Resource Types: Program/Practice

Kognito At-Risk in the ED is a one-hour, online, interactive training simulation that teaches Emergency Department (ED) staff how to (1) recognize patients who exhibit warning signs of suicide and substance abuse risk, (2) screen patients for suicide and substance abuse risk, and (3) respond to patients who screen positive for suicide and substance abuse risk. In the training, users engage in simulated conversations with three emotionally responsive avatars representing patients who may be at risk for suicide and/or substance abuse. In these virtual role-plays, users learn how to effectively interview patients in order to recognize warning signs and gain patients’ trust. If users suspect that patient avatars are at-risk, they engage in further simulated conversations and screen the patient avatars using evidence-based suicide and substance abuse toolkits (including SAD PERSONS, the RAPS4-QF, and the CRAFFT). Physicians are eligible to receive 1.5 CME AMA PRA Category 1 Credits™ upon course completion. Nursing and other staff may receive CEUs depending on local requirements.

The program was developed by Kognito Interactive with input from a group of mental and behavioral health experts and ED clinicians including face-to-face and phone-based focus groups with ED personnel during program development and as part of beta testing.

Program Objectives

After completing the training, Emergency Department personnel will have increased knowledge of:

1. Warning signs for suicide and substance abuse risk, including verbal, behavioral, and situational clues.
2. Evidence-based tools that can be used to screen patients for suicide and substance abuse risk.
3. Communication techniques to use with at-risk patients in order to gain their trust, motivating them to respond truthfully during conversations.
4. Next steps when patients screen positive for suicide and substance abuse risk.
5. Best practices for effective risk management documentation of patient interviews related to suicide and substance abuse risk.
6. Protective factors and means restriction when patients are identified as at risk.

Implementation Essentials

• Emergency departments should have protocols in place to manage those who are found to be at risk for suicide.

2012 NSSP Objectives Addressed: 

Objective 7.2: Provide training to mental health and substance abuse providers on the recognition, assessment, and management of at-risk behavior, and the delivery of effective clinical care for people with suicide risk.

Dynamic Deconstructive Psychotherapy (DDP) is a 12- to 18-month, manual-driven treatment for adults with borderline personality disorder and other complex behavior problems, such as alcohol or drug dependence, self-harm, eating disorders, and recurrent suicide attempts. DDP combines elements of translational neuroscience, object relations theory, and deconstruction philosophy in an effort to help clients heal from a negative self-image and maladaptive processing of emotionally charged experiences. Neuroscience research suggests that individuals having complex behavior problems deactivate the regions of the brain responsible for verbalizing emotional experiences, attaining a sense of self, and differentiating self from other, and instead activate the regions of the brain contributing to hyperarousal and impulsivity.

DDP helps clients connect with their experiences and develop authentic and fulfilling connections with others. During weekly, 1-hour individually adapted sessions, clients discuss recent interpersonal experiences and label their emotions, while also reflecting upon their experiences in increasingly complex and realistic ways, to start the longer-term process of self-acceptance. Therapists must learn to recognize, understand, and make use of their own intense emotional reactions elicited by clients in order to foster recovery, avoid burnout, and provide novel experiences in the client-therapist relationship that support individuation and challenge clients’ basic assumptions about themselves and others.

Implementers should be licensed therapists (i.e., psychologists, clinical social workers, psychiatrists, marriage and family therapists). Training is required to implement the full model.

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).

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

1: Symptoms of borderline personality disorder (3.3)
2: Depression (3.5)
3: Parasuicide behaviors (3.0)
4: Heavy drinking (3.4)

Read more about this 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.

LifeSavers Training is a three-day suicide and crisis prevention program that trains high school students to listen to peers compassionately and confidentially using specialized techniques designed to help them make healthier decisions. Trained LifeSavers intervene, often quietly and behind the scenes, to help prevent difficult situations from developing into crises. With the help of the non-judgmental and confidential support provided by LifeSavers, troubled peers and friends are often able to find their own solutions to their problems.

LifeSavers also acquire the ability to discern when problems are more serious and then ensure that the troubled student connects with a responsible adult. The skills LifeSavers learn help them step out of their comfort zone, take the initiative to recognize and respond to others’ needs, value diversity, and value themselves. Students carry these skills and values on into their adult lives.

The original LifeSavers Training curriculum was developed at Belleville (Illinois) East High School in 1980, using some original materials and considerable adaptation from existing programs that were recognized as effective. LifeSavers Training Corp. was incorporated as a not-for-profit in 1998 following years of implementation of the training in additional schools by volunteers. The curriculum has been continually updated and enhanced with materials and activities that have proven effective for the current audience of young people (often with their input).

