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From Role-Play to Real Life: Using Gatekeeper Skills in Real-World Situations

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Title: From Role-Play to Real Life: Using Gatekeeper Skills in Real-World Situations
Language: English
Authors: Marian Reiff (ORCID 0000-0003-1199-6598), Alaina Spiegel, Elizabeth Williams, Brinda Ramesh, Soumya Madabhushi, Batsirai Bvunzawabaya
Source: Journal of College Student Mental Health. 2024 38(1):119-148.
Availability: Routledge. Available from: Taylor & Francis, Ltd. 530 Walnut Street Suite 850, Philadelphia, PA 19106. Tel: 800-354-1420; Tel: 215-625-8900; Fax: 215-207-0050; Web site: http://www.tandf.co.uk/journals
Peer Reviewed: Y
Page Count: 30
Publication Date: 2024
Document Type: Journal Articles
Reports - Research
Education Level: Higher Education
Postsecondary Education
Descriptors: Intervention, Suicide, Experiential Learning, Skill Development, Counseling Techniques, Guidance Centers, College Students, Prevention, Mental Health, At Risk Persons, School Counselors, Counselor Training, Role Playing
Geographic Terms: Pennsylvania
DOI: 10.1080/87568225.2022.2144789
ISSN: 8756-8225
1540-4730
Abstract: While gatekeeper trainings have demonstrated their effectiveness in appraisals of preparedness, efficacy, and intention to intervene, evidence has been lacking regarding gatekeeper behaviors in real life. The I CARE training aims to increase intervention in real-world situations involving suicidality through informational and experiential learning, enhanced by emotional support and guidance from counseling center facilitators. In mixed-method follow-up assessments, respondents reported utilizing specific skills they learned during the training, noting their ability to listen, ask directly about suicidality, connect others with services, and draw on a variety of supportive resources. Of those who encountered a potentially suicidal student, two-thirds asked the student if they were thinking of hurting or killing themselves; others reported taking preventive actions. Perceived support and gatekeeper outcomes were correlated. The findings affirm the effectiveness of communal efforts to support college students' mental health and suggest ways to enhance effective intervention in actual situations with students in distress.
Abstractor: As Provided
Entry Date: 2024
Accession Number: EJ1420065
Database: ERIC
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  Value: <anid>AN0178074296;[nm80]01jan.24;2024Jun27.08:14;v2.2.500</anid> <title id="AN0178074296-1">From Role-Play to Real Life: Using Gatekeeper Skills in Real-World Situations </title> <p>While gatekeeper trainings have demonstrated their effectiveness in appraisals of preparedness, efficacy, and intention to intervene, evidence has been lacking regarding gatekeeper behaviors in real life. The I CARE training aims to increase intervention in real-world situations involving suicidality through informational and experiential learning, enhanced by emotional support and guidance from counseling center facilitators. In mixed-method follow-up assessments, respondents reported utilizing specific skills they learned during the training, noting their ability to listen, ask directly about suicidality, connect others with services, and draw on a variety of supportive resources. Of those who encountered a potentially suicidal student, two-thirds asked the student if they were thinking of hurting or killing themselves; others reported taking preventive actions. Perceived support and gatekeeper outcomes were correlated. The findings affirm the effectiveness of communal efforts to support college students' mental health and suggest ways to enhance effective intervention in actual situations with students in distress.</p> <p>Keywords: Suicide prevention; college students; gatekeeper training; gatekeeper behavior; perceived support</p> <hd id="AN0178074296-2">Introduction</hd> <p></p> <hd id="AN0178074296-3">Literature review</hd> <p>The need for mental health awareness, enhancing well-being, and suicide prevention on college campuses is a critical public health issue that has gained national attention in recent years. Reports of student distress have continually increased, as evidenced by annual nationwide studies of college undergraduate and graduate students (Lipson, Lattie, & Eisenberg, [<reflink idref="bib23" id="ref1">23</reflink>]). Recent data reveal that 45.1% of students felt so depressed that it was difficult to function, 65.7% felt overwhelming anxiety, 13.3% seriously considered suicide, and 2% attempted suicide in the past year (American College Health Association, [<reflink idref="bib3" id="ref2">3</reflink>]). Moreover, among students who screened positive for depression or anxiety in the past year, less than half reported receiving counseling or therapy from a health professional (Healthy Minds Study, [<reflink idref="bib17" id="ref3">17</reflink>], [<reflink idref="bib18" id="ref4">18</reflink>], [<reflink idref="bib19" id="ref5">19</reflink>]). A study in 2015 reported that 86% of students who died by suicide during the preceding year had not sought campus counseling center assistance, suggesting that many college students struggling with their mental health were not accessing treatment (Gallagher, [<reflink idref="bib14" id="ref6">14</reflink>]). More recent studies have shown promising changes in help-seeking among college students. Student treatment rates have gradually increased, with rates of treatment and diagnosis increasing from 19% in 2007 to 34% in 2017 (Lipson et al., [<reflink idref="bib23" id="ref7">23</reflink>]). Given high rates of student distress, gatekeeper trainings are vital to equip campus community members with intervention and referral skills to support students in need.</p> <p>Gatekeeper training (GKT) programs address the need for mental health awareness and suicide prevention on college campuses. They aim to equip community members to identify students at risk of suicidal behavior, respond effectively, and facilitate referrals to treatment and support services (Yonemoto, Kawashima, Endo, & Yamada, [<reflink idref="bib42" id="ref8">42</reflink>]). Generally, these trainings target knowledge, beliefs, and attitudes about mental health, suicide, and healthcare, and teach listening and response skills (Burnette, Ramchand, & Ayer, [<reflink idref="bib10" id="ref9">10</reflink>]; Harrod, Goss, Stallones, & DiGuiseppi, [<reflink idref="bib16" id="ref10">16</reflink>]; Lipson, [<reflink idref="bib22" id="ref11">22</reflink>]; Quinnett, [<reflink idref="bib31" id="ref12">31</reflink>]). In studies of gatekeeper training effectiveness, three levels of outcomes are examined, as described by Coleman and Del Quest ([<reflink idref="bib12" id="ref13">12</reflink>]): The first outcome level includes trainee attitudes, knowledge, self-efficacy, and intention to intervene. Many studies have demonstrated evidence for these. The second outcome level addresses the transfer of knowledge, beliefs, and skills learned in the training to actual intervention and suicide prevention behaviors. Evidence here has been mixed. The third outcome, and ultimate goal of reducing suicide attempts and suicide, is difficult to assess and rarely studied; however, one study reported a reduction in youth suicide rates in counties implementing gatekeeper training compared with counties not implementing the training (Walrath, Garraza, Reid, Goldston, & McKeon, [<reflink idref="bib38" id="ref14">38</reflink>]).</p> <p>Regarding the first outcome, multiple studies have shown evidence of pre-post change in trainee attitudes and knowledge (e.g., Burnette et al., [<reflink idref="bib10" id="ref15">10</reflink>]; Coleman & Del Quest, [<reflink idref="bib12" id="ref16">12</reflink>]; Yonemoto et al., [<reflink idref="bib42" id="ref17">42</reflink>]). However, for many gatekeeper trainings, the benefits appear to diminish over time, shown by follow-up studies at three- and six- months post-training (Shtivelband, Aloise-Young, & Chen, [<reflink idref="bib35" id="ref18">35</reflink>]). Shtivelband et al. ([<reflink idref="bib35" id="ref19">35</reflink>]) examined ways to sustain the effects of gatekeeper trainings over time, suggesting post-training interventions, such as social networking (e.g., connecting with other gatekeepers), continued learning, community outreach, accessibility, reminders, program improvement, and certification could improve retention (Shtivelband et al. [<reflink idref="bib35" id="ref20">35</reflink>]). It has yet to be determined if these factors aiding retention could also enhance gatekeeper behaviors post-training.</p> <p>Fewer studies have examined the second outcome level, which includes how well trainees apply what they learn to actual real-world interactions. Although findings from some studies addressing behavior change have been encouraging, overall, findings have been mixed and a gap exists in the literature for linking GKT to behavioral outcomes (Zinzow et al., [<reflink idref="bib43" id="ref21">43</reflink>]). Wyman et al. ([<reflink idref="bib40" id="ref22">40</reflink>]) found that, despite an increase in self-reported knowledge, appraisals of efficacy, and service access from pre- to post-assessment, there was no training effect on self-reported suicide prevention behavior compared with controls. Authors have hypothesized reasons for the absence of behavior change, stating it may result from interpersonal discomfort, ambivalence about addressing personal matters (Mitchell, Kader, Darrow, Haggerty, & Keating, [<reflink idref="bib26" id="ref23">26</reflink>]), or inaccurate beliefs that may discourage both discussion of suicide with peers and referral behavior (Rallis et al., [<reflink idref="bib32" id="ref24">32</reflink>]). Results of a systematic review suggested that improved knowledge and appraisals are not sufficient to increase suicide identification behavior, and translation of training into long-term intervention behavior is generally weak (Holmes, Clacy, Hermens, & Lagopoulos, [<reflink idref="bib20" id="ref25">20</reflink>]).</p> <p>Although behavior change post-training has been challenging to demonstrate, some studies have demonstrated an impact on gatekeeper behaviors in real-world contexts. A study by Litteken and Sale ([<reflink idref="bib24" id="ref26">24</reflink>]) assessed help-giving behaviors before and two years after completing the QPR (Question, Persuade, and Refer) GKT, finding that inquiring about suicidal intention increased post-training. Kuhlman, Walch, Bauer, and Glenn ([<reflink idref="bib21" id="ref27">21</reflink>]) found that QPR trainees demonstrated higher knowledge and self-efficacy, and higher rates of gatekeeper behaviors, than untrained controls. Zinzow, Thompson, Fulmer, Goree, and Evinger ([<reflink idref="bib43" id="ref28">43</reflink>]) reported increases in suicide prevention behaviors following training on a college campus. Several studies have found a strong relationship between increased self-efficacy and gatekeeper behaviors (e.g., Kuhlman et al., [<reflink idref="bib21" id="ref29">21</reflink>]; Osteen, [<reflink idref="bib29" id="ref30">29</reflink>]), suggesting that self-efficacy may have an important role in increasing post-training gatekeeper behavior.</p> <p>Other studies have acknowledged the critical role of experiential and affective components of gatekeeper trainings in affecting behavioral change. An analysis of QPR found the addition of role-play simulations, where participants practice intervening and asking about suicide, increased observed prevention behaviors at three-month follow-up (Cross et al., [<reflink idref="bib13" id="ref31">13</reflink>]). Cimini et al. ([<reflink idref="bib11" id="ref32">11</reflink>]) demonstrated that the use of experiential exercises (e.g., role-play with behavioral rehearsal) led to application of learned skills in talking to students about suicidal thoughts or behavior at three-month follow-up. The authors reported that interactive exercises and confronting personal barriers around talking about suicide helped to establish relationships between trainees and professionals on campus who can assist students in distress (Cimini et al., [<reflink idref="bib11" id="ref33">11</reflink>]). Additionally, Mitchell et al. ([<reflink idref="bib26" id="ref34">26</reflink>]) noted that to improve behavioral outcomes, gatekeepers may benefit from information that focuses specifically on the affective factors that make it difficult for people to ask about suicidal thoughts. Given behavioral intention is a proxy indicator for behavior (Ajzen, [<reflink idref="bib1" id="ref35">1</reflink>]), the intention of gatekeepers to ask a potentially suicidal individual about suicide is a critical step in the success of any GKT program. Simply educating trainees on the importance of asking someone about suicidal thoughts does not effectively translate into real world behavioral interventions. These findings indicate factors such as social norms, empathy, resilience, theory of mind, and perceived behavioral control may need to be investigated as a significant driver of intervention behavior. It has been suggested that ample training time and practice around how to talk with suicidal peers, and addressing obstacles to referrals (e.g., belief in suicide myths, inaccurate beliefs about treatment, concern about betraying trust) may help improve outcomes (Rallis et al., [<reflink idref="bib32" id="ref36">32</reflink>]).