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Article 20

Developing Guidelines for Campus Suicide Prevention Anti-Stigma Posters

A Focus Group Approach

Darren A. Wozny & Adetura Taylor

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Paper based on a program presented at the 2009 American Counseling Association Annual Conference and Exposition, March 19-23, Charlotte, North Carolina.

Introduction

One of the primary aims of our campus suicide prevention program is early identification of distressed at-risk students followed by appropriate referral to campus counseling services. Poor help- seeking attitudes and behaviors, on the part of the referring party (faculty, staff, and students) or the distressed student, can result in either referrals not being made or distressed students not following through on a counseling referral. One component of poor help- seeking behavior is a perceived stigma against those who receive mental health counseling (Suicide Prevention Resource Center [SPRC], 2004). SPRC (2004) indicated that one of the primary factors associated with the increased demand for campus counseling services for students with serious psychological issues was decreased stigma associated with mental illness and help-seeking on college campuses. However, this is not to say that mental health stigma is no longer an issue on college campuses, as there are still many college students with serious psychological issues that fail to seek counseling services (American College Health Association, 2001). Thus, an effective campus suicide prevention program must be able to early- identify at-risk college students and encourage those students to seek help from others (including friends, family, and campus counseling services). The anti-stigma project aims to increase early- identification of at-risk students and increase conducive help-seeking attitudes and behaviors among the campus community (faculty, staff, and students). The anti-stigma guidelines will be utilized to develop anti-stigma slogans and artwork for the campus.

Statement of the Problem

Going to college and staying in college is a protective factor for suicide risk. The Big Ten Suicide Study (Silverman et al., 1997) identified reported suicides among Big Ten University campuses over a 10 year period and reported a college suicide rate of 7.5 per 100,000 students. However, the general population suicide rate when matched for age, gender, and race was 15.0 per 100,000 (SPRC, 2004). Yet, suicide and related mental health issues are still a significant problem on college campuses. The American College Health Association (2001) national survey of 16,000 students across 28 college campuses reported that 9.5% of college students had suicidal ideation, 1.5% had made a suicide attempt, 50% reported feeling very sad, 33% reported feeling hopeless, and 22% felt depressed to the point of impaired functioning.

Although suicide and related mental health issues are a problem for the general college student population, there are college subpopulations that are at increased risk for suicide, particularly males, older students (25 years and older), and graduate students (both male and female; Silverman et al., 1997). Nontraditional college students (students 25 years and older) have some unique stressors that include commuting to college (less able to participate in extra-curricular college activities), loss of status if they have quit work to attend college (Silverman, 2004), work/family/school balance for those students that attend college while continuing to work and raise families, and academic-related challenges of returning to school after a prolonged absence (SPRC, 2004). Another college student subpopulation that overlaps with older nontraditional students are commuter students, who tend to have weak ties to their college whereby they only appear on campus to attend classes, lack “school spirit,” and are difficult to engage in school-based programming (SPRC, 2004).

Despite the fact that suicide and related mental health issues are commonplace on all types of college campuses, including commuter campuses, many students fail to seek counseling services. The American College Health Association’s study (2001) found a discrepancy between students who report that depression impaired their functioning (22%) and students who have been diagnosed with depression (6.2% of males and 12.4% of females). This highlights that many students with serious mental health issues are not seeking treatment. One of the primary reasons for not seeking counseling services is the stigma associated with counseling. This results in non- conducive help seeking attitudes and behaviors whereby, regardless of severity of mental health issues experienced, some students do not attend counseling even if referred.

The question then becomes how to increase help-seeking attitudes and behaviors on college campuses so that distressed students can receive counseling treatment when needed.

While there is no evidence base supporting the efficacy of social marketing approaches at present, many suicide prevention practitioners believe that campus social marketing campaigns can stimulate cultural changes that destigmatize mental health problems, remove barriers to accessing appropriate care, and encourage help-seeking. (SPRC, 2004, p. 24)

Research Gaps

In addition to the lack of established efficacy in mental health anti-stigma programming, there is also a dearth of research associated with how to promote mental health or prevent suicides on commuter campuses (SPRC, 2004).

Research Question

What are the key guidelines for the development of effective anti-stigma posters for implementation on a commuter campus?

Anti-Stigma Project

Campus Setting

Our campus is a small regional campus (712 students) of a major public state university (16,206 students). It is located 100 miles from the main campus which houses most university services, including the college counseling center. Our campus is a commuter campus as many students commute to campus from surrounding counties. The regional campus student population (712 students) has the following characteristics related to academic class (71% undergraduate; 29% graduate); gender (76% female; 24% male); race (68% White American; 29% African American; 2.5% American- Indian); and age (71 % nontraditional students; 29% traditional students; 63% older students aged 25-49 years).

Campus Suicide Prevention Program Grant Activities

The SAMHSA federal grant guidelines stipulated that campus suicide prevention grant activities should be limited to the five primary project activities that include development of the following: mental health network; campus crisis response plan; integration of the National Suicide Prevention Lifeline in the campus crisis response plan; informational materials for students and their families; suicide prevention gatekeeper/awareness training workshops, early identification of students-at risk, and promotion of help-seeking behaviors among distressed students. The primary grant project activity of promoting help-seeking behaviors is principally concerned with reduction of stigma associated with students seeking help for mental health issues.

