Development of a Standardized Suicide Prevention Program for Gatekeeper Intervention in Korea (Suicide CARE Version 2.0) to Prevent Adolescent Suicide: Version for Teachers
Article information
Abstract
Objective
The increasing concern over adolescent suicide necessitates suicide prevention training for school teachers, as students spend a significant portion of their time at school. This study’s objective is to develop a suicide prevention program tailored for teachers.
Methods
The program was developed by a multidisciplinary research team, drawing on a review of both domestic and international suicide prevention programs, related scholarly articles, and Korean psychological autopsy interviews of adolescents. This was complemented by a survey of teachers to assess the program’s practicality and usability.
Results
The developed program comprises three parts, consistent with other versions: Careful Observation, Active Listening, and Risk Evaluation and Expert Referral. Careful Observation focuses on training teachers to recognize verbal, behavioral, and situational warning signs of suicidal ideation in students; Active Listening involves strategies for encouraging students to express their suicidal thoughts and techniques for being an empathetic and attentive listener; Risk Evaluation and Expert Referral provides instruction on how to assess suicide risk and assist students safely.
Conclusion
It is anticipated that this program will equip teachers with valuable knowledge and skills, contributing to a reduction in adolescents suicide rates.
INTRODUCTION
Suicide, defined as self-inflicted harm with the intent to die, is a major public issue worldwide. The latest World Health Organization (WHO) report indicates that over 700,000 individuals die by suicide annually, constituting 1.3% of all global deaths in 2019 [1]. The impact of suicide extends beyond the individual, affecting their families, friends, communities, and nations, both psychologically and financially. Those bereaved by suicide often experience severe psychiatric symptoms such as depression, anxiety, and suicidal ideation [2]. In 2013, the economic burden of suicide and suicide attempts in the United States was estimated at $58.4 billion, which increased to $93.5 billion after adjusting for under-reporting [3]. These costs include medical expenses, lost income, and productivity loss.
Suicides among 15–29-year-olds represent one-third of all suicides worldwide [4]. In Korea, suicide ranks as the leading cause of death in this age group, although the absolute number of deaths from suicide is relatively low [5]. In 2019, 298 adolescents (5.9 per 100,000 population) died by suicide, surpassing deaths from malignant neoplasms and transport accidents combined [6]. The stigma surrounding suicide often leads to under-reporting, particularly by parents who have lost children to suicide, suggesting that actual suicide rates may be higher [7].
However, suicide is both predictable and preventable [3,8]. Recognizing risk factors and warning signs, and responding effectively, is crucial. Contributing factors include mental disorders (such as depression, substance abuse, and eating disorders), previous suicide attempts, family dynamics, and specific life events [9]. Most adolescents who die by suicide show observable warning signs, either in their words or actions [10]. A retrospective cohort study based on Korean teachers’ reports using the Student Suicide Report Form revealed that >90% of adolescents who died by suicide exhibited warning signs a week before their death. However, only about 40% of these signs were recognized by teachers [11]. This underlines the importance of suicide prevention programs targeted at teachers. School-based gatekeeper training has proven effective in this regard [12,13]. Given that Korean adolescents spend most of their time at school, such programs are essential.
Although the Ministry of Health and Welfare supported the revision of the Suicide CARE program (Careful Observation, Active Listening, and Risk Evaluation and Expert Referral) in 2014, focusing on different groups including adolescents, office workers, and military personnel, there was no evidencebased gatekeeper training specifically for teachers in Korea. From May to November 2020, a multidisciplinary team including psychiatrists, psychologists, and an Air Force gatekeeper trainer revised the Suicide CARE program for teachers. This revision drew on various suicide gatekeeper training programs and recent findings from adolescents’ psychological autopsies in Korea. This paper describes the process of revising the Suicide CARE program for teachers.
