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Youth Suicide Prevention Programs: A Resource Guide

U.S Department of Health and Human Services, Public Health Service, Centers for Disease Control, National Center for Injury Prevention and Control

Publication date: 09/01/1992

Table of Contents

Acknowledgments

Executive Summary/Background and Approach
Findings
Recommendations

Introduction and Summary/Background
Development of CDC Resource Guide for Youth Suicide Prevention
Study Approach
Youth Suicide prevention programs
Report Organization
Summary of Overall Findings
Recommendations
References Used in the Introduction

School Gatekeeper Training/Overview and Rationale
Research Findings
Illustrative Programs
Evaluation Needs
Summary
References About School Gatekeeper Training Programs
Suggested Additional Reading
School Gatekeeper Training: Program Descriptions

Community Gatekeeper Training/Overview and Rationale
Research Findings
Illustrative Programs
Evaluation Needs
Summary
References About Community Gatekeeper Training Programs
Suggested Additional Reading
Community Gatekeeper Training: Program Descriptions

General Suicide Education/Overview and Rationale
Research Findings
Illustrative Programs
Evaluation Needs
Summary
References about General Suicide Education programs
Suggested Additional Reading
General Suicide Education: Program Descriptions

Screening Programs/Overview and Rationale
Research Findings
Illustrative Programs
Evaluation Needs
Summary
References About Screening Programs
Suggested Additional Reading
Screening Programs: Program Descriptions

Peer Support Programs/Overview and Rationale
Research Findings
Illustrative Programs
Evaluation Needs
Summary
References About Peer Support Programs
Peer Support Programs: Program Descriptions

Crisis Centers and Hotlines/Overview and Rationale
Research Findings
Illustrative Programs
Evaluation Needs
Summary
References About Crisis Centers and Hotlines
Suggested Additional Reading
Crisis Centers and Hotlines: Program Descriptions

Means Restriction/Overview and Rationale
Research Findings
Illustrative Programs
Evaluation Needs
Summary
References About Means Restriction
Suggested Additional Reading

Intervention After a Suicide/Overview and Rationale
Research Findings
Illustrative programs
Evaluation Needs
Summary
References About Intervention After a Suicide
Suggested Additional Reading
Intervention After A Suicide: Program Descriptions

References

Prepared by:

POINT OF CONTACT FOR THIS DOCUMENT:

Tables
Suicide Rates Among 15 To 24 Year Olds In The United States
Changes In Knowledge Among School Gatekeepers After Training
Attitudes Held By 9th And 10th Grade Students/Reporting Attempts
Effects Of A General Suicide Education Program/Knowledge Of Signs
Effects Of A General Suicide Education Program/Where To Get Help
Effects Of A General Suicide Education Program/Who Reported Attempt
Ratings Of General Suicide Education Programs
Methods By Which 15 To 24 Year Olds In The U.S. Commit Suicide
Suicide Rates Among 15 To 24 Year Olds

Figures
Conceptual Model Of Factors Influencing Youth Suicide
Rationale For School Gatekeeper Training Programs
Rationale For Community Gatekeeper Training Programs
Rationale For General Suicide Education Programs/Prevent Suicide
Rationale For Screening Programs To Prevent Youth Suicide
Rationale For Peer Support Programs To Prevent Youth Suicide
Rationale For Crisis Center And Hotline Programs
Rationale For Means Restriction Programs

Acknowledgments

We wish to express our thanks to the many people who, on their own or as representatives of organizations, provided assistance in the development of this Guide. We are particularly grateful for the guidance in the design and conduct of this study provided by Dr. Mark Rosenberg, Mr. Albert Brasile, and Mr. Mark Long in the National Center for Injury Prevention and Control, and Ms. Floy Cross and Ms. Diane Roberts in CDC's Office of Program Planning and Evaluation. We would like to especially recognize and thank Ms. Rachel Lysne in the Epidemiology Branch for her extraordinary dedication in providing administrative and clerical support for this project. Valuable help in initiating and conducting this study was provided by the following individuals:

Most especially, we want to thank the many volunteers and staff of youth suicide prevention programs who spoke with us, sent us materials, and shared much of their joys, frustrations, and experiences in working to help our country's youth.

Patrick O'Carroll, M.D., M.P.H.

James Mercy, Ph.D.

James Hersey, Ph.D.

Casey Boudreau, M.S.

Mary Odell-Butler, Ph.D.

Executive Summary/Background and Approach

Given the continued high rates of suicide among adolescents and young adults (15-24 years of age), it is more urgent than ever that we apply our limited resources for prevention in the most effective manner possible. To that end, we developed this resource guide to describe the rationale and evidence for the effectiveness of various youth suicide prevention strategies and to identify model programs that incorporate these different strategies. The guide is for use by persons who are interested in developing or augmenting suicide prevention programs in their own communities. Because the diagnosis and treatment of mental disorders is so widely accepted as a cornerstone of suicide prevention, we excluded from this guide programs that provide mental health services in traditional health service delivery settings. We did include, however, programs that were designed to increase referral to existing mental health services.

We developed this resource guide through networking. Initially, 40 experts in youth suicide prevention around the country were asked to identify exemplary youth suicide prevention programs. Representatives from these programs were then contacted and asked to describe their activities and to identify other programs that they considered exemplary. The list was supplemented by contacting program representatives who participated in the 1990 national meeting of the American Association of Suicidology (AAS) and by soliciting program identification through Newslink, the newsletter of AAS. The resulting list of programs is not meant to represent all exemplary youth suicide prevention programs, but it does characterize the diversity of existing programs and can serve as a resource guide for those interested in learning about the types of prevention activities in the field.

For this guide, we delineated eight different suicide prevention strategies, most of which were incorporated in some combination into the programs we reviewed. These were:

Findings

Overall, we noted that:

Recommendations

Although we do not have sufficient information to recommend one suicide prevention strategy over another at this stage, the following recommendations seem prudent:

Like many prevention programs, the suicide prevention programs described in this resource guide are evolving. They are subject to changes in staff, funding, and program emphasis. Hence, readers should contact programs directly to obtain current information on their activities.

Introduction and Summary/Background

For many years, we have known that persons suffering from mental disorders, particularly affective illnesses, are at markedly increased risk of committing suicide. In past decades, most people who died from suicide were older adult males who appeared to have been suffering from clinical depression or other treatable mental disorders at the time of their death. As a consequence, suicide prevention was viewed primarily as a problem of identifying and treating persons with mental disorders associated with increased risk of suicide. Mental illness is not, of course, a sufficient cause of suicide in itself; if it were, everyone who suffered from mental illness would die from suicide. There are, in fact, a variety of other factors that contribute to any given suicide and, consequently, a variety of potential points for preventive intervention (Figure 1). Nevertheless, identifying and treating persons with mental disorders remains an important mainstay of suicide prevention.

In recent years, however, there has been increasing evidence that we need to go beyond this paradigm for suicide prevention, particularly for young people (CDC, 1986). In 1950, the rate of suicide among adolescents (15-19) was 2.7 per 100,000; among young adults (20-24), the rate was 6.2 per 100,000. By 1980, the rate among both adolescents and young adults had tripled, to 8.5 and 16.1 per 100,000, respectively (Table 1). This alarming increase in the rate of youth suicide was accompanied by research indicating that only about one-third of adolescent suicide victims appeared to satisfy clinical criteria for depression or other treatable mental illness (Shaffer, et al., 1988).

