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My Journey in Suicide Prevention


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Richard Ramsay\'s 45 year journey in suicide prevention from 1968 to 2011

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My Journey in Suicide Prevention

  1. 1. My 45 year journey in suicide prevention: From Ottawa to Washington DC with several stops along the way 2011 Annual Saskatchewan Trainers Conference November 16-18, 2011
  2. 3. Supporting Cast <ul><li>In the beginning . . . </li></ul><ul><li>7 development volunteers </li></ul><ul><li>Devolved to 4 founders </li></ul><ul><li>By 1999 . . . . </li></ul><ul><li>3 founders plus 1 </li></ul><ul><li>1 full time staff </li></ul><ul><li>Now . . . </li></ul><ul><li>36 full time and contract </li></ul><ul><li>Calgary </li></ul><ul><li>Edmonton, Toronto, Ottawa </li></ul><ul><li>NC, CO, AZ, DC </li></ul>
  3. 4. The Journey Begins . . . <ul><li>Any review of SP training, research, intervention in NA has to start with the LASPC and its founders – Farberow, Shneidman, Littman, Heilig. All of us have tried to build on their shoulders ever since. My remarks may sound more like a travelogue of interesting places than musings on suicide prevention. I begin in Ottawa go west to Edmonton and Calgary, then north to Yellowknife. South to California - the break of our lives, up to Washington, Oregon, cross to Colorado and down again to Arizona and Nevada, over to Aus, jumping continents to Norway over to UK and Ireland, back to the U.S. - several more states and eventually to Washington, DC. Don’t be surprised if several unannounced side trips pop-up. </li></ul>
  4. 5. The Nation’s Capitol . . . <ul><li>It all starts Centennial year - 1967- in Ottawa with little to no awareness of LASPC or Samaritans. Just a young SW in a new position – director of a 1 person JHS branch – me! That is until I met a Samaritan advocate who had recently arrived from England. Disturbed at the lack of a telephone crisis line, she set about to change that. I got caught up in her enthusiasm (not knowing of a prof-vol conflict underlying her quest as profs had tried to set up an after hours crisis line to support the police that had failed) and ended up being 1 of 4 founding members – the young advocate, 2 clergymen and myself. She was the obvious director/leader. The clergymen volunteered to raise funds and find donated furniture. Still being unsure of why I was there, I didn’t volunteer. I was told there was one job left and it looked like I had it. Turned out (obviously) that someone had to train the volunteers. My hoped for salvation was to turn to my recent social work education only to discover I had learned at the knee of supervisors combing over lengthy process records of my casework interventions. This was hardly a good model for someone on the line with no immediate access to a supervisor. In retrospect, maybe the process record was a forerunner to the manualized op procedure script we now provide as a guide to trainers. </li></ul>
  5. 6. The Nation’s Capitol . . . <ul><li>I developed a Listening Model graphic that listeners could place by the phone and use as a “c h eat sheet” if they needed it and serve as a self-supervision guide in the middle of a call. Turned out to be the forerunner of SIM – a simple 4 part stepping stone model with recycle circles in each step. </li></ul><ul><li>A very important lesson learned came out of our pre-operation training. The LM was meant to be a foundation for all crisis calls. On top of that extra sessions were given to deal with special calls – still the usual for anyone connected to crisis lines - suicide, drunk, silent, sexual calls. The volunteers were understandably nervous about the suicide call. The literature I had said suicide constituted no more than 10% of the calls, probably less. My attempt to alleviate (M-Dismiss-A their worry was to reassure them that the likelihood of such a call was quite low. That changed very quickly when one of the first training class volunteers scolded me at a volunteer function shortly after the line opened. Guess what happened my first night on the line, he said. His first two calls were both suicide risk situations. I got my first hard knocks lesson in dealing with suicide openly and directly. Avoidance was not on! Suicide can be an issue any time, any place and with anyone. I learned my lesson but not completely as I will describe later. </li></ul>