</p> <p>While available research is mixed, there is evidence suggesting that gatekeeper behaviors may be increased when trainings include experiential exercises, emotional and relational components, and a focus on self-efficacy. In addition, a study involving staff working with youth found that organizational and supervisor support increased gatekeeper behaviors following training, suggesting an important role for support resources in participants' work settings (Moore, Cigularov, Chen, Martinez, & Hindman, [<reflink idref="bib27" id="ref37">27</reflink>]). In a recent review, Holmes et al. ([<reflink idref="bib20" id="ref38">20</reflink>]) suggest that more research is needed on the role of support for gatekeepers, and that lack of support may lead to compassion fatigue and increased stress, resulting in reduced suicide prevention behavior among trained gatekeepers.</p> <hd id="AN0178074296-4">I CARE training</hd> <p>I CARE training, at the University of Pennsylvania, is a GKT designed to equip participants with the knowledge and skills to engage and intervene appropriately with students experiencing stress, distress, and/or crisis (Reiff et al., [<reflink idref="bib33" id="ref39">33</reflink>]). The training is a campus-wide initiative developed in the aftermath of a series of student deaths by suicide in 2013 and 2014. It was developed by mental health clinicians at University of Pennsylvania's Counseling and Psychological Services (CAPS), now called Student Health and Counseling. Since its inception, this program has continued to offer space for Penn community members to come together to learn skills, address fears and anxieties, and provide opportunities for connection and healing. The training is offered in a hybrid format, comprising a 30-minute online module followed by a three-hour, interactive training that emphasizes experiential learning and role-plays. At the heart of the training is caring for others, and the I CARE acronym refers to specific skills to communicate with others (Inquire, Connect, Acknowledge, Respond, and Explore).</p> <p>The training includes several components: psychoeducation about college mental health trends; recognizing signs of stress, distress, and crisis; discussions around attitudes, stigma, and cultural factors influencing mental health; a review of counseling center services; and models for supportive listening techniques and crisis intervention skills (e.g., asking directly about someone's suicidal ideation). I CARE facilitators are all qualified clinicians from Penn's counseling center who hold graduate degrees in the mental health field. The trained clinicians use therapeutic skills throughout the training to create a safe space where participants can learn mental health content, discuss the complexities, practice skills without judgment, raise questions, process emotional reactions, and connect meaningfully with peers and counseling center staff.</p> <p>The I CARE training accentuates the importance of a caring community, emphasizing the importance of connection, relationships with others, and that everyone needs to play a role in supporting student mental health. The presenters model "caring in action" by getting to know participants, using active listening skills during the activities, and modeling their own vulnerability to the audience. The I CARE facilitators represent a "face" to a large institution, often serving as a resource for students, faculty, and staff to ask questions about counseling services or the referral process. Throughout the training, participants are reminded they are not alone, that "we are your partners," and that they can consult 24/7 with counseling center staff as situations arise in the real world. See Reiff et al. ([<reflink idref="bib33" id="ref40">33</reflink>]) for a more detailed description of the program.</p> <hd id="AN0178074296-5">Present paper</hd> <p>Assessment data from I CARE have demonstrated pre-post change in gatekeeper attitudes and knowledge and significant retention of attitudes, knowledge, and use of gatekeeper skills over a 3–15-month period (Reiff et al., [<reflink idref="bib33" id="ref41">33</reflink>]). In the present paper, we evaluate these constructs again using more refined measures and replicate previous findings. However, this paper primarily addresses how specific informational and experiential training components, as well as support resources, may help gatekeepers effectively move toward rather than move away from situations of stress, distress, and crisis in real life. We will also explore factors that may impede the effective use of gatekeeper skills and provide suggestions for future directions.</p> <hd id="AN0178074296-6">Materials and methods</hd> <p></p> <hd id="AN0178074296-7">Overview</hd> <p>This paper presents data collected from participants in I CARE trainings conducted at the University of Pennsylvania between January 2017 and December 2018. During this time, approximately 1,428 people attended 34 I CARE trainings, where 20 trainings were for students and 14 were for faculty/staff.</p> <p>Evaluation includes quantitative and qualitative methodologies conducted at pre-training, post-training, and follow-up (3–15 months post-training). Follow-up surveys were conducted in March 2018 and March 2019, with participants who completed training during each previous calendar year, i.e., between January and December of 2017 and 2018, respectively (Table 1). Data from the two follow-up surveys were combined for analyses presented in this paper.</p> <p>Table 1. Program evaluation: data collection.</p> <p> <ephtml> <table><thead><tr><td>Pre/Post-training</td><td>Follow-up</td></tr></thead><tbody><tr><td>January-December 2017</td><td>March 2018 (Completed training Jan.-Dec. 2017)</td></tr><tr><td>January-December 2018</td><td>March 2019 (Completed training Jan.-Dec. 2018)</td></tr></tbody></table> </ephtml> </p> <p>The University of Pennsylvania Institutional Review Board approved the evaluation of the I CARE program as a quality improvement project.</p> <hd id="AN0178074296-8">Participants</hd> <p>The sample included 361 trainees who completed pre-, post-, and follow-up assessments.</p> <p>There was a total of 1,428 trainees (958 students and 470 faculty/staff) between January 2017 and December 2018. Of these, 789 (527 students and 262 faculty/staff) completed both pre- and post-training assessments and were sent invitations to participate in a follow-up survey. The combined follow-up sample comprised 361 participants, a response rate of 45.8%. The follow-up sample included 217 (60.1%) students and 144 (39.9%) faculty/staff (Table 2).</p> <p>Table 2. I CARE participants and study sample.</p> <p> <ephtml> <table><thead><tr><td /><td>Students N (%)</td><td>Faculty/Staff N (%)</td><td>Total N</td></tr></thead><tbody><tr><td>Trained</td><td>958 (67.1%)</td><td>470 (32.9%)</td><td>1428</td></tr><tr><td>Pre/post assessments with valid emails</td><td>527 (66.8%)</td><td>262 (33.2%)</td><td>789</td></tr><tr><td>Follow-up (Total)</td><td>217 (60.1%)</td><td>144 (39.9%)</td><td>361</td></tr><tr><td>Follow-up (2018)</td><td>95 (55.6%)</td><td>76 (44.4%)</td><td>171</td></tr><tr><td>Follow-up (2019)</td><td>122 (64.2%)</td><td>68 (35.8%)</td><td>190</td></tr></tbody></table> </ephtml> </p> <p>The final sample comprised: 73% women, 26% men, and 1% gender non-conforming; 51% identified as White, 22% Asian/Asian American, 9% Black/African descent, 8% Hispanic/Latino, 3% Middle Eastern, and 3% Multi-Ethnic/Mixed; 81% identified as heterosexual/straight, and 18% as gay, lesbian, queer, bisexual, asexual, pansexual, or questioning.</p> <hd id="AN0178074296-9">Measures</hd> <p></p> <hd id="AN0178074296-10">Measures at pre-, post, and follow-up</hd> <p></p> <hd id="AN0178074296-11">The Gatekeeper Behavior Scale (GBS)</hd> <p>The GBS was used to assess gatekeeper skills that predict behavior and is composed of 11 items in three subscales: <emph>preparedness to intervene, efficacy</emph>, and <emph>likelihood of intervening</emph> (Albright, Davidson, Goldman, Shockley, & Timmons-Mitchell, [<reflink idref="bib2" id="ref42">2</reflink>]). <emph>Preparedness to intervene</emph> was assessed by asking participants to rate their agreement with five statements using a four-point Likert scale ("Very Low" to "High"). <emph>Efficacy</emph> was measured by four statements using a four-point Likert scale ("Strongly Disagree" to "Strongly Agree"). <emph>Likelihood of intervening</emph> was measured by two statements using a four-point Likert scale ("Very Unlikely" to "Very Likely"). Higher scores on the combined statements for each subscale indicated greater preparedness to intervene, efficacy, and likelihood of intervening respectively. The GBS measure showed good internal reliability,.86 ≤ α ≤.90 across all three time points.</p> <hd id="AN0178074296-12">Knowledge of intervention skills</hd> <p>Knowledge was assessed using two statements on a seven-point Likert scale ("Disagree Strongly" to "Agree Strongly"). These items assessed knowledge around different parts of the training: "When a student is upset, it's best to quickly suggest solutions in order to help the student calm down" (Disagree is correct) and "If I suspect that a student might be suicidal, I should ask the student: "Are you thinking about killing yourself?" (Agree is correct). The sum of the two statements indicated more knowledge on how to intervene. One item was recoded so that higher scores on the combined two statements indicated more knowledge.</p> <hd id="AN0178074296-13">Comfort and readiness to intervene</hd> <p>Comfort involved six statements with a seven-point Likert scale ("Strongly Disagree" to "Strongly Agree"). Higher scores on the combined six statements indicated greater comfort intervening and referring individuals. The comfort/readiness measure showed good internal reliability,.74 ≤ α ≤.83 across all three time points.</p> <hd id="AN0178074296-14">Satisfaction with training</hd> <p>Satisfaction was assessed by a single item asking: "Would you recommend this training to others in a similar position to you?" (yes/no). Open-ended responses allowed for more detailed feedback on the training.</p> <hd id="AN0178074296-15">Referrals</hd> <p>Respondents were asked how many students they had ever referred to the counseling center and other campus resources. These items were asked at pre- and follow-up assessments.</p> <hd id="AN0178074296-16">Measures at follow-up</hd> <p>In the follow-up survey, in addition to the measures described above, participants were asked about implementation of skills and application of gatekeeper behaviors since completion of the training. Respondents also provided quantitative and qualitative data regarding support resources that aided them in their gatekeeper role.</p> <hd id="AN0178074296-17">Application of skills</hd> <p>Respondents were asked whether they interacted with any students, colleagues, or persons in their private life who were in distress or crisis (yes or no). If the respondents gave a "yes" response, they were asked the extent to which they used the I CARE skills, using a 5-point Likert scale (from 1 "not at all" to 5 "very much").</p> <hd id="AN0178074296-18">Gatekeeper behaviors</hd> <p>Respondents were asked three statements regarding their actions taken when interacting with a student (or students) in distress or crisis, indicating the extent to which they discussed their concerns with the student, knew where to refer, and recommended services. A four-point Likert scale ("Strongly Disagree" to "Strongly Agree") was used for each statement. Additionally, respondents reported how many students they encountered who they felt concerned might be considering suicide, and what actions they took to support these individuals (selected from a list of options and wrote in any action steps not listed).</p> <hd id="AN0178074296-19">Perceived support and use of support resources</hd> <p>Additional questions were added to the 2019 follow-up survey about participants' perceived support, sources of support, and the impact of support on their gatekeeper behavior. Adding items later explains the lower sample size for these questions reported in the results.