The newly revised National Strategy for Suicide Prevention, advanced through the National Action Alliance for Suicide Prevention, calls for a new conversation to reduce suicidal actions and death. That conversation is being given a new voice and a new tone by inviting suicide attempt survivors to share their insights on both staying alive and finding hope.
The mission of the Suicide Attempt Survivors Task Force of the Action Alliance is to create a resource that would convey the voice of suicide attempt survivors. The untold stories of hope and recovery that belong to attempt survivors are the stories of suicide prevention; what they learned is what we all must learn. With these new voices come new ideas, new questions, and new insights. The Way Forward emerges from those new voices.
For far too many years suicide prevention has not engaged the perspectives of those who have lived through suicidal experiences. Because of social stigma and fear, as well as personal shame, a culture of silence prevailed. The Way Forward represents a seminal moment in this field’s history; it is an opportunity to benefit from the lived experience of suicide attempt survivors. Many of its recommendations are derived from evidence-based practices, and several are aspirational. All are grounded in the evidence of recovery and resiliency that is clear in the lives of our Task Force members. Viewing suicide prevention through the lens of the eight core values presented in The Way Forward can help us enhance safety while also bringing hope and meaning to those in suicidal despair.
It is our hope that The Way Forward will also help serve as a bridge to developing a conversation about suicide prevention between mental health policymakers and consumer advocates. Often, many mental health professionals have narrowly focused on ‘identifying persons at risk and getting them into treatment.’ Conversely, many mental health consumer advocates either avoid or react negatively to suicide prevention discussions, at times due to traumas associated with historically coercive practices and policies. This resource may enable these two powerful forces for change to come together and develop new, more effective approaches to reducing suicide attempts and deaths.
Like the Task Force itself, we, its co-leads, bring a range of personal and professional perspectives to these efforts. Through our work together over years, one a survivor of suicide attempts and mental health advocate, the other a psychologist with years of experience working with people in suicidal crisis, we have come to believe that collaboration and understanding are critical. Like all of the partners, colleagues, and supporters that helped to develop this resource, we feel deeply that suicide is preventable. It will be the spirit of collaboration – from policy-makers and advocates to clinicians and clients – that will make suicide prevention possible.
We greatly hope that The Way Forward will serve as a model for your new collaborations with others, aligned around a new vision for a world free of the tragedy of suicide.
Mental Health Association of San Francisco
National Suicide Prevention Lifeline
The Way Forward seeks to filter the evidence base used for suicide prevention through the core values shared by many attempt survivors (the Core Values). These Core Values were generated through an extensive dialogue of the Task Force membership. Many are based in the tenets of mental health recovery developed through decades of work by peer advocates, behavioral health professionals, and community feedback. They reflect the consensus perspectives that emerged and were clarified through Task Force discussions and correspond with many protective factors that counter risk for suicidal thinking and behavior.
“Our best route to understanding suicide is… directly through the study of human emotions described in plain English, in the words of the suicidal person.”
– Shneidman in The Suicidal Mind, 1996.
Every form of help and support for someone who has been suicidal depends on that person’s willingness and capability to seek and accept help. Further, given that the suicidal crisis is predominately internal, all changes, regardless of where they are initiated, must ultimately occur within individuals. Beginning with the individual attempt survivor is consistent with mental health recovery practices, person-centered care practices, and the Core Values.
The journey to recovery often begins with self-help practices (e.g., self-advocacy, community involvement, religious/spiritual activity, exercise) which can be supported by family, friends, and professionals. An additional approach to extend support is the peer-operated warm line, which can provide non-crisis assistance at times when traditional services are unavailable. After surviving a suicidal crisis and successfully navigating available systems and supports, peers can model self-care practices, and provide unique and powerful contributions to another’s recovery.
The Task Force recommends that suicide prevention and behavioral healthcare organizations engage, hire, and/or collaborate with peer support professionals. Beyond work as peer support professionals, attempt survivors should be included as key partners in a wide range of suicide prevention efforts.
Community connectedness is one of the Core Values and an established protective factor against suicide. An essential part of that is the assistance provided by family and friends. Each attempt survivor should define a support network, and the people in that network should be offered educational and other resources. It is important to establish who those supportive persons are and how they can assist before, during, and after a crisis.
Family and friends also need support for themselves. Unfortunately, there are very few support resources that have been developed to fulfill this need.
The Task Force recommends developing, evaluating, and promoting programs specifically intended to help the family and friends of attempt survivors.
Behavioral healthcare organizations can enhance care and support for individuals experiencing, or recovering from, a suicidal crisis in multiple ways. At the leadership level, organizations should make suicide prevention a core component of care. Individual professionals should begin care with clear discussions about how they approach crisis situations. Beyond a focus on the suicidal crisis, however, professionals should conduct a comprehensive assessment that recognizes the strengths and challenges in multiple dimensions of life whenever possible. Similarly, all treatment, including the use of medication, should take place within a collaborative approach that discusses multiple options, respects informed choices, and engages a wide range of supports.
