Suicide Prevention: An Issue of Social Justice

Scope of the Problem

To provide a context for the discussion of suicide prevention, and especially suicide prevention as it relates to social justice, several key statistics concerning suicide emerge as important. The most current data available, from 2018, indicate that there were 48,344 suicides in the United States, which is one every 11 min. Suicide is the 10th leading cause of death overall in the United States, and the second leading cause of death among 15- to 24-year-olds. In 2018, there were 596 suicides by children between the ages of 10 and 14 years. More than 50% of suicides are carried out utilizing a firearm (Drapeau & McIntosh, 2020; Westefeld et al., 2016).

The suicide rate has steadily increased over about the past 10 years. Among U.S. ethnic groups, American Indians/Alaskan Natives have the highest suicide rate (Drapeau & McIntosh, 2020). Between 1991 and 2017, there was an increase of 73% in suicide attempts among Black adolescents (Lindsey et al., 2019). When suicide rates were examined among Black and White youth below the age of 13 years, the rate among Black children was twice that of White children (Bridge et al., 2018).

Systemic Prevention

Numerous definitions have been advanced across many professions concerning the term prevention. Jordaan et al. (1968) conceptualized prevention as strategies designed to stop problems in advance of potential negative consequences. Prevention often involves working with large groups of people in an effort to make a significant impact on an issue (Fretz, 1985; Kagan et al., 1988). The Prevention Guidelines, published by the American Psychological Association (APA, 2014), focus on multiple principles related to prevention. These guidelines draw heavily on the work of Romano and Hage (2000) and Hage et al. (2007), emphasizing the importance of stopping/delaying problems before they occur, thereby creating a situation where problematic impact can be reduced, general well-being can be promoted, and opportunities for policy impacts can be created. The guidelines themselves emphasize evidence-based interventions, multicultural considerations, human strengths, research and evaluation, ethics, and policy considerations. For the purpose of this article, systemic prevention programs will refer to interventions designed to prevent problems before they occur, and programs that are typically intended to reach a wide audience. Psychoeducational programming is often an example of this strategy. Individual interventions, however, focus on working with individuals through the psychotherapeutic process, including both assessment and treatment.

One of the most recent and broad-based examples of systemic suicide prevention is the Zero Suicide Model (ZSM; www.zerosuicide.com). This plan was developed by the National Action Alliance for Suicide Prevention: Transforming Health Systems Initiative Work Group (2018). There are a number of significant components to this model: identifying those persons at risk; training both professionals and paraprofessionals; engaging those who are deemed at risk; utilizing evidence-based practices in treatment; making this a comprehensive effort; transitioning those who are in need from initiative to initiative; and striving to improve the provision of services. This model has begun to be utilized extensively, and early indications are that this program has the potential to be effective in a variety of settings (Labouliere et al., 2018; Stanley, 2017). Examples of a social justice focus in this program include its comprehensive nature as well as its emphasis on identifying persons particularly at risk.

In terms of prevention foci with specific settings and populations, there is a history of systemic suicide prevention programming being implemented in colleges and universities across the United States. The JED Foundation (2017; www.jedfoundation.org) has been a particularly effective force. JED emphasizes providing adequate counseling/mental health resources; restricting means; trying to both identify students at risk and assist them in getting treatment; helping students to focus on both academics and more general wellness approaches to living; and helping students to become socially connected and carry out some strategic and life skills planning. The foundation describes itself as an organization committed to the principles of social justice, including inclusion and equity as well as principles around being responsive to diversity. An area that needs increased emphasis is empirical studies examining the effectiveness of JED Foundation programs.

Suicide prevention educational programs/psychoeducation workshops represent another area of suicide prevention application and can be conducted in a variety of venues. These workshops often emphasize three areas: risk factors; what a person should do if they are concerned about a friend/loved one being suicidal; and an in-depth discussion of both local and national resources that are available for suicide prevention and treatment (Westefeld et al., 2000). It is important that those leading these efforts reach out to underserved populations throughout the community and beyond. It is also important that such efforts address particular at-risk groups, and the needs of those groups, as well as address access to mental health services for underserved populations.

