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    Suicide prevention and life promotion

    Suicide prevention is a broad term for any activity that prevents suicide, from stopping someone from dying by suicide in the moment to promoting life throughout a community, with the goal of ultimately reducing suicide risk in the long-term. It is used to both define the over-arching continuum of prevention-intervention-postvention, and the upstream efforts communities can take to promote wellness, resilience, and hope.

    4,000

    people die by suicide every year in Canada.

    3x

    Males die by suicide three times more often than females.

    4x

    Females attempt suicide four times more often than males.

    What are suicide prevention and life promotion?

    Suicide prevention and life promotion are used interchangeably: everything that promotes life prevents suicide. There is a place for both terms. Using specific language, suicide prevention helps destigmatize suicide. Using strengths-based or positive language, life promotion helps focus our larger goal: promoting meaningful life.

    Current approaches to suicide prevention and life promotion focus on a person’s strengths instead of their deficits. They also acknowledge the whole person, including trauma and its impact.

    Stigma

    Stigma remains the biggest barrier in suicide prevention. Suicide has been taboo in our society for so long that this taboo is ingrained in our language, our thoughts, and our subconscious behaviours. For example, “commit suicide” is still common in everyday language but refers to the formerly criminal act. Suicide was decriminalized in 1972, yet this terminology persists.

    What perpetuates stigma? Misunderstanding and fear are at its root, therefore learning more about suicide and its prevention helps break down stigma. People who have been impacted by suicide play a significant role in breaking down the stigma too, by talking about their experiences, both what it’s like to experience thoughts of suicide, and what it’s like to lose someone to suicide.

    Is suicide preventable?

    Suicide is complex because people are complex – there is never any one reason a person will think about suicide, and each person who considers suicide does so for reasons unique to them. We do know that people who think about and attempt suicide don’t want to die: they want a way out of their intense, psychological pain or their deep sense of burdensomeness. They describe feelings of being overwhelmed, being stuck, of not being able to see a way out. They’re experiencing conflict (or ambivalence): they want to live but they want the unbearable pain to end. Suicide is not inevitable.

    See more about how to work with ambivalence in Intervention.

    Warning signs and acute warning signs

    People who think about suicide typically exhibit warning signs.

    Any significant change in behaviour can be a warning sign for suicide. We can be more alert to warning signs when we are sensitive to those around us, and when we appreciate that anyone can have thoughts of suicide. Active listening can help us tune in to comments they make that may indicate they’re struggling.

    Some warning signs include:

    • Statements that indicate hopelessness or being a burden
    • Threatening suicide or talking about wanting to die*
    • Looking for ways to die*
    • Suicide attempt
    • Increased substance use
    • No sense of purpose in life or evident reason for living
    • Withdrawal from friends and family
    • Rage, anger, irritability
    • Recklessness
    • Dramatic mood changes

    *These warning signs indicate immediate suicide risk. Stay with the person who is exhibiting these signs and connect them to help. In Canada, call the crisis line at t 1-833-456-4566.

    (American Association of Suicidology, n.d.)

    Risk and protective factors

    Even before a person displays warning signs, we can learn something about their suicide risk by considering different factors in their lives. We all have characteristics or traits that may contribute to or diminish our risk of suicide: risk factors and protective factors.

    Risk factors

    People who have the following characteristics, behaviours, or circumstances may be at a higher risk of suicide:

    • Previous suicide attempt
    • Suicide loss (someone close to them has died by suicide)
    • Mental illness (especially if untreated, including depression and postpartum depression)
    • Unresolved traumatic experiences (including childhood trauma, intergenerational trauma, and racism-related trauma)
    • Access to lethal means
    • Reluctance to seek help
    • Belief that showing emotions means showing weakness
    • Risk-taking
    • Aggression and impulsivity
    • Social isolation
    • Alcohol or drug use that disrupts everyday functioning

    (Pearlstein et al., 2009; Houle, Mishara & Chagnon, 2008; Ogrodniczuk & Oliffe, 2011; American Psychological Association, 2005)

    Protective factors

    Certain factors or circumstances can guard a person against thinking about suicide and increase their resiliency. These are some protective factors that can build resiliency:

    • Close, positive, and supportive relationships with family, friends, and others
    • Tendency to look for support when needed
    • Comfortable showing and expressing emotion
    • Easy access to mental health care; the ‘right care’ at the ‘right time’ (It’s important that this care is stigma-free, culturally appropriate and trauma-informed)

    Individuals and groups

    Up until now, we have focused on an individual’s experience. Suicide prevention happens at the individual level, AND it happens at the group or community level, too. Anyone can consider suicide, however, some groups of people by nature of the group, experience suicide more. This is not to say that individuals in the group are necessarily affected, but as a group, they carry increased risk. It is important to understand the characteristics of these groups so that prevention efforts can be tailored in meaningful ways. We refer to these groups as priority populations.

