Sources + CDPHE = Powerful Prevention in Colorado

Sources of Strength pilot program works “upstream” in seven schools to prevent the need for youth suicide intervention

By Jan Stapleman | Office of Communications
It’s an overused adjective, but well-earned by the Sources of Strength youth suicide-prevention program. It also applies to the way the program is being piloted by the Colorado Department of Public Health and Environment in seven middle and high schools across the state over the next two years.
Most youth suicide-prevention programs are designed to identify kids who are at risk of suicide and launch an intervention. In contrast, Sources of Strength works “upstream” to build a support system of connections to schools and caring adults that helps protect kids from needing such interventions. Suicide is the leading cause of death among Colorado children ages 10 to 17.
Research shows the program’s protective factors are effective against a range of problems, which is why the program is being piloted in an unusual way in Colorado, supported partially by CDC funds designated for rape prevention and education. 
“We know school connectedness is protective for suicide, sexual violence, substance abuse, bullying and more,” said Jarrod Hindman, director of the Office of Suicide Prevention. “It was unique and cool and innovative for the CDC to fund something that works across programs like this.”
The CDC funding, $70,000 over two years, will pay for implementing and supporting the program in the seven pilot schools: two in Adams County; one in Trinidad; and one each in Boulder, Denver, El Paso and Fremont counties. State funding from the Child Fatality Prevention System and the Office of Suicide Prevention paid for “train-the-trainer” sessions for personnel from the pilot schools and other Colorado schools that have local funding to pay for implementation. Having certified trainers in the schools significantly reduces the cost of implementation and can improve the program’s sustainability.
At the June 23-26 training, Sources of Strength founder Mark LoMurray led the Colorado educators, along with school counselors, local public health staffers and community youth group leaders from various states, through games they will use to prepare adult advisers and student leaders for their roles. The games, and the program, are designed to help teens identify and connect with their own sources of strength from eight possible realms: family support, positive friends, mentors, healthy activities, generosity, spirituality, medical access and mental health. LoMurray demonstrated a light and fun approach, using the games to introduce a quick lesson, not a heavy moral imperative.
“We ask our mental health professionals to scrub that mental health language,” he said. “We use teen language here.”
Participants took turns leading the games in small groups. They practiced asking questions and summarizing lessons learned in a quick, light-hearted way, then evaluated their success. LoMurray’s son Scott, who has taken up the mantle of his father’s work as deputy director of the program, helped lead the small group practice sessions. This fall, he and other Sources of Strength personnel will go into Colorado schools and help the newly trained participants implement the program.
Mark LoMurray developed the program over his 40-year career as a social worker working with teens and young adults in crisis intervention and suicide prevention. In 2009, Sources of Strength was listed on the National Best Practices Registry by the Suicide Prevention Resource Center and the American Foundation for Suicide Prevention. In 2011, the program gained listing on the Substance Abuse and Mental Health Services Administration’s National Registry of Evidence-based Programs and Practices. The program was the subject of one of the nation’s largest studies on peer leaders and their impact in suicide prevention, with results published in 2010 in the American Journal of Public Health. Among other results, the study found:
  • Peer leaders’ connectedness to adults increased.
  • Peer leaders’ school engagement increased.
  • Peer leaders in larger schools were four times more likely to refer a suicidal friend to an adult.
“We will be the first to evaluate the program for sexual violence outcomes,” said Tomei Kuehl, supervisor of the Sexual Violence Prevention Unit. “This is all about taking an innovative approach to work across programs.”
“We used our partnerships at the local level to recruit schools for the pilot,” explained Colleen Kapsimalis, unit supervisor of the Child Fatality Prevention System. Kapsimalis said connections with the state’s local child fatality prevention teams helped identify interested schools. One of three recommendations made in the 2015 Colorado Child Fatality Prevention System Annual Legislative Report, to prevent youth suicide, is “expand implementation and evaluation of school-based suicide-prevention programs that promote resilience and positive youth development as protective factors from suicide statewide.”
Hindman said Sources of Strength is a priority for his office. “There are a lot of good programs out there designed to identify kids at risk and intervene,” he said. “But Sources of Strength builds a support system to prevent kids from getting to that point. Our hope is that five years down the road Sources of Strength will be in 100 Colorado schools.”