Preventing suicide throughout the military has become a major area of focus for suicidologists, as rates have increased dramatically. These programs are important not only for their focus on military suicide but also because they can be adapted for utilization with the civilian population. In 2016, the estimate of daily suicides in the military was 20 veterans per day. Between 2001 and 2014, suicide among veterans increased by 32% (Shane & Kime, 2016). Because of this rapidly increasing problem, suicide prevention programs in the military have assumed major importance. Programs within each branch of the service have been developed, including the “Green Dot” model in the U.S. Air Force (Gibson, 2017) and the SAIL program in the U.S. Navy (Mabeus, 2017). However, the most broad-based efforts to affect the issue of suicide in the military are the ideas contained in the “VA National Suicide Data Report 2005–2016” (2018) and the “National Strategy for Prevention of Veteran Suicide, 2018–2028.” A review of these reports indicates that there were 6,000+ suicides among veterans each year from 2008 to 2016; that in 2016, 69% of veteran suicides utilized firearms; that suicide rates are highest among the ages of 18 to 29 years, although the actual number of suicides is higher among middle-aged and older veterans; and that in 2016, the suicide rate among veterans was 1.5 times greater than for non-veterans after adjusting for gender and age. The highlights of the national strategy include the following: (a) defining the problem; (b) identifying risk and protective factors for suicide; (c) developing and testing specific prevention strategies; and (d) working for widespread adoption of prevention strategies. Additional components include increasing services to women veterans, making available telehealth approaches, using portable applications available on smartphones, increasing screening and treatment, utilizing telephone coaching, reducing the stigma around mental health services, and reducing lethal means (especially firearms). Several of these components (e.g., reducing mental health stigma, increasing service to women, and reducing lethal means) emanate from a social justice framework. The mission of the strategy is summarized in the report with the acronym SAVE: educate people about the warning signs for suicide; learn to ask about suicidal risk; validate suicide feelings as appropriate; and be willing to escort people at risk to treatment.

Postvention—services provided to survivors of a friend or loved one after the friend or loved one has died by suicide (Westefeld et al., 2000)—is also a very important prevention strategy (Andriessen, 2009; Dafoe & Monk, 2005). Postvention can continue after a completed suicide and often involves several key principles (Bongar & Sullivan, 2013): (a) postvention should be initiated as early as is reasonable after the suicide; (b) most survivors will embrace the postvention process; (c) emotions need to be explored, however negative emotions (e.g., anger) should be explored later rather than sooner; (d) a medical evaluation is an important part of the process; (e) it is important to avoid unreasonable optimism; and (f) it needs to be emphasized that working through grief can take an extensive amount of time, and in most cases that process never ends.

The American Association of Suicidology (AAS, 1990) has provided multiple resources concerning postvention. The AAS emphasizes that the key components of postvention involve individual/group counseling, facilitating the grief process, prevention, managing funerals, dealing with the media, psychoeducation, and potential referral. The AAS also maintains on its website (www.suicidology.org) a national directory of suicide survivor support groups.

Crisis lines are considered an important part of suicide prevention. The idea of a crisis line began in 1958, when Norman Farberow, Edwin Shneidman, and Robert Litman, with assistance from a grant awarded by the National Institute of Mental Health, founded the Los Angeles Suicide Prevention Center (Morris, 2011). This Los Angeles center is generally considered the nation’s first crisis line, and the center continues to do outstanding work in the area of suicide prevention and response (Westefeld et al., 2008). Although data collection from and analyses of crisis lines are complex for many reasons, Gould et al. (2017) found that suicides were reduced through the utilization of such lines. Crisis lines can be particularly useful because they have the potential to serve those with reduced access to mental health care, thus providing a social justice focus.

In summary, a variety of important systemic prevention strategies can be utilized to try and reduce the risk of suicide. All of the programs described in this article basically meet the criteria enumerated above in terms of defining systemic prevention, that is, programs that are designed to prevent problems before they occur, reach a wide audience, and involve psychoeducational programming. Many of the programs represent efforts with a social justice component—yet more certainly needs to be done to increase this focus. It is important to note that an area of weakness with some systemic suicide prevention programs is the lack of empirical research related to effectiveness. This is an area that should be addressed in the future.

