Setting Limits and Boundaries with Callers

Introduction

Setting limits with Helpline callers is one of the most difficult tasks for a new helpline worker to master. It may go against a volunteer’s nature for them to be required to end calls with callers who still feel they need support or to set limits with callers who may be struggling with mental or cognitive disorders that make it more difficult for them to understand these limits.

The opposite side of that coin is that if volunteers do not set adequate limits with their callers, they will experience increased levels of burnout as they handle calls that are upsetting or even abusive; additionally, if limits are not placed on regular callers, they will “crowd out” crisis callers who may have less of an opportunity to receive support while at imminent risk because a repeat caller is using a disproportionate amount of service delivery.

5 Step Limit Setting Process

There is a 5-step process to setting limits with callers that is commonly used at the Distress Centre and I imagine other helplines or organizations where limit-setting is required. The five steps are as follows:

  1. Identify the inappropriate behaviour
  2. Identify what correct behaviour is
  3. Indicate the consequences for failing to change behaviour
  4. Give the caller an opportunity to change their behaviour
  5. Follow through on consequences (e.g. hanging up) if behaviour does not change

Let’s examine each of these steps in sequence:

Identify the inappropriate behaviour

The first step is to identify what inappropriate behaviour is. This can be an agency limit such as a prohibition on the discussion of sexual explicit content or of a caller masturbating on the phone, or this can be a personal limit like a volunteer being uncomfortable with a caller swearing.

The volunteer will identify the inappropriate behaviour, e.g. “I recognize you’re very angry but I need you to refrain from swearing during our conversation”

Identify what correct behaviour is

In a situation where there is a correct behaviour, the volunteer should indicate that. For example, “We can discuss this sexual experience but I need to stay focused on the emotions and not the physical elements of the act.”

Indicate the consequences for failing to change behaviour

This identifies what happens if a caller does not change their behaviour. “If we can’t stay focused on the emotions, I’m going to have to end the call.”

Give the caller an opportunity to change their behaviour

This is to allow the caller to show us they have recognized the issue, such as by refraining from swearing.

Follow through on consequences (e.g. hanging up) if behaviour does not change

In this step, the caller has not changed their behaviour so the volunteer ends the call. “I’m sorry, but I asked you to refrain from discussing the physical elements of this call. As you have continued to do so, I have to end the call now.” This should be followed by the volunteer hanging up!

This limit setting procedure can be used in a variety of settings, both in person and on the phone.

Call Restrictions

Call restrictions are different from in-call limits (described above), and instead describe things such as a caller being put on a 20 minute time limit per call, or being limited to one call a day. These limits are best deployed when a caller is using significantly more service than average.

One way that Distress Centre determines limits is by examining how often a caller uses our services and for how frequently. Our goal is to limit most callers (who have limits) to one call, once per day, and then to decide on how long. For instance, if a caller tends to call twice a day and speak for 30 minutes, we may set their restriction to one call a day, for 30 minutes.

This restriction is always suspended when a caller is in crisis so that we can de-escalate them or connect them to emergency support.

When placing a caller on restrictions it’s important to speak to them about the rationale for that. A caller who calls repeatedly is likely getting less out of each call than they would otherwise. One focused 30 minute call may deliver much more support to a caller than three 10 minute calls, for instance. One focused hour long call will provide more support to a caller than three hour long calls.

Speaking to the caller, you can explain that we want to make sure our service is available for that caller and help meet their needs but also meet the needs of our other callers and volunteers. If a caller is upset, we can help them find additional supports in their community in addition to the Distress Centre that can help meet their needs.

Working with Abusive Callers

Abusive callers can be very challenging. These are callers that frequently disregard the Five Step Limit Setting Procedure above and instead abuse volunteers by being insulting, sexually graphic or simply by disregarding their time limits consistently.