    Intersectionality and priority populations

    In suicide prevention, priority populations include, but are not limited to, 2SLGBTQ+ youth, men and boys, Indigenous communities, newcomers, racialized populations, and older adults. Individuals within these groups may not ever consider suicide, but data show that the group as a whole is more affected by suicide than other groups.

    Sometimes people belong to more than one of these groups. Intersectionality refers to (inter)connecting ‘social’ categories or when people identify and feel the effects of different groups. For example, men die by suicide most often. This group also includes Indigenous men, who may experience intergenerational trauma and discrimination based on their race (both risk factors for suicide). Therefore, an Indigenous man may feel the effects of the defining characteristics of both groups, that is, intergenerational trauma from colonialism and the expectations of being strong and stoic. This complexity needs to be considered in any suicide prevention efforts designed to support people experiencing intersectionality.

    Best practices

    Suicide is complex, therefore there are few best practices in suicide prevention.

    Some best practices operate at the individual level and some at the group or community level. This guide focuses on community-level approaches. As with many social issues, change in suicide prevention is best effected when the best practices are implemented in a coordinated response: a multi-pronged approach. The 5 prongs are:

    • Specialized supports: providing appropriate mental health care in a timely way
    • Training and networks: building a web of skilled helpers in the community
    • Public awareness campaigns: reducing stigma through mass communication
    • Means safety: reducing access to lethal means of suicide
    • Research and evaluation: understanding what is happening and what is working

    (Mental Health Commission of Canada, n.d.)

    Specialized supports

    Specialized supports are activities that directly assist a person considering suicide. They can be provided by a variety of caregivers including professionals, skilled volunteers, and trained peers and in a variety of settings such as emergency departments, inpatient and outpatient care, and community agencies. Support groups, and self-help practices also play roles. Coordinated systems and access to services is key. Here are some examples of specialized supports:

    Suicide crisis lines provide free, 24/7 access to speak with a trained responder. Responders provide a listening ear in a moment of crisis. This alone can be life-saving: a person in suicidal crisis cannot stay in that heightened state forever. Offering them the space to talk about what they’re experiencing is often enough to keep them safe in the moment. Responders can also begin the safety planning process with them and encourage them to seek further help (Centre for Suicide Prevention, 2018). Further, responders assess immediate suicide risk and send emergency services when needed.

    Canada Suicide Prevention Service 1-833-456-4566crisisservicescanada.ca
    Hope for Wellness 1-855-242-3310 hopeforwellness.ca
    Kids Help Phone 1-800-668-6868 kidshelpphone.ca

    In many communities, hospitals play a pivotal role in medical care. Emergency departments (ED) offer brief, rapid interventions in times of crisis. Presenting at the ED does not necessarily lead to being admitted to in-patient care, and in-patient care is not always the appropriate setting for someone considering suicide. Therefore, it is important for hospitals to be connected to community care to provide smooth transitions for people in crisis (Centre for Suicide Prevention, 2017).

    Psychological treatment (or psychotherapy) is the treatment of mental unwellness including suicidality. This treatment does not involve medication, though the two can be paired together. When psychological treatment is trauma-informed and culturally appropriate, it can help people learn healthy and effective ways of coping with challenges.

    Health care professionals are more aware than ever of the effects of trauma. This has led to the creation of Trauma-Informed Care (TIC) — an approach that specifically takes into account the impact previous traumatic experiences have had on an individual. TIC represents a significant paradigm shift from what has been called a “deficit perspective” to one that is strengths-based (British Columbia Ministry of Health, 2013).

    Cultural safety and competence are key components in providing services to Indigenous people, newcomers, and racialized populations. Without them there are greater chances of inaccurate or inappropriate assessments, inadequate treatment, and risk of re-traumatization in the treatment of trauma (Twigg & Hengen, 2009).
    For example, to effectively treat traumatized people who are Indigenous, caregivers:

    – need to be trained to deliver a trauma-informed approach in an Indigenous context
    – must be aware of the interplay of traumatic historical events and social conditions that impact both the community and the individual

    (Haskell & Randell, 2009; Linklater, 2014)

    People who have attempted suicide may find positive support among others who have had the same experience. Many people who have attempted suicide experience ambivalence – the dual experience of wanting to live and wanting to die – an experience that may be addressed among peers in a support group.

    Respite centres are an under-utilized but promising alternative to hospital settings for those who attempt suicide. Some people who have attempted suicide have had negative experiences in hospitals – respite centres can be a welcoming environment where the mental health of the patient or “guest” is the primary focus (Croft et al., 2016).

