Running head: SUICIDE PREVENTION AND INTERVENTION THROUGH MTSS

Suicide Prevention and Intervention Through a Multi-Tiered System of Support

Rachel Han

Chapman University

CSP 512: Advanced Counseling and Mental Health Intervention

Dr. Michael Hass and Professor Cynthia Olaya

Spring 2021
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Suicide is a major public health issue that significantly affects the adolescent population.

As a leading cause of death worldwide, and the third leading cause of death amongst adolescents

in the United States, suicide trends pose significant health concerns (Pelkonen et al., 2011). In

direct correlation to increasing numbers of completed suicides are other suicidal phenomena. The

term suicidal phenomena include attempted suicides, deliberate self-harm, suicidal thoughts and

ideation, and suicide plans and threat (Evans et al. 2005). Suicide attempts are defined as

potentially self-injurious behavior associated with at least some intent to die. Deliberate

self-harm denotes any type of self-injurious behavior, including suicide attempts and

non-suicidal self-injury. However, it is important to note that deliberate self-harm is viewed as

distinct from suicidal behavior, though non-suicidal self-harm and suicidal behavior may

co-occur (Bridge et al., 2006). Suicidal ideation includes both active and passive thoughts

(McHugh et al., 2019). Active thoughts entail ideas about taking action to end one’s life,

including identifying a method and plan, or having intent to act. Passive thoughts include ideas

about death or wanting to be dead without any plan or intent.

Young people over recent decades have shown increased tendencies to attempt or

complete suicide and engage in deliberate self-harm. Although the rates of suicide are low, when

ideation and nonlethal suicidal behavior are taken into account, the weight of this public health

issue exponentially grows. It is noted that approximately 20 to 25% of American high school

students seriously considered suicide, with 15% having developed a plan, and 10% having

attempted suicide in the previous 12 months (Greydanus et al., 2009).

Demographics

Demographic factors including race and ethnicity, age, gender, and sexual orientation can

affect suicidal behavior among adolescents. When looking at the data trends of race and
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ethnicity, White youth show the highest rates of suicide, followed by African Americans and

Latinos (Borowsky et al., 2001). Though suicide seems to affect Whites more so than other

ethnic groups, data shows that the rate of suicide among African Americans has been increasing

in rates as large as 234% (Miller & Eckert, 2009). When proportionately considering population

sizes, Native Americans show the highest rates of youth suicide, whereas Asian and Pacific

Islanders tend to be among the lowest (Miller, 2011). The differences in rates between ethnic

groups may be attributed to exposure to various risk factors, including geography and

socioeconomic status, thus increasing susceptibility rates. Suicide rates are typically higher in

communities with lower socioeconomic status and in rural towns, which may be due to a lack of

financial and physical access to resources like mental health services (Balis and Postolache,

2008).

Differences within age groups also impact suicide rates amongst youth. Suicide is

uncommon in childhood and early adolescence, but increases in the late teens and continues to

rise until the early twenties (Gould et al., 2003). The underlying causes of these differences may

be attributed to the delayed development of risk factors that will be further explained below. For

example, two common risk factors include depression and exposure to drugs and alcohol, which

typically onsets in later adolescence. In accordance with completed suicides, suicide attempts are

also relatively low among younger children and increase through adolescence (Gould et al.,

2003).

Gender also plays a part in the variation of suicide rates. Vajani et al. (2007) reveal that

males account for a majority of completed suicides, while females report much higher rates for

suicidal ideation and suicide attempts. Some differences between male and females suicide rates

may be attributed to the contrasting methods of self-harm. Studies have shown that males are
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more likely to use lethal means to commit suicide, like suffocation or firearms, whereas females

tend to use less lethal means such as poisoning (Vajani et al., 2007). Additional factors may

include that males are less likely than females to engage in various protective behaviors. These

include seeking help, being aware of warning signs, having flexible coping skills, and building

social support systems (Miller & Eckert, 2009).

