Addressing social isolation, loneliness, and elevated suicidality 

among older adults during COVID-19 and beyond: A Partially 

Nested Randomized Control Trial of the BE WITH Innovation

Laura Shannonhouse, Matthew Fullen, Audrey Leroux, Sebastian Franck Love, Jordan Westcott

A “small dose of a sincere connection” may make a difference for persons at risk of 

suicide (Joiner, 2005). We also believe it can make a difference for older adults that are further 

upstream, and may not yet be at risk of suicide, but rather are struggling with isolation, 

loneliness, and depression. Addressing their social needs through a standardized and manualized 

warm calling program may improve mental health, not just during the pandemic, but for older 

adults across the spectrum of loneliness to suicide risk. 

During COVID-19, warm calling programs emerged across the aging network (AN), 

however challenges occurred, such as protecting the confidentiality of older adults, ASN 

providers risk and fear in responding effectively to suicidality, and funding, training, and 

supervising the aging network service providers that provided effective warm calling services. 

The BE WITH innovation grew out of the contextual needs of older adults during the 

COVID pandemic, and the AN’s challenge in finding innovative solutions. BE WITH stands for 

Belongingness and Empathy, With Intentional Targeted Helping, which is a standardized and 

manualized warm calling program fostering sincere human connection at a time older adults may 

need it the most. 

Treatment

 The BE WITH program includes an 8-week warm calling treatment that is delivered to

older adults (urban racially diverse, suburban, and/or rural) in 20-30 minute "dosages", over 

three conditions: 

(a) BE condition which involves receiving services from providers trained to foster 

belongingness and empathy (2 hours), grounded in the befriending literature (Wiles et al., 2019; 

Fakoya et al., 2021), and narrative reminiscence (Yousefi, 2015). Aging Network Providers 

trained in BE provide a “small dose of sincere connection”, through narrative reminiscence, 

and the “befriending” strategies. The five core components to the BE training include: 

1. reciprocity: the feeling that both parties are benefiting 

2. intimacy: willingness to share deeply (superficial sharing at first helps build the 

relationship, but deeper sharing is what leads to positive outcomes)

3. reliability & respect (calling at the time you say you are going to call creates 

consistency and reliability, and that the older adult matters 
4. proximity: feeling more connected to people within your community

5. autonomy: feeling both parties are willingly participating with each connection 

While the majority of the warm calling of BE WITH centers on this basic connections 

intervention, there will also be individuals who need more than connection, but rather targeted 

intervention as approximately 20% of older adults receiving home and community based services 

are at risk of suicide (Fullen, Shannonhouse, Mize, Miskis, 2020). 

(b) BE WITH condition includes the above BE training + the aging variant of LivingWorks 

ASIST (Applied Suicide Intervention Skills Training; Lang et al., 2013), which we have been 

adapting to use with older adults over the past four years (total 16 hours of training). Analogous 

to CPR (lay providers equipped to help someone that is drowning), anyone can learn “suicide 

first aid”, or LivingWorks ASIST! Persons trained in ASIST connect directly with the older adult 

at risk through a six-step model called the Pathway for Assisting Life (PAL). The PAL model 

matches six needs of the older adult-at-risk with six tasks of the caregiver.. 

 Persons-at-risk (and helpers) often perceive only two options: (a) to die by suicide, or (b) 

to live. Choosing to live or die can be a tough choice when an individual is struggling with 

suicidality. The ASIST training introduces a third option, which is to stay safe for now. Through 

engaging the PAL model those trained help the patient-at-risk identify ambivalence about dying, 

confusion, and even reasons for living. This is a little miracle that saves lives, as it removes the 

dichotomy of life/death, and ASIST training equips lay providers to do this. Caregivers are not 

taking away the choice to suicide, and the person’s autonomy. Rather, through the intervention, 

caregivers return autonomy to persons-at-risk by helping them identify their own reason(s) to 

live, and link that to a safety plan that puts suicide on hold for the moment, which may turn into 

staying safe in the long term. The 6 steps of the PAL include: 

1. Notice and explore invitations (i.e. voluntary stopping of eating and drinking, 

withholding medical treatment, withdraw, talking directly about suicide, etc.)

2. Asking directly about suicide 

3. Not only listen, but sincerely hear the story about suicide 

4. Work effectively with ambivalence about dying, which involves listening closely for 

confusion, ambivalence, hesitancy to die by suicide as the person is sharing their story, 

and offering a 3rd option (to stay safe for right now) which is an easier choice to make, 

and more aligned with the reality that there is some hopelessness that things will never 

change, and offering this 3rd option creates space for the opportunity for some things to 

change 

5. Developing mutually and agreed upon safety plans 

6. Confirming actions (or asking the older adult to repeat the safety plan back to us that we 

have developed together to assess their degree of commitment to it)
(c) control group (no treatment). 

 For each of the three conditions our research lab calls older adults and administers a 

batter of baselines measures: suicide desire (thwarted belongingness and perceived 

burdensomeness), depression, fearlessness about death, loneliness, and social needs being 

met. We then score those measures, rank order, assign a risk tier, and randomly assign to one of 

the three conditions. The older adults randomized into one of the two treatment conditions are 

then assigned to a calling partner (aging service network provider), that we have trained in either 

BE or BE WITH who begins administering the corresponding treatment. Every two weeks our 

graduate research students administer the baseline measures again for a total of five 

measurement occasions across the trial. 

