“We all need suicide prevention training--just like CPR.”

-Gatekeeper Trainer

Introduction

Since its initial funding in July of 1995, the Youth Suicide Prevention Plan for Washington State sparked interest among lawmakers and voters, professionals and lay-persons, teachers--even students--to recognize youth suicide for what it is:  The second leading cause of death among youth aged 15-24 years here in the Evergreen State.

It was time! Our youth suicide rate had ranked 10^th in the nation--almost twice that of homicide. Something clearly had to be done.

The youth suicide prevention plan would not have been developed, if it had not been for the dedication of parents of youth suicide victims, like Scot and Leah Simpson. They and other concerned citizens and health professionals banded together to form a “grass roots” movement in 1992.

Two years later, the momentum in the State Capital was sufficient to result in modest funding for the development of the Youth Suicide Prevention Plan for Washington State. In January, 1995, this plan was submitted to the legislature. As a result of open dialogue between concerned citizens, health-care professionals and lawmakers, the plan was approved for funding. Accordingly, in July of 1995, the state allocated funds to the Department of Health to implement selected prevention components in Washington's master plan.

The overall goals of the comprehensive plan were to:

• Reduce youth suicide and suicidal behaviors in Washington;
• Reduce the impact of suicidal behaviors on significant others; and
• Improve access and availability of prevention services statewide.

In September, 1995, Bruce Miyahara, Secretary of the Department of Health, requested a multi-component needs assessment report on youth suicide prevention. This assessment involved an inventory of community-based capacity—to identify service gaps, determine the commitment of communities to address youth suicide prevention, and enlist recommendations.

As revealed in Section II, priorities were endorsed by counties and local health jurisdictions across five state regions (Olympic, Northwestern, Southwestern, Central and Eastern).  In rank order, the priorities were:

• Gatekeeper training for adult caregivers of youth (e.g., for parents and people working in close, frequent contact with youth);
• A public education campaign to enhance the public's understanding of and ability to respond to suicidal youth; and
• Crisis team enhancements to increase existing capacity and services in responding to suicidal youth.

Implications were drawn from the needs assessment results and incorporated in detailed action plans for each of the three prioritized prevention components during spring and summer, 1996. Thus, the Youth Suicide Prevention Program--described in Section I--was launched in the fall of 1996 and carried through to the end of June, 1997.

Simultaneously, both process and outcome evaluation activities were designed and carried out. Prevention activities were tracked to determine how the components were being implemented and to assess the outcomes.

Overall, as the Youth Suicide Prevention Program was implemented, what characterized the work most was strong collaboration among Department of Health representatives, UW project directors, and subcontractors working on the three prevention components--public education, gatekeeper training and crisis services.

Each of the prevention components are detailed briefly here to acquaint the reader with the expectations, key findings and recommendations that constitute the individual sections of the Washington State Youth Suicide Prevention Program:  Report of 1995 - 1997 Activities.

1. Public Education Campaign

To reach those people who can most effectively intervene to pre­vent youth suicide and suicidal behaviors, the campaign was designed to address public expectations regarding: 1) awareness of the campaign, 2) knowledge of youth suicide warning signs, and 3) actual helping behaviors--taking the prevention steps of: show you care, ask the question, and call for help.

The materials produced by the campaign are a lasting legacy:

• The brochures and posters were critical support materials for grassroots organizations--such as crisis hotlines, local health departments, schools, churches and so forth.
• The Orientation Packet provided quintessential information for campaign spokespersons and community advocates for youth suicide prevention.
• The News Media Information Packet and newspaper “filler stats” provided reporters with facts and perspectives they needed to promote the prevention message and report fittingly on the topic of youth suicide.
• The paid advertising, transit and billboard signs, served to attract the public’s attention to the prevention campaign messages.
• Public service announcements on TV and radio further spread the global education information on youth suicide prevention.

Producing the materials was only the first step.  Dissemination occurred from January through June, 1997 and included statewide distribution of:

• 75,000 brochures and 22,000 posters;
• Transit signs/billboards in 19 markets; and
• News media stories totaling 167 news print stories;
  44 TV and 45 radio interviews and talk shows.