Method

Participants

Seven counselor education graduate students took part in a 90 minute focus group regarding the development of anti-stigma poster guidelines. The participants’ demographic characteristics included: gender (85.7% female); age (average age 38.4 years, range 27-57 years); education (100% graduate students); employment status (85.7% work full-time; 14.3% work part-time); marital status (71.4% married; 14.3% divorced; 14.3% single); number of children (average 1.43 children per participant).

Procedures

Focus group participants were shown three student-developed suicide prevention anti-stigma posters as well as a four-part professionally developed anti-stigma poster series (Don’t Erase Your Future, n.d.) that have different anti-stigma messages and are visually different in design.

Focus Group Questions.

All focus group participants were asked the following questions:

1. What is your initial reaction to the posters?

2. What do you think is the purpose or intent of these posters?

3. How well do you think that these posters achieve their purpose?

4. In terms of visual design of the posters, what seems to work and what changes would you recommend for future posters?

5. In terms of the content or message of the posters, what seems to work and what changes would you recommend for future posters?

Task.All focus group participants were instructed to write anti-stigma slogans (maximum one sentence/slogan) for our campus aimed at raising awareness of campus mental health issues and encouraging help-seeking behaviors among campus students. Each of the anti-stigma slogans was critiqued by the focus group to maximize their potential effectiveness. For each developed anti-stigma slogan, focus group participants were asked, “What, if any, changes would you recommend with this developed anti-stigma message?” All suggested changes were debated among the focus-group participants until a group consensus was reached on each slogan.

Data Analysis Methods

Researchers read the focus group transcript to become familiar with content. The first researcher wrote in the margin the basic meaning of each participant’s statement (in black ink). The second researcher read the transcript and the first researcher’s basic meaning statement in the margin. If the second researcher concurred with the basic meaning statement of the first researcher, the meaning statement was left unchanged in the margin. If the second researcher disagreed with the basic meaning statement of the first researcher, the second researcher wrote a second meaning statement beside the first meaning statement (in blue ink). The member check process involved returning the focus group transcript and their respective meaning statements to the participants to have them provide feedback on the meaning of their original statement. The participants agreed with the first or second researcher’s meaning statements (with a check mark in red ink) or wrote a third meaning statement beside the existing meaning statements (in red ink). Participant meaning statements were then organized and sorted into categories to answer the research question (developing guidelines for anti-stigma posters).

Results

The analysis of the focus group transcript was sorted into three primary categories. Each of the three primary categories of mental health anti-stigma guidelines had subcategories of more specific guidelines.

Category 1: Visually Engaging Aspects of Mental Health Anti-Stigma Posters

Sub-category 1: Use of color is visually engaging.“My initial reaction is that it’s colorful.”

Sub-category 2: Use of pictures on poster is visually engaging.“My initial reaction was to see if there is anyone I know.” Sub-category 3: Creative artwork on posters is visually engaging. “Because like aside from what is actually said content wise, just art alone could actually engage us even if we don’t particularly like the message.”

Sub-category 4: Must use appropriate font size and attractive font.“When you read the bottom (of the poster) it makes sense. If I was just walking by I would not have stopped to read it. If it (font) was bigger it (poster) would have caught my eye.”

Sub-category 5: Use of non-message space on poster is more visually engaging (brief messages result in larger non-message space). “With the ‘I have a dream’ (poster), my initial reaction was that it was a good theme but why did they erase the dream off (chalkboard in poster).”

Sub-category 6: Use of visual contrast through color is visually engaging.“The poster with all the people on it (student anti- stigma poster), if it had one single person maybe be black and white instead of color, that was obviously unhappy, I think would probably catch the attention in a way that the message was trying to bring out.” Sub-category 7: Pictures that show human diversity are visually engaging. “My initial reaction is that there are a lot of people (student anti-stigma poster), different people from different walks of life, background and age.”

Category 2: Engaging Aspects of Mental Health Anti-Stigma Poster Messages (Slogans)

Sub-category 1: Message has to be age-appropriate (use of common issues). “I was thinking maybe this (Don’t Erase Your Future poster) would be geared toward an elementary child because of the blackboard and the cursive writing.”

Sub-category 2: Message can be culturally targeted. “But the Martin Luther King one and the one with Rosa Parks (Don’t Erase Your Future posters) those are the ones we as African Americans hear often. The ‘I have a dream’ one kind of catches my eye to read it…and you just know those words. They caught my attention more than the others. I didn’t read the other (posters).”

Sub-category 3: Messages need to be clear and unambiguous. “Talking can help.”

Sub-category 4: Message needs to arouse curiosity. “Okay, why did they start writing (on chalkboard on the Don’t Erase Your Future poster series) and then erase it off?”

Sub-category 5: Message needs to be in positive terms. “Talking is helpful.”

Sub-category 6: Messages that use “play on words” of existing slogans are engaging.“Yeah, she was the one who took an existing slogan (‘great taste, less filling’), and then did a play on words with it (‘great taste, less feeling’), right? And that part of it was good.”

