Contents of the Standardized Suicide Prevention Program for Gatekeeper Intervention in Korea, Version 2.0
Article information
Abstract
Objective
Suicide is a huge nationwide problem that incurs a lot of socio-economic costs. Suicide also inflicts severe distress on the people left behind. The government of the Republic of Korea has been making many policy efforts to reduce suicide rate. The gatekeeper program, ‘Suicide CARE’, is one of the meaningful modalities for preventing suicide.
Methods
Multidisciplinary research team collaborated to update the ‘Suicide CARE’ to version 2.0.
Results
In the ‘Introductory part’, the authors have the time to think about the necessity and significance of the program before conducting full-scale gatekeeper training. In the ‘Careful observation’ part, trainees learn how to understand and recognize the various linguistic, behavioral, and situational signals that a person shows before committing suicide. In the ‘Active listening’ part, trainees learn how to ask suicide with a value-neutral attitude as well listening empathetically. In the ‘Risk evaluation and Expert referral’ part, trainees learn intervening strategies to identify a person’s suicidal intention, plan, and past suicide attempts, and connect the person to appropriate institutes or services.
Conclusion
Subsequent studies should be conducted to verify the efficacy of the gatekeeper program.
INTRODUCTION
Suicide is to lead to death by deliberately harming oneself with intent to die. Suicide does not end with taking one life. It is usually known that when one person commits suicide, there are more than six close family and friends left behind [1]. Suicide causes significant psychiatric symptoms such as depression, anxiety, and complicated grief to those left behind [2,3]. Suicide also has a serious social and economic impact. In an Australian workplace suicide study, the economic cost of suicide and non-fatal suicidal behavior was reported to reach $6.73 billion [4]. In the United States, the total national cost of suicide attempts was $58.4 billion and if the under-reported ones are corrected, the cost was reported to total $93.5 billion or $298 per population [5].
Although the suicide rates tend to decrease worldwide since the 1990s [6], and there are claims that the proportion of suicide that contributes to mortality is less than previously known [7], suicide remains a serious national problem that needs to be resolved urgently in some countries and cultures. One of the representative countries is the Republic of Korea. The suicide rate of the Republic of Korea in 2018 was 26.6 per 100,000 population, an increase of 2.3 (9.5%) compared to 2017 [8]. This is also the highest level among the countries in the Organization for Economic Cooperation and Development [9].
The Republic of Korea has implemented many strategic policies to lower suicide rates. On March 30, 2011, ‘Act on the Prevention of Suicide and the Creation of Culture of Respect for Life’ was enacted [10]. The purpose of this Act is to protect the precious lives of the people and foster a culture of respect for life by defining necessary matters regarding national responsibility and prevention policies for suicide. According to this Act, the Korea Suicide Prevention Center was opened in 2011 and the Korea Psychological Autopsy Center was also opened in 2014. The Korean government announced the ‘National Action Plan for Suicide Prevention (2018–2022)’ after a joint meeting of related ministries on January 23, 2018 [11]. According to the national action plan, Suicide Prevention Policy Department, a department dedicated to suicide prevention, was separately established within the Bureau of Health Policy in the Ministry of Health & Welfare in February 2018. In addition, the national budget for suicide prevention has increased from 8.5 billion won in 2016 to 9.9 billion won in 2017 and 16.8 billion won in 2018. However, Korea has meager budget for the prevention of suicide. The per capita budget for the prevention of suicide in Korea is still 326 won, which is only onetwentieth that of Japan, which is 6,200 won [11].
Whereas it is needed to increase the amount of budget, it is also essential to use a budget efficiently. The gatekeeper program occupies a significant part of the national suicide prevention policy. The gatekeeper program aims to enhance the ability of gatekeepers to determine the level of risk of suicide by acquiring knowledge, attitudes, and skills to identify those who have the risk of suicide, and to connect them to appropriate services [12]. Indeed, the gatekeeper program is included in the ten tasks of ‘the National Suicide Prevention Action Plan (2018–2022)’, and making a gatekeeper training system for the entire nation is being implemented as one of 20 detailed tasks [11].
The ‘Careful observation, Active listening, Risk evaluation and Expert referral (Suicide CARE)’, which is the standardized suicide prevention program for gatekeeper intervention in Korea, was first developed in Korea in December 2012 [13]. The first version was 1.0. In 2014, ‘Suicide CARE’ was updated to version 1.6 [14]. After that, ‘Suicide CARE’ began to apply life cycle approach. The ‘Suicide CARE: version 1.6A’ was developed for teenagers in 2015 [15], and ‘Suicide CARE: version 1.6W’ was developed for office workers in 2016 [16]. According to the goal in the national suicide prevention action plan, a total of 1 million gatekeepers have been trained by the national gatekeeper programs in Korea by 2018 [17].
Since ‘Suicide CARE’ was first developed in 2012, many evidence-based results, which could be the basis for establishing and implementing strategies for suicide prevention, have been reported over the past seven years. In addition, after the Korea Psychological Autopsy Center opened in 2014, various signals that the suicide victims had shown while they were alive began to be identified, so it became possible to analyze them scientifically. On the other hand, as ‘Suicide CARE’ version 1.6 has been widely distributed to local communities in various regions and conditions, a lot of feedback from the field has been collected. Based on all the various grounds and opinions collected in this way, there have been growing calls for updating the existing version of ‘Suicide CARE’ version 1. Therefore, the development of ‘Suicide CARE’ version 2.0 was begun in August 2019, and the development was completed in December 2019 [1].
There are many gatekeeper programs around the world [18]. However, there would be no such program as that of Korea’s ‘Suicide CARE’ in which the government creates a standardized gatekeeper program, continuously updates it, actively distributes and utilizes it, and trains about 2% of the entire citizens as gatekeepers. ‘Suicide CARE’ is the fruit of the Korean government’s steady efforts to lower suicide rates through the systematic implementation of such suicide prevention policies. Therefore, it is meaningful for Korea to share the contents of ‘Suicide CARE’ with other countries in the world. However, whereas ‘Suicide CARE’ has been regarded as one of the representative suicide prevention programs in Korea, it has been unknown to foreign countries or has been introduced incorrectly. Suicide CARE is called ‘Bogo Deudgo Malhagi’ in Korean, abbreviated as ‘Bo-Deud-Mal’. Even though this is a Korean standard suicide prevention program developed and distributed by the government, the English translation has not been consistent. Some researchers translated ‘Bogo Deudgo Malhagi’ into ‘Watch, Listen and Talk.’ [19] In the ‘Mental Health ATLAS 2017’ published by the World Health Organization, it was translated into ‘Seeing, Listening, and Speaking’ [20].
METHODS
Given the above consideration, multidisciplinary research team updated the Suicide CARE to version 2.0 and wrote an introductory paper to spread the official English name and essential components to multidisciplinary researchers related to suicide prevention worldwide. The detailed description for the development process of the Suicide CARE has been reported and published separately in a recent article [21]. The authors introduced ‘Suicide CARE’ version 2.0 according to the composition of ‘Introductory part’, ‘Careful observation’, ‘Active listening’, and ‘Risk evaluation and Expert referral’. The author also looked at what is needed and what needs to be improved for the most useful use of suicide prevention policy tools such as ‘Suicide CARE’ version 2.0.
RESULTS
The ‘introductory part’
The purpose of the introductory part is to think about its necessity and significance before we go into full-scale gatekeeper training. This part is mainly composed of Lecture Overview, Introductory Video, Comparison between Suicide and Traffic Accidents, Unknown Suicides, and Necessity of Gatekeeper Program. In the “Introductory Video”, the current impact of suicide in Korea is introduced, and it is taught that many suicides are preventable. In “Comparison between Suicide and Traffic Accidents,” the changes in suicide deaths and traffic accident deaths over the past few decades were compared to each other. Traffic accident deaths have fallen to about one-third for about 20 years thanks to a steady investment by the Korean government, while suicide deaths have nearly doubled for the same period. The authors suggested that public interest, social awareness, systematic planning, and sufficient investment can lead to good results through comparisons of traffic accident deaths and suicide deaths. “Unknown Suicides” refers to suicides that are not reflected in statistical figures. In this section, it is suggested that there are 5% of the entire population with the cases in which even if it is not counted as official suicide, it can be said to be actual suicide. It is also emphasized that suicide is never a rare or of little important event in our society. Lastly, the “Necessity of Gatekeeper Program” includes that the World Health Organization and the US Centers for Disease Control and Prevention recognize the gatekeeper program as an effective intervention strategy for suicide prevention.