This public education information was integrated through outdoor advertising, news media relations and grassroots dissemination.

The evaluation results of the public education campaign are fully detailed in Section III.  In brief, the campaign did result in a significant increase in the public's awareness of youth suicide prevention messages.  Gains of 10 percent were registered between January and the end of May, 1997.  This represents an increase of about 550,000 people--from before versus after the campaign--who noticed information about youth suicide prevention.

Although the campaign served to increase the public’s awareness of youth suicide prevention, it did not work to change either their knowledge of suicide-risk warning signs, or their ability to take the desired prevention steps of: show you care, ask the question, call for help.

On average, over the course of the campaign, one in four residents reported having had contact with a suicidal youth in the prior month. Of these respondents, the heartening news was that:

• 70% were likely to tell the youth they cared and were concerned;
• 50% would also ask if the youth was thinking about suicide;
• but only 20% were likely to offer advice about how to get help, such as calling their local crisis clinic or hotline.

These findings suggest that further public education efforts will be needed to achieve the expectations that all Washington citizens know:  1) the warning signs of youth suicide, and 2) how to respond with desired prevention steps.

2. Gatekeeper Training

Trained gatekeepers (persons in close, day-to-day contact with youth) are critical if we are going to decrease the incidence of youth suicide and suicide-risk behaviors in Washington State.

In the statewide needs assessment regarding youth suicide prevention, gatekeeper training was assigned the highest priority.  This endorsement supported the initiation of a selective prevention approach--namely the statewide training of “front-line” adult caregivers.

Creating this network of caring adults capable of responding to youth at risk of suicide required a two-stage process. The objectives were:

• first, to establish a cadre of Gatekeeper Trainers who could demonstrate a high degree of suicide intervention knowledge and the skills to conduct Suicide Intervention Workshops, and
• second, to support the Trainers in establishing a statewide corps of gatekeepers who possessed a high degree of suicide intervention knowledge and intervention efficacy.

Objective 1 was achieved: 63 Gatekeeper Trainers now exist statewide. Initially, in the fall of 1996, 41 were trained, 36 (88%) of whom became actively involved in training gatekeepers in their local communities. In May of 1997, 22 additional trainers were trained, most of whom are currently conducting the required gatekeeper training workshops.

Following the 5-day LivingWorks training for trainers, the 63 trainers:

• demonstrated a high level of assessment knowledge and intervention theory with a  90% suicide risk assessment accuracy;
• believed they would intervene with someone at risk of suicide and that this intervention could be successful;
• revealed high levels of comfort, competence and confidence in intervening with youth at risk of suicide; and
• demonstrated high levels of gatekeeper training efficacy and were committed to delivering Suicide Intervention Workshops.

Moreover, these levels of efficacy and competence had increased when trainers were assessed after conducting at least two workshops.

Objective 2 was also largely met.  By July, 1997, the average active trainer had taught five workshops and trained an average of 105 new gatekeepers. Overall, Washington's Gatekeeper Trainers:

• conducted 104 Suicide Intervention Workshops;
• averaged 20.67 participants per workshop, and
• trained 2,150 gatekeepers (falling short of the expected 3,500).

The number of gatekeepers and active trainers within each region are:

Eastern WA                             435                                             11

Seattle Metro                          1083                                            19

Evaluation results, detailed in Section IV, showed that compared to the general public, gatekeepers were significantly more likely to recognize warning signs and respond with the prevention steps: for example,

• 72% of gatekeepers vs. 24% of the general public were able to identify 2 targeted warning signs;
• 90% of gatekeepers vs. 61% of the public would tell a youth how concerned they were about them;
• 90% of gatekeepers vs. only 30% of the public would ask if the youth was considering suicide; and
• 90% of gatekeepers vs. 50% of the public would get the youth help.

In short, gatekeepers were significantly better prepared than the general public and more willing to intervene with youth at risk of suicide.  While the differences cannot be attributed entirely to the gatekeeper training, these findings argue strongly for the 2-day Suicide Intervention Workshops.  Gatekeeper training resulted in significant gains in the desired knowledge and behaviors needed to prevent youth suicide.

