Effects of brief training on mental health provider’s knowledge of working with youth at risk of suicide in Guatemala

Abstract

Background:

Resources for mental healthcare are lacking in Guatemala, yet rates of mental illness and suicide are quite high. Mental healthcare providers often lack the knowledge needed to effectively work with young at-risk of suicide. To address this gap, we developed a training program for mental health professionals focused on increasing knowledge and understanding of engaging and working with youth at risk of suicide and present its acceptability and preliminary effectiveness.

Methods:

Mental health providers (N = 17) from a low SES community participated in the training, Formacion CUIDAR (Comunidades Unidos para Individuales De Alto Riesgo; CARE Training; Communities United for Individuals at High Risk). Mixed methods were used to explore outcomes including, self-reported knowledge and understanding of warning signs; risk and protective factors; effective risk assessment; and, techniques for working with at-risk youth.

Results:

Findings indicate that the training was effective at increasing all targeted domains of knowledge (t = 2.46, p < .05, Cohen’s d = .56). Acceptability was also rated as high.

Conclusion:

Scarcity of mental health specialists and lack of training on suicide assessment and management have resulted in inadequate resources for at-risk youth in need of mental health services in Guatemala. Results of our study demonstrate that our training is an acceptable, effective program for practicing mental health providers to address their lack of specialized training on how to work with individuals at risk of suicide. Further examination of the training in a larger RCT is required to attain more robust indictors of effectiveness and to assess long-term impact.

Keywords

Adolescent mental health mental healthcare providers suicide training effectiveness

Background

Thirty-six years of armed conflict had devastating effects on Guatemala. Today, more than twenty years after the conflict ended, Guatemala continues to struggle with a corrupt law enforcement system and government; family and community fragmentation; endemic poverty; discrimination; gender-based violence; drug and gang related violence; rampant organized crime; and, a government characterized by intimidation (Alvarado & Massey, 2010; Branas et al., 2013; Brands, 2011; Carey & Torres, 2010; Garcia, 2004; Gavigan, 2009; Herrera et al., 2005; Musalo & Bookey, 2013; Reimann, 2008; Rodríguez et al., 2002; Sabin et al., 2003; Puac-Polanco et al., 2015; Alonzo et al., 2020). These conditions have had serious psychological consequences for Guatemalans, including high rates of psychiatric illness and suicide.

Approximately 1 in 4 Guatemalans will experience a mental illness in their lifetime (WHO, 2016). Anxiety disorders appear to be the most prevalent (20.6%) (WHO, 2016). High rates of ideation and behavior have also been reported in Guatemala, despite a significant lack of data in this area due to stigma, under-reporting and misclassification of suicides. Guatemalan youth are particularly vulnerable, with rates of suicide among adolescents (15–19 years) increasing over the past years for both genders, among boys from 3.07 in 1990–1999 to 4.74 2000–2009, and among girls from 1.63 in 1990–1999 to 3.12 in 2000–2009 (Kõlves & De Leo, 2016).

One study conducted in a rural southwest region of Guatemala found rates of suicide ideation of 10.7% for males and 12.7% females between the ages of 12 and 18 (Johnson et al., 2019). Additionally, a study of adolescents aged 12 to 16 found that the prevalence of past year suicide attempt was 16.6%, 12.2% among boys and 20.2% among girls (Pengpid & Peltzer, 2019). Among students with a suicide attempt in the past year, 52.8% had a suicide plan in the past year (Pengpid & Peltzer, 2019). Despite these high rates, there is no national strategy for suicide prevention established for the country (WHO, 2016).

Further contributing to the high rates of suicide is the fact that only 2% to 15% of those with a mental illness receive needed psychiatric treatment (Rissman et al., 2016; USAC, 2009). This low rate is in large part due to a lack of awareness and stigmatizing beliefs around mental illness that prevent at-risk individuals from seeking help, and in part due to the dramatic lack of resources dedicated to the provision of mental health services in the country (Avila et al., 2015; Cauce et al., 2002; Duarte & Martinez, 2015; Rissman et al., 2016; WHO, 2016). Less than 1% of the country’s general health budget is devoted to mental health care (Duarte & Martinez, 2015; Rodriguez et al., 2002), 90% of which funds the national hospital in Guatemala City (Duarte & Martinez, 2015). Further, Guatemala does not have public policies or legislation focused on providing to protection to individuals suffering from mental illness (WHO, 2014).