Lastly, data shows that sexual orientation also has an effect on suicidal behavior and

ideation. In comparison to heterosexual, cisgender adolescents, LGBTQ+ youth are five times

more likely to attempt suicide (Erps et al. 2020). Additionally, 92% of transgender adults report

attempting suicide at least once before the age of 25 (Erps et al. 2020). It is important to note that

adolescence is a highly vulnerable time for sexual minorities. These individuals are often

exposed to more risk factors like bullying, ostracism, physical assault, and familial discord (Erps

et al. 2020). These various factors pose a greater risk for mental health issues and increases in

suicidal ideation and attempts.

Risk Factors

Suicide is a complex phenomenon with psychological, social, biological, cultural, and

environmental involvement. Although there are no specific tests capable of identifying suicidal

people, certain risk factors exist that may suggest higher vulnerabilities to suicidal tendencies.

These include personal and family characteristics, adverse life circumstances, and

socio-environmental and contextual factors.

Personal characteristics take into account factors like psychopathology, prior suicide

attempts, and cognitive and personality factors (Gould et al. 2003). Individuals with mental

health issues are increasingly more vulnerable to suicidal behavior and ideation. Shain (2007)

reports that more than 90% of youth who completed suicide has had at least one psychiatric
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disorder, with depressive disorders being the most prevalent amongst adolescent suicide victims.

Other common mental health disorders known to impact suicidal behavior and ideation include

depression, bipolar disorder, substance abuse, psychosis, and post-traumatic stress disorder

(Shain, 2007). Furthermore, prior suicide attempts and cognitive and personality factors,

including feelings of hopelessness, poor interpersonal problem-solving abilities, and

aggressive-impulsive behaviors, have shown to be strong predictors of suicide (Chang, 2002;

Russell and Joyner, 2001; Sourander et al., 2001).

Family characteristics include a family history of suicidal behavior, parental

psychopathology, parental divorce, and parent-child relationships (Balis and Postolache, 2008).

Familial history of suicidal behavior and parental psychopathology account for genetic

contributions to increased suicide rates. Results from twin studies support the idea of the

heritability of suicidal behavior, which emphasizes correlations between familial history and

completed suicides (Gould et al. 2003). Parental divorce and parent-child relationships take into

consideration environmental risk factors that contribute to suicide rates. Trends show that suicide

victims are more likely to come from divorced families and have poor cohesion (Shain, 2007).

Adverse life circumstances include stressful life events, physical abuse, and sexual abuse.

Life stressors like break-ups, legal or disciplinary problems, and bullying are often associated

with completed suicides (Greydanus et al., 2009). Additionally, longitudinal studies examining

the effects of physical and sexual abuse on suicide found an increased risk of suicide in

individuals with a history of abuse (Bridge et al., 2006). Correlations between abuse and suicide

rates can be attributed to difficulties in developing social skills and increased social isolation,

which increases risks for suicidal behaviors.

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Lastly, socio-environmental and contextual factors include school and work problems, as

well as contagion and imitation. Difficulties within school and work pose significant risks for

completed suicides. Individuals that report serious suicide attempts are more likely to drop out of

high school or not attend college (Gould et al., 2003). Other socio-environmental and contextual

factors have increasingly become more common amongst suicidal adolescents. Contagion and

imitation refer to the impact media have on suicide rates. With the growing prominence of media

coverage and content, the magnitude of suicide has proportionately increased amongst

adolescents (Griffin et al., 2018). Social media and websites include mass amounts of self-harm

or suicide content that children can easily access in this day and age.

Suicide is a complex tragedy and is also preventable. Therefore, it is pertinent to

understand that risk factors are distal predictors that may increase an individual’s likelihood of

engaging in suicidal behavior in the future. It is also important to note that risk factors should not

be confused with warning signs, which are proximal predictors and might suggest an increased

possibility of a suicidal crisis (Miller 2011).

Addressing Suicide Within Schools

Regarding suicide, it is imperative to identify suicidal behaviors and ideations, and other

threats of suicide early on. As the onset of mental illness often occurs in childhood or

adolescence, it is essential for schools to provide prevention, intervention, and postvention

resources. With adolescents spending large amounts of time in school settings, school-based

mental health professionals and other educators are well suited to provide prevention and

intervention programs (Torok et al., 2019). School personnel can develop detailed procedures for

identifying and intervening with at-risk students who exhibit suicidal behavior through training

and education. Furthermore, under the notion that suicide is preventable, school personnel have
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ethical and legal responsibilities to provide and engage in preventative efforts for at-risk students

(Erps et al., 2020). Thus, the purpose of this paper is to analyze and examine suicide prevention

and interventions within a Multi-Tiered System of Support (MTSS), and state ways in which

school-based mental health providers can ensure successful implementation of effective

programs within each tier.

Multi-Tiered Systems of Support

With the use and implementation of Multi-Tiered Systems of Support, different

evidence-based interventions can be set in place to prevent suicides in school-aged students.

Multi-Tiered Systems of Support (MTSS) provides a framework for interventions and supports

to address academic, social, emotional, and behavioral challenges in schools (Marsh and Mathur,

2020). A key component of MTSS is its three tiers of support that outline a structured method for

providing support for students at universal, targeted, and indicated levels. MTSS is described as

a prevention-based framework to enhance the development and implementation of a continuum

of evidence-based practices and achieve academically and behaviorally important outcomes for

all students (Belser et al., 2016).

Tier 1 of the MTSS model addresses the needs of all students. This tier provides universal

and primary support for every student, but generally reaches about 80% of students

(Goodman-Scott et al., 2019, p.98). As Tier 1 is a preventative and foundational stage, it reaches

a majority of students and decreases the number of students who need Tier 2 or 3 support. Tier 2

is the secondary level of support within the MTSS framework, reaching about 10-15% of the

student population (Goodman-Scott et al., 2019, p.246). This tier addresses the student

population that needs additional intervention while still participating in Tier 1 supports. The final

tier of the MTSS framework is Tier 3. This tertiary level supports about 5-10% of the student
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population (Goodman-Scott et al., 2019, p.301). Students receiving Tier 3 support include those

with significant needs who do not respond to Tier 1 and 2 interventions. These students receive

individualized support to meet academic and behavioral needs.

Methodology

Research was conducted through Chapman University’s online databases, including

EBSCO in addition to google scholar. Words and phrases such as “suicide prevention and

intervention,” “school-based suicide prevention,” “adolescent suicide,” “MTSS suicide

programs,” and “role of school counselors” were used as key terms. Search results were limited

to scholarly peer-reviewed journals.

Tier 1: Primary and Universal Prevention

Within the MTSS framework, Tier 1 interventions serve as universal and primary

supports. Core curriculums and programs are implemented at this level to proactively and

preventatively help all students. Though Tier 1 interventions are aimed to address the needs of all

students, a small number of students may not respond to this level of intervention and will

require services within Tiers 2 or 3 (Marsh and Mathur, 2020). Therefore, it is essential to

implement evidence-based programs at the universal level to reduce the number of students in

need of Tier 2 or 3 support. Suicide prevention and interventions within this tier include various

types of programs, including universal curricular suicide education, in-service education for

gatekeepers, and school-wife suicide screening programs (Granello and Zyromsk, 2018).

teen Mental Health First Aid (tMHFA)

Teen Mental Health First Aid (tMHFA) is an example of a universal suicide education

curriculum. The primary focus of tMHFA is to train students to seek assistance from trusted and

reliable adults when a peer is experiencing a mental health problem (Hart et al, 2018). This
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curriculum includes presentations, videos, role-play, group discussions, small groups, and

workbook activities to educate children about adolescent mental health. The intervention

consists of three sessions covering general mental health education, helping a friend in a mental

health crisis, and helping a friend who is developing a mental health problem. tMFHA addresses

these topics through the implementation of an action plan. The action plan provides five first aid

strategies taught through a mnemonic that is easy to remember (Hart et al., 2016). The five

strategies include Look for warning signs, Ask how they are, Listen up, Help them connect with

an adult, and Your Friendship is important.

tMHFA is an effective intervention that has shown to be effective in improving

knowledge, attitudes, and behaviors related to mental health. The program is well-researched and

has been recognized with various awards for excellence including the US Substance Abuse and

Mental Health Services Administration’s National Registry of Evidence-Based Programs and

Practices (Hart et al, 2016). Results have shown that tMHFA is effective in the domains of

knowledge, recognition of mental illness, stigmatizing attitudes, confidence, helping intentions,

and helping behavior (Ng et al., 2020). Of these domains, improved knowledge and confidence

have shown the strongest and most significant results. However, the sustainability of these

improvements may be difficult to assess. Though many studies failed to provide follow-up

periods of six months or longer, it is reassuring to note that the articles reported sustained

benefits despite the short duration of training (Ng et al., 2020). Another study conducted by

Guajardo et al. (2019) revealed significant impacts on increasing knowledge of helpful adults,

improving participants’ intention to help, and decreasing some negative attitudes. This

evaluation study is consistent with the findings that tMHFA is beneficial to improving and

educating adolescents on screening and seeking techniques regarding mental health and suicide.
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Gatekeeper Training: Question, Persuade, and Refer (QPR)

Gatekeeper training is provided to individuals who serve as gatekeepers for a specific

population (Pistone et al., 2019). Gatekeepers within a school setting can include school-based

mental health providers, teachers, and other educators. The rationale for gatekeeper training is

that suicidal individuals often do not seek help on their own accord, and makes it necessary for

others to initiate help-seeking on their behalf (Reis and Cornelll, 2008). Therefore, gatekeeper

training is well suited to provide universal intervention within school settings. Curriculum

focusing on training gatekeepers teach personnel to identify vulnerable youth and intervene

before or during a crisis (Torok et al., 2019). One of the most widely used forms of gatekeep

suicide prevention training is “Question, Persuade, and Refer” (QPR). QPR is an emergency

mental health intervention training that teaches gatekeeps to recognize and respond positively to

individuals exhibiting suicide warning signs and behaviors. The training emphasizes four points

for the intervention to be effective including early recognition of suicide warning steps, early

QPR, early referral, and early professional assessment and treatment (Quinnett, 2007). QPR has

been shown improvements in knowledge, sustaining position attitude and social norms, and

increased frequency of suicide prevention behavior (Hangartner et al., 2019). Participants of the

training often feel more comfortable helping youth and lead to increased intentions to follow

through on learned skills, which is a strong predictor of engagement in suicide prevention

behaviors.

Screening Program: Signs of Suicide

Screening programs like, Signs of Suicide (SOS), are also effective interventions used at

the Tier 1 level. SOS is a universal school-based suicide prevention program designed to educate

students that suicidal intent and behavior are often signs of mental illness and part of diagnostic
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criteria for major depressive disorder (Schilling et al., 2016). The goals of the prevention

program are to increase an understanding of depression and suicide, improve attitudes toward

intervening, and encourages youth who are contemplating suicide to seek help. Through videos

and discussion guides, school personnel are able to support students within two days. The

curriculum incorporates two prominent suicide prevention strategies including raising awareness

of suicide and screening for depression and other risk factors associated with suicidal behavior

(Aseltine Jr. and DeMartino, 2004). Within the program, students are also encouraged to

complete the Columbia Depression Scale (CDS), a brief self-administered screening instrument,

to raise awareness of symptoms and depressive symptomatology.

This program has been extensively researched and is currently listed in the National

Registry of Evidence-based Programs and Practices (NEREPP; Schilling et al., 2016). Volungis

(2020) conducted a three-year pilot study demonstrating the program’s effectiveness in

enhancing students’ knowledge and awareness of depression and suicide, including how to seek

help for themselves and their peers. These findings are consistent with previous studies

examining the benefits of the SOS program. As the prevention program places a relatively little

burden on time and resources to foster a supportive school climate, it appears to be an effective

intervention when implemented at the Tier 1 level.

