How to Perform Social Return on Investment

Introduction

Social Return on Investment (SROI) is a way of measuring the impact of projects or programs that is especially suited to the work that non-profits do. To see the difference, let’s move from a for-profit to a non-profit mindset. A for-profit’s return on investment (ROI) focuses on money only: for instance, $25,000 investment in supply chain management results in an additional $75,000 in revenue; this means the ROI is 3:1, or $50,000.

Because non-profits don’t often generate revenue, this measure is less useful. Instead, non-profits often track outcomes like the number of clients served. At the Distress Centre, we receive over 7500 calls a year and save approximately 35 lives through emergency intervention. These numbers are useful, but they don’t translate well into a per-dollar figure. For instance, on a budget of $260,000 (a rough estimate), we pay $35 per call, or $7,429 per emergency intervention.

Is $35 per call reasonable? It may appear to be too expensive. What about when we divert an individual from hospital, or prevent a suicide attempt in progress? We have no way to track the monetary benefits of these, until we use SROI.

How SROI Works

SROI works by assigning a monetary value to activities that until now could not be monetized. Some of these are easier to calculate because real dollars are involved (for instance, when you de-escalate someone and they don’t need to go to the hospital, you’ve saved the cost of the police/ambulance and the emergency room service), while some are more difficult (the increased quality of life that one gets from a conversation on a crisis line.)

Value is assigned by a variety of methods that try best to approximate the costs involved. These items that are used to approximate value are called “proxies”, and lists of proxies are available on SROI-related websites.

Performing SROI

SROI has six major steps:

  1. Establish the scope and identify stakeholders
  2. Mapping outcomes
  3. Demonstrating outcomes and giving them a value
  4. Establishing impact
  5. Calculating the SROI
  6. Reporting, using and embedding

These are reviewed in more detail below. The data (charts, financial proxies, explanations, etc.) is reproduced from an unpublished SROI analysis conducted by myself, of the ONTX Chat and Text Program at Distress Centre Durham.

Establish the Scope and Identify Stakeholders

Establishing the scope for an SROI analysis involves identifying the purpose, audience and focus of the analysis. 

The audience for this analysis includes the four pilot Centres, our funding partners (Trillium, United Way and Greenshield Canada) and other services interested in producing a similar analysis of their service. The focus will be on one year of outcomes data collected in the operation of the ONTX project.

Stakeholders, in the SROI methodology, are individuals who experience gains as a result of the service provided. These can be direct gains (such as the reduction in distress experienced by a visitor to the crisis chat service or the savings experienced by not having to use EMS resources transporting a suicidal person to hospital) or indirect gains (such as the career benefits experienced by a responder who delivers the service or the of improved relationships with friends and family visitors may experience.)

In order for stakeholders to be included in the analysis, they must be material – that is, they must experience a benefit as a result of the service.

Mapping Outcomes / The Theory of Change

A theory of change, also known as a logic model, is a cornerstone of the SROI methodology that describes how inputs (the funds and people used in direct service delivery) result in changes (outcomes) that can be quantified to value the service. An example logic model for the ONTX Chat and Text Program is listed below:

Stakeholder Intermediate Outcomes Final Outcome
Visitors
  • Decreased harmful intentions
  • Immediate crisis diffused
  • Decreased suicidal intent
Reduced likelihood of visitor attempting suicide
  • Improved self-esteem, self-control or confidence
  • Less distressed or anxious
  • Options explored
  • Action plan explored
Improved visitor coping skills
  • Decreased isolation and loneliness
  • Improved connectedness
  • Knowing a responder is there for them
Enhanced visitor belonging
Police / EMS
  • Less likely to require ambulance or police service because of a high-risk suicidal caller
Reduced use of 911
  • Fewer responses to suicide deaths because of Responder intervention
Reduced cost to 911/EMS
Medical System
  • Less instances of hospital admission because of self-harm/suicide attempts
Reduced use of public health system

Demonstrating Outcomes and Giving Them a Value

Each of the final outcomes from the chart above needs to be operationalized, which involves identifying concrete elements to suggest an outcome has or will occur. This allows an assignment of financial value to those outcomes in determining the SROI.

Each of the above outcomes requires a financial proxy, or a method of quantifying its value. Some financial proxies are simple unit costs, like the cost of deploying police and an ambulance to respond to a suicidal crisis, while others are more difficult to quantify.

In consultation with stakeholders, a review of the SROI literature (including with other crisis chat services), the following financial proxies were decided upon:

Final Outcome Financial Proxy Calculation (all figures in dollars unless noted) Value per Instance
Reduced Likelihood of Visitors Attempting Suicide One month of life, adjusted with the disability weight assigned to Suicide and Self Harm (Value of a Statistical Life Year (VSLY) / 12 months) x 0.64 weighting $6,900.49
Improved Visitors Coping Skills Cost of two visits to a family doctor/general practitioner 40 per visit x 2 $80
Enhanced Visitor Belonging One week of leisure for the median Canadian income 3922 (yearly leisure expenses) / 52 $75.42
Reduced Cost of 911/EMS Cost of ambulance response for a suicide attempt 600 $600
Reduced Cost of Police Response to Suicide Death Unit cost of two police officers and two paramedics responding for total of 5 hours at median wage 36.53 x 2 x 2 (Police)

25.81 x 2 x 1 (Paramedic)

$249.36
Reduced Use of Public Health System Cost of hospitalization for suicide attempt minus the average cost of an ED visit (998 x 7.74) – 267 – 249.36 $7,208.16

Establishing Impact

The SROI methodology involves totaling the number of outcomes (now quantified as dollar values) against the total cost of inputs required to operate the service. Inputs can include direct service, such as employees, technology costs, advertising and so on.

Because three of the four Centres did not receive funding to hire an independent staff person, a value of 25% on a salary of $40,000 was used. This provides an estimation of the dollar value.

Input Description Value ($)
Distress Centre Durham Staff (prorated to 8 mos.) $15,000 x 10 months = $12,500
ONTX Grant (pro-rated to 6 mos.) $257,700 / 4 = $64,425
Community Torchlight Staff (est.) $10,000
Distress Centre Toronto Staff (est.) $10,000
Spectra Helpline (est.) $10,000
Total Inputs $106,925

Number and Dollar Value of Final Outcomes

Based on one year of data (June 29 2015 to June 29 2016), we can see the following outcomes. Only the items directly from the call reports are reported below for this sample analysis. The other intermediate outcomes (such as Less likely to require ambulance or police service because of a high-risk suicidal caller) have been operationalized in the report but are not listed here for space and complexity reasons.