Abusive callers may need to be temporarily blocked until a staff member can speak with them, in order to reign in that behaviour. If a caller continues to be abusive, the best option may be to simply block that caller from using your service, referring them to alternates in your community.

Winding Up on Text and Chat

Text and chat is a different beast from the telephone. Conversations can stretch much longer if your responder is not careful. Fortunately there are a variety of winding up strategies that can be used on text and chat conversations.

When it comes time to wind up a conversation, you have a few options:

  • We’re just coming up on (45/60/75/90) minutes so we’ll need to wrap up soon. I’m wondering if there’s anything else on your mind?
  • We’ve been talking for (45/60/75/90) minutes, how are you feeling?
  • I’m going to have to open up our queue soon, is there anything you haven’t told me yet that you want to?
  • We’ve been talking for about an hour now so I’ll have to let you go for now

In situations where someone is using the service multiple times per day, you may wish to try things like:

  • I saw that you’ve spoken to one of our responders earlier today, how did that conversation go?
  • I’m wondering if we can focus on some coping strategies that can help you get through the rest of the night

In my experience most visitors respond positively to these gentle wind-ups and allow you to move towards wrapping up the conversation at the appropriate point.

Call Blocking

In a future post I will discuss the technological options available for call blocking; it’s a good idea to check with your telephone provider about the option of blocking abusive or harassing callers from your helpline.

Conclusion

Limit setting can be a challenging task for your volunteers to master but is essential for their continued success on your lines!

Cite this article as: MacDonald, D.K., (2017), "Setting Limits and Boundaries with Callers," retrieved on November 23, 2017 from http://dustinkmacdonald.com/setting-limits-and-boundaries-with-callers/.
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Language Learning for Social Service Workers

Introduction

An important part of cultural competency for social workers is the ability to speak a language understood by their clients. In the US and Canada there are significant populations of Spanish, French, and South Asian language speakers, and their ability to access social work support may be impaired by the lack of speakers of those languages.

The good news is that it’s not an insurmountable goal to learn a language, especially with new technologies. Many resources exist for free that help an individual learn their language of choice. Some people wonder about the time commitment, but luckily the US State Department has already answered this question.

The State Department operates the Foreign Service Institute (FSI), a language school for US Diplomats. Based on their extensive research and experience actually training complete beginners to speak a variety of languages, they’ve separated them into four categories. Each of these categories are listed below with some of the languages that fit into them:

Category I Language (languages closely related to English)

  • Danish
  • Dutch
  • French
  • Italian
  • Norwegian
  • Portuguese
  • Romanian
  • Spanish
  • Swedish

Category II Languages (languages similar to English)

  • German
  • Indonesian
  • Malay
  • Swahili

Category III Languages (languages moderately different from English)

  • Albanian
  • Amharic
  • Armenian
  • Azerbaijani
  • Bengali
  • Bulgarian
  • Burmese
  • Czech
  • Dari
  • Estonian
  • Farsi
  • Finnish
  • Georgian
  • Greek
  • Gujarati
  • Hausa
  • Hebrew
  • Hindi
  • Hungarian
  • Icelandic
  • Kazakh
  • Khmer
  • Kurdish
  • Lao
  • Latvian
  • Lithuanian
  • Macedonian
  • Mongolian
  • Nepali
  • Pashto
  • Polish
  • Russian
  • Serbo-Croatian
  • Sinhala
  • Slovak
  • Slovenian
  • Somali
  • Tagalog
  • Tajiki
  • Tamil
  • Telugu
  • Thai
  • Tibetan
  • Turkish
  • Ukrainian
  • Urdu
  • Uzbek
  • Vietnamese

Category IV Languages (languages significantly different from English)

  • Arabic
  • Chinese (Mandarin)
  • Japanese
  • Korean

For each of these categories the State Department prescribes how much time it will take for an English learner to reach a useful level of language knowledge. For Category I languages you must study for 600 hours, for Category II 750 hours, for Category III 900 hours and for Category IV 1100 hours. Of course, this may be an under-estimation because these individuals are in class for 30 hours a week, but it gives you a good idea.

