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Toward an open, constructive discussion of community-based suicide prevention

Responding to a critique of safeTALK

 communications@livingworks.net

 
The upcoming release of the revised safeTALK program, in its 10th anniversary year, speaks volumes about how well this program has been received. However, an article by Dr. Stan Kutcher and colleagues, recently published online in the Canadian Journal of Psychiatry (CJP), [1] shows that the vision for community-based approaches to suicide prevention is not universally shared and that programs like safeTALK have their critics. This article was submitted and published as a Perspective, meaning it was “not expected to provide a comprehensive coverage of existing literature." [2] A Perspective article is just that: an opinion piece that invites discussion and debate.
 
We welcome well-informed discussion and debate in the field of suicide prevention, and in relation to our programs, when it has constructive goals and is committed to open inquiry, collaborative work, and program improvement. However, when critiques of our programs emerge, we will also challenge assertions and conclusions that we believe to be inaccurate or misleading and invite people to consider whether the claims that are made are supported by evidence in the field.
 
The publication of this Perspective article provides a timely opportunity to address some of the issues that periodically arise about the role of community initiatives in creating suicide-safer communities and how to evaluate these initiatives' effectiveness. Some of these issues directly influence what some critics say about the safeTALK program. LivingWorks is submitting a detailed response to the CJP article, expecting them to be published together.
 
Here is a summary of our response to some of these issues. We encourage you to share it with anyone who may have questions about the recent review, or about the issues that periodically arise in conversation with trainers, stakeholders, funders, or participants considering attending safeTALK. We welcome any questions or comments at the email address above. At the outset, we want to be clear that safeTALK is designed to help training participants be alert to the possibility of suicide, confidently ask about thoughts of suicide, and help make connections that can be helpful in staying safe from suicide. 
 
1. Why should suicide prevention be a community-wide approach?
 
Issue: The underlying debate here is whether suicide is primarily explained by mental illness or by a complex combination of many things in a person’s life reflected in their lived experience of suicide. A related issue is whether preventing suicide should focus mainly on treating mental illness and be limited to mental health professionals, or be a responsibility shared by the whole community.
 
Response: Mental ill health does feature in suicides but the centrality of this fact in large percentages of suicides is much less supported in recent analyses than in older evidence commonly cited by critics of community-based prevention programs. [3] Suicide care and mental illness treatment are both required when mental health concerns are assessed to be present. In addition, a substantial body of research and experience in helping relationships shows that personal experiences of suicide often include themes of pain, loss, abuse, trauma, bullying, guilt, and grief among many other factors and that these may be present with or without an associated mental illness. Anyone can play a role in hearing personal stories that feature these themes and working with people to keep them safe and connect them to further help. This includes informal caregivers working alongside those with designated professional helping roles. Programs like safeTALK recognize that increasing the number of suicide-alert helpers improves the likelihood that people with thoughts of suicide are identified and connected with the help they need.
 
LivingWorks is proud to stand with the United Nations [4] [5] in advocating a community-based approach to preventing suicide. The groundwork for a broad community involvement was set in the 1970s [6] and 80s [7] when suicide was largely ignored and avoided as a community or clinical issue. Then, as now, it was recognized that many of those with suicide experience were not respected or linked with people able to strengthen safety and offer suicide care. Community caregivers and professional helpers were inadequately prepared to deal with suicide. As far back as the 70s, medical and mental health professionals often held disrespectful attitudes toward community-based helpers, and “deep down felt that these kinds of people should not be involved in the serious process of treating mental illnesses” (p. 40). [8] Taboo and stigma fears were palpable.
 
safeTALK is among many community training programs that have helped to break down taboo and stigma and prepare people for their role in helping to prevent suicide. This leads us to the next issue:
 
2. Should we talk openly and directly about suicide?
 
Issue: The concern here is whether programs that encourage open talk about suicide compromise the safety of those who attend and those they help. It is a concern that has hindered the development of school and community based suicide prevention programs for decades, although less so recently, for reasons discussed below.
 
