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