Research & Evaluation

Shannonhouse L, Lin Y-W D, Shaw K, Wanna R, Porter M (2017): Suicide intervention training for college staff: Program evaluation and intervention skill measurement. Journal of American College Health.
This study examined the impact of ASIST training for college staff including faculty, counselors, administrators, and other support personnel. The results showed improvement in both self-assessed competencies and objective measures using the SIRI-2 scale compared to a control group. Areas of improvement included suicide intervention skills, attitudes toward suicide, knowledge of suicide, and comfort, competence, and confidence in responding to individuals at risk. The authors wrote: “these results agree with others that show ASIST increases SI- [suicide intervention] skills.”

Shannonhouse L, Lin Y-W D, Shaw K, Porter M (2017). Suicide Intervention Training for K-12 Schools: A Quasi-Experimental Study on ASIST. Journal of Counseling and Development. 
This study found that ASIST-trained school staff, including teachers and counsellors, saw improved knowledge and competencies on an objective scale (SIRI-2) compared to a control group. The areas of improvement included suicide intervention skills, attitudes toward suicide, knowledge of suicide, and comfort, competence, and confidence in responding to individuals at risk. The authors wrote that their findings provide “support for the use of ASIST in schools, particularly those in rural areas with limited access to mental health services.”

Ashwood, J S, Briscombe B, Ramchand R, May L, Burnam M A (2015). Analysis of the Benefits and Costs of CalMHSA’s Investment in Applied Suicide Intervention Skills Training (ASIST).
Conducted by researchers from the RAND Corporation, this cost-benefit analysis found that California’s implementation of ASIST will significantly reduce suicide attempts, deaths, and associated costs for years to come. Drawing on a wide cross-section of data, the research illustrates how ASIST training is a cost-effective way to save lives on a large scale.

Gould M S, Cross W, Pisani A R, Munfakh J L, Kleinman M (2013). Impact of Applied Suicide Intervention Skills Training on the National Suicide Prevention Lifeline. Suicide and Life-Threatening Behavior.
This Randomized Controlled Study found that callers who talked to a crisis line counselor trained in ASIST were statistically less suicidal, less depressed, less overwhelmed, and more hopeful than callers who talked to a crisis line counselor trained in a method other than ASIST. On the basis of this study, ASIST was listed on the United States NREPP (National Registry of Evidence-based Programs and Practices) under the new, stricter guidelines.

SAMHSA and ICF/MACRO (2010). Applied Suicide Intervention Skills Training: Trainee Experiences, Recommendations, and Post-Training Behavior.
This qualitative study of ASIST training participants found increased self-efficacy, heightened awareness, improved communication skills, increased information sharing and increased interventions due to ASIST training. 

Griesbach D, Russell P, Dolev R, Lardner C (2008). The Use and Impact of Applied Suicide Intervention Skills Training (ASIST) in Scotland: An Evaluation.
This Scottish study of ASIST found increased knowledge, helping attitudes, skills and interventions in ASIST-trained caregivers in addition to broad reductions stigma and increased suicide prevention awareness within communities and organizations.

McAuliffe N and Perry L (2007). Making it Safer: A Health Centre’s Strategy for Suicide Prevention. Psychiatric Quarterly.
This study demonstrated that ASIST training in a large community hospital contributed to improved clinical outcomes for consumers. Outcomes associated with ASIST training included increased identification of those at risk for suicide and a corresponding reduction in hospital admissions as hospital staff were better able to assess risk and provide appropriate alternatives to hospitalization.

REVIEWS

LivingWorks Education Inc (2013). Applied Suicide Intervention Skills Training: Evidence in Support of the ASIST 11 Program.
This review provides evidence in support of the rationale, content, teaching and learning processes of ASIST training, particularly as it applies to ASIST 11.

Rodgers P (2010). Review of the Applied Suicide Intervention Skills Training Program (ASIST): Rationale, Evaluation Results, and Directions for Future Research.
This review compiles results from 20 evaluations of ASIST from five different countries. The review found that ASIST training consistently increased knowledge, attitudes, skills and intervention behaviors of participants.

