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Excerpted from: Youth Suicide Prevention Programs: A Resource Guide, Centers for Disease Control, 1992
The following information is intended to serve as an aid to those interested in developing or augmenting youth suicide prevention/intervention programs in their own communities. Types of youth suicide prevention programs that are in operation or that have been proposed are described, and several exemplary youth suicide prevention programs are provided. The programs described are intended to characterize the diversity of programs that exist and to serve as a resource for those interested in learning more about prevention activities in this field.
Strategies for Suicide Prevention
Different prevention strategies are designed to prevent suicide in various ways. For example, gatekeeper training and screening programs are designed to identify people at risk of suicide and refer them to mental health services, while hotlines are intended to help people who are experiencing a crisis. Although prevention programs are typically comprehensive, many program directors recommend implementing one component at a time, in order to get the activity fully operational before new program components are added. Following are eight different kinds of program activities representing different strategies for suicide prevention.
School Gatekeeper Training
This type of program is directed at school staff (teachers, counselors, coaches, etc.) to help them identify students at risk of suicide and refer such students as appropriate. These programs also teach staff how to respond in cases of a tragic death or other crisis in the school. Gatekeeper training usually consists of learning about warning signs of suicide, what referral sources exist and how to contact them, and what the school policy is for handling crisis situations. Other topics include legal issues involved with suicide and how to communicate with at-risk students. It is not meant to replace professional mental health care or to empower school staff to act as counselors, but is simply meant to enable staff to "sound the alarm". Combined with appropriate professional treatment, this intervention may help prevent suicides.
Community Gatekeeper Training
The goal of these programs is to train community members to identify young people at risk of suicidal behaviors and to refer them to appropriate sources of help. Examples of gatekeepers include coaches, clergy, police officers, health care professionals, hairdressers and barbers, and bartenders.(As well as school personnel discussed above). Gatekeeper programs have two kinds of activities: media campaigns and training programs at various levels of intensity/expertise directed at specific types of gatekeepers, such as the police or clergy.
The fundamental idea behind these programs is that people at risk of suicide often come into contact with police, clergy, doctors, friends, or others who do not recognize the risk of suicide and therefore do not act to access, obtain or arrange appropriate help for them. These programs are designed to increase a potential gatekeeper's sense of confidence and competency in helping a person at risk of suicide. There are several core objectives of community gatekeeper programs: to increase gatekeepers' knowledge of suicide warning signs; to increase knowledge of referral sources in the community; and to foster a greater willingness to refer high-risk youths to mental health or other appropriate services.
General Suicide Education
General Suicide education programs are typically school-based programs that review with students the facts and myths about suicide, alert them to warning signs, and provide information about how to seek help for themselves and others. Some programs also encourage students to share their feelings and develop their interpersonal coping skills. The programs try to provide alternatives for solving problems other than suicide and many provide training in stress management and coping skills to help students deal with their problems. Programs also promote the development of listening and interpersonal skills to help students improve their relationships with peers, parents, and others.
The basic premise is that the more students know about suicide warning signs and sources of help, the more likely they will be to ask for help for themselves or refer others for help. Implicit in the general suicide education approach is a recognition of the difficulty of determining who, among thousand of healthy adolescents, is truly at high risk of suicide. For this reason, programs employing this strategy are given to all students. Prudence suggests that school which undertake general suicide education programs should have in place staff and resources to recognize and deal with students who might be upset by participation in these programs.
Screening Programs
Typically, screening programs are conducted in schools and involve the administration of a screening instrument to identify high-risk youths. Persons identified by the initial screening test then receive in-person counseling and, if warranted, referral and treatment.
One model of such a program could involve multistage screening to identify students with psychological problems or personality traits that could be related to suicide, such as depression, and impulsive or aggressive behavior. Students might be identified through a general screening questionnaire, students with high scores would then consult with a guidance counselor or social worker specially trained to identify the signs of a potentially suicidal youth. Students thought to be at risk would then be given a third screening by a specialist and referred to receive treatment.