  6. 7. West to Edmonton . . . <ul><li>Adding a distress line to AID centre had me engaged in my 2nd start-up </li></ul><ul><li>Exposed to LASPC for first time as conference speakers invited to help us with crisis line work in Alberta. </li></ul><ul><li>One of them played a audio recording of a real call that years later became our Shot gun exercise. She was faced with the Give me a reason or I will shoot myself on line. She told us of her spontaneous, without thinking, not-by-the-book response “Yo u must be going through a rough time” or something close. Instant engagement was successful. Her safeplan, when the recording got to that point, wasn’t nearly as impressive. It was direct enough but totally absent of anything that resembled a collaborative safeplan. It was an abrupt command-like response. “Y o u are at risk! Be here for a 2pm appointment”. </li></ul>
  7. 8. North to Yellowknife . . . <ul><li>A branch of my Edmonton experience led me to the NWT to help open their first crisis line. </li></ul><ul><li>2 nd lesson in what not to reassure volunteers about and the folly of thinking you know something about cultural differences. </li></ul><ul><li>Training was more focused on suicide crises by now and we knew more about special calls. This time the volunteers in training were concerned about sexual calls – the masturbator call in particular. </li></ul><ul><li>Forgetting the hard knocks lesson learned in Ottawa I confidently reassured them that this type of call was common in the South but not likely something they would encounter in the North. “G u ess again” was tapping me on the shoulder. First call when line opened was – you guessed it – the call they didn’t have to worry about. It was if he had been lying in waiting for the official opening. Lesson about dismissing possibilities finally sunk in. </li></ul>
  8. 9. Down to Calgary . . . 70s <ul><li>Beginnings of LW team; Started with Tanney and me . </li></ul><ul><li>Both volunteers in community crisis care committees. </li></ul><ul><li>Think Tank 5-yr plan with CMHA – Bryan’s leadership; unique membership – paired professionals - and motivated with promise – don’t have to work, just think. Eventually back fired. We were stuck in the end with doing the work. </li></ul><ul><li>Plan called for public awareness, frontline training, computer accessible library; gatekeepers first priority </li></ul><ul><li>Report shelved - no funds to do it </li></ul>
  9. 10. Calgary . . . 80s <ul><li>Gov’t takes action on Boldt Report; sets strategy goals: info, training, interagency community coordination, research; Establishes citizen advisory committee (me included) to work with Prov Suicidologist. Gave us fiscal authority as long as no conflicts </li></ul><ul><li>Recommendations similar to CMHA plan; integrated into strategy. Training start-up assigned to me; library start-up to Bryan; research centre planning to both of us. </li></ul><ul><li>Rest of training team came together – Roger and Bill joined with psych and curriculum development backgrounds; curriculum designed and piloted; year long field tests of curriculum and T4Ts. </li></ul><ul><li>Knowledge of Snyder and Maris work in 70s surfaced. As almost 10 years old we wrongly assumed that someone had already developed the needed training. Turned out not so. Decided to give it a try: </li></ul><ul><li>Standardized foundation curriculum with add-on module or program flexibility, large scale dissemination, quality control trainer delivery; </li></ul>
  10. 11. ASIST is reviewed and updated on a 5-year cycle <ul><li>Based upon Rothman’s social R & D method </li></ul><ul><li>Four stages of intervention development and dissemination </li></ul><ul><ul><li>Collecting and assessing available knowledge </li></ul></ul><ul><ul><li>Creating and pilot testing an initial design </li></ul></ul><ul><ul><li>Refining program & preparing for dissemination </li></ul></ul><ul><ul><li>Disseminating program </li></ul></ul><ul><li>R&D method allows cultural and practical adaptations to meet local needs. </li></ul><ul><li>Stages are dynamic, continuous process of program improvement. </li></ul>Development of ASIST
  11. 12. Calgary . . . 80s <ul><li>Discovered social R&D method to transfer generated knowledge into practical applications; converted from industrial R&D by Jack Rothman Uof Michigan SW professor in the late 70s and early 80s. </li></ul><ul><li>Focused on minimum application knowledge needed for caregivers to make a difference. Drew on LAPSC discovery of risk estimation knowledge: stress, symptoms, R esources, P rior behavior, C urrent plan – reverse order assessment. </li></ul><ul><li>Surfaced another order of conflict: old guard and 1 st generation introduction of something new; rift was deep enough that voice of critics CMHA put a stop to development – forced into a 6 month moratorium and 3 external evaluators - Roman Coliseum thumbs up/down mandate to determine our fate. Gave a whole new meaning to our current thumbs up OK signal. </li></ul><ul><li>Literature identified absence of attitude component in skills training on stigma affected subjects. Pioneered inclusion of attitudes component, use of trigger-tape technology – 1 st Cause of Death? Produced film w/o curriculum development support </li></ul>
  12. 13. Calgary . . . 80s <ul><li>Tierney dissertation discovers identified suicide intervention skills – ask directly in a timely manner (pre-17; post-9min) </li></ul><ul><li>Corrections Canada evaluation discovered life altering changes from being trained – reason to live to lifers and others helping visitors who were at risk. </li></ul><ul><li>Drew on expertise of Farberow and 5 others to provide research centre advice (3 U.S.; 3 UK). AISR - our major failure. UQAM and UMB Health Sciences have answered filled the gap. </li></ul><ul><li>UN request to correct error in believing suicide was primarily a MH problem; led to our leadership 15 reps from 12 countries develop UN national strategy guidelines. Tremendous support from U.S. reps: Lloyd Potter, Mort Silverman, Peter Meuher </li></ul>
  13. 14. California . . . mid 80s <ul><li>Link to LASPC happened w/o our awareness; Farberow’s report to DMH on youth SP recommended training component be provided by Canadians from Alberta. No one in the world had anything comparable. Result: 3 year sole source contract to place 2 trainers in every county. </li></ul><ul><li>Relationship lived for 10 years; produced a self-supporting trainer team. Kathyrn vB was a key member. Application of practical training; research was secondary; done by a few independent evaluators; </li></ul><ul><li>Informal feedback from satisfied counties: first program of value offered by state to county MH. Visited Jack Rothman now at UCLA to let him know that social R&D works. State-wide training was positive proof of large scale dissemination phase. None of his own R&D projects had ever reached the final stage. </li></ul><ul><li>Years later when LW received the Canadian Knowledge Broker Award , I told Jack of my acceptance remarks that included his part in the achievement. Deeply grateful at the public recognition of something that he had no idea would be all that important. </li></ul><ul><li>Full circle again in 2011, LW submitted and was awarded $1m 3-year contract to provided complementary/layered training programs to CA network of counties. Will see the launch of e-SuicideTALK </li></ul>
  14. 15. Washington . . . mid 90s <ul><li>Missed sole source invitation - one of two trainings recommended in a DOH study: ASIST and QPR (a new WA program at that time). ASIST prevailed. Agreed to use QPR as the trainer awareness program instead of our YSAP, forerunner of SuicideTALK. </li></ul><ul><li>This time focus on research ; Project team led by UofW nursing researchers; good evidence of training benefits compared with general public. Value of training youth in SFA was established; performance was equal to comparable adults. </li></ul><ul><li>Down side was never seeing the research reports prepared for peer review publication. </li></ul><ul><li>Research leader (Eggert) and I asked to write Forewords for a Lee-Ann Hoff Crisis book in 1998. 1st edition foreword by AG Everett Koop. Hoff one of thumbs-up evaluators (‘84). All 3 reprinted in new 2012 edition for their continued relevancy. Good News - Bad News! </li></ul>
  15. 16. Caregivers Early intervention Attitudes Knowledge Skills Resources Connecting Und’standing Assisting Networking support First-aid treat effectiv e behaviors received entered Core knowledge 1973 Retention ASISTR 2003 1st aid, support, treatment ASIST workshop 1985 I.0 2004 X.0 2010 X.1.6 2013 XI.0 Behavioral results Gatekeeper Training Program Foundation Workshop (FW) Suicide Intervention Workshop (SIW)
  16. 17. U of C researchers helping suicide prevention across the world By Greg Harris, Gazette staff The Surgeon General of the United States has adopted a national policy statement on suicide prevention that has its roots at the University of Calgary. Richard Ramsay, a professor in the Faculty of Social Work, says the impetus for the American suicide prevention strategy can be traced to a 1993 Banff conference he organized with Bryan Tanney, Department of Psychiatry, at the invitation of the United Nations. At that conference, representatives from 14 countries created a policy document for the UN called Prevention of Suicide: Guidelines for the Formulation and Implementation of National Strategies. The Surgeon General’s policy statement is the latest highlight for Ramsay and LivingWorks Education Inc., a University Technologies International Inc. start-up company that provides training in suicide intervention.
