Introduction

In 1995, the Youth Suicide Prevention Plan for Washington State [1] sparked interest among lawmakers and voters, professionals and laypersons, teachers and students. Many realized for the first time that suicide was the third leading cause of death among young people aged 15-24 years. Few knew that between 1980-1995, death by suicide among youth aged 15-24 years had increased significantly by 16%, averaging 15.4/100,000 persons. [2] Most were surprised that Washington’s youth suicide rates were higher than homicide rates, ranking above the national average.

Washington's Youth Suicide Prevention Plan was created with the support of the Department of Health and the advocacy of the Washington State Youth Suicide Prevention Committee. Department of Health officials assembled many concerned citizens, health professionals, policy makers and survivors of youth suicide, like Scot and Leah Simpson, to form an advisory council. Together, and under the guidance of Dr. Leona Eggert and her colleagues Drs. Elaine Thompson, Brooke Randell, and Elizabeth McCauley, the plan was created. Unique features were its state-of-the-art prevention framework of universal, selective, and indicated approaches, a compilation of empirically supported strategies for each prevention domain, and an evaluation plan for testing the efficacy of the proposed prevention strategies.

The major goals of Washington's Youth Suicide Prevention 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 January 1995, the plan was submitted to the legislature. State lawmakers appropriated $1 million in 1995 and again in 1997, charging the Department of Health to implement and evaluate select components of Washington's master plan--that is, the Public Education, Gatekeeper Training, and Crisis Services Enhancement components. These were selected from the empirically supported and recommended universal and selective strategies.

The Youth Suicide Prevention Program was carried out in partnership with Dr. Eggert and her colleagues at the University of Washington School of Nursing. What follows is a brief summary of the prevention approaches implemented and evaluated between 1995 - 1997 and 1997 - 1999.

In Phase I of the Washington State Youth Suicide Prevention Program, [3] a statewide needs assessment was conducted through local health jurisdictions. These stakeholders endorsed three prevention approaches for implementation in the following rank order of priorities:

1. Gatekeeper training for adult caregivers of youth--e.g., for parents and people working in close, frequent contact with youth;
2. A public education campaign to enhance Washington citizens' understanding of appropriate prevention steps and their ability to use these steps in responding to suicidal youth; and
3. Crisis team enhancements to improve existing crisis services statewide for responding to suicidal youth with timely, youth-friendly approaches.

Process and outcome evaluation activities were employed to determine the quality of program implementation and outcome effects.

Phase I Outcomes:

Public Education Campaign

A campaign was designed to educate Washington citizens in how to prevent youth suicide and suicidal behaviors. Thus the goals were to enhance: (1) awareness of suicide prevention campaign messages, (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.

Campaign efforts included disseminating brochures, posters, transit and billboard signs, and news media stories printed in major and community newspapers and aired on TV and radio talk shows.

The campaign resulted in a significant increase in the public's awareness of youth suicide prevention messages. Gains of 10 percent were registered between January and May 1997--an increase of about 550,000 people who noticed information about youth suicide prevention. However, no significant changes occurred in either the public's knowledge of suicide-risk warning signs or their ability to take the desired prevention steps.

Gatekeeper Training

Creating a network of caring adults capable of responding to youth at risk of suicide required a two-stage process: (1) establishing a cadre of Gate­keeper Trainers who could skillfully conduct LivingWorks^® Suicide Intervention Workshops, [4] and (2) supporting these Trainers in training gate­keepers statewide in youth suicide prevention knowledge and intervention efficacy. Gatekeepers recruited were adults from all walks of life--primarily adults who have frequent or daily contact with youth, representing professionals, laypersons, and parents.

By June of 1997, 63 Gatekeeper Trainers had been trained. They, in turn, conducted 82 workshops, training 1,639 gatekeeper participants in suicide prevention knowledge and intervention behaviors.

Evaluation results showed that compared to the general public, gate­keepers were significantly more likely to recognize warning signs and respond with the prevention steps. 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 training these findings argue strongly for LivingWorks® two-day Suicide Intervention Workshops. Gatekeeper training resulted in significant gains in knowledge and behaviors needed to prevent youth suicide.

Crisis Services 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 was deemed as critical that crisis services and hotlines in Washington be enhanced to provide consistent care to youth.