The purpose of this paper is to outline the rationale, conceptual framework, and evidence informing safeTALK.

safeTALK Literature Review: An Overview of It's Rationale, Conceptual Framework, and Research Foundations

Kaplan, G. (2018). A Formative Evaluation of the safeTALK Training in Manitoba. 
This study assessed the impact of safeTALK training across nine Manitoba schools, with participants including teachers, students, parents, and support staff. Findings indicated that safeTALK improved participants' self-assessed abilities to recognize when someone had thoughts of suicide and take appropriate steps in connecting them to safety. The study looked for iatrogenic safety effects as a result of training and found none, indicating that safeTALK posed no danger to any participants. A smaller follow-up study also looked at interventions, finding that a plurality of safeTALK participants reported carrying out an intervention based on their training.

Robinson J, Bailey E, Spittal M, Pirkis J, Gould M (2016). Universal Suicide Prevention in Young People: An Evaluation of the safeTALK Program in Alice Springs High Schools.
This study was conducted by researchers from Orygen, Australia’s National Centre of Excellence in Youth Mental Health, in collaboration with the University of Melbourne and New York’s Columbia University. It examined the impact of safeTALK training for high school students in Australia, finding increases in knowledge about suicide, confidence in talking about issues related to suicide, willingness to talk about suicide, and likelihood of offering and seeking help. The study also found that safeTALK was safe for the school students and that it had no ill effects on their mental health.

Niagara Region (2015). Evaluation of safeTALK Training in a Convenience Sample of 500 Niagara Health Region Residents, Health Professionals and Volunteers.
Conducted by the Niagara Suicide Prevention Coalition and Distress Centre Niagara, this study discovered that over 90% of participants felt “mostly prepared” or “well prepared” to ask someone about suicide after attending safeTALK, whereas less than 50% felt this way beforehand. In summary, the researchers wrote: “The resounding feedback was that those undertaking the training found it extremely useful if not for themselves, then for others (especially young people and general lay groups).”

McKay K, Hawgood J, Kavalidou K, Kolves K, O'Gorman J, De Leo D (2012). A Review of Operation Life Suicide Awareness Workshops: Report to the Department of Veterans’ Affairs.
Conducted by the Australian Institute for Suicide Research and Prevention, among others, this study found “…real and substantial improvements following safeTALK in (participants’) perceptions of their capabilities in dealing with a person who may be considering suicide and that these improvements did not deteriorate over a three-month period” (p. 43). Participants included veterans, veteran family members and veteran support providers. 

Eynan R (2011). Preventing Suicides in the Toronto Subway System: A Program Evaluation.
From the University of Toronto, this dissertation examined the impact of safeTALK and one other training program among transit workers, including constables, train operators, supervisors and others.  The author found increased “knowledge of suicide and suicidal behavior, enhanced positive attitudes toward the suicidal individual, suicide intervention, and improved intervention skills” (p. ii) through the use of both quantitative and qualitative methods.

Mellanby RJ, Hudson NP, Allister R, Bell CE, Else RW, Gunn-Moore DA, Byrne C, Straiton S, Rhind SM (2010). Evaluation of suicide awareness programmes delivered to veterinary undergraduates and academic staff.
Published in the journal Veterinary Record, this study found that safeTALK increased the likelihood that veterinary students would recognize signs of suicide risk, ask about suicide, and connect someone at risk with help. 

McLean J, Schinkel M, Woodhouse A, Pynnonen A, McBryde L (2007). Evaluation of the Scottish safeTALK Pilot.
Conducted by researchers from the Scottish Development Centre for Mental Health, this study focused on the use of safeTALK among a variety of audiences including mental health, physical health, education, law enforcement and corrections. The study found high levels of satisfaction and increased skills and confidence to intervene with someone at risk for suicide. 

The first independent clinical evaluation of suicide to Hope is currently underway.

Out of over 900 participants, 92% of the said that suicide to Hope gave them greater hope for success in working with people who have suicide experience, while 91% said suicide to Hope improved their knowledge and skills for working with those who have suicide experience.

suicide to Hope is an evidence-informed program developed in accordance with Rothman's six-stage social R&D model. Here are the sources consulted in the development of suicide to Hope:

• American Psychological Association (2014). Recovery to practice initiative curriculum: Reframing psychology for the emerging health care environment. APA: Author.
• Anthony, W. A. (1992). Psychiatric rehabilitation: Key issues and future policy. Health Affairs, 11, 164-171.
• Anthony, W.A. (1993). Recovery from mental illness: The guiding vision of the mental health service system in the 1990s. Psychosocial Rehabilitation Journal, 16 (4), 11-23.
• Anthony, W.A., Rogers, E. S., & Farkas, M. (2003). Research on evidence-based practices: Future directions in an era of recovery. Community Mental Health Journal, 39 (2), 101-112.
• Anthony, W.A., Cohen, M.R, Farkas, M.D. & Gagne, C. (2002). Psychiatric Rehabilitation. 2nd Ed., Boston: Center for Psychiatric Rehabilitation. Boston University. Cited in Recovery from Serious Mental Illness, www.bu.edu/cpr.
• Beck, A. T., Kovacs, M., & Weissman, A. (1975) Hopelessness and Suicidal Behavior: An Overview. JAMA, 234 (11), 1146-1149.
• Beck, A. T., Steer, R. A., Kovacs, M., & Garrison, B. (1985). Hopelessness and eventual suicide: A 10-year prospective study of patients hospitalized with suicidal ideation. American Journal of Psychiatry, 142, 559-563.
• Beck, A.T., Brown, G, Berchick, R.J. & Stewart, B.L. (1990). Relationship between hopelessness and ultimate suicide: A replication with psychiatric outpatients. American Journal of Psychiatry, 147, 190-195.
• Boardman, J & Roberts, G. (2014). Risk, safety and recovery. London: Centre for Mental Health and Mental Health Network, NHS Confederation.
• Bonano, G.A. (2009). The other side of sadness: What the new science of bereavement tells us about life after loss. New York: Basic Books.
• Bosse, H. M., Schultz, J. H., Nickel, M., Lutz, T., Möltner, A., Jünger, J., & Nikendei, C. (2012). The effect of using standardized patients or peer role play on ratings of undergraduate communication training: A randomized controlled trial. Patient Education and Counseling, 87 (3), 300-306.
• California Department of Mental Health (2008). California Strategic Plan on Suicide Prevention: Every Californian is Part of the Solution. Sacramento, CA: Author.
• Commonwealth Department of Health and Aged Care. (2000). Promotion, Prevention and Early Intervention for Mental Health—A Monograph. Canberra, Australia: Mental Health and Special Programs Branch, Commonwealth Department of Health and Aged Care.
• Cook, J. A., Copeland, M E., Jonikas, J. A., et al. (2011). Results of a randomized controlled trial of mental illness self- management using Wellness Recovery Action Planning. Schizophrenia Bulletin, 38 (4), 881-891.
• Crowe, T. P., Deane, F. P., Oades, L. G., Caputi, P., and Morland, K. G. (2006). Effectiveness of a collaborative recovery training program in Australia in promoting positive views about recovery. Psychiatric Services, 57, 1497-1500.
• Department of Health (2011a). Framework for Recovery-Oriented Practice. Melbourne: State Government of Victoria.
• Department of Health (2011b). Recovery-Oriented Practice Literature Review. Melbourne: State Government of Victoria.
• Duncan, B.L., Miller, S.D., Wampold, B.E. & Hubble, M.A. (2010). The heart and soul of change: Delivering what works in therapy (2nd ed.). Washington, DC: American Psychological Association.
• Everly, G.S. (2011). Fostering human resilience in crisis. Ellicot City MD: Chevron.
• Fairchild, R.W. (1980). Finding hope again: A pastor’s guide to counseling depressed persons. New York: Harper and Row.
• Farkas, M. & Anthony, W.A. (2010). Psychiatric rehabilitation interventions: A review. International Review of Psychiatry, 22 (2), 114-129.
• Frank, J.D. & Frank, J.B. (1991). Persuasion and healing: A comparative study of psychotherapy. Baltimore: Johns Hopkins University Press.
• Frankl, V. (1988). The will to meaning: Foundations and applications of logotherapy. New York: New American Library.
• Hernandez, J.G. (2011). Gabriel Marcel’s ethics of hope. New York: Continuum international publishing group.
• Hysong, S. J., Galarza, L., & Holland, A. W. (2007). A review of training methods and instructional techniques: Implications for behavioral skills training in U.S. astronauts. Hanover, MD: NASA.
• Jacobson, N., & Greenley, D. (2001). What is recovery? A conceptual model and explication. Psychiatric Services, 52 (4), 482-485.
• Jamison, K.R. (1999). Night falls fast: Understanding suicide. New York: Alfred A Knopf.
• Joseph, S. (2011). What doesn’t kill us: The new psychology of post-traumatic growth. New York: Basic Books.
• Kirschenbaum, H & Henderson, V.L. (Eds.) (1990). The Carl Rogers Reader. London: Constable.
• Knowles, M. S. (1980). The modern practice of adult education: From pedagogy to andragogy (Rev. ed.). New York, NY: Cambridge.
• Knowles, M. S., Holton, E. F., III, & Swanson, R. A. (2005). The adult learner: The definitive classic in adult education and human resource development (6th ed.). Burlington, MA: Elsevier.
• Lang, W.A., Ramsay, R.F., Tanney, B.L., Kinzel, T., Turley, B & Tierney, R.J. (2013). ASIST Trainer Manual. Calgary: LivingWorks Education Inc.
• Loveland, D., Randall, K. W., and Corrigan, P. W. (2005). Research Methods for Exploring and Assessing Recovery. In R. Ralph & P. W. Corrigan Eds. Recovery in Mental Illness: Broadening Our Understanding of Wellness. Washington DC: American Psychological Association.
• Mancini, A.D. & Bonano, G.A. (2012). Differential pathways to resilience after loss and trauma. In R.A. McMackin, E. Newman, J.M. Fogler and T.M. Keane (Eds.), Trauma therapy in context: The science and craft of evidence-based practice (pp. 73-78). Washington DC: American Psychological Association.