Individual Prevention Strategies

In addition to systemic suicide prevention strategies, individual assessment and psychotherapy are mechanisms for suicide prevention. Individual prevention strategies are centered around an understanding of suicide risk factors (e.g., hopelessness), a previous attempt, ideation, depression, history of trauma, family history, modeling/imitation of suicide, substance abuse, impulsivity, and firearm access (Bongar & Sullivan, 2013; Westefeld et al., 2000, 2016).

A significant contributor to the understanding of suicidal risk/prevention is Edwin Shneidman (1987, 1989, 1993). Although Shneidman’s original work was done many years ago, his work continues to influence contemporary thought concerning suicidology—especially his ideas concerning prevention. Shneidman wrote extensively about the topic of suicide and mechanisms for preventing it. One of his theses was that suicide is largely about an individual having psychological pain (psychache). The key to understanding suicidal risk, he felt, was assessing the degree to which all other variables may have affected this pain. Shneidman provided an excellent summary of his work wherein he described what he saw as the key psychological variables that indicate a high risk for suicide: (a) the person being very upset or agitated—he referred to this as perturbation; (b) having a variety of fantasies about the experience of death as an escape process; (c) feeling shame/humiliation; (d) experiencing anhedonia; (e) not liking the self; (f) believing that death may offer a means to escape pain; (g) having lethal means available; (h) feeling depressed; (i) feeling hopeless; and (j) feeling helpless. Among these variables, shame, anhedonia, not liking the self, death as escape, lethal means availability, depression, helplessness, and hopelessness are all especially important variables at the forefront of suicidality currently (Bongar & Sullivan, 2013; Westefeld, 2000, 2019). Once again, the issue of lethal means emerges as an issue related to social justice.

Additional individualistic strategies can be utilized to determine the level of risk, and therefore potentially prevent a suicide. One of the most useful ways is asking the client directly about their level of suicidal risk. Bongar and Sullivan (2013) suggest asking about feeling depressed, about how concerned about their life they are, and then asking questions to ascertain the frequency and duration of these feelings. In addition, they advocate asking about hopelessness, the nature of suicidal thoughts that may enter the client’s mind, if they have a plan, access to firearms, and finally, “Can you manage these feelings if they come back? What is your plan for getting through the next down period? Whom should you tell when you have these feelings?” (p. 115).

In addition to knowledge of risk factors and direct questioning, a wide range of assessment inventories purports to be able to predict suicide. One excellent assessment tool is the Reasons for Living Inventory (RFL; Linehan et al., 1983), as it is prevention-based as well as strength-based (Gelso et al., 2014). The RFL consists of 48 items and six factors: fear of suicide, responsibility to family, survival and coping beliefs, child-related concerns, fear of social disapproval, and moral objections. The uniqueness of this instrument lies in the fact that respondents are asked why they would not take their own life even if they were to have thoughts about doing it. Internal consistency data and multiple statistical analyses of the RFL over many years support its use (e.g., Bongar & Sullivan, 2013; Flowers et al., 2014; Linehan et al., 1983; Osman et al., 1993). Linehan et al. (1983) found that Cronbach’s alphas had reliabilities ranging from .72 to .89. The RFL could also potentially be utilized in a systemic manner explicitly for suicide prevention. For example, it could be administered to a group as a screening mechanism or it could be administered multiple times to individual clients, to both assess risk over time and also as a means of identifying possible interventions (i.e., building on the strengths of particular clients’ reasons for living). The RFL is also an excellent example of the phenomenon whereby certain prevention strategies may be both systemic and individually focused.

In addition to the RFL, there is a college version of the RFL, the College Student Reasons for Living Inventory (CSRLI; Westefeld et al., 1992), and a brief version, the Brief Reasons for Living Inventory (BRFL; Ivanoff et al., 1994). Psychometric data generally support the utilization of these instruments (Ivanoff et al.,1994; Westefeld et al., 1992, 1996). For the CSRLI, Westefeld et al. (1992) found that internal consistency values of five of the six factors ranged from .73 to .87. One factor had a coefficient alpha of .45.