    Training and networks

    Varying levels of suicide prevention training are relevant for people playing different roles in a community. It is not exclusively for professional caregivers. Training helps break down stigma. It gives people language and license to talk about suicide. It can create a caring safety net among caregivers.

    Typically, social workers, first responders, healthcare workers, teachers, and other ‘caring professions’ receive some level of suicide prevention training. However, anyone can learn how to identify and support someone considering suicide.

    Skills training is effective suicide prevention because it equips community members to recognize, reach out, and help someone who is thinking about suicide. There are many different levels of training available, from one-hour online learning modules that teach people how to recognize warning signs and have a conversation, to two-day workshops that train people to step in and intervene with a person who is actively thinking about suicide, and possibly even attempting suicide.

    Training should always be brought in as part of a larger suicide prevention strategy including other best practices – when training is the only best practice implemented, its effectiveness is limited.

    People considering suicide display warning signs, or, put out invitations, for help. Typically, these signs are communicated to people they trust – ordinary people in their lives. People are more likely to go to friends and colleagues when they’re struggling than to a professional. If we see a friend struggling, do we know what to do? Gatekeeper training provides people with the skills and knowledge to recognize someone considering suicide, and connect them to help. A gatekeeper can be anyone with the will and capacity to help.

    Community gatekeepers are people like first responders, social workers, healthcare workers, and teachers, who see lots of people, especially those who may be considering suicide, on a regular basis.
    Gatekeeper training has been shown, in studies, to be an effective form of suicide prevention (Shannonhouse et al., 2017; Coleman & Del Quest, 2015; Gould et al., 2003).

    A large majority of people who die by suicide see a doctor within a year of their death, and over half of those within the month before (Gould et al., 2003). Training for primary care physicians is key. This type of training focuses on identifying suicidality in a patient, regardless of the health concern which prompted the appointment. It also involves breaking down stigma in health care settings, and instilling confidence in physicians to have conversations with their patients about suicide. Finally, it equips physicians to direct the patient to follow-up support and care (Centre for Suicide Prevention, 2017; Centre for Suicide Prevention, 2016).

    Suicide screening is used in clinical settings to identify people who may be considering suicide. Screening methods include questionnaires about thoughts of suicide, suicidal behaviours, and risk factors. Based on the screening results, participants are connected to further supports.

    Public awareness campaigns

    Normalizing dialogue about suicide is key to stigma reduction. Public awareness campaigns promote suicide awareness to the general public by driving the larger conversation. Messaging can use many platforms including social media, brochures, posters, and mainstream media outlets.

    Research suggests that public awareness campaigns can improve knowledge, awareness, and attitudes around suicide in the general population, however, results are mixed on whether or not they are effective in promoting help-seeking behaviours. We do know that campaigns show greater outcomes when they are targeted with a specific message. As with each of these best practices, campaigns are most effective when used together with the other strategies.

    Public awareness campaigns must follow safe messaging guidelines, otherwise, they may be unsafe for the public. For example, if they frame suicide as a normal and common reaction, they normalize suicide and may influence some people to believe that suicide is an option.

    The media plays a significant role in suicide: by reporting on suicide in a thoughtful manner that considers the complexities involved, as well as by promoting the fact that recovery from suicide is possible, the media can prevent suicide. Positive stories of recovery can be especially powerful. However, when suicide is sensationalized or glamourized in the media, or when it is made to seem simplistic (caused by only one factor, for example), media reportage may actually influence someone’s decision to take their own life, if they’re already struggling. This is known as contagion. Responsible media reporting can go a long way in educating the public about suicide, break down stigma, and demonstrate that people with thoughts of suicide can recover and go on to live meaningful lives (Niederkrotenthaler & Till, 2019).

    Means safety

    Means safety refers to the identification of methods that are used to die by suicide and making those methods more difficult to access. At the community level, this is the most effective suicide prevention approach. However, because it typically requires government involvement, change can be an involved process. Why does it work? As people’s thoughts of suicide intensify, their perspective narrows until it tunnels. If their method of suicide is blocked, they are unable at that point to change and come up with a new plan. Instead, they do not attempt suicide at this time. Means safety creates a pause for someone thinking about suicide to reconsider their plan, and gives further opportunity to seek help.

    Some examples of means safety include:

    • Gun control
    • Medication blister packaging
    • Pesticide controls
    • Bridge barriers (and barriers on other heights)
    • Safely storing methods of suicide in the home (like firearms, medications, ropes)

    Studies have shown that means safety is an effective form of suicide prevention, especially when it comes to firearm control, restriction on pesticides, detoxification of domestic gas, and restrictions on certain prescription medications (Gould et al., 2003).

    Research and evaluation

    How do we know what’s working? How do we know what effect our efforts are having? Continuous research and evaluation give us a window into what impact our work is realizing and where the gaps continue to be. Research in suicide prevention is broad. It studies everything from priority populations, to the impact of risk factors, to trauma, to means restriction, and more recently to examining protective factors and mental well being. Ideally, research guides our practice.