Additionally, mental health providers are quite scarce. According to the World Health Organization, there are .29 psychiatrists, .53 psychologists, and .07 social workers per 100,000 residents (WHO, 2016). Other studies report somewhat similar rates, with 0.57 psychiatrists, and 0.35 psychologists per 100,000 residents (Paiz, 2012). Providers are generally concentrated in the capital (71%), making access to care for those living in low-income and rural areas even more limited. Despite efforts in recent years to decentralize mental health services and offer local care, there remain very limited facilities for primary mental health care available at the community level. Only five health facilities outside the city have a psychiatrist on staff and only 20 have a psychologist (Duarte & Martinez, 2015). There are no studies indicating a presence of social workers within healthcare facilities in the country.

This lack of mental healthcare providers is directly related to the limited training in mental health available in the country (WHO, 2016). There are virtually no training programs on mental health issues for primary health care personnel. Where training does exist, it is often inadequate in length and depth (Alonzo et al., 2020). For example, training in psychiatry during residency and in medical school for non-mental health specialties is less than 1 month. Licensed psychologists have only the equivalent amount of training as do those with a Bachelor’s degree in the US (Calhoun & Barnes, 2018). More advanced training in mental health remains even more scarce (WHO, 2016) and specialized training focused specifically on suicide assessment and intervention is not provided at all. As a result, even where mental health professionals are available to provide treatment to at-risk individuals, they are often under-trained and ill-prepared to do so effectively.

To address this gap we developed a culturally-based, brief suicide assessment and management training, Forma-cion CUIDAR(Comunidades Unidos para Individuales De Alto Riesgo) (CARE Training (Communities United for Individuals at High Risk), to meet the specialized training needs of community-based mental health providers currently providing services to at-risk youth in highly vulnerable communities around Guatemala City. This program aims to train providers to: engage with clients around suicide by increasing self-awareness of attitudes, biases, and assumptions regarding suicide; assess for relevant risk and protective factors with a special focus on the role of community and intra-familial violence; and to intervene with evidence-based strategies. This study examines the acceptability and preliminary effectiveness of the training at increasing providers’ knowledge and understanding regarding working with clients experiencing suicidal thoughts and/or behaviors.

Method

Procedures

We conducted an uncontrolled trial of Formacion CUIDAR in El Limon, Guatemala with community-based mental health providers. El Limon is noted to be a ‘Red Zone’ district, characterized by violent crime, overcrowding, pollution, and gang activity (i.e. extortion, violent street crime, and narcotics trafficking) (Alonzo et al., 2020). Domestic violence, child abuse, and neglect occur at high rates. Access to electricity and water is limited, and cable and wifi services are often lacking entirely or unreliable when available (Alonzo et al., 2020).

Participants received an 8-hour training focused on addressing attitudes toward suicide, key issues of adolescent development related to the onset and/or maintenance of suicidal thoughts and feelings, suicide risk assessment, and management of suicidal thoughts and behaviors. The training was delivered over the course of 2 days and consisted of lectures, role-plays, and, small group exercises. The main outcomes assessed included changes between pre-and post-training in self-reported knowledge regarding: (1) warning signs; (2) risk factors; (3) protective factors; (4) components of an effective risk assessment; and (5) techniques for engaging and treating at risk youth.

Participants

A total of 17 mental healthcare providers working with youth at risk for suicide in a community-based settings (11 psychologists, 4 social workers, and 2 community health workers) participated in the training. Inclusion criteria included active employment as a mental healthcare provider working with adolescents and their families; and current employment in a community-based organization.

Training

We developed a suicide assessment and management training targeting the needs of mental health providers based, Formacion CUIDAR (Comunidades Unidos para Individuales De Alto Riesgo) (CARE Training (Communities United for Individuals at High Risk). Using a participatory approach, we based the training on the areas of concern and need identified by the mental health providers in an initial needs assessment survey along with evidence-informed content demonstrated to improve the quality of care provided to at-risk individuals. We focused on key developmental factors in childhood and adolescents; psychological and behavioral responses to exposure to violence and abuse; core components of suicide risk assessment; self-awareness regarding attitudes, values, beliefs toward suicide; strategies for engaging at-risk youth; tools for managing at-risk youth (i.e. safety planning, Stanley & Brown, 2012), and key CBT techniques (i.e. identifying and modifying automatic thoughts (Britton et al., 2011; Brown et al., 2005; Slee et al., 2008; Tarrier et al., 2008; Wells & Heilbron, 2012); and, strategies for engaging parents/family. In order to improve the feasibility and acceptability of the training, the material centered relevant risk and protective factors for depression and suicide among youth in Guatemala (such as family and community violence) and assessment and management strategies were adapted for cultural and familial values and norms of the population (i.e. gender role norms, familismo, machismo, etc.).