In response to these findings, concerned people began to implement a variety of innovative programs they believed might help to reduce the rate of youth suicide- Many such programs were designed to enhance the ability of people to recognize signs of suicidal tendencies, either in themselves or in others, and to increase referrals of adolescents and young adults with psychiatric disorders to existing mental health services. Other programs tried to interrupt the chain of suicide causation at another point, by focusing on the social milieu in which suicide occurs, or on so-called "trigger factors", for suicide, such as a stressful event or the loss of a loved one.

Despite these efforts, the rate of youth suicide remains high: in 1988, the rate among adolescents was 11.3 per 100,000; among young adults, the rate was 15.0. Faced with these continuing high suicide rates, it is more urgent than ever that we determine which of the current prevention strategies are effective and, in particular, which are most effective relative to their cost. Over the years, a great variety of suicide prevention programs have been implemented, incorporating many different strategies. Despite this experience, there is still (1) no ready way to identify model programs for others who are interested in developing suicide prevention programs in their own communities, and (2) no consensus as to the relative effectiveness of particular suicide prevention strategies. In the absence of this information, people interested in suicide prevention have had no choice but to employ whatever strategies seemed most appealing, often requiring them to "re-invent the wheel" in their community and, at least potentially, leading them to expend scarce prevention resources on ineffective or relatively less effective strategies.

Development of CDC Resource Guide for Youth Suicide Prevention

We developed this resource guide to address these two needs. It is intended as an aid to those who are interested in developing or augmenting youth suicide prevention programs in their own communities. To gather information for the guide, we contacted a wide variety of suicide prevention experts and asked them to identify and describe "exemplary" youth suicide prevention programs (i.e., programs that in their judgment were likely to be effective in the prevention of suicide).

When we cast our net for youth suicide prevention programs, we deliberately excluded programs designed to deliver mental health services in traditional health service delivery settings. As mentioned previously, the diagnosis and treatment of mental disorders has been and continues to be a cornerstone of suicide prevention. Even among teenagers, at least 1 in 5 suicide victims appears to have been suffering from clinical depression when he or she committed suicide; almost 4 in 10 appear to have had a diagnosable drug abuse disorder (Shaffer, et al., 1988). In addition, the evidence is clear that current treatment for clinical depression and certain other mental disorders is effective in reducing the duration of mental illness. Although there is surprisingly little objective evidence that treating persons with mental disorders actually reduces the overall rate of death from suicide, no one doubts that we must continue our efforts to diagnose and treat persons with mental disorders as part of any larger effort to prevent suicide. Because this approach to suicide prevention is so widely accepted, we excluded traditional mental health service delivery programs from our review. We did include, however, programs that were designed to increase referral to existing mental health services.

Study Approach

This study was designed to help clarify the issues involved in preventing suicide by describing the types of youth suicide prevention programs that are in operation or that have been proposed. We began by reviewing research studies on youth suicide prevention. We then attempted to identify and describe exemplary youth suicide prevention programs around the United States. Our general approach was, first, to identify a wide variety of suicide prevention programs that suicide prevention experts considered most likely to be effective and that might be evaluated and replicated. These judgments were made on the basis of a number of broad criteria, including the number of persons exposed to the intervention. the number of years of program operation, the nature and intensity of the intervention, and the availability of data to facilitate evaluation. After identifying these reportedly exemplary programs, we contacted the various program directors to gather further information that we believed would be valuable to others in the suicide prevention community and valuable to us in identifying programs that might be amenable to scientific evaluation. Finally, in compiling this information, we attempted to identify knowledge gaps and the kinds of evaluation questions that, if addressed, would increase our understanding of the effects of youth suicide prevention activities.

We identified the programs described in this report by contacting more than 40 experts in youth suicide prevention around the country and asking them to identify exemplary youth suicide prevention programs. Directors of these programs were then asked to describe their activities and send us any written material about their operations. We expanded our list of contacts by asking the director of each program to identify other programs that they considered exemplary. We supplemented our list by contacting participants in the 1990 national meeting of the American Association of SuicidologY (AAS) and by soliciting responses from program staff in Newslink, the newsletter of AAS.

Staff in suicide prevention programs rarely identified more than one or two other exemplary programs- Moreover, the programs nominated were typically in other areas of the country rather than in the same state. This leads us to speculate that the resource network that would allow programs to provide advice to one another and share information is not as well developed as it might be.

Programs in the resulting list are described in this report. This list is not meant to represent all exemplary youth suicide prevention programs, nor does the Centers for Disease Control endorse this list of programs as being the most effective or worthy of emulation. Rather, the programs we describe are intended to characterize the diversity of programs that exists and to serve as a resource guide for those interested in learning about the various types of suicide prevention activities in this field.

Youth Suicide prevention programs

There is a broad spectrum of youth suicide prevention programs ranging from general education about suicide to crisis center hotlines. The different prevention strategies are designed to prevent suicide in various ways ( Figure 1). For example, gatekeeper training and screening programs are designed to identify people at risk of suicide and refer them to mental health services. Conversely, hotlines are intended to help people who are experiencing a crisis.

This report focuses on eight different kinds of program activities representing different strategies for suicide prevention-However, suicide prevention programs are typically quite comprehensive, incorporating several different strategies. For example, general suicide education programs in schools are almost always associated with gatekeeper training for school personnel. Similarly, in many communities, general suicide education programs are conducted by crisis center personnel. Many suicide prevention programs include several of these components in their activities, and many in the field believe that comprehensive programs offering multiple components facilitate the type of synergy and coordination that is more effective than any individual component.

Still, in planning, implementing, or evaluating suicide prevention efforts, we need to think about individual program components and prevention strategies. 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. In addition, the types of evaluation questions that need to be asked will be quite different for various types of prevention strategies. Therefore, this report has been organized according to major program components and strategies.

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.

Community Gatekeeper Training. This type of gatekeeper program provides training to community members, such as clergy, police, merchants, and recreation staff, as well as physicians, nurses, and other clinicians who see youthful patients. This training is designed to help these people identify youth at risk of suicide and refer them as appropriate.

General Suicide Education. These programs provide students with facts about suicide, alert them to suicide warning signs, and provide information about how to seek help for themselves or for others. These programs often incorporate a variety of self-esteem or social competency development activities.

Screening Programs. Screening involves the administration of an instrument to identify high-risk youth in order to provide more targeted assessment and treatment. Repeated administration of the screening instrument can also be used to measure changes in attitudes or behaviors over time, to test the effectiveness of an employed prevention strategy, and to obtain early warning signs of potential suicidal behavior.

Peer Support Programs. These programs, which can be conducted in either school or non-school settings, are designed to foster peer relationships, competency development, and social skills among youth at high risk of suicide or suicidal behavior.

Crisis Centers and Hotlines. Among other services, these programs primarily provide telephone counseling for suicidal people. Hotlines are usually staffed by trained volunteers. Such programs may also offer a "drop-in" crisis center and referral to mental health services.

Means Restriction. This prevention strategy consists of activities designed to restrict access to handguns, drugs, and other common means of suicide.

Intervention After a Suicide. Strategies have been developed to cope with the crisis sometimes caused by one or more youth suicides in a community. They are designed in part to help prevent or contain suicide clusters and to help youth effectively cope with feelings of loss that come with the sudden death or suicide of a peer. Preventing further suicides is but one of several goals of interventions made with friends and relatives of a suicide victim--so-called "postvention" efforts.

