Suicide Prevention Frameworks

Primary Goal: Build Community Coalitions for the Prevention of Suicide and for the Implementation and Management of Suicide Cluster Contagion Containment

Introduction: Over the last 15 years research has clearly demonstrated that death by suicide creates powerful and long-lasting impact on families and communities and that death by suicide is preventable.

When communities are impacted by multiple teen and adult suicide deaths and attempts suicide prevention frameworks (SPF) are necessary and when possible should be put in place prior to multiple deaths by suicide. Multiple domains of research are now indicating that friends of both death by suicide and attempters may be at a significantly increased risk for suicidal behaviors.

Primary Factors that Underscore the Necessity for More Resources to Build SPF’s

“Youth play an important role in suicide prevention: Despite the support systems and safety nets that adults provide for teens and young adults, the first lines of defense in successful prevention efforts of youth suicide are youth themselves. Teens and young adults frequently bypass the adult world support systems and instead turn to their friends for help and understanding. Thus, it is imperative that youth be regularly trained in recognizing signs of depression or increased risk for suicide and know how to connect their friends with professional help. Teens should never be asked to be suicide counselors, but rather to be a peer to adult referral ‘system’.

Suicide is a public health problem: In 2017, there were 47,173 recorded suicides, up from 42,773 in 2014, according to the CDC’s National Center for Health Statistics (NCHS). On average, adjusted for age, the annual U.S. suicide rate increased 24% between 1999 and 2014, from 10.5 to 13.0 suicides per 100,000 people, the highest rate recorded in 28 years.

With over 47,000 suicides in the US each year and estimated suicide attempts minimally being 10 times that, suicide impacts on all aspects of our society. Preventing suicide is the responsibility of the whole community. Most youth prevention efforts are school based; however, this misses out on many youth and young adults who may have dropped out, or are homeschooled, or otherwise not connected with schools. This is particularly true for young adults in the 18-24 year old age group where suicide rates double. Suicide is a complex issue and preventing suicide will take a coordinated effort between law enforcement, mental health providers, educators, social service agencies, family, friends, neighbors, etc.

We are all “gatekeepers”: Gatekeepers is the term used for anyone who does not have a professional treatment relationship with teens and young adults. Gatekeepers are family, friends, relatives, neighbors, coaches, librarians, hairdressers, employers, etc. Regardless of what our professional role might be, we are all potential gatekeepers in our community. For the postvention protocols, a gatekeeper is anyone who has experienced the death by suicide of someone they know in their community. Or anyone who is regularly working with youth or adults at risk. Gatekeepers play an important role in the postvention and prevention process by assisting the immediate family/survivors grieve and ensuring that the community response to the death does not promote suicide contagion.  In addition, having gatekeepers trained to recognizewarning signs of suicide and how to connect with the youth and connectthe youth with help is an essential component to reducing risk for survivors of suicide.” From Frameworks Postvention Protocols

Goals of the Community Coalition

Communities may significantlystrengthen Community Coalitions to Prevent Suicide.Per the Frameworks Models, CDC and Post Traumatic Stress Management (PTSM) models,these programs strive to strengthen the development of the community coalition of elected officials, education leaders, service providers, parents, and youth. Please see examples below.

(1) CDC contagion containment protocols:

Please review CDC Recommendations for a Community Plan for the Prevention and Containment of Suicide Clusters: MMWR Supplement (Circular) August 19, 1988 / 37(S-6); 1-12 at

(See Article II-Elimination of Gaps in the Service Network and CDC Injury Center’s Circular Volume 37/NO. S-6 Article VII-At Risk Identification Protocols)

(2) PTSM suicide postvention protocols

Please review Robert D. Macy, et. al., Community-Based, Acute Posttraumatic Stress Management: A Description and Evaluation of a Psychosocial-Intervention Continuum;

Harvard Review of Psychiatry, Issue # 12.4, Taylor & Francis, September 2004 and Robert D. Macy, Issue Editor, Youth Facing Threat and Terror: Supporting Preparedness and Resilience; New Directions In Youth Development, No. 98, Jossey-Bass, June 2003

(3) Frameworks model

Please review

SPF coalitions can be developed and trained to support all stakeholders in their skill, ability and confidence to recognize youth and adults at risk and connect those people in an integrated, systematic and comprehensive way with help. This usually includes:

  • more gatekeeper training for community stakeholders-especially parents
  • specialized training and protocol development for the Police Department, First Responders and Medical Examiner and more training in both gatekeeper and suicide assessment for clinical service providers
  • funding to support a large-scale effort to train youth (18-12 year old) and adults in Signs of Suicide (S.O.S.) and in other appropriate gatekeeper functions
  • funding to support critically needed school based mental health service provision at schools, community centers and in First Responder Populations.

Communities need to identify clear system gaps that exist between the schools, hospitals, police, medical examiner, public health and mental health providers. The emphasis must be on coordination, communication, and connections between governance, local resources, providers, citizens, and youth. This can foster significantly increased help-seeking behaviors among our students and older youth.

