Resource Types: Program/Practice

RESPONSE is a comprehensive high school-based program that increases awareness about suicide among high school staff, students and parents. All program components are designed to heighten sensitivity to depression and suicidal ideation, increase identification, and facilitate referral. The program also provides procedures to refer a student who may be at-risk for suicide. Components include (1) a two-hour awareness training for staff, (2) a four-hour student curriculum (spread across four class periods), and parent awareness materials. An implementation assistance manual is also included for administrators. Before implementing the awareness components, participating schools must identify key staff to serve on a suicide prevention team. Key school-based staff should include the principal or vice-principal, a school-based RESPONSE coordinator, two “suicide contacts” responsible for handling referrals, and a counselor. Each component of RESPONSE integrates extensive “in the field” experience and key evaluation findings from other school-based programs. Videos for the awareness components were developed in collaboration with an award-winning film company.

Program Objectives

After implementation, participants should have:

1. Increased knowledge of signs of depression and suicide.
2. Increased understanding of attitudes and behaviors that can hinder help seeking.
3. Increased understanding of steps to seek help for self and others.
4. Increased knowledge of “crisis contacts” at the school for immediate help.

Implementation Essentials

• Review of school or district readiness for RESPONSE (through implementation checklist).
• In-service training for staff and faculty prior to classroom instruction.
• Advanced training for selected staff to act as “crisis contacts” prior to classroom instruction (ASIST training is recommended; see their fact sheet on the registry for more information).

2012 NSSP Objectives Addressed: 

Objective 5.2: Encourage community-based settings to implement effective programs and provide education that promote wellness and prevent suicide and related behaviors.

Objective 7.1: Provide training on suicide prevention to community groups that have a role in the prevention of suicide and related behaviors.

American Indian Life Skills (AILS) is a universal, school-based, culturally grounded, life-skills training program that aims to reduce high rates of American Indian/Alaska Native (AI/AN) adolescent suicidal behaviors by reducing suicide risk and improving protective factors. The curriculum includes between 13 to 56 lesson plans and is typically delivered over 30 weeks during the school year or as an afterschool program, with students participating in lessons three times per week. The curriculum emphasizes social–cognitive skills training and includes seven main themes: 1) building self-esteem, 2) identifying emotions and stress, 3) increasing communication and problem-solving skills, 4) recognizing and eliminating self-destructive behavior, 5) information on suicide, 6) suicide intervention training, and 7) setting personal and community goals. The curriculum also incorporates three domains of well-being that are specific to tribal groups: 1) helping one another, 2) group belonging, and 3) spiritual belief systems and practices. Lessons are interactive and incorporate situations and experiences relevant to AI/AN adolescent life such as friendship issues, rejection, divorce, separation, unemployment, and problems with health and the law. Lessons may be delivered by teachers working with community resource leaders and representatives of local social service agencies.

AILS is the currently available version of the former Zuni Life Skills Development program, which was developed with cultural components relevant to the people of the Zuni Pueblo in New Mexico, including Zuni norms, values, beliefs, and attitudes; sense of self, space, and time; communication style; and rewards and forms of recognition. The Zuni curriculum served as the basis for the broader AILS curriculum that is now in use, which can be used with other AI/AN populations when implemented with appropriate and culturally specific modifications.

Designation as a “Program with Evidence of Effectiveness”

SPRC designated this intervention as a “program with evidence of effectiveness” based on its inclusion in SAMHSA’s National Registry of Evidence-Based Programs and Practices (NREPP). 

Outcome(s) Reviewed (Evidence Rating)*

• Depression and Depressive Symptoms (Promising)
• Suicidal Thoughts and Behaviors (Promising)
• Self-concept (Ineffective)

Read more about this program’s ratings.

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* NREPP changed its review criteria in 2015. This program was reviewed under the post-2015 criteria.To help practitioners find programs that fit their needs, NREPP reviews the evidence for specific outcomes, not overall programs. Each outcome was assigned an evidence rating of Effective, Promising, or Ineffective. A single program may have multiple outcomes with different ratings. When considering programs, we recommend (a) assessing whether the specific outcomes achieved by the program are a fit for your needs; and (b) examining the strength of evidence for each outcome.

Implementation Essentials

• Prior to launching the program, crisis management protocols should be fully implemented and adult leaders should be identified and prepared for their roles in the program.

2012 NSSP Objectives Addressed: 

Objective 3.1: Promote effective programs and practices that increase protection from suicide risk.

