Summations
Social work research efforts should focus on how to increase the role of social workers in suicide prevention and the management of suicidal patients.
Social work education programmes should modify their curricula and increase their attention on suicide prevention.
Mental health social workers need to educate the patient and their family on suicide risk factors. Furthermore, mental health and non-mental health social workers need to educate the general public on suicide risk factors.
Perspectives
Social work research in the area of suicide prevention is limited. Several researchers report that there is a scarcity of research that identifies effective evidence-based interventions that social workers could utilise with suicidal persons. Social workers need to conduct more research studies in the area of suicide prevention. This may lead to improvement in the identification and management of suicidal individuals by social workers.
There is an insufficient amount of social workers and mental health care in many countries. People who are at risk for suicide may not be getting the treatment that they need. Public policy efforts should seek to increase the amount of social workers in areas that are in need. Additionally, there needs to be an improvement in the quality of mental health care.
Social work education programmes often offer insufficient training in suicide prevention. Suicide prevention training needs to be improved in social work education programmes.
Introduction
Suicide is a major public health problem affecting individuals, families and societies, and one of the leading causes of premature death in many regions of the world (Hawton & van Heeringen, Reference Hawton and van Heeringen2009; World Health Organization [WHO], 2014). At least 800 000 people kill themselves every year around the world and many more individuals make non-lethal suicide attempts (WHO, 2014). Rates of suicide death are very significant in many countries across the world (Hawton & van Heeringen, Reference Hawton and van Heeringen2009; WHO, 2014; Hedegaard et al., Reference Hedegaard, Curtin and Warner2018; Office for National Statistics [ONS], 2019). A report issued in November 2018 by the United States Centers for Disease Control and Prevention indicates that from 1999 through 2017, the age-adjusted rate of suicide in the USA rose 33% from 10.5 to 14.0 per 100 000 (Hedegaard et al., Reference Hedegaard, Curtin and Warner2018). A recent report indicates that the suicide rate has also increased in the United Kingdom (ONS, 2019). The United Kingdom Office for National Statistics (ONS, 2019) has reported that there is a statistically significant increase in the suicide rate, with 11.2 suicide deaths per 100 000 population in 2018, compared with 10.1 suicide deaths per 100 000 population in 2017. Higher suicide rates have been reported in men compared to women in almost all countries of the world (Sher, Reference Sher2018).
Research works in the USA suggest that more than 90% of victims of suicide have a psychiatric disorder (Sher et al., Reference Sher, Oquendo and Mann2001; Mann, Reference Mann2002; Hawton & van Heeringen, Reference Hawton and van Heeringen2009; Brådvik, Reference Brådvik2018). Also, most individuals who make non-lethal suicide attempts have a psychiatric illness. The most common psychiatric sicknesses associated with suicide or severe suicide attempt are mood disorders (Sher et al., Reference Sher, Oquendo and Mann2001; Mann, Reference Mann2002; Hawton & van Heeringen, Reference Hawton and van Heeringen2009; Brådvik, Reference Brådvik2018). Psychotic, substance use, anxiety and personality disorders are also associated with elevated suicide risk (Sher et al., Reference Sher, Oquendo and Mann2001; Mann, Reference Mann2002; Hawton & van Heeringen, Reference Hawton and van Heeringen2009; Brådvik, Reference Brådvik2018; Sher & Kahn, Reference Sher and Kahn2019). Medical conditions, especially illnesses associated with chronic pain, considerably raise risk of suicide (Ahmedani et al., Reference Ahmedani, Peterson, Hu, Rossom, Lynch, Lu, Waitzfelder, Owen-Smith, Hubley, Prabhakar, Williams, Zeld, Mutter, Beck, Tolsma and Simon2017; Rogers & Joiner, Reference Rogers and Joiner2019). Multiple observations indicate that unemployed and homeless people, immigrants, and individuals with legal problems are at risk of stress-related disorders and suicidal behaviour (Beautrais et al., Reference Beautrais, Joyce and Mulder1997; Blakely et al., Reference Blakely, Collings and Atkinson2003; Desai et al., Reference Desai, Liu-Mares, Dausey and Rosenheck2003; Sher, Reference Sher2010; Lundin et al., Reference Lundin, Lundberg, Allebeck and Hemmingsson2012; Harenski et al., Reference Harenski, Brook, Kosson, Bustillo, Harenski, Caldwell, Van Rybroek, Koenigs, Decety, Thornton, Calhoun and Kiehl2017; Forte et al., Reference Forte, Trobia, Gualtieri, Lamis, Cardamone, Giallonardo, Fiorillo, Girardi and Pompili2018).
International studies provide consistent evidence that the presence of psychiatrists in a region is associated with lesser suicide rates (Brooks Holliday, Reference Brooks Holliday2018). However, many psychiatric patients including suicidal patients do not have access to psychiatrists (New American Economy, 2017; Wainberg et al., Reference Wainberg, Scorza, Shultz, Helpman, Mootz, Johnson, Neria, Bradford, Oquendo and Arbuckle2017). For example, more than 60% of all counties in the USA, including 80% of all rural counties, do not have a single psychiatrist (New American Economy, 2017). Many others lack enough psychiatrists to treat residents with mental illness. In rural counties, just 590 psychiatrists serve more than 27 million Americans (New American Economy, 2017). These data indicate that mental health and non-mental health social workers need to be involved in suicide prevention efforts.
The National Association of Social Workers (NASW), a professional organisation of social workers in the USA reports ‘there are more clinically trained social workers—over 200 000—than psychiatrists, psychologists and psychiatric nurses combined’ (NASW, n.d.). Social workers are an underappreciated and, probably, underused suicide prevention resource. This paper is the first comprehensive work that discusses how to increase the role of social workers in the area of suicide prevention.
Aims of the study
The aim of this review is to discuss ways to increase the role of social workers in suicide prevention and the management of suicidal patients. Recommendations are provided incorporating universal, selective and indicated suicide preventive interventions.
