receiving the emails didn’t know the student who had died. But the emails would prompt them nonetheless to agonize over futile what-ifs: Had they known the student, would there have been some way they could have helped?

Administrators now contact only “high-risk groups” of students they feel are most likely to be affected by the loss. Those include classmates, club mates, teammates, dating partners, and siblings who are also enrolled at the university. Those groups are invited to a mourning room, where they can grieve with counselors on hand. Students can write messages in a memorial book that is then offered to the family of the person who died. Other students aren’t barred from the room, but it isn’t publicized.

Like all postvention practices, it’s a matter of balance, says Victor Schwartz, the Jed Foundation’s chief medical officer. “If you don’t communicate anything, then you’re liable to make students more anxious, because they then start to wonder if something’s being covered up,” he says. “But if you communicate too much, you can make them more anxious or increase the risk of contagion.”

Involving students themselves in postvention efforts can also be effective — if done carefully. You don’t want to dwell on the topic in a disproportionate and morbid way, says Cornell’s Mr. Eells. But students are smart, and they’re often aware of the threat of contagion. If they can and want to generate a therapeutic and supportive climate, they should be helped and encouraged to do so. He gives as an example Cornell’s Lift Your Spirits campaign that, along with music and free snacks, offers peer-to-peer information about mental-health services.

Postvention started to gain momentum in the 1990s after shootings in elementary and secondary schools, says Ms. Wiggins. It was advanced in the early 2000s as experts started shifting from an individual-counseling approach to a comprehensive public-health strategy for suicide prevention. Postvention is part of that strategy, along with eight other components, including treatment and identifying troubled students. The concept was bolstered, says Mr. Pavela, when a scientific and not just anecdotal consensus was reached that suicide clusters are real and might at least sometimes be averted. Summarizing studies going back to the 1970s, Madelyn S. Gould and Alison M. Lake wrote in a 2013 paper published by the National Academy of Sciences that “suicide contagion exists and contributes to suicide risk along with psychopathology, biological vulnerability, family characteristics, and stressful life events.”

Increased scrutiny of suicide hazards and trends is warranted, Mr. Pavela says, given the growing prevalence of depression among incoming Generation Z students. He points to National College Health Association data showing a rise, from 32.6 percent to 40.2 percent, between 2013 and 2017, in the number of college students who reported feeling “so depressed that it was difficult to function” at least once in the past year. Suicidal ideation rose from 8.1 percent to 11.5 percent and attempted suicide from 1.3 percent to 1.7 percent.

Postvention’s effectiveness, experts say, is hard to gauge. It comes down to sensing, if not measuring, what isn’t occurring that might have, and in a realm where numerous factors come into play. But as part of that comprehensive public-health mind-set cited by Ms. Wiggins, postvention is, if nothing else, a system to help colleges stay mindful regarding a campus’s mood, volatility, and vulnerability.

Beyond messaging, the public-health approach to suicide has more visible, material implications. There are instances in which a common method, if not cause, links suicides. For instance, in 2003 and 2004, there was a series of six deaths at New York University, where all of the students jumped from buildings. (Five were considered suicides; the sixth was ruled an accident.) At Cornell, in 2009-10, a series of students killed themselves by jumping off bridges, prompting David J. Skorton, the president, to take out a full-page ad in the student paper that read: “Your well-being is the foundation on which your success is built. If you learn anything at Cornell, please learn to ask for help.”

Jumping deaths get disproportionate attention because of their grim visibility and the news coverage. But they also demonstrate one clear benefit to analysis after suicides: the need to physically restrict sites tempting to those already prone to harming themselves. There’s a myth, says Mr. Eells, that people intending to kill themselves will manage to do so one way or another. Not necessarily, he says. Relatively easy opportunities and methods to do so in a dark moment matter, and the fewer of those opportunities that are available the better.

Fencing, netting, awnings, and screens to obscure vertical sightlines have been erected at Cornell, in parking garages at the University of Texas at Austin, and elsewhere. Less obvious than fencing is carefully restricted access to firearms and chemicals. Firearms continue to be the most frequently used means of suicide in the United States, says Chris Brownson, associate vice president for student affairs and director of the counseling and mental-health center on the Austin campus.

To make smart changes in a college’s facilities or culture requires data. But a recent AP survey found that only 46 of the largest 100 public universities track suicides on their campuses. Without such data, Mr. Pavela says, colleges miss out on important patterns, like the increased suicide rate among transfer students that Clemson University discovered from its analysis.

In response to that information, Clemson is now including staff members from its suicide-prevention effort at the university’s transfer-student convocation, says Almeda R. Jacks, vice president for student affairs. It also plans to provide suicide-prevention materials to transfer students in their residences when they get to campus. And it is planning to add mental-health wellness and suicide-prevention material to a course that transfer students take to transition to the university.

Tracking suicide statistics can be difficult. Various departments on campuses — the dean of student’s office, the registrar’s office, the counseling center, and the police department, among others — might have information that’s not shared or centralized, possibly leading to under- or overcounting. Hipaa and other privacy guidelines can be obstacles. Some deaths occur off campus or during vacations. Others are recorded as accidents, or overdoses or poisonings, in which suicidal intent is partial or unclear.

Still, colleges that don’t at least try to track that information are only hurting themselves, says Mr. Brownson, of the University of Texas, because they might miss those patterns that could help save lives.

Alexander C. Kafka is a senior editor and oversees Idea Lab. Follow him on Twitter @AlexanderKafka, or email him at alexander.kafka@chronicle.com.