The training consisted of five core lectures focused on: (1) Key considerations in adolescent development related to depression and suicidal thoughts and behaviors (cognitive development; autonomy; relatedness, competence, self-direction); (2) Warning signs, risk and protective factors for suicide; (3) Suicide assessment strategies; (4) CBT: theory, strategies and techniques; and (5) Safety planning. Total lecture time is 3.5 hours. Role-play exercises of assessment strategies and small group exercises (4–5 participants per group) examining case vignettes of at risk youth are used to reinforce the concepts in the lectures and to highlight attitudes, assumptions, and biases regarding suicide. Large group discussions led by the facilitators are used to review material and debrief on exercises. Total exercise and discussion time is 4.5 hours.

Measures

A questionnaire developed and previously used by the study PIs was used to assess sociodemographic characteristics of the participants and self-reported knowledge and understanding pre- and post-training. Sociodemographic variables gathered included participants’ age, sex, level of education, years of experience as a mental health provider.

Knowledge was assessed using six items on which participants rated their knowledge and/or understanding of various developmental and psychological concepts related to youth suicide risk and behavior. Items were rated on a 5-point Likert scale ranging from 1 = strongly disagree to 5 = strongly agree. Items specifically targeted knowledge and understanding of the role of resiliency, protective factors against suicide, the role of cognitive development and autonomy in mental health, the impact of stressful environments on mental health, how to engage at-risk youth in treatment, and how to engage parents in the treatment of their children. Questions included, for example, ‘I am confident in my knowledge regarding protective factors for suicide’; ‘I am confident in my understanding of the meaning of resiliency’.

Acceptability of was assessed by: (1) participants’ self-reported ratings of the usefulness of the training, satisfaction with the training and the degree to which the training met their expectations; and, (2) rate of retention in the training. Participants were asked to rate on a Likert scale of 1 to 5 (1 = lowest, 5 = highest): ‘To what degree has the training met your expectations?’, ‘How relevant has the training been for your professional development?’, and ‘How satisfied are you with the training?’

At post-test, participants were also invited to comment on an open-ended question regarding the training: ‘Indicate at least one key point that you learned from the training’.

Data analysis

The mixed-methods evaluation of the training was guided by the principles outlined by Kirkpatrick and Kirkpatrick (2006) that includes several levels of evaluation relevant for the current study including, (1) Reaction level, which evaluates the participant’s attitudes toward the program; (2) Learning level, which evaluates the knowledge achieved by the participants as a result of the program; and, (3) Results level, which measures whether the overall goal of the training was met (Alturki & Aldraiweesh, 2016). More specifically, when evaluating the training, we explored both the learning (the extent to which knowledge and attitudes changed and skills developed) and the reaction of participants (levels of satisfaction with the training) to determine whether the goals of the training were reached (Kirkpatrick & Kirkpatrick, 2006).

All statistical analyses were conducted using SPSS version 20 (SPSS Inc., 2011). Descriptive statistics, including means, standard deviations, and skewness were calculated for all variables. Paired t-tests were used to analyze mean differences in pre-test and post-test scores. The p-values equal to or less than .05 were considered statistically significant. Missing data were replaced with the mean. Replacing missing values with the mean is a standard method used to estimate missing values (Tabachnick & Fidell, 1996).

Conventional content analysis was used to analyze qualitative data, a widely accepted methodology that allows for the description of qualitative data through a systematic process of coding and classification, (Elo & Kyngäs, 2008; Hsieh & Shannon, 2005). Participants' responses were reviewed by all authors to identify recurring themes. Initial coding was conducted independently after which team meetings were held to review the categories and redundant categories were collapsed. In the case of discrepancies, definitions of the categories were clarified and rating was repeated until inter-rater consistency of at least 80% for these items was reached, per standards in the literature (Shek et al., 2005).

