Suicide is the tenth leading cause of death in the United States and in their efforts to prevent this tragic loss of life, communities have increasingly emphasized the importance of disseminating suicide prevention trainings to broaden the public’s knowledge of suicide, its risk factors, and intervention strategies. Unfortunately, the existence of evidence-based trainings is scant [1
]. One notable study exception is the Applied Suicide
Intervention Skills Training (ASIST) [2
]. Evaluated behavior changes in telephone crisis responders who participated in ASIST workshops, and outcomes of their crisis line calls. Compared to responders not trained in ASIST, those who were trained exhibited specific behaviors (e.g., ability to explore callers’ reasons for living, ambivalence about dying, and informal support contacts; increased length of calls) that were positively associated with improved caller outcomes (e.g., the appearance that callers were less depressed, suicidal, and overwhelmed [3
]. Though not as rigorous, other research studies that have evaluated ASIST support these findings, indicating that participants in ASIST workshops had self-reported increased knowledge and skills in pre-post surveys [4
] however, we acknowledge one study that found no changes in similar outcomes [5
ASIST workshops are designed to span two days and teach participants “suicide first aid
” so they can recognize those at-risk of suicide and intervene accordingly. Participants are taught how to recognize suicide risk factors, to respond in a manner that increases immediate safety, and to link suicidal persons to appropriate resources [6
]. Workshops are typically led by at least two trainers who take turns presenting the ASIST curriculum. Throughout both days, the trainers present activities geared to the whole group and in smaller breakout groups. Both training days explore participant’s attitudes about suicide, reactions to video scenarios, and discuss the Suicide Intervention Model (SIM) framework and its three phases – connecting, understanding and assisting. Connecting is the process of establishing rapport and engaging the person at risk to continue the interaction; the understanding phase is active listening to reasons for living and dying through the perspective of the person at risk; and assisting is providing an opportunity for the person at risk to consider resources and a plan to stay safe.
Although shown to be effective in a trial, in order to ensure that such effects are replicated in other communities it is important that trainings be administered with high quality [7
]. Specifically, it is important to monitor the fidelity
of trainings to understand whether trainers were delivering workshops with high fidelity (i.e., covering all aspects of the manual-based training) and adherence (i.e., whether the training followed the recommended style of presenting). In addition to monitoring hotline responder behaviors and caller outcomes, the findings of [6
] were complemented by a study [8
] that assessed ASIST fidelity during workshops with crisis hotline responders. Video and audio segments of 66 ASIST workshops were coded. Results suggest that about 35% of trainers delivered ASIST with high fidelity as measured by more than 75% of the workshop content delivered, but less than 18% of trainers were adherent and able to demonstrate solid competence on the competency scales (e.g., presentation style/delivery [7
]. These results suggest that trainers might easily present workshop content, but may have a more challenging time delivering the content within the recommended facilitation style. This is an important finding because the style of information delivery is just as important as training content and may have a direct effect on whether participants learn the information [8
]. By documenting both fidelity and adherence
, research can provide evidence of knowledge uptake and that training was implemented as intended and with high quality (e.g., best practice). Collecting data on adherence and fidelity help ensure that past results evaluating ASIST may be translatable to the new trainings in which ASIST is being delivered, providing a way of accountability for monitoring how existing funds are being spent.
In addition to fidelity and adherence, it is also important to monitor whether trainings are associated with improved outcomes for training participants and the clients they serve. With respect to trainings like ASIST, a new conceptual model states that such courses can change participants’ knowledge about suicide, beliefs and attitudes about whether suicide can be prevented, reluctance to intervene, and self-efficacy to intervene; changes in these domains can then change intervention behaviors [9
The current study extends past research by evaluating both the participant (N=2006) satisfaction and outcomes across 127 ASIST workshops and the quality (fidelity and adherence) of five ASIST workshops in California. The current study has three goals: (1) to examine participant outcomes for ASIST workshops delivered in California, (2) to provide a preliminary assessment of whether trainers were delivering workshops with high fidelity and adherence, and (3) to provide a quality improvement model for ongoing ASIST evaluation that could be applied to other communities.
The delivery of ASIST trainings in California occurred as a result of voter-approved Proposition 63, the Mental Health Services Act (MHSA). Proposition 63 is funded by levying a 1% tax on personal income above $1 million. A portion of Proposition 63 funds were dedicated to prevention and early intervention (PEI) services, including for suicide prevention. As part of this effort, LivingWorks, was awarded a contract to provide Train-the-Trainer (T4T) trainings in ASIST with the intent that these trainers would disseminate ASIST workshops in their community. Sixteen T4T trainings were conducted to train Californians to become registered ASIST trainers. To date, 327 people have been trained at these T4Ts, and they have subsequently trained 4,887 people at 267 ASIST workshops in California [10