  17. 18. Arizona . . . 1995 <ul><li>AAS in Phoenix (April) - met Jerry Weyrauch, founder of SPAN. Never heard of him; Banner and draft copy of 1993 UN Guide on an otherwise bare exhibit table. </li></ul><ul><li>Sept 9th - wrote me about his dream - to mobilize survivors to influence political support for a national strategy; will march on Capitol Hill next Mother’s Day with thousands of petition letters. </li></ul><ul><li>Serendipitous notice of dream come true reached me during ASIST portability F-Trial in Australia. Similar reunion in DC this past Sept 9. </li></ul><ul><li>Kept a scrapbook of the origins of the 1991 UN interest in suicide- to the 1993 UN meeting in Calgary - and all the stepping stones that saw the “social movement” influence of SPAN spread throughout the country to the final stages of launching the U.S. strategy in 2001. </li></ul><ul><li>No other record of its kind was kept. Now, with a paper I presented to AAS in 2001, it is being used to help revise the U.S. National Strategy for Suicide Prevention in 2011. </li></ul>
  18. 19. Nevada . . . 1998 <ul><li>Bryan and I only out of country guests at Reno Summit that saw 450 reps gather for 4 days to draft Consensus Conference recommendations for a national SP strategy that were hand delivered to the U.S. Surgeon General at the closing event; </li></ul><ul><li>The next year the SG issued a Call to Action for an independent national strategy - separated from a revised MH strategy. </li></ul><ul><li>2 years later U.S. had its first comprehensive national strategy modeled on the UN’s citizen initiated initiative. Lloyd Potter slipped me note on a copy of the draft given to the Surgeon General that said “wi thout your involvement no one knows this would never have happened”. </li></ul><ul><li>Full circle on this too. U.S. launched a plan on 2010 WSPD to update their 10 year old strategy. </li></ul><ul><li>I was appointed to NSSP Revision Task Force in Jan 2011. April 2012 target date. Been a regular commuter to DC all year. Marks my 3 rd decade of active involvement in the development of national strategies: UN meeting (1993), Reno Summit (1998), U.S. strategy (2001), U.S. Revision (2011). Likely to be my last decade at this level. </li></ul><ul><li>With Heather Stokes our new business development VP, we have a permanent presence in DC. From one national capitol to another in a short 45 years. </li></ul>
  19. 20. NSPL 273-TALK . . . 2006 <ul><li>2006 NSPL – election of Gary M (OR) and Kathyrn vB (AZ) to standards committee and expert review of several training programs to select one that was closest to training standards of NSPL. </li></ul><ul><li>ASIST was chosen over others reviewed. Crisis network centers voluntarily decided to include ASIST into their standards </li></ul><ul><li>5 years later more than 60% have adopted ASIST and in the spring of 2010 the Didi Hirsch center in LA included ASIST as part of their training standard. An accomplishment never dreamed of at any time in 45 years but one I couldn’t be more proud of. </li></ul><ul><li>To put icing on our LASPC connection, Didi Hirsch is now one of 3 crisis center partnerships involved in the dissemination of training through the 2011 CA award. </li></ul><ul><li>From the innumerable gifts we received from Norm Farberow, the research of Sneidman, Farberow and others, and the training tips from key staff since the early 70s, we have been able to gift a little back to their unmatched legacies. </li></ul>