The objectives were to: (1) provide training to establish statewide norms for crisis intervention with suicidal youth; and (2) incorporate crisis workers into the Youth Suicide Prevention Program--especially as “grassroots” participants in achieving the public education campaign objectives.

Achieving these objectives resulted in significant gains in crisis workers' competencies in assessing levels of suicide risk among youth and conducting community-based youth suicide prevention activities. Another major outcome was the creation of the first statewide crisis line directory.

Phase 2 of the Washington State Youth Suicide Prevention (YSP) Program was based on conclusions and recommendations from Phase 1. The action plan involved continued implementation of the three funded components: (1) Public Education, (2) Gatekeeper Training, and (3) Crisis Services Enhancement. Program evaluation was built into the plan to continue investigating the efficacy of these prevention efforts.

Each of the three prevention components is summarized here to acquaint the reader with the primary program activities and key findings that constitute the individual sections of the Washington State Youth Suicide Prevention Program: Final Report, 1999.

Public Education Campaign

The YSP Program implementation plan involved a three-pronged approach to public education during 1997-99:

1. Developing a YSP web site;
2. Implementing school-based youth suicide prevention education campaigns in four demonstration communities in Kitsap, South King, Spokane and Yakima counties; and
3. Continuing statewide public education activities in collaboration with the Washington State PTSA.

The overall objectives of the public education campaign component were to increase: (1) awareness of suicide prevention campaign messages, (2) knowledge of youth suicide-warning signs, and (3) actual helping behaviors with suicidal youth--taking the desired prevention steps of show you care, ask the question, “are you thinking of suicide,” and call for help.

The Web Site

The YSP web site was designed to provide valuable information to citizens across Washington. This resulted in placing key information on the web that was created during the 1995-97 campaign as follows:

• Educational approaches to preventing youth suicide/suicidal behaviors.
• Warning signs of youth suicide and how to get help.
• A Suicide Intervention Workshop calendar of gatekeeper training.
• Youth-generated media products developed by the suicide prevention teams during the first year of the 1997-99 school-based campaigns.

Between April 1998 and June 1999, a tally of visits to the web site totaled 184,949. Increased activity at the height of the school-based suicide prevention campaigns suggests that the web site was successful in capturing public awareness of youth suicide prevention efforts and in disseminating important information to all citizens of Washington state.

The web site address is: teen-media.net/ysp

School-Based Suicide Prevention Campaigns

School-based suicide education campaigns were instituted during the 1997-99 program efforts based on research showing that youth often talk to each other about their suicidal intentions before they ever consider approaching an adult. School-based suicide prevention programs can be an effective way to:

• Correct misconceptions about youth suicide and suicidal behaviors,
• Teach youth communication skills that instill hope without conveying insincere reassurances and include seeking professional help.¹

The development and implementation of the school-based suicide prevention campaigns was a two-stage process in four demonstration sites (i.e., Kitsap, South King, Spokane, and Yakima counties):

1. During 1997-98, educators and youth were recruited to participate. Once selected, they (a) attended a Suicide Intervention Workshop and a media production workshop, (b) attended a community celebration to showcase the youth-generated campaign media products, and (c) committed to implementing a suicide prevention campaign in the next school year.
2. During 1998-99, students chose a campaign theme and graphics from artwork created by students in Stage 1¾artwork that had received high ratings and met suicide prevention guidelines and criteria. Following production of these campaign items, students implemented the youth suicide prevention campaigns in their schools.

In evaluating the efficacy of the school-based youth suicide prevention campaigns, we asked, Did the school-based YSP campaigns: (1) raise awareness of youth suicide prevention messages among high-school youth? (2) educate students to recognize youth suicide warning signs? (3) increase students’ willingness to help a youth at suicide-risk? and (4) increase the desired preventive interventions with at-risk youth?

Findings

In brief, evaluation results (detailed fully in Section II) showed that:

1. In a comparative analysis of youth in the four demonstration and five comparison counties in eastern and western Washington:
   • 90% of youth in the demonstration sites versus only 40% in comparison sites reported being aware of suicide prevention information.
   • Only youth in the demonstration sites evidenced increased knowledge of suicide-warning signs¾in breadth and quantity¾and a 6% increase in the numbers of students advising a suicidal youth about where to get help¾one of the key prevention steps.
   • No changes occurred in the show you care, ask the question prevention steps in either the demonstration or comparisons sites.
2. Further, the school-based campaigns had an impact beyond the schools into the community. Many adults in the demonstration communities endorsed having learned about the campaign from a high school student.
   