Objective 5.2: Encourage community-based settings to implement effective programs and provide education that promote wellness and prevent suicide and related behaviors.

Objective 5.3: Intervene to reduce suicidal thoughts and behaviors in populations with suicide risk.

SafeTALK is a half-day training program that teaches participants to recognize and engage persons who might be having thoughts of suicide and to connect them with community resources trained in suicide intervention. SafeTALK stresses safety while challenging taboos that inhibit open talk about suicide. The program recommends that an ASIST-trained resource or other community support resource be at all trainings. The ‘safe’ of safeTALK stands for ‘suicide alertness for everyone’. The ‘TALK’ letters stand for the practice actions that one does to help those with thoughts of suicide: Tell, Ask, Listen, and KeepSafe.

The safeTALK learning process is highly structured, providing graduated exposure to practice actions. The program is designed to help participants monitor the effect of false societal beliefs that can cause otherwise caring and helpful people to miss, dismiss, or avoid suicide alerts and to practice the TALK step actions to move past these barriers. Six 60-90 second video scenarios, each with non-alert and alert clips, are selected from a library of scenarios and strategically used through the training to provide experiential referents for the participants.

SafeTALK was developed by LivingWorks Education to complement longer suicide intervention training. Developers in Australia and Canada designed and field trialed the program in 2004-05 based on stakeholder reports of a training gap between short suicide awareness sessions and longer suicide intervention skills training.

Program Objectives

After training, participants in the safeTALK program should be able to:

1. Challenge attitudes that inhibit open talk about suicide.
2. Recognize a person who might be having thoughts of suicide.
3. Engage them in direct and open talk about suicide.
4. Listen to the person’s feelings about suicide to show that they are taken seriously.
5. Move quickly to connect them with someone trained in suicide intervention

Implementation Essentials

• 2.5-3.5 hour training by a certified safeTALK trainer.

2012 NSSP Objectives Addressed: 

Objective 7.1: Provide training on suicide prevention to community groups that have a role in the prevention of suicide and related behaviors.

Developed by NAMI New Hampshire, Connect Suicide Prevention/Intervention provides training in suicide prevention across the lifespan for professionals and laypersons. Using a unique socio-ecological model, Connect examines suicide prevention in the context of the individual, family, tribe, community and society.

Participants learn to recognize early warning signs of suicide and how to connect with individuals at risk and get them help. Additionally, Connect training addresses “systems” issues including the need for community-wide collaboration, safe messaging, restricting access to lethal means, and the impact of social media.

Specific best practice protocols have been developed for gatekeepers, social services agencies, mental health and substance abuse providers, education, law enforcement and first responders, medical providers and faith communities.  Connect protocols were created through statewide stakeholder groups and were then reviewed by national suicide prevention experts. Connect training activities and materials are based on these protocols and were developed in consultation with experts in training and suicide prevention, and then tested and evaluated.

Connect training includes interactive case scenarios, facilitated discussion, activities, written materials, PowerPoint, and consultation. Connect staff welcome collaboration with organizations, tribes, or villages to customize the training to be culturally effective. Connect staff encourage and facilitate dialogue between service systems and key stakeholders to help strengthen the response to persons at risk.

Program Objectives

After training, participants in the Connect Suicide Prevention/Intervention training will have increased:

1. Competency in how to recognize and respond to suicide warning signs.
2. Skills in how to intervene and connect a suicidal person to resources.
3. Understanding of attitudes toward suicide and the effects of stigma.
4. Knowledge of the scope of suicidal behavior through suicide trends and statistics.
5. Knowledge of individual and community risk and protective factors.
6. Awareness of restricting access to lethal means, safe messaging, and the influence of electronic communication and social media.
7. Understanding of the respective roles of local service providers in suicide prevention and intervention.
8. Opportunities for networking, relationship building, information sharing, and problem solving during the training.

Implementation Essentials

• Community support and resources to support prevention efforts. 

2012 NSSP Objectives Addressed: 

Objective 1.2: Establish effective, sustainable, and collaborative suicide prevention programming at the state/territorial, tribal, and local levels.

Objective 7.1: Provide training on suicide prevention to community groups that have a role in the prevention of suicide and related behaviors.