Peer Support Programs
Peer support programs, which can be conducted in either school or nonschool settings, are designed to foster peer relationships, competency development, and coping skills among high-risk youths as a method of preventing suicide among them. The goal of peer support programs is to provide a setting in which young people who may be at risk for suicide can receive the support of their peers and develop interpersonal and coping skills. (These programs are not intended to be therapeutic programs or psychiatric treatment programs). The rationale for peer support programs is to enhance the interpersonal and coping skills of participants, allowing them to increase their use of natural social support networks and to improve their school attendance and school and job performance. Peer support programs might help to reduce antisocial behavior and substance abuse, factors associated with suicide. Success of peer support programs with other high-risk behaviors suggests that the programs have potential as an intervention approach to preventing youth suicide.
Crisis Centers and Hotlines
The rationale for crisis hotlines relies on the premise that suicide attempts are often precipitated by a critical stressful event, are often impulsive, and are usually contemplated with substantial ambivalence. Hotlines are designed to respond to the crisis and to deter a caller from self-destructive acts until the immediate crisis has passed. Crisis center hotlines offer an immediately available source of support; they do not require a trip to a clinic; and they are anonymous, allowing callers the opportunity to say anything in a context in which they may feel secure and in control.
Many of the hotlines are part of a more comprehensive suicide prevention program, with strong linkages to schools and to mental health services. many programs offer drop-in counseling services, whereas others offer only information and referrals, linking callers with existing community services.
Means Restriction
Means restriction refers to suicide prevention efforts that reduce access to firearms, drugs, high places, and other common means of committing suicide. The rationale behind this approach is based on several elements. First, impulsiveness appears to play in important role in suicide, especially youth suicide. Furthermore, for practically all suicides, ambivalence is a prominent characteristic. For these reasons, many suicide prevention specialists argue that if lethal means are not readily available when a person decides to attempt suicide, he or she might either delay the attempt, allowing for the possibility of later deciding against suicide, or use a less lethal means, allowing for a greater possibility of medical rescue.
Ready access to firearms may be a particularly important risk factor for suicide among young people. Among males, 15 to 24 years of age, nearly two-thirds of all suicides are committed with guns. Evidence is sufficiently compelling to strongly advocate that parents prevent their children from having unsupervised access to handguns and other firearms. Despite increasingly convincing research evidence and broad consensus among prevention specialists that means restriction may be highly effective, few programs have a major component dealing with restricting access to the means of suicide.
Intervention After a Suicide
In the event of a youth suicide, one of the aims of crisis intervention involves mobilizing the staff and other resources in order to reduce the risk of a suicide cluster developing. Suicide clusters are groups of suicides occurring closer in space and time than would normally be expected. Such clusters occur predominantly among adolescents and young adults.
Schools and other community agencies should be prepared to respond quickly to minimize the likelihood of suicide contagion following one or more teen suicides. Crisis response has many other important functions and benefits as well: The crisis intervention response is guided by a contingency plan developed in advance of the event as a part of suicide prevention efforts. The crisis intervention plan should identify a coordinating committee to manage day-to-day response to the situation; a host agency to "house the plan, monitor youth suicide; and call the coordinating committee into action. The plan should be activated in the event of a suicide cluster or one or more traumatic deaths that might lead to the development of a suicide cluster.
The first step taken by the coordinating committee should be to contact and prepare key groups, especially teachers, school counselors, support staff in schools, and other who will deal directly with friends and classmates of the suicide victim. These people should be briefed on the proper means of announcing the death, supporting the reactions of teenagers, and identifying and counseling close friends of the victim and other high-risk persons. The crisis response should be conducted in ways that avoid glorifying the victim and sensationalizing the suicide. High risk persons, such a relatives, boyfriends or girlfriends, close friends and past suicide attempters, should be identified, screened and if needed, referred for further counseling. Accurate data, in a timely flow, should be provided to the media. Elements in the environment that might increase the likelihood of further suicide should be identified and changed. Immediate access to the means of suicides, especially those used by the victim , should be restricted.
Summary
Although sufficient information is not available to recommend one suicide prevention strategy over another, the following recommendations seem prudent:
- Ensure that new and existing suicide prevention programs are linked as closely as possible with professional mental health resources in the community. Many of the strategies are designed to increase referrals of at-risk youth and this approach can be successful only to the extent that there are appropriate, trained counselors to whom referrals can be made.
- Avoid reliance on one prevention strategy. Most successful programs incorporate several if not all of the eight strategies described.