Mental health professionals also need to be aware of the protective factors related to suicide when trying to ascertain potential risk and prevent a suicide. In the 1999 Surgeon General’s Call to Action to Prevent Suicide (U.S. Department of Health and Human Services, 1999), the following protective factors were emphasized: (a) availability of care for physical, mental, emotional, and psychological disorders; (b) support for seeking help; (c) easy access to help; (d) cultural/spiritual/religious beliefs that support self-preservation and discourage suicide; (e) continuity of care and support from medical and psychological relationships; (f) social support from friends, family, and community; (g) skill in resolving conflict; (h) skill in solving problems; and (i) skill in resolving disputes non-violently. Clearly, a number of these variables are strongly connected to social justice concepts (e.g., availability of care, access, cultural/spiritual/religious beliefs, and social support).

Thus far, various strategies have been discussed in terms of assessing risk. But what about actually working with a client who has been deemed at risk? What are the best ways to treat clients who are suicidal and prevent a suicide? Firestone (2011) provides excellent commentary on this very complex issue, stating that safety planning is key with any suicidal client. She emphasizes the following points about a safety plan: (a) work with the client to develop a “personal set of warning signs” (p. 4); (b) help the client to make sure their home is safe; (c) work very closely with the client to develop a comprehensive safety plan that includes suggestions the client has for what may help them to calm down, actions the client can take to deal with isolation, and important people in the client’s world whom they can contact in the event of evolving bad feelings/crises; (d) the therapist should be available to the client between sessions, and should make the client aware of walk in emergency resources, and the National Suicide Prevention Lifeline (800-273-8255); and (e) “Write the safety plan down, and make a copy for the client to have in hand and another to keep in your chart” (p. 4).

Firestone (2011) continues by making suggestions concerning treatment of a suicidal client. Important points include but are not limited to obtaining a commitment from the client to therapy, seeing clients more often when the client is in crisis, allowing the client to express whatever negative feelings they are experiencing that may be contributing to their pain, following up if the client leaves therapy, and developing coping strategies such as a list of reasons for living. Firestone also emphasizes the importance of the therapeutic relationship stating,

People who are suicidal . . . have trouble regulating and tolerating emotion. It is the aim of the therapist to help clients feel connected and valued, while assisting them in developing the fundamental skills to regulate and tolerate emotions . . . It is important that the therapist join with the person to form an alliance . . . (p. 3)

Obviously, there are a wide variety of specific psychotherapeutic approaches that can be employed when working with a suicidal client and trying to prevent their suicide, depending on the specifics of the situation as well as the theoretical orientation of the therapist (Westefeld, 2019). Dialectical behavior therapy (DBT), developed by Linehan (1993), is an approach that has received widespread support (Linehan et al., 2006). In addition to DBT, cognitive behavioral therapy (CBT; (Beck, 1996; Comtois & Linehan, 2006) and Joiner’s Interpersonal Model (Joiner, 2005; Joiner & Van Orden, 2008) are psychotherapeutic approaches that are considered by many to be effective in working with suicidal clients (Bongar & Sullivan, 2013). Joiner’s theory in particular has elements of a social justice focus, in that it emphasizes the concepts of “perceived burdensomeness” and “failed belongingness.”

A relatively new approach to suicide prevention is Caring Contacts (Reger et al., 2017), and this approach is focused on what happens after a client who has been treated for suicide is released from treatment. Caring Contacts involves sending caring messages to clients after their release, so that ongoing contact can be maintained. This approach provides continuity of care, and a simple means of re-entering therapy should that become necessary. Data are somewhat equivocal with this approach. It is suggested that more empirical investigation needs to be carried out to assess the long-term effectiveness of this model. The continuity of care component of this model in particular illustrates an element of suicidality that is social justice related, and of great import.

The second area of development has been the utilization of smartphone applications (“apps”), which are designed to help suicidal or potentially suicidal people. These apps can be viewed as both a means of prevention and a means of intervention. There are many of these that have been marketed. In one of the most comprehensive studies to date, Larsen et al. (2016) reviewed almost 50 applications designed to be responsive to potentially suicidal individuals. They summarized their findings by indicating that there were several key components to these applications that the researchers felt were especially relevant, and these were social support, access to a crisis response service, and having a comprehensive safety plan in place.