Material and methods
The articles that were included in this paper were found using PubMed/MEDLINE, Current Contents/Web of Science, PsychINFO, Index Copernicus International and Google Scholar databases. The keywords that were utilised consisted of ‘social work’, ‘social worker’, ‘suicide prevention’, ‘suicide’, ‘suicide attempt’, ‘suicidality’, ‘depression’, ‘public health’, ‘stress’, ‘prevention’, ‘intervention’, ‘postvention’, ‘risk factors’, ‘psychiatric disorders’, ‘mental health’, ‘psychosocial stressors’ and ‘psychotherapy’. These keywords were used in different variations and combinations.
The full text of the chosen literature was manually reviewed to determine inclusion into this paper. Additional references were found after reviewing the literature. No specific exclusion criteria were used as we included reviews, studies, opinion pieces, perspectives and commentaries. The entirety of the literature included in this paper was written in the English language.
Results
Social workers are a considerable and important workforce
Social workers are part of a large and educated workforce. In 2015, the approximate number of active social workers in the USA with at least a bachelorʼs degree ranged from 650 000 to 672 000, with females accounting for 83% and males accounting for 17% (Salsberg et al., Reference Salsberg, Quigley, Mehfoud, Acquaviva, Wyche and Sliwa2017). Social workers who actively practice in the USA have varying levels of educational attainment with 43% having non-social work bachelorʼs degrees, 12% having bachelorʼs degrees in social work and 45% having a masterʼs degree or greater (Salsberg et al., Reference Salsberg, Quigley, Mehfoud, Acquaviva, Wyche and Sliwa2017). The types of settings where social workers are employed consist of mental health clinics, non-mental health clinics, schools, child and adult welfare and human service agencies, hospitals, settlement houses, community development corporations and private practices (U.S. Department of Labor, 2019). Social work is the largest occupational group of behavioural health practitioners in the USA with an estimated 232 900 social workers trained at the masterʼs level or higher (HHS Health Resources and Services Administration, 2016).
In addition to the USA, social workers play a significant role in many societies. For example, there are approximately 25 000 (Sandström, Reference Sandström2007) to 30 000 (Nelson, Reference Nelson2013) social workers in Sweden; females account for 79% and males account for 21% of this range (Sandström, Reference Sandström2007). There are about 330 social workers for every 100 000 inhabitants in Sweden (Höjer & Dellgran, Reference Höjer and Dellgran2013; Nelson, Reference Nelson2013). In China, there is an estimated 200 000 social workers, which gives a ratio of about 13 social workers for every 100 000 inhabitants (Höjer & Dellgran, Reference Höjer and Dellgran2013).
Social workers and suicidal persons
Social workers across all fields of practice may encounter suicidal persons (Feldman & Freedenthal, Reference Feldman and Freedenthal2006), especially those who work in the field of mental health (Jacobson et al., Reference Jacobson, Ting, Sanders and Harrington2004). In a United States survey of 697 mental health social workers with a masterʼs degree or higher, 52.5% of respondents reported that they had experienced a person who engaged in either fatal or nonfatal suicidal behaviour, and 33.0% experienced a person who engaged in fatal suicidal behaviour (Jacobson et al., Reference Jacobson, Ting, Sanders and Harrington2004). Another United States national survey of 515 masters-level mental health social workers found that 55% of respondents had experienced at least 1 individual who engaged in a suicide attempt, 31% experienced an individual who had died by suicide and 30% had experienced both someone who had a suicide attempt and died by suicide (Sanders et al., Reference Sanders, Jacobson and Ting2008). Feldman and Freedenthal (Reference Feldman and Freedenthal2006) created a web-based survey that surveyed 598 mental health and non-mental health social workers on their experience with suicidal persons. The survey found that 92.8% of respondents reported working with at least one suicidal person in their career, 53.4% had worked with at least one suicidal person in the previous month and 78.1% had worked with at least one suicidal person in the previous year (Feldman & Freedenthal, Reference Feldman and Freedenthal2006). A questionnaire administered to 2999 social workers in the Tokyo Chapter of the Japanese Association of Certified Social Workers found that 47.7% of respondents had worked with an individual who attempted suicide, 36.9% had worked with someone who died by suicide and 46.0% had worked with someone who had suicidal thoughts (Kodaka et al., Reference Kodaka, Inagaki, Poštuvan and Yamada2012). The fact that 36.9% of social workers had worked with someone who later died by suicide shows that improving social work training, education and practice interventions can assist in decreasing suicide risk. Slater et al. (Reference Slater, Scourfield and Greenland2013) conducted a secondary analysis of the ‘Adult Psychiatric Morbidity Study in England 2007’ and determined that people with a suicidal history were more likely to have contact with a social worker than the general population. Perhaps social workers could work to improve the lives of these people and consequently reduce the possibility of suicidal ideation and suicidal behaviours. The authors recommended that more attention needs to be given to the role of social workers in suicide prevention, social work practice interventions and research (Slater et al., Reference Slater, Scourfield and Greenland2013).
Social work students and education
Social work students also encounter suicidal persons (Jacobson et al., Reference Jacobson, Osteen, Sharpe and Pastoor2012; Sharpe et al., Reference Sharpe, Jacobson Frey, Osteen and Bernes2014). In a randomised controlled trial of 72 social work students enrolled at the University of Maryland, Baltimore School of Social Work, 71% of student respondents indicated that they had worked with at least one suicidal individual at their field placement in the previous 6 months (Jacobson et al., Reference Jacobson, Osteen, Sharpe and Pastoor2012). However, research shows that social work education programmes focus little on suicide prevention (Feldman & Freedenthal, Reference Feldman and Freedenthal2006; Osteen et al., Reference Osteen, Jacobson and Sharpe2014; Scott, Reference Scott2015). Given the fact that social work students often engage with suicidal individuals, social work education programmes should modify their curricula towards educating about suicide prevention. In Feldman and Freedenthalʼs (Reference Feldman and Freedenthal2006) web-based survey, only 21.2% of respondents reported that they received formal suicide prevention training in their master of social work (MSW) programme, and 40.8% of respondents indicated that they did not take any classes that addressed suicide intervention or prevention. In a study that surveyed deans and directors of MSW programmes from a Council on Social Work Education list, 85.2% of respondents reported that MSW students were not required to participate in suicide-related education, and 1.9% reported that their MSW programme offered courses specifically devoted to suicide prevention (Ruth et al., Reference Ruth, Gianino, Muroff, McLaughlin and Feldman2012).