Prevention of Suicide in Primary Care Elderly: Collaborative Trial (PROSPECT) aims to prevent suicide among older primary care patients by reducing suicidal ideation and depression. It also aims to reduce their risk of death. The intervention components are (1) recognition of depression and suicidal ideation by primary care physicians, (2) application of a treatment algorithm for geriatric depression in the primary care setting, and (3) treatment management by health specialists (e.g., nurses, social workers, psychologists). The treatment algorithm assists primary care physicians in making appropriate care choices during the acute, continuation, and maintenance phases of treatment. Health specialists collaborate with physicians to monitor patients and encourage patient adherence to recommended treatments. Patients are treated and monitored for 24 months.

Designation as a “Program with Evidence of Effectiveness”

SPRC designated this intervention as a “program with evidence of effectiveness” based on its inclusion in SAMHSA’s National Registry of Evidence-Based Programs and Practices (NREPP).

Outcome(s) Reviewed (Overall Quality of Research Rating-scale of 0 to 4)*

1: Depression (3.6)
2: Suicidal ideation (3.6)
3: Mortality Rate (3.5)

Read more about the program’s ratings.

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* NREPP changed its review criteria in 2015. This program is a “legacy program,” meaning that it was reviewed under the pre-2015 criteria. The evidence for each outcome was reviewed and scored on a scale of 0-4, with 4 indicating the highest quality of evidence and 0 indicating very poor quality of evidence. The overall rating was based on ratings of six criteria: 1) reliability of measures, 2) validity of measures, 3) intervention fidelity, 4) missing data and attrition, 5) potential confounding variables, and 6) appropriateness of analysis. When considering programs, we recommend (a) assessing whether the specific outcomes achieved by the program are a fit for your needs; and (b) examining the strength of evidence for each outcome. 

2012 NSSP Objectives Addressed: 

Objective 7.5: Develop and implement protocols and programs for clinicians and clinical supervisors, first responders, crisis staff, and others on how to implement effective strategies for communicating and collaboratively managing suicide risk.

CAST (Coping and Support Training) is a school-based small group counseling program for at-risk youth that has demonstrated decreased suicide risk factors among other positive outcomes in adolescents. CAST is conducted over 12 55-minute sessions. It can be delivered by trained teachers, counselors, social workers, or others with similar experience. It is available from Reconnecting Youth, Inc. for a fee.

The United States Air Force Suicide Prevention Program (AFSPP) is a population-oriented approach to reducing the risk of suicide. The Air Force implemented 11 initiatives aimed at strengthening social support, promoting development of social skills, and changing policies and norms to encourage effective help-seeking behaviors. AFSPP’s 11 initiatives include: 1) Leadership Involvement, 2) Addressing Suicide Prevention in Professional Military Education, 3) Guidelines for Commanders on Use of Mental Health Services, 4) Community Preventive Services, 5) Community Education and Training, 6) Investigative Interview Policy, 7) Trauma Stress Response, 8) Integrated Delivery System (IDS) and Community Action Information Board (CAIB), 9) Limited Privilege Suicide Prevention Program, 10) IDS Consultation Assessment Tool, and 11) Suicide Event Surveillance System.

The program manual is available at no charge.

Designation as a “Program with Evidence of Effectiveness”

SPRC designated this intervention as a “program with evidence of effectiveness” based on the World Health Organization’s 2014 publication Preventing Suicide: A Global Imperative. The report states:

“Multicomponent interventions. There are multiple causes and pathways for suicide. Interventions that contain more than one prevention strategy might therefore be particularly useful for preventing suicide. Indeed, research suggests that multicomponent programme  strategies are associated with successful reductions in suicide rates. For example, the United States Air Force programme, consisting of 11 community and health-care components with accountability and protocols, was shown to be highly effective in preventing suicides in the Air Force” (p. 63).

Outcomes

A cohort of active-duty U.S. Air Force personnel exposed to the intervention between 1997 and 2002 was compared to a cohort not exposed between 1990 and 1996. The intervention cohort experienced a 33% relative risk reduction compared to the control cohort (p < 0.001). The intervention cohort also experienced relative risk reductions for homicide (51%, p = 0.05), accidental death (18%, p = 0.05), severe family violence (54%, p < 0.0001), and moderate family violence (30%, p < 0.0001) when compared to the control cohort (Knox et al., 2003).