Reduced Likelihood of Visitor Attempting Suicide ($6900.49 x 1,190)

Decreased harmful intentions – 522
Immediate crisis diffused – 301
Decreased suicidal intent – 367

Improved Visitor Coping Skills ($80 x 3,794)

Improved self-esteem, self-control or confidence – 796
Less distressed or anxious – 1831
Action plan explored – 1167

Enhanced Visitor Belonging ($75.42 x 1473)

Decreased isolation and loneliness – 1473

Total

$6900.49 x 1,190
$80 x 3,794
$75.42 x 1473
= $8,626,196.76

Deadweight and Attribution

Next, we have to estimate deadweight and attribution. Deadweight is the percentage of the outcome that would have happened regardless of our involvement. For instance, if a visitor told us that if they couldn’t reach our service, they knew five others they could, it is unlikely that much of the outcome would be lost if they could not access the ONTX pilot.

We have decided to calculate deadweight as a 15% reduction in overall value for every resource a visitor could identify as an alternative to our service. Since the average was 2, we assume 30% in deadweight.

Attribution is the amount of the benefit that is attributed to other persons. Because our service is often the primary intervention we have limited attribution, so for this analysis we will not note any attribution.

This takes our benefit value of $8,626,196,76 and reduces it to $6,038,337.732.

Finishing our Calculation

We take our total benefits generated, divide them by the total cost of the input to find the SROI ratio.

$6,038,337.732 Total Benefit / $106,925 Total Inputs = SROI Ratio of $56.47

For every one dollar invested in the ONTX pilot there is a social benefit of $56.47.

Sensitivity Analysis

Sensitivity analysis is a way of repeating calculations to take into account higher or lower than expected figures. See the table below:

Final Outcome Low Financial Proxy Original Financial Proxy High Financial Proxy Low Value Moderate Value (used for analysis) High Value
Reduced Likelihood of Visitors Attempting Suicide One week of life, adjusted with the disability weight assigned to Suicide and Self Harm One month of life, adjusted with the disability weight assigned to Suicide and Self Harm Two months of life, adjusted with the disability weight assigned to Suicide and Self Harm 1,592.42 6,900.49 13,800.98
Improved Visitors Coping Skills Cost of one visits to a family doctor/general practitioner Cost of two visits to a family doctor/general practitioner Cost of four visits to a family doctor/general practitioner 40 80 160
Enhanced Visitor Belonging One day of leisure for the median Canadian income One week of leisure for the median Canadian income One month of leisure for the median Canadian income 10.75 75.42 301.68
Reduced Cost of 911/EMS N/A Cost of ambulance response for a suicide attempt N/A 600 600 600
Reduced Cost of Police Response to Suicide Death Unit cost of two police officers and two paramedics responding for total of 2 hours at median wage Unit cost of two police officers and two paramedics responding for total of 5 hours at median wage Unit cost of two police officers and two paramedics responding for total of 7 hours at median wage 99.74 249.36 349.10
Reduced Use of Public Health System Cost of hospitalization for 3 days minus the average cost of an ED visit Cost of hospitalization for suicide attempt minus the average cost of an ED visit Cost of hospitalization for 12 days minus the average cost of an ED visit 2,477.64 7,208.16 11,339.64

Based on the low and high values specified we have benefits as follows. The reason we multiply by 0.7 is our deadweight, estimated earlier.

Low
1,894,978.8 + 3200 + 15834.75 = 1,914,013.55 x 0.70 = 1,339,809.485

High
16,423,166.2 + 607,040 + 444,374.64 = 17,474,580.84 x 0.70 = 12,232,206.588

Returning to our original formula:

  • Low $1,339,809.485 Total Benefit / $106,925 Total Inputs = SROI Ratio of $12.53
  • Moderate (already calculated) $6,038,337.732 / $106,925 Total Inputs = SROI Ratio of $56.47
  • High $12,232,206.588 Total Benefit / $106,925 Total Inputs = SROI Ratio of $114.40

Therefore our SROI analysis ranges from $12.53 – 114.40. Given this wide range, it may be safer to use a value of +/- 15% of our middle value, or to explore more carefully the value of the Final Outcome Reduced Likelihood of Visitors Attempting Suicide (which is currently calculated in terms of months of life, adjusted with the disability weight assigned to Suicide and Self Harm.)

Cite this article as: MacDonald, D.K., (2016), "How to Perform Social Return on Investment," retrieved on September 28, 2016 from http://dustinkmacdonald.com/perform-social-return-investment/.
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Quit Smoking Counselling

Introduction

Counselling clients to quit smoking may be a part of your practice no matter what kind of therapy you do. While many clinicians may wish to refer clients to others for this work, learning the skills to handle smoking cessation may be a valuable addition to your work with clients in other areas and so is worth the time.

In Canada, about 1 in 5 individuals smoke (Statistics Canada, 2014) and this level has been going down, as it has in most western countries, for many years. Tobacco smoking often begins in the teen years (U.S. Department of Health and Human Services, 2012) with the Surgeon General noting that “vast majority of Americans who begin daily smoking during adolescence are addicted to nicotine by young adulthood.”

Smoking often affects the poor, mentally ill and other marginalized groups. (Passey & Bonevski, 2014) The mortality rate of both male and female smokers is three times higher than non-smokers and the rate of heart attack in middle aged men is four times higher. (CDC, n.d.)

Most individuals who attempt to quit smoking will require multiple attempts to quit, with sources citing between 5 and 30 (Chaiton, et. al., 2016).

Benefits of Quitting Smoking

The following list of health benefits comes from the World Health Organization (n.d.), and may help convince a smoker who believes that there is no point in quitting, to attempt to do so:

Within 20 minutes of your last cigarette, your heart rate and blood pressure drop.

Within 12 hours, the carbon monoxide level in your blood drops to normal.

2-12 weeks, your circulation improves and your lung function increases.

1-9 months, coughing and shortness of breath decrease.

1 year, your risk of coronary heart disease is about half that of a smoker’s.

5 years, your stroke risk is reduced to that of a nonsmoker 5 to 15 years after quitting.

10 years, your risk of lung cancer falls to about half that of a smoker and your risk of cancer of the mouth, throat, esophagus, bladder, cervix, and pancreas decreases.

