Stratifying Suicide Risk among College Students: The Role of Ambivalence

Résumé

Suicide prevention continues to be an area of major public concern, with suicide ranking as the third leading cause of death among U.S. youths ages 18 to 25 years-old (CDC, 2015), and the second leading cause of death on college campuses (SPRC, 2004). Researchers have advocated for greater attention to the assessment and treatment of at-risk college students; yet, it remains exceedingly difficult to determine which individuals will move from passive ideation to either death by suicide or resolution of suicidal ideation. Additionally, a factor that is missing from many contemporary models of suicide is the subjective ambivalence a person experiences when choosing to live or die. Consequently, the primary aim of this dissertation was to investigate the role of ambivalence in the suicidal mind and its usefulness in stratifying risk among suicidal college students. Two distinct methodologies developed to-date have demonstrated clinical utility in categorizing patients and in predicting clinical outcomes based on variations in ambivalence. The first, called the “Suicide Index Score” is derived from the internal struggle hypothesis (i.e., ambivalence pertaining to one’s desire or wish to live versus die), whereas the second stems from studies of a ‘‘Suicide Motivation’’ construct (i.e., ambivalence pertaining to one’s reasons for living versus dying). However, previous studies using these methodologies typically involved only small, homogenous samples and did not assess how these two types of ambivalence may interact to better predict risk or treatment response. Thus, this study employed a series of binary logistic regression and longitudinal multilevel modeling analyses to investigate these ambivalence constructs and relevant moderators within an archival data set (n=226) of suicidal college students treated at a University Counseling Center between 2008 and 2013. Overall, the results support the notion that suicidal individuals are a clinically heterogeneous group and that the Suicide Index Score and Suicide Motivation methodologies are related but distinct measures of ambivalence. Clients’ Suicide Index Scores at treatment onset significantly impacted baseline ratings of suicide risk and treatment response over time. Wish to live clients started at lower risk than ambivalent or wish to die clients. Both wish to live and wish to die clients peaked in treatment response (i.e., reduction of suicide risk) by approximately session 16, whereas ambivalent clients peaked by session 20. Further, having a greater number of reasons for living was associated with faster rate of improvement among wish to die clients, but a slower rate of treatment progress among ambivalent clients. Regarding resolution of suicidal ideation, among clients who reported more reasons for living than for dying, wish to live clients were nearly three times more likely to resolve than were ambivalent clients. On the other hand, among clients who reported more reasons for dying than for living, ambivalent clients were more likely to resolve. Baseline self-hate ratings and gender were also significant moderators of the associations between Suicide Index Score and resolution, and Suicide Motivation and resolution, respectively. Secondary findings further revealed that suicidal international students were between three to five times more likely to drop out of treatment or withdraw from the university than were suicidal domestic students, and that Asian/Asian-American clients were nine times more likely to drop out or withdraw than were students who identified as other non-white ethnicities. Taken together, these findings indicate that understanding suicidal ambivalence at treatment onset can provide useful insight into how a client will respond to suicide-focused treatment, and in the long-term, may help inform clinical efforts to match a range of suicidal clients to optimal levels and styles of care. ÉTATS-UNIS JEUNE-ADULTE ÉTUDIANT-UNIVERSITAIRE IDÉATION AMBIVALENCE MOTIVATION FACTEUR-RISQUE CULTURE DÉSESPOIR