3. Crisis Service Enhancements

When a gatekeeper-trained adult successfully reaches a suicidal youth, one of the first avenues of preventive intervention is a telephone call to a Crisis Services Clinic.  Thus, it is absolutely critical that each crisis clinic or hotline in Washington provides consistent service.  In the statewide needs assessment, health-care professionals throughout the state endorsed the need to enhance the existing crisis team services and hotlines, rather than establishing a statewide 1-800 crisis hotline.

At the outset of the Youth Suicide Prevention Program, five regional meetings were conducted across the state--in Ellensburg, Spokane, Chelan, Shelton and Everett--to assess crisis line workers' needs. The emerging picture revealed that 80 percent of crisis lines linked with local Mental Health Centers were small and sorely lacking in resources needed to effectively handle potential suicide calls from youth.

Other needs identified ranged from significant under-funding; low staff morale and credibility within their community; and little consistency in services offered, data collected or how calls were tracked.  Resources and training in assessing suicidal youth were given priority.

Based on these expressed needs, the overall objectives for enhancing crisis response services were to:

• facilitate communication among crisis workers statewide;
• provide training to establish statewide norms for crisis intervention with suicidal youth; and
• incorporate crisis clinics into the overall Youth Suicide Prevention Program--especially as “grassroots” participants in achieving the public education campaign objectives.

The crisis service enhancement activities offered regionally across Washington to all crisis intervention services were:

• a resource manual specially produced to provide standardized protocols and procedures for operating crisis hotlines and services;
• an individual review of the Orientation Packet--part of the public education campaign materials--to enable crisis workers to become local advocates for disseminating the prevention messages of the program; and
• two regional workshops providing training in how to:
  1. recruit and retain volunteers to increase available workers in crisis services;
  2. screen youth callers and assess their level of suicide risk using a special tool developed for this purpose; and
  3. develop and encourage implementation of community-based crisis response teams in local school settings.

The expected outcomes for this component of the Youth Suicide Prevention Program were that crisis line workers would:

1. benefit from standardized resources for delivering crisis services;
2. acquire increased competencies in crisis intervention presentations;
3. demonstrate greater crisis intervention risk assessment efficacy; and
4. indicate strong intentions to integrate this knowledge in enhancing their local community-based capacity for responding to and preventing youth suicide and suicidal behaviors.

The good news is that thanks to the Youth Suicide Prevention Program efforts, the first statewide crisis line directory was created. This resulted from the need to provide each center with labels to advertise their crisis hotline phone number on the public education brochures and posters.

Other findings, detailed in Section V, revealed that:

• 92% of counties participated in at least one offered activity;
• 97% of crisis centers noted some benefit from resources provided;
• 19% of crisis centers are using the youth screening tool provided;
• significant gains were made in the staff's comfort and competency in assessing level of suicide risk among youth; and
• significant increases occurred in the staff's comfort, competency and confidence in conducting community-based training activities.

The regional training sessions brought crisis line providers together in collaboration for the first time. A major success of the crisis services enhancement effort was the dialogue established among various regional crisis line administrators. This promoted a sense of community and provided a mechanism by which varied solutions to common problems were revealed and implemented.

One of the important outcomes of the Youth Suicide Prevention Program thus far was the development of a grassroots network of crisis workers and gate­keepers representing lay people, parents and professionals.

When looking to the future effectiveness of the prevention program, we suggest this network of lay people and helping professionals be systematically supported to continue carrying out these youth suicide prevention strategies. These grassroots efforts will add a more “personal” touch to public education, utilize education materials already developed, and capitalize on the cadre of Gatekeeper Trainers that exist statewide.

Only three of the endorsed strategies of the Youth Suicide Prevention Plan for Washington State (1995) were implemented in 1995-97. These prevention activities were a good beginning, but only the “first steps.” Without continued funding and coordinated efforts, we can expect few long-term changes in actions taken by the public to prevent youth suicide.

What is clearly needed and recommended for the Washington State Youth Suicide Prevention Program in the next biennium is specified below.