Current Community Coalition Infrastructure-Membership/Stakeholders:

  • Community Gatekeepers
    • Board of Selectmen, Mayor’s Office or County Government
    • School-County Office of Education
    • Boys and Girls Clubs
    • YM/WCA’s
    • Parent Groups
    • Primary Care Doctors
    • Community Based Behavioral Health Organizations
    • Interfaith Clergy Councils
  • State Agencies
    • DMH
    • DPH
  • Social Service Agencies
  • Law Enforcement
  • Primary Care Providers
  • Teens/Students
  • Clergy
  • Judiciary
  • Schools/Educators
    • Public Schools
    • Private Schools
    • Mental Health and Substance Abuse Providers
    • Behavioral Health Services
    • Alliance for Substance Abuse Prevention
  • Emergency Medical Services
  • Emergency Departments
  • Funeral Directors 

SPF-Coalition Skill Building

County Behavioral Health Clinicians: Suicide Assessment Clinical Training

Provide advanced trainings in

(1) the Chronological Assessment of Suicide Events (C.A.S.E. Approach)

School Containment: Gatekeeping, Casefinding, Screening & Suicide Prevention Programs

High Schools: Review Evidence-Based Gatekeeping, Casefinding and Screening Suicide Prevention Programs

Schools will need to review programming for their campuses that is deemed evidence based and appropriate for school. Several selections are fundamental to the SPF (see below). Both the Frameworks model and the PTSM contagion containment model indicate it will be necessary for the school to add additional programming to Counseling Centers and consider the SOS, SAP and Student Drop in Center programs given the level of possible risk at the school and in the community. This must include the development and consistent support of a student based S.O.S. ‘culture’.

School Based Mental Health

School Counselors and school staff working directly with students on a weekly basis to conduct treatment, stabilization, assessment and referrals is resource dependent (needs appropriate funding) and a critical foundation layer to the success of the SPF.

Signs of Suicide Program (S.O.S.)(Screening Component)

SOS trainings for school and non-school based gatekeepers is necessary with follow up post-SOS training to conduct small group work for identified at risk students, and the development and consistent support of a student based S.O.S. ‘culture’.

Student Assistance Program (SAP)

Schools and their community need to provide the funding to hire a 1.0 SAP specialist.

Drop In Center at the Schools

The School Administration may need to consider the launch of a full-time student drop in center which will be staffed with School Counselor personnel. Clinicians who already known by staff and students should also be a consistent part of the drop-in center personnel.

Teacher/Parent Support

There is usually an immediate need to develop and practice a “buddy” system for teachers in case of another attempt or suicide death which can be implemented by the PTSM team members: the teacher group for “buddies” would be with them during the school day(s) immediately following the event to offer PTSM support to the teachers and their classroom. There is usually an immediate need for psychoeducation groups for the teachers on how suicide occurs-and how it is inhibited.

Resiliency Building Groups for students as part of School Health Curriculum

Schools may need to consider, in collaboration with DMH and Public Safety, using the newest evidence base from the psychosocial interventions used in the US and abroad to build a resiliency focused curriculum as part of the existing health curriculum.

Joint Incident Command System (ICS) Meetings

It is important to develop the possibility of building a School ICS collaborating with the  Town/County ICS managers to discuss how to share command during major high-risk behaviors or suicide deaths among residents. The the Town and School ICS should meet with some regularity to decrease any gaps in the level of understanding of shared command and agreed upon response protocols during a suicide crisis event. A good example of this is the arrest of students at risk for suicide. A protocol is in place that

all students who are arrested will be evaluated by a DHS-trained clinician prior to their release by the law enforcement.

Other suggestions for development and dissemination

(From Frameworks Model and PTSM Model)

  • Provided supports to survivors by convening a Survivors Committee
  • Consider a survivor newsletter with lists of support groups and County and State resources
  • Consider sending two residents to national training to become survivor support group facilitators
  • Consider the development and distribution of PSA’s with resource information to next of kin of suicide victims
  • Consider the development and funding of a Community Health and Healing fund to provide small grants for postvention activities
  • Consider the development and distribution to all Libraries of a bibliography of suggested books for suicide survivors.
  • Worked local and state media to promote responsible reporting of suicide events by distribution of CDC Media Recommendations to media outlets
  • Respond to various media outlets following sensational/inappropriate media coverage

And worked to decrease stigma and promote increased help seeking behaviors including:

  • Consider forming a workgroup to create messages that decrease stigma and promote help seeking behaviors
  • Consider Negotiated Memorandums of Understanding (MOU’s) between schools Police Chief, Medical Examiner, and clinical providers.

Our ITC partner, Emotion Technology, launches hotlines and other large scale suicide prevention and mental health programs that integrate mobile, social and interactive technology. These include: