The following is a presentation I prepared in 2012 on Suicide Awareness for delivery at Durham College. It’s just been sitting on my hard drive since then, so I’ve made it available for other organizations that wish to provide suicide awareness presentations. The content is reproduced below, and you can download the slides here. Although the content takes a Canadian focus, I’ve noted US statistics where possible.
- About Me
- A Note on Wording
- Suicide Statistics
- Suicide True and False
- Risk Factors for Suicide
- Warning Signs for Suicide
- How to Help
- Support Networks
- Case Study
- Currently Director of Online Support & Communication @ Distress Centre Durham
- Distress Centre Durham History
- 1600+ hours of telephone experience
- 600+ hours of online chat and text
- Former Placement Student, Summer Student (x3)
- Trainer Experience
- Distress Centre Durham Basic Training
- DCIB Suicide Risk Assessment
- Online Chat and Text (ONTX) Training
Before we start…
- People do not commit suicide
- You commit a crime, you get committed to a psychiatric hospital
- Instead, people who take their own lives are said to have suicided or alternately died by suicide, as one dies of lung cancer or a person is murdered.
- Suicide – Intentional taking of one’s own life
- Suicidal ideation – Clinical term for suicidal thoughts
- A suicidal attempt that is designed to fail or be discovered
- Not necessarily attention-seeking behaviour
What is a Crisis?
A crisis is any event that overwhelms someone’s coping mechanisms, those things a person does to solve or deal with a problem
- Suicide is the 2nd leading cause of death in Canada for 18-24 year olds (behind car accidents) (Statistics Canada, 2015)
- More than 90% of suicide victims may have had diagnosable mental illness (Bertolote, et. al., 2004) – Note that there is still not consensus on this figure, it still makes an important point about mental health treatment for suicide
- 21,115 people died by suicide in Ontario in 2005
- The suicide rate is 12.7 per 100,000 males and 4.1 per 100,000 females in Ontario (Statistics Canada, 2014a)
- The Aboriginal suicide rate is 11 times higher than the national average (Public Health Agency of Canada, 2011)
Risk Factors for Suicide (CDC, 2016)
- Mental Illness
- Clinical Depression, Borderline Personality Disorder (BPD), Schizophrenia all increase risk
- Financial Difficulties
- Bullying (+ Cyber-bullying) for young adults
- Relationship Troubles
- Academic / School Troubles
- Legal Problems
- History of Physical / Sexual Abuse
- Bereavement Grief and Loss
- Especially a suicide-related loss
- Interrupted (or “Complicated” Grief)
Suicide True and False
(See: Common Suicide Myths)
- Most suicides involve drugs or alcohol…True! Up to 70% percent of suicides involve alcohol or drugs (Pompili, 2010)
- Talking about suicide can plant the idea in someone’s head False! Most people feeling suicidal want to talk about their feelings
- Teenagers have the highest rate of suicide False! The highest risk population is 45-54 years of age in Canada (Statistics Canada, 2014b), and in the US (CDC, 2014)
- The most common suicide method is pills False! The most common method (overall) is hanging (in Canada: Statistics, 2016); in the US it is firearm: Barber & Miller, 2014)
- Most suicidal people leave notes False! Only about 30% of suicides leave notes (Shioiri, et. al., 2005)
- Suicidal people want to die False! Most suicidal people don’t want to die, but want the pain to stop
Suicide Risk Factors vs. Suicide Warning Signs
- Risk Factors are things that increase the likelihood someone will suicide because those things make coping more difficult
- Warning signs are clues that a suicidal crisis may be imminent
- It takes careful clinical examination by a trained mental health professional to determine a person’s level of risk in the medium and long-term
Suicide Warning Signs (AAS, n.d.)
- Sudden Mood changes (either very happy or very sad)
- Sudden appetite changes
- Talking about life in the past tense
- Telling people goodbye, tying up loose ends
- Talking about suicidal acts, feeling hopeless or helpless
- Making lethality statements (“I wish I could fall asleep and not wake up”)
How to Help
- Provide empathy
- Refer to resources
- Distress Centre (1-800-452-0688, 905-430-2522)
- Durham College Counselling Services
- Durham Mental Health Services
- Other resources (e.g. spiritual)
- Explore options
- Build support network
- Three levels of support
- Strong support network allows developing the resources that provides the strongest defence against suicide
- Internal Supports
- Things that we do ourselves to cope with stress
- Examples include:
- Listening to music / Playing an Instrument
- Running / Working Out / Exercise
- Prayer / Meditation / Spirituality
- Yoga / Massage
- Deep Breathing
- Other Hobbies
- External Supports
- People in our “inner circle” we reach out to
- Examples include:
- Peripheral Supports
- Community agencies and others outside of our inner circle
- Examples include:
- Distress Lines (e.g. Distress Centre)
- Family Doctors
- Psychiatrists / Psychologists
- Durham Mental Health Services
- Suicide is usually preventable
- Asking about suicidal thoughts is the most important thing you can do
- Never be afraid to reach out to a professional for help
The original training included a case study derived from Distress Centre Durham training materials.