Role of the School Counselor

Within the Tier 1 framework, school counselors are responsible for providing proper

resources and support for all students. Support at the universal level is crucial for laying the

foundation for preventive programs and supports. Wiley (2012) states that school counselors are

essential to the planning and implementation of suicide interventions and programs. School

counselors and other school-based mental health providers serve as liaisons between potential
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suicidal students the mental health resources that are needed for intervention. The role of a

school counselor includes creating a school wife plan consisting of prevention programs,

creating proactive and supportive environments, and understanding the warning signs and

possible mental health influences that will reduce the stigma and incidences of youth suicide.

The efforts to organize, lead and implement screening practices and prevention programs are

consistent with guidelines and models put forth by organizations like the American School

Counselor Association (ASCA; Erikson and Abel, 2013). Examples of standards and

competencies include the knowledge of mental health services including prevention and

intervention strategies (B-SS 4), providing services to all students (M 1), and coordinating and

facilitating counseling and other services to ensure all students receive the care they need (M 4)

(ASCA, 2019).

Tier 2: Secondary and Targeted Prevention

Tier 2 practices are oriented for students who are less responsive to Tier 1 programs and

require more targeted support (Sugai et al., 2016). Interventions within this tier typically consist

of focused programs that are often delivered in small group formats and social skills training

(August et al., 2018). Secondary preventions within the MTSS framework should be used to

identify and support students that may be at risk of suicide. Targeted students within this tier may

be at increased risk of suicide, who have been identified at-risk through prior screening and

assessment, or because they possess known risk factors of suicide (Singer et al., 2018). Students

found to be at-risk should be further assessed and given additional support. Assessment programs

like Counselors CARE (C-CARE) can be used alongside small group interventions like Coping

and Support Training (CAST) and Coping with Depression (CWD-A) for at-risk students in

school settings. All three programs have shown to be effective in reducing risk factors and
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suicidal behaviors by developing social skills and support (Katz et al., 2013; Rohde et al.,

2004a).

Counselors CARE (C-CARE) and Coping and Support Training (CAST)

CARE (Care, Assess, Respond, Empower), also known as Counselors CARE (C-CARE),

is a school-based brief assessment and intervention for adolescents at risk for suicide. The

C-CARE prevention protocol consists of two major elements: assessment and intervention. The

program identifies high-risk youth through the Measure of Adolescent Potential for Suicide

(MAPS), a two-hour, one-to-one, computer-assisted suicide assessment (Eggert et al., 2002). The

MAPS provides a comprehensive assessment of direct suicide risk factors, related risk factors,

and protective factors (Randell et al., 2001). The assessment is then followed by a brief two-hour

motivational counseling session that is designed to provide students with empathy and support, a

safe environment for sharing, and encourages positive coping and help-seeking behavior (Katz et

al., 2013). The goal of C-CARE is to decrease suicidal behaviors and related risk factors and

increase personal and social assets.

Coping and Support Training (CAST) is a standardized, small-group, skills-training, and

social-support program. The CAST intervention is often implemented following the C-CARE

program. Students identified as at-risk by the C-CARE program, go on to receive small group

support by participating in CAST. The small-group skills training and social support program

includes twelve, one-hour sessions conducted over the course of six weeks in groups of six or

seven (Eggert et al., 2002). The programs’ target goals include increasing mood management,

decreasing drug involvement, and increasing school performance (Randell et al., 2001). In order

to address these goals, group sessions focus on teaching skills such as goal setting,

decision-making, self-esteem, academic ability, and control of drug use (Katz et al., 2013). Each
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session is then concluded with identifying help and support, and a “lifework” assignment, in

which students are called to implement the skills into their daily lives.

As previously mentioned, CAST is often implemented in conjunction with C-CARE.