</p> <hd id="AN0178074296-20">Perceived support and use of support resources</hd> <p>These factors were measured by level of agreement with three statements, using a five-point Likert scale (from 1 "not at all" to 5 "very much"): the extent they consulted with someone about what to do, talked with someone about how they felt, and had the support they needed to intervene with a student in distress or crisis. Type of support resources (e.g., counseling center, staff, faculty, etc.) were also assessed.</p> <hd id="AN0178074296-21">Qualitative items</hd> <p>The following open-ended questions elicited qualitative information in both the 2018 and 2019 follow-up surveys: "Please describe your experience when you interacted with someone who was in distress or crisis: What happened, and what was the outcome?"; "Please let us know about any challenges or barriers you have encountered in situations with students in distress or crisis?" There was also a section for additional comments.</p> <p>Additional Questions. The 2018 survey asked one additional question: "What has been the impact of the I CARE training on your ability to support others in distress or crisis?" The 2019 survey asked three additional questions: "What has helped you most to intervene in situations of distress or crisis?"; "How does the support you receive (e.g., from Penn resources, peers, family, advisors, or other individuals) shape whether and how you intervene in situations of distress/crisis?"; and "How do you think we could help you continue to be effective at intervening with students in distress/crisis in the long run?"</p> <hd id="AN0178074296-22">Procedures</hd> <p>The pre-training assessment was completed at the beginning of the 30-minute online module. Participants received this link via e-mail prior to the in-person training. The post-training assessment was completed at the end of the in-person training via an online link that participants access on their personal mobile devices or laptops. The surveys took approximately five to ten minutes to complete.</p> <p>For the follow-up survey, a link was sent to e-mail addresses provided by participants when they completed the pre- and post-assessments. The follow-up survey took approximately ten minutes to complete. As an incentive, participants were offered an opportunity to participate in a raffle for a prize with an approximate value of $50.</p> <hd id="AN0178074296-23">Analysis</hd> <p>To test the effect of the training on participants' gatekeeper skills, knowledge of support and crisis intervention skills, comfort intervening in a situation of distress or crisis and with referring individuals for support, and sense of connection, paired sample t-tests were conducted to examine the significance of pre- and post- mean differences. In addition, to test the effect of time since the training, we conducted a hierarchical linear regression, with number of days since completing the training as the predictor, nested within participants. Outcome variables included gatekeeper behavior scale, knowledge of support and crisis intervention skills, and comfort with intervention skills.</p> <p>Pearson correlations were conducted to examine the relationships among perceived support and gatekeeper behaviors. Specifically, we focused on four gatekeeper behaviors as outcome variables, including "utilized skills," "discussed concern with student," "knew where to refer," and "recommended mental health services."</p> <p>Responses from qualitative data were analyzed using thematic content analysis, with an inductive coding approach to identify themes. Two coders independently coded the responses, reviewed the codes, and reconciled coding discrepancies to reach a consensus (Bazeley, [<reflink idref="bib5" id="ref43">5</reflink>]; Bernard, [<reflink idref="bib7" id="ref44">7</reflink>]; Morse, [<reflink idref="bib28" id="ref45">28</reflink>]).</p> <hd id="AN0178074296-24">Results</hd> <p></p> <hd id="AN0178074296-25">Responders vs. Non-responders</hd> <p>Responders to the follow-up survey did not differ significantly from non-responders regarding their pre-training scores for readiness, knowledge, and the GBS. Responders did not differ significantly from non-responders regarding post-training scores for readiness and the GBS, but did have slightly higher post-training scores for knowledge (M = 12.16 vs. 11.36, p <.01). Responders and non-responders did not differ regarding their satisfaction at post-training (96% in both groups would recommend the training).</p> <hd id="AN0178074296-26">Pre/post-training and follow-up assessments</hd> <p>Participants' satisfaction with the training was generally very positive, with 96% of the sample reporting in the post-assessment that they would recommend the training to others in a similar position to themselves. Paired-sample t-tests demonstrated significant improvement from baseline to post-training for all measures (GBS mean scores and each of the three GBS subscales (preparedness to intervene, self-efficacy, and likelihood of intervening); knowledge of intervention skills; comfort/readiness to intervene; and sense of connection (see Appendix A, Table A1).</p> <p>Paired-sample t-tests showed significant increases from baseline to follow-up, and decreases from post-training to follow-up, for all measures: (GBS mean scores and each of the three GBS subscales (preparedness to intervene, self-efficacy, and likelihood of intervening); knowledge of intervention skills; comfort/readiness to intervene; and sense of connection. While scores decreased significantly from post-training to follow-up, the amount of change was slight compared with the substantial increases from pre-training to follow-up assessment (see Appendix A, Table A1).</p> <hd id="AN0178074296-27">Duration of training effects</hd> <p>The follow-up surveys were conducted in March 2018 and 2019. Respondents had completed training workshops between the previous January and December, and time since the I CARE training ranged from 91 to 428 days (approximately 3–15 months). To test the effect of time since the training on the outcome variables related to intervening behaviors, we conducted hierarchical linear regressions, with GBS, knowledge of intervention skills, and comfort/readiness to intervene as the outcome variables, and number of days since the training as the predictor, nested within participants.</p> <hd id="AN0178074296-28">Gatekeeper Behavior Scale (GBS)</hd> <p>The effect of time since the training on GBS scores was statistically significant and negative, with each day associated with a decrease of 0.0004 points (t(<reflink idref="bib310" id="ref46">310</reflink>) = −6.03091, <emph>p</emph> = <0.01) in GBS scale scores (Appendix B, Figure B1).</p> <hd id="AN0178074296-29">Knowledge of intervention skills</hd> <p>The effect of time since the training on knowledge was statistically significant and negative, with each day associated with a decline in knowledge of 0.003 points (t(<reflink idref="bib291" id="ref47">291</reflink>) = −6.72882, <emph>p</emph> = <0.01) in knowledge (Appendix B, Figure B2).</p> <hd id="AN0178074296-30">Comfort/readiness to intervene</hd> <p>The effect of time since the training on readiness was statistically significant and negative, with each day associated with a decrease of 0.0008 points (t(<reflink idref="bib291" id="ref48">291</reflink>) = −4.98568, <emph>p</emph> = <0.01) in readiness (Appendix B, Figure B3). As shown in Figures B1, B2, and B3, while scores decline slightly over time, they remain substantially higher at follow-up than at baseline.</p> <hd id="AN0178074296-31">Application of skills and gatekeeper behaviors</hd> <p></p> <hd id="AN0178074296-32">Utilizing skills</hd> <p>A majority of respondents reported that since their training they had interacted with someone (either a student or a person in their private life) in distress or crisis (66.5%, N = 240/361). Out of those who reported interacting with someone in distress or crisis, 88.3% (N = 212/240) reported using the I CARE skills during these interactions (based on a score of 3, 4, or 5 on a Likert scale, indicating using the skills "somewhat," "a good deal," or "very much"). Approximately half of the respondents, 50.1% (N = 181/361) reported they had interacted with a student in distress and 16.1% (N = 58/361) reported interacting with a student in crisis.</p> <hd id="AN0178074296-33">Referrals and actions taken</hd> <p>Of those who interacted with a student(s) in distress or crisis, 89.5% (N = 162/181) of participants indicated that they discussed their concerns with the student(s) about the signs of psychological distress they were exhibiting. 98.9% (N = 180/182) of participants also indicated that they knew where to refer the student(s) for mental health support and 88.4% (N = 160/181) recommended mental health/support services (such as the counseling center). These results are based on ratings of 3 or 4 on a 4-point Likert scale ("Agree" or "Strongly Agree"). The number of respondents who referred students to the counseling center increased significantly from baseline (26.0% ever referred) to follow-up (49.9% referred during last semester).</p> <p>Since the I CARE training, 16.9% (N = 61/361) of respondents reported encountering one or more students who they were concerned might be considering suicide. Of those respondents, 98.4% (N = 60/61) reported taking preventive actions when they were concerned that a student might be considering suicide. 75.4% (N = 46/61) recommended support services on campus, 70.5% (N = 43/61) helped the person to seek help, and 67.2% (41/61) asked the person if they were thinking of hurting or killing themselves (Figure 1).</p> <p>Graph: Figure 1. Actions taken when concerned about a suicidal individual.</p> <hd id="AN0178074296-34">Perceived support and resources</hd> <p>Respondents identified friends (44.0%, N = 74/168) and family members (27.4%, N = 46/168) as their main sources of support when intervening to help others. Other resources were Penn staff (17%), colleague (14%), counseling center (12.5%), faculty at Penn (10%), and student in support role at Penn (6%). (This question was only asked in the 2019 follow-up survey, thus explaining the N of 168.)</p> <p>Of those who encountered a student in distress or crisis, 86.0% (N = 117/136) of respondents reported having the support they needed to intervene effectively (based on scores of 3, 4 or 5, indicating having "somewhat," "a good deal," or "very much" of the support they needed); 68.4% (N = 93/136) reported consulting with someone about what to do; and 64.7% (N = 88/136) reported talking to someone about how they felt (Table 3).</p> <p>Table 3. "When you encountered a student/students in distress or crisis, to what extent did you do the following."</p> <p> <ephtml> <table><thead><tr><td>Statement</td><td>Mean (SD)</td><td>Percent (N = 136)*</td></tr></thead><tbody><tr><td>Consult with someone about what to do?</td><td>2.99 (1.09)</td><td>68.4% (93)</td></tr><tr><td>Talk to someone about how you felt?</td><td>2.98 (1.18)</td><td>64.7% (88)</td></tr><tr><td>Have the support or back-up that you felt you needed to intervene effectively?</td><td>3.59 (1.04)</td><td>86.0% (117)</td></tr></tbody></table> </ephtml> </p> <p>1 <bold>*</bold>This question was only asked in the 2019 follow-up survey, and included only those who reported encountering someone in distress or crisis, thus explaining the N of 136.</p> <hd id="AN0178074296-35">Relationships among perceived support and gatekeeper behaviors</hd> <p>In the 2019 survey, 80 respondents (16 men, 64 women) who reported interacting with a person in distress or crisis were asked the question "Do you feel you have the support you need to help others when they are in distress or crisis?" Pearson correlations were conducted to examine relationships among perceived support and gatekeeper behaviors (<emph>utilized skills, discussed concern with student, knew where to refer</emph>, and <emph>recommended mental health services)</emph>. As shown in Table 4, perceived support was positively related to <emph>utilized skills, knew where to refer</emph>, and <emph>recommended services</emph>.</p> <p>Table 4. Correlations among perceived support and gatekeeper outcome variables (N = 80).</p> <p> <ephtml> <table><thead><tr><td /><td>Have the support you need</td><td>Utilized I CARE skills</td><td>Discussed concerns</td><td>Knew where to refer</td></tr></thead><tbody><tr><td>Have the support you need</td><td /><td /><td /><td /></tr><tr><td>Utilized I CARE skills</td><td>r =.541** p =.000</td><td /><td /><td /></tr><tr><td>Discussed concerns</td><td>r =.069 p =.545</td><td>r =.228* p =.042</td><td /><td /></tr><tr><td>Knew where to refer</td><td>r =.28* p =.012</td><td>r =.278* p =.013</td><td>r =.164 p =.146</td><td /></tr><tr><td>Recommended services</td><td>r =.311** p =.005</td><td>r =.439** p =.000</td><td>r =.427** p =.000</td><td>r =.411** p =.000</td></tr></tbody></table> </ephtml> </p> <p>2 * <emph>p</emph> <.05 ** <emph>p</emph> <.01.