American Association of Suicidiology (AAS). (n.d.) “Warning Signs | American Association of Suicidology. Retrieved on August 24, 2016 from www.suicidology.org/resources/warning-signs
Barber, C.W., Miller, M.J. (2014) Reducing a Suicidal Person’s Access to Lethal Means of Suicide: A Research Agenda. American Journal of Preventive Medicine. 47(3S2):S264–S272
Bertolote, J. M., Fleischmann, A., De Leo, D., & Wasserman, D. (2004). Psychiatric Diagnoses and Suicide: Revisiting the Evidence. Crisis: The Journal Of Crisis Intervention And Suicide Prevention, 25(4), 147-155. doi:10.1027/0227-5910.25.4.147
Centers for Disease Control and Prevention (CDC). (2011) Web-based Injury Statistics Query and Reporting System (WISQARS). National Center for Injury Prevention and Control. Retrieved on August 24, 2016 from http://www.cdc.gov/injury/wisqars/index.html.
Centers for Disease Control and Prevention (CDC). (2016) Suicide: Risk and Protective Factors. Retrieved on August 24, 2016 from http://www.cdc.gov/violenceprevention/suicide/riskprotectivefactors.html
Pompili, M., Serafini, G., Innamorati, M., Dominici, G., Ferracuti, S., Kotzalidis, G. D., … Lester, D. (2010). Suicidal Behavior and Alcohol Abuse. International Journal of Environmental Research and Public Health, 7(4), 1392–1431. http://doi.org/10.3390/ijerph7041392
Public Health Agency of Canada. The Human Face of Mental Health and Mental Illness in Canada 2006. Ottawa, ON: Public Health Agency of Canada, 2011. Available at: http://www.phac-aspc.gc.ca/publicat/human-humain06/
Shioiri, T., Nishimura, A., Akazawa, K., Abe, R., Nushida, H., Ueno, Y., & … Someya, T. (2005). Incidence of note-leaving remains constant despite increasing suicide rates. Psychiatry & Clinical Neurosciences, 59(2), 226-228. doi:10.1111/j.1440-1819.2005.01364.x
Statistics Canada. (2014a) “Suicides and suicide rate, by sex and by age group (Both sexes no.)” from CANSIM, table 102-0551. Retrieved from http://www.statcan.gc.ca/tables-tableaux/sum-som/l01/cst01/hlth66a-eng.htm on August 24, 2016.
Statistics Canada. (2014b) “Suicides and suicide rate, by sex and by age group (Both sexes no.)” from CANSIM, table 102-0551. Retrieved electronically from http://www.statcan.gc.ca/tables-tableaux/sum-som/l01/cst01/hlth66a-eng.htm on August 24, 2016.
Statistics Canada. (2015) Table 102-0561 – Leading causes of death, total population, by age group and sex, Canada, annual, CANSIM (database). Retrieved on August 24, 2016.
Statistics Canada. (2016) 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
Introduction to Interprofessional Education
This is an essay I wrote in 2015 for the course HSRV 306 Critical Reflection for Practice at Athabasca University.
Interprofessional education (IPE) is defined as “the process, through which two or more professions learn, with, from and about each other to improve collaboration and the quality of service” (CAIPE, 1997) IPE has been practiced in various forms for decades (Smith & Clouder, 2010) but is most commonly associated with healthcare and the social sciences.
The advantage of interprofessional education is that it allows allied fields to benefit from “pooling together of expertise in teams [that] would make them more effective and efficient” (Illingworth & Cheivanayagam, 2007) than those professions working on their own. As there is much overlap in the work provided by professionals in social work, psychology and psychiatry this pooling together of resources has the potential to improve their skills and competencies.
One competency required by these professions is the ability to prevent suicide, which involves the interrelated skills of risk assessment and suicide intervention. How much an individual may need to intervene will differ depending on their role, with some professionals needing only to recognize the signs and refer them on, while others may be required to perform regular and comprehensive suicide risk assessment and intervention.
Suicide and Mental Health Professionals
The suicide rate in Canada has remained relatively steady in Canada for several years, with more than 3,000 individuals dying by suicide in Canada each year. (Statistics Canada, 2014) A 2002 meta-review demonstrated that many of these people visited physicians or nurses for physical health complaints before their death. (Luoma, Martin & Pearson, 2002) Whether or not these physical complaints were related to their mental health issues or not, an opportunity for suicide screening and subsequent referral was missed.