Program Objectives

Students who participate in the LifeSavers Training program will have:

1. Increased understanding of warning signs of suicide.
2. Greater ability to intervene with students who may be at risk for suicide.
3. Greater knowledge of referral points for students who may be a risk for suicide.
4. Enhanced listening skills.

Implementation Essentials

• If implemented in a school setting, a school-based crisis management plan, such as that found in the Maine Youth Suicide Prevention, Intervention, and Postvention Guidelines should be adopted prior to implementing the LifeSavers Training program.

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.

Survivor Voices: Sharing the Story of Suicide Loss is a two-day training designed to teach those bereaved by suicide how to speak safely and effectively about their experience and loss. Through the sharing of personal stories, survivors of suicide loss provide insight that goes beyond traditional suicide prevention training. These insights can promote healing for those who are newly bereaved, educate the public about how to support survivors of suicide loss, and increase awareness and understanding of risk factors and warning signs for suicide.

The training prepares each participant to tell his or her story safely and effectively to various audiences, enhances public speaking skills and the ability to respond safely to audience and media questions, and provides education about suicide prevention and resources for survivors of suicide loss. The process of sharing stories and messages is very personal and intense, and the training encourages and promotes mutual support and healing among participants. The small group size is intended to allow time for sharing and caring.

Developed by NAMI New Hampshire, Survivor Voices: Sharing the Story of Suicide Loss combines key aspects of NAMI training; information from the Connect Suicide Prevention and Postvention Training Programs; and knowledge gained through a long history of working with survivors of suicide loss. Specific best practices and guidelines found in the training include information on safe messaging, media recommendations for reporting on suicide, and memorial guidelines. Participant feedback collected since 2008 has guided revisions of the training.

Program Objectives

Survivors of suicide loss who complete the two-day training will have:

1. Greater knowledge of how to safely and effectively tell one’s story of loss publicly.
2. Greater ability to hone one’s message for a general or specific audience.
3. Greater ability to safely respond to questions from audience members or media.
4. Greater ability to familiarize others with suicide prevention resources and resources for survivors of suicide loss.
5. Greater comfort with telling one’s story after having practiced it in a safe environment.
6. Greater ability to connect survivors of suicide loss to each other and to resources.

Implementation Essentials

Survivor Voices: Sharing the Story of Suicide Loss participants should be screened to ensure they are emotionally ready to tell their story without having a setback in their own healing.

2012 NSSP Objectives Addressed: 

Objective 10.1: Develop guidelines for effective comprehensive support programs for individuals bereaved by suicide and promote the full implementation of these guidelines at the state/territorial, tribal, and community levels.

Sources of Strength, a universal suicide prevention program, is designed to build protective influences and reduce the likelihood that vulnerable youth will become suicidal. The program trains students as peer leaders and connects them with adult advisors at school and in the community. Advisors support the peer leaders in conducting well-defined messaging activities that aim to change peer group norms influencing coping practices and problem behaviors (e.g., self-harm, drug use, unhealthy sexual practices). The program is strength-based and promotes eight critical protective factors that are linked to overall psychological wellness and reduced suicide risk. Specifically, program activities aim to reduce the acceptability of suicide as a response to distress, increase the acceptability of seeking help, improve communication between youth and adults, and develop healthy coping attitudes among youth. The program is also designed to positively modify the knowledge, attitudes, and behaviors of the peer leaders themselves.

Students are recruited through staff and student nominations to form a team of peer leaders, who are mentored by 2-5 adult advisors. Certified trainers provide the peer leaders and adult advisers with an initial 4-hour interactive training. Adult advisors facilitate peer leader meetings over 3-4 months to plan, design, and practice individual, classroom, and media messaging activities. The peer leaders have one-on-one conversations within their network of friends; develop posters and public service announcements with local faces and voices; give peer-to-peer presentations; and develop messages to be delivered via video, the Internet, or text messages.

The program is often initiated as a 3- to 6-month project, but it is designed as a multiyear project with ongoing peer messaging and contacts growing over time. Adult advisors receive training and ongoing support.

Sources of Strength curriculum was developed by Mark LoMurray in 1998 and has been used extensively in tribal/rural areas of North Dakota as well as with other diverse populations. The program can be implemented in schools or colleges, as well as in faith, cultural, and community-based settings.