METHODS
The revision of the Suicide CARE program for teachers, supported by the Korea Suicide Prevention Center (a designated agency of the Ministry of Health and Welfare) and the School Mental Health Resources and Research Center (under the Ministry of Education), was conducted from May to November 2020. Initially, we reviewed both domestic and international gatekeeper training programs dedicated to adolescents’ suicide prevention, as well as Korean psychological autopsy interview reports. We also examined the latest suicide statistics and analyzed trends. The program’s content was informed by feedback from previous program participants, as well as school counselors and principals. This study received approval from the Institutional Review Board of Soonchunhyang University Hospital (No. 2020-07-034). All survey participants voluntarily provided written informed consent. Similar to other versions of Suicide CARE, the teachers’ version included Introduction, Careful Observation, Active Listening, and Risk Evaluation and Expert Referral sections.
RESULTS
Review of previous programs
We conducted a review of various adolescents’ suicide prevention programs. Given that adolescents spend a significant portion of their day at school, school-based programs are pivotal for mental health education and identifying students at risk. Most of these programs employ strategies such as suicide awareness, peer leadership training, and screening. Suicide awareness programs focus on educating about warning signs and promoting help-seeking behavior. Peer leadership training involves helping peers assist those at risk of suicide by responding appropriately and referring them to trusted adults. Screening programs involve identifying at-risk adolescents using reliable and valid screening tools. One of the most effective strategies is implementing gatekeeper programs for school staff.
International suicide prevention programs
In Japan, in accordance with the government’s “Health Japan 21” initiative, Adachi City implemented the “Health Adachi 21 Action Plan,” aimed at reducing suicide rates [14]. This plan involved practical community-level initiatives, focusing on educating children about stress management and increasing the availability of mentors for socially isolated adolescents, such as hikikomori. Key components included the “Respect Yourself” training program, which taught students how to signal for help (SOS), and a gatekeeper program for school staff, which included distributing cards listing counseling centers to students reluctant to attend school [15]. The SOS program’s lessons encapsulate four main messages, summarized as STARS: Self-esteem (emphasizing the importance of each individual), Trusted Adults (encouraging conversations with reliable persons about difficult feelings), Community Resources (guidance on contacting support centers), and Help-seeking Skill [16].
In Canada, the LivingWorks organization offers evidence-based suicide prevention programs: LivingWorks Start, LivingWorks safeTALK, and LivingWorks Applied Suicide Intervention Skills Training [17,18]. These programs aim to educate individuals about mental health issues, including suicide warning signs. By debunking myths and presenting facts about suicide, these programs raise awareness of its preventability, reduce stigma associated with mental health and addiction, and encourage help-seeking behavior. Notably, these programs include videos featuring real stories of individuals with serious mental health challenges.
The United States hosts the “Question Persuade and Refer (QPR)” program, developed in response to the WHO’s assertion that suicide is not just an individual issue but requires national-level intervention. Created in 1995 by Paul Quinnett, QPR [19] is similar to CPR, serving as an emergency mental health intervention for suicidal individuals. It focuses on recognizing suicide warning signs, offering hope, and providing guidance on how to seek help to save lives.
In addition to these programs in Japan, Canada, and the United States, various other general and specific programs have been developed (Table 1).
Summary of international programs for suicide prevention
Domestic suicide prevention programs
Numerous entities in Korea, including local suicide prevention centers, universities, and mental health welfare centers, have developed and implemented their own suicide prevention programs (Table 2). We analyzed 27 domestic programs focused on adolescents’ suicide prevention. However, some programs have not been updated due to financial constraints. Despite the abundance of domestic suicide prevention initiatives, only a few are based on evidence.
Summary of domestic programs for suicide prevention
Review of psychological autopsy interview reports
In recent decades, psychological autopsy studies on suicides have become more prevalent. These studies involve interviews with key informants, examination of records, and follow-up studies with individuals who have attempted suicide. They provide critical insights into risk factors for adolescent suicide. Our review encompassed psychological autopsy studies of student suicides from 2015 to 2018. Identified suicide risk factors included psychiatric disorders (such as depressive disorder, anxiety disorder, attention deficit hyperactivity disorder, and media overuse); family psychopathologies (including maternal depression, family relationships, and parental divorce); psychological traits (such as introversion, fear of failure, obsessive-compulsive tendencies, and low self-esteem); experiences of suicide among close relationships; and school-related stressors, including academic pressure and conflicts with peers.
Survey
We conducted a survey of teachers, school counselors, and school principals regarding suicide prevention training. The survey covered various aspects, including the implementation of existing suicide prevention training programs, their frequency and duration, satisfaction with the training, and challenges faced. A key objective of the survey was to identify essential strategies for increasing the number of suicide prevention training initiatives.
Contents
Introduction
The introduction section of the Suicide CARE gatekeeper program takes about 10 minutes to complete. It outlines the role of gatekeepers and the structure of the program, and it emphasizes the current severity of the suicide issue based on statistics, focusing on the preventability of suicide and the effectiveness of the Suicide CARE approach. An attention-grabbing introductory video is included, highlighting that the adolescents’ suicide attempt rate was 3% in 2019, with approximately 300 adolescents dying by suicide annually. The video also addresses common struggles among adolescents, such as academic pressure, conflicts with parents, and peer disputes, and underscores the potential for intervention and assistance. According to statistics, the adolescent suicide rate in Korea in 2019 was 5.9 per 100,000 population, exceeding deaths from car accidents or cancer. In evaluations of Suicide CARE’s effectiveness, 20% of trainees reported encountering someone with suicidal ideation. Among these trainees, 95% applied the training by asking about and listening to suicidal concerns, and 71.5% provided information and connected individuals to professionals. These statistics reinforce the need for suicide prevention and the effectiveness of the Suicide CARE program.
Careful Observation
The “Careful Observation” section is the program’s first step. It educates about the verbal, behavioral, and situational signs that may indicate a high risk of suicide, emphasizing the importance of recognizing these signs. This is crucial since individuals contemplating suicide may not explicitly disclose their thoughts or intentions. Changes in students’ usual behavior can be indicative of suicide risk, necessitating vigilant observation to identify behavioral shifts. This segment also aims to enhance understanding of the processes leading to suicide. Given that warning signs in students at risk often go unnoticed, it is vital for teachers to become more familiar with these indicators. Therefore, suicide warning signs are categorized into three groups: verbal, behavioral, and situational (Table 3).
Subsections and core content of “Careful Observation”
Active Listening
The “Active Listening” step instructs on how to inquire about suicidal thoughts and listen attentively to the reasons for a desire for death. There is often hesitation to ask about suicidal thoughts due to fears that it might increase the risk of a suicide attempt or to uncertainty in the ability to respond adequately if students discuss such thoughts. However, inquiring about suicidal thoughts can help reduce them and enable appropriate responses, potentially preventing suicide attempts. Active listening helps in two ways: organizing and venting. Organizing refers to the process where a student verbalizes their thoughts, thereby creating logic and structure in their mind. It also allows them to listen to themselves and view their situation more objectively. Ventilation is akin to opening a window to let fresh air in; engaging in a calm conversation can alleviate frustration. This section includes examples and case studies to assist gatekeepers in practicing clear questioning and listening to students’ voicing suicidal thoughts (Table 4).
Subsections and core content of “Active Listening”
Risk Evaluation and Expert Referral
The “Risk Evaluation and Expert Referral” section focuses on assessing a student’s suicide risk and assisting them safely. It features sample questions for evaluating suicide risk, particularly regarding current suicidal thoughts and past attempts, and describes high-risk situations to aid in identifying emergencies. Once a risk is identified, the program outlines step-by-step interventions for safe assistance and advises on handling situations where a student refuses help, enhancing the practicality of the guidance. It also includes information on services currently provided by various organizations. Contrasting with a previous video that depicted an unsuccessful suicide prevention attempt, this section features a video with a positive outcome, demonstrating successful suicide prevention through careful observation, active listening, risk evaluation, and professional referral. This video serves to reinforce the motivation for gatekeepers. Suicide CARE involves a process of “Careful Observation,” “Active Listening,” and ultimately, referral to professionals by a gatekeeper for suicide prevention. An important reminder throughout this process is that gatekeepers are not expected to solve the entire problem on their own (Table 5).
Subsections and core content of “Risk Evaluation and Expert Referral”
DISCUSSION
The increasing concern over adolescent suicide highlights the importance of suicide prevention training for school staff. Given the significant amount of time adolescents spend in school, Suicide CARE for teachers, a gatekeeper program specifically tailored for school staff, is considered a highly effective method for identifying students exhibiting warning signs of suicide risk. This program was developed to meet the need for such specialized training.
Previous research indicates that many school staff members fail to recognize suicide warning signs in their students. Additionally, a majority of teachers report lacking the skills necessary to effectively address students’ suicide-related behaviors. The Suicide CARE for teachers program is designed to enable school staff to detect these warning signs, encourage students to discuss their suicidal thoughts, and respond suitably, including making professional referrals.
There are two key strengths of Suicide CARE for teachers. First, it is based on Korean psychological autopsy interview reports and a survey of teachers. The autopsy reports provided a comprehensive list of verbal, behavioral, and situational warning signs indicative of suicidal ideation in students. Insights obtained via the survey helped tailor the program to meet teachers’ needs and address the challenges they face in preventing student suicide, making the program both practical and evidence-based. Second, the program incorporates videos and numerous examples. These examples, applicable in real-world scenarios, are designed to be easily comprehensible and implementable.
We anticipate that this gatekeeper program will be an effective tool for reducing suicide rates by enhancing the knowledge and ability of school staff to deal with at-risk students. Training in Suicide CARE for teachers, alongside the previously developed Suicide CARE for students, is expected to significantly reduce student suicide rates.
Notes
Availability of Data and Material
The datasets generated or analyzed during the study are available from the corresponding author on reasonable request.
Conflicts of Interest
Jong-Woo Paik and Hong Jin Jeon, a contributing editor of the Psychiatry Investigation, were not involved in the editorial evaluation or decision to publish this article. All remaining authors have declared no conflicts of interest.
Author Contributions
Conceptualization: Yeon Jung Lee, Hyeon-Ah Lee, Hwa-Young Lee. Data curation: Hwa-Young Lee. Formal analysis: Kyong Ah Kim, Hwa-Young Lee. Funding acquisition: Jong-Woo Paik, Seon Wan Ki, Hwa-Young Lee. Investigation: all authors. Methodology: Kyong Ah Kim, Myungjae Baik, Jinmi Seol, Sang Min Lee, Eun-Jin Lee, Haewoo Lee, Meerae Lim, Jin Yong Jun, Hong Jin Jeon, Sun Jung Kwon, Hwa-Young Lee. Project administration: Jong-Woo Paik, Seon Wan Ki, Hong Jin Jeon, Hwa-Young Lee. Resources: Kyong Ah Kim, Myungjae Baik, Jong-Woo Paik, Jinmi Seol, Sang Min Lee, Eun-Jin Lee, Haewoo Lee, Meerae Lim, Jin Yong Jun, Seon Wan Ki, Hong Jin Jeon, Sun Jung Kwon, Hwa-Young Lee. Software: Hwa-Young Lee. Supervision: Jong-Woo Paik, Seon Wan Ki, Hong Jin Jeon, Hwa-Young Lee. Validation: Jong-Woo Paik, Seon Wan Ki, Hong Jin Jeon, Hwa-Young Lee. Visualization: Yeon Jung Lee, Hyeon-Ah Lee, Hwa-Young Lee. Writing—original draft: Yeon Jung Lee. Writing—review & editing: Yeon Jung Lee, Hyeon-Ah Lee, Hwa-Young Lee.
Funding Statement
This study was supported by grants from the School Mental Health Resources and Research Center and Soonchunhyang University Research Fund.
Acknowledgements
We would like to express our sincere gratitude to Professor Se-Won Lim for his dedication to the development of “Suicide CARE” versions 1.0 and 1.6.