Therefore, research on the efficacy of these programs is also intertwined. A study conducted by

Katz and colleagues (2013) showed C-CARE and CAST to be effective in decreasing depressive

symptoms, suicide risk behaviors, anger control issues, and family distress. This study also

revealed that the programs led to increases in skills like problem solving and self-control.

Another study conducted by Eggert et al. (2002) demonstrated that the program significantly

reduced suicide risk behaviors, depression, and drug involvement. These findings suggest that

even brief suicide risk assessments and interventions produce sizeable reductions in suicide risk.

There is great promise for brief school-based interventions for reducing suicide-risk behaviors

and related depression.

Adolescent Coping with Depression (CWD-A)

Adolescent Coping with Depression (CWD-A) is an adolescent modification of the

Coping with Depression (CWD) course, that was originally developed for depressed adults.

CWD-A is a cognitive-behavioral treatment (CBT) group program that aims to decrease

depressive symptoms, a major suicidal risk factor, in at-risk adolescents (Christner et al., 2007;

Listug-Lunde et al., 2013). The course is free of charge, and is designed to be used with

adolescents from 14 to 18 years of age, and consists of sixteen, two-hour sessions. CWD-A is

also adaptable and can be modified to fit within school settings. Studies conducted by Wilkes

(2010) and Christner et al. (2007), created variations of the curriculum, including eight two-hour

school-based sessions or 16 one-hour sessions. The program provides structured group

interventions consisting of 7 to 14 adolescents. CWD-A focuses on cognitions as targets for

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change, structured intervention sessions, repeated practice of skills, use of rewards and contracts,

and homework assignments (Rohde et al., 2004a). The course teaches skills in mood monitoring,

increasing pleasant activities, social skills, relaxation training, problem-solving, conflict

resolution, and relapse prevention (Kaufman et al., 2005). Each session is taught through the use

of direct instruction, modeling, and assignments. The main focus of CWD-A is on helping

adolescents develop the skills to better cope and prevent episodes of depression.

CWD-A has been tested in National Institutes of Health supported studies and shown to

be an efficacious CBT group intervention for reducing adolescent depression (Wilkes, 2010).

The program has shown to significantly decrease rates of depression post-treatment in youth

(Rohde et al., 2004b). When considering efficacy, it is also important to note that many of the

outcome ratings were based on adolescent self-report, a common limitation in CWD-A studies.

However, these ratings are often acceptable in adolescent depression treatment studies in which

youth are often the most accurate informants (Rohde et al., 2004a).

Role of the School Counselor

With unique skill sets and training, school counselors play a critical role in developing,

implementing, and evaluating Tier 2 programs and interventions. School counselors are

responsible for identifying students in need of support, aligning interventions with needs, and

utilizing data-based decision-making within the secondary and targeted tier. Tasks at this level

may include providing evidence-based classroom interventions, short-term individual or group

counseling, progress monitoring, and school-to-home communication (Sink, 2016). It is pertinent

that school counselors lead, collaborate, advocate, and increase the capacity to serve at-risk

students within Tier 2 to adequately address highly sensitive and serious cases of suicidal

ideation and behaviors among youth.

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Tier 3: Tertiary and Indicated Prevention

Tier 3 represents students who are in need of intensive individualized interventions.

Tertiary and intensive supports are appropriate for students identified as high-risk and have not

responded positively to Tier 1 and 2 (Belser et al., 2016). Counseling interventions within this

level include individual counseling, one-on-one mentoring, or referrals to community agencies

for more intensive services (Sink, 2016). Suicide prevention and intervention within this tier

target high-risk students with current or prior history of suicidal behavior (Singer et al., 2018).

Tier 3 programs should also include staff education and training that focus on equipping

school-based mental health professionals with skills to intervene and monitor students identified

at high risk of suicide. Interventions like Dialectal Behavior Therapy (DBT) and Applied Suicide

Intervention Skills Training (ASIST) may effectively address the main objectives within tertiary

suicide programs of reducing the risk of suicidal behaviors and mitigating crises.