Social work research
Social work research in the areas of suicide and suicide prevention is limited. Joe and Niedermeier (Reference Joe and Niedermeier2008) conducted a systematic review on social work literature and found that ‘suicide research articles made up only 0.2 per cent of the total articles published from 1980-2006 in social work journals’ (p. 514). The authors point out that less than 8% of these articles were control studies that discussed the development of effective interventions for suicide and suicidal behaviours (Joe & Niedermeier, Reference Joe and Niedermeier2008). An example of one of the studies that was discussed was an intervention study that provided group therapy to 28 women who were the victims of childhood sexual abuse (Bagley & Young, Reference Bagley and Young1998). Six years after the study, it was found that the women ‘retained their gains in self-esteem and reduction of depression and suicidality’ (Bagley & Young, Reference Bagley and Young1998, p. 63).
Rosen et al. (Reference Rosen, Proctor and Staudt1999) conducted a review of social work research literature, not specifically related to suicide, between January 1993 and July 1997. The authors found that ‘only 3 percent of published articles (53 of 1849) could inform a practitioner of how to implement reliably the intervention that was studied’ (Rosen et al., Reference Rosen, Proctor and Staudt1999, p. 12). This finding underlines a need to improve the activities of social work in suicide prevention. Social work research efforts need to focus on how to increase the role of social workers in suicide prevention and the management of suicidal persons.
Summary
Social workers play a role in suicide prevention efforts; however, there is still more that needs to be done. This is especially important, because in the USA, there are more clinical social workers than psychiatric nurses, psychologists and psychiatrists combined (NASW, n.d.). Research shows that social workers often encounter suicidal persons (Feldman & Freedenthal, Reference Feldman and Freedenthal2006). Unfortunately, several authors point out that social work education programmes focus little on suicide prevention (Feldman & Freedenthal, Reference Feldman and Freedenthal2006; Osteen et al., Reference Osteen, Jacobson and Sharpe2014; Scott, Reference Scott2015). In addition, social work research on suicide prevention is limited, and seldom discusses clinical interventions that social workers could utilise with suicidal persons (Joe & Niedermeier, Reference Joe and Niedermeier2008). This paper discusses how to improve the activities of social work in regard to suicide prevention.
Discussion
A comprehensive review of activities of mental health and non-mental health social workers is beyond the scope of this paper. This paper only discusses aspects of social work related to suicide prevention.
Sher (Reference Sher2004) introduces the idea of dividing suicide prevention efforts into three categories: universal preventive interventions, selective preventive interventions and indicated preventive interventions. This idea was further developed from the Institute of Medicineʼs recommendations for preventing psychiatric disorders (Muñoz et al., Reference Muñoz, Mrazek and Haggerty1996). This section will provide recommendations for how social work can improve upon suicide prevention while incorporating Sherʼs (Reference Sher2004) suggestion of universal, selective and indicated preventive interventions.
Social workerʼs and universal preventive interventions
Universal preventive interventions are constructed for people in a specific population who are not necessarily at risk for suicide (Sher, Reference Sher2004). Gatekeeper training programmes and education to the general public are examples of universal preventive interventions.
Gatekeepers
Several researchers identify gatekeeper training as an effective suicide prevention intervention (Mann et al., Reference Mann, Apter, Bertolote, Beautrais, Currier, Haas, Hegerl, Lonnqvist, Malone, Marusic, Mehlum, Patton, Phillips, Rutz, Rihmer, Schmidtke, Shaffer, Silverman, Takahashi, Varnik, Wasserman, Yip and Hendin2005; Isaac et al., Reference Isaac, Elias, Katz, Belik, Deane, Enns and Sareen2009; Yonemoto et al., Reference Yonemoto, Kawashima, Endo and Yamada2019). Gatekeepers are individuals within the community who are trained to identify suicide risk factors (Mann et al., Reference Mann, Apter, Bertolote, Beautrais, Currier, Haas, Hegerl, Lonnqvist, Malone, Marusic, Mehlum, Patton, Phillips, Rutz, Rihmer, Schmidtke, Shaffer, Silverman, Takahashi, Varnik, Wasserman, Yip and Hendin2005). One example of a gatekeeper training programme is the Question, Persuade, and Referral (QPR) suicide gatekeeper training programme (Quinnett, Reference Quinnett1995). The purpose of the QPR programme is to train people in the community how to identify suicide risk factors, interrupt the crisis from escalating further and connect the person at risk for suicide to the proper resources (Quinnett, Reference Quinnett1995). Jacobson et al.(Reference Jacobson, Osteen, Sharpe and Pastoor2012) conducted a study that randomly assigned 72 social work students to a control group or to an intervention group that received the QPR suicide gatekeeper training programme. At the conclusion of the study, it was found that the intervention group demonstrated improvement in regard to their skills, knowledge and efficacy to perform in the gatekeeper role (Jacobson et al., Reference Jacobson, Osteen, Sharpe and Pastoor2012). Additionally, a follow-up study that analysed secondary data from the aforementioned study revealed that the intervention group maintained improvements for all gatekeeper behaviours after 4 months (Osteen, Reference Osteen2018). A similar study that provided the Dutch gatekeeper training programme (based off the QPR suicide gatekeeper training programme principles) to 526 professionals found significant improvement in their knowledge and confidence when responding to suicidality (Terpstra et al., Reference Terpstra, Beekman, Abbing, Jaken, Steendam and Gilissen2018). Social workers should create gatekeeper training programmes to increase the amount of community gatekeepers in a community.