Finally, Westefeld and Heckman-Stone (2003) presented a crisis intervention model, the integrated problem-solving model (IPSM) that has applicability in the area of responding to clients who have attempted suicide. This model consists of 10 generic steps related to crisis intervention. Thus, the model would be applied specifically to individuals who have attempted, and/or may be dealing with suicidal risk. The specific steps are to establish and maintain rapport, ensure safety, assess clients and to begin processing trauma, set goals, generate options, evaluate options, select plan, implement plan, evaluate outcome, and follow-up. Social justice issues are addressed in the model, as the authors state that their model “in particular is based on a framework that focuses on cultural context and empowerment” (p. 224).

There may be situations in which a combination of systemic and individual prevention strategies could be utilized. For example, a client in individual psychotherapy might also attend a suicide prevention workshop. Conversely, a person attending a workshop might be referred to individual therapy. Therefore, it is important to note that the individual/systemic discussion is not a dichotomous phenomenon. It is, rather, continuous. It is a very fluid situation, constantly subjected to change. The level of risk present may help guide the extent to which individual prevention, systemic prevention, or a combination may be utilized with a given individual or group: for example, Is someone actively suicidal? Have they attempted suicide? Do they have a plan? Are they ideating? The characteristics of the audience/individual being served can, therefore, affect the type of prevention strategy used. This also has implications in terms of social justice because the level of risk and characteristics of the individual and the environment from which they come will very often affect the type of prevention strategies utilized.

Multiculturalism

As suicide prevention is a social justice issue, prevention programs need to be developed that address issues that may be particularly important to particular groups. For example, Canetto’s (2016) review of Muslim women and suicide concluded that for a variety of reasons, suicide in this population is often related to oppression, and therefore an important human rights issue. Canetto (2016) states,

Understanding and preventing Muslin women’s suicidality and the socially sanctioned oppression it is often a response to, require system-level—not just individual-level—analyses and interventions as well as a human rights perspective. (p. 1)

Suicide prevention within this population might focus in particular on the ways that oppression can contribute to suicidality—and ways to mitigate this.

Choi et al. (2009) have focused on risk assessment in the Asian American college student population. The authors examine cultural issues related to confidentiality and discuss ideas for working with Asian American college students at risk, including being culturally informed, being aware of the complex relationship between self-disclosure and -assessment, understanding the client’s acculturation process, and understanding potential intergenerational conflicts. Again, suicide prevention programs with this population should take these issues into consideration. The concept of not treating groups homogeneously is a very important concept for future suicide research, as has been stated previously.

Wong et al. (2014) discuss a variety of issues that link social justice to suicide, including culturally relevant prevention practices, access to treatment, and focusing on groups that have been historically neglected in terms of suicide prevention strategies. These are all points of relevance in the current context. For example, particular barriers to treatment within specific groups should be assessed and responded to in appropriate ways.

Although there have been important contributions in this overall area, more is needed. In particular, further examination of risk and protective factors among specific groups, prevention strategies, and research/interventions that do not view racially minoritized groups homogeneously need to be researched. This will allow suicidology as a profession to respond more directly to the fact that suicide is in fact a social justice issue.

Firearm Restrictions

Westefeld et al. (2016) have written in detail about the relationship between firearm availability and suicidal risk, and state that based on an extensive literature review, there is a strong positive relationship between firearm access and suicidal risk. They posit that additional advocacy is urgently needed. Using psychologists as one example of a profession that could become increasingly involved in advocacy, they state that “Psychologists . . . should meet with their elected officials and educate them about this issue as well as encourage them to examine potential avenues of legislation” (p. 275). This suggestion of political advocacy in terms of the relationship between firearm availability and suicide is one more example of how suicide prevention is a social justice issue. The human service professions are urged to advocate strongly for stricter gun control legislation. This will affect suicide prevention. Advocacy on the part of the human service professions is also mandated because it is a mechanism for mental health professionals to acknowledge and utilize their privilege as experts, thus advocating for and implementing social change. It will be important to examine whether different approaches need to be taken with different groups in terms of firearm restrictions. There is another example of the fact that suicide prevention is not a “one size fits all” phenomenon.