One study on suicide screening, focused on Emergency Departments in the United States found that when universal screening was implemented, requiring all patients to be screened for suicide regardless of their presenting problem, the rate of detected suicidal thoughts doubled. (Boudreaux, et. al., 2015) This demonstrates the importance of all healthcare professionals being competent in the basics of suicide screening.
Mental health professionals regularly treat suicidal clients, with Feldman & Freedmanthal’s 2006 study reporting 78% of social workers had provided service to a suicidal client in the previous year. While mental health professionals regularly work with suicidal clients they may lack the skills or confidence to respond appropriately.
Ruth et. al. (2006) conducted interviews with social work students, faculty and Deans and discovered that the majority of programs provided their social worker students less than 4 hours of education on suicide assessment during their graduate programs. This resulting lack of coverage left social work students feeling unconfident working with suicidal clients, and indeed scared of the possibility that a client will reveal suicidality, a fact noted by other researchers as well. (Osteen, Jacobson & Sharpe, 2014) This paralyzing fear may contribute to burnout or other negative professional consequences and ultimately make them less effective practitioners.
Interprofessional education has the potential to improve the care of suicidal clients by allowing professionals to take advantage of the best practices in education present in allied fields. By borrowing best practices from other helping professions the number of competent professionals may ultimately be increased and the number of suicides or potential suicides that are undetected may be reduced.
Potential drawbacks to adopting interprofessional education that have been documented in the literature include the costs of implementation (such as redesigning curriculums) and the possible loss of professional identity among different groups who learn the same skills (Smith & Clouder, 2010) Given that mental health care is already well-diffused (with each professional area like social work, psychology and psychiatry having specialties but ultimately all being able to provide counselling or therapy with training), this may be less of an issue in suicide prevention, which is currently practiced by volunteers all the way up to Psychiatrists and Psychologists holding doctorates.
Interprofessional Education in Physical and Mental Health
There are a number of approaches to education in mental health fields (social work and psychology) and physical health fields (nursing and non-psychiatric medicine), including best practices that have demonstrated improved knowledge transfer, satisfaction and skill within their respective professional programs.
Physical health professions include general medicine practiced by physicians as well as nurses, who are recognized as professionals in their own right (College of Registered Nurses of Manitoba, n.d.). Professional schools of nursing have a long history, stretching back to the early 1900s (Schekel, 2009), while the first medical school opened in Italy in the 9th century. (de Divitiis, Cappabianca, & de Divitiis, 2004)
Education of physicians and nurses has always emphasized hands-on treatment and “learning by doing”, but especially since the 15th century when the first cadaver dissections were performed for medical students. (Rath & Garg, 2006)
Current techniques used in medical and nursing education include case studies, where the signs and symptoms of an illness and a patient’s history are described in detail and a diagnosis or treatment is sought (Raurell-Torreda, et. al., 2015), and simulated patients who are specially trained actors that medical students interact with in order to experience conducting clinical interviews, assessment and diagnosis (Uys & Treadwell, 2014).
Both case studies and simulated patients have shown utility in general nursing and medicine according to Luebbert & Popkess (2015). Some studies have specifically explored their utility with suicidal patients, such as Norrish (2009) who used cases to teach suicide risk assessment skills to Omani medical students.
Techniques that have demonstrated effectiveness with Psychology and Social Work students on the other hand, include role-playing (Murdoch, Bottorff & McCullough, 2013) where students practice simulated complaints with each other in order to develop the skills of recognizing and responding to suicidal statements, and evidence-based lecture. (Scott, 2015)
Gate-keeper training programs that are designed to teach lay people the basic skills of recognizing the signs of suicide and referring individuals to trained professionals, for instance, QPR (Lancaster, et. al., 2014) have demonstrated effectiveness in increasing confidence and skill in both nursing (Bolster, Holliday, Oneal & Shaw, 2015) and social work students. (Sharpe, Frey, Osteen & Bernes, 2014)
While domain-specific education for nurses and physicians has begun to be developed, it lacks the exploration of knowledge-transfer and rigorous methodology necessary for it to be as effective as possible. One example of beginning nurses education is Kishi et. al. (2014), who had emergency room nurses in Japan completing a 1 day workshop. The workshop covered suicide risk assessment, management of the immediate suicidal crisis, referring patients to long-term resources, and attitudes towards suicidal patients. This workshop was taught using lectures and case studies, with a pre and post-test design on a scale measuring attitudes towards suicide (but not knowledge transfer or skill acquisition.) The lack of a knowledge-transfer component means these nurses are unable to demonstrate whether they learned anything or if they apply their training to their patients.
Other exercises in integrating suicide prevention into social work including Scott (2015) who developed a full-semester course for MSW students that taught suicide risk assessment, intervention, and public health interventions such as media guidelines around suicide. Luebbert & Popkess (2015) had students complete either a video-taped lecture or speak to a standardized patient after being exposed to material on suicide assessment and found that the group that worked with the standardized patient felt much more confident.