</p> <hd id="AN0178074296-36">Qualitative data</hd> <p>Responses from qualitative data were extracted from six open-ended questions from the 2019 follow-up survey:</p> <olist> <item>I_"Please describe your experience when you interacted with someone who was in distress or crisis: What happened, and what was the outcome?";_i_</item> <item>I_"Please let us know about any challenges or barriers you have encountered in situations with students in distress or crisis?" There was also a section for additional comments;_i_</item> <item>I_"How do you think we could help you continue to be effective at intervening with students in distress/crisis in the long run?";_i_</item> <item>I_"What has helped you most to intervene in situations of distress or crisis?"_i_</item> <item>I_"How does the support you receive (e.g., from Penn resources, peers, family, advisors, or other individuals) shape whether and how you intervene in situations of distress/crisis?; and_i_</item> <item>I_Other comments._i_</item> </olist> <p>Thematic content analysis was performed using Nvivo 12, a software for qualitative data management, coding, and analysis (Bazeley, [<reflink idref="bib5" id="ref49">5</reflink>]). Two researchers independently reviewed data and came up with potential thematic categories to develop the first iteration of the codebook. The two coders tested and modified the codebook until all discrepancies were resolved and sufficient agreement was reached. The full qualitative dataset was coded using the final iteration of the codebook, and data were organized along thematic lines and recurrent ideas.</p> <p>The questions from the 2019 follow-up survey focused on facilitators and barriers to intervention, and on the role of support resources. To identify more specifically how the training helped participants to intervene, we analyzed responses to one question from the 2018 survey: <emph>"What has been the impact of the I CARE training on your ability to support others in distress or crisis?"</emph></p> <hd id="AN0178074296-37">Major themes from qualitative analyses</hd> <p>Four major themes arose related to the main factors that tend to help or impede gatekeeper behaviors: 1) Support resources, 2) salient training elements, 3) challenges to intervention, and 4) perceptual/relational shifts. The major themes were broken down into sub-themes, presented below.</p> <hd id="AN0178074296-38">1. Support resources</hd> <p>When discussing what helped participants intervene, participants reported receiving support from institutional resources and personal social networks. Institutional resources included various campus services, such as the counseling center, the health center, and the student emergency response team. When describing "what happened" during the intervention with someone in distress, almost all narratives included referrals to campus resources as a component of their intervention response. Additionally, respondents reported seeking advice and reassurance from their network of family and friends if they needed support during an intervention. These connections appeared to positively impact respondents and help facilitate interventions.</p> <hd id="AN0178074296-39">1a. Institutional support</hd> <p>Most respondents who reported intervening with a distressed individual shared that they referred them to an academic or emotional support resource offered by the university. Typically, respondents referred individuals to the university counseling center; however, some reported referring individuals to other off-campus treatment centers, if preferred. Respondents reported that learning about university resources and how to contact them during the training influenced the effectiveness of their interventions. Respondents shared positive outcomes that resulted from using university resources, which highlighted the importance of creating strong relationships between the university's mental health resources, the students who utilize them, and students, faculty, and staff who refer to these resources. Respondents reported that those who they had helped and referred ultimately appreciated being connected to care.</p> <p>I was put in contact with a friend of a friend who was 'having a hard time.' ... I was able to listen and tell the person about on- and off-campus resources. I checked in a few weeks later and the person said that they had made an appointment at CAPS [counseling center] and was happy that we had talked.</p> <p>Knowing that I can easily call CAPS or campus police is a huge relief as well. I never feel like I have to handle everything on my own!</p> <p>A family member had passed away and they were going through a depressive episode where they spent days at home without doing anything. I strongly encouraged them to seek out CAPS and listened through their thoughts. I reminded them that I was there for them if they needed me ... They ended up going to CAPS and ... are doing much better.</p> <p>A student came to me to talk about their eating disorder. We talked through what they were experiencing. I recommended CAPS and SHS [Student Health Service]. The student now has a counselor and a nutritionist.</p> <hd id="AN0178074296-40">1b. Social support</hd> <p>Many respondents found that having support from family and friends was helpful in empowering them to intervene with those that they thought needed intervention. Respondents relied on their support systems in a variety of ways, including seeking reassurance about their decision to intervene, debriefing emotionally intense interactions, and connecting to maintain their own mental health and self-care. <emph>Prior</emph> to an intervention, receiving feedback from a trusted family member or friend helped respondents feel empowered to act and intervene. <emph>Following</emph> an intervention, having someone to speak with to relieve their own distress was helpful.</p> <p>It helps to talk to others to not just share concerns, but gauge responses. It can also embolden you to act when you know you are not alone in an assessment; others' experiences are invaluable.</p> <p>Knowing I have a friend to debrief with or to support my decisions helps me feel better about situations.</p> <p>I think that I would intervene anyways, but it would be much more difficult to do so without bouncing my thoughts and feelings off of one of my good friends.</p> <hd id="AN0178074296-41">2. Salient training elements</hd> <p>When asked about what helped to intervene in situations of distress or crisis, and what was the impact of the training on ability to intervene, some participants referenced specific I CARE concepts that they utilized, or described general principles taught during training, while others noted how applying the skills shifted their way of interacting with others.</p> <hd id="AN0178074296-42">2a. Recognizing signs of distress and crisis</hd> <p>In sharing details about their interactions with distressed individuals, respondents demonstrated that they were able to recognize when individuals were exhibiting indications of stress, distress, or crisis. The indicators and continuum of stress, distress, and crisis are heavily covered during the I CARE training so that trainees can identify physical and behavioral signs that suggest an intervention is needed. When describing their interventions, participants often shared the important and relevant signs that motivated them to act, such as noticing changes in physical appearance, energy, and mood.</p> <p>A student was canceling work shifts on short notice and looking stressed. I have been taking more time and care checking in with this student. They have been having family crises and are stressed about classwork.</p> <p>The person I interacted with called me over to tell me [they] were depressed and not suicidal. I noticed scratches on [the person's] arm which seemed fresh. I talked to [the person] about [their] issues and also about other things and slowly helped them to reach out for help. I also made sure that they stayed over with a friend and didn't sleep alone that night. It's been a few months and the person is doing much better now.</p> <hd id="AN0178074296-43">2b. Role-plays and intervention skills</hd> <p>Respondents reported that role-plays were the most notable part of their training experience. They said that practicing scenarios that simulated real-life situations was helpful preparation when intervening with students in real life. As part of the role-play practice, respondents are asked to apply the active listening and crisis intervention skills they learned in the training. Respondents reported finding the skills taught in this training to be extremely transformative. Active listening skills, especially the "Acknowledge" skill is referenced by respondents, which includes keeping the focus ("the spotlight") on the person in distress and summarizing what the speaker said with care and acceptance. Respondents referenced this skill as being an important way to express empathy and support that translated into successful interventions.</p> <p>Honestly, the I CARE training role-plays helped me tremendously when it came to real situations where I had to help a student.</p> <p>I allowed that person to share, and would listen ... [I am] now more aware to ask follow up questions that stay focused on their concerns, echoing their thoughts back to themselves so they confirm verbally that yes that's what they really feel, or if not, can identify the real reason(s) why they feel upset. Patience with this kind of listening has been SO helpful for myself and those who open up to me.</p> <p>Perhaps the biggest takeaway for me from the I CARE session I attended was how to be a better listener. Body language, eye contact, squaring your shoulders, not trying to finish the conversation or jump in with my take/opinion/story, etc., were all outstanding reminders on good listening skills.</p> <hd id="AN0178074296-44">3. Challenges to intervention</hd> <p>When asked about barriers they faced, some participants' narratives revealed two main challenges that arose before and during the intervention. Some respondents mentioned feelings of personal discomfort when approaching someone they suspected was in distress. Several also noted resistance that came from students when respondents tried to offer help.</p> <hd id="AN0178074296-45">3a. Discomfort</hd> <p>Some participants reported feeling unsure of their role in the intervention, and experienced doubts about whether they were asking appropriate questions. Participants reported experiencing complicated emotions around whether they were improperly crossing boundaries, (e.g., a professor speaking with a student). In such situations, interpersonal dynamics influenced how comfortable the interactions felt.</p> <p>Sometimes I am not 100% sure I said the right thing to them or I listened in the way they needed me to.</p> <p>Feeling like I did not want to intrude on their personal life, but also feeling like I needed to gain a deeper understanding of the problem.</p> <hd id="AN0178074296-46">3b. Student resistance</hd> <p>Participants reported coming across two types of resistance when intervening with distressed individuals: resistance to open dialogue and resistance to utilizing resources. Some participants found that it was hard to facilitate conversations and develop rapport with individuals who were reluctant to disclose information about how they were feeling. Participants also found it challenging to come up with next steps when a distressed individual rejected available resources such as on-campus counseling and health services, due to unwillingness to seek help or privacy concerns.</p> <p>It can be difficult to get students to open up and admit they are having trouble.</p> <p>Bottom line-it's always a difficult situation. If the student self-identifies that they are distressed and want help it's easier. It's much harder when they are unaware or in denial of the distress. In those situations I am unsure if I am assessing things accurately.</p> <p>Resistance. The students who were in crisis both seemed to want help but were resistant to many on-campus resources. This was a challenge so I needed to reach beyond this.</p> <hd id="AN0178074296-47">4. Perceptual/relational shifts</hd> <p>When asked about the impact of the I CARE training on their ability to support others in distress or crisis, some respondents mentioned changes in their ways of perceiving and relating to others. While there was some overlap with the factors described above regarding salient aspects of the training, respondents described how these aspects were internalized to change their behaviors. Respondents mentioned improvements in active listening skills, including keeping the focus on the person in distress and not rushing to provide advice. They discussed having enhanced awareness (e.g., recognizing the signs of stress, distress and crisis, and knowing the steps to help) and how these skills helped them to feel more prepared or comfortable to intervene. Finally, participants discussed increased confidence when talking to someone about their distress. Some respondents mentioned being more proactive and asking about suicide specifically.