Saskatchewan Regional Trainers Conference

We’ve come a long way in creating suicide safer communities....

Where to now?”

2011 Annual Saskatchewan Trainers Conference

November 16-18, 2011

Return to Saskatoon

• Gift of Life

– One donation at a time

– Blood donorship

• Saving Lives

– One intervention at a time

– Suicide prevention

QuickTime and aª decompressor

are needed to see this picture.



Magnitude

• Canada– 4,000 annually – 10 a day– 40,000 every decade– 48,000 since 2000– Tip of huge iceberg

• World– 1,000,000 per year– Rates have increased

60% in past 45 years– More than all other

violence deaths– Annual equivalent to

9/11 loss





Divided Opinions

• Rare event• Not preventable• Abnormal death• Taboo talk • Avoid “S” word• Required referral

• Commonly known• Preventable• Normal cause of death• Non-contagious talk• Talk directly about suicide• First aid sufficient

Erratic Progress

• Task Force Report (1987) • Update (1994)

• Provincial strategies• CASP Blueprint (2004)

• Parliament motion (2011)

• Jurisdictional resistance• Up and down funding• Come and go action

plans• Fallen well behind other

nations

Foundational Roots

• Crisis Lines– Samaritans 1950s– LASPC 1950s– Canada 1960s

• Few champions– CMHA branches

• My Journey– Crisis line start-ups– Listening Model– SW application– Alberta strategy– Foundation workshop– UN Guidelines– U.S. Revision Task

Force

Where we’ve come from . . . .

In suicide prevention training





Seminal Understanding of Gatekeeper in Suicide Prevention, 1971

• Gatekeepers “any person to whom troubled people are turning for help” (Snyder, p. 39).

• “. . . a full understanding of the gatekeeper philosophy is that it is against formal referral as a standard operating procedure.”

• Against professional beliefs "we . . really know how to help people . . . your job (everyone else) is to get these people to us so we can save them. You better not meddle or you will really mess things up.”

Suicide prevention in the 70s

• Seminal chapter on education and training (Maris, 1973)

• Growing body of core knowledge

• Absence of standardized training & trained disseminators

• Practical training method needed for frontline practitioners

• Absence of quality-controlled diffusion

Ron MarisThe Maris report made it clear there was an adequate evidence based body of knowledge in suicide but it wasnÕt being disseminated in practical ways to helping practitioners who needed it.

Suicide prevention in the 80s

• Little progress in developing standardized training

• Practitioners report inadequate preparation in higher education

• Most in need were “gatekeeper” professionals & other community caregivers

• In positions to give “first aid” assistance &

link to other resourcesBoldt Report 1976

Can standardized training be designed for diverse groups? Can standardized training be delivered on a large scale? Can quality assurance be maintained with a diverse pool of trainers?



Can standardized training be designed for diverse groups?

Can standardized training be delivered on a large scale?

Can quality assurance be maintained with a diverse pool of trainers?

LivingWorks founders rose to the knowledge transfer challenge using state-of-the-art social R&D to develop a standardized and locally adaptable suicide intervention training program.

2-day ASIST pioneered attitude inclusiveness with knowledge and skill components.

A unique Suicide Intervention Model (SIM) was developed to integrate AKS through interactive simulation practice and to guide real interventions

• Cooperation is the essence of intervention

• Intervention skills are known and teachable

• It is possible to train large numbers of caregivers in intervention skills

LivingWorks Core Beliefs - Intervention

Caregivers Earlyintervention

Attitudes

Knowledge

Skills

Resources

Connecting

Und’standing

Assisting

Networking

support

First-aid

treat

effective behaviors

received

entered

Core knowledge 1973

Retention ASISTR 2003

1st aid, support, treatment

ASIST workshop1985 I.02004 X.0

2010 X.1.62013 XI.0

Behavioral results

Gatekeeper Training Program

Foundation Workshop (FW) Suicide Intervention Workshop (SIW)

Original Developments in Suicide Intervention Training



Designed to provide statistical evidence of the size of the problem and to help participants know what was the most and least useful empirical information in a risk factor approach to risk assessment later modified to risk estimation

Risk Estimation (HML) was based on 7 factors:

Age, Gender, Stress, Symptoms, Resources, Prior Behavior, Current Plan

Suicide First Aid application was reverse order: CPR

ASIST is reviewed and updated on

a 5-year cycle

• Based upon Rothman’s social R & D method • Four stages of intervention development and dissemination

– Collecting and assessing available knowledge

– Creating and pilot testing an initial design

– Refining program & preparing for dissemination

– Disseminating program

• R&D method allows cultural and practical adaptations to meet local needs.

• Stages are dynamic, continuous process of program improvement.

Development of ASIST

• Suicide is a community health problem

• Suicide is understandable, idiographic and interpersonal

• Suicide is dangerous, temporary, ambivalent and preventable

• Open and honest talk about suicide should be encouraged

Our Core Beliefs - Suicide

U of C researchers helping suicide prevention across the worldBy Greg Harris, Gazette staff



The Surgeon General of the United States has adopted a national policy statement on suicide prevention that has its roots at the University of Calgary.

Richard Ramsay (left), a professor in the Faculty of Social Work, says the impetus for the American suicide prevention strategy can be traced to a 1993 Banff conference he organized with Bryan Tanney, Department of Psychiatry, at the invitation of the United Nations.

At that conference, representatives from 14 countries created a policy document for the UN called Prevention of Suicide: Guidelines for the Formulation and Implementation of National Strategies. The Surgeon General’s policy statement is the latest highlight for Ramsay and LivingWorks Education Inc., a University Technologies International Inc. start-up company that provides training in suicide intervention.