Youth Today Article

Originally posted at Youth Today

What Three People Learned About Suicide and Kids

Students who take part in the suicide prevention program Sources of Strength identify trusted adults in their lives who can offer support. Here a teen writes down names of two such adults.

Rate in rural areas twice as high; innovative prevention program can work — and life can be good

When Cynthia Fontanella saw the numbers, she was surprised.

It wasn’t that almost 66,595 kids in the United States had killed themselves from 1996 to 2010, although that was bad enough.

It was that the suicide rate for rural kids was double that of urban kids — and the gap was getting wider.

The Ohio State University assistant professor and fellow researchers examined suicide data for youth ages 10 to 24 and published their results in March in the journal JAMA Pediatrics.

Males had a suicide rate of almost 20 per 100,000 in the countryside, compared with more than 10 per 100,000 in the city, according to the article “Widening Rural-Urban Disparities in Youth Suicides, United States, 1996-2010.” Among young women, the rural suicide rate was more than four per 100,000, compared with an urban rate of more than two.

Guns were the most widely used method, and more youth used guns in rural areas than in cities.

Suicide is the third-leading cause of death among young people ages 10 to 24, according to the Centers for Disease Control and Prevention (CDC). Only accidental injuries and homicides account for more deaths, according to the CDC.

Among young Native Americans, many of whom live in rural areas, suicide is the second-leading cause of death. It’s 2.5 times the national rate among ages 15 to 24, according to the Center for Native American Youth at the Aspen Institute.

Suicide is also the second-leading cause of death among lesbian, gay and transgender kids, according to the CDC.

Outside the cities

Fontanella, an assistant professor of psychiatry, is concerned with the mental health of children and how to best get services to kids who need them. She wanted a clear picture of the difference in suicide rates between rural and city kids in order to develop effective policies and programs.

So, what accounts for the higher rate of suicide among rural youth?

“The big factor is the greater access to and ownership of guns,” Fontanella said. Rural residents in many cases grow up around guns and use them for hunting. Gun ownership is more prevalent in rural areas, and, where there are more guns, there are more gun accidents and suicides, according to the Harvard Injury Control Research Center.

In addition, Fontanella said, rural areas have a chronic shortage of mental-health providers. More than half of U.S. counties — all rural — have no psychologist, psychiatrist or social worker, according to a 2012 book “Rural Mental Health.”

“Residents have to travel further for appointments and wait longer,” Fontanella said. As a result, they get treatment later and develop more severe symptoms.

They also are less likely to have health insurance.

Stigma also plays a role, too, she said. “There’s more of a culture of self-reliance” in rural communities. “People tend to believe they should solve their own problems and not turn to others for help,” Fontanella said.

Rural areas were hard hit by the recession and poverty has increased.

“Many residents out-migrate to get jobs,” she said. It changes the social structure when young people leave the area.

In rural areas gun ownership is stable or increasing, but the number of guns has dropped in urban areas, based on research in “Social Trends in American Life,” published in 2012 by Princeton University Press. Fontanella said these changes may help explain the widening gap between suicide rates among rural and urban teens.

Problems and solutions in North Dakota

For many years, North Dakota was among the states with the highest rates of youth suicide in the nation. Mark LoMurray had a front-row seat on the problem. As director of the Police Youth Bureau in Bismarck, N.D., which worked to keep kids out of trouble with the law, he often saw teens in crisis. Over a three-year period, LoMurray attended 30 teens’ funerals, many of which were suicides.

“He was filled with a sense that we could do more to get in front of this,” said his son, Scott LoMurray.

The senior LoMurray helped develop a mentoring program aimed at suicide prevention at Standing Rock and Turtle Mountain, tribal lands of the Sioux and Chippewa tribes, respectively.

His goal was to build resilience among rural and Native American teens.

“A lot of suicide-prevention programs weren’t training teens,” Scott LoMurray said. “To be effective, we have to have teens involved.”

Many programs focused on teaching the warning signs and risk factors for suicide. People could list the risk factors, but it didn’t help them get better, he said.

Today, Mark LoMurray’s program, Sources of Strength, trains teens to be peer leaders and teaches adults to work with them. Mark is executive director and Scott is deputy director.

Teen leaders learn to identify the sources of strength in their own lives. They then talk with five to 10 of their friends about the supports they have. The teen leaders create a series of messages for a wider audience. They determine the form of the message, ranging from bulletin boards to text messages to videos.