Report Organization

In the chapters that follow, we describe and present the rationale for various types of suicide prevention strategies, review the research on these strategies, provide a brief summary of our judgments concerning the potential and pitfalls of these approaches, and then present brief descriptions of programs that might serve as a resource or guide for others. When program descriptions were sent out for review, program staffers were asked what advice they would share with others who might want to implement that type of program. When supplied, these comments are reported as well.

Summary of Overall Findings

Several important conclusions may be drawn from an overall consideration of the information we gathered and collated in this resource guide:

Recommendations

Although we do not have sufficient information to recommend one suicide prevention strategy over another at this stage, the following recommendations seem prudent:

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. We hope that the information in this document will help communities make this determination. Finally, like many prevention programs, the suicide prevention programs described in this resource guide are evolving. They are subject to changes in staff, funding, and program emphasis. Hence, readers should contact programs directly to obtain current information on their activities.

References Used in the Introduction

Centers for Disease Control. Youth Suicide in the United States, 1970-1980. Atlanta: Centers for Disease Control, 1986.

Shaffer, D., Garland, A., Gould, M., Fisher, P., and Trautman, P. Preventing teenage suicide: a critical review. Journal of the American Academy of Child and Adolescent Psychiatry 1988;27:675-687.

School Gatekeeper Training/Overview and Rationale

Gatekeeper training programs are designed to help members of the community identify youth with a high potential for suicide and refer them to appropriate sources of help. A "gatekeeper" can be anyone who has significant contact with youth during the course of the day, such as coaches, clergy, police, or volunteers. A particularly important group of gatekeepers is school personnel. Because of their importance and the effort that has been devoted to developing programs for school personnel, these programs are described in this chapter. The next chapter, "Community Gatekeeper Training," focuses on programs for gatekeepers who can reach youth in other settings.

School gatekeeper training programs are school-based programs designed to help school staff identify students at risk of suicide and to refer them for help. School gatekeepers may include any adult in the school (e.g., counselors, teachers, coaches, administrators or cafeteria staff) in a position to observe and interact with students.

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. As illustrated in Figure 2, knowledge of these topics enhances the ability of school staff to handle potentially suicidal students and to refer them to appropriate sources of help.

School gatekeeper training is primarily intended to educate staff on how to identify students with emotional or other problems who may also be potentially suicidal. 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.

School gatekeeper programs may also help school staff recognize and take action to reduce sources of stress in the social environment of the school system, such as adjustment to a new school (Caplan, 1964, Kelly, 1979), and to develop relationships with students at times of transition or vulnerability that can help them in their subsequent functioning (Hersey, 1977).

Research Findings

School gatekeeper training programs have been well received by teachers and school staff. Staff have reported these programs as helpful in California (Nelson, 1987), Colorado (Barrett, 1985), and Rhode Island (Spirito, et al., 1988). For example, as shown in (Table 2), researchers evaluating the school gatekeeper education component of the New Jersey Adolescent Suicide Prevention Project found that school personnel who participated in a 2-hour training program showed increased awareness of suicide warning signs, knowledge of treatment resources, and willingness to make referrals to mental health professionals (Shaffer, Garland, and Whittle, 1988). Improvements in knowledge were also observed in the evaluation of a gatekeeper education program in Colorado (Barrett, 1985). In addition, Barrett found that referrals for counseling increased after a school gatekeeper training program. A delphi panel of experts estimated that school gatekeeper programs could reduce youth suicide by about 12 percent (Eddy, Wolpert, and Rosenberg, 1989). We are not aware, however, of any formal evaluation of the effect of school gatekeeper training on changes in the behavior of trainees.

Illustrative Programs

This report lists eight programs as examples of school gatekeeper training programs. These programs were selected because of their substantial time in operation, the extensiveness of the training they provided, and their tie-in with mental health or other more comprehensive youth suicide prevention programs. These programs are included: 

Program                                      Rationale for Inclusion
----------------------                       -------------------------
East:
 BRIDGES                                     -  Comprehensive program
 Piscataway, New Jersey                      -  Plans for evaluation

Pennsylvania Network for Student             -  Extent of training
 Assistance Services (PNSAS)                 -  Linkage with mental health
Pittsburgh, Pennsylvania agencies.              agencies
                                             -  Statewide operation

 STAR                                        -  Strong community outreach
 Pittsburgh, Pennsylvania                    -  Linkage with mental health

Midwest:
 Suicide Prevention Center Programs          -  Comprehensive programs
Dayton, Ohio                                 -  Length of operation

South:
 Crisis Intervention                         -  Use of tools to help

 Dade County, Florida                           identify at-risk students
                                             -  High minority population

 Project SOAR
 Dallas, Texas                               -  Comprehensive program
                                             -  Three years in operation

 Adolescent Suicide Prevention Program
 Fairfax County, Virginia                    -  Eight years in operation
                                             -  Extensive documentation

West:
 Weld County Suicide Prevention Program
 Johnstown, Colorado                         -  Extent of training
                                             -  Coverage of grades

The school gatekeeper programs in Dayton, Ohio, in Dallas, Texas, and in Fairfax County, Virginia provide examples of well-crafted school gatekeeper training programs in large school systems, and the program in Weld County, colorado, offers an example in a smaller community. These programs are relatively expensive to implement and maintain.

The BRIDGES program in Piscataway, New Jersey, is listed because of its active work in evaluation research. Program officials are planning to assess how well the ratings of youth provided by gatekeepers coincide with more extensive assessments by mental health professionals.

The Dade County, Florida program is listed because it provides a quarterly "screening tool" of "at-risk" students based on such easily accessible factors as absences and poor school performance.

The Pennsylvania Network for Student Assistance Services (PNSAS) is listed not only because of its statewide implementation but also because of the extensive training it provides to key personal in each school and the strong linkages it seeks to build with community mental health services.

Evaluation Needs

The following questions are appropriate to ask in the evaluation of school gatekeeper training programs:

The data needed to answer questions about the number of referrals and follow-ups should be relatively easy to obtain, and many of the programs listed here are collecting this information as part of internal evaluations. The questions about the appropriateness of referrals and about treatment effectiveness would probably require assistance from qualified mental health professionals as well as a more extensive effort.

Summary

School gatekeeper training programs are relatively common, though they vary in the extent of training and the strength of linkages to mental health programs. We view this linkage as fundamental to the success of these programs. Evaluations studies indicate that gatekeeper training programs are effective at educating participants and increasing their willingness to refer at-risk students for appropriate help. The effects of school gatekeeper training programs on the subsequent behavior of gatekeepers is unknown.

Two potential negative consequences should be guarded against in implementing school gatekeeper training programs. First, school personnel should be sensitive to the feelings of individuals referred for help lest they feel bad about being singled out. Second, program officials should seek to minimize inappropriate referrals, which might needlessly burden the mental health system, causing delays in treatment for those truly in need.

References About School Gatekeeper Training Programs

Barrett, T.C. Youth in Crisis: Seeking Solutions to Self-Destructive Behavior. Longmont, CO: Sopris West, 1985.

Caplan, G. Principles of Preventive Psychiatry. New York: Basic Books, 1964.

Eddy, D.M., Wolpert, R.L., and Rosenberg, M.L. Estimating the effectiveness of interventions to prevent youth suicides. In: Alcohol, Drug Abuse, and Mental Health Administration. Report of the Secretary's Task Force on Youth Suicide. DHHS Pub. No. (ADM)89-1624, Vol 4. Washington, D.C.: Supt. of Docs., U.S. Govt. Print. Off., 1989:37-81.