What is lacking in nursing and medical education is a focus on evidence-based practice in suicide prevention, an issue noted by nursing faculty (Kalb et. al., 2015) Additionally providing opportunities for hands-on practice through exercises like case studies, simulated patients, and roleplaying will allow for necessary deep knowledge transfer.
Suicide prevention is a field ripe for improvement by integrating the best practices from a variety of allied fields. Most notably, from nursing and general medicine the case study and simulated/standard patients may help social workers and psychologists reduce their fear of working with suicidal clients, while the strong evidence-based lecture, roleplaying and gate-keeeper training may give busy nurses and physicians an opportunity to develop suicide awareness and referral skills that will allow them to intervene to prevent death.
Bolster, C., Holliday, C., Oneal, G., & Shaw, M. (2015). Suicide Assessment and Nurses: What Does the Evidence Show?. Online Journal Of Issues In Nursing, 20(1), 1-1 1p. doi:10.3912/OJIN.Vol20No01Man02
Boudreaux, E., Allen, M., Goldstein, A.B., Manton, A., Espinola, J. & Miller, I. (2015) Improving Screening and Detection of Suicide Risk: Results from the Emergency Department Safety Assessment and Follow-up Evaluation (ED-SAFE) Effectiveness Trial. Society for Prevention Research 23rd Annual Meeting. Accessed Dec 10 2015 from https://spr.confex.com/spr/spr2015/webprogram/Paper23206.html
de Divitiis, E., Cappabianca, P. & de Divitiis, O. (2004) The “schola medica salernitana”: the forerunner of the modern university medical schools. Neurosurgery. 55(4);722-44
CAIPE (1996) Principles of Interprofessional Education. London: CAIPE.
College of Registered Nurses of Manitoba. n.d. “Standards of Practice for Registered Nurses: Nursing Practice Expectations” Accessed electronically from https://www.crnm.mb.ca/uploads/document/document_file_89.pdf?t=1438266260 on Dec 11 2015.
Feldman, B. N., & Freedenthal, S. (2006). Social work education in suicide intervention and prevention: An unmet need? Suicide and Life-Threatening Behavior. 36. 467–480
Illingworth, P. & Chelvanayagam, S. (2007) Benefits of interprofessional education in health care. British Journal of Nursing. 16(2):121-4
Kalb, K.A., O’Conner-Von, S.K., Brockway, C., Rierson, C.L. & Sendelbach, S. (2015) Evidence-Based Teaching Practice in Nursing Education: Faculty Perspectives and Practices. Nursing Education Perspectives. DOI: 10.5480/14-1472
Kishi, Y., Otsuka, K., Akiyama, K., Yamada, T., Sakamoto, Y., Yanagisawa, Y., Morimura, H., Kawanishi, C., Higashioka, H., Miyake, Y. & Thurber, S. (2014) Effects of a Training Workshop on Suicide Prevention Among Emergency Room Nurses. Crisis. 35(5):357–361 DOI: 10.1027/0227-5910/a000268
Lancaster, P.G., Moore, J.T., Putter, S.E., Chen, P.Y., Cigularov, K.P., Baker, A., Quinnett, P. (2014) Feasibility of a web-based gatekeeper training: implications for suicide prevention. Journal of Suicide and Life Threatening Behaviour. 44(5):510-23. DOI: 10.1111/sltb.12086
Luebbert, R. & Popkess, A. (2015) The Influence of Teaching Method on Performance of Suicide Assessment in Baccalaureate Nursing Students. Journal of the American Psychiatric Nurses Association. 21(2) 126-133. DOI: 10.1177/1078390315580096
Luoma, J.B., Martin, C.E. & Pearson, J.L. (2002) Contact with mental health and primary care providers before suicide: a review of the evidence. American Journal of Psychiatry. 159(6):909-16
Murdoch, N.L., Bottorff, J.L. & McCullough, D. (2013) Simulation Education Approaches to Enhance Collaborative Healthcare: A Best Practices Review. International Journal of Nursing Education Scholarship. 10(1):307-321. DOI: 10.1515/ijnes-2013-0027
Norrish, M. (2009) The effectiveness of a vignette approach to teaching suicide risk factors: An Omani perspective. Medical Teacher. 31:539-544. DOI: 10.3109/01421590902849511
Osteen, P. J., Jacobson, J. M., & Sharpe, T. L. (2014). Suicide Prevention in Social Work Education: How Prepared Are Social Work Students?. Journal Of Social Work Education, 50(2), 349-364. DOI: 10.1080/10437797.2014.885272
Rath, G. & Garg, K. (2006) Inception of cadaver dissection and its relevance in present day scenario of medical education. Journal of the Indian Medical Association. 104(6):331-3
Raurell-Torreda, M., Olivet-Pujol, J., Romero-Collado, A., Malagon-Aguilera, M. C., Patiño-Maso, J., & Baltasar-Bague, A. (2015). Case-Based Learning and Simulation: Useful Tools to Enhance Nurses’ Education? Nonrandomized Controlled Trial. Journal Of Nursing Scholarship. 47(1). 34-42 9p. DOI: 10.1111/jnu.12113
Ruth, B.J., Gianino, M., Muroff, J., McLaughlin, D. & Feldman, B.N. (2012) You Can’t Recover From Suicide: Perspectives on Suicide Education in MSW Programs. Journal of Social Work Education, 48(3). 501-516. DOI: 10.5175/JSWE.2012.201000095
Scott, M. (2015) Teaching Note—Understanding of Suicide Prevention, Intervention, and Postvention: Curriculum for MSW Students, Journal of Social Work Education, 51(1), 177-185
Scheckel, M. (2009). Nursing Education: Past, Present, Future. In Roux, G., & Halstead, J.A. (Eds.) Issues and Trends in Nursing: Essential Knowledge for Today and Tomorrow. (pp. 27-35).