A follow-up study assessed the AFSPP’s impact on suicide rates from 1981 through 2008, providing 16 years of data before the program’s 1997 launch and 11 years of data after launch. Implementation of program components was measured at 2 points in time: during a 2004 increase in suicide rates, and 2 years afterward. Suicide rates in the Air Force were significantly lower after the AFSPP was launched than before, except during 2004. The study determined that the program was being implemented less rigorously in 2004 (Knox et al., 2010).

References

Knox, K. L., Litts, D. A., Talcott, G. W., Feig, J. C., & Caine, E. D. (2003). Risk of suicide and related adverse outcomes after exposure to a suicide prevention programme in the US Air Force: cohort study. Bmj, 327(7428), 1376. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/14670880/

Knox, K. L., Pflanz, S., Talcott, G. W., Campise, R. L., Lavigne, J. E., Bajorska, A., … Caine, E. D. (2010). The US Air Force Suicide Prevention Program: Implications for Public Health Policy. American Journal of Public Health, 100(12), 2457–2463. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2978162/

Dialectical Behavior Therapy (DBT) is a cognitive-behavioral treatment approach with two key characteristics: a behavioral, problem-solving focus blended with acceptance-based strategies, and an emphasis on dialectical processes. “Dialectical” refers to the issues involved in treating patients with multiple disorders and to the type of thought processes and behavioral styles used in the treatment strategies. DBT has five components: (1) capability enhancement (skills training); (2) motivational enhancement (individual behavioral treatment plans); (3) generalization (access to therapist outside clinical setting, homework, and inclusion of family in treatment); (4) structuring of the environment (programmatic emphasis on reinforcement of adaptive behaviors); and (5) capability and motivational enhancement of therapists (therapist team consultation group). DBT emphasizes balancing behavioral change, problem-solving, and emotional regulation with validation, mindfulness, and acceptance of patients.

Therapists follow a detailed procedural manual. Generally, mental health professionals will need additional training to implement DBT. Training and training materials are available from Behavioral Tech, LLC for a fee.

Designation as a “Program with Evidence of Effectiveness”

SPRC designated this intervention as a “program with evidence of effectiveness” based on its inclusion in SAMHSA’s National Registry of Evidence-Based Programs and Practices (NREPP).

Outcome(s) Reviewed (Overall Quality of Research Rating-scale of 0 to 4)

1: Suicide attempts (3.7)
2: Nonsuicidal self-injury (parasuicidal history)  (3.3)
3: Psychosocial adjustment (3.4)
4: Treatment retention  (3.4)
5: Drug use (3.3)
6: Symptoms of eating disorders (3.2)

Read more about the program’s ratings.

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* NREPP changed its review criteria in 2015. This program is a “legacy program,” meaning that it was reviewed under the post-2015 criteria. The evidence for each outcome was reviewed and scored on a scale of 0-4, with 4 indicating the highest quality of evidence and 0 indicating very poor quality of evidence. The overall rating was based on ratings of six criteria: 1) reliability of measures, 2) validity of measures, 3) intervention fidelity, 4) missing data and attrition, 5) potential confounding variables, and 6) appropriateness of analysis.  When considering programs, we recommend (a) assessing whether the specific outcomes achieved by the program are a fit for your needs; and (b) examining the strength of evidence for each outcome. 

2012 NSSP Objectives Addressed: 

Objective 8.3: Promote timely access to assessment, intervention, and effective care for individuals with a heightened risk for suicide.

This intervention provides four sessions of psychotherapy for adults who have deliberately poisoned themselves. Treatment is provided in the patient’s home by trained nurse therapists. A study conducted in the UK showed decreased suicidal ideation in those who received the four 50-minute treatments compared to those who received regular treatment. In addition, at the 6-month follow-up, it was found that only 9% of psychotherapy group members had harmed themselves again compared with 28% of treatment as usual group members. 

Note: This intervention is a legacy program from the SPRC/AFSP Evidence-Based Practices Project (EBPP), which stopped conducting evidence-based reviews in 2005 when SAMSHA began reviewing suicide-related interventions for NREPP.

Implementation Essentials

Therapists skilled in interpersonal therapy.

2012 NSSP Objectives Addressed: 

Objective 8.2: Develop and implement protocols for delivering services for individuals with suicide risk in the most collaborative, responsive, and least restrictive settings.

Objective 8.3: Promote timely access to assessment, intervention, and effective care for individuals with a heightened risk for suicide.

Objective 9.5: Adopt and implement policies and procedures to assess suicide risk and intervene to promote safety and reduce suicidal behaviors among patients receiving care for mental and/or substance use disorders.