Choose a Language

Choosing a language is a very personal choice, but there are a few things that might be able to help you decide: number of speakers (or number of speakers in your area), ease of accessing language material, career usefulness and closeness to your native language.

For individuals who choose a language based on number of speakers, here are the top 5:

  1. Chinese (Mandarin)
  2. Hindi
  3. Spanish
  4. English
  5. Arabic

Ease of accessing language material is hard to quantify but there are certainly many products available for the Romance languages (French, Spanish, Italian, etc.) as opposed to others.

Career usefulness can be looked at in terms of languages critical to US interests (just a few of the 60 languages listed:

  1. Arabic
  2. Chinese (Cantonese and Mandarin)
  3. Hindi
  4. Indonesian
  5. Korean
  6. Russian
  7. Turkish

For those interested in using their language in their Social Work career, knowing the number of US speakers may be important:

  1. English
  2. Spanish
  3. Chinese (Cantonese and Mandarin)
  4. French
  5. Tagalog

Measuring Fluency

If you had attended an FSI or DLI (Defense Language Institute – the military’s language school) course, you would be considered at a level useful enough to understand the language as spoken and to produce it yourself. But how do you know what that actually means, especially when compared to another individual? That’s where various proficiency tests and assessments come in.

Although I won’t go into detail about specific language-related tests (like the DELF tests for French), I will discuss two common standards, the Common European Framework of Reference for Languages and the Defense Language Proficiency Test.

Common European Framework of Reference for Languages (CEFR)

The CEFR is the worldwide standard for proficiency. It is grouped into 6 categories, A1, A2, B1, B2 and C1 and C2. A1 and A2 are beginner and low-intermediate levels of proficiency. B1 and B2 are considered intermediate users of the language who are independent, while C1 and C2 are advanced language learners. For each language you wish to take, there are CEFR assessments that match.

An FSI language course would place a learner at B1 at completion, enough to use the language independently, engage in conversations and understand the world around them.

Defense Language Proficiency Test (DLPT)

The DLPT is another proficiency test for languages. The reason that I list it, is that there are a lot of people using DLI language learning materials who might want to understand this test. After completing the DLPT, a learner is assessed a scale from 0-3, with 2/2 generally corresponding to B1, and 3/3 corresponding to C1. In each category, there are plus (+) options available to indicate a level of proficiency higher than the number.

Language Learning Resources

Language learning resources differ based on what language an individual is learning. Below are a few resources I’m familiar with a heavy influence towards French (the language I’m learning now), Spanish (a language I spent 3 years learning in high school) and Arabic (the next challenge I want to tackle.)

Duolingo

Available Languages: Spanish, French, German, Italian, Portuguese, Russian, Dutch, Swedish, Irish, Turkish, Danish, Norwegian, Polish, Esperanto, Hebrew, Ukranian, Vietnamese, Welsh (In Beta): Hungarian, Greek, Romanian (In Progress): Swahili, Czech, Hindi, Korean, Klingon, Indonesian

Price: Free

Description: Duolingo offers you a skills tree with all the information you need to reach approximately A2 (some people say B1) of your language, and learn about 2000 words in the process. It’s very intuitive and by working through the course you learn to translate between your native language and English while developing knowledge of vocabulary.

Pros: It’s simple and very fun. You get to see your progress and work your way to the end. You get a trophy when you finish!

Cons: The grammar instruction can be light in some areas which can be very confusing

Memrise

Available Languages: (Made by Memrise Team): English, Japanese, French, Spanish, German, Chinese, Korean, Italian, Russian

Price: Free

Description:  Memrise is like a flashcards program on steroids, but organized into courses. You do a lot of filling in the blanks or other exercises that teach you words and helps build your vocab.