Hersey, J.C. The High School Environment, School Performance, and Psychological Health: A Five Year Longitudinal Study of Male Adolescents [dissertation]. Ann Arbor (MI): University of Michigan, 1977.

Kelly, J.G. Adolescent Boys in High School: A Psychological Study of Coping and Adaptation. Hillsdale, NJ: Lawrence Erlbaum Associates, 1979.

Nelson, F.L. Evaluation of a youth suicide prevention program. Adolescence 1987;20:813-825.

Shaffer, D., Garland, A., and Whittle, R. An evaluation of three youth suicide prevention programs in New Jersey. New Jersey Adolescent Suicide Prevention Project.' Final Project Report. Trenton (NJ): New Jersey Department of Human Services: Governor's Advisory Council on Youth Suicide Prevention, 1988.

Spirito, A., Overholser, J., Ashworth, S., Morgan, J., and Benedict-Drew-, C. Evaluation of a suicide awareness curriculum for high school students. Jour, al of the American Academy of Child and Adolescent Psychiatry 1988;27:705-711.

Suggested Additional Reading

The County School Board of Fairfax County, Virginia. The Adolescent Suicide Prevention Program: A Guide for Schools and Communities. Fairfax, VA, 1987.

Davidson, L.E., Rosenberg, M.L., Mercy, J.A., Franklin, J., and Simmons, J.T.

An epidemiologic study 0 risk factors in two teenage suicide clusters. Journal of the American Medical Association 1989;262:26872692.

Garland, A., Whittle, B., and Shaffer, D. A survey of youth suicide prevention programs. Journal of the American Academy of Child and Adolescent Psychiatry 1988;28:931-934.

Overholser, J., Hemstreet, A. Spirito, A. and Vyse, S. Suicide awareness programs: effects of gender and personal experience. Journal of the American Academy of Child and Adolescent Psychiatry 1989;28:925930.

School Gatekeeper Training: Program Descriptions

BRIDGES: Building Skills to Reach Suicidal Youth --

Location: Piscataway, New Jersey

Contacts: Charlsetta Sutton, ACSW, BCD; Karen Dunne-Maxim, R.N., M.S., (908) 463-4109

Targets:

Years in operation: 7

Source of funding:

Amount of funding (per year): Varies.

Program description: 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 crises 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.

Exposure: School personnel training lasts 16 hours (2 days).

Coverage: The BRIDGES program has been provided to 594 participants since 1986.

Content/topics: BRIDGES trains school personnel to accurately distinguish students at risk for suicidal behavior from those who are depressed. Personnel learn to assess students' risks, 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.

Referral/selection procedures: Appropriate school personnel (guidance staff, child study team members, student assistance counselors) are referred to BRIDGES by school administrators.

Evaluation: Evaluation studies are being developed. Officials are particularly interested in conducting an impact evaluation of the BRIDGES program. This evaluation would determine the efficacy of the BRIDGES program in training school personnel to accurately identify' suicidal youth. Some of their ideas for evaluation include collecting data on the functioning of students at risk, the school climate, and teachers' feelings immediately after and 2 weeks after a suicide takes place to:

BRIDGES staff want to collect data on how many students are targeted and how many are identified correctly as being suicidal. If a student is accurately identified, they would then collect information on referrals and follow-ups to see if the student was making progress. Assessments would be made by readministering tests and interviewing school staff or the student. Periodic follow-ups would be conducted as long as the individual was in the school system. BRIDGES staff would look for changes in test indices and in suicide and suicide attempt rates as indicated by hospital records.

Data available: Process evaluation data have been collected for the last five years. Data have also been collected on participants' pre- and post-training knowledge of suicide risk factors. Results have demonstrated significant gains in participants' knowledge.

Special population outreach: None.

Related components:

Address: BRIDGES: Building Skills to Reach Suicidal Youth Charlsetta Sutton, ACSW, BCD Karen Dunne-Maxim, R.N., M.S. UMDNJ--CMHC 671 Hoes Lane Piscataway, NJ 08855-1392

Reports: Brief descriptive brochure.

Pennsylvania Network for Student Assistance Services (PNSAS) -- Location: Pittsburgh, Pennsylvania
Contact: Roberta Chuzie, (412) 394-5837

Targets: All buildings at the secondary level in all school districts.

Years in operation: 6

Source of funding: Collaborative effort among the following:

Amount of funding (per year): $11.5 million (this includes core team training, D/A & MH treatment, consultation and education, and administrative costs for the Commonwealth).

Program description: 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.

Exposure: 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.

Coverage: Five hundred of the 501 school districts in Pennsylvania have had representatives trained in student assistance at the secondary level, which means a total of 1,039 buildings have representatives trained in SAP to date.

Content/topics: Adolescent development, suicide, depression and other mental health problems, chemical dependency, family dynamics, treatment, continuity of care, group process, and action planning.

Referral/selection procedures: 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. Reasons for a student being referred vary from violation of school policy, behavioral concerns (D/A & MH), suicidal ideation, other mental health concerns, self-reported problems, and recovery and transition back into school after treatment.

Evaluation: Preliminary data are available on the following two evaluations:

Findings: The 1989-90 SAP aggregate student tracking data indicate an increase in the number of students referred from 10,480 in 1988-89, to 26,739 in 1989-90, and to 41,399 in 1990-91. The number of disciplinary referrals to the core teams has decreased, indicating that a more positive approach is being taken to the program, and classroom teacher, parent, student, and self referrals have all increased. The information on the percentage of referred students who complete treatment has been difficult to track statewide. SAP does not have a mechanism to collect those data but can use a tracking form to track the students until they leave the school for services. SAP is looking into cross-referencing data collection forms with the Department of Health and the Department of Public Welfare in order to track the students once they begin treatment following a SAP referral.

Data available: The program collects data on the number of students processed by core teams during the year, referrals by grade and by race, number of referrals by source and by reason for referral, and the numbers of students in different types of treatment programs. Standardized forms are used to collect the following required data:

Special population outreach: All at-risk students.

Related components: Postvention.

Address: Roberta Chuzie
Student Assistance Services Station Square
200 Commerce Court Building, 2nd Floor Pittsburgh, PA 15219

Reports:

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.

Services for Teens At Risk (STAR) --

Location: Pittsburgh, Pennsylvania

Contact: Dr. David Brent, (412) 624-5211

Targets: School personnel, at-risk youth.

Years in operation: 4 (for both the Outreach and Outpatient Clinic programs).

Source of funding: Pennsylvania.

Amount of funding (per year): The Outreach program has 5 full-time employees and the Outpatient Clinic has 33 full-time employees of different disciplines. Additionally, STAR has an annual budget of $170,000 for expenses other than salaries.

Program description: 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 ST.A_R 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 (WPIC).

Exposure: Varies (see program description above)

Coverage: Not described.

Content/topics: Identification of potentially suicidal students, risk assessment, and referral procedures.

Evaluation: The Outreach program screens children identified during postvention sessions. The Outpatient Clinic provides a day-long clinical evaluation that combines both structured and unstructured assessment tools.

Data available: The Outreach program has data regarding the number and types of people trained in the various levels. Additionally, the number of children screened during postvention is also available.

Related components:

Address: Dr. David Brent, Director Services for Teens At Risk (STAR) WPIC Pittsburgh, PA 15213

Special population outreach: None.