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

1: Attitudes about seeking adult help for distress (3.1)

2: Knowledge of adult help for suicidal youth (3.1)

3: Rejection of codes of silence (3.1)

4: Referrals for distressed peers (3.0)

5: Maladaptive coping attitudes (2.8)

Read more about this 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.

Implementation Essentials

• Prior to training the peer team, crisis management protocols found in the Sources of Strength Start-up Guide should be fully implemented and local adult advisors should be identified and trained.

2012 NSSP Objectives Addressed: 

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

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 Youth Health Connection (YHC), How Not To Keep A Secret (HNTKAS) is a peer leader training program designed to provide education to teens about depression and suicide, increase help-seeking behaviors, and decrease stigma associated with mental illness. The day-long HNTKAS training includes a clinical presentation, the documentary Break Free from Depression, and interactive activities. Students create and perform skits highlighting risk factors and warning signs of depression and suicide, as well as how to reach out for help. The skits are then presented by the peer leaders to their home schools. The day-long HNTKAS training and follow-up implementation are part of a comprehensive recommended program that includes: consultation on policy and procedure for addressing mental health issues in schools; educator gatekeeper training; use of advisory groups in schools; parent education and training; primary care and nurse training; community partnership, including clergy and law enforcement representatives; and an e-newsletter.

HNTKAS was developed over a period of 15 years and incorporates the power of peer to peer relationships, the interactive dynamic process of drama and discussion, and connection to a trusted adult. The manual, clinical presentation and DVD have been piloted and revised after implementation across public, charter, independent, and parochial schools, including multicultural populations. The manual represents the work of mental health professionals who have been on the YHC Mental Health Advisory Board. The DVD, Break Free from Depression, is the work of the Swensrud Depression Prevention Initiative, Children’s Hospital, Boston, MA.

Program Objectives

At the end of training, participants will be able to:

1. State that depression is a treatable illness and that suicide is preventable.
2. List a minimum of four symptoms of adolescent depression.
3. List a minimum of three warning signs of suicide.
4. Identify a minimum of three adults, inside and outside the school setting, with whom they would connect and talk if they are concerned about their own mental health and safety or that of relevant others.

Implementation Essentials

• Schools that participate in the How Not To Keep A Secret program should have policies and procedures in place to respond to students who are at risk for depression and suicide.
• It is strongly recommended that schools provide gatekeeper training to all faculty prior to implementing How Not To Keep A Secret with their peer leaders.

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.

Teens for Life Program: Youth Curriculum is an interactive classroom-based suicide prevention program for high school and middle school students and youth served by community-based agencies in Alameda County, California. The one-hour curriculum is taught by personnel trained by Crisis Support Services of Alameda County. The curriculum features information on:

• Reducing stigma towards mental disorders and help-seeking behavior.
• Recognizing warning signs of depression and suicide.
• Seeking help for yourself or a friend in crisis.

Students who participate in the curriculum receive a crisis line card and a referral sheet specific to their school. The referral sheet includes information on how to access school and local community-based mental health services.
The Teens for Life Program curriculum was developed 20 years ago through a collaborative effort between Alameda County teachers, students, and clinical staff, volunteers, and board members of Crisis Support Services of Alameda County. The curriculum was recently revised to better reflect the program logic model and student evaluation outcomes. The current curriculum also incorporates feedback and suggestions from the Suicide Prevention Resource Center and Alameda County Behavioral Health Care Services.

Program Objectives

Students who participate in the Teens for Life Program: Youth Curriculum will have:

1. Increased knowledge of the warning signs of depression and suicide.
2. Increased knowledge of where to get help for themselves or peers who may be at risk for suicide.
3. Increased willingness to seek help for themselves or a friend in crisis.
4. Reduced stigma towards those with mental disorders.

Implementation Essentials

Schools and institutions that use the Teens for Life Program: Youth Curriculum should have crisis management plans and protocols in place to respond to those who may be at risk for suicide.

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.

The Safety Plan Treatment Manual to Reduce Suicide Risk: Veteran Version was developed by Barbara Stanley, Ph.D., of Columbia University, and Gregory K. Brown, Ph.D., of the University of Pennsylvania, in collaboration with VA staff. The 20-page Treatment Manual provides instructions for developing a safety plan for Veterans who are at risk for suicide. A corresponding Safety Plan Quick Guide for Clinicians pocket card is also available. The steps outlined in the Treatment Manual and Quick Guide are recommended for use whenever a Veteran is identified as an attempt survivor, or is otherwise identified as being at high-risk for suicide. Using the Treatment Manual and Quick Guide results in a written safety plan that helps the Veteran identify:

• Personal warning signs
• Internal coping strategies
• Social contacts who may distract from the crisis
• Family members or friends who may offer help
• Professionals and agencies to contact for help
• Safe environments

Working groups of clinicians and others helped shape the manual and corresponding Safety Plan Quick Guide for Clinicians into its final form.

