The goal of the current study is to assess the potential for enhanced proximal outcomes of brief, community-based gatekeeper suicide prevention training for youth by (a) testing the impact of a theoretically supported, active learning behavioral rehearsal condition and (b) broadening the targets for a school-based training strategy to include parents. We used a randomized control design and standardized patient assessment methods to evaluate gatekeeper skills following training and at follow-up. As expected, knowledge and attitudes improved from pre to post and were maintained at follow-up for both training condition groups. Our findings are consistent with previous research showing a brief (1-h) gatekeeper training program effectively changes knowledge and attitudes over time (Keller et al. 2009
; Tompkins et al. 2010
; Wyman et al. 2008
). Contrary to our hypothesis, however, practicing gatekeeper skills did not further improve these enhanced knowledge or attitude outcomes.
We also compared the impact of gatekeeper training on school personnel and parents. Our results showed no difference between school staff and parents in terms of knowledge or attitudes about youth suicide prevention at baseline or after training. We were initially surprised that teachers and other school personnel who work daily with youth were no more knowledgeable or confident about intervening with suicidal youth than parents. Upon reflection, however, we realized that, with the exception of mental health professionals, school personnel do not typically receive training about mental health issues including suicide prevention (Koller et al. 2004
; Walter et al. 2006
). School personnel and parents are, therefore, equally uninformed when it comes to suicidality and, without specific training, hold similar attitudes and beliefs about youth suicide. This finding is particularly salient for the community partner because, unlike parents, teachers deal daily with a high concentration of youth, and up to 5–10% of students may have diagnosable mental health symptoms that are likely to impact learning and student well-being. The implication is that being a classroom teacher does not guarantee an educator will have a working knowledge of mental health concerns, especially suicidality, which might affect students. Considering the significance of suicidal thoughts and behavior among youth, this finding suggests that school-based training of teachers and administrators about how to identify and respond effectively to mental health issues that arise in the classroom should be part of a comprehensive approach to mental health issues in the school setting. Moreover, the training can be as brief as 1 h to have a positive and enduring impact on knowledge and attitudes. The community partners were particularly interested in this finding.
We anticipated that participants who had the opportunity to practice would demonstrate significantly better gatekeeper skills after training and at follow-up than those who received the standard training. Results showed that rigorously assessed, observed gatekeeper skills were improved with role play practice. In particular, the general ability to communicate comfortably with a youth in distress was enhanced, as was the specific ability to ask directly about suicide. Although the positive impact of practice persisted over time, both training conditions showed significant decrements at follow-up. Thus, while practice did improve skills the impact was certainly not perfect.
How can enhanced training skills be maintained over time? Because interacting with suicidal youth is a low-base-rate event, there is little opportunity for newly trained gatekeepers to use, and thus retain, their abilities. Simply put, skills decay without use. One clear implication is that boosters may be needed for effective gatekeeper training. Several strategies may be enlisted to support maintenance of gatekeeper skills including reminders via video applications for phones or web-based interactive practice opportunities (Hanauer et al. 2009
Positive practice effects may be further enhanced and maintained with feedback. In the current study, we provided feedback to participants on their skills assessment with actors only at follow-up as part of the debrief process. Adult learning models indicate that feedback on performance during the learning process enhances outcomes (Hattie and Timperley 2007
). Future studies that incorporate feedback on demonstrated gatekeeper skills during role play practice and, potentially, following skills assessment could strengthen gatekeeper skills which may improve maintenance over time.
We anticipated that role play practice would improve participants’ ability to ask directly about suicide. The difference between the two training conditions was consistent with our expectation, but it was only a trend. What accounts for this finding? One factor may be that there was an attempt to desensitize participants during the large group training attended by all participants: Trainers led the whole group in repeating “are you thinking of killing yourself” and “are you feeling suicidal.” This small addition to the standard training may have been sufficient practice to confound the difference between conditions. Nevertheless, survey feedback from participants across conditions indicated that asking directly about suicidal thoughts and feelings was extremely difficult. Given our findings, community-level gatekeeper training requires modifications to prepare participants to develop and comfortably use gatekeeper skills. Alternatively, it may not be reasonable to expect this level of gatekeeper training to transform all comers into active gatekeepers in their communities. A selection process that targets those who are most likely to learn and use gatekeeper skills within a brief training program may be necessary.
Another way to evaluate training outcomes is to define adequate gatekeeper behaviors. Cross et al. (2010)
defined participants as having adequate gatekeeper skills if they asked directly about suicidality (Q
-score = 3), used persuasive communication for help-seeking (P
-score ≥2), and provided a referral that would successfully connect the distressed person to appropriate assistance (R
-score ≥2). Based on their stringent criteria, 10% of participants demonstrated adequate gatekeeper skills at baseline, and 54% met criteria after training. In the current study, there was no difference between training conditions, and 56% of participants met this criteria immediately post training, with a decrement to 41% 3 months later. Clearly, there is room for improvement on suicide-specific skills developed in training and for maintenance of those skills.