Reports: Brochures and articles about the activities of STAR.

Suicide Prevention Center Programs --

Location: Dayton, Ohio
Contact: Linda Mates, LPCC, (513) 297-9096

Targets: Students (junior high and high school), gatekeepers. Years in operation: 10

Source of funding: United Way, and state and community taxes. Amount of funding (per year): $50,000.

Program description: The Suicide Prevention Center (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 targets minorities and uses nontraditional gatekeepers, such as barbers and hairstylists. Finding Hope: Training program for parents.

Life Saver III: A 3-year pilot program training undergraduate, graduate, and postgraduate students (teachers, administrators, school counselors, and nurses).

Exposure: Not described.

Coverage: Teachers in all county schools and youth leaders and special gatekeepers (three selected each year).

Evaluation: Several are ongoing: quality assurance, client satisfaction, and client outcome.

Data availability: Participant feedback. Intervention, referral, and follow-up information may be available.

Special population outreach: African-Americans.

Related components:

Address: Linda Mates, LPCC Executive Director
Suicide prevention Center, Inc. PO Box 1393
Dayton, OH 45401

Reports: program manuals and pamphlets, and evaluation materials.

Crisis Intervention Dade County Public Schools --

Location: Miami, Florida
Contact: Dr. J.L. DeChurch, (305) 995-7315

Targets: All students.

Years in operation: 5

Source of funding: Dade County school district and grant.

Amount of funding (per year): $120,000.

Program description: Dade County established a Department of Teenage Pregnancy and Suicide Prevention in 1987, which in turn became the Department of Crisis Intervention, whose purpose 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.

Exposure: 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, and so far approximately 1,000 individuals have been trained.

Coverage: 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.

Content/topics: How to identify, assist, and refer students at risk; suicide prevention, intervention, and postvention.

Evaluation: Participant written and verbal feedback, which has been positive.

Findings: There were 19 suicides in 1988 and only 7 in 1989, but program staff members are not sure whether to take credit for this apparent decline. They found students in middle school to be most at risk and also found a link between suicidal tendencies and a history of sexual abuse.

Data available: Program staffers are building a data base and want to use it for research and evaluation, but it is not yet operational.

Special population outreach: Not described.

Related components:

Address: Dr. J.L. DeChurch Executive Director Division of Student Services Dade County Public Schools
1444 Biscayne Boulevard, Suite 202
Miami, FL 33132

Project SOAR (Suicide: Options, Awareness, Relief) --
Dallas Independent School District

Location: Dallas, Texas
Contact: Judie Smith, MA, (214) 565-6700

Target: Teachers, staff, and counselors.

Years in operation: 3

Source of funding: Local school district funds.

Amount of funding (per year): $90,000, which provides the salary for three professionals. The costs of clerical help, office supplies, and training materials are absorbed by-the Psychological/Social Services Department budget.

Program description: Project SOAR is 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.

Exposure: 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 (DISD) Psychological/Social Services Crisis Team, are always available for consultation. A school psychologist or home school coordinator will assist with high-risk cases. The course was adapted for use by other student services personnel: school psychologists, home school coordinators, parent ombudsmen, special education crisis staff, nurses, and drug counselors.

Coverage: The professional staff of the DISD includes 9,600 employees made up of teachers (83%), professional support personnel (8%), campus administrators (5%), and central office administrators. An additional 5,400 employees provide support services, such as maintenance, cafeteria help, and transportation.

Content/topics: The objectives of the course are to examine attitudes toward suicide, gain knowledge about crisis theory and the dynamics of suicide, sharpen skills of empathy and active listening, and learn a counseling model for crisis intervention. 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 the DISD Psychological/Social Services Department, and refer the at-risk student to a mental health agency or private therapist as needed.

Referral/selection procedures: One counselor was selected from each school to receive training in crisis intervention and become the designated crisis counselor for his or her campus.

Evaluation: No written evaluations or tests are done at this time.

Data available: Verbal feedback from students, teachers, and parents. Reports have been entered into a new computer system, but no in-depth analysis has been completed. On file for each student seen by the program is a written summary of each year's records describing sex, age, race, grade, schools, risk assessment, sources of stress, warning signs, and action plans. The director keeps records of high-risk youths in her office. The records consist of reports filed by whoever did the risk assessment or intervention, whether the primary caregiver or a staff member of psychological/Social Services. To evaluate the effectiveness of Project SOAR,' project officials established an accurate reporting and recordkeeping system of all suicide threats, attempts, and completions to compare with past records kept by the county medical examiner. From this data system, officials hope to chart and analyze trends and determine whether the training and the procedures are effective.

The suicide records kept by the county medical examiner indicate many suicides in the Dallas area are committed by school-age teenagers who are not enrolled in school. The school drop-out rate is about 15 percent. They also discovered a ruling of suicide for a death that had been reported to the school as a homicide.

Special population outreach: The Dallas Independent School District serves a population that is 80 percent black and Hispanic. Most suicides are committed by whites.

Related components:

Address: Project SOAR Judie Smith, MA

Specialist in psychological Social Services Dallas Independent School District 1401 South Akard Dallas, TX 75215

Reports: Program manual.

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 --

Location: Fairfax, Virginia

Contact: Myra Herbert, LICSW, (703) 246-7745

Targets: Gatekeepers (primarily school personnel).

Years in operation: 8

Source of funding: Fairfax County School Board.

Amount of funding (per year): Funding is invisible. The program provides an organized, systematic method for improving services that are in place. Fairfax County spends between $6,000 and $10,000 on printing material that is helpful with workshops, but this is not essential.

Program description: 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 crises 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.

Exposure: 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.

Coverage: Faculty and staff in all intermediate and high schools.

Content/topics: Suicide awareness and prevention techniques, profile of the suicidal youngster, how to help a suicidal youngster, assessing suicidal potential in young people (signs and symptoms), typical reasons why young people commit or attempt suicide, helpful responses, and organizing a referral network that includes community agencies and mental health resources.

Evaluation: None.

Data available: Not described.

Special population outreach: None.

Related components:

Address: Adolescent Suicide Prevention Program Myra Herbert, LICSW Coordinator, Social Work Services Special Education Department Fairfax Public Schools 10310 Layton Hall Drive Fairfax, VA 22030

Reports:

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 --

Location: Johnstown, Colorado

Contact: Susy Ruof, M.A., (303) 587-2336

Targets: Students, school staff, parents, community members.

Years in operation: 6

Source of funding:Weld Board of Cooperative Educational Services (BOCES) and local school district.

Amount of funding (per year): The start-up cost in 1984 was $1,000 (today,it would be about $2,500). Additional yearly cost is about $500 for additional training and materials, since all program functions are carried out by in-place staff.

Program description: 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, procedures 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.

Exposure: The crisis team members undergo extensive training (30 hour) in suicide awareness, counseling techniques, and methods and resources for help and referral. A l-hour training session is provided each year to all school staff to give them a basic understanding and an 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.

Coverage: All school staff (about 170).

Content/topics: For the general staff, the program provides handouts on myths and facts, behavioral and verbal warning signs, legal issues, and what to do when students exhibit warning signs. The presenters discuss legal rationales for suicide prevention training, referral procedures, and school district and school staff responsibilities.

Evaluation: Program evaluation consists of feedback from teachers, administrators, crisis team members, and community members; statistics on referral rates after student, staff, and community education sessions; information from other county crisis teams have been in place in most districts in the county. (Weld County's adolescent suicide rate is now about half the state rate.)