Education of the general population
Social workers play a role in the education of the general public on healthcare issues (Mann et al., Reference Mann, Golden, Cronk, Gale, Hogan and Washington2016; Taylor et al., Reference Taylor, Coffey and Kashner2016; Saxe Zerden et al., Reference Saxe Zerden, Lombardi and Jones2019). Mental health and non-mental health social workers should educate the general public on suicide risk factors with or without the use of gatekeeper training programmes. Lectures on suicide risk factors and suicide prevention interventions should be provided by social workers in community centres, schools or local businesses. If social workers can increase the knowledge of the general public on suicide risk factors in a specific region, this may decrease the amount of suicides in that area.
Education via mass media and social media
Social media can be instrumental in suicide prevention efforts (Robinson et al., Reference Robinson, Cox, Bailey, Hetrick, Rodrigues, Fisher and Herrman2016; Sher, Reference Sher2019). Robinson et al. (Reference Robinson, Cox, Bailey, Hetrick, Rodrigues, Fisher and Herrman2016) conducted a systematic review that examined social media and suicide prevention. The researchers found that social media could be advantageous in engaging hard to reach people, it could act as a platform to identify people who expressed suicidal ideation online, it is easily accessible and it allows for people to anonymously receive support and share their experiences (Robinson et al., Reference Robinson, Cox, Bailey, Hetrick, Rodrigues, Fisher and Herrman2016). Several researchers report that social media can possibly contribute to increased suicide risk (Luxton et al., Reference Luxton, June and Fairall2012; Robinson et al., Reference Robinson, Rodrigues, Fisher, Bailey and Herrman2015; Robinson et al., Reference Robinson, Cox, Bailey, Hetrick, Rodrigues, Fisher and Herrman2016). There were concerns that individuals who utilise social media for support may become further isolated from society, or they might access content that normalises suicidal behaviours (Robinson et al., Reference Robinson, Cox, Bailey, Hetrick, Rodrigues, Fisher and Herrman2016). Social media also posed as a risk for contagion (Robinson et al., Reference Robinson, Rodrigues, Fisher, Bailey and Herrman2015; Robinson et al., Reference Robinson, Cox, Bailey, Hetrick, Rodrigues, Fisher and Herrman2016). Respondents of a stakeholder survey felt that the benefits of using social media for suicide prevention efforts outweighed the risks (Robinson et al., Reference Robinson, Rodrigues, Fisher, Bailey and Herrman2015). Sher (Reference Sher2019) recommended that mental health professionals provide education to the general public and vulnerable people on how social media could impact mental health. Social workers should provide psychoeducation on the positive and negative effects of social media on mental health in their practice settings. This could serve as a way to decrease suicide risk.
Social workerʼs and selective preventive interventions
A selective prevention intervention is designed for populations who are at increased risk for suicide (Sher, Reference Sher2004), such as those who are unemployed, homeless or have a psychiatric disorder.
Improving a social workerʼs diagnostic abilities
Mental health social workers in the USA who have successfully satisfied their jurisdictionʼs clinical examination requirements can obtain clinical licensure. The clinical license allows a social worker to legally diagnose and treat mental disorders (Harkness, Reference Harkness2011; Shah et al., Reference Shah, Anderson, Li, Meadows and Breitsprecher2018). Efforts should be aimed towards improving a mental health social workerʼs diagnostic abilities to better be able to diagnose psychiatric disorders and suicidal behaviours. Improving social work education and training can strengthen a social workerʼs diagnostic abilities.
Social workers often work with individuals who have psychiatric disorders including mood and psychotic disorders, anxiety disorders, stress-related disorders, sleep disorders, substance use disorders and personality disorders. It is well known that there is a close relationship between psychiatric illnesses and suicidality (Harris & Barraclough, Reference Harris and Barraclough1997; Sher et al., Reference Sher, Oquendo and Mann2001; Maris, Reference Maris2002; Arsenault-Lapierre et al., Reference Arsenault-Lapierre, Kim and Turecki2004; Mann et al., Reference Mann, Apter, Bertolote, Beautrais, Currier, Haas, Hegerl, Lonnqvist, Malone, Marusic, Mehlum, Patton, Phillips, Rutz, Rihmer, Schmidtke, Shaffer, Silverman, Takahashi, Varnik, Wasserman, Yip and Hendin2005; Joe & Niedermeier, Reference Joe and Niedermeier2008; Osborn et al., Reference Osborn, Levy, Nazareth and King2008; Manthorpe & Iliffe, Reference Manthorpe and Iliffe2011; Qin, Reference Qin2011; Pascal de Raykeer et al., Reference Pascal de Raykeer, Hoertel, Blanco, Olfson, Wall, Seigneurie, Schuster, Lemogne, von Gunten and Limosin2018). Psychological autopsy studies conducted in the USA revealed that approximately 90% of people who died by suicide had at least one mental disorder (Mann et al., Reference Mann, Apter, Bertolote, Beautrais, Currier, Haas, Hegerl, Lonnqvist, Malone, Marusic, Mehlum, Patton, Phillips, Rutz, Rihmer, Schmidtke, Shaffer, Silverman, Takahashi, Varnik, Wasserman, Yip and Hendin2005). Another meta-analysis that reviewed 27 studies that comprised of a total of 3275 suicides found that in 87.3% of the suicides the individual had a mental disorder (Arsenault-Lapierre et al., Reference Arsenault-Lapierre, Kim and Turecki2004). Studies found that mental illness increased suicide risk in elderly persons aged 65 and older (Rubenowitz et al., Reference Rubenowitz, Waern, Wilhelmson and Allebeck2001). Baca-Garcia et al. (Reference Baca-Garcia, Parra, Perez-Rodriguez, Diaz Sastre, Reyes Torres, Saiz-Ruiz and de Leon2007) conducted a study that consisted of 258 suicide attempters treated in a hospital emergency room in Madrid and found that 55% of these individuals had a diagnosis of major depressive, 21% had alcohol abuse or dependence, 11% had adjustment disorder, 10% had generalised anxiety disorder and 64% exhibited cluster B personality traits. Furthermore, the researchers suggested that psychosocial stressors created higher suicide risk than biological factors (e.g. hormones and genetics) (Baca-Garcia et al., Reference Baca-Garcia, Parra, Perez-Rodriguez, Diaz Sastre, Reyes Torres, Saiz-Ruiz and de Leon2007). A population-based study that analysed young adults between ages 18 and 34 in New South Wales, Australia found that individuals with a psychiatric illness were 11 times more likely to attempt suicide and 5 times more likely to die by suicide (Milner et al., Reference Milner, Page, Morrell, Hobbs, Carter, Dudley, Duflou and Taylor2014). Once the presence of a psychiatric disorder is identified, the social worker can work towards determining an effective treatment approach and/or referral to a psychiatrist.