Pros: Great audio narration accompanies the cards. There are courses for the most common languages that correspond to the CEFR Levels. For instance, French has 7 courses. French 1-3 correspond to A1, French 4-6 correspond to A2, and French 7 corresponds to B1.

Cons: There’s zero grammar instruction which means Memrise is not useable on its own. There’s also no indication on the number of words, and many of the smaller courses (not created by the Memrise team) are of varying quality.

Lingvist

Available Languages: French, German, Russian, Spanish

Price: Free

Description: Lingvist is a deceptively simple but very powerful program designed to build your vocabulary up to 5000 words. It uses an endless card interface that presents you with a “fill in the blank.” You can double click on the sentence or any word to get a translation to help you, and if you get it wrong you’ll get an opportunity to fill in the correct answer.

Pros: Never-ending interface allows you to go much longer before you get bored or tired. Beautiful interface. 5000 words beats Memrise and Duolingo

Cons: No grammar instruction similar to Memrise

GLOSS (Global Language Online Support System)

Available Languages: Albanian, Arabic (Egyptian, Gulf, Iraqi, Levantine, MSA, Sudanese, Yemeni), Azerbaijani, Balochi, Chinese (Mandarin), Croatian, Dari, Farsi, French,German, Greek, Hausa, Hebrew, Hindi, Indonesian, Japanese, Korean (North and South), Kurmanji, Pashto, Portuguese (Brazilian and European), Punjabi, Russian, Serbian, Somali, Sorani, Spanish, Swahili, Tagalog, Thai, Turkish, Turkmen

Price: Free

Description: Created by the US military, GLOSS exercises are sorted into the 3/3 DLPT proficency areas and allow you to view real material in those languages and answer questions or complete exercises.

Pros: Lots of exercises available for lots of languages, native material means it’s very high quality

Cons: Not a language course per se

Headstart2

Available Languages: Amharic, Arabic (Egyptian, Iraqi, Levantine, MSA, Moroccan) Baluchi, Cebuano, Chavacano, Chinese (Mandarin), Dari, French, German, Hausi, Hindi, Indonesian, Italian, Japanese, Korean, Kurmanji, Malay, Pashto, Persian-Farsi, Portguese (Brazilian, European), Russian, Somali, Spanish, Swahili, Tagalog, Tausug, Thai, Turkish, Turkmen, Urdu, Uzbek, Yemeni

Price: Free

Description: Brought to you by the Defense Language Institute, Headstart2 provides you with approximately 750 words, and basic grammar with the goal of getting you to 0+ (memorized proficiency) on the DLPT.

Pros: For languages like Hindi, Arabic and Pashto that don’t use the Latin alphabet, Headstart2 is a great teaching resource

Cons: Vocabulary is very military-focused (if you consider that a con.) Will need to move on to other courses quickly.

Peace Corps

Available Languages: Albanian, Arabic, Armenian, Azerbaijani, Bambara, Bengali, Bulgarian, Chinese, French, Georgian, Hausa, Kyrgyz, Macedonian, Malagasy, Mongolian, Romanian, Moldovan, Russian, Siswati, Thai, Tswana, Turkmen, Ukrainian, Wolof

Price: Free

Description: The Peace Corps requires all individuals who deploy as volunteers to reach a certain level of language training. Although the Peace Corps uses a simple proficiency scale (Beginner, Intermediate, Advanced, with Low, Intermediate, High for each level.) Part of these training resources are available online.

Pros: Very audio-focused, with lots of survival phrases

Cons: Some languages have limited material; the accents can be challenging

Special Operations Language Training (SOLT)

Available Languages: IndonesianRussian, SerbianSpanishThai, many others (if active-duty military)

Price: Free

Description: Similar to the Peace Corps, members of the US Special Forces are required to reach a certain level of language proficiency (in their case 1/1 on the DLPT scale.) When completed in person, this 18 weeks (for Pashto) or 24 weeks (for Arabic); other languages are shorter.