  20. 21. International . . . 1996 and beyond <ul><li>From portability Field Trials in Australia to emerging opportunities in South Korea and South Africa, the scope is unlimited. </li></ul><ul><li>Norway was the first to full adapt and translate program Evolved from training medical students at the University of Northern Norway to a permanently funded component of Norway’s national strategy. Adapted to work with indigenous Sami in far north. Led to developments in Barrants Region of northern Russia. </li></ul><ul><li>Spread to UK through N. Ireland and ground work of Sue Eastgard (WA) and Frank Campbell (LA). Became part of Scotland’s 10 year strategy in 2002, Ireland 2005, Wales 2008 and substantially embedded in England thru Grassroots Training. </li></ul><ul><li>Training in Australia has spread to NZ and Pacific Islands, including Guam </li></ul><ul><li>In the U.S., the spread from CA and WA is almost to long to list: OR, CO, MT, WY, AZ, NM, TX, LA, IL, TN, MI, NY, VA, CT, NC, AK, HI, MD . . . Not to mention Army, AF, NG, CG, AR and combat zone workshops in Afghanistan and Iraq - never done before. </li></ul><ul><li>Our history with U.S. Army goes back to 1989 when we were invited to be part of a major fitness program in Germany. ASIST is now one of two approved Army SP training programs. </li></ul>
  21. 22. Research and Evaluation . . . <ul><li>CSC prisoner feedback eval – new meaning of life to those without freedom and the those close to them that they helped - risk assessments with family-visitors </li></ul><ul><li>Roger’s ground breaking contribution to measurable skills of SI </li></ul><ul><li>Pioneering social R&D in SP against many odds, reluctance of university evaluators to give Bryan and I recognized credit for this research. </li></ul><ul><li>National evaluations in Norway, Scotland, Ireland, U.S. Wales, Canada (VAC) paved the way for national adoption of the program and recognition that training is one of the best ways to get mainstream adoption of SP initiatives. </li></ul><ul><li>First large scale, RCT of training program funded by SAMHSA (approved by NIMH) to document transfer of learning from manual to T4T to SI in a CI call. </li></ul><ul><li>Building on NOR medical student research; UofMB conducting first ever RCT study comparing ASIST vs TAU. </li></ul><ul><li>Evaluations with ASIST involvement have documented decreases in suicide – Ireland, Scotland, Colorado; positive impact on agency policies and interagency ways of working together. </li></ul><ul><li>Being part of the GLS cross-site evaluations of funded projects had more projects (50%) using LW programs than any other program. One of two (ASIST & QPR) most used programs in all projects. </li></ul>
  22. 23. Suicide Risk Assessment Patient Safety Project (N=600 beds) <ul><li>A caring conversation </li></ul><ul><ul><li>focus group research. Patients said abrupt questioning about suicide was not helpful. SRA should be part of a caring conversation. 8 </li></ul></ul><ul><li>Success </li></ul><ul><ul><li>SRA project selected ASIST. Clinical outcomes improved. Staff felt more supported to ask about suicide and have the skills to effectively intervene. Patient bed days were saved. </li></ul></ul><ul><li>Leading Practice </li></ul><ul><ul><li>Accreditation Canada recognized Trillium’s SSRA project as a national Leading Practice in 2007. 10 </li></ul></ul><ul><li>Lengthy Process </li></ul><ul><ul><li>Took 4 years of task force and staff time. LW is proud of this partnership. Similar leading practices are possible in other health systems. </li></ul></ul>
  23. 24. <ul><li>Arizona Workforce Survey (N=1600) </li></ul><ul><li>Based on % above mean: </li></ul><ul><ul><li>ASIST-trained tied clinicians (6% + ) but behind nurses, physicians </li></ul></ul><ul><ul><li>ASIST Trainers 1st overall (15% + ), ahead nurses, physicians, clinicians </li></ul></ul><ul><li>Moving community mental health from Niche Expertise to Core Focus </li></ul><ul><li>Making suicide prevention our primary business: </li></ul><ul><ul><li>Train the entire work-force with ASIST </li></ul></ul><ul><ul><li>2000 by end of 2010 (87%); 100% by March 2011. </li></ul></ul><ul><li>Change culture & equip case managers, clinicians, physicians, nurses with the skills, knowledge, attitudes and support </li></ul>