Response: Every suicide prevention training program needs to make safety a paramount concern. The maxim “first, do no harm” is a foundational requirement, and vigilance about vulnerability is essential, which is why programs like safeTALK, using research-informed development methods, [9] pay so much attention to this issue in their materials and trainer training. safeTALK trainers are encouraged to read through their manuals to see how often and in how many ways safety is attended to as part of the face-to-face training experience—more than ever in the latest edition.
 
However, it is hard to think of any public health and safety initiative that says that the best way to deal with an issue is to avoid talking about it. There is also a growing body of evidence suggesting that respectfully asking about suicide in the context of a caring conversation does not pose significant threats to safety and has benefits that far outweigh the risks. [10] [11] [12] [13] safeTALK, with its alertness to risk and referral to safety resources, is a Suicide Prevention Resource Center (SPRC) best practice (adherence to standards) program and an Indian Health Service Resource for Providers as listed the SPRC Best Practice Registry. [14] Moreover, a recent Australian evaluation study addressing safety issues for participants found safeTALK to be acceptable to young people, with no negative safety effects. [15]
 
3. Should a single program bear the burden of reducing population suicide rates?
 
Issue: The key question here is whether the success or failure of any training or intervention program can be determined by reviewing changes in community suicide rates. The Perspective article is an example of an approach that seeks to infer a verdict on the effectiveness of community initiatives and programs like safeTALK based on rate fluctuations.
 
Response: Suicide rates are a helpful indication of how well the community as a whole is succeeding in its collective attempts to save lives. Sometimes these results are promising. Scotland, for example, came within half a percent of meeting its target of reducing suicide rates by 20% over a decade in an initiative that included ASIST and safeTALK as key training components along with many other factors. [16] Sometimes community results are disappointing and efforts by some critics are made to single out particular programs as the reason. However, as noted by the World Health Organization, “no single approach can impact alone on an issue as complex as suicide” (p. 11). [17]
 
It is also puzzling that, although the article concedes correlation does not mean causality, it nevertheless proceeds to imply some causal connection when delivering its verdict on school and community-based interventions. Furthermore, Statistics Canada data shows increases, decreases, and plateaus in suicide rates during the years in question, rather than the increases asserted in this article. [18]
 
Notwithstanding the article’s unsupported claim that safeTALK is the most widely distributed and applied community suicide prevention training program in the country, which it isn’t, the saturation levels of this or any program are far from the levels required to impact national rates in either direction.
 
4. How do we measure what works in preventing suicide?
 
Issue: The fundamental debate here is what counts as evidence of program effectiveness, given the difficulties of assessing program performance by reviewing trends in suicide rates. The Perspective article in the CJP asserts that because “few if any” community interventions have been the subject of rigorous research investigations, they lack evidence to justify their widespread application.
 
Response: Investigations into what works need to focus on people who directly participated in a particular initiative, such as suicide intervention training, and ask whether it produced measurable positive results for participants and those they then sought to help. However, researchers differ on what counts as good evidence.
 
Some argue that the randomized control trials (RCTs) frequently used in scientific experiments, such as testing particular medical treatments, are the only rigorous and reliable measure of effectiveness. However, as these studies can be very expensive and pose significant challenges in the field of suicide prevention, relying solely on this research design would mean that practically every school- and community-based suicide intervention program in the field for youth and/or adults would be abandoned.
 
Support for more RCTs is warranted and needed. But the singular “gold standard” merit of RCTs should not be assumed without considering their limitations when dealing with complex issues such as suicide. [19] [20] RCTs are one of many types of evaluation that can help advance our knowledge about suicide prevention.
 
“Evidence” of the effectiveness of a suicide prevention training program such as ASIST or safeTALK might come in many forms—such as whether participants are more likely than before the training to approach rather than avoid people who present as suicidal, and to do so more often than previously, or whether they are better able to ask about suicide, make a safe connection, and work collaboratively and competently to develop a safety plan. People with lived experience of suicide and the interventions they received from others are also a valuable source of evidence of what is needed, what works, and what helped.
 
There are many levels of evidence to be considered when deciding what works in suicide prevention training and what produces safe outcomes. The field of community-based suicide prevention interventions does need to increase its commitment to comprehensive evaluation and research. LivingWorks actively encourages such research and evaluation and would welcome evaluation and research partnerships to add to the numerous studies that have confirmed safeTALK's effectiveness in improving the knowledge, attitudes, and responses of participants.
 