One powerful message is a list of each person’s “trusted adults” posted on a bulletin board.

Sources of Strength is based on the idea of spreading change through a social network. Just as suicide can be contagious, so can attitudes and behaviors that counter suicide, Scott said.

Sources of Strength trains a diverse group of peer leaders, encouraging them to identify where they gain strength to deal with adversity — whether from positive friendships, music, spirituality, family or other areas.

“We’re training peer leaders, not as counselors, but to be agents of change in their school and culture,” he said. “Adults can educate, but not change the underlying culture. Kids can, however.”

At first, teens may think it’s snitching to tell an adult about a friend’s suicidal thoughts. But the code of silence can shift.

The program is now in more than 300 schools in 20 states and 32 tribal communities, many of which are very remote, according to Sources of Strength.

Teens take part in a Sources of Strength training, which was developed initially in rural North Dakota. The program strengthens relationships, and evidence shows it has been successful in changing a “code of silence” around suicide.

The program, initially developed in a rural area, is adaptable to different groups of people, Scott said, and is used by youth and community organizations as well as schools.

Sources of Strength is one of the few prevention programs with evidence to show its impact, and it’s listed on the SAMHSA National Registry of Evidence-Based Programs and Practices.

Researchers, led by Peter Wyman at the University of Rochester in New York, studied the program

over three years at 18 schools in South Dakota, New York and Georgia. Six were urban schools and 12 were rural.

Researchers found the program increased students’ likelihood of referring a suicidal friend to an adult. Students were four times more likely to do so after they became peer leaders. Students who had been suicidal showed the biggest change in their willingness to seek help.

One teenager’s experience

Whitney Bischoff became a Sources of Strength peer leader her junior year at Rapid City., S.D., Central High School.

Two years before that, on the first day of ninth grade, she had faced a calamity: A childhood friend shot and killed herself.

“It was completely out of the blue,” Bischoff said. Only a few friends had had hints of trouble.

Bischoff took part in group counseling with other students who had been friends of the girl. “It never made me feel any better,” she said.

Bischoff also had problems within her family. Her father died when she was small, and her mother was an alcoholic with an abusive boyfriend.

Bischoff had never considered suicide before her friend died, but she began having suicidal thoughts. She even thought about a plan.

When the school introduced Sources of Strength, Bischoff expected “to sit around a table and be talked at,” she said. Instead, students were asked to name the things that gave them strength in their lives. The peer leaders began to feel connected to each other, she said.

To present the program to other students they created a skit. “We wanted to come up with a new approach,” she said.

She began to realize that although she lacked family support, she had other things that gave her strength, including good friends, adult mentors, church and her own interest in theater.

“[The program] just opened my eyes to things I didn’t know how to communicate before,” she said.

Since then, life has thrown some punches. Her mother died when she was a sophomore in college. But she’s felt resilient.

Now a senior at Black Hills State University in Spearfish, S.D., Bischoff studies psychology and theater, and recently directed a production of “The Breakfast Club,” based on the movie about five struggling teenagers.

Her plan is to attend graduate school and to use Sources of Strength as a suicide-prevention program among college students.

“People need to know about it,” she said. “I know it works.”

More change needed

In addition to school and community programs that reach youth, Fontanella wants to see mental-health services made more accessible in rural areas. Mental-health care could be integrated into primary medical care in rural communities, Fontanella said. Sixty-five percent of rural residents see a primary-care doctor, she said, and integrating mental-health care would make those services more acceptable.

She would also like to see the spread of video or Internet consultations with mental-health providers, known as telemedicine. The practice has been shown effective in dealing with mental-health disorders, she said.

And not least, she said, are education campaigns on the need to store guns safely.

The Role of Guns in Rural Suicides

More than half the young people in rural areas who kill themselves do so with guns, according to research published in JAMA Pediatrics in March.

Guns, which are more prevalent in rural areas, are a particularly effective way to commit suicide, compared with ingesting substances, according to the research.

And to compound the tragedy of suicide is the fact that it’s often an impulsive act, said Frederick P. Rivara, editor of JAMA Pediatrics and professor of pediatrics at the University of Washington. He noted in an editorial that one study found 48 percent of people who attempted suicide did so only 10 minutes after thinking about the action.