</p> <p>Respondents reported not only awareness of support resources, but also improved networking with resources, suggesting more agency in connecting with others in supportive roles. For some, the training seemed to engender a relational shift in their ways of being with others, for example, being more proactive and taking initiative when they would not have previously, relating differently to and being perceived differently by others, or an increased sense of empathy. One respondent described how the skills enabled this type of shift:</p> <p>Active listening training made me a better listener and for that reason more people come to me now and share what they are going through.</p> <p>The following comments illustrate some of the personal changes respondents experienced regarding becoming more proactive and willing to be a supportive presence in someone's life:</p> <p>I have become more proactive and feel it is correct to take initiative when I see student in distress–rather than wait for student to seek me out.</p> <p>Very meaningful, students see me as a person that can listen, offer suggestions and support.</p> <p>Opened my eyes to what others are going through.</p> <p>I more deeply understand the need to reach out and help others ...</p> <p>Significant - before I CARE I didn't have a framework with which I could approach others in distress or crisis. I thought being a nice person would be enough, but the I CARE session helped establish the framework and debunk myths I otherwise would have believed.</p> <p>Many respondents also indicated a general positive impact of the training:</p> <p>I think I CARE is actually incredible. I doubted it initially, but it has been so helpful to me this year as I've had so many different friends suffer severe mental health issues. I really think that I CARE can be a game changer for a ton of people. These skills are so important.</p> <hd id="AN0178074296-48">Discussion</hd> <p>The I CARE training aims to increase capacity for caring at the individual and community level. The caring community is illuminated through relational dynamics woven throughout the training in the form of affective processing and emphasis on support resources. In addition to the informational components (e.g., focus on enhancing knowledge and self-efficacy) and experiential components (e.g., asking about suicide; role-playing skills), the caring community is the thread throughout the training. Quantitative and qualitative analysis demonstrate that participants know who and where to call to refer students in distress and/or crisis and that they are not alone in this effort. Overall, participants leave this training more equipped than when they entered and more ready to take action in the real world.</p> <p>Results demonstrate a substantial increase in gatekeeper behavior skills from pre- to post-training and pre-training to follow-up, with slight decline from post-training to follow-up. These results replicated our previously published findings, suggesting that the results of the training are robust. Additionally, a high percentage of respondents (96%) indicated they would recommend the training to others, suggesting high satisfaction with the training.</p> <p>This paper examined factors that facilitate effective use of gatekeeper skills in real-world contexts, based on follow-up surveys. The findings demonstrate that the majority of respondents reported interacting with students in distress or crisis and most of them utilized the I CARE skills during these interactions. Additionally, these participants reported recognizing and addressing the signs of students' psychological distress and that they knew where to refer for mental health support. The number of participants making referrals to the counseling center increased significantly from baseline to follow-up. Among the participants who reported encountering one or more students who might be considering suicide, 98.4% took some kind of preventive action, and over 67% of these participants reported asking the student whether they were thinking of hurting or killing themselves.</p> <p>Participants reported having improved listening skills, increased confidence and comfort, and feeling more prepared to intervene, suggesting that both informational and experiential training components may support participants' learning and application after the training. Participants' qualitative descriptions revealed several factors that facilitate participants' effective use of gatekeeper skills in real-world contexts. When describing their interactions with people in distress, they referenced aspects of the training, such as their knowledge of warning signs and the skills they practiced during the role-plays. The role-plays, all facilitated by mental health professionals from the university counseling center, are largely cited as the most transformative part of the training. Although the role-play sections of the training include set scenarios, the clinicians utilize their therapeutic and facilitation skills to meet the participants where they are. This flexibility allows for moments of vulnerability, such as processing a group member's tears or discussing a real-life situation in which someone felt they failed. The members of the role-play group often serve as the in-the-moment support system for individuals practicing scenarios that can feel both raw and real.</p> <p>Qualitative analyses from other gatekeeper training programs also demonstrate the importance of trust and safety, for example, Cimini et al. ([<reflink idref="bib11" id="ref50">11</reflink>]) discussed how participants appreciated learning how to respond to suicide risk by practicing new skills in a safe environment that was tailored to their group or department. These findings are also consistent with previous literature that suggests gatekeeper trainings should provide participants with knowledge and comfort using skills and resources, experiential exercises (e.g., role-plays and practice), and space to process emotional and relational concerns (Cimini et al., [<reflink idref="bib11" id="ref51">11</reflink>]; Mitchell et al., [<reflink idref="bib26" id="ref52">26</reflink>]; Pasco, Wallack, Sartin, & Dayton, [<reflink idref="bib30" id="ref53">30</reflink>]; Rallis et al., [<reflink idref="bib32" id="ref54">32</reflink>]). Moreover, this is convergent with other studies suggesting the efficacy of combined didactic and experiential gatekeeper trainings, and the utility of psychoeducation and rehearsal of prevention behaviors for behavioral change in real life (Coleman & Del Quest, [<reflink idref="bib12" id="ref55">12</reflink>]; Holmes et al., [<reflink idref="bib20" id="ref56">20</reflink>]; Zinzow et al., [<reflink idref="bib43" id="ref57">43</reflink>]).</p> <p>A major factor participants described in their intervention process was accessing support resources, specifically institutional (academic and counseling services from the university) and social support networks. These qualitative findings relate to the quantitative findings showing the high percentages of participants who were made aware of the university services during the training and increase in number of referrals made after the training. Moreover, positive correlations among perceived support and gatekeeper outcomes suggest that when interacting with others in distress or crisis, those who feel they have more support are also more likely to engage in gatekeeper behaviors (utilize I CARE skills, know where to refer, and recommend services). This outcome is consistent with findings by Moore et al. ([<reflink idref="bib27" id="ref58">27</reflink>]) that organizational support increased gatekeeper behaviors in a work setting, and the notion that lack of support may impede gatekeeper behaviors (Holmes et al., [<reflink idref="bib20" id="ref59">20</reflink>]). Participants' sense that they have university-wide support in the process of supporting others is highly encouraged during the training. The clinicians conducting the training emphasize that people do not have to feel alone when supporting someone in crisis. Throughout the training, the facilitators answer questions about counseling services and encourage 24/7 consultation with trained clinicians from the university's counseling center. Notably, almost all qualitative narratives included making referrals to campus resources as a crucial step of connecting students with care.</p> <p>In addition to institutional support, participants reported receiving interpersonal support from friends and family. It is worth noting that respondents in this study rated friends very highly in their ranking of support resources. These sources of support appeared to help respondents before <emph>and</emph> after intense interactions by providing feedback to the helper before they intervened and debriefing their feelings after the intervention, ultimately providing the helper with reassurance and supporting their own self-care. A review of research suggests that young people (up to age 26) experiencing suicidal thoughts tend to seek help from informal support networks such as friends and family rather than professional resources (Michelmore & Hindley, [<reflink idref="bib25" id="ref60">25</reflink>]). A recent survey also found that when facing a serious mental health issue, students are most likely to first turn to a peer before other figures like a parent or campus staff (Born This Way Foundation, Mary Christie Institute, [<reflink idref="bib9" id="ref61">9</reflink>]). Our findings suggest that social networks may be a valuable resource not only for those in distress, but also for the gatekeepers seeking to support those in distress. Mental health professionals are encouraged to use multiple avenues of support in the service of helping others including peer support and supervision groups, personal psychotherapy, and individual supervision, which can also help with their own self-care (Barnett, Baker, Elman, & Schoener, [<reflink idref="bib4" id="ref62">4</reflink>]). Similarly, the findings in this study suggest the potential benefit of peer consultation for nonprofessional gatekeepers. A study on the use of peer group consultation for residence hall staff found that sharing, feedback, and discussing their stress with others felt helpful, and many reported that the groups helped them to recognize that others were experiencing similar concerns and to feel less isolated (Benshoff & Cashwell, [<reflink idref="bib6" id="ref63">6</reflink>]).</p> <p>Respondents also reported challenges that impeded their use of gatekeeper skills in real-world contexts. They described being unsure about their intervention abilities and actions, given the magnitude of distress or crisis situations. They also expressed fear of being intrusive in the moments leading up to and after an intervention. This is consistent with studies with college resident assistants (RAs) who found that, when presented with gatekeeper scenarios, RAs worried about offending their peers or that they would become defensive when offered support (Silverman, [<reflink idref="bib36" id="ref64">36</reflink>]). Additionally, participants reported experiencing resistance from distressed students around opening up, seeking help, and connecting to care, making it difficult to implement the gatekeeper skills. These important findings suggest that gatekeeper trainings, which are relational in nature, also must address the complexities around having difficult conversations or managing interventions that do not go as planned. The facilitators in the I CARE training name this complexity, provide tips for helping unwilling students, and use the role-plays to unpack participants' fears or insecurities. However, more time could be dedicated to potential challenges in further trainings. Additionally, ongoing peer consultation groups could be helpful to provide additional support and address any challenges that may arise.