Data available: Information is available on the number of students referred and the number of suicide attempts or gestures made. Detailed and longitudinal information is available on each student referred (stressors, symptoms, resources, history, family information, plan of action, follow-up). Also available are notes on all interventions done following unintentional deaths of students, parents, or staff, and suicide attempts or gestures. No suicides have occurred in the district since the program was instituted in 1984.

Special population outreach: Potentially at-risk students at grades K-2 (about one-tenth of the student body) are seen weekly in small counseling groups. At grades 3-12, outreach for these students includes ongoing counseling, being paired with teachers for individual attention, crisis intervention as needed, and long-term follow-up by the district crisis team (through graduation).

Community outreach includes training crisis intervention teams in many neighboring school districts, starting a countywide suicide prevention coalition, establishing a monthly support group for survivors of suicide, and receiving a Comprecare grant to reduce suicides among the. elderly in Weld County.

Related components:

Address: Weld County Suicide Prevention Program Susy Ruof, M.A. 5290 Mesquite Court Johnstown, CO 80534

Reports: Program manual and descriptive articles.

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-up 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.

Community Gatekeeper Training/Overview and Rationale

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. This triage or "gatekeeping" function can be undertaken by anyone who has significant contact with youth in the course of professional or volunteer activities. Examples of gatekeepers include coaches, clergy, police officers, health care professionals, hairdressers and barbers, and bartenders. (Gatekeepers also include school personnel; however, because of their frequency and special administrative requirements, gatekeeper training programs designed specifically for school personnel were already described. 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 rationale for community gatekeeper programs is illustrated in (Figure 3 ). 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. Some gatekeeper programs also stress the need to build confidence and a broader competency for directly helping suicidal youths among community gatekeepers. Some community gatekeeper programs also help community people recognize and take action to reduce sources of stress for youth in the community. Examples of this might include efforts to improve employment opportunities for young people or to improve access to recreational facilities for high-risk youth. For instance, one prevention program in New York provided a drop-in setting for youth in shopping malls.

One of the challenges to community gatekeeper training programs is to provide psychologists, nurses, primary care physicians, psychiatrists, and other traditional caregivers with needed suicide prevention training. Many studies demonstrate that approximately 50 percent of suicide victims had seen a physician during the month before their death (Johnson, Ferrence, and Whitehead, 1973). The assumption that these helpers are adequately prepared to manage the issue of suicide or even to perform the basic gatekeeper role has been questioned. Bongar and Harmatz (1991) surveyed psychology training facilities and report that only 40 percent of all graduate programs in clinical psychology offer formal training in the study of suicide. Medical students receive relatively little training about the warning signs of suicide and the role of physicians in helping to prevent a suicide.

Research Findings

Three kinds of evaluation should be considered: (1) assessment of the degree to which these programs have sensitized "gatekeepers" to their role in identifying and appropriately helping those youths who might be at risk of suicidal behaviors; (2) assessment of the degree to which these programs result in appropriate identification and disposition of suicidal persons; and (3) assessment of the impact of these programs on youth suicides or suicide attempts. Very little has been done in any of these areas. In one study, the investigator assessed how community gatekeepers responded to simulated cases 6 months after completion of a 2-day workshop in suicide intervention skills; the results showed that most workshop participants retained the skills they were taught in the program (Tierney, 1988).

Results of a follow-up survey in California (McConahay, G. Suicide Intervention Training Effectiveness, Garlington Center N/NE Community Mental Health Center, Portland (OR), unpublished manuscript, 1990) showed that, 6 months after a 2-day intervention skills workshop, most participants reported that they felt more capable of dealing with a person they thought was suicidal. The participants reported that they drew on a greater number of mental health resources when dealing with individuals who were potentially suicidal. However, the number of people with whom they intervened did not increase.

Illustrative Programs

This report lists seven programs as examples of community gatekeeper programs, two of which are in a single agency. Most of these programs provide both training and informational materials for parents, teachers, counselors, health-care professionals, clergy, policemen and the general public. One is exclusively a media program. These programs are described below.

Adolescent Suicide Awareness Program (ASAP) --

"Don't Say Goodbye" Media Campaign

Lyndhurst, New Jersey

This is an extensive program with training initiatives directed at a variety of professionals, such as teachers, emergency room staff, clergy, and policemen. 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. An evaluation of the impact of the campaign on the use of the crisis phone line was to be completed by the Rutgers School of Applied Psychology in the fall of 1991.

Youth Suicide Prevention Program --

Manassas, Virginia

This is a comprehensive, community-focused program operated by a community- focused program coalition that seeks to disseminate information on youth suicide and to train school personnel to identify high-risk teens. Print and broadcast media and special events are used to provide information. This program has not been evaluated, but findings from an ongoing study monitoring suicide attempts and gestures in Prince William County will provide input to further program development.

LivingWorks Education, Inc. --

Calgary, Alberta

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. More than 50,000 people in the United States and Canada have participated. An evaluation indicates that people retain the skills they were taught for up to 6 months after they complete the workshop. Further evaluations confirm the effectiveness of the strategy used to ensure widespread community use of the training materials.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.

Suicide Intervention Skills Workshop --

California Department of Mental Health

Sacramento, California

Identical to the Calgary, Alberta, "LivingWorks Education, Inc.," program described above, this Suicide Intervention Skills Workshop offers an intensive 2-day workshop in suicide intervention skills. More than 10,000 people throughout the state have been trained in the program. A helper's handbook reinforces workshop learning. The Trainer Corps has developed as a strong community advocacy group for local and statewide suicide prevention activities.

Center for Indian Youth Program Development --

Albuquerque, New Mexico

This community-based program targeted to Native Americans is directed toward the prevention of a variety of violent behaviors, one of which is youth suicide. The center provides support and technical assistance to community coalitions seeking to establish youth suicide prevention programs.

Jail Suicide Prevention Program --

National Center on Institutions and Alternatives (NCIA) Mansfield, Massachusetts

NCIA develops training materials to support jail staff in screening and providing appropriate monitoring for incoming detainees. The jail population overlaps but is not the same as the youth target group under consideration here. This program, however, is included because it has implications for increasing the sensitivity of support staff to high-risk young people in stressful environments.

Evaluation Needs

Assessing the impact of these programs on the rate of youth suicide in the community is extremely difficult. Intermediate outcomes that are easier to assess include changes in peoples' knowledge of suicide warning signs, their attitudes toward seeking or providing help, and their referral of high-risk youth to counseling or treatment. Another way to evaluate any type of suicide prevention program is by assessing changes in suicide attempts and gestures, either over time in one community or by comparing these events in experimental and control communities. These endpoints will reflect both the effectiveness of this strategy and the degree of program penetration (i.e., the extent to which the information generated by the program has reached members of the community who are likely to be in a position to encounter and help teens at high risk of suicide). Some questions that might be addressed in an evaluation are--

Many of these questions could be answered by evaluation studies without much disruption of program operation. The youth suicide prevention workers we talked with over the course of this investigation were strongly convinced of the importance of what they are trying to accomplish and were very interested in evaluation. The development of mechanisms capable of evaluating the effectiveness of these programs in training gatekeepers would help the programs improve their efforts.