Sharpe, T.L., Frey, J.J., Osteen, P.J. & Bernes, S. (2014) Perspectives and
Appropriateness of Suicide Prevention Gatekeeper Training for MSW Students, Social Work in Mental Health, 12:2, 117-131, DOI: 10.1080/15332985.2013.848831
Smith, S., & Clouder, L. (2010). Interprofessional and Interdisciplinary Learning: An Exploration of Similarities and Differences. In A. Bromage, L. Clouder, J. Thistlethwaite, & F. Gordon (Eds.) Interprofessional E-Learning and Collaborative Work: Practices and Technologies (pp. 1-13). Hershey, PA: . DOI: 10.4018/978-1-61520-889-0.ch001
Statistics Canada. (2014) “Suicides and suicide rate, by sex and by age group (Both sexes no.)” from CANSIM, table 102-0551. Retrieved electronically from http://www.statcan.gc.ca/tables-tableaux/sum-som/l01/cst01/hlth66a-eng.htm on Dec 6, 2015.
Uys, Y., & Treadwell, I. (2014). Using a simulated patient to transfer patient-centred skills from simulated practice to real patients in practice. Curationis, 37(1), 1-6 6p. DOI: 10.4102/curationis.v37i1.1184
If you’re like me, you value certification and being able to demonstrate that you have the knowledge to provide crisis intervention in a safe and responsible manner. For those who work in private practice or perform training or other consulting, having crisis intervention certifications can help those who want to hire you feel confident that you know your stuff.
What follows below are a number of crisis intervention and suicide certifications and trainings that you can use to build your knowledge, increase your skills and improve your portfolio.
AAS Crisis Worker Certification
- 21 years of age or older
- 500 hours or 2 years full-time crisis intervention experience
- Completion of an approved crisis intervention training program/course
- Completion of the AAS exam
Description: The American Association of Suicidology offers this crisis intervention certification. The description from their website is below:
The training program AAS offers is designed to provide a standardized set of understandings and opportunities to practice both basic crisis worker skills and more advanced skills that, we believe, will help crisis workers be the best they can be. With this training and reading the backup bibliographic resources, they should be well prepared to successfully pass the AA’s individual crisis worker certification exam.
Advanced Crisis; Intervention and Counselling
Cost: Approximately $385 x 6 courses = $2,310 for domestic students
Prerequisites: Degree or diploma in a health, human, or social services discipline, or reelvant work or volunteer experience
Description: Offered by Humber College in Toronto, Canada, the Crisis Intervention and Counselling certificate program is six courses that provide comprehensive training focusing “on the immediate support and intervention individuals often require in crisis situations.”
Applied Suicide Intervention Skills Training (ASIST)
Cost: Varies, typically $150-250
Description: Applied Suicide Intervention Skills Training (ASIST) is a two-day training in suicide intervention. Completion of ASIST shows that you recognize the signs and symptoms of suicide, understand how to ask someone about suicide, perform a risk assessment and finally complete a suicide intervention or safety plan before referring individuals for more long-term help.
ASIST is another option for crisis intervention certification. If you want to further develop your training, LivingWorks also offers Suicide to Hope, an advanced training in suicide case management.
Certified Volunteer Helpline Worker
Prerequisites: Volunteer at a Distress Centre
Description: If you volunteer for Distress Centre Durham (DCD) or a similar crisis line, they may offer a Certified Volunteer Helpline Worker option to you. At DCD, you’re required to complete and pass our 18 hour Basic Training, 16 hours of on-the-phone supervised shifts and a 3-hour Advanced Training session in order to be awarded the Certified Volunteer Helpline Worker title. Other crisis lines may have slightly different options for crisis intervention certification.