</p> <p>While some participants discussed the challenges in relationships, qualitative analysis also showed that others experienced positive perceptual and relational shifts around relating to others, primarily becoming more proactive and more <emph>caring</emph> toward others in distress or crisis. These participants appeared to understand and appreciate the importance of concern for others <emph>and</emph> taking action to help, both of which are essential elements of a caring community. While this concept has received little attention in the gatekeeper literature, it has been addressed in the literature on social and emotional learning, such as the Ways of Being model described by Blythe et al. ([<reflink idref="bib8" id="ref65">8</reflink>]) in terms of interrelationship between ways of feeling, ways of relating, and ways of doing. The model encourages attention to an individual's identity (attitudes and beliefs they hold about themselves and their culture), as well as the skills they use in the ways they feel, relate, and act (awareness of self, others and goals) (Blythe et al., [<reflink idref="bib8" id="ref66">8</reflink>]). The qualitative findings showing changes in trainees' perceptions of themselves and others, are suggestive of potential changes in their ways of being with others (e.g., more proactive and caring), and should be explored further in future research.</p> <p>It is important to mention the structural and institutional challenges arising from increased demand for mental health services and managing referrals within systems of limited capacity. The prevalence of service utilization among college students has increased steadily over the past several years, placing increased demand on college counseling centers (Lipson et al., [<reflink idref="bib23" id="ref67">23</reflink>]; Xiao [<reflink idref="bib41" id="ref68">41</reflink>]). The COVID-19 pandemic created additional mental health concerns, and greater strain on mental health services (Salimi, Gere, Talley, & Irioogbe, [<reflink idref="bib34" id="ref69">34</reflink>]). While counseling centers are designed to provide support for all students on campus, many counseling centers may not be equipped to adequately manage the demand for services, and college professionals nationwide have had to think creatively about ways to support students' emotional well-being. Universities are faced with a difficult balance that involves providing accessible mental health services, while also setting expectations around what these services can provide. Many campuses aim to provide easy access to services by providing 24/7 phone service and drop-in services (no appointment needed), but must limit the number of sessions by using brief therapy models and referrals for longer-term therapy. Providing multiple avenues for access and resources can help provide quick assessment and a determination of next steps for support. Therapeutic campus initiatives can also be promoted at the institutional level among a range of campus departments and student organizations, providing opportunities to foster a caring and supportive campus environment (Glass, [<reflink idref="bib15" id="ref70">15</reflink>]).</p> <p>By providing a framework for a continuum of emotional concerns (stress, distress, crisis) to help gatekeepers intervene, the I CARE training helps gatekeepers and students recognize levels of distress along the continuum and identify appropriate resources. For example, if a person is feeling mildly stressed, they might get support from campus and community resources (e.g., friends, family, clergy, cultural centers) rather than mental health services. Additionally, equipping students with awareness of their own emotional needs can not only build insight, but also the likelihood and comfort to seek out personal or community-based resources.</p> <p>As a complement to the I CARE training, professionals at the University of Pennsylvania developed a short psychoeducational video in collaboration with Penn students. The video, "I SHARE: Connection, Healing and Hope" (University of Pennsylvania, [<reflink idref="bib37" id="ref71">37</reflink>]), includes student testimonials and psychoeducational information to encourage students to reach out and share with peers or professionals during times of stress, distress, and crisis. The video also includes warning signs for suicide and resources for support on campus. While I CARE focuses on helping others, I SHARE focuses on helping oneself, and both illuminate the caring community at its core. The students in the video encourage disclosure over silence and some reassurance that others want to listen and provide support. By strengthening the network of support on campus outside of the professional mental health resources, students have more options in times of need. This can provide a safety net of support and help students feel less alone.</p> <p>The I CARE trainings are often conducted with specific campus communities and involve close collaboration with campus partners in their organization, preparation and administration. The training itself exemplifies ways in which the counseling center, and the clinicians providing the training, are closely connected with the campus community. This sense of community and support is conveyed through the facilitators' words and felt in their actions. The training can be understood as a type of outreach intervention that is embedded in the campus and can help transform the community by enhancing attitudes and skills around caring, relationships, and help-seeking. In addition to providing skills and knowledge to individual trainees, this type of outreach also addresses student needs at the collective level, gradually promoting a more supportive campus community (Glass, [<reflink idref="bib15" id="ref72">15</reflink>]). It may seem complex, but it is fundamentally simple: to cope with the effects of individual and collective stress, distress, and crisis, we recognize the need to take care of one another. The caring community must begin in the training room and extend into the real world to support gatekeepers in their service of supporting others.</p> <hd id="AN0178074296-49">Limitations</hd> <p>There are several limitations to the data presented in this article. First, this study did not use a control group and random assignment, since it was a quality improvement project and resources for additional research were not available. Second, clinicians and participants present for each training session were different, which introduced an inevitable source of variation in each training. However, the overall effectiveness despite these differences suggests that this did not adversely affect the outcomes. Third, due to the collection of data at only one site, the generalizability of the findings is limited. Fourth, self-report of intervention behavior is subject to recall bias, but generally people tend to under-report, as they do not recall all the relevant events. Fifth, despite a fairly high response rate, there was attrition in the sample, however, differences in pre/post scores between respondents and non-respondents were not significant. Sixth, similar to most research on gatekeeper trainings, we were not able to assess the outcomes of interactions with gatekeepers for the students in situations of distress (Wolitzky-Taylor, LeBeau, Perez, Gong-Guy, & Fong, [<reflink idref="bib39" id="ref73">39</reflink>]).</p> <p>Future research could further explore the role-play groups more in depth using qualitative interviews or focus groups. More exploration is needed to better understand the experiential and affective environment created in these groups, the impact, and what inspires people to take what they have learned in the training and translate it into real life. More information can be gathered around the use of active listening skills practiced during the role-plays and how this translates into gatekeeper behaviors and impacts relational dynamics after the training.</p> <hd id="AN0178074296-50">Conclusions and recommendations</hd> <p>The findings affirm the importance of gatekeeper trainings, and emphasize a communal effort in supporting college students' mental health. In follow-up surveys, participants reported applying I CARE skills in their interactions with students in distress and crisis, making referrals, and receiving helpful support from both the institution and personal social networks. During interactions with people in distress, participants relied on their knowledge of warning signs, the skills they practiced during the role-plays, and support resources, suggesting that informational and experiential training components as well as relational aspects within and beyond the training, may support gatekeeper behaviors after the training.</p> <p>Qualitative themes demonstrated that after a 3-hour training, participants not only gain the knowledge and skills needed to be an effective gatekeeper, but also a sense of confidence and self-efficacy to move these discussions and actions into the real world. Our findings suggest several factors that may contribute to these behaviors including a safe space where participants gain knowledge, self-efficacy, familiarity with resources, practicing skills without judgment, asking tough questions, processing emotions, and feeling part of a caring culture.</p> <p>The caring community involved in I CARE expands the discussion on the importance of a sense of support in bolstering real-world gatekeeper interventions following training. Although it is not clear how the specific components impact behavioral change, the combined informational, experiential, and relational aspects of the training may contribute to its effective application.</p> <p>The results suggest that by creating a safe and supportive environment where personal exploration, difficult dialogue, intellectual understanding, and experiential learning can take place, clinicians help participants increase their self-efficacy and skills when intervening.</p> <p>However, the findings also suggest that, despite having knowledge and skills, many trainees continue to have doubts and fears around engaging with people in distress or crisis. The I CARE training aims to normalize these fears and provides small group role-plays to practice and process participants' emotions and reactions. Future trainings could place a greater emphasis on helping participants cope with their discomfort and respond to students' resistance. The findings suggest that more time can be dedicated to unpacking gatekeepers' reactions to the relational dynamics involved with supporting others who are not aware, not ready, or unwilling to seek help.</p> <p>To help gatekeepers to translate their trainings to real-life situations, we recommend continued inclusion and emphasis of role-play and practice led by trained clinicians as essential components of training. We also suggest a focus on increasing gatekeepers' knowledge of resources and comfort in using learned skills. Additionally, to enhance the use of support resources, and to help participants process relational barriers, future gatekeeper trainings should emphasize using formal (e.g., professional) and informal (e.g. peer) consultation around difficult interactions to provide space to process challenging situations, to aid in intervention or referral, and to assist with gatekeepers' own self-care while supporting others.</p> <hd id="AN0178074296-51">Acknowledgments</hd> <p>The authors are grateful to the University of Pennsylvania's Student Health and Counseling staff who helped to facilitate and organize the trainings, and the students, staff and faculty who participated in the assessments.</p> <hd id="AN0178074296-52">Disclosure statement</hd> <p>No potential conflict of interest was reported by the authors.</p> <hd id="AN0178074296-53">Appendix A</hd> <p>Table A1. Mean scores at baseline, post-training and follow-up assessments, with significance levels based on paired t-tests.</p> <p> <ephtml> <table><thead><tr><td>Statement</td><td>Baseline</td><td>Post</td><td>Follow-up</td><td>Sig. Post-Base</td><td>Sig. Foll-Post</td><td>Sig. Foll-Base</td></tr></thead><tbody><tr><td><bold>Knowledge_Sum</bold><italic>[1 to 14]</italic></td><td><bold>8.7 (2.4)</bold></td><td><bold>12.2 (2.0)</bold></td><td><bold>11.2 (2.2)</bold></td><td><bold>0.000</bold></td><td><bold>0.000</bold></td><td><bold>0.000</bold></td></tr><tr><td>When a student is upset, it's best to quickly suggest solutions in order to help the student calm down (Disagree is correct) <italic>[1 = Agree Strongly to 7 = Disagree Strongly]</italic></td><td>4.5 (1.6)</td><td>5.8 (1.6)</td><td>5.4 (1.6)</td><td>0.000</td><td>0.000</td><td>0.000</td></tr><tr><td>If I suspect that a student might be suicidal, I should ask the student: "Are you thinking about killing yourself?" (Agree is correct) <italic>[Recoded to 1 = Disagree Strongly to 7 = Agree Strongly]</italic></td><td>4.2 (1.7)</td><td>6.4 (0.8)</td><td>5.9 (1.4)</td><td>0.000</td><td>0.000</td><td>0.000</td></tr><tr><td><bold>Comfort/Readiness_Mean</bold><italic>[1 = Disagree Strongly to 7 = Agree Strongly]</italic></td><td><bold>4.8 (1.0)</bold></td><td><bold>6.1 (0.7)</bold></td><td><bold>5.9 (0.8)</bold></td><td><bold>0.000</bold></td><td><bold>0.000</bold></td><td><bold>0.000</bold></td></tr><tr><td>I am comfortable speaking with students who are very upset</td><td>5.1 (1.4)</td><td>5.9 (1.0)</td><td>5.8 (1.1)</td><td>0.000</td><td>0.00</td><td>0.000</td></tr><tr><td>If I suspect that a student is in severe emotional distress, I am comfortable asking "are you thinking about killing yourself?"