Summary

Community gatekeeper training programs are designed to teach people likely to come in contact with young people how to recognize, handle, and refer for assistance youths who exhibit warning signs of suicide. Prospective gatekeepers include coaches, police, clergy, and health-care staff. A number of training programs exist and have been successfully adapted to specialized settings. In implementing these programs, officials should ensure that referrals are appropriate, since inappropriate referrals could make it more difficult for the mental health system to respond to those truly in need.

References About Community Gatekeeper Training Programs

Bongar, B., and Harmatz, M. Clinical psychology graduate education in the study of suicide: availability, resources, and importance. Suicide and Life Threatening Behavior 1991;21:231-244.

Hayes, L., and Rowan, J. National Study of Jail Suicide: Seven Years Later. Alexandria (VA): National Center on Institutions and Alternatives, 1988.

Johnson, F.G., Ferrence, R., and Whitehead, P.C. Self-injury: identification and intervention. Canadian Psychiatry Association Journal 1973;18:101-105.

Tierney, R.J. Comprehensive evaluation for suicide intervention training [dissertation]. Calgary, Alberta: University of Calgary, 1988.

Suggested Additional Reading

Ramsay, R.F., Cooke, M.A., Lange, W.A. Alberta suicide prevention training programs: a retrospective comparison with Rothman's developmental resource model. Suicide and Life Threatening Behavior 1990;24:335-351.

State of California Department of Mental Health. The California Helpers Handbook for Suicide Intervention. Sacramento, CA, 1987.

Community Gatekeeper Training: Program Descriptions

Adolescent Suicide Awareness Program (ASAP) --

"Don't Say Goodbye" Media Campaign

Location: Lyndhurst, New Jersey

Contact: Diane Ryerson, MSW, (201) 935-3322

Adolescent Suicide Awareness Program (ASAP)

Targets: Police, clergy, emergency room personnel, staff of pediatricians' and family practice physicians' offices.

Years in operation: 9

Source of funding: United Way, state and local government.

Amount of funding (per year): Varies.

Program description: 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. A multitiered training program will be established for clergy, involving seminarians, parochial school teachers, funeral directors, and youth ministers. To supplement instructional units, a "Clergy Specific" information package will be developed and widely distributed.

Exposure:

Coverage:

Content/topics:

Evaluation: Participant evaluation forms.

Data available: None.

Special population outreach: Out-of-school youth.

"Don't Say Goodbye" Media Campaign --

Bergen County Taskforce on Youth Suicide prevention

Targets: Middle school and high school students, parents, educators, general public, dropouts.

Years in operation: 1

Source of funding:United Way, corporate and foundation grants, state and county government.

Amount of funding (per year): ,$20,000 for original production of print ads and $2,000 for external evaluation of the program's impact;$60,000 is being sought to fund production of TV and radio spots. All development work was done pro bono by a local ad agency.

Program description: Multimedia public mental health education campaign encourages teens and adults to recognize youths at risk and get them professional help by calling a county psychiatric crisis phone number. Phase 1: Set of six posters, wallet cards, brochures, print ads, and bill boards. Phase 2: Six TV and four radio spots.

Exposure: General public through print and electronic media.

Coverage: Pilot program directed to 850,000 Bergen County residents.

Content/topics: Viewers are encouraged to recognize warning signs and take action to save a life by calling the county psychiatric emergency service for advice, evaluation and/or outreach and screening.

Evaluation: The Rutgers School of Applied psychology is evaluating the impact of the campaign on the use of the countywide psychiatric emergency service program, whose phone number appears on all campaign material. Data was to be available in the fall of 1991.

Related components:

Address: Adolescent Suicide Awareness Program (ASAP) Diane Ryerson, MSW Director, Counseling and Education Services South Bergen Mental Health Center 516 Valley Brook Avenue Lyndhurst, NJ 07071

Youth Suicide Prevention Program --

Location: Manassas, Virginia

Contact: Evelyn Hatfield, (703) 792-7730

Targets: Students, parents, professionals, and the general public of Prince William County.

Years in operation: 4

Source of funding: State and local sources.

Amount of funding (per year): $50,000 for staff support.

Program description: This is a comprehensive community program aimed at promoting positive mental health attitudes. Program staff members train school personnel how to identify and help suicidal youths and help them to develop crisis teams. They will also conduct suicide prevention classes and provide postvention support when asked. Program staffers already work with junior and senior high schools and are starting to move into elementary schools.

There is also a community group on suicide prevention called the "Prince William Youth Suicide Prevention Coalition," whose activities include an annual "Love Life Day" and the providing of grants to schools to establish prevention activities. Another component is a student group ("Friends Are Needed" (FAN) Club) concerned with suicide prevention. School representatives attend training sessions to learn how to initiate suicide prevention programs in their schools. In addition, the coalition produces parent and teen directories of warning signs, actions to take, and sources of help, and is involved in legislative efforts to limit methods of committing suicide.

Coverage: Countywide.

Evaluation: None.

Data available: The Community Service Board is collecting data on the number of suicide attempts, gestures, and ideations among Prince William County youth from a variety of sources, including schools, local hospitals, detention centers and hotlines. The information gathered will be used for program development.

Related components:

Address: Youth Suicide Prevention Program Evelyn Hatfield Youth Suicide Prevention Specialist Prince William County Community Services Board--Prevention Branch (PWCCSB-PB) 8033 Ashton Avenue Manassas, VA 22110

Special population outreach: High-risk youth and minorities. A Minority Issues Task Force works to identify appropriate ways to reach minority youth.

Reports:

Advice to others interested in starting this type of program: Offering comprehensive services is very important because techniques helpful to some youths may not be appropriate for others. Programs will be more effective if a variety of approaches is used.

LivingWorks Education, Inc. --

Location: Calgary, Alberta

Contact: Bryan Tanney, M.D., (403) 242-3397; FAX (403) 268-9201

Targets: Community gatekeepers, employee assistance staff, mental health caregivers, police, corrections agency personnel, school personnel (at all levels of expertise).

Years in operation: 10

Source of funding: University of Calgary, grants, community support, strategic partnerships with other helping agencies, royalties from workshop presentations.

Amount of funding (per year): Varies.

Program description: The core of this program is the Intervention Workshop, originally modeled after the American Heart Association's 'Heart Saver' Program. Based on an adult education model of continuing professional education, the program is designed for all caregiver groups, including, but not limited to, often under-served community "gatekeepers." Its content is fully described in the Suicide Intervention Skills Workshop of the California Department of Mental Health also included in this chapter. A "Training for Trainers" course certifies trainers to present the workshop and other components of the program. Other activities are integrated with the workshop presentation and include sensitization and awareness education, bereavement intervention training, advanced treatment seminars, and refresher training.

Exposure: The core program is a 2-day workshop on emergency first aid in suicide intervention. The first day covers issues related to attitudes and knowledge about suicide. The second day focuses on modeling and practicing intervention skills.

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.

Sensitization materials for community-wide distribution include pamphlets and an audiovisual.

The Awareness Program, intended for a general public audience, can vary from an hour to a day. Different modules cover definition of suicide, magnitude of the problem, warning signs, first aid hints, and policy and program issues. Interested presenters are provided a manual complete with suggested scripts and slides. There is also instructional design information for building additional topic modules.

The bereavement training and the advanced treatment seminars and workshops are l-day sessions. Refresher training incorporates workshop activities, a helper's handbook, and various self-directed learning activities using audiovisuals.

Coverage: More than 50,000 participants in the United States, Canada, and parts of Europe and Australia have taken the Intervention Workshop. A network of over 600 certified trainers is available. Several teams of senior trainers are available to present "Training for Trainers" courses.

