FOREWARNING: At the time of writing, one of my efforts to stave off COVID-19 isolation-inducing madness has been to try my hand at gardening. Although the success of my ability to avoid madness may be debatable, one positive outcome from immersing myself in this new skill is that this review is full of thrilling, green-fingered analogies; you’re welcome!
Suicide prevention gatekeeper training (GKT) is a term which embodies the practice of educating the public on how to recognise, approach, and support a person at risk of suicide (WHO, 2014; Burnette, Ramchand, & Ayer, 2015). A wide array of diverse educational programs exist, but they tend to be united through their commitment to improving a set of core constructs; namely, these are factual knowledge about suicide; attitudes about suicide intervention; and self-efficacy to intervene in a suicidal crisis (Osteen, 2018; Burnette et al., 2015).
These core gatekeeping constructs are informed by two particular social cognitive theories, within which, specific antecedents are highlighted to mediate a person’s likelihood of engaging in a given behaviour (Cascammo Jr, 2011; Zinzow et al., 2018; Burnette et al., 2015). The primary theoretical framework for GKT is the Theory of Planned Behaviour (TPB; Azjen, 1985), which posits that a person’s behavioural intention is determined by their attitude, subjective norms, and perceived behavioural control (a factor originating from the Theory of Self-Efficacy; Bandura, 1977).
Existent GKT evaluation research suggests that the strategy produces promising immediate changes in the core constructs (Burnette et al., 2015). Commonly cited limitations, however, reside in the lack of follow-up data on the endurance of changes induced by GKT (Isaac et al., 2009); as well as, the important identification that improved behavioural intention does not translate into effective suicide prevention (Pisani, Cross, & Gould, 2011).
As promised, an analogised summary:
- Theory of Planned Behaviour antecedent = the seeds
- Gate Keeper Training = the topsoil
- Gate Keeper Training constructs = the budding stem
- Engaging in suicide prevention behaviour = a flourishing, vibrant tulip
- Gate Keeper Training evaluation literature = the fertiliser
This blog will explore a particularly exciting fertiliser, a systematic literature review conducted by Holmes, Clacy, Hermens, and Lagopoulos (2019), which investigates the long-term efficacy of gatekeeper training.
In their search for peer-reviewed articles, Holmes and colleagues utilised PubMed, Cochrane Library, and PsycNET online databases. Search terms included ‘gatekeeper’ and ‘suicid*’ present in the title and/or the abstract, with the terms ‘follow-up’, ‘pre-post’, or ‘long-term’ present anywhere in the text. Included studies needed to focus on a suicide specific program, such as SafeTalk, Question Persuade, & Refer, and applied Suicide Skills Training. Studies which included mental health care professionals were excluded from the review, as previous education and vocations are likely to skew outcome effects when compared with the general population. This exclusion is of further relevance, considering the particular utility of suicide prevention gatekeeper training (GKT) is its informal, community orientated nature (WHO, 2014). Studies must have included a participant assessment pre-test (T0), post-training (T1), and the addition of at least one follow-up assessment (T2), which is entirely relevant considering the aim of the study was to analyse constructs across time points.
Twenty-four relevant articles met the required criteria for this study. From these investigations, the follow-up periods ranged from 1 month to 24 months.
Knowledge about suicide
79% (n=19) of the total studies reviewed, assessed knowledge about suicide as an outcome measure, all of which demonstrated a significant improvement from T0 to T1. A large proportion of the studies (n=17) reported a significant decay in knowledge from T1 to T2. However, the majority of these studies (n=12) reported that despite the evident decreases of knowledge between T1 and T2, significant improvements from T0 (i.e. baseline) were maintained. Three studies found no changes from T1 to T2; and the remaining studies report a significant decrease in knowledge, almost reaching T0.
71% (n=17%) of total studies evaluated self-efficacy, all of which revealed a significant improvement from T0 to T1, as well as each reporting that follow-ups remained above baseline levels. Ten studies, despite reporting a significant deterioration of scores between T1 and T2, found that T2 assessment results remained significantly higher in comparison with T0. Three studies reported no significant reduction in self-efficacy between T1 and T2.
Attitude to prevention
Attitude was assessed by 29% (n=7) of the total reviewed articles. Two studies found that attitude increases remained at T2; however, 1 of these acknowledged that high T0 scores increase the studies susceptibility to ceiling effects* (i.e. reduces variability in data gathered). The other had a short time-period between T1 and T2, which may have increased the likelihood of maintenance. One study found that T2 was maintained above T0; however, T2 scores were significantly reduced from those at T1. The remaining four studies found no long-term effects of suicide prevention gatekeeper training (GKT) on attitude, three of which reported that assessment scores increased from T0 to T1, but subsequently returned to T0 levels.