15 years, the risk of coronary heart disease is that of a nonsmoker’s.

The benefits are clear! But that doesn’t mean quitting smoking is easy.

Nicotine Withdrawal

When a client stops their regular smoking, they begin to experience withdrawal symptoms within about 2 hours (Medline, 2015) as the nicotine begins to leave their bloodstream. The Mood and Physical Symptoms Scale (West & Hajek, 2004) is a tool for measuring withdrawal symptoms. These symptoms can include depression, anxiety, irritability, restlessness, hunger, inability to concentrate, poor sleep and more.

Assessment of Smoking Behaviours

The Fagerstrom Test for Nicotine Dependence is a common measure of smoking-related behaviour. It asks six questions:

  1. How soon after waking do you smoke your first cigarette?
  2. Do you find it difficult to refrain from smoking in places where it is forbidden? E.g. Church, library
  3. Which cigarette would you hate to give up?
  4. How many cigarettes in a day do you smoke?
  5. Do you smoke more frequently in the morning?
  6. Do you smoke even if you are sick in bed most of the time?

See my article on assessments for substance use disorders for more information on the Fagerstrom Test.

Interventions to Quit Smoking

Nicotine Replacement Therapy (NRT)

Nicotine replacement therapy (NRT) includes products like patches, gum, inhalers and lozenges. Use of nicotine replacement therapy nearly doubled a client’s ability to quit smoking in a Cochrane review (Silagy, et. al., 2012) NRT is contraindicated  in the following groups (Department of Health, Western Australia, 2012):

  • Lactating women
  • Smokers under 12 years of age

As well, those:

  • Between 13 and 18
  • With severe heart problems

Should receive NRT under physician supervision. Additional recommendations (e.g. for people with diabetes, mental health issues or from specific cultural groups) are found in the Clinical Guidelines in the References. In general, clients should receive medical support from a GP who can properly monitor them when taking any medications, including NRT.

Motivational Interviewing

Motivational interviewing (MI) is a brief intervention that aims to highlight and amplify intrinsic motivation and intent to quit smoking that already exists in clients. (Rollnick & Allison, 2001) Some elements of motivational interviewing include (Sciacca, 2009):

  • Change and sustain talk, messages from the client that indicate either a willingness to change or a desire to keep things the way they are
  • Rolling with resistance, and recognizing a client’s desire not to change may be the result of the clinician’s approach, the client’s unreadiness or both
  • Ensuring empathy to build a strong relationship
  • Identifying discrepancies, for instance where a client’s values (“I want to be there for my children”) conflict with their behaviours (“My daughter had to wait in the rain so I could have a smoke”)

There is a large body of research (e.g. the metareview by Lundahl & Burke, 2009) supporting the effectiveness of motivational interviewing in helping clients to quit smoking or using other substances.

The 5 A’s of Quitting Smoking

The 5 A’s describe simple set of steps for a brief tobacco intervention, they come from MDQuit (2012).

  1. Ask – It’s important to ask the patient about their smoking. Do they smoke at all?
  2. Assess – If they do smoke, how much do they smoke. You may wish to use the Fagerstrom criteria for this (see above, Assessment for Substance Use Disorders)
  3. Assist – Help the client make an informed decision about their smoking behaviour if they wish to cut down.
  4. Advice – Provide information on the risks of continuing and the benefits of quitting.
  5. Arrange – Finally, arrange some form of followup if possible to check on their progress.

Quit Smoking Training

The Government of Western Australia has produced the Brief Tobacco Intervention Training Program designed to teach basic cessation skills to clinicians (nurses and doctors) in advising clients on how to quit smoking. It is available freely online and takes about 2 hours to complete.

The California Smokers Helpline provides a number of free courses and online webinars covering a variety of smoking cessation-related topics that may be eligible for Continuing Education (CE) credits.

In Canada, the Centre for Addiction and Mental Health provides the Training Enhancement in Applied Cessation Counselling and Health (TEACH) program, comprised of online and in-person workshops to teach clinicians skills in smoking cessation.

References

Centers for Disease Control and Prevention. (n.d.) “CDC – Fact Sheet – Tobacco-Related Mortality – Smoking & Tobacco Use”. Retrieved on August 11, 2016 from https://www.cdc.gov/tobacco/data_statistics/fact_sheets/health_effects/tobacco_related_mortality/

Chaiton, M., Diemert, L., Cohen, J., Bondy, S., Selby, P., Philipneri, A., & Schwartz, R. (2016). Estimating the number of quit attempts it takes to quit smoking successfully in a longitudinal cohort of smokers. BMJ Open, 6(6), doi:10.1136/bmjopen-2016-011045

Department of Health, Western Australia. (2011) Clinical guidelines and procedures for the management of nicotine dependent inpatients. Perth: Smoke Free WA Health Working Party, Health Networks Branch, Department of Health, Western Australia; Retrieved on August 11, 2016 from http://www.health.wa.gov.au/smokefree/docs/Clinical_guidelines.pdf

Lundahl, B., & Burke, B. L. (2009). The effectiveness and applicability of motivational interviewing: a practice-friendly review of four meta-analyses. Journal Of Clinical Psychology, 65(11), 1232-1245. doi:10.1002/jclp.20638

Medline. (2015). Martin, L.J. “Nicotine and tobacco” Retrieved on August 11, 2016 from https://medlineplus.gov/ency/article/000953.htm

MDQuit. (2012) “Brief Interventions & 5 A’s | MDQuit.org” Retrieved on August 11, 2016 from http://mdquit.org/cessation-programs/brief-interventions-5

Passey, M., & Bonevski, B. (2014). The importance of tobacco research focusing on marginalized groups. Addiction, 109(7), 1049-1051. doi:10.1111/add.12548

Rollnick S., & Allison J. (2001) Motivational interviewing. In: Heather, N., Peters, T.J, & Stockwell T. International handbook of alcohol dependence and problems. New York, NY: Wiley; pp. 593-603.