New Developments inSuicide Intervention Training

SUICIDOLOGI 2004, VOLUME. 9, N0. 3



Working with ambivalence and collaborative skills to listen to reasons for dying is a new priority in suicide intervention. This parallels proponents in psychotherapy who favor a collaborative responsibility in treatment care.

Risk Estimation categories were replaced with Risk Review and SafePlan

ASIST is different from most other gatekeeper programs

• Most models are linear - 3-step process: identification, intervention, referral.

• ASIST follows Snyder’s philosophy: teaches a Suicide Intervention Model (SIM) that does not require direct referrals to professional MH services.

• ASIST recognizes that referrals may not be the best solution (or even a possible solution) for the person at risk.

• Focuses on interaction quality. . . uses a safeplan that connects with a variety of community resources, including, if indicated, MH services.

ASIST safeplan considers best safe care

• SIM includes review of suicide risks & development of a safeplan

• Safeplan provides individualized options to counter specified risks.

• Suicide safety actions include not only referral to formal mental healthcare professionals but also to friends, family members, and other sources of support

Philosophy of ASIST is that SIM may be sufficient to reduce risk without the need for a

required referral

Other Notable Features

• Longer than most GK training programs. Most 1- 5 hours.

• Greater time allows for a more skill dependent training to focus on attitudes impact and engage in simulations.

• Multiple simulations to rehearse & refine intervention skills.– trainer to trainer, trainer to audience, trainer to trainee, trainee to

trainee.

• Interactive methods, particularly simulations, more likely to change behavior than simple didactic presentations (Davis et al, 1999).

• Active learning may increase gatekeeper training effectiveness (Cross et al, 2007).

• Complementary programs to help create suicide-safer communities.

Evaluations

Independent Policy• National evaluations

– Scotland, Norway– USA, Wales– Ireland, Canada

• RCT Studies– Crisis call interventions– Transfer training– Medical students

1 Intervention at a time• Post-Deploy friends• Train platform stranger• Norwegian sailor• Mother’s letter• Gaming chat room

“. . . . Where to now?”

One intervention at a timeGrowth of complementary education & training programs

Continuity of careAssessing risk within caring conversations

Shifting niche service to core service

Continuation of commitmentSustaining suicide-safer communities

GOOD WORKS OF LIVINGWORKS

newsb u l l e t i nI n t e r n a t i o n a l A s s o c i a t i o n f o r S u i c i d e P r e v e n t i o n

MAY/JUNE 2011

LivingWorks' founders have a long history on the sideof seeing niche suicide intervention training become part of the “core business” of mental and behavioral health care providers. Collaboration with a large provider of adult services to persons with severe mental illness and incorporation of suicide prevention into their core business is a current test of whether a cultural shift of this magnitude can be modeled. LivingWorks also has a keen interest in furthering the field's differential use of gatekeeper training between those with required-referral procedures and those with referral options in their safeplanning framework and sufficient training for first aid intervention to be an end in itself.

Looking to the future, LivingWorks is engaged in higherlevel thinking about the traditional prevention, interventionand postvention framework for suicide prevention activities.A revised cycle model has led to some exciting possibilitiesin “upstream” prevention work and innovative responsesto Ed Shneidman's long held belief that “postvention isprevention”. Some of the work is well into the R&Dprocess. Some is still conceptual. The commitment ofLivingWorks to suicide-safer communities is deep and robust.

Suicide Risk Assessment Patient Safety Project (N=600 beds)

• A caring conversation– focus group research. Patients said abrupt questioning

about suicide was not helpful. SRA should be part of a caring conversation.8

• S u c c e s s – SRA project selected ASIST. Clinical outcomes improved.

Staff felt more supported to ask about suicide and have the skills to effectively intervene. Patient bed days were saved.

• Leading Practice– Accreditation Canada recognized Trillium’s SSRA project

as a national Leading Practice in 2007.10

• Lengthy Process– Took 4 years of task force and staff time. LW is proud of

this partnership. Similar leading practices are possible in other health systems.

Arizona Workforce Survey (N=1600)

• Based on % above mean:

● ASIST-trained tied clinicians (6%+) but behind nurses, physicians

● ASIST Trainers 1st overall (15%+), ahead nurses, physicians, clinicians

• Moving community mental health from Niche Expertise to Core Focus

• Making suicide prevention our primary business:

●Train the entire work-force with ASIST

● 2000 by end of 2010 (87%); 100% by March 2011.

• Change culture & equip case managers, clinicians, physicians, nurses with the skills, knowledge, attitudes and support







Suicide-Safer Community Initiative

Suicide-Safer Communities

CASP and LivingWorks recognize that it is critically important for communities to establish their own suicide prevention action plans defined by their unique character and needs.

Communities across Canada have demonstrated leadership and a commitment to tackle this critical public health issue.

Canadian communities are doing their part to prevent suicides and ensure that those who are bereaved by suicide have support that is both compassionate and informed.

It is time we recognize the commitment, innovations and accomplishments of these communities and offer our support and encouragement to communities that wish to do the same.

Contact: [email protected]

Creating suicide-safer communities

• ASIST is best when its part of a community-based comprehensive approach;

• Involves lay-persons, paraprofessionals, and professionals alike.

• Community-wide efforts lead to increased awareness, advocacy, capacity building, and beneficial policies (Greisbach et al, 2007).

A checklist to become aSuicide-Safer Community

1. Suicide-Safer Community committee name 2. Population size of your community 3. Organizations representing your committee 4. Action plan or strategy with identified priorities 5. Accessible suicide intervention services 6. Accessible suicide bereavement support 7. Promotion of mental health and wellness activities 8. Active suicide prevention activities 9. Established pool of formally trained gatekeepers 10. Participation in World Suicide Prevention Day

© Suicide-Safer Communities 2011

Documents

Saskatchewan Regional Trainers Conference