5. What evaluation evidence do we have about safeTALK?
 
Issue: Evaluation and research play a vital role in program development, program improvement, and assessing how well programs achieve results that are consistent with their objectives. It is pertinent to ask what safeTALK evaluations are available and what further work is needed.
 
Response: The field of community-based suicide prevention interventions does need to strengthen the body of evaluation and research and more studies on the effectiveness of safeTALK are needed and welcome. However, they need to be based on an accurate understanding of what this program seeks to achieve in equipping participants to ask about suicide and enable help-seeking connections or referrals to those trained to clarify suicide plans and develop a plan for safety.
 
With respect to safeTALK, available evaluation studies provide a foundation on which future work can build. LivingWorks is developing a review of the rationale for safeTALK that will describe the research and development process for the program, include a summary of evaluations that are currently available, propose a more specific framework for evaluation inquiry, and identify potential areas for future evaluation and research.
 
Effectiveness evaluations of safeTALK as part of comprehensive programs are promising, such as Scotland’s evaluation of their comprehensive national strategy approach [21] and the American study, reported as promising evidence by critics in the CJP article, showing trends toward lower attempted suicide rates in counties where safeTALK and other gatekeeper training programs were implemented. [22] [23] [24] [25] There is also a recently reported Australian evaluation which concluded that the safety of youth safeTALK participants was not at risk and that “the safeTALK program was found to be effective in terms of increasing knowledge of suicide risk and warning signs, willingness to help others and the likelihood of seeking help for suicide-related thoughts and behaviors." [26]
 
Conclusion
 
As a social mission-based private enterprise and supporter of the growing call for public-private alliances in suicide prevention, [27] we are constantly working to improve our programs in support of our vision of a suicide-safer world through effective community training programs. To that end we welcome the opportunity to work with individuals and organizations to assess and evaluate our training. Greater knowledge about effectiveness and impact can only benefit the suicidology community at large, and most importantly, those with lived experience of suicide.
 
Based on the available evidence, we are left to restate what we have consistently tried to achieve using our longstanding research-informed program development method: [28] safeTALK is safe and effective at improving participants’ suicide alertness and willingness to ask about suicide. We encourage those who have adopted safeTALK to continue using it with confidence to help individuals be safer from suicide and participate in building suicide-safer communities.

 
[1] Kutcher S ONS, MD, FRCP©, FHCAHS, Wei Y Med, PhD, Behzadi P, MD. (2016). School- and Community-Based Youth Suicide Prevention Interventions: Hot Idea, Hot Air, or Sham? Canadian Journal of Psychiatry, online publication, 1-7.
http://cpa.sagepub.com/content/early/2016/07/08/0706743716659245.full.pdf?ijkey=gT1ZY4E5VINDWKf&keytype=finite
 
[2] Canadian Journal of Psychiatry Author Guidelines. http://cpa.sagepub.com/site/misc/CJPAuthorGuidelines.pdf
 
[3] Hjelmeland H, Dieserud G, Dyregrov K, Knizek BL, Rasmussen ML (2014). Suicide and Mental Disorders. Tidsskr Nor Legeforen nr. 14(134), 1369 – 70.
 
[4] United Nations (1996). Prevention of Suicide: Guidelines for the Formulation and Implementation of National Strategies. New York: U.N. Department of Policy Coordination and Sustainable Development, ST/ESA/245.
 
[5] WHO (2012). Public Health Action for the Prevention of Suicide: A Framework. Geneva: Switzerland. http://www.who.int/mental_health/publications/prevention_suicide_2012/en/
 
[6] Snyder, J.A. (1971). The use of gatekeepers in crisis management. Bulletin of Suicidology 8, 39-44.
 
[7] Boldt, M. (1985). Toward the development of a systematic approach to suicide prevention: The Alberta Model. Canada’s Mental Health 30(2), 12-15.
 
[8] Snyder, J.A. (1971). The use of gatekeepers in crisis management. Bulletin of Suicidology 8, 39-44.
 
[9] Rothman, J. (1980). Social R&D: Research and Development in the Human Services. Englewood Cliffs: Prentice-Hall.
 