1. Expand the Public Education Campaign

2. Expand Gatekeeper Training to Include Youth

3. Further Support Community-Based Crisis Intervention Services

4. Continue Evaluation of Each Prevention Component

The current campaign focused on reaching all Washington's citizens, particularly parents and other adults, and served to increase the public’s awareness of youth suicide prevention messages.  It will be important to further disseminate the public education materials statewide (e.g., through local health departments).  The logical next step, detailed in the Youth Suicide Prevention Plan, is to expand the campaign into high schools, colleges and workplaces to reach youth aged 15-24 years.  Peers of suicidal youth are in the best position to recognize the warning signs, ask if thoughts of suicide are present, and call for help from a local crisis hotline.  Suicide awareness education for youth can utilize the existing public education campaign materials, include information on safe handling/storage of firearms, and be integrated into existing school curricula, health services and employee assistance programs.

The first steps were to train 63 Gatekeeper Trainers who, in turn, trained over 2,000 “frontline” adult caregivers. According to the Youth Suicide Prevention Plan for Washington State the next step is to train peers, the “natural helpers” of youth, and school personnel.  The existing Gatekeeper Trainers need support in training youth in high schools and colleges. To this end and because they are under-represented, we recommend adding educators to the grassroots network.  Peers of youth need the knowledge and skills to: a) recognize the risk factors of youth suicide, b) ask comfortably if their friend is contemplating suicide; and c) connect these at risk youth with an adult capable of helping.

Steps taken thus far resulted in a directory of all Washington's crisis hotlines, increased resources for standardizing crisis intervention services, and a suicide risk assessment tool designed especially for use with youth. Crisis workers statewide indicated a need for continued efficacy training and for development of school-based crisis response plans.  These efforts will continue to promote the prevention of youth suicide by having timely, effective and accessible “youth friendly” services statewide. We recommend strong efforts be made to foster better coordination among the crisis line staff, gatekeeper training activities and future public education efforts in high schools and colleges.

In the initial phase of the Washington State Youth Suicide Prevention Program, many evaluation methods were set in place. Both process and outcome evaluation instruments and activities were designed and carried out to track how the prevention activities were implemented and to assess the efficacy of each program element. Many of these same evaluation methods can be used in ensuing phases of the program. Evaluation is essential in learning which components of the prevention program are most critical to curbing and reducing the incidence of completed suicides and suicidal behaviors among Washington's youth. Continued evaluation and improvement are essential to make our efforts successful.

You Can Help!  Take Action--the Key to Successful Intervention

Is there a light at the end of the tunnel?  Can the Washington State Youth Suicide Prevention Program measurably reduce the number of young adults in Washington state who kill themselves?

Definitely! The proposed prevention strategies can work to reduce suicide risk behaviors and other related risk factors evidenced among our youth. However, we knew that implementing a statewide youth suicide prevention program would not be easy. There are no “quick-fixes.” It will take continued efforts and strategic implementation of the Youth Suicide Prevention Plan for Washington State over the next six to ten years before we can hope to see actual reductions in the rates of completed youth suicides. One clear advantage of the plan is that the next steps are systematically specified, ready for implementation.

Suicide, as a social phenomenon, thrives on ignorance.  Unfortunately, public education, in the “dose” funded during 1995-97, was not enough to solve the problem.  That is why the Washington State Youth Suicide Prevention Program is rooted in the efforts of many concerned citizens who are determined to act, before it is too late. We need thousands more trained gatekeepers--Washington citizens in every community--who can recognize the youth suicide warning signs, comfortably ask whether a youth is thinking about suicide, and call for help when this is needed.

When a citizen takes action, he or she is offering “an invitation to hope and to life.” Reaching out to a troubled young adult is not an easy prospect. It requires courage and compassion as well as the right training. With an extended grant from the Department of Health, our public education materials, gatekeeper training program and crisis intervention services will continue to bridge the gap between good intentions and successful intervention. Concerned Washington State residents will be supplied with the practical tools and resources needed to save lives.

Youth suicide requires each of us to take action. We all must be willing to fight suicide through a caring mode of intervention. Prevention can work to reduce suicidal thoughts and behaviors among our youth and young adults. Together, we can save our suicidal youth--one life at a time.