Suicide prevention should not only be the responsibility of mental health social workers. Efforts should also be focused on improving the diagnostic abilities of non-mental health social workers. Gatekeeper training programmes, such as the QPR (Quinnett, Reference Quinnett1995), can be used to educate non-mental health social workers to identify suicide risk factors. Non-mental health social workers should be required to participate in gatekeeper training programmes so that they can better educate the general public on suicide risk factors.
Interventions for patients with psychiatric disorders
Psychotherapy
Once the mental health or non-mental health social worker determines that there is a psychiatric disorder present, they can begin to establish a treatment plan in collaboration with other mental health professionals and select an appropriate psychotherapeutic intervention. Lieberman (Reference Lieberman1987) points out that social workers have historically been involved and contributed to psychotherapy. Psychotherapy has been found effective in the treatment of psychiatric disorders (Lazar, Reference Lazar2014; Cook et al., Reference Cook, Schwartz and Kaslow2017).
Cognitive-behavioural therapy (CBT) was found to be an effective intervention for the treatment of depression (Sudak, Reference Sudak2012; Lazar, Reference Lazar2014). A meta-analysis that reviewed 53 studies concluded that psychodynamic treatment, CBT, behavioural activation treatment, interpersonal psychotherapy, social skills training, nondirective supportive treatment and problem-solving therapy were efficacious in the treatment of mild to moderate depression in adults (Cuijpers et al., Reference Cuijpers, van Straten, Andersson and van Oppen2008). Additionally, problem-solving therapy and CBT were determined to be effective treatments for depression and anxiety disorders (Zhang et al., Reference Zhang, Franklin, Jing, Bornheimer, Hai, Himle, Kong and Ji2019). A systematic review that examined psychological therapies for bipolar spectrum disorders revealed that CBT had promising results for reducing anxiety symptoms (Stratford et al., Reference Stratford, Cooper, Di Simplicio, Blackwell and Holmes2015). Rubin et al. (Reference Rubin, Weiss and Coll2013) identify cognitive processing therapy, prolonged exposure therapies and trauma-focused CBT as effective interventions in the treatment of posttraumatic stress disorder (PTSD). Another type of therapeutic intervention that has been proven effective for PTSD is narrative therapy (Herman, Reference Herman1997). A randomised controlled trial found that CBT was an effective intervention for the treatment of early schizophrenia (Lewis et al., Reference Lewis, Tarrier, Haddock, Bentall, Kinderman, Kingdon, Siddle, Drake, Everitt, Leadley, Benn, Grazebrook, Haley, Akhtar, Davies, Palmer, Faragher and Dunn2002). Škodlar and Henriksen (Reference Škodlar and Henriksen2019) describe the use of phenomenological psychotherapy as a possible therapeutic intervention for the treatment of schizophrenia. In the treatment of substance use disorders, motivational enhancement therapy (Lenz et al., Reference Lenz, Rosenbaum and Sheperis2016), motivational interviewing (Smedslund et al., Reference Smedslund, Berg, Hammerstrøm, Steiro, Leiknes, Dahl and Karlsen2011), group therapy (Lazar, Reference Lazar2014) and CBT (Magill & Ray, Reference Magill and Ray2009) were identified as effective interventions. Dialectical behavioural therapy (DBT) was found to be an effective intervention in the treatment of borderline personality disorder (Lazar, Reference Lazar2014; Panos et al., Reference Panos, Jackson, Hasan and Panos2014; Linehan et al., Reference Linehan, Korslund, Harned, Gallop, Lungu, Neacsiu, McDavid, Comtois and Murray-Gregory2015). In their systematic review, Taylor and Pruiksma (Reference Taylor and Pruiksma2014) recommend CBT for insomnia as a ‘first line’ treatment for primary insomnia.
Mental health social workers need to have knowledge on how to effectively utilise psychotherapeutic interventions to treat psychiatric disorders. This is especially important because there is a close relationship between psychiatric disorders and suicidality (Harris & Barraclough, Reference Harris and Barraclough1997; Maris, Reference Maris2002; Arsenault-Lapierre et al., Reference Arsenault-Lapierre, Kim and Turecki2004; Mann et al., Reference Mann, Apter, Bertolote, Beautrais, Currier, Haas, Hegerl, Lonnqvist, Malone, Marusic, Mehlum, Patton, Phillips, Rutz, Rihmer, Schmidtke, Shaffer, Silverman, Takahashi, Varnik, Wasserman, Yip and Hendin2005; Joe & Niedermeier, Reference Joe and Niedermeier2008; Osborn et al., Reference Osborn, Levy, Nazareth and King2008; Manthorpe & Iliffe, Reference Manthorpe and Iliffe2011; Qin, Reference Qin2011; Pascal de Raykeer et al., Reference Pascal de Raykeer, Hoertel, Blanco, Olfson, Wall, Seigneurie, Schuster, Lemogne, von Gunten and Limosin2018). Joe and Niedermeier (Reference Joe and Niedermeier2008) recommend that social workers utilise interventions to reduce psychiatric disorders, such as psychotherapy, as a way to decrease suicide risk. Social work education programmes should improve training on psychotherapeutic interventions for social workers who anticipate pursuing a career in mental health. Furthermore, mental health social workers should pursue additional trainings and certifications to enhance their ability to utilise various psychotherapies.
