**The North Dakota Adolescent Suicide Prevention Project**

**Project Director: Mark LoMurray, 701-471-7186, Email
<outreach@btinet.net>**

**Fiscal Agent: Mental Health Association in North Dakota**

**A Blended Approach to Prevention**

The North Dakota Adolescent Suicide Prevention Project has taken a
holistic approach toward suicide prevention blending three overall
strategies.

-   Awareness/Education

-   Increase Treatment Access

-   Resiliency and Asset Building

The North Dakota experience has led to a prevention philosophy that
believes education, treatment access, and resiliency strategies are
interwoven -- one impacts the other. Also that increasing strengths and
protective factors is as important as being risk focused. This is
significant in tribal and rural communities that have experienced risk
factor statistics as discouraging rather than empowering.

**History**

**1998 -**14 North Dakotans participate in SPAN Conference helping
developing 1^st^ national suicide prevention plan

**1999 -** ND Adolescent Suicide Prevention Task Force formed

-   Initial state surveys, data analysis completed

-   1^st^ North Dakota state plan developed with recommendations

**2000 - Awareness Phase**

-   Mental Health Assoc. in North Dakota lead agency in grant project
    (\$75,000 ND CSCC)

-   All of North Dakota state regions and tribal areas receive awareness
    and planning workshops

-   126 workshops to 2600 participants

**2001 Action Phase**

-   Implementation of five core strategies

-   145 workshops to 3200 participants

-   \$75,000 grant ND CSCC

**2002 Capacity Building**

-   Three regions fund part time suicide prevention coordinators

-   Funding \$80,000 from five grant sources to continue state
    coordination efforts

**2003 Integration**

-   8 rural and tribal mentoring coordinators hired - \$180,000 a year
    Safe and Drug Free School grant through 2005

-   Train the trainer sessions continue

-   Developing system (rapid community mobilization) of targeted
    prevention response to suicide contagion or impact areas

-   Continue pursuing pilot project for home-base tracking in rural and
    tribal settings

-   ND legislature turns down request for suicide prevention coordinator
    in ND Health Dept. budget -- continue to fund through grants

-   175 workshops/technical assistance sessions to over 4500
    participants to date in 2003

**2004 Funding -- Research -- Capacity Building**

-   Prevention research grant pursued through United Tribes

-   ND Suicide Prevention Conference to focus on action efforts

-   Expand state suicide prevention plan to include all ages

-   Involve stakeholders, survivors in legislative funding effort

-   Regional training the trainer around gatekeeper, mentoring, teen-led
    efforts, support groups, screening efforts, and crisis response
    through rapid community mobilization.

-   Expand infrastructure through partnerships with local, regional,
    statewide groups.

**Outcomes**

-   A four year trend since the start of the project shows a sustained
    47% reduction in ND 10-19 year suicide fatalities, compared to the
    ten year average in the 1990's.

-   North Dakota Youth Risk Behavior Survey's comparing years 1999 to
    2003 9^th^ -12^th^ grade responses to suicide questions: 29%
    reduction in teens having seriously thought about suicide, 20%
    reduction in teens having made a suicide plan, 20% reduction in
    teens having made suicide attempt needing medical attention, 7%
    increase in teens having made suicide attempts.

-   Every state and tribal region has initiated at least 2 of 5
    recommended strategies.

-   29,000 participants have attended suicide prevention awareness and
    action workshops

-   6800 key teen leaders have received a Peer Gatekeeper training
    involving over 90 ongoing teen-led prevention projects

-   Three phase "peer gatekeeper curriculum" developed, implemented, and
    dispersed.

-   35 new teen-led prevention projects received start-up training -- 15
    in tribal communities

-   8000 professionals received updated training on suicide intervention
    and prevention strategies (physicians, nurses, pastors, law
    enforcement, EMT's, residential treatment and detention, school
    staff, recreation programs, and mental health specialists)

-   26 new schools and communities are implementing screening strategies
    -- Prairie Screening Project partnership, National Depression
    Screening Day, plus targeted screening groups.

-   9 new mentor coordinators have been hired with mentor teams starting
    in 20 tribal communities and 5 rural communities

-   175 new mentor matches 2003-04 -- 125 are from tribal communities
    and our project was recently highlighted in summer of 2004 National
    Mentoring Center's Quarterly Bulletin on recruitment of mentors in
    tribal communities.

-   Workshop satisfaction has averaged 8.8 of 10 being very helpful.

-   4 state or tribal regions have hired part-time suicide prevention
    coordinators working on recommended core strategies

-   Over 95 tribal and rural entities have signed coalition agreements
    and belong to councils working on specified mentoring and suicide
    prevention activities.

-   Over 50 Native American Injury Prevention students have been trained
    on suicide prevention strategies and are being placed in numerous
    tribal communities. Suicide prevention is becoming part of their
    core curriculum.

-   60 third year UND medical students have participated in year long
    mentoring to teens, received training on science-based substance
    abuse and suicide prevention, and holistic suicide interventions.

-   Adolescents involved in the medical student mentoring project showed
    a 35% reduction in suicidal ideation and 38% reduction in feelings
    that their families did not care about them.

-   Eight detention centers, attendant care sites, and residential
    centers have updated their suicide response protocol.

Targeted Populations

Adolescents and young adults became the primary focus for North Dakota's
suicide prevention efforts with data indicating suicide fatalities for
10-24 year olds at almost twice the national rate. North Dakotan's of
all ages rated 26^th^ nationally and North Dakota suicide fatalities for
elderly were significantly under the national average. Males made up 85%
of all suicide fatalities and Native American youth and young adults
were 35% of the suicide fatalities while representing only 8% of North
Dakota's youth. In 2004 the North Dakota Suicide Prevention Task Force
will rewrite the state plan to address goals and objectives for all ages
related to suicide.