Pros: Not a lot of “fluff”, courses get down to business quickly

Cons: Only a few courses are available online

Cite this article as: MacDonald, D.K., (2017), "Language Learning for Social Service Workers," retrieved on November 23, 2017 from http://dustinkmacdonald.com/language-learning-social-service-workers/.
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Preventing Burnout on Crisis Lines

Introduction

Burnout is defined as a state of ineffectiveness comprising “emotional exhaustion, depersonalization, and reduced personal accomplishment.” (Maslach, 1982) It is a pervasive and frustrating state, accounting for a large portion of the turnover experienced in mental health services, including volunteer and paraprofessional organizations like crisis lines.

There are a number of models of burnout, but one stage model is presented below from Cherniss (1980) and reproduced in Kinzel & Nanson (2000):

Stage 1: Stress

Stress is the first stage of burnout, when an individual is functioning at a level that exceeds their optimal operating conditions. This could be because of internal factors (like wanting a promotion or being intensely devoted to work), external factors (like being given a larger caseload due to budget cuts) or interpersonal factors (like a negative relationship with a colleague or supervisor.)

Stage 2: Strain

When a person experiences strain, they have now operated in a state of stress long enough that they are reaching a point of emotional exhaustion. Their coping begins to be maldaptive and they often experience negative somatic or physical complaints like headaches.

Stage 3: Defensive Coping

In the final stage of burnout, an individual’s burnout begins negatively impacting their ability to take calls or otherwise perform their helpline work. There is a lack of empathy or concern for the callers and this may be accompanied by blaming the callers or detachment from the situation. At this stage

Causes of Burnout

There are a variety of causes of burnout. Some listed by Kinzel & Nanson (2000) include:

  • Nature of crisis calls
  • Negative emotions experienced during the calls like anger or guilt
  • Countertransferrence (being triggered by one’s own experiences while supporting another)
  • Repeat or regular callers creating a feeling of powerlessness or ineffectiveness
  • A lack of effective coping skills

Additionally Kinzel & Nanson note studies that revealed the presence of magical thinking (assuming the situation would get better on its own) and escape-avoidance coping skills were associated with an increase in burnout, along with detachment and personality responsibility.

Paradoxically, workers who were too involved (taking personal responsibility for callers) were more likely to experience burnout as were volunteers who were detached. The least likely to experience burnout is the crisis line worker who stays emotionally connected to a caller but also recognizes that their life is their life and it is not the worker’s responsibility to change it. (Mishara & Giroux, 1993)

Assessing Burnout

The Maslach Burnout Inventory (MBI; Maslach, C., Jackson, S.E., & Leiter, 1996) is the most common measure for assessing burnout. It is a 21-item scale that produces scores on three subscales: Emotional Exhaustion, Personal Accomplishment and Depersonalization.

Morse et. al. (2012) notes example cut-off scores for the three scales as follows “emotional exhaustion scores of at least 21, depersonalization scores of at least 8, and personal accomplishment scores of 28 or below” but with the caveat that those scores may be lower than necessary, artificially inflating the presence of burnout in mental health professionals.

Helpline managers will need to take the lead in determining whether their workers are experiencing symptoms of burnout. This may be witnessed in the quality of listened calls, in the comments made on call reports, or contacts that occur off the lines. For instance, volunteers who:

  • Started giving more advice to callers
  • Talked to staff about frustration with non-suicidal callers “wasting” distress line time
  • Missed shifts because of not being emotionally capable

These may be situations where you would recommend burnout prevention activities. Potential treatments for burnout are discussed more in-depth below, but in the helpline environment a leave of absence (LOA) from the lines for a while, increased self-care or decreased activity (e.g. limiting hours weekly or monthly) can help avoid burnout.