    Data collection is a key element of research, too. In Canada, suicide death data is initially compiled provincially/territorially by the coroner or medical examiner, and then the data is submitted to Statistics Canada. We know that suicide death data is underreported, however, collecting it and surveilling it is a vital input into understanding the suicide landscape.

    Evaluation involves monitoring and assessing the effectiveness of suicide prevention activities directly, as well as the way they are implemented.

    Evaluation helps determine if the desired outcomes are being realized and where change to programming is needed. A robust evaluation identifies what is working (strengths), what is not (gaps), and what needs to be modified.

    References

    American Association of Suicidology. (n.d.). Warning signs. https://suicidology.org/resources/warning-signs/

    American Psychological Association. (2005). Men: A different depression. http://www.apa.org/research/action/men.aspx

    British Columbia Ministry of Health. (2013). Trauma-Informed Practice Guide. Retrieved from http://bccewh.bc.ca/wp-content/uploads/2012/05/2013_TIP-Guide.pdf

    Canetto, S. & Sakinofsky, I. (2010). The gender paradox in suicide. Suicide and Life-Threatening Behavior, 28(1), 1-23. https://onlinelibrary.wiley.com/doi/full/10.1111/j.1943-278X.1998.tb00622.x

    Centre for Suicide Prevention. (2018). A caring conversation: What suicide prevention can look like. https://www.suicideinfo.ca/resource/caring-conversation-suicide-prevention/

    Centre for Suicide Prevention. (2017). Aiming for perfection: The zero suicide movement. https://www.suicideinfo.ca/resource/ie23-aiming-perfection-zero-suicide-movement/

    Centre for Suicide Prevention. (2016). What does successful recovery look like?  https://www.suicideinfo.ca/resource/recovery-suicide/

    Coleman, D. and Del Quest, A. (2015). Science from Evaluation: Testing Hypotheses about Differential Effects of Three Youth-Focused Suicide Prevention Trainings. Social Work in Public Health, 30(2), 117-128.

    Croft, B., Ostrow, L., Italia, L., Camp-Bernard, A. & Jacobs, Y. (2016). Peer interviewers in mental health services research. The Joural of Mental Health Training, Research and Practice, 11(4), 234-243.

    Gould, M. S., Greenberg, T. E. D., Velting, D. M., & Shaffer, D. (2003). Youth suicide risk and preventive interventions: a review of the past 10 years. Journal of the American Academy of Child & Adolescent Psychiatry42(4), 386-405
    Haskell, L. & Randall, M. (2009). Disrupted attachments: A social context complex trauma framework and the lives of Aboriginal peoples in Canada. Journal of Aboriginal Health, 5(3), 48-99.

    Houle, J., Mishara, B., & Chagnon, F. (2008). An empirical test of a mediation model of the impact of the traditional male gender role on suicidal behavior in men. Journal of Affective Disorders, 107(1-3), 37-43.

    Linklater, R. (2014). Decolonising trauma work: Indigenous practitioners share stories and strategies. Toronto, ON.: Fernwood Books Ltd.

    Mental Health Commission of Canada. (n.d.). Roots of Hope: A community suicide prevention project. https://www.mentalhealthcommission.ca/English/roots-hope

    Niederkrotenthaler, T. & Till, B. (2019). Suicide and the media: From Werther to Papageno effects – A selective literature review. Suicidologi. DOI: https://doi.org/10.5617/suicidologi.7398

    Ogrodniczuk, J.S., & Oliffe, J. L. (2011). Men and depression. Canadian Family Physician, 57(2),153-155.

    Pearlstein, T., Howard, M., Salisbury, A. & Zlonsky, C. (2009). Postpartum depression. American Journal of Obstetrics & Gynecology, 200(4), 357-364.

    Ritchie, H., Roser, M., Ortiz-Ospina, E. (2015). Suicide. Published online at OurWorldInData.org. Retrieved from: ‘https://ourworldindata.org/suicide’

    Shannonhouse, L., Yung-Wei, D., Shaw, K., Wanna, R. & Porter, M. (2017). Suicide intervention training for college staff: Program evaluation and intervention skill measurement. Journal of American College Health.

    Statistics Canada. (2019) Table 13-10-0392-01 Deaths and age-specific mortality rates, by selected grouped causes [CANSIM Database]. Retrieved 31 October 2019 from https://www150.statcan.gc.ca/t1/tbl1/en/tv.action?pid=1310039201

    Twigg, R. & Hengen, T. (2009). Going back to the roots: Using the medicine wheel in the healing process. First Peoples Child & Family Review, 4(1), 10-19.