The ‘careful observation’
In the ‘Careful observation’ part, we deal with detecting signals from high-risk people at suicide. This part consists of eight parts (Table 1). The contents of this part were updated largely through the active use of the results of the ‘2018 Psychological Autopsy Interview’ by the Central Psychological Autopsy Center. The resources provided by the Central Psychological Autopsy Center made it possible to reflect as much of the danger signals that real suicide victims have shown in their lives. The first section, “Three Examples,” show situational and behavioral signals of suicides that those around people at risk for suicides may have perceived while they were alive. This section can remind us of the importance of timely perception of danger signals that suggest suicide. The “Undetected Suicide Signal” shows how suicide risk signals were not correctly detected in the real world by suggesting that the suicide victims expressed 92% suicide risk signals, but 77% of people around the suicide victims did not notice the signals. The “The Process of Reaching Suicide” section shows three stages of suicide, which are suicide thought, a suicide plan, and suicide attempt. The “Linguistic Signals” visually show the danger signals that suicide victims showed most in their lives: expressions of death including suicide, physical discomfort, and selfdeprecating words. In addition, suicide risk signals such as posting death-related content on social media, interest in the afterlife, and expressions of suicide are frequently presented. The “Behavioral Signals” show various behaviors of suicidal deaths including changes in emotions and behaviors before death, depressive symptoms, settling affairs before death, and death-related behaviors. In particular, the situation in which urgent intervention is needed was emphasized by highlighting the dangerous behaviors of suicides when suicides are imminent, such as three months or one week before suicide. The “Situational Signals” shows the situational difficulties suicide victims experienced during their lifetime, including mental health, work, economics, and family-related problems. In particular, the age group is divided into the young, the middleaged, and the elderly, respectively, and high-risk situational signals for the corresponding age group are presented. For example, academic and interpersonal issues such as study and date in the young, economic problems such as debt in the middle-aged, and chronic illness & physical symptoms in the elderly are presented as dangerous situations. In the “Video,” the examples of young people are adapted and the scenario is composed. In the last section, “What Should We Do After Careful Observation?,” we take time to think about how the surrounding people should have responded after watching the video with the bad ending. Throughout this section, trainees are motivated to learn the next step, ‘Active listening.’
Components & main contents of ‘careful observation’
The ‘active listening’
Listening consists of nine parts (Table 2). First of all, the first “Video” shows linguistic, behavioral, and situational signals suggesting suicide from a self-employed middle-aged man. This video shows a surrounding person who fails to empathize with a person at risk of suicide. The surrounding person consequently fails to engage in suicide prevention intervention as a result of speaking and acting only according to his or her thoughts and judgments. This makes trainees think about how to respond initially to suicide high-risk group people. In the “Question 1 for listening: Do you think about suicide?,” based on evidence-based research results, it emphasizes that trainees directly ask about suicide and asks a question about it because referring to suicide does not increase the danger of suicide, but rather helps to prevent it. The “The Listener’s Mind” deals with various emotions that arise when it is directly confirmed that a person is thinking about suicide. The “Unhelpful Listening” shows that helpful interventions cannot be made if the listeners follow only their own emotions, not those of people at risk of suicide. In the “Question 2 for Listening: Why did you think about suicide?” We show that sympathizing with the minds of people at risk of suicide, not the listener’s mind, is the most basic mindset. We show that sympathizing with people at risk of suicide begins by asking why they thought they should commit suicide. The “Listening Skill: Active Listening” shows how to create an atmosphere at which people at risk of suicide can comfortably tell his story through sympathetic listening and a non-judgmental attitude. The “The Response of Gatekeeper” is a section that trainees can practice the skills acquired in the “Listening” section. Intervention can be practiced naturally by the trainees actually doing the expressions such as “You were so hard that you wanted to die.,” “It must have been a tough situation for you to tell the story, but thank you for telling me.” The “Ambivalence” makes trainees know that someone who thinks of suicide also has a desire to live. The last section, “The Reason to Live,” shows that people at risk of suicide can identify the reasons why they should live.
Components & main contents of the ‘active listening’
The ‘risk evaluation and expert referral’
The ‘Risk evaluation and Expert referral’ consists of nine parts (Table 3). The first part, “Video 3,” comprehensively shows the situational, behavioral, and linguistic signals of people at risk of suicide. The “Checking Suicide Risk” teaches questions accurately identifying suicide plans, methods, and prior suicide attempts. The “Helping safely” shows how to secure safety for people at risk of suicide. For example, it includes not recommending alcohol to people at risk of suicide. In the “Understanding Depression,” we introduce mental illnesses such as depression and explain the symptoms. In the “Piece Together a Puzzle of Hope,” we introduce people, institutions, and services that people at risk of suicide can call or use for help. In the “Core Contacts,” we introduce Korea’s representative suicide prevention services (e.g., 24-hour suicide prevention hotline 1577-0199). The “Good Ending” shows a finale that a selfemployed middle-aged man who was once at risk of suicide was referred to appropriate suicide prevention service without acting suicide attempt. The good finales could be accomplished by making good use of all the skills trainees have learned. In the “Role Play,” trainees do a role play based on the “Good Ending” script. In “Arrangement,” the core contents of the ‘Suicide CARE’ are arranged and presented.
