The Task Force initiated the development of its core values (Core Values) by examining the tenets used in the Substance Abuse and Mental Health Services Administration (SAMHSA) Mental Health Recovery Framework. 7 Those tenets reflect the combined contributions of peer advocates, mental health professionals, and community feedback over three decades. Many also echo the values and principles outlined in “Practice Guidelines: Core Elements for Responding to Mental Health Crises8 .” Through group discussions that took place over email, telephone conference calls, and in-person meetings, the Task Force identified principles that could be further specified, enhanced, or added to fit the context of suicide prevention. The Core Values represent the group consensus on the values that attempt survivors want suicide prevention professionals and organizations to consider when developing or implementing suicide prevention supports. Research has indicated that promoting protective factors and addressing risk factors for suicide can prevent suicidal behavior.9 Therefore, it is reasonable to believe that activities that support the Core Values have the potential to prevent future suicide attempts, and improve the quality of life for people who have survived a suicide attempt.
The purpose of adhering to the values is to identify actions that would be both helpful and preferable for attempt survivors. Each Core Value is linked to protective and/or risk factors, or best practices in behavioral health care. Please note that to reinforce the intent of the Core Values and to communicate the voice and perspective of the Task Force each value in this section is written in first person. All activities designed to help suicide attempt survivors should be consistent with one or more of the following values:
It has long been recognized that the absence of hope (i.e., hopelessness) is a major risk factor for suicidal thinking and behavior.10 More recently, studies have found that hope and optimism can help guard against suicide. 11-14 Hope is also linked to self-esteem and self-efficacy, as well as improved problem-solving.15,16 The pursuit of meaning can help a person cope with pain and suffering.17 Similarly, research on reasons for living has demonstrated that meaning and purpose are keys to recovery in many different groups of people who have lived through a suicidal crisis.18,19
When we find hope, we are less suicidal. Hope is a key protective factor against suicidal behavior, and it is a catalyst for the recovery process. Hope is nurtured by finding meaning and purpose in life. If we can see our lives as having meaning and purpose, then we can picture a hopeful future.
The negative perceptions of behavioral health issues and subsequent discrimination pose major barriers to help-seeking.20 Use of negative stereotypes and discriminatory actions robs people of their dignity, stifles compassion, and crushes hope.20 Social rejection and discrimination have negative effects on life satisfaction and well-being.21
Stigma, negative stereotypes and discrimination (overt or subtle) are particularly damaging when we are already suffering from depression, hopelessness, damaged self-image, trauma, self-doubt, and shame – thoughts and feelings common during a suicidal crisis. In contrast, when we are treated with dignity and compassion it reaffirms our sense of worth and value. On a larger scale, direct and implied messages about hope, recovery, and genuine concern can encourage us to seek out help and support when needed.
The meaning of “peer” depends on context, applying to fellow students or military veterans, for example. For the purposes of The Way Forward, a peer is someone who has lived experience with a similar mental health condition or issue (i.e., suicidal feelings or past suicide attempt).
Research indicates that people engaged in peer support tend to have positive mental and behavioral health outcomes along with general psychological and social benefits.22,23 Recent practice guidelines recommend that peer supports be available in response to mental health crises because peers are in a unique position to “convey a sense of hopefulness.”8(p8) Thus, providing and receiving help from peers counteracts risk factors for suicidal behavior such as hopelessness, impulsiveness, isolation, shame, and symptoms of mental health disorders.24-26
As peers, we can provide social support and a sense of community while also sharing experiential knowledge and practical advice about coping skills, serving as positive role models for others. Furthermore, when we enter the role of helper we also experience benefits.
The report Promoting Individual, Family, and Community Connectedness to Prevention of Suicidal Behavior notes that “Connectedness is a common thread that weaves together many of the influences of suicidal behavior and has direct relevance for prevention.”27(p3) The report indicates that connectedness includes relationships between individuals and between organizations. Through social connections, risk factors of loneliness and isolation are countered, while protective factors of belongingness and social integration are enhanced. Benefits also come from access to resources through social capital and networking. Some studies have found that social connections help people cope with stress (i.e., psychological, physiological, and neurological responses to stress) and enhance general health.28,29
Connections between community organizations facilitate access to care and continuity of care, enabling services like follow-up programs to help many people after a crisis.27,30 Furthermore, as noted in the report Suicide Care in Systems Framework from the Action Alliance Clinical Care and Intervention Task Force (CCI Report), 18 connections between professionals eases fears about providing services and equips them with additional resources.31 Additionally, both personal connections and organizational ties can be used to encourage community groups and organizations to contribute tangible supports (e.g., funds, meeting space, use of equipment or supplies, availability of volunteers) to suicide prevention efforts.