While most of the professional care for suicidal persons takes place within behavioral healthcare settings, many key services are provided in general healthcare offices, clinics, and hospitals. In every setting and situation, care for someone who is in, or recovering from, a suicidal crisis would be greatly improved by addressing negative stereotypes, prejudice, and discrimination around suicide and mental health issues among medical professionals. Treating people with dignity and respect can help ease tensions and facilitate the type of collaborative care relationships that are most effective in addressing suicide risk.
The Task Force recommends that medical and behavioral health providers integrate principles of collaborative assessment and treatment planning into their practices.
Many crises can be addressed before emergency services are needed through the use of key crisis supports such as hotlines and crisis respite centers. In support of the Core Value emphasizing timely access to care, developing and/or sustaining supports and services that can be available 24/7/365 is critical. Yet, many people are wary of hotline services because they fear police involvement or inpatient commitment, based on prior experience or stories from others. Crisis hotlines can do much to alleviate such concerns by following protocols like those established by the National Suicide Prevention Lifeline for active engagement of callers and the use of least invasive approaches, with active rescue being a “last resort.” As an additional resource, more crisis respite centers (particularly ones that employ peer providers) should be developed and promoted.
In cases where active rescue, or non-medical on-site intervention, is required, it would be ideal to call a mobile crisis team that includes peer support professional. When such a team is unavailable, first responders with training about behavioral health emergencies should be engaged.
The recommendations for professionals in emergency departments mirror those for general medical and
behavioral healthcare professionals in many ways. Improvements in care should begin with shifting attitudes toward collaborative, respectful, and dignified treatment of persons undergoing a suicidal crisis. The person in crisis can also benefit greatly from the expanded support available from family, friends, and peers, who should be offered relevant information and resources. Peer professionals could provide additional support during onsite crisis intervention, follow-up after a crisis, or emergency department visit and/or discharge.
The Task Force recommends that providers of crisis or emergency services develop formal partnerships with organizations which offer peer support services and especially organizations that are operated or driven by people with lived experience.
Long-term connections between educational, social, healthcare, and behavioral healthcare settings are solidified through formal agreements and partnerships. As one example, both educational systems and hospitals can establish formal ties with peer support programs or organizations to enhance services. Connecting attempt survivors to peer specialists provides an additional source of support, connection to the community, and a means to facilitate access to other services.
Continuity of care can be furthered through follow-up and/or innovative approaches with technology. Follow-up practices or programs can demonstrate compassion and caring while encouraging help-seeking. Innovative approaches such as online self-help tools and mobile applications can be used to facilitate timely access to care.
The Task Force recommends that hospitals and providers of crisis services establish formal strategies for ensuring continuity of care by helping people transition to community supports.
At the broadest level of support, community organizations often use communications and/or social marketing campaigns. The Action Alliance Framework for Successful Messaging encourages campaign developers and champions to have a clear strategy, convey a hopeful message, and follow relevant guidelines including maintaining safety. Those messages could be effectively promoted by individuals who have lived through a suicidal crisis.
Many recommended programs and practices in The Way Forward can be seen as promising, often having
evidence for supporting Core Values but lacking formally measured evidence of effects on suicidal thinking or behavior. Research and evaluation efforts are needed to strengthen the evidence base for such approaches, adding science-based knowledge to the insights from lived experience. Developing a network of professionals with lived experience related to suicide to initiate and implement such research and evaluation projects would be a major catalyst for this work.
As a key message in this section, and overall, the Task Force recommends that suicide prevention and behavioral health groups engage attempt survivors as partners in developing, implementing, and evaluating efforts.
Each year, millions of people in the U.S. seriously consider suicide. Some who survive suicide attempts have recurring or ongoing suicidal thoughts and feelings, and a substantial number of people attempt suicide again. It is imperative to develop and disseminate effective supports that are critically needed. Confronting and abolishing the fear, discrimination, and misunderstanding that have blocked these efforts is long overdue.
With The Way Forward, the Task Force aims to begin a new and more inclusive chapter in suicide prevention, sparking the development of innovative programs and projects, altering public policy, and promoting much needed social change. The recommendations in this resource combine research and practice with lived experience from attempt survivors to help put the NSSP into action. They provide a blueprint for a newly invigorated community effort to reduce suicide attempts and deaths.
Achieving these goals requires social and political support from attempt survivors, families, friends, and allies. To translate the collective vision of The Way Forward into reality, the Task Force recommends developing a national center focused on helping attempt survivors and including attempt survivor peer specialists in current mental health technical assistance centers.
In creating the Core Values, the Task Force identified values and tenets that have been used in mental health recovery, the mental health consumer movement, and personal experiences. The Task Force modified the concepts to make them more applicable to the suicide prevention context. The NSSP was a key resource. As a result, the Core Values are consistent with recognized principles of recovery and concepts used throughout the NSSP (see Table 1).
Table 1. Core Values compared to recovery principles and NSSP concepts