- Incorporate promising but underused strategies into current programs where possible. The restriction of lethal means by which to commit suicide may be the most important candidate strategy here. Peer support groups for those who have felt suicidal or have attempted suicide also appear promising, but great care should be taken to ensure that there are no adverse consequences from involving peers in such activities.
- Incorporate evaluation efforts into all new and existing suicide prevention programs, preferably based on outcome measures, such as the incidence of suicidal behavior, or measures closely associated with such behavior. Be aware that suicide prevention efforts, like all health interventions, may have unforeseen negative consequences. Evaluation measures should be designed to identify such consequences should they occur.
When developing a youth suicide prevention program in a particular community, the needs and resources of the community must be identified to determine which strategy or combination of strategies is most appropriate.
ILLUSTRATIVE PROGRAMS: School Gatekeepers
BRIDGES: Building Skills to Reach Suicidal Youth
Reports: Brief descriptive brochure
NJ(908) 463-4109
Bridges is a training program for selected school personnel (e.g., guidance staff, child study teams, personnel from student assistance programs, and teachers working with emotionally disturbed adolescents) to help them to develop skills in assessing suicide risk, to intervene in the crisis of suicidal youth, to intervene with families and peers of suicidal youth, to follow referral procedures, and to develop school policies and procedures for suicide prevention and postvention.
School personnel training lasts 16 hours (two days) and trains personnel to accurately distinguish students at risk for suicidal behavior from those who are depressed. Personnel learn to assess students' risk, to intervene when appropriate, to work with families and peers, to follow referral procedures and to develop school policy and procedures with regard to suicide prevention and postvention. In addition to Gatekeeper training, BRIDGES includes the following related components: postvention, screening, survivors' support groups.
Pennsylvania Network for Student Assistance Services
Reports:Annual statistical report; Program curriculum and description; evaluation- preliminary data
PA (412) 394-5837
The Student Assistance Program (SAP) focuses on early identification, intervention and referral of at-risk students to community resources for assessment and treatment. A SAP core team within a school building consists of six school personnel trained to identify and refer at-risk-students to community resources. Two service-provider representatives (one mental health and one drug and alcohol expert) train with the core team and serve as ad hoc members on the team. SAP team members do not diagnose or offer treatment to students; instead, they refer them to appropriate community assessment and treatment resources. There is a direct link between schools and local mental health and drug and alcohol service providers.
SAP team members attend an initial 5-day residential training course: 2 days of lectures; 2 days of exercises, role-playing, and practicing intervention models to establish team roles and responsibilities; and 1 day of questions, reinforcement and planning for the creation and implementation of individual SAPs.
Students can be referred to the team through a variety of sources: administrators, teachers, counselors, nurses, child study teams, parents or guardians, peers, and the students themselves. Related components include Postvention.
ADVICE to others interested in starting this type of program: All interested parties should network: schools, mental health agencies, drug and alcohol agencies, parents and any other interested people. Each department at the state level (Education, Health, Public Welfare) and the governor's office should work collaboratively towards the same goal.
STAR (Services for Teens At Risk)
Reports:Brochures and articles about the activities of STAR
PA (412) 624-5211
STAR Center offers three programs designed specifically to help school personnel identify and refer at-risk youths. Level 1: Administrators, teachers, counselors and others who are in daily contact with students learn to identify potential risk factors, recognize behavior patterns of adolescents who may possibly become suicidal, and follow referral procedures. Level 2: During a 2-day workshop, school personnel learn to evaluate a youth's level of risk and to work effectively with families, students and mental health agencies. Level 3: Trains in-house personnel to continue Level 1 training in their school.
STAR Center also works to implement programs in communities and schools immediately following a suicide. Teams from STAR Center conduct postvention sessions that are designed to prevent further suicides through individual student screening, small group discussions and education. In addition, STAR Center offers outpatient clinical treatment for adolescents at Western Psychiatric Institute and Clinic. Related components include Clinical treatment, postvention and screening.