Program Objectives

Veterans using the safety plan will improve their ability to:

1. Recognize personal warning signs of suicide.
2. Use internal coping strategies to reduce suicide risk.
3. Access social and family contacts who may help reduce suicide risk.
4. Contact appropriate professionals and agencies for help.
5. Make their environment safer.

Implementation Essentials

• The Safety Plan is a tool to engage the Veteran and is only one part of a comprehensive suicide care plan.

2012 NSSP Objectives Addressed: 

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

Objective 6.1: Encourage providers who interact with individuals at risk for suicide to routinely assess for access to lethal means.

Objective 9.2: Develop, disseminate, and implement guidelines for clinical practice and continuity of care for providers who treat persons with suicide risk.

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.

Created by the Canadian Coalition for Seniors’ Mental Health (CCSMH), the Late Life Suicide Prevention Toolkit is an educational program developed for use by front-line providers, medical and mental health care clinicians, and health care trainees. It focuses on how to identify suicide warning signs, establish rapport and assess suicide risk and resiliency factors, and manage immediate and ongoing risk for suicide among older adults. The Toolkit contains:

1. Suicide Assessment & Prevention for Older Adults: Life Saving Tools for Health Care Providers DVD
2. PowerPoint presentation (57 slides)
3. Facilitator’s Guide (19 pages)
4. Suicide Assessment & Prevention for Older Adults clinician pocket card
5. CCSMH National Guidelines for Seniors’ Mental Health: The Assessment of Suicide Risk and Prevention of Suicide

The toolkit is based on CCSMH’s National Guidelines on the Assessment of Suicide Risk and Prevention of Suicide in Older Adults (Canada’s first ever interdisciplinary, evidence-based guideline on the topic). Focus groups with health care providers, educators, family members, and older adults provided input on the core elements of the toolkit. CCSMH staff led a volunteer committee of clinicians, researchers and academics, community agencies/organizations, and family and advocacy groups to create a knowledge translation tool based on the original evidence-based guideline for the assessment of risk and prevention of suicide in older adults.

Program Objectives

Those who participate in the Toolkit’s training program will be able to:

1. Demonstrate a basic understanding of the epidemiology of late life suicide.
2. List risk and protective factors for suicide.
3. Identify suicide warning signs.
4. Initiate conversations about depression and suicide risk using key questions to assess for suicide risk.
5. Describe late life suicide risk assessment and clinical intervention strategies.
6. Integrate components of the Toolkit into clinical care.

Implementation Essentials

• The toolkit contains multiple components, which work best when used in concert.

2012 NSSP Objectives Addressed: 

Objective 7.2: Provide training to mental health and substance abuse providers on the recognition, assessment, and management of at-risk behavior, and the delivery of effective clinical care for people with suicide risk.

Offered by the Samaritans of Merrimack Valley, MA, a program of Family Service, Inc., the Suicide Prevention Training for Gatekeepers of Older Adults is an eight-hour gatekeeper training program for those who have regular contact with older adults through their personal, professional or volunteer activities.

Suicide Prevention Training for Gatekeepers of Older Adults is organized into the following five sessions:

1. Overview of aging, mental health, and suicide
2. Risk and protective factors for suicide; warning signs for suicide; and suicide risk assessment
3. Working with older adults at risk for suicide
4. Ongoing care and support of older adults at risk for suicide
5. Self-care

Suicide Prevention Training for Gatekeepers of Older Adults is provided on site (at nursing homes, assisted living facilities, etc.) in one eight-hour session or two four-hour sessions. It is designed for between 6 and 20 participants. The training was adapted, with permission, from the Suicide Prevention for Older People Training Manual developed by Centre for Mental Health, South Western Sydney Area Health service, Elderly Suicide Prevention Network and the Hunter Institute of Mental Health in Australia.

Program Objectives

At the end of training, participants will be able to:

1. Understand the difference between issues of normal aging and mental health.
2. List risk and protective factors, and warning signs for suicide in older adults.
3. Understand levels of suicide risk.
4. Engage and intervene with older adults at risk for suicide.
5. List local services available for older adults who are at risk for suicide.
6. Provide ongoing care and support for older adults at risk for suicide.

Implementation Essentials

• Training participants should be provided with a list of local resources relevant to the care of older adults who are at risk for suicide.

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.