• Marcel, G. (1962). Homo Viator: Introduction to a Metaphysic of Hope. Emma Craufurd trans. New York: Harper and Brothers.
• McCranie, A. (2010). Recovery in Mental Illness: The Roots, Meanings, and Implementations of a “New” Services Movement. In D. Pilgrim & A. Rogers (Eds.) The SAGE Handbook on Mental Health and Illness. London: Sage Publications Inc.
• Mental Health Commission of Canada. (2009). Toward Recovery & Well-Being: A Framework for a Mental Health Strategy for Canada. Calgary, Alberta, Canada. Author. www.mentalhealthcommission.ca
• Mental Health Commission of Canada.(2015). Guidelines for recovery-oriented practice. Calgary, Alberta, Canada. Author. www.mentalhealthcommission.ca
• Park, N (2012). Adversity, resilience and thriving: A positive psychology perspective on research and practice. In R.A McMackin, E. Newman, J.M. Fogler and T.M. Keane (Eds.), Trauma therapy in context: The science and craft of evidence-based practice (pp. 121-140). Washington DC: American Psychological Association.
• Probert, J. (2014). Part I. Toward a more trauma-and recovery-informed practice of lethality assessment and suicide prevention. SAMHSA Recovery to Practice Highlights, 5 (4). Retrieved from www.dsgonline.com/rtp/wh/2014/
• Ragins, M. (2011). What’s really different about recovery? A case study. Exploring Recovery: The Collected Village Writings. Mental Health America of Los Angeles. Retrieved from www.MHALA.org
• Ralph, R. O. (2005). Verbal Definitions and Visual Models of Recovery: Focus on the Recovery Model. In R. Ralph & P. W. Corrigan Eds. Recovery in Mental Illness: Broadening Our Understanding of Wellness. Washington DC: American Psychological Association.
• Ralph, R. O., Kidder, K. & Phillips, D. (2000). Can We Measure Recovery? A Compendium of Recovery and Recovery-Related Instruments. Cambridge, MA: The Evaluation Center, Human Services Research Institute.
• Repper, J & Perkins R (1913). The team recovery implementation plan: framework for creating recovery-focused services. London: Centre for Mental Health and Mental Health Network, NHS Confederation.
• Rodgers, M. L., Norell, D. M., Roll, J. M., and Dyck, D. G. (2007). An overview of mental health recovery. Primary Psychiatry, 14(12), 76-85.
• Rogers, C.R. (1942). Counseling and psychotherapy: New concepts in practice. Boston: Houghton Mifflin.
• Rogers, C.R. (1957). The necessary and sufficient conditions of therapeutic personality change. Journal of Consulting Psychology, 21, (2) pp. 95-103.
• Rosenzweig, S. (1936). Some implicit common factors in diverse methods of psychotherapy: “At last the Dodo said, ‘Everybody has won and all must have prizes’”. American Journal of Orthopsychiatry, 6, 412-415.
• Rudd, M.D., Joiner, T & Rajab, M.H. (2001). Treating suicidal behavior: An effective, time-limited approach. New York: The Guilford Press.
• SANE Australia. (2013). Suicide Prevention and Recovery Guide: A Resource for Mental Health Professionals. South Melbourne, AU: Author.
• Shepherd, G., Boardman, J. Rinaldi, M. & Roberts, G. (2014). Supporting recovery in mental health services: Quality and outcomes. London: Centre for Mental Health and Mental Health Network, NHS Confederation
• Shneidman, E.S. (1996). The suicidal mind. Oxford: Oxford University Press.
• Slade, M. (2010). Mental illness and well-being: The central importance of positive psychology and recovery approaches. BioMed Central Health Services Research. Retrieved from www.biomedcentral.com/1472-6963/10/26.
• Snyder, C.R. (1994). The psychology of hope: You can get there from here. New York: The Free Press.
• Steger, M.F. & Park, C.L. (2012). The creation of meaning following trauma: Meaning making and the trajectories of distress and recovery. In R.A McMackin, E. Newman, J.M. Fogler and T.M. Keane (Eds.), Trauma therapy in context: The science and craft of evidence-based practice (pp. 171-192). Washington DC: American Psychological Association.
• U.S. Department of Health and Human Services (HHS) Office of the Surgeon General and National Action Alliance for Suicide Prevention. (2012) National Strategy for Suicide Prevention: Goals and Objectives for Action. Washington, DC: HHS.
• U.S. Department of Health and Human Services. (2003). New Freedom Commission on Mental Health, Achieving the Promise: Transforming Mental Health Care in America. Final Report. Rockville, MD: Author.
• U.S. Department of Health and Human Services. (2009). Access to Recovery (ATR) Approaches to Recovery-Oriented Systems of Care: Three Case Studies. Rockville, MD: Author.
• U.S. Department of Health and Human Services. (2012). SAMHSA’s Working Definition of Recovery: 10 Guiding Principles of Recovery. Rockville, MD: Author.
• Wampold, B.E. (2011). Qualities and actions of effective therapists. Washington DC., American Psychological Association, CEP series.
• Wampold, B. E. & Imel, Z.E. (2015). The great psychotherapy debate: The evidence for what makes psychotherapy work. (2nd Ed.). New York: Routledge.
• Warner, R. (2010). Does the scientific evidence support the recovery model? The Psychiatrist, 34, 3-5.
• Webb, D. (2010). Thinking about suicide: Contemplating and comprehending the urge to die. Ross-on-Wye: PCCS Books.
• Yalom, I.D. (1980). Existential psychotherapy. New York: Basic Books.
• Yohani, S.C. & Larsen, D.J. (2012). The cultivation of hope in trauma-focused counseling. In R.A. McMacklin, E. Newman, J.M. Fogler and T.M. Keane (Eds.), Trauma therapy in context: The science and craft of evidence-based practice (pp. 193-210). Washington, DC: American Psychological Association.