   This comparative analysis between demonstration versus comparison communities revealed that:
   • There was a 10% increase in community members' awareness of suicide prevention efforts in the demonstration sites. In contrast, no increased awareness occurred in the comparison sites.
   • There was a 12% increase in the likelihood of community members in demonstration sites to advise youth about where to get help, compared to only a 5% increase in the comparison communities.
   • There was no impact on knowledge of suicide warning signs, willing­ness to help a distressed youth and two of the three actual helping behaviors--show you care, and ask the question.
3. A third comparative analysis involved 3 groups of youth in only the demonstration communities: (1) youth gatekeepers (attended Suicide Intervention Workshop and media production workshop), vs. (2) youth campaign workers (participated in campaign implementation), vs. (3) youth campaign recipients (randomly sampled in the demonstration high schools).
   
   These results were definitive in revealing the effect of these varying levels of exposure to the prevention efforts as follows:
   • 100% of the youth-trained gatekeepers and campaign workers and 93% of the youth campaign recipients reported noticing youth suicide prevention information at the close of the campaigns.
   • 84% of youth-trained gatekeepers and 88% of campaign workers knew at least two of the targeted suicide-warning signs. This compares to a significantly lower percentage (69%) of campaign recipients who knew at least two suicide warning signs.
   • Compared to campaign recipients, youth gatekeepers and youth campaign workers were significantly more likely to endorse the desired prevention steps. For example when youth respondents had actual contact with a suicidal youth,
     • 63% of youth-trained gatekeepers vs. 30% of campaign recipients reported asking the question, are you thinking of suicide?
     • 83% of youth-trained gatekeepers vs. 51% of campaign recipients reported showing concern; and
     • 100% of youth-trained gatekeepers vs. 49% of campaign recipients reported getting help

In short, students who received the LivingWorks® gatekeeper training,⁴ attended the media production workshops, and worked on the campaign implementation were significantly better prepared to intervene with youth at suicide-risk than were students who were simply campaign recipients. Nonetheless, gains among the youth campaign recipients in the four demonstration sites were also significant

Ongoing Public Education

A collaborative effort with the Washington State PTSA and YSP program staff was used to extend the public education efforts of 1995-97. The goal was to reach a target population noted in the Youth Suicide Prevention Plan for Washington State, namely “families, especially parents.”

Evaluation results of this statewide public education effort are fully detailed in Section II. In brief, the news was encouraging--over 18 months significant gains were made in awareness of the campaign and knowledge of suicide-warning signs. Specifically:

• There was a modest significant increase of 8% in the numbers of citizens who became aware of youth suicide prevention messages.
• A significant increase of 10% occurred in citizens able to identify two or more suicide-warning signs. As shown in prior surveys, most residents could identify at least one warning sign—i.e., depression.
• Those able to identify three or more warning signs increased by 6%.

Washington residents became more willing to help a distressed youth. Overall, residents endorsed that:

• They thought it was very appropriate to ask the question, “are you thinking about suicide?”and
• They were highly likely to ask this question despite feeling somewhat uncomfortable in doing so.

These findings suggest that ongoing public education commitments showed steady gains in the desired outcomes. Increasing numbers of Washington citizens: (1) know the warning signs of youth suicide, and (2) respond with the desired prevention steps of show you care, ask the question “are you thinking of suicide?” and get help.

Gatekeeper Training and Crisis Services

During 1997-99 of the Youth Suicide Prevention Program, two aspects of gatekeeper training were (1) training youth as gatekeepers in the demonstration sites, and (2) establishing a statewide network of Gatekeeper Trainers.

Expanding the gatekeeper training program to include high-school and college youth was a logical next step in Washington's Youth Suicide Prevention Program given that youth tend to talk about their problems with peers, rather than adults. This includes talk about thoughts of suicide.

Evaluation results of the gatekeeper training program component are fully detailed in Section III of this report. Findings are briefly summarized here.

Findings Related to Youth Gatekeeper Training

Three questions were addressed to test the effects of youth gatekeeper training.