Treatments for Burnout

Smullens (2013), writing for Social Worker magazine notes a number of strategies including:

  • Stimulus control and counterconditioning. Stimulus control involves active decisions like not choosing to eat lunch at your desk or bringing a plant into the office while counterconditioning involves physical exercise, hobbies, or other diversions
  • Mental health treatment. Therapists should seek their own therapy when their personal issues interfere, and someone who is experiencing or worried about experiencing burnout is certainly under that category
  • Diversify. This refers to the idea of changing your responsibilities to give you non-clinical activities that help to refresh and restore you. For many social workers, this involves teaching, conferences, or other activities, but for heplline workers it can also involve becoming a leadership volunteer, serving on a non-profit Board or another form of volunteerism

Oser et. al. 2013) added to this with burnout prevention strategies including:

  • Coworker support. Being able to vent to colleagues who have a sense of what you’re going through and understand your organizational culture can be very helpful. Feeling like (or being) isolated without anyone to discuss concerns with can exacerbate feelings of ineffectiveness. This applies to helpline workers as well, who can make frequent use of debriefing
  • Clinical supervision. Supervision can also help reduce feelings of isolation and ineffectiveness by giving individuals an opportunity to identify maladaptive coping strategies or other issues that may lead to burnout

Research is continuing so hopefully in the future we have specific therapies designed for burnout and options; a number of individuals leave the helping professions each year because of burnout, which is obviously not ideal.

References

Bowden, G. E., Elizabeth Smith, J. C., Parker, P. A., & Christian Boxall, M. J. (2015). Working on the Edge: Stresses and Rewards of Work in a Front-line Mental Health Service. Clinical Psychology & Psychotherapy, 22(6), 488-501. doi:10.1002/cpp.1912

Cherniss (1980). Staff Burn-Out. Job Stress in the Human Services. Sage Publications.

Kinzel, A., & Nanson, J. (2000). Education and debriefing: Strategies for preventing crises in crisis-line volunteers. Crisis: The Journal Of Crisis Intervention And Suicide Prevention, 21(3), 126-134. doi:10.1027//0227-5910.21.3.126

Maslach, C. (1982). Burnout: The Cost of Caring. New Jersey: Prentice-Hall, Inc.

Mishara, B.L., Giroux, G. (1993). The relationship between coping strategies and perceived stress in telephone intervention volunteers at a suicide prevention center. Suicide and Life Threatening Behavior, 23(3).

Maslach, C., Jackson, S.E., & Leiter, M.P. (1996) Maslach Burnout Inventory (3rd ed.). Palo Alto, CA: Consulting Psychologists Press.

Morse, G., Salyers, M. P., Rollins, A. L., Monroe-DeVita, M., & Pfahler, C. (2012). Burnout in Mental Health Services: A Review of the Problem and Its Remediation. Administration and Policy in Mental Health, 39(5), 341–352. http://doi.org/10.1007/s10488-011-0352-1

Smullens, S. (2013) What I Wish I Had Known: Burnout and Self-Care in Our Social Work Profession. Social Worker. Retrieved on December 28, 2016 from http://www.socialworker.com/feature-articles/field-placement/What_I_Wish_I_Had_Known_Burnout_and_Self-Care_in_Our_Social_Work_Profession/

Cite this article as: MacDonald, D.K., (2017), "Preventing Burnout on Crisis Lines," retrieved on November 23, 2017 from http://dustinkmacdonald.com/preventing-burnout-on-crisis-lines/.
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Crisis Hotline Certification

Introduction

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

Cost: $85

Prerequisites:

  • 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

Prerequisites: None

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

Cost: $0

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

Prerequisites: None

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.

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Building a Suicide Prevention Group

Introduction

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.

Building Capacity

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
  • Education
  • 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.

Choosing Interventions

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:

  1. 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
  2. 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
  3. 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

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.

References

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

Cite this article as: MacDonald, D.K., (2016), "Building a Suicide Prevention Group," retrieved on November 23, 2017 from http://dustinkmacdonald.com/building-suicide-prevention-group/.

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