Dialectical Behavior Therapy (DBT)

Dialectical Behavior Therapy (DBT) is a cognitive-behavioral treatment designed for

populations with complex mental health disorders and high-risk behaviors (Rizvi and Sayrs,

2020). DBT was initially formed as a treatment for individuals with borderline personality

disorder and a history of chronic suicidality (Flynn et al., 2021). DBT theorizes that pervasive

emotion dysregulation leads to impulsive and maladaptive behaviors, including self-directed

violence and interpersonally destructive behaviors (DeCou et al., 2019). DBT focuses on four

sets of skills based on acceptance and change to address difficulties in emotion regulation,

including mindfulness, distress tolerance, interpersonal effectiveness, and emotion regulation

(Swales, 2009). DBT structures the treatment in three stages: pre-treatment, stage one, and stage

two. The pre-treatment stage includes the establishment of client goals, orientation, and
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commitments to the treatment. Stage one focuses on achieving behavioral stability, and once the

client has achieved a more stable life, clients move onto stage two, where emotional processing

can take place (Swales, 2009). Within these stages, DBT focuses on the following hierarchically

ordered behavioral targets: decreasing life-threatening suicidal and parasuicidal acts, decrease

therapy-interfering behaviors, decrease quality of life interfering behaviors, and increase

behavioral skills (Panos et al., 2013). Adaptations of DBT including, Dialectical Behavior

Therapy Skills Training for Emotional Problem Solving for Adolescents (DBT STEPS-A), have

been created to teach adolescents skills within a general school-based setting. The DBT

STEPS-A curriculum is designed to fit within a general education curriculum and teaches skills

for emotion regulation, reducing impulsive behaviors, problem-solving, and building and

repairing interpersonal relationships (Flynn et al., 2018). DBT for adolescents aims to teach

students decision-making and coping strategies to aid them in emotionally stressful times.

DBT has shown positive outcomes in terms of reducing self-injurious behavior,

psychiatric inpatient admissions, and psychopathology. A meta-analysis conducted by DeCou

and colleagues (2019) found that DBT reduced self-directed violence and the frequency of

psychiatric crisis services. Improvements in emotion regulation, interpersonal functioning,

executive functioning, and inhibition have also been observed (Asarnow et al., 2021; Smith et

al., 2019). McCauley et al. (2018) and Swales (2009), have also supported the efficacy of DBT in

reducing self-harm, suicide attempts, suicidal ideation, and general psychiatric symptoms in

highly suicidal self-harming youth. Adolescents receiving DBT have also shown significantly

fewer psychiatric hospitalizations during treatment, and better treatment completion when

compared to control groups (Swales, 2009). It is important to note that though current studies are
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heavily concentrated in clinical settings, findings show promising results in treating adolescents

with DBT that should be considered for future studies regarding DBT in schools.

Applied Suicide Intervention Skills Training (ASIST)

Applied Suicide Intervention Skills Training (ASIST) is a form of gatekeeper training

that teaches participants, who are likely to come in contact with high-risk individuals, how to

properly intervene to improve safety and provide referrals to appropriate resources (Ashwood et

al., 2015). ASIST is a 14-hour, two-day, suicide intervention training model used for assessing

and responding to suicide risk (Shannonhouse et al., 2015). The ASIST Suicide Intervention

Model (SIM) has three caregiving phases, including connecting, understanding, and assisting

(Gould et al., 2013). The “Connecting” phase is a time for the counselor to explore the client’s

invitations. Examples of invitations include presenting problems, stressful life events, feelings of

anger, loneliness, and sadness. Counselors are to examine and form connections between shared

invitations and suicidal thoughts with the client. The “Understanding” phase focuses on the

client’s reasons for dying and living. In this phase, counselors listen to the at-risk individual’s

reasons for dying with the assumption that doing so can uncover reasons for living. Lastly, the

“Assisting” phase focuses on establishing a safe plan that addresses each element of risk

identified in the previous phases of the intervention. ASIST provides participants with general

knowledge of suicide and opportunities like role-playing, open-ended questioning, and

simulations to practice dialogue that can be used with suicidal individuals (McAuliffe and Perry,

2005).