Family interventions
Family members and caregivers of individuals who are at risk for suicide should be educated and trained by mental health providers including social workers on how to identify suicide risk factors. Often times family members and caregivers struggle with caring for a loved one at risk for suicide, because they might have anxiety towards the situation or they may lack the knowledge or support systems (Sun et al., Reference Sun, Chiang, Lin and Chen2013). Sun et al. (Reference Sun, Chiang, Lin and Chen2013) conducted a randomised controlled study that had family caregivers of individuals who were suicidal participate in a 2-hour suicide care education programme. The results of the programme exhibited statistically significant effects on the caregiverʼs ability to care for the person at risk for suicide (Sun et al., Reference Sun, Chiang, Lin and Chen2013). In addition, the suicide care education programme helped generate positive caregiver attitudes towards the individual at risk for suicide (Sun et al., Reference Sun, Chiang, Lin and Chen2013). Other researchers report there is significant evidence which demonstrates that providing psychoeducation to the family after an individualʼs suicide attempt reduces the risk for immediate danger and subsequent suicide attempts, while also improving aftercare treatment compliance (Dunne, Reference Dunne, Wasserman and Wasserman2009).
Another phenomenon that should be considered is expressed emotion. Amaresha and Venkatasubramanian (Reference Amaresha and Venkatasubramanian2012) define expressed emotion as the ‘care giverʼs attitude towards a person with a mental disorder as reflected by comments about the patient made to an interviewer’ (p. 12). Several researchers point out that expressed emotion is a significant psychosocial stressor for the individual in psychiatric distress and their family (Amaresha & Venkatasubramanian, Reference Amaresha and Venkatasubramanian2012; Napa et al., Reference Napa, Tungpunkom and Pothimas2017; Öksüz et al., Reference Öksüz, Karaca, Özaltin and AlpayAteş2017; Demir, Reference Demir2018). Demir (Reference Demir2018) conducted a study with 350 Turkish psychiatric outpatients that examined the relationship between suicide probability and expressed emotions. The study concluded that as expressed emotion increased, suicide probability also increased (Demir, Reference Demir2018). Providing psychoeducation to family members was found to be an effective intervention in reducing the negative effects of expressed emotion (Amaresha & Venkatasubramanian, Reference Amaresha and Venkatasubramanian2012; Napa et al., Reference Napa, Tungpunkom and Pothimas2017; Öksüz et al., Reference Öksüz, Karaca, Özaltin and AlpayAteş2017). Psychoeducation was found to decrease negative views and depressive symptoms of family members, as well as improve their overall psychological well-being and knowledge of the illness (Napa et al., Reference Napa, Tungpunkom and Pothimas2017). Social workers should provide psychoeducation to family members of individuals with psychiatric disorders to improve their abilities to care for the individual and to decrease the negative effects of expressed emotion.
Interventions with social groups who may be at elevated risk for suicide
The NASW (2013) in the USA identifies diagnostic ability, psychotherapy, psychosocial help, case management, community referrals and the ability to navigate employment, housing and legal issues as some of the knowledge essential to social work practice. These interventions can be effective in reducing suicide risk in people and populations that are at elevated risk for suicide.
Unemployment was found to increase suicide risk (Kposowa, Reference Kposowa2001; Blakely et al., Reference Blakely, Collings and Atkinson2003; Schneider et al., Reference Schneider, Grebner, Schnabel, Hampel, Georgi and Seidler2011; Lundin et al., Reference Lundin, Lundberg, Allebeck and Hemmingsson2012). A systematic review and meta-analysis established that long-term unemployment was associated with increased risk of suicide compared to those who have current employment (Milner et al., Reference Milner, Page and La Montagne2013). Classen and Dunn (Reference Classen and Dunn2012) found that recent job loss in the context of a mass-layoff increased suicide rates. The two researchers recommended that intervention programmes should be targeting persons or populations who lost their job in a mass-layoff as a way to decrease suicide risk (Classen & Dunn, Reference Classen and Dunn2012). Social workers who work with unemployed persons should aim to provide psychotherapy, job placement assistance, referrals to vocational rehabilitation programmes and other supportive interventions as a way to decrease suicide risk.
The homeless population is vulnerable as they have higher rates of substance abuse, mental health disorders, economic/employment problems, relationship problems, early childhood adversity, social exclusion and nutritional problems (Bonner & Luscombe, Reference Bonner and Luscombe2009). A study that examined 7224 homeless people with mental illness found that 66.2% of the individuals had a lifetime prevalence of suicidal ideation, and 51.3% had attempted suicide on at least one occasion (Desai et al., Reference Desai, Liu-Mares, Dausey and Rosenheck2003). Furthermore, the researchers concluded that people who were homeless for the first time in their lives were at highest risk for suicide (Desai et al., Reference Desai, Liu-Mares, Dausey and Rosenheck2003). Lee et al. (Reference Lee, Jun, Kim, Roh, Moon, Bukonda and Hines2017) examined the impact of substance abuse and mental health on suicide risk of 156 homeless adults. The study concluded that substance abuse was significantly associated with increased suicidal ideation, and anxiety was significantly related to suicide attempts in the homeless adults (Lee et al., Reference Lee, Jun, Kim, Roh, Moon, Bukonda and Hines2017). The researchers recommended that social workers at homeless shelters provide screening and referrals for treatment to homeless people who have mental health and substance abuse issues (Lee et al., Reference Lee, Jun, Kim, Roh, Moon, Bukonda and Hines2017). In addition, it was suggested that social workers assist the homeless individual with obtaining stable housing, employment, transportation, education, health insurance and other documentation that can assist in their treatment (Lee et al., Reference Lee, Jun, Kim, Roh, Moon, Bukonda and Hines2017). Social workers who work with homeless persons should seek to obtain housing placement for these individuals. In addition, the social worker should provide supportive interventions based on the specific needs of the individual. For example, if the homeless person has mental health issues, they can provide psychotherapy to that individual or referral to an appropriate community resource such as a psychiatrist. In cases of substance abuse, the homeless individual can be referred to a residential rehabilitation programme, which can address the substance abuse issue and act as a temporary placement option.