Sciacca, K. (2009) “MOTIVATIONAL INTERVIEWING –MI, GLOSSARY & FACT SHEET” Retrieved on August 11, 2016 from http://www.motivationalinterview.net/miglossary.pdf

Silagy, C., Lancaster, T., Stead, L., Mant, D. & Fowler, G. (2007) Nicotine replacement therapy for smoking cessation (Review). The Cochrane Library. (3)

Statistics Canada. (2014) “Smoking, 2014”, Retrieved on August 11, 2016 from http://www.statcan.gc.ca/pub/82-625-x/2015001/article/14190-eng.htm

U.S. Department of Health and Human Services. (2012) Preventing Tobacco Use Among
Youth and Young Adults: A Report of the Surgeon General. Retrieved on August 11, 2016 from http://www.surgeongeneral.gov/library/reports/preventing-youth-tobacco-use/full-report.pdf

West, R. & Hajek, P. (2004). Evaluation of the mood and physical symptoms scale (MPSS) to assess cigarette withdrawal Psychopharmacology, 177, 195-199.

Cite this article as: MacDonald, D.K., (2016), "Quit Smoking Counselling," retrieved on September 28, 2016 from http://dustinkmacdonald.com/quit-smoking-counselling/.
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Canadian Suicide Statistics 2016

Introduction

There are a variety of sources related to Canadian suicide statistics, but no source effectively summarizes all of the statistics, with graphs and charts, and links back to the original citation. The purpose of this article is to provide the most up-to-date information on suicide by method, gender, province, age-range, and other characteristics. The most common source of data is Statistics Canada.

Suicide Rate in Canada

The overall rate for suicide in Canada is 11.3 per 100,000 based on the 2012 Statistics Canada data (released in 2015), for both genders. This is mostly unchanged from the 5 year average of 11.36 per 100,000. The next data will be released in 2017.

Although other countries may calculate suicide differently, Canada ranks approximately 70 for both sexes suicide, 70 for male suicides and 73 for female suicides (out of a total of 170 countries, where lower is better), based on 2012 data from the World Health Organization. (WHO, 2012)

Suicide by Age in Canada

The largest population of suicides in Canada are from men and women 45-59. All Ages data includes suicide of those of unknown age and those under 10.

Age Rate per 100,000 persons % of Total
10 to 14 1.8 1%
15 to 19 10.2 5%
20 to 24 12.1 6%
25 to 29 11.4 6%
30 to 34 11.6 6%
35 to 39 12.8 6%
40 to 44 15.5 8%
45 to 49 17.5 9%
50 to 54 17.1 9%
55 to 59 17.6 9%
60 to 64 13.4 7%
65 to 69 10.5 5%
70 to 74 11.1 6%
75 to 79 9.3 5%
80 to 84 9.9 5%
85 to 89 11.1 6%
90 and older 8.1 4%

Chart, Suicide by Age in Canada

Suicide by Age in Canada

 

 

 

 

 

 

Suicide by Gender in Canada

In Canada, like most countries, male suicides outnumber female suicides. (Statistics Canada, 2012)

Age at time of death Male per 100,000 Female per 100,00 people
All Ages 17.3 5.4
5-9 0 0
10-14 1.8 1.9
15-19 14.1 6.2
20-24 18.1 5.9
25-29 18.1 4.7
30-34 17 6.1
35-39 19.5 6.2
40-44 24.9 6
45-49 24.8 10
50-54 25.9 8.2
55-59 26.7 8.6
60-64 20.5 6.4
65-69 16.2 5.1
70-74 18.9 4.1
75-79 15.9 3.7
80-84 20.6 2.2
85-89 24.2 3.9
90 and older 20.5 3.5

The chart below shows the gross number of suicides in order to demonstrate the male percentage of the total. (Statistics Canada, 2012)

Age Range

Male Female Total

Male %

10 to 14 17 17 34 50%
15 to 19 160 67 227 70%
20 to 24 221 70 291 76%
25 to 29 217 56 273 79%
30 to 34 202 73 275 73%
35 to 39 223 71 294 76%
40 to 44 297 71 368 81%
45 to 49 331 132 463 71%
50 to 54 354 111 465 76%
55 to 59 323 105 428 75%
60 to 64 210 67 277 76%
65 to 69 130 43 173 75%
70 to 74 107 26 133 80%
75 to 79 67 19 86 78%
80 to 84 62 9 71 87%
85 to 89 38 11 49 78%
90 and older 13 6 19 68%
Total 2972 954 3926

Chart, Suicide by Gender in CanadaSuicide by Gender in Canada

Suicide Attempts in Canada

Suicide attempts usually do not lead to suicide deaths. In the US, Han et. al. (2016) reported that in 2012, there were over 1.3 million suicide attempts and 39,426 suicide deaths, leading to a ratio of approximately 33 suicide attempts for every suicide death.

Statistics Canada (2016) notes a World Health Organization source that notes up to 20 suicide attempts for every suicide death.

Suicide Attempts by Gender in Canada

Females attempt suicide 1.5 times more often than males (Langlois & Morrison, 2002) Mustard, et. al. (2012) note that the rate of suicide attempts among women is 3 times that of men. Both sources are referred to in Statistics Canada (2016).

Suicide by Method in Canada

Suicide methods impact lethality, therefore it is important to understand the most common methods used to attempt suicide in Canada. Men are likelier to use more lethal means like hanging and firearm than women are (Bilsker & White, 2011) increasing their suicide lethality. 1998 data reveals the following gender breakdown by method for suicide (Langlois & Morrison, 2002)

Total Male Female
# % # % # %
Total Suicide Deaths 3698 100 2925 100 773 100
Suffocation 1433 38.8 1171 40 262 33.9
Total Poisoning Deaths 965 26.1 646 22.1 319 41.3
Firearms 816 22.1 765 26.2 51 6.6
Jumping From High Place 160 4.3 115 3.9 45 5.8
Drowning/Submersion 122 3.3 79 2.7 43 5.6
Cutting/Piercing Instrument 59 1.6 48 1.6 11 1.4
Other/Unspecified Means 143 3.9 101 3.5 42 5.4

Additionally, the following information is provided for poisonings (these numbers make up the total poisoning deaths number above):

Total Male Female
# % # % # %
Drugs and Medication 487 13.2 246 8.4 241 31.2
Motor Vehicle Exhaust 269 7.3 229 7.8 40 5.2
Other Carbon Monoxide 164 4.4 135 4.6 29 3.8
Other/Unspecified Poisoning 45 1.2 36 1.2 9 1.2

Chart, Suicide by Method in Canada

Suicide by Method in Canada

The above chart shows total poisoning deaths. The below chart breaks out poisoning into the various types:

Suicide by Method in Canada, Poisoning

Suicide by Province in Canada

Suicide in Canada has a distinct provincial impact, with northern territories having a higher rate of suicide and the Maritimes having a lower rate of suicide as compared to the provincial average. (Statistics Canada, 2016b)

Both Sexes Male Female
Nunavut 63.5 93.9 30.6
Yukon 18.7 30 6.8
Northwest Territories 18.4 30.5 5
New Brunswick 13.9 22.5 5.5
Manitoba 13.4 18 9
Quebec 12.2 18.9 5.4
Alberta 12.2 18.3 6
Saskatchewan 11.9 18.6 5.1
Nova Scotia 11 15.9 6.3
British Columbia 9.5 14.5 4.7
Ontario 8.5 13.1 4.1
Newfoundland and Labrador 7.8 12.3 3.4
Prince Edward Island 5.8 7.4 4.4

Chart, Suicide by Province in Canada

Youth Suicide in Canada

Youth suicide in Canada has been relatively stable for several years. Suicide is the 2nd leading cause of suicide in Canada for ages 15 to 34. (Statistics Canada, 2015a) Additionally, there are more suicide attempts in youth than adults, with Schwartz (2003) estimating between 50 and 200 attempts per youth suicide death.

See my article Risk Factors Predicting Youth Suicide Attempts for more information.

LGBT Suicide in Canada

It has been well-documented that the LGBT community has a higher rate of suicide than the general population.

Approximately 30% of suicide deaths and 28% of suicide attempts in Canada involve lesbian, gay or bisexual individuals. (LGB; Banks, 2003) The LGB population was estimated by Statistics Canada (2015c) at approximately 2%, though this is likely an underestimate.

The trans suicide rate is dramatically higher than the LGB rate. Between 20 and 40% of transgender individuals report suicide attempts, while a study of trans youth in Ontario reported that 35% had suicidal thoughts and 11% had a suicide attempt in the previous year. (Bauer, 2015)

Veteran/Military Suicide in Canada

Military member and military veteran suicide has increasingly been in the public consciousness. In 2012, the Canadian Forces had 10 suicide deaths by current members and 11 suicide attempts by current members according to a Global News article citing Department of National Defence data. (Minsky, 2015)

Given a strength of approximately 68,000 Regular Force members and 27,000 Reserve members, 10 suicides leads to a suicide rate per 100,000 of approximately 9.5, slightly lower than the general population rate of 13.1.

See my article Suicide Prevention in the US Military.

References

Bauer, G. R., Scheim, A. I., Pyne, J., Travers, R., & Hammond, R. (2015). Intervenable factors associated with suicide risk in transgender persons: a respondent driven sampling study in Ontario, Canada. BMC Public Health, 15(1), 1-15. doi:10.1186/s12889-015-1867-2

Banks, C. (2003) The Cost of Homophobia: Literature Review on the Human Impact of Homophobia On Canada. Community-University Institute for Social Research. Retrieved on August 27, 2016 from http://www.usask.ca/cuisr/sites/default/files/BanksHumanCostFINAL.pdf

Bilsker, D. & White, J. (2011) The silent epidemic of male suicide. BCMJ. 53(10) 529-534.. Retrieved on August 27, 2016 from www.bcmj.org/articles/silent-epidemic-male-suicide

Han, B., Kott, P. S., Hughes, A., McKeon, R., Blanco, C., & Compton, W. M. (2016). Estimating the rates of deaths by suicide among adults who attempt suicide in the United States. Journal Of Psychiatric Research, 77125-133. doi:10.1016/j.jpsychires.2016.03.002

Langlois, S & Morrison, P. (2012) Suicide deaths and suicide attempts. Health Reports. 13(2):9-21. Retrieved on August 26, 2016 from http://www.statcan.gc.ca/pub/82-003-x/2001002/article/6060-eng.pdf

Minsky, A. (2013, 4 Dec.) “For every suicide in the Canadian Forces, at least one attempt was recorded: documents”. Global News. Retrieved on August 27, 2016 from http://globalnews.ca/news/1009779/soldier-suicide-one-attempt-for-every-death/

Mustard, C., Bielecky, A., Etches, J., Wilkins, R., Tjepkema, M., Amick, B., Smith, P.M., Gnam, W.H. & Aronson, K. (2012). Suicide Mortality by Occupation in Canada, 1991-2001. Canadian Journal Of Psychiatry-Revue Canadienne De Psychiatrie, 55(6), 369-376.

Schwartz, M.W. (2003) The 5-minute Pediatric Consult. Lippincott Williams & Wilkins. pp 796.

Statistics Canada. (2015a) Table 102-0561 – Leading causes of death, total population, by age group and sex, Canada, annual, CANSIM (database). Accessed August 27, 2016.

Statistics Canada. (2015b) “Suicides and suicide rate, by sex and by age group (Both sexes rate).” CANSIM, Table 102-0551. Retrieved on August 27, 2016 from http://www.statcan.gc.ca/tables-tableaux/sum-som/l01/cst01/hlth66d-eng.htm

Statistics Canada. (2015c) “Same-sex couples and sexual orientation… by the numbers” Retrieved on August 27, 2016 from http://www.statcan.gc.ca/eng/dai/smr08/2015/smr08_203_2015

Statistics Canada. (2016a) Table  102-0563 –  Leading causes of death, total population, by sex, Canada, provinces and territories, annual,  CANSIM (database). Retrieved on August 27, 2016 from http://www5.statcan.gc.ca/cansim/a47

Statistics Canada. (2016b) Navaneelan, T. Suicide rates: An overview. Retrieved on August 24, 2016 from www.statcan.gc.ca/pub/82-624-x/2012001/article/11696-eng.htm

World Health Organization (WHO). (2012) “GHO | By category | Suicide rates – Data by country.” Retrieved on August 27, 2016 from http://apps.who.int/gho/data/node.main.MHSUICIDE?lang=en

Cite this article as: MacDonald, D.K., (2016), "Canadian Suicide Statistics 2016," retrieved on September 28, 2016 from http://dustinkmacdonald.com/canadian-suicide-statistics-2016/.
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Assessments for Substance Use Disorders

Introduction

Substance use disorders (also known as substance abuse) are a group of conditions where an individual experiences “the recurrent use of alcohol and/or drugs causes clinically and functionally significant impairment, such as health problems, disability, and failure to meet major responsibilities at work, school, or home.” (SAMHSA, 2015)

There are a variety of assessment tools used for determining the severity of the substance use disorder. These are reviewed below.