Components & main contents of the ‘risk evaluation and expert referral’
DISCUSSION
The updated ‘Suicide CARE’ version 2.0. has significant implication for the prevention of suicide in Korea. A lot of recent evidence for the risk and protective factors for suicide have been incorporated into the program. Throughout the brisk discussion among the multidisciplinary team members, the best contents in each category (i.e., “careful observation,” “active listening,” and “Risk evaluation and Experts referral”) were confirmed by consensus. Hence, we believe that the quality of the program has been much improved. Individuals trained to this gatekeeper program is likely to successfully help suicidal people to escape from the suicidal crisis. Together with other preventive strategies, we hope that the ‘Suicide CARE’ version 2.0 will contribute to decrease of the national suicide rate in Korea.
On the other hand, there are several things to consider for using properly ‘Suicide CARE’ version 2.0. First, the government should play its role actively. The suicide prevention program using gatekeeper training will be used more widely in the community than in the clinical group. Therefore, it is necessary to provide policy and financial support for the central government and local governments to effectively carry out community-based gatekeeper programs. In other words, the program should not be carried out individually in the private sector, but the government should consistently lead suicide prevention projects. Second, people’s perception of suicide and mental health problems should be improved, whereas stigma of those should be eliminated. If there are many misconceptions and prejudices about suicide and mental health problems in local communities, the people at risk of suicide will not seek help. As a result, it will be difficult for those around people at risk of suicide to notice signals of suicide. For the success of the gatekeeper program, there needs to be an active campaign to improve people’s perception of suicide and mental health problems and eliminate stigmatization in local communities. Third, a systematic instructor training course should be established and implemented. According to a recently published systematic review, the short-term effect of the gatekeeper program for suicide prevention was excellent, whereas the preventive effects gradually showed a tendency to return to the state before training [22]. The results provide significant implications in the environment in which gatekeeper training is implemented for large-scale local community members like Korea. In the end, the quality management of gatekeeper training should be done well, and this can be achieved by standardization and quality control of the instructor training process. Instructor training is mainly conducted for personnel engaged in suicide prevention and the promotion of mental health. Given the amount and number of components of the ‘Suicide CARE’, eight hours per day would be appropriate for the training. In addition, inactive instructors during a year should receive refresher training. Before the instructor qualification expires, they should be reminded of the qualification period and encouraged to receive refresher training.
One final thing which is required to be performed is to verify the effect of the Korean standard gatekeeper program ‘Suicide CARE’ version 2.0 on the gatekeeper and suicide high-risk groups through the rigorous study. According to a systematic review of recently conducted gatekeeper training [23], studies using randomized controlled trials (RCT) showed that the effect of gatekeeper training on suicide-related knowledge, appraisals, and self-efficacy is unclear. In addition, the quality of many RCTs was evaluated to be low. The objective, composition, and socio-cultural conditions of each gatekeeper program are different. Therefore, we cannot conclude that the gatekeeper program is ineffective by referring only to the results of systematic reviews so far. The controversy about the efficacy of the Gatekeeper program needs to be resolved, and Korea should implement RCT to verify the efficacy of ‘Suicide CARE’ version 2.0 and confirm the results.
Acknowledgements
We would like to express our sincere gratitude to Prof. Se-Won Lim for his dedication to the development of “Suicide CARE” versions 1.0 and 1.6. This work was supported by the Standardized Suicide Prevention Program for Gatekeeper Intervention in Korea, version 2.0, a development grant from the Korea Suicide Prevention Center. This work was also supported by the Korea Psychological Autopsy Center. This work was also supported by the Soonchunhyang University Research Fund.
Notes
The authors have no potential conflicts of interest to disclose.
Author Contributions
Conceptualization: Hwa-Yong Lee, Hong Jin Jeon, Jong-Woo Paik, Kang Seob Oh. Funding acquisition: Hwa-Yong Lee. Investigation: all authors. Projected administration: all authors. Writing—original draft: Kyoung-Sae Na, Seon Seon-Cheol Park, Hwa-Young Lee, Jong-Woo Paik. Writing—review & editing: all authors.