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National Strategy for Suicide Prevention:
Goals and Objectives for Action
Foreword
Suicide has stolen lives around the world and across the centuries.
Meanings attributed to suicide and notions of what to do about it have
varied with time and place, but suicide has continued to exact a relentless
toll. Only recently have the knowledge and tools become available to
approach suicide as a preventable problem with realistic opportunities to
save many lives. The goals and objectives presented here, a cornerstone
of our Nation's strategy to prevent suicide, are framed upon these
To most of those who have experienced it, the horror of depression
is so overwhelming as to be quite beyond expression, hence the frustrated
sense of inadequacy found in the work of even the greatest
artists....If our lives had no other configuration but this, we should
want, and perhaps deserve, to perish; if depression had no termination,
then suicide would, indeed, be the only remedy. But one need
not sound the false or inspirational note to stress the truth that
depression is not the soul’s annihilation; men and women who have
recovered from the disease – and they are countless – bear witness
to what is probably its only saving grace: it is conquerable.
William Styron
Suicide is a particularly awful way to die: the mental suffering leading
up to it is usually prolonged, intense, and unpalliated. There is no
morphine equivalent to ease the acute pain, and death not uncommonly
is violent and grisly. The suffering of the suicidal is private and
inexpressible, leaving family members, friends, and colleagues to
deal with an almost unfathomable kind of loss, as well as guilt.
Suicide carries in its aftermath a level of confusion and devastation
that is, for the most part, beyond description.
Kay Redfield Jamison
Public Efforts Leading to the Goals and Objectives for Action
Suicide has stolen lives around the world and across the centuries.
Meanings attributed to suicide and notions of what to do about it have
varied with time and place, but suicide has continued to exact a relentless
toll. Only recently have the knowledge and tools become available to
approach suicide as a preventable problem with realistic opportunities to
save many lives. The goals and objectives presented here, a cornerstone
of our Nation's strategy to prevent suicide, are framed upon these
advances in science and public health. Suicide is a serious public health
problem.
The French social scientist, Emile Durkheim (1858-1917) developed a
method of study that became the foundation for scientific inquiry about
suicide. Instead of basing his conclusions only upon commonalities
among people known to have died by suicide, Durkheim originated the
scientific exploration of risk factors for suicide by comparing one group
with another (Durkheim, 1897/1951). To Durkheim, the differences in
rates of suicide could be attributed to distinguishing sociological characteristics
among those population groups. Comparing those who are suicidal
with those who are not, or groups having high rates of suicide with
those having low rates is the incremental process by which risk and protective
factors for suicide have been unveiled.
In the United States, large-scale efforts to prevent suicide began in
1958 through funds from the U.S. Public Health Service to establish the
first suicide prevention center. Based in Los Angeles, Edwin Shneidman,
Norman Farberow, and Robert Litman studied suicide in the context of
providing community service and crisis intervention (Shneidman and
Farberow, 1965). Other crisis intervention centers were founded across
the country to replicate the Los Angeles Suicide Prevention Center's service
component.
A more direct Federal role in suicide prevention began in 1966 when the
Center for Studies of Suicide Prevention was established at the National
Institute of Mental Health (NIMH). In time, this unit became the Suicide
Research Unit (no longer existing) that championed the risk factor
approach to suicide prevention, a central tenet in the public health model
of prevention embodied in this National Strategy for Suicide Prevention
(National Strategy or NSSP). During the next two decades, the American
Association of Suicidology and then the American Foundation for Suicide
Prevention were established. Among their activities these professional and
private voluntary organizations worked to increase the scientific understanding
of suicide as a base for effective prevention activities.
In 1983, the Centers for Disease Control and Prevention (CDC) established
a violence prevention unit that brought to public attention a disturbing increase in youth suicide rates. In response, the Secretary of
Health and Human Services established the multi-year public/private
Secretary's Task Force on Youth Suicide to review what was known about
risk factors for youth suicide and promising interventions. These reviews
and the Task Force's prevention recommendations were published in
1989 (ADAMHA, 1989).
Shortly thereafter an international effort culminated in the United
Nations/World Health Organization's 1996 summary, Prevention of
Suicide: Guidelines for the Formulation and Implementation of National
Strategies (UN/WHO, 1996). In the U.S., the Suicide Prevention Advocacy
Network (SPAN USA), a grassroots advocacy organization including suicide survivors (persons close to someone who completed suicide), suicide
attempt survivors, and community activists championed these guidelines
as a way to encourage development of a national suicide prevention
strategy for the United States. Their work to marshal social will for suicide
prevention generated Congressional Resolutions recognizing suicide
as a national problem and suicide prevention as a national priority. These
resolutions provided further impetus to develop a national suicide prevention
strategy.