38% (n=9) of the total studies reviewed, measured behavioural intention. Two studies found that there was no significant decline in behavioural intention from T1 to T2; five identified an increase from T0 to T1, with a reduction between T1 and T2. One study measured behavioural intention through both ‘likelihood’ and ‘preparedness’ to intervene, from which the former had no significant decline between T1 and T2; however, the latter did. The final study revealed no significant change in behavioural intention across T0, T1, and T2.
Suicide prevention behaviour
46% (n=11) of the total studies reviewed suicide prevention behaviour. From which, four identified an increase in behaviours subsequently to GKT. Two studies measured three categories of behaviour (identification, questioning, and referring), from which only referral behaviour increased between T0 to T2. Two studies identified that the application of knowledge increased during the follow-up assessment. Three studies found no changes in behaviour over time-points.
The review highlights the validity of suicide prevention gatekeeper training (GKT), concerning the strategy’s ability to exert positive effects over the core constructs, knowledge about suicide, and self-efficacy to intervene in a crisis. Also, within the studies reviewed, Holmes and colleagues found that improvements were maintained above baseline over time; however, that these positive changes do decay.
Strengths and limitations
The necessity of suicide prevention gatekeeper training (GKT) is accurately and coherently made. The article achieves what it set out to do, by providing a detailed and enlightening analysis surrounding the duration at which the positive effects of GKT appear to subside. The important link between GKT and theoretical models of behavioural probability (TPB and Self-Efficacy Theory) are appropriately discussed, grounding the rationale for GKT in a scientific framework. Moreover, the importance of follow-up data to research the efficacy of a suicide prevention strategy is argued, echoing advice from the WHO, (2018), though, in addition, the authors stress that follow-ups may also shine a light on the presence of GKs’ compassion fatigue!
With each critique I put forward, I do so while acknowledging that this is a systematic review of the long-term efficacy of GKT, and as such, it cannot entertain each detail of every extant GKT evaluation. However; as I hope this blog could at least add an ingredient to the GKT fertilisation process, it would be remiss of me if I did not highlight the fact that baseline scores (T0) for core constructs, as well as the observed influential power that GKT can exert over these scores at T1 and T2, can be impacted by more than merely the provision of GKT (Osteen, Frey, Woods, Ko, & Shipe, 2016). Holmes and colleagues; for instance, accurately highlight the importance of context during training evaluations, but do not appear to consider the influence of gender on core constructs. However, alongside the occupational effects that the authors noted (i.e. previous mental health training, and ‘captive’ versus volunteer environments), gender is cited as an important factor to be aware of when evaluating the efficacy of training. Females, for instance, appear to have broader previous experience with intervening in a friend’s or a relative’s suicidal crisis, are more likely to discuss their own suicidal ideations and attempts openly, and have more adaptive attitudes about suicide (Aseltine and DeMartino, 2004; Aseltine et al., 2007; Clark, 2010). Gender, therefore, may be a factor that increases the likelihood of ceiling effects when measuring core GKT constructs.
Moreover, Holmes and colleagues touch on teaching strategies used, categorised under ‘program attributes’. The discussion seems to be orientated around the value of program attributes during ‘booster-training’ and directed towards practice-based learning and spaced learning (learning over the course of time as opposed to in a single period) and subsequently suggests that role-playing activities do not exert an effect on gatekeeper outcomes. However, in a review of Question, Persuade, and Refer training, which in this instance incorporated an additional role-playing procedure, Cross, Matthieu, Cerel, and Knox (2007) concluded that the inclusion of a standardised simulation procedure enhanced the gatekeepers’ ability to directly ask about suicide, to encourage a person at risk to seek and accept assistance, as well as to choose an appropriate referral pathway. Furthermore, attendees responded favourably to partaking in role-play activities, attributing having done so, to enhancements in their suicide knowledge and intervention skills (Cross et al., 2007).
GKT evaluations can benefit from mixed-method designs, focusing on participant-directed feedback. Pre- and post-training scales are able to indicate areas of participant change and can, therefore, be used to validate a course’s ability to achieve standardised outcome measures (Frick, Chada, Watson, & Zlatkovska, 2010). However; in a meta-analysis of education evaluation procedures, the authors found that standalone quantitative data is limited in its capacity to provide comprehensive feedback on how and why a program may have had an impact on learners (Frick et al., 2010). Implementing qualitative feedback in addition, therefore, is advised during course evaluations (Choy and Lidstone, 2013).
Implications for practice
The implications of studying the long-term efficacy of core suicide prevention gatekeeper training (GKT) constructs, on future research and practice, might be best explained with another gardening analogy: hold on tight!