</td><td>3.4 (1.8)</td><td>5.4 (1.2)</td><td>5.0 (1.6)</td><td>0.000</td><td>0.000</td><td>0.000</td></tr><tr><td>I am comfortable referring a student to CAPS.</td><td>5.9 (1.2)</td><td>6.6 (0.8)</td><td>6.5 (0.9)</td><td>0.000</td><td>0.000</td><td>0.000</td></tr><tr><td>I am comfortable calling Penn Police (or 911) if I suspect that a student is a danger to himself/herself or to others</td><td>5.1 (1.7)</td><td>6.1 (1.1)</td><td>5.9 (1.3)</td><td>0.000</td><td>0.007</td><td>0.000</td></tr><tr><td>I am comfortable contacting CAPS if I need to consult about a student.</td><td>5.0 (1.6)</td><td>6.5 (0.8)</td><td>6.1 (1.1)</td><td>0.000</td><td>0.000</td><td>0.000</td></tr><tr><td>I am aware of on-campus resources I can refer students to in case they need support in specific areas of their lives</td><td>4.9 (1.5)</td><td>6.3 (0.9)</td><td>6.1 (1.1)</td><td>0.000</td><td>0.190</td><td>0.000</td></tr><tr><td><bold>Sense of Connection</bold><italic>[1 = Disagree Strongly to 7 = Agree Strongly]</italic> I feel connected with the community at Penn.</td><td>4.9 (1.4)</td><td>5.4 (1.3)</td><td>5.1 (1.5)</td><td>0.000</td><td>0.000</td><td>0.014</td></tr><tr><td><bold>Prep_Mean</bold> How would you rate your preparedness to: <italic>[1 = very low to 5 = very high]</italic></td><td><bold>2.9 (0.6)</bold></td><td><bold>3.6 (0.3)</bold></td><td><bold>3.5 (0.4)</bold></td><td><bold>0.000</bold></td><td><bold>0.000</bold></td><td><bold>0.000</bold></td></tr><tr><td>Recognize when a student's behavior is a sign of psychological distress?</td><td>2.9 (0.7)</td><td>3.2 (0.5)</td><td>3.5 (0.6)</td><td>0.000</td><td>0.000</td><td>0.000</td></tr><tr><td>Recognize when a student's physical appearance is a sign of psychological distress?</td><td>2.7 (0.8)</td><td>3.5 (0.6)</td><td>3.2 (0.7)</td><td>0.000</td><td>0.000</td><td>0.000</td></tr><tr><td>Discuss with a student your concern about the signs of psychological distress they are exhibiting?</td><td>2.7 (0.8)</td><td>3.6 (0.5)</td><td>3.4 (0.6)</td><td>0.000</td><td>0.000</td><td>0.000</td></tr><tr><td>Motivate students exhibiting signs of psychological distress to seek help?</td><td>3.0 (0.7)</td><td>3.7 (0.5)</td><td>3.6 (0.6)</td><td>0.000</td><td>0.001</td><td>0.000</td></tr><tr><td>Recommend mental health/support services (such as the counseling center) to a student exhibiting signs of psychological distress?</td><td>3.2 (0.8)</td><td>3.8 (0.4)</td><td>3.7 (0.5)</td><td>0.000</td><td>0.004</td><td>0.000</td></tr><tr><td><bold>Likely_Mean</bold> How likely are you to: <italic>[1 = very unlikely to 4 = very likely]</italic></td><td><bold>3.0 (0.6)</bold></td><td><bold>3.6 (0.4)</bold></td><td><bold>3.4 (0.5)</bold></td><td><bold>0.000</bold></td><td><bold>0.000</bold></td><td><bold>0.000</bold></td></tr><tr><td>Recommend mental health/support services (such as the counseling center) to a student exhibiting signs of psychological distress?</td><td>3.2 (0.6)</td><td>3.7 (0.5)</td><td>3.5 (0.6)</td><td>0.000</td><td>0.000</td><td>0.000</td></tr><tr><td>Discuss your concerns with a student exhibiting signs of psychological distress?</td><td>2.9 (0.7)</td><td>3.5 (0.5)</td><td>3.3 (0.6)</td><td>0.000</td><td>0.000</td><td>0.000</td></tr><tr><td><bold>Efficacy_Mean</bold> Please rate your agreement with the following statements: <italic>[1 = strongly disagree to 4 = strongly agree]</italic></td><td><bold>2.7 (0.5)</bold></td><td><bold>3.4 (0.4)</bold></td><td><bold>3.3 (0.5)</bold></td><td><bold>0.000</bold></td><td><bold>0.000</bold></td><td><bold>0.000</bold></td></tr><tr><td>I feel confident in my ability to discuss my concern with a student exhibiting signs of psychological distress.</td><td>2.7 (0.7)</td><td>3.4 (0.6)</td><td>3.2 (0.6)</td><td>0.000</td><td>0.001</td><td>0.000</td></tr><tr><td>I feel confident in my ability to recommend mental health/support services to a student exhibiting signs of psychological distress.</td><td>2.8 (0.7)</td><td>3.5 (0.6)</td><td>3.4 (0.6)</td><td>0.000</td><td>0.013</td><td>0.000</td></tr><tr><td>I feel confident that I know where to refer a student for mental health support.</td><td>2.8 (0.7)</td><td>3.6 (0.5)</td><td>3.5 (0.6)</td><td>0.000</td><td>0.004</td><td>0.000</td></tr><tr><td>I feel confident in my ability to help a suicidal student seek help.</td><td>2.4 (0.8)</td><td>3.3 (0.6)</td><td>3.1 (0.7)</td><td>0.000</td><td>0.012</td><td>0.000</td></tr><tr><td><bold>GBS_Mean</bold></td><td><bold>2.9 (0.5)</bold></td><td><bold>3.6 (0.3)</bold></td><td><bold>3.4 (0.4)</bold></td><td><bold>0.000</bold></td><td><bold>0.000</bold></td><td><bold>0.000</bold></td></tr></tbody></table> </ephtml> </p> <p>3 *Due to a data deletion error on Qualtrics in Baseline survey, data for questions GBS, comfort, and knowledge were missing between 8/2/2018 – 10/3/2018. Data collected from questions that were not missing from the affected 8/2/2018 – 10/3/2018 responses were compared to all other responses for these questions. Respondents with the missing data did not have significantly different responses from other respondents, therefore not causing any bias in the results.</p> <hd id="AN0178074296-54">Appendix B</hd> <p>Graph: Figure B1. Change in GBS score as a function of time since training.</p> <p>Graph: Figure B2. Change in knowledge as a function of time since training.</p> <p>Graph: Figure B3. Change in comfort/readiness as a function of time since training.</p> <ref id="AN0178074296-55"> <title> References </title> <blist> <bibl id="bib1" idref="ref35" type="bt">1</bibl> <bibtext> Ajzen, I. (2011). The theory of planned behaviour: Reactions and reflections. Psychology & Health, 26 (9), 1113 – 1127. doi: 10.1080/08870446.2011.613995</bibtext> </blist> <blist> <bibl id="bib2" idref="ref42" type="bt">2</bibl> <bibtext> Albright, G., Davidson, J., Goldman, R., Shockley, K., & Timmons-Mitchell, J. (2016). Development and validation of the gatekeeper behavior scale: A tool to assess gatekeeper training for suicide prevention. Crisis the Journal of Crisis Intervention and Suicide Prevention (CRISIS), 37, 1 – 10. doi: 10.1027/0227-5910/a000382</bibtext> </blist> <blist> <bibl id="bib3" idref="ref2" type="bt">3</bibl> <bibtext> American College Health Association. (2019). American college health associate national college health assessment II. Retrieved from https://<ulink href="http://www.acha.org/documents/ncha/NCHA-II%5fSPRING%5f2019%5fUS%5fREFERENCE%5fGROUP%5fEXECUTIVE%5fSUMMARY.pdf">www.acha.org/documents/ncha/NCHA-II%5fSPRING%5f2019%5fUS%5fREFERENCE%5fGROUP%5fEXECUTIVE%5fSUMMARY.pdf</ulink></bibtext> </blist> <blist> <bibl id="bib4" idref="ref62" type="bt">4</bibl> <bibtext> Barnett, J. E., Baker, E. K., Elman, N. S., & Schoener, G. R. (2007). In pursuit of wellness: The self-care imperative. Professional Psychology: Research and Practice, 38 (6), 603 – 612. doi: 10.1037/0735-7028.38.6.603</bibtext> </blist> <blist> <bibl id="bib5" idref="ref43" type="bt">5</bibl> <bibtext> Bazeley, P. (2007). Qualitative analysis with nvivo. Thousand Oaks, CA : Sage Publications.</bibtext> </blist> <blist> <bibl id="bib6" idref="ref63" type="bt">6</bibl> <bibtext> Benshoff, J. M., & Cashwell, C. S. (1996). Time to talk: Investigation of a peer consultation group for residence hall directors. Journal of College and University Student Housing, 26, 19 – 29.</bibtext> </blist> <blist> <bibl id="bib7" idref="ref44" type="bt">7</bibl> <bibtext> Bernard, H. R. (2013). Social research methods: Qualitative and quantitative approaches. Thousand Oaks; CA : Sage Publications.</bibtext> </blist> <blist> <bibl id="bib8" idref="ref65" type="bt">8</bibl> <bibtext> Blyth, D., Olson, B., & Walker, K. (2017). Ways of being: A model for social & emotional learning.</bibtext> </blist> <blist> <bibl id="bib9" idref="ref61" type="bt">9</bibl> <bibtext> Born This Way Foundation, Mary Christie Institute, The MassInc Polling Group. (2022, January). Peer counseling in college mental health: A survey of students' attitudes and experiences with mental health peer counseling. Retrieved from https://marychristieinstitute.org/reports/peer-counseling-in-college-mental-health/</bibtext> </blist> <blist> <bibtext> Burnette, C., Ramchand, R., & Ayer, L. (2015). Gatekeeper training for suicide prevention: A theoretical model and review of the empirical literature. Rand Health Quarterly, 5 (1), 16.</bibtext> </blist> <blist> <bibtext> Cimini, M. D., Rivero, E. M., Bernier, J. E., Stanley, J. A., Murray, A. D., Anderson, D. A., ... Bapat, M. (2014). Implementing an audience-specific small-group gatekeeper training program to respond to suicide risk among college students: A case study. Journal of American College Health, 62 (2), 92 – 100. doi: 10.1080/07448481.2013.849709</bibtext> </blist> <blist> <bibtext> Coleman, D., & Del Quest, A. (2015). Science from evaluation: Testing hypotheses about differential effects of three youth-focused suicide prevention trainings. Social Work in Public Health, 30 (2), 117 – 128. doi: 10.1080/19371918.2014.938397</bibtext> </blist> <blist> <bibtext> Cross, W. F., Seaburn, D., Gibbs, D., Schmeelk-Cone, K., White, A. M., & Caine, E. D. (2011). Does practice make perfect? A randomized control trial of behavioral rehearsal on suicide prevention gatekeeper skills. The Journal of Primary Prevention, 32 (3–4), 195 – 211. doi: 10.1007/s10935-011-0250-z</bibtext> </blist> <blist> <bibtext> Gallagher, R. P. (2015). National survey of college counseling centers, 2014 (Project report). The International Association of Counseling Services (IACS) Retrieved from <ulink href="http://dscholarship.pitt.edu/28178/">http://dscholarship.pitt.edu/28178/</ulink></bibtext> </blist> <blist> <bibtext> Glass, G. D. (2020). College counseling center outreach—an organizing framework. Journal of College Student Psychotherapy, 34 (4), 271 – 286. doi: 10.1080/87568225.2019.1596773</bibtext> </blist> <blist> <bibtext> Harrod, C. S., Goss, C. W., Stallones, L., & DiGuiseppi, C. (2014). Interventions for primary prevention of suicide in university and other post-secondary educational settings. Cochrane Database of Systematic Reviews, 10. doi: 10.1002/14651858.CD009439.pub2</bibtext> </blist> <blist> <bibtext> Healthy Minds Study. (2019). Fall 2019 healthy minds study national data report. Retrieved from https://healthymindsnetwork.org/wp-content/uploads/2020/08/f2019_HMS_national_final.pdf</bibtext> </blist> <blist> <bibtext> Healthy Minds Study. (2020). Winter/spring 2020 healthy minds study national data report. Retrieved from https://healthymindsnetwork.org/wp-content/uploads/2020/08/w2020_HMS_national_Final.pdf</bibtext> </blist> <blist> <bibtext> Healthy Minds Study. (2021). Winter 2021 healthy minds study national data report. Retrieved from https://healthymindsnetwork.org/wp-content/uploads/2021/09/HMS_national_winter_2021.pdf</bibtext> </blist> <blist> <bibtext> Holmes, G., Clacy, A., Hermens, D. F., & Lagopoulos, J. (2021). The long-term efficacy of suicide prevention gatekeeper training: A systematic review. Archives of Suicide Research, 25 (2), 177 – 207. doi: 10.1080/13811118.2019.1690608</bibtext> </blist> <blist> <bibtext> Kuhlman, S. T., Walch, S. E., Bauer, K. N., & Glenn, A. D. (2017). Intention to enact and enactment of gatekeeper behaviors for suicide prevention: An application of the theory of planned behavior. Prevention Science, 18 (6), 704 – 715. doi: 10.1007/s11121-017-0786-0</bibtext> </blist> <blist> <bibtext> Lipson, S. K. (2014). A comprehensive review of mental health gatekeeper-trainings for adolescents and young adults. International Journal of Adolescent Medicine and Health, 26 (3), 309 – 320. doi: 10.1515/ijamh-2013-0320</bibtext> </blist> <blist> <bibtext> Lipson, S. K., Lattie, E. G., & Eisenberg, D. (2019). Increased rates of mental health service utilization by US college students: 10-year population-level trends (2007–2017). Psychiatric Services, 70 (1), 60 – 63. doi: 10.1176/appi.ps.201800332</bibtext> </blist> <blist> <bibtext> Litteken, C., & Sale, E. (2018). Long-term effectiveness of the question, persuade, refer (QPR) suicide prevention gatekeeper training program: Lessons from Missouri. Community Mental Health Journal, 54 (3), 282 – 292. doi: 10.1007/s10597-017-0158-z</bibtext> </blist> <blist> <bibtext> Michelmore, L., & Hindley, P. (2012). Help-seeking for suicidal thoughts and self-harm in young people: A systematic review. Suicide and Life-Threatening Behavior, 42 (5), 507 – 524. doi: 10.1111/j.1943-278X.2012.00108.x</bibtext> </blist> <blist> <bibtext> Mitchell, S. L., Kader, M., Darrow, S. A., Haggerty, M. Z., & Keating, N. L. (2013). Evaluating question, persuade, refer (QPR) suicide prevention training in a college setting. Journal of College Student Psychotherapy, 27 (2), 138 – 148. doi: 10.1080/87568225.2013.766109</bibtext> </blist> <blist> <bibtext> Moore, T., Cigularov, K. P., Chen, P. Y., Martinez, J. M., & Hindman, J. (2011). The effects of situational obstacles and social support on suicide-prevention gatekeeper behaviors. Crisis, 32 (5), 264 – 271. doi: 10.1027/0227-5910/a000090</bibtext> </blist> <blist> <bibtext> Morse, J. M. (2005). Evolving trends in qualitative research: Advances in mixed-method design. Qualitative Health Research, 15 (5), 583 – 585. doi: 10.1177/1049732305275169</bibtext> </blist> <blist> <bibtext> Osteen, P. J. (2018). Suicide intervention gatekeeper training: Modeling mediated effects on development and use of gatekeeper behaviors. Research on Social Work Practice, 28 (7), 848 – 856. doi: 10.1177/1049731516680298</bibtext> </blist> <blist> <bibtext> Pasco, S., Wallack, C., Sartin, R. M., & Dayton, R. (2012). The impact of experiential exercises on the communication and relational skills in a suicide prevention gatekeeper training program for resident advisors. Journal of American College Health, 60 (2), 134 – 140. doi: 10.1080/07448481.2011.623489</bibtext> </blist> <blist> <bibtext> Quinnett, P. (2007). QPR gatekeeper training for suicide prevention: The model, rationale, and theory.