[10] McAuliffe N, Perry L (2007). Making it Safer: A Health Centre’s Strategy for Suicide Prevention. Psychiatric Quarterly 18, 295-307.
 
[11] Gould MS, Marrocco FA, Kleinman M, Thomas JK, Mostkoff K, Cote J, Davies M (2005). Evaluating iatrogenic risk of youth suicide screening programs: a randomized controlled trial. JAMA, 293(13), 1635-43.
 
[12] Rudd MD, Mandrusiak M, Joiner TE, Berman AL, Van Orden KA and Hollar D (2006). The Emotional Impact of Ease of Recall of Warning Signs for Suicide: A controlled study. Suicide and Life-Threatening Behavior 36(3), 288-295.
 
[13] Deeley ST, Love AW (2010). Does asking adolescents about suicide ideation induce negative mood state? Violence 25(5), 677-88.
 
[14] Suicide Prevention Resource Center (USA) Best Practices Registry: http://www.sprc.org/resources-programs?keyword=safeTALK&type=67&populations=138&settings=All&problem=All&planning=All&strategies=All&state=All
Indian Health Services, Promising Prevention Practices, Resources for Providers: https://www.ihs.gov/suicideprevention/providers/
 
[15] Robinson J (2016). Evaluation of the safeTALK Program in the Northern Territory. AAS annual conference, Chicago, Illinois.
 
[16] Scottish Government (2010). Why is this HEAT target important? Suicide prevention training and rate reductions:
http://www.gov.scot/About/scotPerforms/partnerstories/NHSScotlandperformance/suicideprevention
 
[17] WHO (2014). Preventing Suicide: A Global Imperative. Geneva, Switzerland. http://www.who.int/mental_health/suicide-prevention/world_report_2014/en/
 
[18] Statistics Canada (2012). Suicides and suicide rate by sex and by age group. Ottawa: Government of Canada.
 
[19] Clay RA (2010). More than one way to measure: Randomized clinical trials have their place, but critics argue that researchers would get better results if they also embraced other methodologies. APA 41(8), p. 52.
 
[20] Cartwright N, Munro E (2010). The limitations of randomized controlled trials in predicting effectiveness. Journal of Evaluation in Clinical Practice 16(2), 260-266.
 
[21] Scottish Government (2010). Why is this HEAT target important? Suicide prevention training and rate reductions:
http://www.gov.scot/About/scotPerforms/partnerstories/NHSScotlandperformance/suicideprevention
 
[22] Garraza LG, Walrath C, Goldston DB, Reid H, McKeon R (2015). Effect of the Garrett Lee Smith Memorial suicide prevention program on suicide attempts among youths. JAMA Psychiatry, 72(11), 1143-1149.
 
[23] Walrath CM, Garraza LG, Reid H, Goldston DB, McKeon R (2015). Impact of the Garrett Lee Smith Youth Suicide Prevention Program on suicide mortality. American Journal of Public Health 105(5), pages 986-993.
 
[24] Condron DS, Walrath CM, McKeon R, Goldston DB, Heilbron NS (2015). Identifying and Referring Youths at Risk for Suicide Following Participation in School-Based Gatekeeper Training. Suicide and Life-Threatening Behavior, Volume 45, Issue 4, pages 461-476.
 
[25] Goldston, DB, Walrath CM, McKeon R, Puddy RW, Lubell KM, Potter LB and Rodi MA (2010). The Garrett Lee Smith Memorial Suicide Prevention Program. Suicide and Life-Threatening Behavior, Volume 40, Issue 3, June 2010, Pages: 245–256, Article first published online 31 DEC 2010, DOI: 10.1521/suli.2010.40.3.24
 
[26] Robinson J (2016). Evaluation of the safeTALK Program in the Northern Territory. AAS annual conference, Chicago, Illinois.
 
[27] National Action Alliance for Suicide Prevention: The public-private partnership advancing the U.S. national strategy for suicide prevention: http://actionallianceforsuicideprevention.org/
 
[28] Rothman, J. (1980). Social R&D: Research and Development in the Human Services. Englewood Cliffs: Prentice-Hall.
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