CAGE Alcohol Questionnaire

The CAGE Alcohol Questionnaire (O’Brien, 2008) is a four-item test to assess alcohol abuse. The letters “CAGE” are an acronym to help you remember the four questions:

  1. Have you ever felt you should cut down on your drinking?
  2. Have people annoyed you by criticizing your drinking?
  3. Have you ever felt bad or guilty about your drinking?
  4. Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover (eye-opener)?

Each question is scored yes or no, with one point per yes. A score of 2 or higher represents clinically significant potential for alcohol abuse. (Malet, et. al., 2005) There is also a modified scale for Drug Use, below:

CAGE Questions Adapted to Include Drug Use (CAGE-AID)

The psychometric properties of the CAGE-AID were tested in Dyson et. al. (1998) where it was found to be an effective tool.

  1. Have you ever felt you ought to cut down on your drinking or drug use?
  2. Have people annoyed you by criticizing your drinking or drug use?
  3. Have you felt bad or guilty about your drinking or drug use?
  4. Have you ever had a drink or used drugs first thing in the morning to steady your nerves or to get rid of a hangover (eye-opener)?

Self-Administered Alcoholism Screening Test-Revised (SAAST-R)

The Self-Administered Alcoholism Screening Test (SAAST) was originally a 35-item self-administered test for alcohol abuse developed by Swenson & Morse in 1975 (see the Reference List for the citation – I haven’t been able to track down the original to read it.) It was updated by Vickers-Douglas, et. al. (2005) as the SAAST-R, and this is the version presented below.

The SAAST-R has shown good validity and reliability in subsequent studies (Patten, et. al., 2006)

SAAST-R Items

  1. In your entire lifetime, have you ever had a drink of an alcoholic beverage?
  2. Have you ever felt that you used more alcohol than the average person?
  3. Have your close friends, relatives, or spouse ever worried or complained about your drinking?
  4. Have you ever had to struggle to stop drinking after one or two drinks?
  5. Have you always been able to stop drinking when you wanted to?
  6. Have you ever found that over time you needed to drink more and more alcohol to get the same effect?
  7. Have you ever gotten into physical fights when drinking?
  8. Has your drinking ever created problems between you and your spouse, parents, or other people you care about?
  9. Have you ever lost friendships because of your drinking?
  10. Have you ever gotten into trouble at work or school
  11. Have you ever lost a job because of your drinking?
  12. Have you ever neglected your obligations, your family, your work, or school activities for two or more days in a row because of drinking?
  13. Because of your drinking, have you ever given up or spent less time doing important recreational, social, or work activities?
  14. Have you ever spent a lot of your time getting alcohol, drinking alcohol, or recovering from drinking?
  15. Have you ever found that, over time, drinking the same number of drinks had less effect?
  16. Have you ever used alcohol in the morning or at the beginning of the day?
  17. Have you ever felt the need to cut down on you drinking?
  18. Within several hours or days of not drinking or drinking less than usual, have you ever experienced: (count each of the following present as one “yes” for the total score)
    1. restlessness, anxiety, or pacing?
    2. shaking?
    3. trouble sleeping?
    4. nausea or vomiting?
    5. seizures?
    6. hearing voices, seeing things, or feeling things on your skin that were not really there?
  19. Have you ever used alcohol to get rid of or reduce any of the above symptoms?
  20. Have you ever used alcohol to prevent any of the above symptoms from occurring?
  21. Have you ever had more to drink than you planned?
  22. Have you ever been told by a doctor to stop drinking (not including when you were pregnant, nursing, or taking a medication that should not be used or taken with alcohol)?
  23. Have you ever been a patient in a hospital or treatment facility because of problems related to your drinking?
  24. Have you ever continued to drink despite knowing you had a physical problem (for example, blackouts, liver disease) or a mental health problem (for example, depression) caused or made worse by your drinking?
  25. Have you ever been arrested, ever for few hours, because of driving while intoxicated?
  26. Other than driving-related arrests, have you ever been arrested, even for a few hours, because of your behavior while drinking?
  27. Have you repeatedly driven a car, truck, boat, or recreational vehicle or operated machinery when you had too much to drink?
  28. Have you ever received treatment for alcoholism?
  29. Have you ever attended a meeting of Alcoholics Anonymous (AA) because of your drinking?

The below items are used for the clinician’s benefit but are not calculated into the total score:

  1. How recently have you used any alcohol?
    1. Never have 6 <1
    2. In the past month
    3. 2 to 3 months ago
    4. 4 to 6 months ago
    5. 7 to 9 months ago
    6. 10 to 12 months ago
    7. 13 months to 2 years ago
    8. 2.1 to 5 years ago
    9. More than 5 years ago
  2. Which of the following best describes your entire life experience regarding use of alcohol?
    1. I have never used alcohol in my entire lifetime
    2. I currently use alcohol and I have never had a drinking problem
    3. I no longer use alcohol and I have never had a drinking problem
    4. I no longer use alcohol, but in the past I had a drinking problem
    5. I currently have a drinking problem
    6. Other

SAAST-R Scoring

In the original SAAST the cut-off score was greater-than or equal to 6 indicating the potential for alcoholism, with 10 indicating probable alcoholism (Davis & Morse, 1987), but in the revised SAAST-R the cut-off score is 4. (Patten, et. al., 2006) Given that the moderate to severe options explored in the original SAAST have not been validated yet, attempting to apply those ratings (e.g. equating a score of 10 on the SAAST-R with a score of 10 on the SAAST) should be done with caution.

Drug Abuse Screening Test (DAST)

The Drug Abuse Screening TEST (DAST) was developed as a 28-item self-report test for substance use or drug abuse by the Psychologist Harvey Skinner. It was based on the Michigan Alcohol Screening Test (MAST) but with the word alcohol changed to drugs. Subsequent review shortened the tool from 28 items to 20 and then to 10. It is now available in those two formats, the DAST-10 and the DAST-20.

The European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) provides a copy of the DAST-20 along with a review of its psychometric properties showing it is an effective tool for identifying struggling with addiction (2008).