SPAN propelled the creation of an innovative public/private partnership
to jointly sponsor a National Suicide Prevention Conference convened
in Reno, Nevada, in October 1998 (Reno Conference). Participating
agencies within the U.S. Department of Health and Human Services were
the Centers for Disease Control and Prevention, the National Institutes of
Health, the Office of the Surgeon General, the Substance Abuse and
Mental Health Services Administration, the Health Resources and Services
Administration, the Indian Health Service and the Public Health Service
Regional Health Administrators. Conference participants, including
researchers, health, mental health and substance abuse clinicians, policy
makers, suicide survivors, consumers of mental health services, and community
activists and leaders discussed eight background papers that
were commissioned to summarize the evidence base for suicide prevention
(Silverman, Davidson, and Potter, 2001). Working in regional, multidisciplinary
groups, participants at the Reno Conference offered many
recommendations for action that were shaped into a list of 81 by an
expert panel.
Moving forward with the work of the Reno Conference, the Surgeon
General issued his Call to Action to Prevent Suicide in July 1999,
emphasizing suicide as a serious public health problem. (USPHS, 1999)
The Surgeon General's Call introduced a blueprint for addressing suicide
prevention through Awareness, Intervention, and Methodology (AIM),
which describes 15 broad recommendations, containing goal statements,
broad objectives, and recommendations for implementation,
consistent with a public health approach to suicide prevention. AIM represents
a consolidation of the highest-ranked of the 81 Reno Conference
recommendations according to their scientific evidence, feasibility, and
community support.
Continuing attention to suicide prevention issues and the significant
role of mental health and substance abuse services in suicide prevention
is reflected in the landmark Mental Health: A Report of the Surgeon
General (DHHS, 1999) and in the nation's public health agenda, Healthy
People 2010, (see Objectives 18-1 and 18-2)(DHHS, 2000). The effective
implementation of the National Strategy will play a critical role in reaching
the suicide prevention goals outlined in Healthy People 2010. In
early 2000, the Secretary of Health and Human Services officially established
the National Strategy Federal Steering Group (FSG) to, "...ensure
resources identified...for the purpose of completing the National
[Suicide Prevention] Strategy are coordinated to speed its progress." The
FSG carefully reviewed the recommendations of both the Reno meeting
and the Call to Action with a view to developing a comprehensive plan
outlining national goals and objectives that would stimulate the subsequent
development of defined activities for local, State and Federal partners.
The National Strategy Leadership Consultants (see
Acknowledgments) met to identify the scope and priorities for these
Goals and Objectives for Action. The Leadership Consultants have continued
to refine the goals and objectives as part of a broadly inclusive
process which has invited critical examination by scientific, clinical, and
government leaders; other professionals; and the general public. Revised
draft goals and objectives were also posted on the World Wide Web inviting
comment. During 2000, public hearings on Goals and Objectives
for Action were held in Atlanta, Boston, Kansas City, and Portland to
provide a face-to-face forum for additional input and clarification.
Working in collaboration to develop the National Strategy has been
a process that has promoted investment in the goal of suicide prevention
and promoted broad collaboration in prevention activities. This volume,
the National Strategy for Suicide Prevention: Goals and Objectives
for Action, represents a significant milestone and continuing progress
towards all of the elements in a planned national strategy.
The National Strategy Concept
A national strategy to prevent suicide is a comprehensive and integrated
approach to reducing the loss and suffering from suicide and suicidal
behaviors across the life course. It encompasses the promotion,
coordination, and support of activities that will be implemented across
the country as culturally appropriate, integrated programs for suicide
prevention among Americans at national, regional, tribal, and community
levels.
A broad public/private partnership is essential for developing and
implementing a national strategy. Interwoven within a national strategy
are three key ingredients for action to improve suicide prevention: a
knowledge base, the public will to support change and generate
resources, and a social strategy to accomplish change. Developing a
national strategy provides an opportunity to convene public and private
partners across many sectors of society – government, public health,
education, human services, religion, voluntary organizations, advocacy,
and business – to sustain a true, national effort.
Benefits of a National Strategy
A national strategy for suicide prevention can raise awareness and help
make suicide prevention a national priority. This can help direct resources
of all kinds to the issue.
A national strategy provides an opportunity to use public-private partnerships
and the energy of survivors to engage those who may not have
considered suicide prevention within their purview. It supports collaboration
across a broad spectrum of agencies, institutions, groups, and
community leaders as implementation partners.
A national strategy can link information from many prevention programs
to avoid unintentional duplication and disseminate information
about successful prevention interventions.
A national strategy can direct attention to measures that benefit the
whole population and, by that means, reduce the likelihood of suicide
before vulnerable individuals reach the point of danger.
Suicide is an outcome of complex interactions among neurobiological,
genetic, psychological, social, cultural, and environmental risk and protective
factors. Multiple risk and protective factors interact in suicide prevention.
Development of a national strategy can bring together multiple
disciplines and perspectives to create an integrated system of interventions
across multiple levels, such as the family, the individual, schools, the
community, and the health care system.