Results

All participants received and completed the intervention and pre- and post-assessments. Participants were largely female (76%) with a mean age of 33.19 (SD ± 9.41). Participants’ had on average 7 years of experience as a mental health provider (SD ± 4.06) providing services to children, adolescents, and families. The majority of participants had a degree in Psychology (see Table 1).

Table 1.

Sociodemographic characteristics of the sample.

Sociodemographic characteristic	N (%)	Mean (±SD)
Age (in years)		33.19 (9.41)
Sex
Female	13 (76%)
Male	4 (24%)
Years of experience		6.93 (4.06)
Professional degree/occupation
Psychology	11 (65%)
Social work	4 (23%)
Community health workers	2 (12%)

Table 2 shows the change in total outcome scores. Particpants experienced significant increase in their knowledge as a result of the training (t = −2.07, p< .05, Cohen’s d = .56). Additionally, the Cronbach’s alpha for the knowledge scale indicated high reliability, at .920.

Table 2.

Results of paired t-test indicating change in scores from pre-test to post-test.

Outcome	Pre-test scores		Post-test scores		t-Test
Outcome	Mean	SD	Mean	SD	t-Value	Cohen’s d	p-Value
Knowledge	3.35	.93	3.77	.53	2.46	.56	.03

Table 3 indicates the results regarding acceptability of and satisfaction with the training. Results indicate that acceptability of and satisfaction with Formacion CUIDAR is high. Participants reported that the program met their expectations (Mean 4.44 (SD = .527)); was useful for their work and professional development (Mean 4.25 (SD = .707)); and, that they were satisfied with the training they received (4.63 (SD = .518)). Additionally retention rates demonstrated high acceptability/satisfaction, as well, with 98% of participants completing the training. Those participants that left the training early were reported to do so due to unexpected work issues and/or unanticipated scheduling conflicts.

Table 3.

Acceptability and satisfaction with Formacion CUIDAR (N = 17).

Item	Mean	SD
Met expectations	4.44	.527
Useful for professional development	4.25	.707
Satisfied with training	4.63	.518

Results of the qualitative analyses of the open-ended question revealed that participants identified 2 main categories of the key learning points including, knowledge of risk and protective factors and strategies for engaging at-risk youth. The majority of identified learning points fell within the knowledge of risk and protective factors category (50%), followed by the strategies for engaging at-risk youth category (30%). Overall, the single most frequently identified learning point was how to engage at-risk youth endorsed by 24% of participants.

In terms of knowledge of risk and protective factors, participants identified that they learned: ‘What the warning signs of suicide are’, ‘Risk factors for suicide’, ‘How community violence affects adolescent risk’, ‘Family conflict is a risk factor’ ‘What resilience is’, ‘The importance of a supportive family nucleus’.

In terms of engaging at-risk youth, participants reported learning: ‘How to attend to suicidal adolescents’; ‘How to manage the emotional intelligence of adolescents’, and, ‘How to manage difficult emotions’.

Discussion

This is the first study to examine the effectiveness of a culturally-based brief training program for practicing mental health providers focused on suicide assessment and management of youth at risk of suicide in Guatemala. Our results indicate that Formacion CUIDAR is an acceptable training program among mental health providers that is effective at increasing knowledge and improving understanding regarding assessing and managing youth at-risk of suicide.

Our findings are consistent with prior research that has demonstrated that empirically based skills taught in a brief continuing education format can positively impact knowledge and understanding of suicide risk assessment and management of suicidal patients and that such improvements are maintained over time (Kubota et al., 2016, 2018; McNiel et al., 2008; Oordt et al., 2009). These types of trainings have the potential to make a significant impact on suicide prevention as they are grounded in existing community resources, require little, if any, additional financial commitment, can be conducted in a short period of time, and are sustainable over time. Further, research indicates that if at-risk individuals do not feel that treatment will be effective, as is often the result of working with mental health providers who have not received proper training in treating suicidal individuals, they may prematurely end treatment, become discouraged about talking with mental health professionals, and may resist future help-seeking, leaving them at even higher risk for suicide (Grimholt et al., 2014; Taylor et al., 2009; Wingate et al., 2004). Therefore, by increasing knowledge and understanding of how to engage with suicidal individuals, such trainings are likely to improve the mental health service utilization of at-risk individuals thereby reducing their risk of suicide.