In the first type of connectedness, we benefit from maintaining or (re)building social connections and support networks in the community. As a second form of connectedness, it is easier to get quality care when healthcare organizations (i.e., medical, mental health, behavioral health, and insurance groups) and social services have formal relationships that allow them to work together.
Research indicates that people often turn to family and friends for help19, even when they do not seek help from mental health or medical professionals, emphasizing the critical role of support networks. A strong support network can serve as a safety net in times of crisis and a trusted resource during recovery. This core value is also consistent with NSSP Objective 9.4 to engage a person’s support network throughout the course of care. The CCI Report recommended that “families and significant others should be engaged and empowered” in care plans whenever “appropriate and practical.”31(p8) It is also clear from research that it is extremely stressful to care for
someone else, especially in life-or-death situations.32 Family and friends need additional support. Moreover, a robust literature exists describing the risk for suicide in family members and friends of an attempt survivor or person who has died by suicide. 33 Similar research points to the higher-than-average chance of risk behaviors in friends of a suicidal person. 34 Thus, support for family and friends may have direct benefits to all involved, even if the focus is primarily on helping the attempt survivor.
We have to decide which family, friends, and/or significant persons to engage in our care or support. This agreed-upon support network should be included in informed care decisions, treatment, follow-up, and other forms of help. However, the family members, friends, and peers in our support network also need education, assistance, and resources for themselves.
Differences in suicide rates by gender, race, ethnicity, sexual orientation, geography, and community point to the potential role of social and cultural factors in risk and resilience.35,36 Such differences form the basis for ongoing research that seeks to understand how human diversity affects suicidal behavior and the practical implications that it has on prevention or intervention efforts.36 Additionally, many people turn to cultural or spiritual leaders as trusted sources of support, and religion or spirituality often serves as a protective factor.37 Incorporating such potential strengths into plans for recovery can open the door to many non-clinical options for support.38 Both contemporary and traditional healing practices can contribute to recovery and wellness. Further, the CCI Report specifically noted that a productive clinical relationship “should respect the cultural preferences and values of the individual as much as possible.”31(p11)
We want programs and services to: (a) acknowledge and respect our beliefs and traditions (cultural, ethnic, spiritual); (b) incorporate them into our recovery plans; and (c) assess how they might interact with care and identify ways for the traditions, healing practices, beliefs, and/or communities to help keep us well.
Many calls for mental health system transformation recommend consumer-driven or person-centered care.39-41 The CCI report recommended that “care for persons at risk for suicide should be person centered, where their personal needs, wishes, values, and resources should be the foundation for continuing care and safety plan.”31(p8) This value is consistent with the practice of shared decision-making (SDM). In SDM, “providers and consumers of health care come together as collaborators in determining the course of care.”42(p2) Research indicates that SDM grants the person seeking care lower stress, a greater sense of control, and better functional outcomes.42 Becoming a partner in care directly counters ideas of helplessness, powerlessness, and hopelessness. Treatment outcomes are generally better when the person has the opportunity to be a partner in the process.43
Programs, policies, and initiatives should preserve our autonomy, promote hope, build from our strengths, and empower us to pursue the goals we identify. Professionals should consider all dimensions of wellness when developing plans for care. We need to be informed about care and support choices in language and terms that we can easily understand. Respect our decisions. Provide us with diverse opportunities for involvement in our own care and in broader suicide prevention and mental health promotion activities.
Objective 8.3 of the NSSP is to “promote timely access to assessment, intervention, and effective care for individuals with a heightened risk for suicide” as something that is “critically important.”(p54) With more timely access to care, someone might be able to get help before attempting suicide. Similarly, the CCI Report recommended “immediate access to care for all persons in suicidal crisis,” with “effective treatment and support services … how and when they need them.”31(p4,5) Early intervention is likely to have a meaningful and long-lasting impact. Recent practice guidelines note that expedient support can reduce the intensity and duration of a crisis and allow the person to choose from a wider variety of options.8 In defining timely access, the guidelines encourage “24-hour/7-days-a-week availability and a capacity for outreach when an individual is unable or unwilling to come to a traditional service site.”8(p7)
“Many a suicide might be averted if the person contemplating it could find the proper assistance when such a crisis impends.”
– Clifford Beers, 1908, A Mind That Found Itself
We should have the opportunity to access care and supports that fit our needs, are acceptable and are appropriate 24/7/365. A full range of supports should be available, including crisis alternatives to hospitalization such as peer respite, call or text lines, and mobile crisis teams. When the ideal form of support is not immediately accessible, we should have timely and expedient access to an alternative and/or get a referral. Professional services should continually assess the quality and accessibility of care and support to identify and remedy any gaps. These reviews should be carried out by a group that includes both professionals and peers.
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.