One of the ways we calculate our impact is by estimating the number of interventions carried out by people trained in our programs based on the best available data. You can find some of these impact estimates in our LivingWorks overview. Here is the methodology that we use to provide these estimates:

Determining the number of interventions: This figure is based on Condron et al.’s finding that ASIST-trained school staff carried out an average of 0.62 interventions resulting in further care for the intervention recipient within three months of the workshop. The same study found that safeTALK-trained school staff carried out an average of 0.39 suicide alert interventions within three months of training. The study by Condron et al. appears in Suicide and Life-Threatening Behavior 45 (4) August 2015, p. 461-76. To account for periods longer than three months, we multiply the intervention rates. For example, to estimate the number of interventions over a six-month period, we double the three-month rates provided by Condron et al. This assumes school intervention rates are reflective of the general population, and assumes no decrease in the frequency of interventions as time goes on within the first year of training.

Determining the number of attempts averted: This number is based on SAMHSA’s 2013 national survey, comparing the number of American adults who expressed suicide thoughts in the past year (9.3 million) against those who attempted suicide (1 million). As 1 million is 14 percent of 9.3 million, the result suggests that approximately 14 percent of people with suicide thoughts progress to attempting suicide. This assumes that adult American suicide thought-to-attempt ratios are indicative of the general world population. The information can be found here. Accordingly, we inferred that because 14 percent of people with suicide thoughts would progress to a suicide attempt, 14 percent of interventions resulted in an averted suicide attempt.

We continue to monitor studies on the impact of our programs to improve our methodology and refine our estimates.

Want a quick snapshot to view or share with others?  What's the Evidence of Effectiveness highlights the latest peer-review studies and government reports on LivingWorks programs. If you have questions about any of the studies, you can also contact us.

We encourage rigorous evaluation of our programs. If you are interested in additional evaluation information or are considering carrying out an evaluation of your own, we invite you to read over the documents listed below and then contact us for more details.

• Considering ASIST Evaluation Research
• Considering safeTALK Evaluation Research
• Considering suicide to Hope Evaluation Research