National Strategy for Suicide Prevention:
Goals and Objectives for Action

GOAL 6:
Implement Training for Recognition of At-Risk
Behavior and Delivery of Effective Treatment

Key gatekeepers, those people who regularly come into contact with individuals or families in distress, must be trained to recognize behavioral patterns and other factors that place individuals at risk for suicide and be equipped with effective strategies to intervene before the behaviors and early signs of risk evolve further. Key gatekeepers interact with people in environments of work, play, and natural community settings, and have the opportunity to interact in other than medical settings.

Although many textbooks, manuals, handbooks, multimedia presentations, journals, and brochures discuss the assessment and management of suicidal risk, as well as the identification and promotion of protective factors (Hawton & von Herringen, 2000; Jacobs, 1999a; Maris, Berman & Silverman, 2000), there is a need to define minimum course objectives in educating each type of key gatekeeper about his or her special role and perspective. Each has a unique relationship to individuals at risk and a responsibility to intervene in a timely and effective manner.

With the advent of safer and/or very effective psychotropic medications, many conditions associated with suicidal behaviors can be treated effectively (Montgomery 1997; Tondo, Jamison & Baldessarini, 1997). Furthermore, advances in family, group, and individual therapies (especially cognitive behavioral therapy, dialectical behavioral therapy, and interpersonal psychotherapies) have led to better treatment of at-risk individuals (Linehan, 1997; Linehan, Heard & Armstrong, 1993; Rudd, Joiner & Rajab, 2000; Zimmerman & Asnis, 1995).

About 45 percent of individuals who die by suicide have had some contact with a mental health professional within the year of their death (Pirkis & Burgess, 1998) and as many as 90 percent carry a psychiatric diagnosis at the time of death (Conwell & Brench, 2000). However, only 18 percent of suicide decedents reported suicidal ideation to a health professional prior to their death (Robins, 1981). Thus, at-risk individuals often seek professional help, but may not have their condition adequately recognized and are not likely to report the true severity of their condition.

Studies indicate that many health professionals are not adequately trained to provide proper assessment, treatment, and management of suicidal patients and clients, or know how to refer them properly for specialized assessment and treatment (Bongar, Lomax & Harmatz, 1992; Ellis and Dickey, 1998; Ellis, Dickey & Jones, 1998; Kleespies, 1998). Despite the increased awareness of suicide as a major public health problem, gaps remain in training programs for health professionals and others who often come into contact with patients in need of these specialized assessment techniques and treatment approaches. In addition, many health professionals lack training in the recognition of risk factors often found in grieving family members of loved ones who have died by suicide (suicide survivors).

Much needs to be done to ensure that all key gatekeepers are adequately trained to identify individuals at risk for suicidal behaviors, as well as respond to those expressing self-destructive behaviors. Key gatekeepers also need to identify opportunities for reinforcing protective factors that do exist and help foster protective factors when indicated. Furthermore, gatekeepers need to be educated about the availability and use of effective treatment interventions and when and how to refer to formal treatment settings those identified as being at risk (Hawton, Arensman, Townsend et al., 1998; Rudd, Joiner, Jobes et al., 1998).

As part of the process for designing and implementing training, it would be useful to develop a baseline of professionals' awareness, attitudes and knowledge of risk and protective factors related to suicide. For instance, awareness of the suicide protective effects of lithium for individuals with bipolar disorder is estimated to be low among certain health care personnel. Knowledge of which health care personnel and the extent of their awareness would permit more targeted training efforts.

Consensus about what needs to be taught and how to ensure appropriate training has not been reached; however, with the provision of appropriate and targeted education and training to each key gatekeeper group, it is likely that many suicide attempts and suicides can be prevented.

Nurses deliver health care education and interventions in many different settings, from community health clinics to school settings to private practice offices to occupational settings and hospital settings. They are often the first to see and hear about signs and symptoms of at-risk behavior, and are often in a unique position to intervene effectively when such behaviors are identified. As important members of the health care delivery team their education and training in this subject is critical (WHO, 2000a).

Physicians and physician assistants can benefit from training in the assessment of at-risk behaviors for suicide and in effective treatment interventions (WHO 2000a, WHO 2000c). They should be skilled in talking with patients about the risk for suicide, in providing crisis intervention for those at imminent risk for the expression of suicidal behaviors (Kleespies, 1998), and in referring their patients for expert assessment and treatment.