Social workers are frequently involved in cases with legal implications. Legal problems have been found to increase suicide risk (Beautrais et al., Reference Beautrais, Joyce and Mulder1997; Pritchard et al., Reference Pritchard, Cox and Dawson1997; Boardman et al., Reference Boardman, Grimbaldeston, Handley, Jones and Willmott1999; Cook, Reference Cook2013; Harenski et al., Reference Harenski, Brook, Kosson, Bustillo, Harenski, Caldwell, Van Rybroek, Koenigs, Decety, Thornton, Calhoun and Kiehl2017). Brent et al. (Reference Brent, Perper, Moritz, Baugher, Roth, Balach and Schweers1993) found a strong association between legal and disciplinary problems with suicide in adolescents. Similarly, one study that examined persons aged 13–24 concluded that legal difficulties were significantly related to suicide attempts (Beautrais et al., Reference Beautrais, Joyce and Mulder1997). Furthermore, 24% of the young people who attempted suicide had legal problems within the past year (Beautrais et al., Reference Beautrais, Joyce and Mulder1997). Cook and Davis (Reference Cook and Davis2012) examined court records from 2000 to 2005 in an urban county of Ohio and determined that one-third of those who died by suicide had recent court involvement. Another study that investigated the suicides of 874 United States Army soldiers from 2001 to 2009 found that 31% of the soldiers who died by suicide had legal problems (Black et al., Reference Black, Gallaway, Bell and Ritche2011). Social workers who work with individuals who have recently experienced a legal problem should screen that individual for suicidality since they are at heightened risk, especially when working with younger people or military personnel. They can also assist in navigating the legal climate and maintaining communication with collaterals, such as psychiatrists, attorneys and parole/probation officers.
Immigrant populations are at increased risk for suicide (Kushner, Reference Kushner1984; Forte et al., Reference Forte, Trobia, Gualtieri, Lamis, Cardamone, Giallonardo, Fiorillo, Girardi and Pompili2018). Immigrants often experience many hardships consisting of unemployment, stressful life events, loss of family and social supports, financial difficulties, disruption of family and social ties, depression and anxiety, which are all risk factors for suicide (Lai et al., Reference Lai, Li and Daoust2017). Colucci et al. (Reference Colucci, Too and Minas2017) report that immigrants are often hesitant to receive services because of stigma and shame. Several researchers recommend that mental health services be provided to immigrants who had traumatic experiences related to their migration, as they are an especially high-risk population (Ilceto et al., Reference Ilceto, Pompili, Candilera, Borges, Lamis, Serafini and Girardi2013). Social workers often work with immigrant populations in their practice settings. When working with immigrants and immigrant families, social workers should provide psychosocial help including psychoeducation on government benefit programmes, housing assistance, job placement services, psychotherapy and community referrals to vocational rehabilitation programmes or other mental health services. Community referrals should try to consider the immigrantʼs ethnic and cultural background, so that they can be connected with service providers who are familiar with their background (Sher, Reference Sher2010). The immigrantʼs migration story should be explored and assessed for trauma, to see if mental health treatment is needed. The social worker should practice with cultural sensitivity and conduct research on the immigrantʼs culture.
Social workerʼs and indicated preventive interventions: management of suicidal patients
Indicated prevention interventions are for people who are at high risk for suicide, such as those who are bereaved by suicide or those who have recent suicide attempts (Sher, Reference Sher2004).
Social workers and acutely suicidal patients
Social workers often come into contact with individuals who are at imminent risk for suicide (Mishna et al., Reference Mishna, Antle and Regehr2002). Rose and Molina (Reference Rose, Molina and Galynker2017) recommended assessing for suicide risk factors, referral to emergency services, crisis intervention and means restriction as interventions that should be utilised when working with acutely suicidal persons. The safety planning intervention is another suicide prevention intervention that can be utilised in a suicide crisis (Stanley & Brown, Reference Stanley and Brown2012). Social workers should employ the aforementioned interventions when working with acutely suicidal individuals.
Social workers can provide psychotherapy to suicidal patients
The use of psychotherapy for the treatment of psychiatric disorders has been discussed earlier. This section will describe how social workers could utilise psychotherapy with suicidal patients.