Public Awareness -- Education -- Gatekeeper Training

Over 29,000 have participated in workshops and technical assistance
sessions to implement recommended suicide prevention strategies. Of
primary focus for awareness sessions, gatekeeper training, or
professional training has been to initiate the following.

-   Present audiences with facts and up to date data and research
    related to North Dakota's suicide.

-   Reduce stigma associated with mental health disorders and treatment.

-   Expand suicide knowledge beyond depression awareness to include
    other risk factors and protective factors.

-   Expand professionals response to include a multilevel intervention
    approach based on multiple sources of support.

-   Present interventionists with research and training on "common
    errors."

-   Provide strategies that encouraged efforts beyond one-shot awareness
    and move postvention crisis teams toward activating local community
    mobilization and long term natural helper support.

-   Community and peer gatekeeper training should address basic steps of
    intervention and referral with a significant emphasis on addressing
    'codes of silence' for youth/young adult audiences. The project's
    own Peer Gatekeeper Curriculum, QPR, and Yellow Ribbon are the most
    commonly used in the state.

Teen-led Efforts in Suicide Prevention

Over 6600 teens have been trained with 35 new teen-led startup efforts
involving teens in ongoing prevention efforts. Our focus has encouraged
a **three phase effort** -- one phase leading to the other.

1.  Peer Gatekeeper -- an interactive four hour curriculum developed to
    address "codes of silence" and partnering with adults

2.  Peer to peer messages on risk factors, protective factors, codes of
    silence, and where to get help

3.  Long-term teen-led prevention efforts that had five clear benchmarks
    (training, supervision, planning input, clear mission and role, and
    recognition.

Screening

Universal and targeted screening strategies have been initiated in 26
new schools, 8 detention or youth facilities, and over 400 faith-based
youth leaders, pastors, and spiritual leaders have received training on
screening tools. Physicians and medical students have received training
on new clinic friendly tools.

-   A screening toolkit packet with a variety of screening devices have
    been regularly distributed.

-   Partnership with Colombia Teen Screen and DISC-R -- Prairie
    Screening Project

-   Addressing significant stigma issues around screening with
    comparison to hearing and vision tests.

Mentoring

North Dakota's suicide prevention efforts have linked the very promising
research on mentoring for violence and substance abuse with suicide
issues. Initial efforts to start rural and tribal mentoring were linked
with significant basic infrastructure problems so the North Dakota
Mentoring Partnership was formed to provide the core components
identified in research on successful mentoring.

-   9 mentor coordinators have been hired for five tribal areas and two
    rural areas of the state

-   Teens, adults, and elders are being actively recruited to mentor in
    school, community, faith-based, and cultural models.

-   From March 2003 -- March 2004 over 175 mentors to 225 youth have
    been matched with 150 of these mentors from tribal communities.

Home-Based Tracking

Approximately 50% of youth and young adults having medical contact due
to a suicide attempt in rural and tribal North Dakota receive no
services two weeks later. Significant promise has been shown in tribal
communities around home-based tracking models for pre and post natal
support, asthma, and diabetes. Funding for a pilot program is being
pursed.

Support Groups

The project through MHAND has provided technical assistance in the
startup of a dozen support groups throughout the state. These groups
vary from depression, survivor, talking circle groups, and groups
addressing trauma. They can be sponsored by community, faith, or
schools, but have the primary purpose of provided emotional support and
a caring community to support them. These would not be considered
therapy groups, but rather support groups. The North Dakota HELPLINE
regularly monitors and refers individuals to a variety of support groups
throughout the state. We presently have 33 support groups statewide and
would like to expand to 50 by the end of the year.

Statewide Hotline and Resource Center

The Mental Health Association in North Dakota (MHAND) just celebrated
it's 50^th^ anniversary and provides a statewide HELPLINE (701-472-2911)
answered in person 24 hours per day. The HELPLINE has an extensive data
system which provides local referral and resources to individuals
needing assistance whether of a crisis or informational nature. The
HELPLINE has just been chosen to expand and become North Dakota's 2-1-1
system. The MHAND Resource Center also carries an extensive system of
several thousand types of pamphlets or print materials and over 500
videos related to mental health and youth related issues.

Crisis Response -- Postvention Focus

We are encouraging schools and community's to have a Crisis Response
Plan in place that enables communities to responds to traumatic events
and tragic fatalities that impact the school or a community. Sample
models of written crisis response plans are available upon request from
the Mental Health Association in North Dakota. We are strongly
encouraging crisis teams to move beyond a single session critical
incident debriefing model and focus on long term support. A model in
which medical and mental health experts partner with local natural
helpers to provide long term support to impacted individuals and
families.

In areas dealing with potential contagion or pandemic suicide situations
we strongly encourage a "rapid community mobilization model" which
encourages whole communities to gather quickly after a second or third
"area suicide fatality." This community response moves beyond the
traditional mental health and school response and encourages involvement
of youth leaders, parents, elders, spiritual communities, 1^st^
responders, health, mental health, media, business, and school. A series
of recommendations are mentioned in the *North Dakota Suicide Prevention
Newsletter -- short term crisis response.*

Human Service Center's and Indian Health Services have mental health
professionals available in all of the regional and tribal areas of the
state and are encouraged as an immediate point of contact. The statewide
HELP-LINE or 2-1-1 System will provide access to these regional and
local support number's 24 hours per day.