Understanding the endurance of the changes influenced by GKT is very useful when planning, implementing and evaluating a GKT course. Because if you support the theoretical seeds that are sown, and believe in the benefit of topsoil, then next, we need to anticipate the deterioration of the very stems that hold our vibrant tulip (suicide prevention behaviour). A decaying stem equals no beautiful budding flower. So, forewarning as to when deterioration is likely to ensue leads to researchers being forearmed with the ability to counteract it; with, for instance, the implementation of a well-timed GKT top-up program. In line with this pragmatism, the review further guides future research by highlighting an important methodological flaw in evaluations: short time points between measurements (i.e. comparing participant scores at T1 and T2, only four weeks apart, may unreliably highlight no decay in knowledge).
I feel that the research conducted by Holmes and colleagues (2019), situates itself as an extremely valuable fertiliser.
Statement of interests
My particular interest in this paper is inspired by my PhD research; wherein, I explore the effect of a culturally responsive GKT designed to support immigrants and refugees.
Glenn Holmes, Amanda Clacy, Daniel F. Hermens & Jim Lagopoulos (2019): The Long-Term Efficacy of Suicide Prevention Gatekeeper Training: A Systematic Review, Archives of Suicide Research, DOI: 10.1080/13811118.2019.1690608
Ajzen, I. (1985). From intentions to actions: A theory of planned behavior Action control (pp. 11–39). Berlin, Germany: Springer.
Aseltine, R. H., & DeMartino, R. (2004). An outcome evaluation of the SOS suicide prevention program. American Journal of Public Health, 94(3), 446–451. DOI:10.2105/AJPH.94.3.446
Aseltine, R. H., Jr., A. James, E. A. Schilling, and J. Glanovsky (2007). Evaluating the SOS Suicide Prevention Program: A Replication and Extension, BMC Public Health, Vol. 7, p. 161.
Bandura, A. (1977). Self-efficacy: Toward a unifying theory of behavioral change. Psychological Review, 84(2), 191–215. DOI:10.1037/0033- 295X.84.2.191
Burnette, C., Ramchand, R., & Ayer, L. (2015). Gatekeeper training for suicide prevention: A theoretical model and review of the empirical literature. Rand Health Q, 5(1), 16.
Clark, Tanisha R., Monica M. Matthieu, Alan Ross, and Kerry L. Knox (2010). Training Outcomes from Samaritans of New York Suicide Awareness and Prevention Programme Among Community- and School-Based Staff, British Journal of Social Work, Vol. 40, No. 7, pp. 2223–2238.
Choy, S., & Lidstone, J. (2013). Evaluating leadership development using the Most Significant Change technique. Studies in Educational Evaluation, 39(4), 218–224. https://doi.org/10.1016/j.stueduc.2013.09.001
Cascamo, J. A., Jr. (2011). Gatekeeper suicide prevention training and its impact on attitudes toward help seeking. Doctoral Dissertation, Walden University, Minneapolis, USA. Retrieved from https://scholarworks.waldenu. edu/dissertations/1061/
Cross, W., M. M. Matthieu, J. Cerel, and K. L. Knox (2007). Proximate Outcomes of Gatekeeper Training for Suicide Prevention in the Workplace, Suicide and Life-Threatening Behavior, Vol. 37, No. 6, pp. 659–670.
Frick, T. W., Chadha, R., Watson, C. & Zlatkovska, E. (2010). Improving course evaluations to improve instruction and complex learning in higher education. Education and Technology Research Development, 58, 115-136.
Isaac, M., Elias, B., Katz, L. Y., Belik, S.-L., Deane, F. P., Enns, M. W., & Sareen, J. (2009). Gatekeeper training as a preventative intervention for suicide: A systematic review. The Canadian Journal of Psychiatry, 54(4), 260–268. DOI:10.1177/070674370905400407
Osteen, P. J., Frey, J. J., Woods, M., Ko, J., & Shipe, S. (2016). Latent variable modelling of direct and indirect effects on clinical skills and behaviors following suicide intervention training. Suicide and Life-Threatening Behavior. DOI:10.1111/sltb.12288
Osteen, P. (2018). Suicide Intervention Gatekeeper Training: Modeling Mediated Effects on Development and Use of Gatekeeper Behaviors. Research on Social Work Practice, 28(7), 848–856. https://doi.org/10.1177/1049731516680298
Pisani, A. R., Cross, W. F., & Gould, M. S. (2011). The assessment and management of suicide risk: State of workshop education. Suicide and Life-Threatening Skill, 41, 255–276. DOI:10.1111/ j.1943-278X.2011.00026.x
World Health Organisation. (2014). Preventing suicide: A global imperative. Retrieved from Http:// www.who.int/mental_health/suicide-prevention/ world_report_2014/en/
World Health Organisation. (2018). Preventing suicide: A community engagement toolkit. Retrieved from https://www.who.int/mental_ health/suicide-prevention/engaging_communities_toolkit/en/
Zinzow, H. M., Thompson, M. P., Fulmer, C. B., Goree, J., & Evinger, L. (2018). Evaluation of a brief suicide prevention training program for college campuses. Archives of Suicide Research. DOI:10.1080/13811118.2018.1509749