Psychotherapy has been found to decrease suicidal behaviours (Mann et al., Reference Mann, Apter, Bertolote, Beautrais, Currier, Haas, Hegerl, Lonnqvist, Malone, Marusic, Mehlum, Patton, Phillips, Rutz, Rihmer, Schmidtke, Shaffer, Silverman, Takahashi, Varnik, Wasserman, Yip and Hendin2005; Calati & Courtet, Reference Calati and Courtet2016; Méndez-Bustos et al., Reference Méndez-Bustos, Calati, Rubio-Ramírez, Olié, Courtet and Lopez-Castroman2019). There have been multiple research studies that explore various psychotherapeutic interventions and their effects on suicide risk. Through their research, Mann et al. (Reference Mann, Apter, Bertolote, Beautrais, Currier, Haas, Hegerl, Lonnqvist, Malone, Marusic, Mehlum, Patton, Phillips, Rutz, Rihmer, Schmidtke, Shaffer, Silverman, Takahashi, Varnik, Wasserman, Yip and Hendin2005) found that cognitive therapy, DBT, problem-solving therapy and interpersonal psychotherapy were effective in reducing suicidality. Brown and Jager-Hyman (Reference Brown and Jager-Hyman2014) reviewed randomised controlled trials of psychotherapeutic interventions and their effectiveness in reducing suicidality. The authors concluded that ‘cognitive therapy for suicide prevention (CT-SP); cognitive-behavioral therapy (CBT); dialectical behavioral therapy (DBT); problem-solving therapy (PST); mentalization-based treatment (MBT); and psychodynamic interpersonal therapy (PIT) have all evidenced positive effects for preventing suicide attempts or self-directed violence in adults’ (Brown & Jager-Hyman, Reference Brown and Jager-Hyman2014, p. S186). Similarly, a meta-analysis that reviewed therapeutic interventions for suicide attempts and self-harm in adolescents found the largest effect sizes in reducing suicidal behaviour with MBT, CBT and DBT (Ougrin et al., Reference Ougrin, Tranah, Stahl, Moran and Rosenbaum Asarnow2015). In their systematic review, Gøtzsche and Gøtzsche (Reference Gøtzsche and Gøtzsche2017) determined that CBT decreased the risk of a new suicide attempt in patients with previous attempts by half. The two authors recommended that CBT be the preferred intervention for treating depression (Gøtzsche and Gøtzsche, Reference Gøtzsche and Gøtzsche2017). Another study found that suicide risk had decreased for the majority of 65 patients who had presented to the Emergency Department following a suicide attempt after utilising assertive brief psychotherapy combined with linkage to general practitioners and community services (Petrakis & Joubert, Reference Petrakis and Joubert2013). Existing social work research and literature has been found to be mostly descriptive in nature and often fails to address effective practice interventions (Rosen et al., Reference Rosen, Proctor and Staudt1999; Joe & Niedermeier, Reference Joe and Niedermeier2008).
Social work research efforts need to be focused on developing specific practice interventions that social workers can utilise with suicidal individuals, as well as enhancing the efficacy of existing psychotherapeutic interventions. Furthermore, social workers need to increase the usage of existing psychotherapeutic interventions when working with suicidal persons.
Postvention
Postvention is an intervention that is utilised to support individuals bereaved by suicide (Andriessen & Krysinska, Reference Andriessen and Krysinska2012; Andriessen, Reference Andriessen2014). Several researchers point out that those who are bereaved by suicide are at an increased risk for suicidal behaviours (Jordan, Reference Jordan2017; Maple et al., Reference Maple, Pearce, Sanford and Cerel2017). Research in the area of postvention is limited. Maple et al. (Reference Maple, Pearce, Sanford and Cerel2017) identified only three postvention articles written by social work researchers since 2003. In a systematic mapping review of global research not specifically related to social work, it was found that there were only about 8.86 papers produced per year on the topics of suicide bereavement and postvention since 1965 (Maple et al., Reference Maple, Pearce, Sanford and Cerel2018). Similarly, Andriessen (Reference Andriessen2014) conducted a review of four suicidology journals (Crisis, Suicide and Life-Threatening Behavior, Archives of Suicide Research, and Suicidology Online) from their inception up until mid-2013 and identified only 144 articles published on suicide bereavement and postvention in the past 40 years. Unfortunately, there are some people who died by suicide. Social workers need to work with the family and friends of the person who died by suicide to decrease suicide risk of those individuals.
Limitations
Social work research in the area of suicide prevention is limited. Several researchers report that there is a scarcity of research that identifies effective evidence-based interventions that social workers could utilise with suicidal persons (Rosen et al., Reference Rosen, Proctor and Staudt1999; Joe & Niedermeier, Reference Joe and Niedermeier2008).
There is an insufficient amount of social workers to help to provide mental health care in many countries. People who are at risk for suicide may not be getting the treatment that they need. In some countries, the number of social workers that are involved in mental healthcare and suicide prevention is small, for example, there are about 13 social workers for every 100 000 inhabitants in China (Höjer & Dellgran, Reference Höjer and Dellgran2013).
Social work education programmes often offer insufficient training in suicide prevention. Multiple authors have conducted research in this area and have established similar findings (Feldman & Freedenthal, Reference Feldman and Freedenthal2006; Ruth et al., Reference Ruth, Gianino, Muroff, McLaughlin and Feldman2012; Osteen et al., Reference Osteen, Jacobson and Sharpe2014; Scott, Reference Scott2015).
In summary, social workers play a key role in suicide prevention, and they can play an even bigger role. There is a lot of work that needs to be done in the fight against suicide. This paper examines areas where the social work profession as a whole should focus suicide prevention efforts such as incorporating Sherʼs (Reference Sher2004) suggestion of universal, selective and indicated preventive interventions. Furthermore, it is important that social work research education, and evidence-based practices and interventions related to suicide prevention are improved upon. Research efforts should focus on how to increase the role of social workers in suicide prevention and the management of suicidal persons. Social workers should become more involved in psychotherapy, gatekeeper training programmes, education of the general public and postvention as a way to reduce suicide risk. Social workers should also work to decrease psychosocial stressors in populations at elevated risk for suicide, such as the immigrant and homeless populations, by providing social help.
Authors contributions
LS conceived this research topic, and both LS and JL designed the review protocol. JL reviewed the literature and identified eligible research. JL interpreted the findings of the included literature with assistance of LS. JL wrote the initial draft, and LS wrote the introduction. Both LS and JL were involved in further revisions of the manuscript, and they have approved the final submitted version of the manuscript.
Financial support
This research did not receive any specific grant from funding agencies in public, commercial or not-for-profit sectors.
Conflict of interest
The authors declare that no competing and financial interests exist.
