Ethan Phillips was 13 years old when he first heard the term "suicide contagion."
It's the scientific concept that after one person dies by suicide, others in the community may be at higher risk.
Phillips learned the phrase growing up in Fairfax County, Va., where more than a dozen teens and preteens died by suicide while he was in middle school. It came up again when a high school classmate killed himself. By the time Phillips entered college at the University of North Carolina-Chapel Hill in 2019, he'd developed "an unfortunate level of experience" in dealing with the topic, he says.
So this fall, when Phillips — now a junior and head of the UNC student government's wellness and safety division — heard that two students had died by suicide on campus within 48 hours, he knew what to do.
Along with his peers in student government, Phillips shared mental health resources on social media, developed email templates for students to request accommodations from professors — if they needed to — to allow extra time to deal with the trauma of losing a friend, and held a meeting of various mental health clubs on campus to coordinate their response. His focus was first on communicating quickly and clearly about the deaths to the student body, and second on informing students about mental health resources available to help them deal with their grief.
Those are two crucial steps in a growing area of study known as "suicide postvention." Just as there's research on how to prevent mental health crises and interventions for people who are actively suicidal, research is also developing around the effective steps that can be taken after a suicide to help communities grieve, restore a sense of stability and limit the risk of more deaths.
It's an area of particular interest for colleges, as suicide is the second-leading cause of death for U.S. teenagers and young adults, and these are the groups most likely to experience contagion. With the COVID-19 pandemic exacerbating depression and thoughts of suicide in some people, several universities have needed postvention strategies over the past year and a half.
Saint Louis University, Dartmouth College and West Virginia University have lost multiple students to suicide during the pandemic. At UNC, the two deaths in October came after a suicide death and suicide attempt in September. A national survey in the spring by the American College Health Association found 1 in 4 students had screened positive for suicidal thoughts and 2% had attempted suicide in the previous 12 months.
"Knowing this, we have to be even more alert," says John Dunkle, former director of counseling services at Northwestern University and a senior director with the nonprofit Jed Foundation, which works to prevent youth suicide. "Getting that postvention plan in place before a tragedy occurs is really critical."
How to prevent suicide's spread and heal vulnerabilities
According to best practices emerging from research, a postvention plan (which should be developed ahead of time, and ready to deploy immediately after any death by suicide) should include:
Creating this type of postvention plan is a challenging task, involving the uncomfortable topic of death and thorny legal questions of liability. It also requires balancing the sometimes conflicting desires of the deceased student's family — who may not want the death acknowledged as a suicide due to stigma or privacy concerns — and those of the students and staff on campus who want to have an open discussion about what happened.
Phillips saw these complexities play out when he was in middle and high school. So when UNC leaders took a day and a half after the first suicide in October before releasing a statement acknowledging the death and the anguish many other students were feeling, he understood why.
Still, he saw the repercussions of that delay in the college community. Rumors swirled on social media, with some people suggesting the university wasn't paying enough attention to mental health concerns at UNC. "Where it showed its negative effects most acutely [was among] faculty who did not know what was occurring on campus," Phillips says. Some were caught off guard by students' grief and anger at the university, or by their requests for extensions on assignments.
UNC declined to answer our questions about its response to the suicides and whether it has a postvention plan in place. On Nov. 15, the university did hold a one-day mental health summit "for faculty, staff and student leaders" to address campus culture, crisis services and prevention. In a written statement, the university said it also plans to launch a campus-wide campaign to make students and other community members aware of the signs and symptoms of mental health distress, and inform them of the different ways they can reach out to each other and to university services for support.
Communicating about these deaths in a healthy way can be tricky
Dunkle says communication about suicide is among the trickiest pieces of postvention. While students want information immediately, universities can be hamstrung by pending death investigations or a family's wishes for privacy. Officials also must avoid sharing details, like the manner of suicide, as research has shown that can increase contagion.
What's most important, Dunkle says, is to quickly and consistently provide mental health resources.
After the two student deaths in October, UNC's communication to students listed the campus counseling center, the office of the dean of students, peer support services and national hotlines. The school also created temporary support centers with counselors throughout campus.
That was a good start, Phillips says, but since the support centers were open only during the daytime, some students found it difficult to go there between classes.
Christopher Grohs, a student in occupational therapy at UNC and director of health and wellness for the graduate and professional student government, echoes that concern. Many graduate students have told him they don't know where the counseling center is on the 729-acre campus or how to use it. "A big barrier to using a resource is being able to locate it," Grohs says.
Get students involved in the solution
This on-the-ground understanding is why students should be consulted when universities develop postvention plans, says Amy Gatto, a senior manager at Active Minds, a nonprofit focused on mental health for young adults. "They're going to be able to give more valuable feedback than just a committee of staff members."
At Johnson C. Smith University — a small, historically Black college in Charlotte, N.C. — counseling services director Tierra Parsons says she looks for opportunities throughout the schoolyear to survey students and adjust the mental health services that are offered accordingly. Over the years, students have suggested they'd like more virtual and text-based options for getting mental health support, she says. In fall of 2020, the school brought on telehealth provider TimelyMD. This year, it asked graduate students in social work to spend their internship hours in undergraduate residence halls, to be available to students where they live.
"We want to be where students need us, and sometimes that requires coming out from behind the desk," Parsons says.
Just as important as this sort of campuswide outreach is directly contacting classmates, teammates, roommates and the like who were closest to the student who died, mental health experts say.
At the University at Albany in New York, the counseling center creates a list of these students and fast-tracks them to an urgent consult if they reach out, says center director Karen Sokolowski. And if the students don't reach out, counselors contact them to talk about grief and ask whether they need extensions on homework or time away from school.
Students should also be asked about their access to guns or other lethal means of self-harm, says Qwynn Galloway-Salazar, student division chair for the American Association of Suicidology. Depending on their answers, the university could distribute gun locks or talk about safe storage of medications, for example. After a series of suicides at Cornell, the university added safety nets to local bridges.
"You are so loved"
Another important postvention step can be limiting memorials. Although students need opportunities to grieve, experts say memorials sometimes glamorize suicide and lead others with suicidal thoughts to see death as a way to receive love and attention. Instead, they suggest directing students to volunteer or donate to a cause they care about in their classmate's memory.
At UNC, in the days after the two suicides, members of the campus Active Minds chapter wrote more than 150 notes of affirmation and distributed them to students with lists of mental health resources, says club co-president Evan Aldridge. Other students wrote messages in chalk outside the student union reminding peers "it's OK to rest" and "you are so loved."
Although those messages have faded in the weeks since, the students' postvention efforts have not.
Phillips says these efforts to bolster mental health in the university community — and teach others how to do so — should continue for years, just as they have where he grew up. "I don't know that we're ever out of postvention."
Kaiser Health News is a national, editorially independent newsroom and program of the Kaiser Family Foundation, and is not affiliated with Kaiser Permanente.
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