Many suicidal individuals make contact with their physicians within a few weeks prior to their death (Beautrais et al., 1998; Pirkis & Burgess, 1998). Their imminent risk for suicide may have gone undetected or unappreciated because, in part, the physicians were not appropriately trained to assess and manage suicide. With such training, fewer suicidal patients will go unrecognized and untreated (Shea, 1999).

Counselors, clinical psychologists, and clinical social workers are often on the "front line" in assessing and treating individuals who are at increased risk for suicidal behaviors. It is important that these mental health personnel receive appropriate graduate school training on the subject of suicide while preparing for their professions (Neimeyer, 2000). Surveys of clinical psychology training programs (Bongar & Harmatz, 1991) and social work training programs (King et al., 1999), reveal that an insufficient number of training programs provide adequate preparation for the recognition of at-risk suicidal behavior and the delivery of effective treatment.

Clergy often provide counseling and interventions for those in distress, and for some, they may be the first or only professionals to be in a position to provide emotional support. Individuals who are adjusting to and recovering from personal losses may be at increased risk for the expression of self-destructive behaviors (Bailley, Kral & Dunham, 1999). Clergy should be trained to identify and respond to suicidal risk as well as to encourage and support appropriate protective factors to lessen the likelihood of suicidal behaviors.

Surveys by the Centers for Disease Control (Brener, Krug, & Simon, 2000) indicate that suicidal thoughts and self-reported suicide attempts are prevalent among high school students. It is well known that adolescents and young adults will not seek out interventions or counseling by adults unless they feel that they can trust the adult to maintain respect, confidentiality, and provide knowledge and appropriate information (Eggert et al., 1990; Kalafat & Elias, 1994). Therefore, it makes sense to train those school personnel who are most likely to come in contact with students at risk (see also Objective 4.2). In addition to educational faculty, bus drivers, custodians, and playground supervisors are among those school staff with frequent contact with students. Although efforts have been taken to develop training manuals and handbooks for educators, many school personnel lack the tools and training to intervene effectively on behalf of students at risk (Zenere & Lazarus, 1997).

The staff and teachers in these systems need to be better equipped to identify and communicate with students about suicidal behaviors, as well as to communicate among themselves about these issues. School staff and faculty are not expected to make clinical diagnoses, but rather to be able to recognize developing signs and symptoms associated with mental disor-ders, substance abuse, or suicidal risk. Providing them with the vocabulary, techniques, and skills to be comfortable with these issues will enhance their ability to intervene effectively and make appropriate referrals (Grossman et al., 1995).

Although the Federal prison system has a lower suicide rate than the general population, there is an alarmingly high rate of suicide attempts and suicides in jails and correctional institutions in the United States. Given the often volatile nature of the circumstances that result in someone being placed in a jail or a correctional facility, suicide and suicidal behaviors are much more common than in the general population. The training of correctional workers is an important step to reduce the likelihood of individuals engaging in self-destructive behaviors when placed in correctional settings (Bonner, 2000) (see also Objective 4.5).

Attorneys involved in divorce proceedings, custody cases, family law cases, and criminal defense cases, often work with clients who are in heightened emotional states, depressed, hopeless, and who may have lost important social support. Such individuals may be at increased risk for violence and suicide, and attorneys are in a position to identify the increased risk and to refer them for specialized interventions.

It has been shown that educating family members about how to understand, monitor, and intervene with family members at risk for suicide results in better management and treatment of those identified individuals (Richman, 1986).

Organizations such as The National Alliance on Mental Illness have conclusively demonstrated the value of family education and support network education to improve the care of individuals who are at risk. Because the exact timing of suicidal behaviors is very difficult to predict, it is important that key members of the family unit and social support network are knowledgeable about potential risks for suicide and about how to protect an individual from self-harm.

The close association between mental disorders, especially depression, and suicidal behaviors warrants ensuring that professionals are competent in applying the tools and techniques of diagnosis, treatment, management, and prevention to those mental disorders associated with suicidal behaviors. In most States, physicians, psychologists, social workers, nurses, and other health professionals must complete licensing examinations or recertification programs in order to maintain active licenses and to ensure ongoing professional certifications. One mechanism to ensure that professionals remain competent to deal with suicidal behaviors is to include the subject area in recertification or licensing programs.

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