Collaborating in a national strategy can help develop priorities in an
equitable way. Resources are always finite and priorities direct resources
to projects that are likely to address the greatest needs and achieve the
greatest benefits. Some types of expertise are not available across all
communities. A national strategy can provide technical assistance with
valuable types of expertise to strengthen community programs.
An evidence-based national strategy can maximize success when recommendations
are implemented locally. Sound evaluation of community
programs, in turn, builds the evidence base.
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Key Elements of a Planned National Strategy
A national strategy for the prevention of suicide has many interrelated
elements contributing to success in reducing the toll from suicide.
- A means of engaging a broad and diverse group of partners to
develop and implement the national strategy with the support of
public and private social policies
- A sustainable and functional operating structure for partners
with authority, funding, responsibility, and accountability for
national strategy development and implementation
- Agreements among Federal agencies and institutions outlining
and coordinating their appropriate segments of the national
strategy
- A summary of the scope of the problem and consensus on prevention
priorities; for example, The Surgeon General's Call to
Action to Prevent Suicide 1999 (USPHS, 1999).
- Specified national strategy aims, goals, and measurable objectives
integrated into a conceptual framework for suicide prevention
- Appropriate and evaluable activities for practitioners, policy makers,
service providers, communities, families, agencies, and other
partners
- A data collection and evaluation system to track information on
suicide prevention and benchmarks for national strategy progress
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About the Goals and Objectives for Action
The Goals and Objectives for Action represents a synthesis of perspectives
from researchers and scientists, practitioners, leaders of nongovernmental
organizations and groups, Federal agencies, survivors, and
community leaders. Because Goals and Objectives for Action is meant to
be useful for applications outside the tightly controlled research environment,
it builds on and extrapolates from the limited realm of scientific
evidence in suicide prevention. While goals and objectives must be
consistent with available scientific evidence and support the expansion of
the scientific knowledge base, they are also intended for use in other
environments: public policy and community action.
Goals and objectives are among many elements needed for a national
strategy, not the entire strategy. The blend of evidence represented in the
Goals and Objectives for Action helps guide an informed selection of
activities for suicide prevention across the spectrum of the nation. The
national dialogue to determine specific activities to accomplish each
objective will be an extension of the consensus reached on these higher
order goals and objectives. In that subsequent step, responsibility and
accountability for carrying out activities will be accorded in the details of
how each activity should be accomplished, by whom, and with what
resources.
Development of specific activities provides the opportunity to address
the particular needs of subgroups at high risk for suicide and particular
cultural/ethnic/social contexts for implementation. For instance, the
objective to "increase the proportion of family, youth, and community
service organizations and providers with evidence based suicide prevention
programs" can be achieved by different prevention activities appropriate
for younger African-American males, the elderly, gay and lesbian
youth, persons with major mental illnesses, or American Indians and
Alaskan Natives.
Several broad themes for the National Strategy for Suicide
Prevention are interwoven throughout the specific goals and objectives
in this volume. These themes are valuable considerations as groups and
individuals across the country move forward in designing and strengthening
suicide prevention activities. The major themes are:
- Draw attention to a wide range of actions so that specific activities
can be developed to fit the resources and areas of interest
of people in everyday community life as well as professionals,
groups, and public agencies. As the eighth leading cause of death among
Americans, suicide affects families
and communities everywhere across the Nation. Suicide prevention
is everyone's business.
- Seek to integrate suicide prevention into existing health, mental
health, substance abuse, education, and human services activities.
Settings that provide related services, such as schools,
workplaces, clinics, medical offices, correctional and detention
centers, eldercare facilities, faith-based institutions, and community
centers are all important venues for seamless suicide prevention
activities.
- Guide the development of activities that will be tailored to the
cultural contexts in which they are offered. While universal interventions
are applicable without regard to risk status, universal
does not mean that one size fits all. The cultural and developmental
appropriateness of suicide prevention activities derived
from these goals and objectives is a vital design and implementation
criteria.
- Seek to eliminate disparities that erode suicide prevention activities.
This is an important commitment in the National Strategy.
Health care disparities are attributable to differences such as
race or ethnicity, gender, education or income, disability, age,
stigma, sexual orientation, or geographic location.
- Emphasize early interventions to reduce risk factors for suicide
and promote protective factors. As important as it is to recognize
and help suicidal individuals, progress depends on measures
that address problems early and promote strengths so that
fewer people become suicidal.
- Seek to build the Nation's capacity to conduct integrated activities
to reduce suicidal behaviors and prevent suicide. Capacity
building will ensure the availability of the resources, experience,
skills, training, collaboration, evaluation, and monitoring necessary
for success.
Moving forward with these Goals and Objectives for Action can
bring suicide prevention into the forefront of the Nation's public commitment
to health and well-being. Working together in a coordinated
and systematic way towards appropriate activities for each objective will
lead to measurable progress.
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