Online Counseling and Suicide Intervention Specialist (OCSIS)
Cost: $199 for volunteers/students, $399 for professionals
Description: The OCSIS course trains individuals to perform crisis intervention and suicide prevention in an online environment. It also provides individuals with a QPR Gatekeeeper certification as well. In addition to the course itself there is the OCSIS Certificate of Competency which involves expert review of a case study in order to receive the QPR crisis intervention certification.
I’ve had the pleasure of serving on the Durham Region Youth Suicide Prevention (YSP) Action Group since February 2016. The goal of the YSP is to address the rising youth suicide rates in Durham Region in Ontario. This group was financially supported by a 3-year grant from the Ministry of Children and Youth Services.
For other regions interested in implementing similar suicide prevention groups (whether to address youth, elderly, military, or other targeted group suicide rates or others) the following may be helpful. Because my group was focused on youth suicide prevention, more of the resources below apply to that but the concepts are equally applicable to others.
The first step is for your suicide prevention group to learn about suicide in your targeted population. Academic journals can be helpful in this way, as can other resources depending on the group you are looking for. I’ve linked some examples below, including a number of blog articles.
Learning About Adult Suicide
Learning About Elder Suicide
Learning About Law Enforcement Suicide
Learning About Male Suicide
Learning About Military Suicide
Learning About Youth Suicide
Choosing Your Suicide Prevention Group Members
In order to develop a suicide prevention group, you must identify individuals in the community who can participate. In order to be most effective, a suicide group should be cross-sectorial – that is, it should include individuals from a variety of stakeholders that are affected by that demographic. Examples of sectors and include:
- Criminal Justice
- Faith / Religion
- Hospital / Medical
- Mental Health
- Substance Abuse
It is important to recognize that regardless of the group you target, many of these stakeholders will be relevant. For instance, in an elderly suicide prevention group, organizations that work with seniors directly (such as seniors centres, long-term care facilities and hospices) will be important, but faith-based organizations, substance abuse workers and criminal justice may provide valuable insight based on their work with elderly clients.
Conducting A Needs Assessment
Once you’ve identified the group of individuals who will make a part of your suicide prevention group, the next step is to conduct a needs assessment. Needs assessments are formal explorations of what exists in your community, and what does not. This allows you to identify the gaps and make a formal plan for eliminating those gaps.
Examples of completed needs assessment for suicide prevention include Shasta County, California and Juneau, Alaska.
This strategic planning tool from TogetherToLive can help you start your needs assessment process. This process should also include community consultation via surveys, focus groups or other methods to collect information from individuals who have lived experience with suicide in your community, especially in your target demographic.
Now that you’ve conducted a needs assessment, you have an idea what elements are lacking in your community. Interventions fall into one of three categories:
- Universal Interventions apply to everyone in a particular area. For instance, all individuals who present to an emergency room are administered a suicide screening measure; this is a universal intervention
- Indicated Interventions apply to individuals who are identified as high-risk for suicide. For instance, students who appear to be experiencing emotional health issues are referred to school mental health counselling
- Selected Interventions apply to individuals who present with suicide risk factors or warning signs. These can include referrals to therapists, crisis lines or transportation to the hospital for emergency mental health treatment.
There are a variety of interventions that your suicide prevention group can choose, targeting four different categories. These categories are Life Promotion (or Primary Prevention), Suicide Prevention, and Postvention.
Life Promotion Interventions
Life promotion interventions are those that focus on “build[ing] their resilience through their personal strengths, available resources and relationships with those around them.” These interventions focus on individuals who haven’t yet experienced suicidality. For youth, this will involve programs about self-esteem, healthy relationships and problem-solving, while for soldiers this might include PTSD awareness, managing combat stress and accessing physical and mental health resources as needed.
Suicide Prevention Interventions
Suicide prevention interventions are those that focus on individuals who have expressed suicidal ideation or at risk for suicide. This is the most common category for intervention because these individuals have begun to slide down the river towards suicide.
- Restricting Access to Means – Restricting access to lethal means involves training individuals to assess and remove lethal means like firearms or lethal quantities from suicidal individuals so that they are able to stay safer. (Johnson, et. al., 2011)
- Web-Based Suicide Prevention/Support Services – These include online discussion boards and other resources that provide platforms for suicidal people to discuss their issues, crisis chat services and other web-based programs. The Best Practices for Online Technologies (Reidenberg, Wolens, & James, 2013) can help with this.
- Suicide Prevention Training for Primary Care Physicians – Primary care physicians represent an important point of contact for suicidal individuals. Primary care physicians often report feeling undertrained to adequately respond to suicide (McDowell, Lineberry & Bostwick, 2011).