The DAST-10 is available from the National Institute on Drug Abuse (n.d.). The DAST-20 and the DAST-10 have an extremely high reliability (r = 0.97) indicating they are virtually identical in their output scores. (Villalobos-Gallegos, 2015)

DAST Scoring

Each item in the DAST is scored yes or no, and the “yes” responses are summed to create a final score. On the DAST-20, a score of 6 or higher indicates an issue with drugs, while a score of 16 indicates severe addiction. (EMCDDA, 2008) on the DAST-20. The DAST-10 was found to have an optimal cut-off score of 4. (Evren, et. al., 2016)

Fagerstrom Test for Nicotine Dependence

The Fagerstrom Test for Nicotine Dependence is a 6-item tool for assessing nicotine dependence or severity of smoking addiction. It was developed in 1991 by Karl-Olov Fagerström. There are 3 yes/no items that are scored “0” (no) or “1” (yes), and 3 multiple choice items scored from 1-3. (NIDA, n.d.)

The items on the Fagerstrom Test are as follows (see the link for a printable version). The scores are in brackets:

  • How soon after waking do you smoke your first cigarette?
    • Within 5 minutes (3)
    • 5-30 minutes (2)
    • 31-60 minutes (1)
  • Do you find it difficult to refrain from smoking in places where it is forbidden? E.g. Church, library
    • Yes (1)
    • No (0)
  • Which cigarette would you hate to give up?
    • The first in the morning (1)
    • Any other (0)
  • How many cigarettes in a day do you smoke?
    • 10 or less (0)
    • 11 – 20 (1)
    • 21 – 30 (2)
    • 31 or more (3)
  • Do you smoke more frequently in the morning?
    • Yes (1)
    • No (0)
  • Do you smoke even if you are sick in bed most of the time?
    • Yes (1)
    • No (0)

The Fagerstrom Test has demonstrated fair reliability and validity but requires more comparative studies to test its validity. (Meneses-Gaya, 2009)

Fagerstrom Test Scoring

From the Brief Tobacco Intervention Training Program (BTITP) at Curtin University Australia comes the following scoring chart:

  • Score of 1-2 = low dependence; monitor for withdrawal symptoms but no Nicotine Replacement Therapy (NRT) necessary
  • Score of 3-4 = low to moderate dependence on nicotine; NRT can be offered
  • Score of 5-7 = moderate to high dependence on nicotine; NRT can be offered alone or in combination (e.g. patches with lozenges and gum)
  • Score of 8+ = high dependence on nicotine; NRT can be offered alone or in combination (e.g. patches with lozenges and gum)

The BTITP program provides a chart with recommendations for NRT:

nicotine replacement chart substance use tool

More Information

More information can be obtained from the book “Sourcebook of Adult Assessment Strategies (Nato Science Series B:)

References

Davis Jr., L. J., & Morse, R. M. (1987). AGE AND SEX DIFFERENCES IN THE RESPONSES OF ALCOHOLICS TO THE SELF-ADMINISTERED ALCOHOLISM SCREENING TEST. Journal Of Clinical Psychology, 43(3), 423-430.

Dyson, V. )., Appleby, L., Altman, E., Doot, M., Luchins, D., & Delehant, M. (1998). Efficiency and validity of commonly used substance abuse screening instruments in public psychiatric patients. Journal Of Addictive Diseases, 17(2), 57-76.

EMCDDA. (2008) EMCDDA | “Drug Abuse Screening Test (DAST-20)” Retrieved on July 31, 2016 from http://www.emcdda.europa.eu/html.cfm/index3618EN.html

Evren C, Can Y, Mutlu E, et al. Psychometric Properties of The Drug Abuse Screening Test (DAST-10) in Heroin Dependent Adults and Adolescents with Drug Use Disorder. Dusunen Adam: Journal Of Psychiatry & Neurological Sciences [serial online]. December 2013;26(4):351-359. Available from: Academic Search Complete, Ipswich, MA. Accessed July 31, 2016.

Malet, L., Schwan, R., Boussiron, D., Aublet-Cuvelier, B., & Llorca, P. (2005). Original article: Validity of the CAGE questionnaire in hospital.European Psychiatry, 20484-489. doi:10.1016/j.eurpsy.2004.06.027

Meneses-Gaya, I.C., Zuardi, A.W., Loureiro, S.R., & Crippa, J.A. (2009). Psychometric properties of the Fagerström Test for Nicotine Dependence. Jornal Brasileiro de Pneumologia, 35(1), 73-82.https://dx.doi.org/10.1590/S1806-37132009000100011

NIDA. (n.d.) “Instrument: Fagerstrom Test For Nicotine Dependence (FTND) | NIDA CTN Common Data Elements”. National Institute on Drug Abuse. Retrieved on July 31, 2016 from http://cde.drugabuse.gov/instrument/d7c0b0f5-b865-e4de-e040-bb89ad43202b

O’Brien, C.P. (2008) The CAGE Questionnaire for Detection of Alcoholism. Journal of the American Medical Association300(17):2054-2056. doi:10.1001/jama.2008.570.
Patten, C. A., Vickers, K. S., Offord, K. P., Decker, P. A., Colligan, R. C., Bronars, C., & … Hurt, R. D. (2006). Validation of the Revised Self-Administered Alcohol Screening Test (SAAST-R). American Journal On Addictions, 15(6), 409-421. doi:10.1080/10550490600996322

SAMHSA. (2015). “Substance Use Disorders | SAMHSA” Retrieved on July 31, 2016 from http://www.samhsa.gov/disorders/substance-use

Swenson, W.M., & Morse, R.M. (1975); “The Use of a Self-Administered Alcoholism Screening Test (SAAST) in a Medical Center;” Mayo Clinical Proceedings, 50, 204-208.

Vickers-Douglas, K., Patten, C., Decker, P., Offord, K., Colligan, R., Islam-Zwart, K., & … Hurt, R. (2005). Revision of the Self-Administered Alcoholism Screening Test (SAAST-R): A Pilot Study. Substance Use & Misuse, 40(6), 789-812. doi:10.1081/JA-200030662

Villalobos-Gallegos, L., Pérez-López, A., Mendoza-Hassey, R., Graue-Moreno, J., & Marín-Navarrete, R. (2015). Psychometric and diagnostic properties of the Drug Abuse Screening Test (DAST): Comparing the DAST-20 vs. the DAST-10. Salud Mental, 38(2), 89-94.

Cite this article as: MacDonald, D.K., (2016), "Assessments for Substance Use Disorders," retrieved on September 28, 2016 from http://dustinkmacdonald.com/assessments-substance-use-disorders/.