</bibtext> </blist> <blist> <bibtext> Rallis, B. A., Esposito‐Smythers, C., Disabato, D. J., Mehlenbeck, R. S., Kaplan, S., Geer, L., ... Meehan, B. (2018). A brief peer gatekeeper suicide prevention training: Results of an open pilot trial. Journal of Clinical Psychology, 74 (7), 1106 – 1116. doi: 10.1002/jclp.22590</bibtext> </blist> <blist> <bibtext> Reiff, M., Kumar, M., Bvunzawabaya, B., Madabhushi, S., Spiegel, A., Bolnick, B., & Magen, E. (2018). I CARE: Development and evaluation of a campus gatekeeper training program for mental health promotion and suicide prevention. Journal of College Student Psychotherapy, 107 – 130. doi: 10.1080/87568225.2018.1433570</bibtext> </blist> <blist> <bibtext> Salimi, N., Gere, B., Talley, W., & Irioogbe, B. (2021). College students mental health challenges: Concerns and considerations in the COVID-19 pandemic. Journal of College Student Psychotherapy, 1 – 13. doi: 10.1080/87568225.2021.1890298</bibtext> </blist> <blist> <bibtext> Shtivelband, A., Aloise-Young, P., & Chen, P. (2015). Sustaining the effects of gatekeeper suicide prevention training: A qualitative study. The Journal of Crisis Intervention and Suicide Prevention, 23, 1 – 8. doi: 10.1027/0227-5910/a000304</bibtext> </blist> <blist> <bibtext> Silverman, A. T. (2014). Resident assistants' reflections, reactions and training needs concerning student suicide prevention on college campuses (Unpublished PsyD. Dissertation). Philadelphia, PA : La Salle University.</bibtext> </blist> <blist> <bibtext> University of Pennsylvania. (2021). I SHARE: Connection, healing and hope. Retrieved from https://wellness.upenn.edu/</bibtext> </blist> <blist> <bibtext> Walrath, C., Garraza, L. G., Reid, H., Goldston, D. B., & McKeon, R. (2015). Impact of the Garrett Lee Smith youth suicide prevention program on suicide mortality. American Journal of Public Health, 105 (5), 986 – 993. doi: 10.2105/AJPH.2014.302496</bibtext> </blist> <blist> <bibtext> Wolitzky-Taylor, K., LeBeau, R. T., Perez, M., Gong-Guy, E., & Fong, T. (2020). Suicide prevention on college campuses: What works and what are the existing gaps? A systematic review and meta-analysis. Journal of American College Health, 68 (4), 419 – 429. doi: 10.1080/07448481.2019.1577861</bibtext> </blist> <blist> <bibtext> Wyman, P., Brown, C., Inman, J., Cross, W., Schmeelk-Cone, K., Guo, J., & Pena, J. (2008). Randomized trial of a gatekeeper program for suicide prevention: 1-year impact on secondary school staff. Journal of Consulting and Clinical Psychology, 76 (1), 104 – 115. doi: 10.1037/0022-006X.76.1.104</bibtext> </blist> <blist> <bibtext> Xiao, H., Carney, D. M., Youn, S. J., Janis, R. A., Castonguay, L. G., Hayes, J. A., & Locke, B. D. (2017). Are we in crisis? National mental health and treatment trends in college counseling centers. Psychological Services, 14 (4), 407. doi: 10.1037/ser0000130</bibtext> </blist> <blist> <bibtext> Yonemoto, N., Kawashima, Y., Endo, K., & Yamada, M. (2019). Gatekeeper training for suicidal behaviors: A systematic review. Journal of Affective Disorders, 246, 506 – 514. doi: 10.1016/j.jad.2018.12.052</bibtext> </blist> <blist> <bibtext> Zinzow, H. M., Thompson, M. P., Fulmer, C. B., Goree, J., & Evinger, L. (2020). Evaluation of a brief suicide prevention training program for college campuses. Archives of Suicide Research, 24 (1), 82 – 95. doi: 10.1080/13811118.2018.1509749</bibtext> </blist> </ref> <aug> <p>By Marian Reiff; Alaina Spiegel; Elizabeth Williams; Brinda Ramesh; Soumya Madabhushi and Batsirai Bvunzawabaya</p> <p>Reported by Author; Author; Author; Author; Author; Author</p> </aug> <nolink nlid="nl1" bibid="bib23" firstref="ref1"></nolink> <nolink nlid="nl2" bibid="bib17" firstref="ref3"></nolink> <nolink nlid="nl3" bibid="bib18" firstref="ref4"></nolink> <nolink nlid="nl4" bibid="bib19" firstref="ref5"></nolink> <nolink nlid="nl5" bibid="bib14" firstref="ref6"></nolink> <nolink nlid="nl6" bibid="bib42" firstref="ref8"></nolink> <nolink nlid="nl7" bibid="bib10" firstref="ref9"></nolink> <nolink nlid="nl8" bibid="bib16" firstref="ref10"></nolink> <nolink nlid="nl9" bibid="bib22" firstref="ref11"></nolink> <nolink nlid="nl10" bibid="bib31" firstref="ref12"></nolink> <nolink nlid="nl11" bibid="bib12" firstref="ref13"></nolink> <nolink nlid="nl12" bibid="bib38" firstref="ref14"></nolink> <nolink nlid="nl13" bibid="bib35" firstref="ref18"></nolink> <nolink nlid="nl14" bibid="bib43" firstref="ref21"></nolink> <nolink nlid="nl15" bibid="bib40" firstref="ref22"></nolink> <nolink nlid="nl16" bibid="bib26" firstref="ref23"></nolink> <nolink nlid="nl17" bibid="bib32" firstref="ref24"></nolink> <nolink nlid="nl18" bibid="bib20" firstref="ref25"></nolink> <nolink nlid="nl19" bibid="bib24" firstref="ref26"></nolink> <nolink nlid="nl20" bibid="bib21" firstref="ref27"></nolink> <nolink nlid="nl21" bibid="bib29" firstref="ref30"></nolink> <nolink nlid="nl22" bibid="bib13" firstref="ref31"></nolink> <nolink nlid="nl23" bibid="bib11" firstref="ref32"></nolink> <nolink nlid="nl24" bibid="bib27" firstref="ref37"></nolink> <nolink nlid="nl25" bibid="bib33" firstref="ref39"></nolink> <nolink nlid="nl26" bibid="bib28" firstref="ref45"></nolink> <nolink nlid="nl27" bibid="bib310" firstref="ref46"></nolink> <nolink nlid="nl28" bibid="bib291" firstref="ref47"></nolink> <nolink nlid="nl29" bibid="bib30" firstref="ref53"></nolink> <nolink nlid="nl30" bibid="bib25" firstref="ref60"></nolink> <nolink nlid="nl31" bibid="bib36" firstref="ref64"></nolink> <nolink nlid="nl32" bibid="bib41" firstref="ref68"></nolink> <nolink nlid="nl33" bibid="bib34" firstref="ref69"></nolink> <nolink nlid="nl34" bibid="bib15" firstref="ref70"></nolink> <nolink nlid="nl35" bibid="bib37" firstref="ref71"></nolink> <nolink nlid="nl36" bibid="bib39" firstref="ref73"></nolink>
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  Label: Title
  Group: Ti
  Data: From Role-Play to Real Life: Using Gatekeeper Skills in Real-World Situations
– Name: Language
  Label: Language
  Group: Lang
  Data: English
– Name: Author
  Label: Authors
  Group: Au
  Data: <searchLink fieldCode="AR" term="%22Marian+Reiff%22">Marian Reiff</searchLink> (ORCID <externalLink term="https://orcid.org/0000-0003-1199-6598">0000-0003-1199-6598</externalLink>)<br /><searchLink fieldCode="AR" term="%22Alaina+Spiegel%22">Alaina Spiegel</searchLink><br /><searchLink fieldCode="AR" term="%22Elizabeth+Williams%22">Elizabeth Williams</searchLink><br /><searchLink fieldCode="AR" term="%22Brinda+Ramesh%22">Brinda Ramesh</searchLink><br /><searchLink fieldCode="AR" term="%22Soumya+Madabhushi%22">Soumya Madabhushi</searchLink><br /><searchLink fieldCode="AR" term="%22Batsirai+Bvunzawabaya%22">Batsirai Bvunzawabaya</searchLink>
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  Label: Source
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  Data: <searchLink fieldCode="SO" term="%22Journal+of+College+Student+Mental+Health%22"><i>Journal of College Student Mental Health</i></searchLink>. 2024 38(1):119-148.
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  Data: Routledge. Available from: Taylor & Francis, Ltd. 530 Walnut Street Suite 850, Philadelphia, PA 19106. Tel: 800-354-1420; Tel: 215-625-8900; Fax: 215-207-0050; Web site: http://www.tandf.co.uk/journals
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  Label: Peer Reviewed
  Group: SrcInfo
  Data: Y
– Name: Pages
  Label: Page Count
  Group: Src
  Data: 30
– Name: DatePubCY
  Label: Publication Date
  Group: Date
  Data: 2024
– Name: TypeDocument
  Label: Document Type
  Group: TypDoc
  Data: Journal Articles<br />Reports - Research
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  Label: Education Level
  Group: Audnce
  Data: <searchLink fieldCode="EL" term="%22Higher+Education%22">Higher Education</searchLink><br /><searchLink fieldCode="EL" term="%22Postsecondary+Education%22">Postsecondary Education</searchLink>
– Name: Subject
  Label: Descriptors
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22Intervention%22">Intervention</searchLink><br /><searchLink fieldCode="DE" term="%22Suicide%22">Suicide</searchLink><br /><searchLink fieldCode="DE" term="%22Experiential+Learning%22">Experiential Learning</searchLink><br /><searchLink fieldCode="DE" term="%22Skill+Development%22">Skill Development</searchLink><br /><searchLink fieldCode="DE" term="%22Counseling+Techniques%22">Counseling Techniques</searchLink><br /><searchLink fieldCode="DE" term="%22Guidance+Centers%22">Guidance Centers</searchLink><br /><searchLink fieldCode="DE" term="%22College+Students%22">College Students</searchLink><br /><searchLink fieldCode="DE" term="%22Prevention%22">Prevention</searchLink><br /><searchLink fieldCode="DE" term="%22Mental+Health%22">Mental Health</searchLink><br /><searchLink fieldCode="DE" term="%22At+Risk+Persons%22">At Risk Persons</searchLink><br /><searchLink fieldCode="DE" term="%22School+Counselors%22">School Counselors</searchLink><br /><searchLink fieldCode="DE" term="%22Counselor+Training%22">Counselor Training</searchLink><br /><searchLink fieldCode="DE" term="%22Role+Playing%22">Role Playing</searchLink>
– Name: Subject
  Label: Geographic Terms
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22Pennsylvania%22">Pennsylvania</searchLink>
– Name: DOI
  Label: DOI
  Group: ID
  Data: 10.1080/87568225.2022.2144789
– Name: ISSN
  Label: ISSN
  Group: ISSN
  Data: 8756-8225<br />1540-4730
– Name: Abstract
  Label: Abstract
  Group: Ab
  Data: While gatekeeper trainings have demonstrated their effectiveness in appraisals of preparedness, efficacy, and intention to intervene, evidence has been lacking regarding gatekeeper behaviors in real life. The I CARE training aims to increase intervention in real-world situations involving suicidality through informational and experiential learning, enhanced by emotional support and guidance from counseling center facilitators. In mixed-method follow-up assessments, respondents reported utilizing specific skills they learned during the training, noting their ability to listen, ask directly about suicidality, connect others with services, and draw on a variety of supportive resources. Of those who encountered a potentially suicidal student, two-thirds asked the student if they were thinking of hurting or killing themselves; others reported taking preventive actions. Perceived support and gatekeeper outcomes were correlated. The findings affirm the effectiveness of communal efforts to support college students' mental health and suggest ways to enhance effective intervention in actual situations with students in distress.
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  Data: As Provided
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  Label: Entry Date
  Group: Date
  Data: 2024
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  Label: Accession Number
  Group: ID
  Data: EJ1420065
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        Value: 10.1080/87568225.2022.2144789
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      – Text: English
    PhysicalDescription:
      Pagination:
        PageCount: 30
        StartPage: 119
    Subjects:
      – SubjectFull: Intervention
        Type: general
      – SubjectFull: Suicide
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      – SubjectFull: Skill Development
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      – SubjectFull: Guidance Centers
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      – SubjectFull: Pennsylvania
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      – TitleFull: From Role-Play to Real Life: Using Gatekeeper Skills in Real-World Situations
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