1. Did the gatekeeper training for youth produce the desired results related to intervention efficacy and behavioral intentions? An analysis of changes over time revealed that:
   • Youth gatekeepers had significant increases in intervention efficacy, taking the desired prevention steps with a person at suicide-risk.
   • Youth gatekeepers also showed significant gains in their behavioral intentions, being more committed to intervene given the opportunity.
2. How did the gatekeeper training results compare for youth vs. adults? The results were encouraging. A comparative analysis among youth and adult gatekeepers revealed no significant differences. That is,
   • Youth gatekeepers were as likely as adult gatekeepers to believe they would act to prevent youth suicide.
   • Youth gatekeepers' levels of comfort, competence, and confidence in helping were comparable to those of the trained adult gatekeepers.
   • Youths’ knowledge of suicide assessment and intervention theory was at the same high levels as that of the trained adult gatekeepers.
3. How did the effects of gatekeeper training vs. the school-based suicide prevention campaigns influence youth and adults? A comparative analysis of four groups was undertaken between youth gatekeepers, adult gatekeepers, youth campaign recipients, and adult campaign recipients.
   
   As expected, the effects of gatekeeper training were stronger than were those of the public education campaigns.
   • First, more adult and youth gatekeepers (69% & 40% respectively) were significantly more likely to have contact with suicidal youth than were adult and youth campaign recipients (24% & 34% respectively).
   • Both youth and adult gatekeepers were more likely to know suicide-warning signs than were adult and youth campaign recipients. Differences in knowledge of two or more suicide warning signs were large enough to suggest that gatekeeper training was more effective than the public education campaigns in learning suicide-warning signs.
   • Youth and adult gatekeepers were significantly more likely than were campaign recipients to intervene with a suicidal youth. Also, youth gatekeepers’ scores were higher than those of adult and youth campaign recipients, lending support for Suicide Intervention Workshops4 for increasing suicide preventive interventions among high school students.

Gatekeeper Trainer Network

It was expected that formalizing a Gatekeeper Trainer Network would result in a self-sustaining group who would continue to provide Suicide Intervention Workshops (SIWs) statewide.

Several key objectives were met regarding the numbers of Washington gatekeepers who were trained and the Trainer Network:

• First, during 1997-99, 37 SIWs were conducted statewide and 1,178 gatekeepers were trained, bringing the total of SIWs for 1995-99 to 149 and the total number of gatekeepers trained in Washington to 2,817.
• Next, 41 active Trainers were surveyed to identify factors that helped or hindered in conducting SIWs. Actual experiences gained in conducting workshops were most helpful, followed by the quality and content of SIW materials, and support from employers and other Trainers. The entrepreneurial aspects of implementing SIWs were most problematic.
• Two strategies served to support the Trainers: (1) the ysp-link, a listserv to which all Trainers were subscribed, and (2) five network support meetings. Both offered the Trainers with opportunities for advanced training as well as professional affiliation and consultation.

Crisis Services

Two objectives were met with varying degrees of success during 1997-99 relative to crisis services enhancement statewide.

1. To enlist crisis workers in the school-based campaigns, fostering their involvement in developing school-based crisis response plans.
2. To explore barriers to delivering crisis services to at-risk youth and recommend ways of improving these services for youth at suicide-risk.

The following summarizes the processes and outcomes achieved:

• First, to foster continued crisis services enhancement statewide, the YSP crisis hotline directory was updated and redistributed to 35 crisis centers.
• Next, the 15 high schools in the demonstration sites were assessed with regard to their crisis response plans. About 30% had written crisis response plans but none contained content-specific actions pertinent to suicidal behaviors. Thus, school principals were given resource materials and offered consultation with their local crisis services agency. Fostering the involvement of crisis service workers in this process was difficult and generally unsuccessful.
• Administrators of the Regional Support Networks in the demonstration sites were interviewed to understand current barriers to crisis response services for youth at suicide risk.  Recommendations are made for next steps in the YSP program below.

The conclusions of the 1997-1999 prevention efforts and recommendations for the next biennium are fully detailed in Section IV of this report. Briefly summarized here, our conclusions and recommendations are as follows.

Whereas findings from universal approaches implemented, suggest...

• The statewide public education campaign realized significant gains in the public’s awareness of the youth suicide prevention efforts, knowledge of two of more suicide warning signs, and the desired prevention behaviors of show you care and ask the question, and
• The high school-based campaigns resulted in more definitive gains— i.e., students trained as gatekeepers and/or implementing the campaign were significantly better prepared to intervene with youth at suicide-risk than were students who were simply campaign recipients; and
• The school-based campaigns had an impact into the community with adults learning about suicide prevention from high school students; and
• The research literature shows that to make a real impact—e.g., achieving the goal of actual reductions in youth suicide rates—can take up to 10 years for public service campaign messages to progress through the state and produce measurable change. [5] , [6]

  We therefore recommend...