Research

More work needs to be done in terms of research foci in the areas addressed in this article. One of the most important areas that needs to be addressed, as discussed above, is the lack of empirical studies examining the effectiveness of systemic suicide prevention programming, as well as individual approaches. More needs to be known about what suicide prevention strategies are best for which groups. Similarly, because postvention is such a pivotal component of prevention, the distinctive needs of groups should be investigated. Increased research attention needs to be focused on mechanisms for making high-impact social justice interventions, so that suicide outreach and prevention can be made available to all people, and become a greater part of the national agenda. Studies examining the most effective ways to advocate politically for suicide prevention should be increased. Both qualitative and quantitative studies are needed, so that more can be learned about risk and prevention effectiveness, as well as what can be done to increase advocacy.

Training

In 2000, Westefeld et al. called for an increased emphasis on training concerning suicide and suicide prevention. In 2014, Wong et al. reiterated this call. What is being suggested here is more developmentally appropriate and sequential training, beginning with didactic coursework, continuing through practicum and internship, and then beyond. This would allow trainees to both understand suicide and how to react to it and prevent it. A specific component of this training needs to be a discussion of the advocacy and social justice components of suicide prevention, many of which have been addressed in this article. Trainers need to be aware of their own biases and privilege to incorporate the social justice theme into the training from the outset. Training needs to be provided throughout the wide variety of human service professions (e.g., psychology, social work, counseling, psychiatry, and public health, as well as in the area of public policy). By providing training across disciplines, including public policy, a true social justice approach to suicide prevention can emerge.

Innovative Strategies for Prevention

Additional and more creative and user-friendly methods of suicide prevention need to be developed. There is some of this beginning to happen. For example, the military is experimenting with sending texts to personnel to reduce suicidal thoughts and attempts (Comtois et al., 2019). In addition, Tufts University is making a strong commitment to mental health treatment and prevention, including examining ways that suicide can be prevented (Suicide Prevention Resource Center, 2019). One of the most exciting developments is the potential development of a three-digit hotline phone app. This is being considered currently and is subsumed under the National Suicide Hotline Improvement Act of 2018. Comments are now being accepted on this proposal. This act would establish a three-digit national call code phone number—similar to 911—targeting suicide prevention and response to mental health crisis (Suicide Prevention Resource Center, 2020). Social justice elements of such an app need to be included in the development of these products.

Suicide and Social Media

Increased attention needs to be given to the entire area of social media and suicide. This includes such issues as bullying through social media as well as responding to the posting on social media of suicidal threats. An example of the potential connection between suicide and social media was the recent adjudication of a case concerning texting. The Massachusetts Supreme Court upheld the conviction of a young woman for involuntary manslaughter who in 2014 encouraged another teen to carry out his own suicide (Richer, 2019). Clearly, it is important to be aware of the pros and cons of utilizing social media in suicide prevention. It can be useful as a suicide prevention mechanism—but can also be utilized as a mechanism for bullying, which is an additional social justice dimension related to social media that needs to be considered.

Suicide Prevention and the Current State of the World

As this article is being written, COVID-19 is raging throughout the world, unemployment is at record-setting levels in the United States, and people in the United States and elsewhere are engaging in demonstrations to address inequality and oppression. These are obviously issues of social justice. There are and will be many mental health consequences from these phenomena, certainly including suicide. In a recent issue of The Weekly Spark, reference is made to the National Action Alliance for Suicide Prevention, a national effort to respond to the issue of suicide and its connection to COVID-19 (May 1, 2020). This response will include multiple strategies, although one of the most central strategies will be advocacy, and is co-chaired by Patrick J. Kennedy, founder of The Kennedy Forum, and Joshua Gordon, Director of the National Institute of Mental Health. Multiple efforts over many years are required to respond to this crisis. As COVID-19 affects different groups of people disproportionally, as do unemployment, access to housing, health care, and education, the despair that emanates from systemic oppression necessitates the need to develop specific suicide prevention strategies. Human service professionals should anticipate the devastating effects of these intersecting issues. Action should be taken now to prepare.