Studies on the efficacy of ASIST have shown positive results within the participants who

completed the training. Gould et al. (2013) noted that counselors who had received the ASIST

training were significantly more likely to link invitations to suicidal thoughts, explore reasons for
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living and uncertainties about dying, and explore informal support contacts for clients’ safe

plans. The program has also shown increases in gatekeepers’ feelings of competence and

confidence to intervene with high-risk individuals (Ashwood et al., 2015). These findings

indicate that gatekeepers trained in ASIST become more knowledgeable in suicide prevention

and interventions, and develop more helpful attitudes and beliefs surrounding suicide.

Role of the School Counselor

The school counselor’s roles within Tier 3 programs may range from supporting or

consultative duties to directly delivering interventions (Belser et al., 2016). However, school

counselors should keep in mind that providing long-term individual counseling is an

inappropriate role (ASCA, 2020). Rather, referrals to community agencies may be most

beneficial in supporting students in need of more intensive one-on-one counseling services.

Additional roles within this tier may include safety planning, procedures, and strategies for

monitoring students upon reentry after hospitalization, and postvention (Singer et al., 2018).

In cases that require immediate intervention, school counselors must assess risk and

facilitate referral is necessary. It is essential to follow state and district policies when tending to

potentially suicidal students. School staff must continuously supervise the student to ensure

safety until the assessment process is complete and parents or guardians are notified. In high-risk

situations, school counselors have legal and ethical obligations to break confidentiality to ensure

safety and care, and should always inform the student when doing so. Following parental

notification, counselors should assist the family with urgent referral to outpatient mental health

providers. In life-threatening situations, the school may be required to contact emergency

services or arrange for the student to be directly transported to a hospital, preferably by a parent

or guardian. If parental abuse or neglect is suspected, appropriate protection officials like Child
SUICIDE PREVENTION AND INTERVENTION THROUGH MTSS 20

Protection Services should be contacted. Once the student is safe, counselors must work with

parents or guardians and outside care providers to receive a release of information. Subsequent

steps include frequent communication with stakeholders and meetings regarding the student’s

re-entry plans.

Conclusion and Implications for Future Research

In response to the literature on suicide prevention and interventions in schools, it can be

concluded that there is a need for further exploration of efficacy in Tier 2 and 3 interventions.

Though there are many programs designed to provide prevention and interventions for

adolescents, much of the research is limited to universal programs. There is a plethora of

information studying various Tier 1 supports, but a gap of knowledge in those following Tier 2

and 3. Current research and findings on the efficacy of Tier 2 and 3 are also often limited to

clinical settings. Future research should observe the effectiveness of programs delivered within

schools. Given the complexity and gravity of suicide, thorough investigation and research in

programs are essential.

Suicide is a serious public health issue that is preventable and can be addressed within

schools. Certain populations are at higher risk due to demographic, socio-environmental, and

contextual factors. Through the implementation of an MTSS framework addressing suicide,

school counselors can ensure proper prevention and interventions are in place to minimize

suicide amongst school-aged youth. School mental health professionals have training and

knowledge in mental health and social, emotional, and behavior strategies and are best equipped

to lead school-based suicide prevention programs and interventions. A crucial starting point in

implementing a comprehensive suicide prevention effort is buy-in from stakeholders. School

counselors should advocate for the prioritization of suicide prevention programs ranging from
SUICIDE PREVENTION AND INTERVENTION THROUGH MTSS 21

gatekeeper training to screening and education. In accordance with MTSS, suicide prevention

programs should be in place for all students and additional programming for students who may

be at-risk and those already identified as high-risk. To provide effective and appropriate

programs, school counselors must assess the needs of students, the capacity and resources of the

school, and the commitment of staff.

SUICIDE PREVENTION AND INTERVENTION THROUGH MTSS 22

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