People who use a gun to commit suicide will be successful more than 90 percent of the time, Rivara said.

“So restricting youth access to guns is important,” he said.

While gun-control laws are controversial, locking up guns in homes with children should not be a contentious issue, he said.

A study of gun storage practices published in 2005 in JAMA Pediatrics concluded that trigger locks and lockboxes could reduce youth gun accidents and suicides by 70 percent.

Guns should be locked away in lockboxes or safes, Rivara asserted. Trigger locks should be used to stop the trigger from being pulled by anyone without the key or combination. Communities should have education campaigns to urge safe storage, he said.

Suicide prevention programs

A sample of evidence-based programs on the SAMHSA National Registry of Evidence-Based Programs and Practices

Preventing Suicide With A ‘Contagion Of Strength’

Reposted from NPR:
Suicide prevention

LA Johnson/NPR

For Whitney Bischoff, high school was tough. On the first day of her freshman year, a childhood friend committed suicide. Things weren’t any better at home — her father died when she was 7 and her mom was an alcoholic with an abusive boyfriend.

She had a hard time making friends.

And when all the stress threatened to overwhelm her, she, too, considered suicide.

“I thought family was everything,” Bischoff says. “I thought, if I didn’t have family support – what am I going to do? Suicide seemed like the only way out.”

As the thoughts persisted, Bischoff started going to group counseling sessions organized by her school in Rapid City, S.D.

But it didn’t help. “I felt like it was always so depressing every time we talked,” she says. “Having all that negative put to your face as a freshman – it was just a lot to take in.”

But then something changed. Rapid City Central High started using a suicide-prevention program called Sources of Strength. The 15-year-old effort is now in more than 250 schools and community centers in 20 states. Researchers and advocates point to it as one of few prevention programs that has research behind it showing it can work.

Strength Is Contagious

I first learned about Sources of Strength last month, when four high schools in the Washington, D.C., suburbs started the program. I headed to Thomas S. Wootton High School — a top performing school in Rockville, Md., with enrollment of just over 2,000 — to see the initial student training.

It’s a cold Friday morning in January. There are about 60 students sitting in folding chairs in the school’s gymnasium. They’re circled up, clustered around Dan Adams, a national trainer with the program. They’re talking about the many stresses of high school.

“The stress of boundaries in dating,” offers Shelby Ting, a sophomore. “Like what you’re willing to do in your first relationship.”

“I think we overlook the stress of being social,” says Noah Braunstein, a senior. “Finding that group you fit in with is hard, and it’s really taken me until senior year to find it.”

Adams, in a black T-shirt and jeans, shifts the conversation to strengths: “What are the strengths in your life that help you deal with stress?” he asks.

Music. Friends. Family. Mac and cheese.

This emphasis on strengths is what Sources of Strength is all about: promoting positive behaviors in teens.

The curriculum is rooted in eight “strengths” – factors that research has shown are protective against suicide risk.

Adams walks the Wootton students through these eight strengths — family support, positive friends, spirituality, healthy activities, medical access, mentors, mental health and generosity.

For each category, students offer up examples from their own lives. “I know my really good friends don’t put me under peer pressure,” says a student. Another shares about how her church family really helped her get through her grandmother’s passing.

“Not one of these pieces is enough to save someone from taking their own life,” says Adams. “But a bunch of them – now that can make a real difference.”

Jeff Brown, the acting principal of Wootton, is watching the training. He says that, like many schools, Wootton has faced issues with suicide. In 2014, the 154,000 student district lost five students to suicide.

And though national suicide rates have remained flat in recent years, it’s still the third most common cause of death for 15- to 19-year-olds. And nationwide, 17 percent of American high school students said they had seriously considered suicide, according to the Centers for Disease Control and Prevention’s 2013 Youth Risk Behavior Surveillance.

Teens are highly influenced by their peers – social development, peer acceptance and personal identity are all part of growing up. Researchers note that adolescents look to their peers to define acceptable ways to deal with problems.

“Kids learn from each other a great deal. So when peers are offering each other solutions, there is a greater chance kids are going to try them,” says Dr. Jill Harkavy-Friedman, who leads research for the American Foundation of Suicide Prevention. She praised the Sources of Strength program for its methods, naming it as one of the few comprehensive suicide prevention programs that’s based on research.