Suicide Prevention Center Programs
Reports:Program manuals and pamphlets and evaluation materials
OH (513) 297-9096
The SPC provides school gatekeeper training as part of a broad range of crisis support services, including a 24-hour crisis hotline, training of professionals (teachers, service providers, clergy, physicians, police), and a crisis response team for postvention work for individuals or groups. The school gatekeeper program provides in-service training on recognition of depression and suicidal behavior; short-term crisis intervention; school and community resources and factual information about suicide. Specific programs operating as part of Project Lifesaver are: Staying Alive- a program that target minorities and uses nontraditional gatekeepers, such as barbers and hairstylists and Finding Hope- a training program for parents. Related components to the program include general suicide education, crisis center and hotline, parent programs and postvention.
Crisis Intervention Dade County Public Schools
FL (305) 995-7315
The purpose of the Department of Crisis Intervention is to prepare staff at the district, region and school levels to identify, assist and refer students at risk. The department trains "crisis care core teams" in every school to counsel staff and the community in times of crisis. A hotline is available to assist administrators, counselors and other support staff.
Training of crisis core teams in the schools is done by the District Crisis Team, which consists of one counselor and one psychologist. Training consists of a 3-hour program. Crisis teams are present in all schools; this is a county-mandated requirement. School staff includes counselors, teachers, social workers, occupational specialists, college advisors, psychologists, bus drivers, cafeteria workers, students, peer counselors and parents. Related components include general suicide education, means restriction, parent education, postvention and screening.
Project SOAR (Suicide: Options, Awareness, Relief)
Reports:Program Manual
TX (214) 565-6700
A comprehensive program that covers prevention, intervention and postvention. Prevention consists of suicide awareness lessons for teachers and staff. Intervention consists of training school counselors in all secondary and elementary schools in risk assessment of potential suicides through personal verbal interviews. A crisis team does postvention for students and teachers. There is also a peer support system and a section called Quest on esteem building. A committee of community mental health professionals advises the suicide and crisis management program.
An 18-hour course was designed to train one school counselor from each high school and middle school to become a primary caregiver. Caregivers coordinate suicide prevention efforts in their local building and conduct the initial intervention when a student threatens or attempts suicide. To minimize the disruption of their ongoing job responsibilities, the 180 primary caregivers were selected to receive training over 4 months. All other elementary and secondary school counselors who are not designated as the primary caregiver receive 6 hours of instruction. All counselors, including the primary caregivers, receive 3 hours of follow-up training each year. the trainers, members of the Dallas Independent School District Psychological/ Social Services Crisis Team, are always available for consultation. A school psychologist or home school coordinator will assist with high-risk cases.
The goal for the training is to help the school counselor develop the skills of a crisis counselor. The training program will provide instruction on how to identify students who may be at risk for suicide, assess the level of that risk, provide crisis intervention counseling, complete and file a report with DISD and refer the at-risk student to a mental health agency or private therapist as needed. Related components include general suicide education, parent programs, peer support, postvention.
Advice to others interested in starting this type of program: Begin by forming a joint school district/community task force to conduct a needs assessment and to review existing school suicide prevention programs and make a recommendation to the school board. The American Association of Suicidology would be a resource for this information. A school policy should be developed that spells out the procedures that primary caregivers would follow in the event of a suicide threat, attempt or completion. The next step would be to assign the responsibilities of training to a facilitator who is knowledgeable in the field of suicide prevention and to review approved training material. A directory of appropriate community referral resources should be made available to all primary caregivers and crisis counselors who work with suicidal students.
Adolescent Suicide Prevention Program
Reports:Program manual:Adolescent Suicide Prevention program- a Guide for Schools and Communities; Adolescent Suicide Prevention In-service Guide for Faculty and Staff; Responding to Adolescent Suicide
VA (703) 246-7745
The program provides an organized, systematic method for improving services that are in place. The aim of this program is to help teachers and school staff become aware of and able to identify suicide-prone youths. The program includes a crisis management plan for schools to use in handling the aftermath of suicides and other crisis that affect both the staff and student populations. The plan involves community agencies as well as school personnel. Related components include sections in the health and family life education curricula that begin in the fourth grade. These sections cover a variety of affective and mental health issues in the early grades and extend to suicide discussion in the higher grades. Students can take an elective course for credit in the Peer Helper program in which the same issues are discussed in greater detail. Workshops that involve both school and community resources are also offered for the parents. Suicide awareness and prevention training is given over a 2-day period to faculty in high schools and secondary schools and in-service sessions are held periodically. Related Components include: general suicide education, parent program, peer support and postvention.