- Suicide Screening – Suicide screening involves administering a tool to individuals without necessarily having identified suicide risk yet. This can be a universal or indicated method. The ED-SAFE study (discussed more under “Emergency Department and Follow-Up Care” explains the advantages of universal screening. Troister et. al. (2015) discusses three screening tools: the Beck Depression Inventory II (BDI-II), the Beck Hopelessness Scale (BHS) and the Psychache Scale.
- Gatekeeper Training – Gatekeeeper Training equips laypersons with the tools to recognize suicide risk and to connect with medium and long-term resources like crisis lines and therapy. Popular (and validated) crisis lines include ASIST (Applied Suicide Intervention Skills Training; Rogers, 2010) and QPR (Question, Persuade, Refer; Quinnett, 2012).
- Suicide Hotlines and Crisis Lines – Suicide hotlines and crisis lines provide immediate emotional support, suicide risk assessment, crisis intervention and safety planning. They are an important element in the suicide prevention framework by catching individuals who may be very close to suicide. Crisis line outcomes have been studied (Kalafat, 2007; Gould, et. al., 2007) and found to have a range of benefits to callers.
- Psychological Treatment / Psychiatric Treatment – Psychological and psychiatric treatment includes therapy, counselling, medication and a range of other treatments that are available and provided by mental health clinicians. The availability of mental health treatment can have an impact on the suicide rate. (Jagodic, 2013; Kapusta, et. al., 2010)
- Emergency Department and Follow-Up Care – Emergency departments represent an important access point for mental health care. Universal screening with the ED-SAFE Tool has been shown to double the rate of detected suicide versus a control population. (Boudreaux, et. al., 2015) Additionally follow up has been shown to reduce the rate of re-admission. (Harrison, et. al., 2011)
- Reducing the Harmful Use of Alcohol – Substance abuse is significantly related to suicidal behaviour. (Wilcox, Conner, & Caine, 2004) By assessing the risk of substance abuse and putting in place treatment options for the targeted population, the impact of addiction or harmful use of substances, including alcohol can be reduced.
Postvention interventions refer to those items that are implemented in the aftermath of a suicide death. A number of interventions are listed on the TogetherToLive Postvention section. Some of these resources are explored below:
- Provide immediate debriefing and information to survivors helps reduce the impact of the loss (Cox et. al., 2012; Parsons, 1996; Celotta, 1995; King, 1999) This debriefing should provide psychoeducation on grieving, depression and potential post-traumatic stress disorder (PTSD) while also emphasizing the importance of grieving.
- Identify individuals at high risk and reach out to them (Celotta, 1995; Carter & Brooks, 1990). How this occurs will differ depending on the targeted population but it is important that a system is in place to refer individuals for support (an indicated risk strategy) and ensure that all those affected know how to reach out.
- Ensure the media provides a respectful response to the suicide that acknowledges its impact without glorifying it (Bohanna & Wang, 2012; MediaWise, 2003) Safe messaging strategies can be implemented to reduce the risk of suicide contagion
Implementing Your Interventions
Once you’ve determined the interventions you would like to choose, you must begin to implement them. This can be accomplished by breaking your suicide group into sub-teams that focus on specific interventions. This allows you to begin to tweak your approach by seeing your chosen interventions applied in actual practice. Examples of implementations for some of the above interventions could include:
- Providing ASIST gatekeeper training to local community members
- Arranging for training of primary care physicians in suicide risk assessment
- Distributing posters with information on local crisis lines in schools
- Working with the hospital to deliver follow-up calls to patients seen in the Emergency Department for mental health issues
This effort usually requires support from the agencies involved (such as the hospital, the school, etc.) and therefore it is helpful if these individuals are present on your suicide prevention group.
Evaluating Your Suicide Prevention Group
Once you’ve implemented your interventions, evaluation will help you see the impact of your suicide prevention group activities. The exact method in which you measure your impact will differ depending on the interventions you choose, but could include things like:
- Tracking the number of calls to local crisis lines or admissions to hospital for suicide-related behaviours
- Counting the number of people you delivered gateekeeper training to
- Providing pre and post-assessment surveys to gauge learning by people attending trainings
- Measuring the suicide rate in your community or in your demographic
Ensuring that you have an evaluation plan designed before you implement your interventions will prevent you from forgetting to collect data or collecting the wrong data. Your suicide prevention group can then review this information and tweak your strategy as time goes on, altering the strategy or focusing on new interventions and goals.