There is a significant treatment gap in Guatemala, where mental disorders remain underdiagnosed and undertreated with fewer than 15% of individuals with a mental illness receiving needed psychiatric treatment (Rissman et al., 2016; USAC, 2009). While numerous barriers contribute to this gap, it is widely acknowledged that a general lack of mental health services is a leading contributor and that even when treatment is available in low income countries such as Guatemala, it is often below minimum acceptable standards and often lacks respect for privacy and human rights, utilizing such methods as involuntary restraint and/or physical and psychological abuse (Kleinman, 2009; Sweetland et al., 2014).

Increasing the quality, availability and provision of mental health services in communities can promote accessibility, acceptability, affordability, scalability of services, and adherence to treatment (Kohrt et al., 2018) and can serve to reduce the likelihood of negative outcomes, such as suicide. Stigma, lack of awareness, limited human resources, and insufficient training on the cultural adaptation and implementation of evidence based practices have been identified as key factors requiring attention in order to begin to close the treatment gap (Sweetland et al., 2014). Formacion CUIDAR addresses these factors and serves to increase the effectiveness of and capitalize on existing resources in highly vulnerable areas of Guatemala City by providing a scalable training program focused on improving practitioner knowledge and understanding regarding engaging and working with at-risk youth to effectively address their needs.

Limitations

This study has some limitations that require consideration. First, the study design was not a randomized control trial (RCT). An RCT would be required to determine causality and obtain more robust results regarding the effectiveness of the training. Additionally, patients were not included in the study and therefore, we were unable to assess the client perspective of the impact of the training and changes in the quality of the care they receive. Further, the study did not employ a longitudinal design. As such, we are unable to determine if the improvements of the training are maintained over time. Also, the role description of social workers and psychologists in Guatemala may differ from the functions of these professionals in other countries (i.e. in the US social workers provide therapy where as in Guatemala they only provide concrete services). Caution should be taken when generalizing the findings to psychologists and social workers in other countries based on the nature/function of their role. Future RCT employing a larger sample and a longitudinal design are warranted to address these limitations based on the positive nature of the findings in this preliminary study,

Conclusion

Scarcity of mental health specialists and lack of training on suicide assessment and management have resulted in inadequate resources for at-risk youth seeking care in Guatemala. Results of our study demonstrate that our training is an acceptable, effective program for practicing mental health providers to address their lack of specialized training on how to work with individuals at risk of suicide. Our training is a successful, culturally adaptable, brief program that has the potential to make a significant impact on suicide prevention. Future research should continue to explore the effectiveness of the training in other settings and with other populations, and measure the impact of such training on building local capacity following a training-of-trainers model.

Footnotes

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Funding was provided by International Social Work Solutions.

ORCID iD

Dana Alonzo

References

Alonzo

Popescu

Zubaroglu-Ioannides

(2020). Training non-mental health professionals to assess and manage suicide risk: Community level intervention for suicide prevention in Guatemala. International Journal of Social Psychiatry, 0020764020970237.

Alvarado

S. E.

Massey

D. S.

(2010). Search of peace: Structural adjustment, violence, and international migration. The Annals of the American Academy of Political and Social Science, 630(1), 137–161.

Alturki

U. T.

Aldraiweesh

(2016). Evaluating the usability and accessibility of LMS “Blackboard” at King Saud University. Contemporary Issues in Education Research (CIER), 9(1), 33–44.

Avila

Bright

Gutierrez

J. C.

Hoadley

Manuel

Romero

(2015). Guatemala health system assessment. United States Agency for International Development.

Branas

C. C.

DiNardo

A. R.

Puac Polanco

V. D.

Harvey

M. J.

Vassy

J. L.

Bream

(2013). An exploration of violence, mental health and substance abuse in post-conflict Guatemala. Health, 5(5), 825–833.

Brands

(2011). Crime, irregular warfare, and institutional failure in Latin America: Guatemala as a case study. Studies in Conflict & Terrorism, 34(3), 228–247.

Britton

P. C.

Patrick

Wenzel

Williams

G. C.

(2011). Integrating motivational interviewing and self-determination theory with cognitive behavioral therapy to prevent suicide. Cognitive and Behavioral Practice, 18(1), 16–27.

Brown

G. K.

Ten Have

Henriques

G. R.

Xie

S. X.

Hollander

J. E.

Beck

A. T.

(2005). Cognitive therapy for the prevention of suicide attempts: a randomized controlled trial. JAMA, 294(5), 563–570.

Calhoun

A. J.

Barnes

(2018). Assessing the barriers to increasing mental health care access for depressed adolescents in Guatemala: Clinical perspectives of a medical student. Journal of the American Academy of Child & Adolescent Psychiatry, 57(10), S250.

10.

Carey

Jr Torres

M. G.

(2010). Precursors to femicide: Guatemalan women in a vortex of violence. Latin American Research Review, 45(3), 142–164.

11.

Cauce

A. M.

Domenech-Rodríguez

Paradise

Cochran

B. N.

Shea

J. M.

Srebnik

Baydar

(2002). Cultural and contextual influences in mental health help seeking: A focus on ethnic minority youth. Journal of Consulting and Clinical Psychology, 70(1), 44–55.

12.

Duarte

A. G. C.

Martínez

A. C. E.

(2015). La psicología en Guatemala, un poco de historia y actualidad. INFORMACIO PSICOLOGICA, 109, 72–85.

13.

Elo

Kyngäs

(2008). The qualitative content analysis process. Journal of Advanced Nursing, 62(1), 107–115.

14.

Garcia

(2004). Lynchings in Guatemala: Legacy of war and impunity. Harvard University Weatherhead Center for International Affairs.

15.

Gavigan

(2009). Organized crime, illicit power structures and Guatemala's threatened peace process. International Peacekeeping, 16(1), 62–76.

16.

Godoy-Paiz

(2005). Obstacles to achieving mental health in post-war Guatemala: The intersection of political and structural. Nexus, 18, 34–64.

17.

Grimholt

T. K.

Haavet

O. R.

Jacobsen

Sandvik

Ekeberg

(2014). Perceived competence and attitudes towards patients with suicidal behaviour: A survey of general practitioners, psychiatrists and internists. BMC Health Services Research, 14(1), 208.

18.

Herrera

de Jesús Mari

Ferraz

M. P. T.

(2005). Mental disorders and the internal armed conflict in Guatemala. Actas Españolas de Psiquiatría, 33(4), 238–243.

19.

Hsieh

H. F.

Shannon

S. E.

(2005). Three approaches to qualitative content analysis. Qualitative Health Research, 15(9), 1277–1288.

20.

Johnson

R. K.

Lamb

Anderson

Pieters-Arroyo

Anderson

B. T.

Bolaños

G. A.

Asturias

E. J.

(2019). The global school-based student health survey as a tool to guide adolescent health interventions in rural Guatemala. BMC Public Health, 19(1), 226. https://doi.org/10.1186/s12889-019-6539-1

21.

Kirkpatrick

(2006). Evaluating training programs: The four levels. Berrett-Koehler Publishers.

22.

Kleinman

(2009). Global mental health: A failure of humanity. Lancet, 374(9690), 603–604.

23.

Kohrt

B. A.

Asher

Bhardwaj

Fazel

Jordans

Mutamba

B. B.

Nadkarni

Pedersen

G. A.

Singla

D. R.

Patel

(2018). The role of communities in mental health care in low- and middle-income countries: A meta-review of components and competencies. International Journal of Environmental Research and Public Health, 15(6), 1279. https://doi.org/10.3390/ijerph15061279

24.

Kõlves

De Leo

(2016). Adolescent suicide rates between 1990 and 2009: Analysis of age group 15–19 years worldwide. Journal of Adolescent Health, 58(1), 69–77.

25.

Kubota

Okuyama

Uchida

Umezawa

Nakaguchi

Sugano

Ito

Katsuki

Nakano

Nishiyama

Katayama

Akechi

(2016). Effectiveness of a psycho-oncology training program for oncology nurses: A randomized controlled trial. Psychooncology, 25, 712–718.

26.

Kubota

Akechi

Okuyama

(2018). Effectiveness of a brief psycho-oncology training program for general nurses: A preliminary study. Japanese Journal of Clinical Oncology, 48(6), 594–597.

27.

McNiel

D. E.

Fordwood

S. R.

Weaver

C. M.

Chamberlain

J. R.

Hall

S. E.

Binder

R. L.

(2008). Effects of training on suicide risk assessment. Psychiatric Services, 59(12), 1462–1465.

28.

Musalo

Bookey

(2013). Crimes without punishment: An update on violence against women and impunity in Guatemala. Hastings Race & Poverty LJ, 10, 265.

29.