“We knew we had to have a peer component … to bring teens into the mix,” says Scott LoMurray, who runs the Sources of Strength program with his father. Mark LoMurray, Scott’s father, developed the program in the late 1990s after working with law enforcement as a crisis-response expert. In a three year period, he attended 30 funerals of teenagers — a number of them due to suicide.

“We couldn’t just train adults and expect that to be effective,” Scott LoMurry says.

But the peer mentors didn’t replace the role of adults. Instead, Sources of Strength uses adult advisers – teachers, parents and administrators – as resources for the peer-leaders.

Harkavy-Friedman says having this combination of peer-to-peer communication with adult backing makes the program stronger.

Dan Adams, a national trainer with Sources of Strength, leads a discussion with student peer-leaders at Wootton High School in Rockville, Md.

An Evidence-Based Approach

Over the next five months of school, Wooton High School’s newly trained peer leaders will meet with their adult advisers and other students. They’ll be talking about the power of positive support and sharing stories of how the eight pillars of strength play out in their own lives.

Administrators at the school are convinced Sources of Strength will have a strong impact on their school culture – and research tends to back that up.

“This is really the first peer-leader program that has shown impact on school-wide coping norms and influence on youth connectedness,” says Peter Wyman, a psychiatry professor at the University of Rochester in New York.

Wyman has been studying suicide prevention for the last 12 years. He was one of the authors of a three-year study in the American Journal of Public Health that looked at the effectiveness of Sources of Strength.

The researchers looked at 18 schools in Georgia, New York and South Dakota and found big changes in health-seeking behavior. Students, the study found, started to think that adults in school could be helpful, and peer leaders successfully encouraged friends to seek help from adults. The biggest changes in behavior occurred among students who were, or had been, suicidal.

“Telling their own life stories, about overcoming adversity and people who helped – that seems to be a very potent tool for having an impact on diverse teens, including teens that may not be receptive to other kinds of information,” Wyman says.

Schools are catching on — Sources of Strength is expanding programs in Palo Alto, Calif., Idaho and in a number of rural Alaskan villages north of Fairbanks. They’re also starting new programs in several communities in Washington state, including one in the Tulalip tribal community.

But the price tag can be a deterrent: It costs close to $5,000 to bring the program to a new school. If a school chooses to spend $4,000 to certify a staff member as an official trainer, then it will cost a school about $500 each year to maintain it.

And despite the research — school counselors sometimes find it difficult to convince schools to make it a priority. Mary Hines-Bone, a prevention specialist for the Cobb County school district, near Atlanta, says it can be tough getting schools to implement it properly. The biggest obstacle in making the program successful: the time commitment.

“It’s been a real challenge to get time during school days,” says Hines-Bone. “And programs where students meet before and after school don’t end up being as effective.”

And so schools may turn to less costly and less time-consuming approaches, like suicide-prevention assemblies or presentations that discuss the warning signs and risks of suicide.

Some prevention experts warn that programs emphasizing risks might not work as well, and researchers say there is little evidence that such one-time lectures have any effect. And they say any sustained effort must include adults talking with kids: making students part of the the intervention and not the target of it.

“The biggest prevention piece that’s out there is connection. When kids feel connected to somebody or their environment they’re going to make fewer risky decisions, ” says Tim McGowan, the school counselor who brought the Sources of Strength program to Rapid City Central High School.

After running the program there for seven years, he says he finally has a student body that has never experienced a fellow student who has died by suicide. He says he gets lots of calls asking for advice, asking how he turned his school around. His best advice: Listen to kids and trust them.

“Sometimes kids tell us things we don’t want to hear,” McGowan says. “But you have to be open to those – because if you’re not open to those, then you lose that opportunity for growth.”

Whitney Bischoff, now 21, says she’s grateful for that openness. The program gave her a space to feel supported and the ability to recognize that, while her family support wasn’t as strong, she had other strengths: her friends from theater, her spirituality and her school mentor — Mr. McGowan.

She says she’s come a long way since freshman year. She’s on track to graduate this spring from Black Hills State University in Spearfish, S.D., with a degree in Psychology.

“That program saved me,” she says, “and it gave me the passion and the confidence to want to pass it on to others.”


Elissa Nadworny/NPR