Advice to others interested in starting this type of program: The best programs are achieved through the collaboration of schools and community agencies. Schools need to be more open and accepting of other professionals , and agencies need to learn the contingencies of educational institutions. Successful networks are only possible through combining efforts and services.
Weld County Suicide Prevention Program
Reports:Program manual and descriptive articles
CO (303) 587-2336
This program develops crisis teams for schools (from in-place staff) and a student curriculum for grades 3-12. The training acquaints the crisis team with the signs of suicidal behavior in students and teaches interviewing skills and counseling techniques for dealing with suicidal students and their parents. The training also addresses legal issues, changes in confidentiality, documentation, public relations, team structure to reduce individual stress, procedure and policies, interagency agreements, suicide contagion and postvention, working with the media, and safety factors in working with students. The student curriculum varies depending on the grade, but mainly consists of information about depression and its role in suicidal thoughts, how and where to get help for one's self or a friend and how to develop coping or problem solving skills.
The crisis team members undergo extensive training (30-hours) in suicide awareness, counseling techniques, and methods and resources for help and referral. A one-hour training session is provided each year to all school staff to give them a basic understanding and awareness of the issue and of what they can do. An additional 4-hour training session is given to all administrators on legal issues, policies and procedures. Related components of the program include general suicide education, parent programs, postvention, community gatekeeper training.
Advice to others interested in starting this type of program: programs that use and train in-place staff rather than rely on outside expertise are not only much cheaper but are more effective (education of all students and staff can be done in-house as needed, referrals are made earlier, interventions can be immediate, follow-ups can be ongoing and extensive). In addition, such programs seem to be much longer lived because the district staff takes ownership of the program. The crisis team needs to be a generic one, dealing with all deaths. Administrative and board support and good agency relationships are crucial.
ILLUSTRATIVE PROGRAMS: Community Gatekeepers
ASAP (Adolescent Suicide Awareness Program)
NJ(201) 935-3322
This is an extensive program with training initiatives directed at a variety of professionals, such as teachers, emergency room staff, clergy and police. Methods and training materials for this program are increasingly sought by other communities that are developing similar initiatives. Part of this program, a multimedia public education campaign titled "Don't Say Goodbye", encourages teens and adults to recognize high-risk people and to refer them to a county psychiatric crisis phone line.
ASAP sponsors a basic training curriculum for police recruits, a 1.5 hour awareness program for all municipal and county police, and an intensive program for juvenile officers. Emergency room and medical office staff are provided informational packets to help first responders identify and manage suicidal children and adolescents.
Living Works Education, Inc.
Reports: Written and audiovisual materials are available as self-learning tools to reinforce the skills presented in the Intervention Workshop.
Calgary, Alberta
(403) 242-3397
The core component of this comprehensive, community-focused program is a 2-day Intervention Workshop offered to a wide variety of gatekeepers. It provides training in "Suicide First Aid" skills. Introductory sensitization and awareness programs, as well as advanced and specialized treatment seminars, are other program components integrated with and reinforcing the Intervention Workshop objectives. These objectives focus on the helping competencies of gatekeepers and aim to strengthen community resource networks.
Based on an adult education model of continuing professional education, the program is designed for all caregiver groups. A "Training for Trainers" course certifies trainers to present the workshop and other components of the program. The trainer's program is a 5-day course on instructing the Intervention Workshop. Certified trainers are provided with trainer handbooks, manuals, workshop handouts, audiovisual aids, and ongoing consultation support.
The bereavement training and the advanced treatment seminars and workshops are one-day sessions. Refresher training incorporates workshop activities, a helper's handbook, and various self-directed learning activities using audiovisuals. Related components include School gatekeeper training, intervention after a suicide.
Advice to others interested in starting this type of program: This program is a long-term commitment with as many as 10 separate components. Delivering some or all of these programs to all potential caregivers in the community takes time and planning, perhaps over several years. If you can present one Intervention Workshop as a demonstration, you always receive invitations to do more. Each program can be flexibly adapted to "feel" as if it fits the needs of the community. If you can get administrators or policymakers involved, they often "champion" the program within their own and other agencies with a sense of commitment and ownership.
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