Category 3: Aspects of Anti-Stigma Poster Messages (Slogans) That Fail to Engage

Sub-category 1: Too much information on poster. “My initial reaction was that there is a lot of stuff to read at one time.”

Sub-category 2: Some parts of poster message not emphasized on poster. “All of the stressful things (mental health issues on poster) stand out to me, but you kind of miss the ‘seek counseling for everyday dilemmas part’ until I looked at it a second time.”

Sub-category 3: Poster message is unclear or ambiguous.“My first reaction to it was that it didn’t seem like a poster at all about hurting people because the people had happy expressions on their faces. But the poster doesn’t tell me anything. I don’t even know what it was about.”

Sub-category 4: Poster message may arouse curiosity but still fail to engage. “I wondered why they left it off (Don’t Erase Your Future poster series). It wouldn’t have been something I would have stopped to read if I was just walking by in the hallway.”

Sub-category 5: Some choice of language in the poster message fails to engage readers.“I’m not really sure that it does decrease stigma because I get what they are saying (Don’t Erase Your Future series). You know, saying that if those people (historical figures represented in the poster series) committed suicide they wouldn’t have done the great things they did, but it really doesn’t relate to the average person being depressed or whatever.”

Through a group critique process, the focus group participants developed 10 mental health anti-stigma slogans (messages) that would be appropriate for our commuter campus.

1. You are not alone. There is a way out of sadness.

2. Depression makes you feel small, seek help before you disappear.

3. Are you going down for the last time? There is help to be had!

4. Don’t let the pressure of life get you down – talk to others!

5. Chill out! Exercise more. Take charge of your life! Run, play and have fun!

6. Just do it! Talk about your daily dilemmas.

7. Everyone struggles at times in life. It is okay to talk about it.

8. What time is it? Time to talk! Talk about what? Talk about you!

9. Is stress taking over your life? Talk to someone.

10. Is it time…to seek advice for those concerns troubling you?

Discussion and Future Directions

How are the research results to be utilized in the campus suicide prevention project? The focus group participants developed mental health anti-stigma slogans (see results section above) based on their guideline discussions on what makes an effective anti-stigma message (see results section – categories 2 and 3). The mental health anti-stigma slogans (messages) and the visual-based guidelines (see results section – category 1) were given to a creative arts teacher education class to paint the canvases for the mental health anti-stigma paintings. The campus mental health anti-stigma painting series (15 paintings; some slogans utilized twice with different artwork) will be part of a permanent campus art collection and will include card boxes under each painting with campus counseling services contact information and emergency phone number wallet cards.

The next step after the campus mental health anti-stigma artwork series is displayed on campus is to evaluate the effectiveness of the project. Why is it important to evaluate this anti-stigma project? Evaluating our anti-stigma project will begin to address the research gaps of establishing efficacy in anti-stigma social marketing programming, as well as how to promote mental health or prevent suicides on commuter campuses (SPRC, 2004).

The future evaluation plans for the campus mental health anti- stigma project include evaluation of campus students’ help-seeking attitudes as well as their help-seeking behaviors. To evaluate the campus students’ help-seeking attitudes, the Attitudes toward Seeking Professional Psychological Help Scale (ATSPPHS) will be included in the evaluation process so that the campus students’ attitudes can then be compared prior to anti-stigma project implementation (pretest) and at one-year post-implementation (posttest) for returning students. To evaluate campus help-seeking behaviors, all campus faculty/staff and student peer helpers will report monthly: (a) number of distressed students that they encountered overall; (b) number of distressed students that they attempted to engage; (c) number of distressed students that they successfully engaged without need for referral; and (d) number of distressed students that they referred for campus counseling services. Our contracted campus counseling service provider will track the following information: (a) number of referrals (quarterly); (b) referral source (self; campus source – faculty, staff, student peer helper; other student, family, or other); (c) follow-through on referral for counseling (first session attendance). Campus students who attend counseling will be asked as part of the intake process which, if any, of the campus suicide prevention project activities, including anti-stigma project, influenced their decision to attend counseling. Students will have the opportunity to check all the activities that apply.

Why should counselors be interested if mental health anti- stigma projects work? Evaluating an anti-stigma project to establish if it decreases mental health stigma and increases help-seeking attitudes and behaviors should be of major interest to all practicing counselors because it begins to address a broader issue of how to encourage individuals with mental health issues to seek help when necessary. Underutilization of counseling services by individuals in need is a continuing problem to the field of counseling. Many helpful guidelines associated with developing a commuter campus mental health anti-stigma artwork campaign were learned through our focus group approach. This focus group approach allowed our commuter campus to develop an effective, targeted, and visually engaging mental health anti-stigma artwork campaign that will be an integral part of our campus suicide prevention program for years to come.

Funding for this conference presentation was made possible (in part) by grant no. 1H79SM057854-01 from SAMHSA. The views expressed in written conference materials or publications and by the speakers and moderators do not necessarily reflect the views, opinions, or official policies of the Department of Health and Human Services and SAMHSA.