Bohanna, I., & Wang, X. (2012). Media guidelines for the responsible reporting of suicide: A review of effectiveness. Crisis: The Journal Of Crisis Intervention And Suicide Prevention, 33(4), 190-198. doi:10.1027/0227-5910/a000137
Boudreaux, E., Allen, M., Goldstein, A.B., Manton, A., Espinola, J., Miller, I. (2015) Improving Screening and Detection of Suicide Risk: Results from the Emergency Department Safety Assessment and Follow-up Evaluation (ED-SAFE) Effectiveness Trial. Society for Prevention Research 23rd Annual Meeting. Accessed Jun 28 2015 from https://spr.confex.com/spr/spr2015/webprogram/Paper23206.html
Carter, B.F., Brooks, A. (1990) Suicide postvention: Crisis or opportunity?. School Counselor. 37(5)
Celotta, B. (1995) The aftermath of suicide: Postvention in a school setting. Journal of Mental Health Counseling. 17(4)
Cox, G.R., Robinson, J., Williamson, M., Lockley, A., Cheung, Y.T.D., Pirkis, J. (2012) Suicide Clusters in Young People Evidence for the Effectiveness of Postvention. Crisis. 33(4) 208-214 doi: : 10.1027/0227-5910/a000144
Gould, M. S., Kalafat, J., HarrisMunfakh, J. L., & Kleinman, M. (2007). An evaluation of crisis hotline outcomes part 2: suicidal callers. Suicide And Life-Threatening Behavior, (3), 338.
Harrison, P. L., Hara, P. A., Pope, J. E., Young, M. C., & Rula, E. Y. (2011). The impact of postdischarge telephonic follow-up on hospital readmissions. Population Health Management, 14(1), 27-32. doi:10.1089/pop.2009.0076
Jagodic, H. K., Rokavec, T., Agius, M., & Pregelj, P. (2013). Availability of mental health service providers and suicide rates in Slovenia: a nationwide ecological study. Croatian Medical Journal, (5), 444. doi:10.3325/cmj.2013.54.444
Johnson, R. M., Frank, E. M., Ciocca, M., & Barber, C. W. (2011). Training Mental Healthcare Providers to Reduce At-Risk Patients’ Access to Lethal Means of Suicide: Evaluation of the CALM Project. Archives Of Suicide Research, 15(3), 259-264. doi:10.1080/13811118.2011.589727
Kalafat, J., Gould, M. S., Harris Munfakh, J. L., & Kleinman, M. (2007). An evaluation of crisis hotline outcomes part 1: nonsuicidal crisis callers. Suicide And Life-Threatening Behavior, (3), 322.
Kapusta, N. D., Posch, M., Niederkrotenthaler, T., Fischer-Kern, M., Etzersdorfer, E., & Sonneck, G. (2010). Availability of mental health service providers and suicide rates in Austria: a nationwide study. Psychiatric Services, 61(12), 1198-1203. doi:10.1176/appi.ps.61.12.1198
King, K. (1999) High School Suicide Suicide Postvention: Recommendations For an Effective Program. American Journal of Health Studies. 15(4).
Lapierre, S., Erlangsen, A., Waern, M., De Leo, D., Oyama, H., Scocco, P., & … Quinnett, P. (2011). A systematic review of elderly suicide prevention programs. Crisis: The Journal Of Crisis Intervention And Suicide Prevention, 32(2), 88-98. doi:10.1027/0227-5910/a000076
McDowell, A. K., Lineberry, T. W., & Bostwick, J. M. (2011). Practical suicide-risk management for the busy primary care physician. Mayo Clinic Proceedings, (8), 792.
MediaWise. (2003) The Media and Suicide. Accessed electronically from http://www.mediawise.org.uk/wp-content/uploads/2011/03/The-Media-and-Suicide-.pdf on November 26, 2016.
Parsons, R.D. (1996) Student suicide: The counselor’s postvention role. Elementary School Guidance & Counseling, 31(1)
Reidenberg, D., Wolens, F. & James, C. (2013). Responding to a cry for help: Best practices for online technologies. Retrieved on November 26, 2016 from http://www.sprc.org/resources-programs/responding-cry-help-best-practices-online-technologies
Rogers, P. (2010) Review of the Applied Suicide Intervention Skills Training Program (ASIST). LivingWorks. Retrieved on November 26, 2016 from https://www.livingworks.net/dmsdocument/274.
Troister, T., D’Agata, M. T., & Holden, R. R. (2015). Suicide risk screening: Comparing the Beck Depression Inventory-II, Beck Hopelessness Scale, and Psychache Scale in undergraduates. Psychological Assessment, 27(4), 1500-1506. doi:10.1037/pas0000126
Quinnett, P. (2012) QPR Gatekeeper Training for Suicide Prevention The Model, Theory and Research. QPR Institute. Retrieved on November 26, 2016 from https://www.qprinstitute.com/uploads/QPR%20Theory%20Paper.pdf.
Wilcox, H. C., Conner, K. R., & Caine, E. D. (2004). Association of alcohol and drug use disorders and completed suicide: an empirical review of cohort studies. Drug And Alcohol Dependence, 76(Supplement), S11-S19. doi:10.1016/j.drugalcdep.2004.08.003