Oordt

M. S.

Jobes

D. A.

Fonseca

V. P.

Schmidt

S. M.

(2009). Training mental health professionals to assess and manage suicidal behavior: Can provider confidence and practice behaviors be altered? Suicide and Life-Threatening Behavior, 39(1), 21–32.

30.

Paiz

(2012). Mental health care in Guatemala, Revue Magazine. Retrieved August, 2012 from http://www.revuemag.com/2012/08/mental-health-care-in-guatemala/

31.

Pengpid

Peltzer

(2019). Prevalence and correlates of past 12-month suicide attempt among in-school adolescents in Guatemala. Psychology Research and Behavior Management, 12, 523–529. https://doi.org/10.2147/PRBM.S212648

32.

Puac-Polanco

V. D.

Lopez-Soto

V. A.

Kohn

Xie

Richmond

T. S.

Branas

C. C.

(2015). Previous violent events and mental health outcomes in Guatemala. American Journal of Public Health, 105(4), 764–771.

33.

Reimann

A. W.

(2008). Hope for the Future – The Asylum Claims of Women Fleeing Sexual Violence in Guatemala. University of Pennysylvania Law Review, 157, 1199.

34.

Rissman

Y. Z.

Khan

C. T.

Isaac

S. K.

Paiz

J. A.

DeGolia

S. G.

(2016). Developing a mental health curriculum to build capacity and improve access to mental health care in rural Guatemala. Academic Psychiatry, 4(40), 692–694.

35.

Rodríguez

Bergonzoli

Levav

(2002). Violencia política y salud mental en Guatemala. Acta Psiquiátrica y Psicológica de América Latina, 48(1/4), 43–49.

36.

Sabin

Cardozo

B. L.

Nackerud

Kaiser

Varese

(2003). Factors associated with poor mental health among Guatemalan refugees living in Mexico 20 years after civil conflict. JAMA, 290(5), 635–642.

37.

Shek

D. T.

Tang

V. M.

Han

X. Y.

(2005). Evaluation of evaluation studies using qualitative research methods in the social work literature (1990-2003): Evidence that constitutes a wake-up call. Research on Social Work Practice, 15(3), 180–194.

38.

Slee

Garnefski

van der Leeden

Arensman

Spinhoven

(2008). Cognitive-behavioural intervention for self-harm: Randomised controlled trial. The British Journal of Psychiatry, 192(3), 202–211.

39.

Speizer

I. S.

Goodwin

M. M.

Samandari

Kim

S. Y.

Clyde

(2008). Dimensions of child punishment in two Central American countries: Guatemala and El Salvador. Revista Panamericana de Salud Pública, 23, 247–256.

40.

Stanley

Brown

G. K.

(2012). Safety planning intervention: A brief intervention to mitigate suicide risk. Cognitive and Behavioral Practice, 19(2), 256–264.

41.

Sweetland

A. C.

Oquendo

M. A.

Sidat

Santos

P. F.

Vermund

S. H.

Duarte

C. S.

Wainberg

M. L.

(2014). Closing the mental health gap in low-income settings by building research capacity: Perspectives from Mozambique. Annals of Global Health, 80(2), 126–133.

42.

Tabachnick

B. G.

Fidell

L. S.

(1996) Using multivariate statistics (3rd ed.). Harper Collins College Publishers.

43.

Tarrier

Taylor

Gooding

(2008). Cognitive-behavioral interventions to reduce suicide behavior: A systematic review and meta-analysis. Behavior Modification, 32(1), 77–108.

44.

Taylor

T. L.

Hawton

Fortune

Kapur

(2009). Attitudes towards clinical services among people who self-harm: Systematic review. The British Journal of Psychiatry, 194(2), 104–110.

45.

Wells

K. C.

Heilbron

(2012). Family-based cognitive-behavioral treatments for suicidal adolescents and their integration with individual treatment. Cognitive and Behavioral Practice, 19(2), 301–314.

46.

Wingate

L. R.

Joiner

T. E.

Jr Walker

R. L.

Rudd

M. D.

Jobes

D. A.

(2004). Empirically informed approaches to topics in suicide risk assessment. Behavioral Sciences & The Law, 22(5), 651–665.

47.

World Health Organization. (2016). World Health Statistics: Monitoring Health for the SDGs. Mental health - World Health Organization. Retrieved from November, 2020, www.who.int›whr›whr01_en