  Continued universal prevention approaches as specified in the Youth Suicide Prevention Plan for Washington1 for promoting the desired prevention steps. Specifically we recommend (1) continued public dissemination of information via the existing campaign printed materials,  public service announcements, and the YSP web site, and (2) replication and extension of the high school-based suicide prevention campaigns statewide.

  Whereas findings from selective approaches implemented suggest...

  • Youth who were trained as gatekeepers evidenced significant increases in intervention efficacy comparable to that of trained adult gatekeepers; and
  • Gatekeeper training of youth and adults realized significantly stronger effects in the desired suicide prevention outcomes than did the public education campaigns; and
  • The established Gatekeeper Trainer network resulted in continued implementation of Suicide Intervention Workshops with a total of 2,817 citizens trained in Washington.

  We therefore recommend...

  Continued selective youth suicide prevention approaches as specified in the Youth Suicide Prevention Plan for Washington State¹. Specifically we recommend (1) sustaining the support network of active Gatekeeper Trainers in their efforts to train adult gatekeepers in suicide preventive interventions, and (2) enhancing connections between the Trainers and schools in their local communities in order to promote gatekeeper training of high school and college students.

  Whereas findings from the crisis enhancements implemented suggest...

  • The enhancement of existing crisis centers and hotlines to provide timely, accessible, “youth friendly” crisis services for suicide-risk youth was problematic and largely under the scope of the Regional Support Networks in Washington, and
  • The vast majority (70%) of high schools participating in the school-based youth suicide prevention campaigns did not have working crisis response plans or teams capable of responding to suicidal youth.

  We therefore recommend...

  The focus of crisis services enhancement be shifted to establishing crisis response teams and plans in high schools and colleges as a standard part of any school-based or college-based youth suicide prevention campaign. This should enhance the ability of school communities to respond to youth at suicide-risk with the desired accessible, timely and youth-friendly services.

  Whereas, indicated prevention approaches, such as...

  • Social support and skills training groups conducted in high schools and colleges to target individual youth at highest risk for suicide has as yet not been implemented according the Youth Suicide Prevention Plan for Washington1; and
  • Support training programs to strengthen family support for individual high-risk youth has also not been implemented to date; and
  • Indicated prevention programs are more costly per individual than are the universal and selective prevention approaches funded to date and require extensive training and supervision to implement; and
  • Whereas, it seems prudent to sustain the prevention efforts already in place with the expected funds.

  We therefore recommend...

  The implementation of the indicated prevention approaches specified in the Youth Suicide Prevention Plan for Washington State¹ be postponed until sufficient funds are available and/or until such time that the universal and selective prevention approaches already in place become self-sustaining.

  Whereas program evaluation of the YSP efforts...

  • Provided critical feedback about whether or not the prevention program components were implemented as designed; and
  • Measured trends in Washington adults' and youths' knowledge and skills in youth suicide preventive interventions which demonstrated the efficacy of the statewide public education and school-based prevention campaigns; and
  • Tracked the numbers of citizens trained as gatekeepers in Suicide Intervention Workshops and the efficacy of this training; and
  • Determined barriers to providing crisis response services to youth at suicide-risk and allowed exploration of school-based alternatives.

  We therefore recommend...

  Continued program evaluation and surveillance approaches as specified in the Youth Suicide Prevention Plan for Washington State.1 Specifically we recommend evaluating each program component funded to assess the efficacy of prevention approaches implemented for achieving the specified outcomes in the master plan.

A Final Word

The ultimate goal of the Washington State Youth Suicide Prevention Program is to make a difference in the lives of Washington’s youth and families, to provide appropriate and timely help, and to prevent youth suicide and suicidal behaviors.

Our commitment to youth at suicide-risk must be “an invitation to hope, an invitation to life.”While this will take the concerted effort of us all, we have demonstrated that gains can be made. Through continued public education and gatekeeper training, more and more citizens can help distressed youth by learning the warning signs, by listening and telling the youth you care, by asking if he or she is thinking about suicide, and by getting help.

Learning the prevention steps means that together we can make a difference!