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Cass Identity Model

Introduction

The Cass Identity Model, formally the Homosexual Identity Formation Model is a 6-stage process for “coming out.” It describes the stages that an individual may go through as they come to terms with their sexuality, both internally and externally. The six stages are as follows:

  1. Identity Confusion
  2. Identity Comparison
  3. Identity Tolerance
  4. Identity Acceptance
  5. Identity Pride
  6. Identity Synthesis

These are explored in more detail below:

Identity Confusion

During this first stage, individuals receive information about LGBT identities, which most people consider personally irrelevant to themselves. At some point, some people will experience thoughts, feelings, or physiological response (arousal) that leads them to ask themselves if they may be LGBT.

This stage may involve significant confusion and concern, as there is a conflict between one’s view as heterosexual and the thoughts they are experiencing. Cass notes the question “If my behaviour may be called homosexual, does that mean I am a homosexual?” This leads to the broader “Who am I?” conversation.

The result of this first stage is one of 3 reactions:

  • If the individual recognizes they are LGBT and likes this, no attempt is made to change their behaviour
  • If the individual recognizes they are LGBT and dislikes this, they may deny their identity and become homphobic (“moral crusader”) – this can lead to a self-hating identity
  • If the individual believes their behaviour is incorrect and also dislikes it, they may respond by redefining it as non-homosexual behaviour. Cass gives the example of a prisoner, or other groups where men who have sex with men may occur without needing to label it

Identity Comparison

During Identity Comparison the individual begins to ask themselves if they’re homosexual. This is the first tentative acceptance of a potential LGBT identity. In Identity Comparison comes the need to tolerate social alienation and belief that they are different (and potentially, alone.)

Two major potential reactions to Identity Comparison result:

  • The individual recognizes they are different and is not bothered by this – the result is that they devalue the judgemental opinions of others
  • The individual recognizes they are different and does not like this. They redefine the meaning of their sexuality (e.g. I am only homosexual with this person) or otherwise denies the meaning of their sexuality

Identity Tolerance

In the identity tolerance stage, the individual has moved towards understanding they are homosexual. They no longer maintain their state of turmoil or identity confusion but may feel more alienated because those who see them as heterosexual struggle to see them otherwise.

At this stage meeting other LGBT individuals helps reduce the feelings of alienation and isolation is helpful in moving through this stage to identity acceptance. The opposite of this, is an alienation from the community and continued self-hatred.

At the end of this stage the individual can firmly say “I am a homosexual.”

Identity Acceptance

In the Identity Acceptance stage, the individual has further normalizing and validating contacts with others in the LGBT community and the LGBT subculture begins to be a larger part of their life.

It’s noted here that there may be a clash between the LGBT individual who wishes to live their life “openly” gay, versus the heterosexual individuals in their life who may tolerate their sexuality but not wish it to be displayed openly. This may result in insulation of the individual from intolerant friends and other methods to limit their exposure to them.

Identity Pride

In Identity Pride, the pendulum has swung far to the right, and the individual may dichotomize the world into two categories, a significant LGBT category and an insignificant heterosexual category. Pride also results in the devaluation of heterosexual institutions and values like marriage and sexual roles.

Heteronormativity appears at this stage as well, with Cass noting the slogan “How dare you presume I’m heterosexual” representing the LGBT individual’s desire to make their homosexuality aware to those around them, at the expense of recognizing heterosexual identities in their life.

Identity Synthesis

Identity Synthesis is the six and final stage. In this stage, the individual’s sexuality becomes just another part of them, and it no longer dominates or defines them. Just as a heterosexual individual doesn’t see the world through just the lens of their heterosexuality (as opposed to ethnic, cultural, gender, or other lenses), nor does the synthesized LGBT individual. The coming out process is complete.

Research on the Cass Identity Model

Kenneady & Oswalt (2014) conducted a comprehensive review of the literature and found a number of other models that closely matched the Cass model, in addition to research supporting its application in the form of questionnaires and other assessment tools. They highlight four major critiques of the model:

  • It is linear and may not represent the process in reality
  • There is only a focus on gay and lesbians, not on bisexual or trans individuals
  • Sexual identity development is assumed to be gender-free, with no difference between men and women
  • There is nothing addressing racial or ethnic impacts on sexual identity development

Degges-White, et. al. (2000) noted that the model was developed primarily in interviews with gay men, and its utility with lesbian women may be limited. Degges-White herself followed up in 2005 with the Adolescent Lesbian Identity Formation Model to address some of these weaknesses.

Gervacio (2012) compared the Cass Identity Model with the Fassinger (1998) model and found that although both required updates to respond to changing social attitudes they were effective in describing the experiences of gay and lesbian individuals.

Zubernis, et. al. (2011) also used the Cass Identity Model along with Chickering’s Model of College Student Development to demonstrate how lesbian and gay college students can be assisted in the coming out process.

References

Cass, V.C. (1979) Homosexual Identity Formation: A theoretical formation. Journal of Homosexuality. 4(3). 219-236

Degges-White, S., Rice, B., & Myers, J. E. (2000). Revisiting Cass’ Theory of Sexual Identity Formation: A Study of Lesbian Development. Journal Of Mental Health Counseling, 22(4), 318.

Degges-White, S. E., & Myers J. E. (2005). The Adolescent Lesbian Identity Formation Model: Implications for Counseling. Journal Of Humanistic Counseling, Education & Development, 44(2), 185-197.

Fassinger, R. E. & Miller, B. A. (1996). Validation of an inclusive model of sexual minority identity formation on a sample of gay men. Journal of Homosexuality, 32(2), 53-78.

Gervacio, J. (2012). A Comparative Review of Cass’s and Fassinger’s Sexual Orientation Identity Development Models. Vermont Connection, 3350-59.

Kenneady, D. A., & Oswalt, S. B. (2014). Is Cass’s Model of Homosexual Identity Formation Relevant to Today’s Society?. American Journal Of Sexuality Education, 9(2), 229-246. doi:10.1080/15546128.2014.900465

Zubernis, L., Snyder, M., & Mccoy, V. A. (2011). Counseling Lesbian and Gay College Students through the Lens of Cass’s and Chickering’s Developmental Models. Journal Of LGBT Issues In Counseling, 5(2), 122-150 29p. doi:10.1080/15538605.2011.578506

Cite this article as: MacDonald, D.K., (2016), "Cass Identity Model," retrieved on September 28, 2016 from http://dustinkmacdonald.com/cass-identity-model/.

 

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