Content/topics: The integrated components of this program meet a wide spectrum of community needs concerning suicidal behaviors: information on general suicide awareness, emergency intervention methods, care and support for the bereaved, and ongoing treatment for suicide risk patients. Each component also addresses the importance of developing community-based, comprehensive, coordinated, and integrated approaches to suicide prevention.

Evaluation: Evaluation studies have found high levels of participant satisfaction, statistically significant improvements in suicide intervention skills, knowledge and skill retention over time, and improved community service profiles for sponsoring agencies.

Data available: Program brochures, published material, program evaluation references, and access to trainer contacts are available upon request.

Special population outreach: None.

Related components:

Address: Bryan Tanney, M.D. LivingWorks Education, Inc. Suite 704 300 Meredith Road, NE Calgary, Alberta T2E 7A8 Canada

Reports: Written and audiovisual materials are available as self-learning tools to reinforce the skills presented in the Intervention Workshop.

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.

Suicide Intervention Skills Workshop --

California Department of Mental Health

Location: Sacramento, California

Contact: David Neilsen, MSW, Program Coordinator, (916) 323-9296

Targets: Community gatekeepers, mental health personnel, school personnel, social services personnel, and law enforcement officers.

Years in operation: 5

Source of funding: California, community support.

Amount of funding (per year): $150,000.

Program description: The "Suicide Intervention Skills Workshop" is identical to the "Intervention Workshop" of LivingWorks Education, Inc., Calgary, Alberta, also described in this chapter. The curriculum features a series of large and small group activities, minilectures, audiovisuals, and role playing exercises designed to help people increase both their abilities and level of confidence when working with suicidal individuals.

Exposure: The workshop includes 14 hours of learning experiences. The first day focuses upon the examination of caregivers' attitudes and specific assessment skills. The second day concentrates upon intervention strategies and skill building through the use of large group simulations and small group role plays that involve all participants.

Coverage: The program is targeted at mental health professionals, probation and law enforcement staff, social services personnel, and educators- all of the front-line gatekeepers in the community that a child or an adult would encounter. The original program focus was upon youth; community demand and the demographics of suicidal persons has required the Department to broaden the focus. Service providers to the elderly, persistently mentally ill, and institutional settings have been included.

More than 330 presenters have completed the 5-day "Training for Trainers" program, which certifies persons to present the workshop within their communities. Fifty-five of California's 58 counties have active training teams, the majority of which feature multidisciplinary teams. Over 15,000 persons have attended the 14 hours of training in the past 5 years.

Content/topics: The workshop presents a forum where participants are encouraged to examine suicide intervention from a number of perspectives involving their attitudes, knowledge, and skills. The workshop presents a specific intervention model with detailed descriptions of key tasks and techniques. The training emphasizes how caregivers are to engage persons at risk while doing accurate assessments for risk. A key feature of the intervention model is the exploration of ambivalence and how this exploration assists in the discussion of resources and the formation of an appropriate action plan to prevent suicide.

An important objective of the workshop is to increase the participants' awareness of community resources and networks, and their value. Participants learn about the range of resources available to at-risk persons in their communities, from the self-help groups to the most intensive levels of hospital care.

Evaluation: Limited. Results of a follow-up evaluation in Canada, using simulated cases, showed that workshop participants retained specific intervention skills 6 months after show completing the workshop. Results of a smaller study in Yolo County, California, did not show an increase in the number of suicidal persons that trainees dealt with. This lack of increase may be due to more accurate identification of persons who were at risk for suicide. Another follow-up study conducted by San Francisco County Mental Health showed a tremendous interest in additional or refresher workshops with more role plays and specific content for specific high-risk groups.

Data available: Trainer materials include a handbook and manual. Participant materials include surveys, questionnaires, worksheets, posters, two audiovisuals, and numerous transparencies as learning aids.

Special population outreach: None: open to all groups.

Related components:

Address: California Department of Mental Health Suicide prevention Project Division of Community Programs, Room 250 1600 Ninth Street Sacramento, CA 95814

Reports:

Advice to others interested in starting this type of program: Staffers of the Suicide Intervention Skills Workshop submitted the following comment in addition to the above that may be relevant to others developing similar programs: "The workshop has connected the entire state and brought about the beginnings of a standardized approach to training that includes an expectation that competency and skills will be imparted to participants. This network, made up of crisis centers, county offices of education, mental health and social services, now serves to advocate for continued funding and programming for this at-risk group of persons. Secondly, and more importantly, it functions to bring together at a local level the necessary partners for improved community responses and services for suicidal persons.

The team-building outcome, while not evaluated in the previous studies, continues to be a primary comment of those who have participated in the workshop."

Center for Indian Youth Program Development --

Location: Albuquerque, New Mexico

Contact: Sally Davis, Director, (505) 277-4462

Targets: Native American youth.

Years in operation: 8

Source of funding: Indian Health Service (IHS).

Amount of funding (per year): Varies.

Program description: The health status of Native American teenagers in the United States is below that of the general population. The usual barriers to the use of health care services by young people (including young Native Americans) are compounded in rural areas by distance, isolation, and lack of appropriate services.

In response, the University of New Mexico (UNM) and the Indian Health Service formed a partnership to develop a teen health project in response to input from communities. Program staffers include nurse practitioners,

health educators, substance abuse educators, psychologists, youth counselors, and other support personnel. In designing the program, they aimed for accessibility, free comprehensive services, teenage participation in planning and carrying out the program, and community support and participation. The program is not medically oriented; instead, it focuses on promoting physical and mental health. Teacher training uses a substance abuse curriculum that includes a section on suicide. Related activities include Students Against Drunk Driving (SADD), Teen Health Awareness Days, Adventure Clubs, improvisational Teen Life Theater, intergenerational events, and a visit to a hospital emergency room that is part of an effort to train students as peer leaders in alcohol and substance abuse prevention (ASAP).

Exposure: Not reported.

Coverage: Center services are available on-site at four rural New Mexico high schools. In addition, the program provides technical assistance to other schools and community groups.

Content/topics: Services provided by the Center include:

Evaluation: At four sites, data gathered through surveys and interviews of students and adults are being used for planning and evaluation.

Findings: Center staffers have received positive feedback on their services in terms of teacher satisfaction and increased awareness of and knowledge about suicide. Both students and teachers reported increased opportunities to discuss suicide openly. The suicide rate has declined since the program began.

Data available: Study survey data and interviews with community gatekeepers.

Related components:

Address: Center for Indian Youth Program Development Sally Davis, Director Division of School Health and Center for Indian Youth Program Development

University of New Mexico School of Medicine Albuquerque, NM 87131

Jail Suicide Prevention Program --

National Center on Institutions and Alternatives (NCIA)

Location: Mansfield, Massachusetts

Contact: Lindsay M. Hayes, M.S., (508) 337-8806

Targets: Staff in jails, detention centers, and police lockups.

Years in operation: 14

Source of funding: National Institute of Corrections, U.S. Dept. of Justice, state and county contracts.

Amount of funding (per year): Not reported.

Program description: The National Center on Institutions and Alternatives determined that, by conducting an intake screening, properly trained correctional personnel can effectively assess inmates' suicidal potential, both at the booking stage and during subsequent phases of the inmates' incarceration. In addition to assessing inmates' suicidal potential, staff members using intake screening can detect any medical or mental health problem, determine alcohol or drug intoxication, and address classification needs. This is a