We found one difference between parent and school personnel groups on observed gatekeeper skills: School personnel scored higher on the ability to provide an effective referral for suicidal youth. Moreover, at follow-up, school personnel reported greater use of the gatekeeper training by referring more students than parents during the intervening time period. Although it is likely that school personnel have greater opportunity to encounter distressed and suicidal youth than most parents as well as greater access to on-site referral sources, it is also possible that the gatekeeper training may require modification to prepare parent participants to effectively refer youth for intervention. It is likely that the school context, which has built-in processes for student intervention, provides a clear and normative referral process for school personnel. Unlike school staff, who use a variety of services to meet students’ academic, physical, and socioemotional needs as a matter of course, parents are faced with an unfamiliar, anxiety-provoking task of approaching a suicidal youth’s parents or initiating community services. Gatekeeper training for parents, or others who are not trained in the context of a supportive institutional setting, may require tailoring to meet the challenge of encountering a suicidal youth in the community and referring them for services. One solution for school districts with mental health services would be to institutionalize a link between counselors and trained gatekeeper parents. Although school districts are unique and may have specific processes to accomplish this link, we offer one for consideration. Many school systems have a designated prevention or outreach counselor on staff who could be identified as the link for trained gatekeeper parents to access a school-based referral process for a distressed or suicidal youth. This and other avenues could potentially assist trained parents to have access to mental health professionals in the school setting.
Two other comments are warranted with respect to participants’ use of this gatekeeper training. We found that previous exposure to suicide (either through contact with someone who was suicidal or other prevention training) was associated with referrals 3 months after training. This finding is consistent with previous studies that show exposure to training content is associated with positive post-training outcomes (e.g., Cross et al. 2010
), and with adult learning theory (Knowles et al. 2005
). The suggestion by Wyman et al. (2008)
that communication with students may be enhanced with training is supported by the current study: Observed general communication skills were enhanced by a brief role play practice exercise. The extent to which targeted behavioral rehearsal can enhance adult relationships with students who may be at risk for suicide is an important focus of future studies. Communication skills may be particularly important when students approach school personnel or other adults for assistance and training, such as a brief role play rehearsal, may be an effective strategy.
In fact, a comprehensive approach to youth suicide will likely include both adult-targeted programs such as gatekeeper training and programs that target youth themselves as part of a multilevel, comprehensive approach to community-based suicide prevention (Fountoulakis et al. 2011
). One program, Sources of Strength (SoS; LoMurry 2005
), aims to increase youth–adult connectedness by engaging diverse adolescent peer leaders to help change student norms regarding the acceptability of suicide, help-seeking, and youth–adult communication. A recent study of SoS found a positive impact of the program on school-wide norms about help-seeking and suicidal behavior, with the largest, most positive changes occurring among suicidal youth (Wyman et al. 2010
). The integration of adult- and youth-focused interventions is a promising next step for school-based suicide prevention. Assessing skills and changes in behavior as well as their use in practice over time are important outcomes of these interventions.
Finally, brief gatekeeper training information and materials were broadly diffused both inside and outside the school community network; almost every participant discussed and shared training information with coworkers, friends, and family members. Clearly, the impact of gatekeeper training extends far beyond the participants. Given the strong societal taboo against talking about suicide (Cvinar 2005
; Lester and Walker 2006
; Sudak et al. 2008
), there may be a previously unacknowledged public health benefit with broad-based enhanced awareness of and comfort addressing youth suicide. Our finding that a brief behavioral rehearsal experience enhanced the spread of gatekeeper information beyond trainingas-usual indicates that active learning strategies such as role play practice may expand the impact of training further. Parents spread the suicide prevention message broadly to their network including children, spouses, friends, and coworkers. They were more likely to suggest the training to friends and other people in their community whereas school personnel were more likely to recommend the training to coworkers. It may be that the context in which gatekeeper training is conducted, either as professional development or as part of a parent training, defines how participants share and use the training. Our finding that school personnel are more likely than (working) parents to report acting like a gatekeeper at work (in their case, school) also suggests that the context of the training may be a factor in subsequent gatekeeper behaviors. Future studies may test this hypothesis by explicitly asking participants to share what they have learned with others in their social and/or professional network and compare ‘targeted’ diffusion outcomes using social network methods.
There are several limitations to the study. The sample is relatively small with limited diversity and may not be generalizable. Although professional development for school staff is required, attendance at specific programs, including our gatekeeper training, was voluntary. School participants along with parent volunteers, therefore, may not be representative. In addition, and consistent with a previous study (Cross et al. 2010
), the Persuade domain of the observational measure of gatekeeper skills had inadequate inter-rater reliability. This step in the Question, Persuade, Refer gatekeeper process may be somewhat elusive for a brief observational measure of skills using standardized patient methodology. Finally, our follow-up period was fairly short and not likely to capture use of training, particularly for parents. On the other hand, it was sufficient to reveal decrements in skills in both training conditions.