We worked with software developers of FriendlyBuzz who built a system to 

automatically record the audio files of the treatment dosages. We have more than 9 thousand 

recorded and transcribed audio files to date. Therefore, our analysis will involve longitudinal 

modeling over the 5 measurement occasions, as well as coding of a sub-set of audio files in 

examining the skills being used by aging network providers and volunteers in reducing risk and 

promoting life with older adults. 

Research Questions

1. Over the course of the 8-week standardized and manualized warm calling program, how 

do mental health outcomes change over time for the BE and BE WITH treatment 

conditions relative to a no treatment group? 

2. Are the changes in outcomes over time different for older adults who started at low, 

medium, or high risk (as defined by a baseline aggregate of measures)? 

Hypotheses

1. Participants in the BE and BE WITH treatment conditions will experience significantly 

more improvement across measures than those in the no treatment condition over the 

course of the 8-week program. 

2. Outcome improvements for those in treatment conditions will be more pronounced for 

those who begin the period at greater risk (i.e., those who can improve more will do so). 

Preliminary Clinical Trial Results

 Our sample is on average about 74 years old, with variability in education. About a third 

reported less than 12 years of education, a third reported some high school, and a third reported 

some college. Most of the participants are lower income, meaning they receive between 500 and 

1500 dollars a month. Most did not own a firearm , and the vast majority identified as Christian 
Protestant. These preliminary results include mostly black female as these findings represent the 

first two waves of the study which was predominately in urban metro-Atlanta. The subsequent 2 

waves of the study include many more rural participants, therefore these initial results are 

somewhat biased towards urban racially diverse older adults. 

As far as the overall sample, we see depression is reduced in the BE WITH treatment 

condition when compared with the control condition. Over time older adults not receiving the 

treatment (control group) became more depressed. The effect sizes are on the right side in 

parentheses and statistical significance is indicated with a * . We see a small significant effect for 

the BE WITH group compared to the no treatment group when looking at depression in the 

overall sample.

When we look more specifically at the older adults at “high-risk” at baseline, the depression 

results are reduced further in both treatment conditions. This is preliminary evidence that older 

adults at higher risk, receiving treatment from an ASIST trained caregiver, have significantly 

lower depression scores by the end of the 8-week intervention. 
As far as older adults’ social needs being met, we see their scores increasing over time for the 

BE WITH treatment group meaning there is preliminary evidence that social needs were 

increasingly being met for those receiving the ASIST trained warm calling treatment. The group 

with the ASIST training increased at a relatively high rate, whereas the control group (older 

adults not receiving treatment) decreased their social needs being met overtime. These 

preliminary findings are in the expected directions, though again preliminary, as we are 

underpowered for the analysis as these results only reflect the first half of the clinical trial. If you 

look at the BE WITH group (green, ASIST condition) vs. no treatment group (light blue, control 

condition) the slopes are in opposite directions over the five measurement occasions. 
When we look at social needs for the older adults in the medium to high risk tier the results are 

stronger, and the BE WITH (older adults receiving warm calling from ASIST trained caregivers) 

effect size is more substantial. The older adults with more risk to start seem to get more out of 

the program, especially if they are in the group that included the ASIST training. 
When we look at Thwarted Belongingness (one of two key predictors of suicide desire) we see 

trends going down in all 3 conditions, albeit at different rates. The effect is largest for the highrisk group in the BE WITH condition (ASIST) condition. Since our lab collects data verbally 

due to digital literacy limitations with the older adults, participated are asked questions about 

thwarted belongingness, perceived burdensomeness, and acquired capability every two weeks 

without getting the treatment, so we are hypothesizing that this is actually functioning as a 

“smaller dose” as all our graduate students, we imagine, may have listened to the older adults a 

little in between questions when collecting the data. While our graduate students have been 

instructed to avoid connecting as much as possible during data collection, it is possible that just 

being asked about their distress has a positive function on the mental health of the older adults. 
Older adults who receive calls from ASN providers trained in BE and ASIST experience greater 

improvements in quality of life than the control group. This is similar trend for the BE group, as 

we see that improvement as well, but not to the same degree as the BE WITH group. The older 

adults receiving dosages from the group who also had the training in ASIST manifested more 

improvements and the effect size was relatively higher when compared to the control group. 
Limitations and Adjustments

While these findings are very encouraging and provide preliminary support that ASN 

providers trained in BE and BE WITH have a positive outcome on older adults’ mental health, 

these findings must be interpreted in the context of the limitations. We did see a slight 

improvement in the no treatment (i.e., control) group on thwarted belongingness, meaning the 

control group may potentially receive a “mini” dose from our lab. We also noticed a “ceiling 

effect” as a third of the sample had “no” to “very low” risk at baseline. Therefore, we revised our 

approach in the 4th and final wave of the study to enroll only medium and high risk to address the 

ceiling effect. Finally, we noticed differential attrition, meaning that those in the treatment 

conditions were dropping out of the study at a higher rate than those assigned to no treatment, 

and this dropout occurred especially between baseline and enrolling in the program. Therefore, 

we moved from launching a full treatment wave at the same time, to a rolling recruitment and 

individual launching of providers trained, in an effort to reduce the time between 

recruitment/baseline and start of the treatment. We learned of these challenges during the halfway point of the trial. In addition, we are over-recruiting for wave 4 through a “weighted” 

stratified random assignment (Efron, 1971) to enable us to address differential attrition 

prospectively. 
Research Take Aways & Implications for the ASN

These findings provide preliminary evidence that older adults receiving warm calling 

treatment from aging network providers experience improved mental health. ASN providers can 

be trained to provide a “small dose of sincere connection” that reduces depression, loneliness, 

and thwarted belongingness (one of two key factors of suicide desire), and increases social needs 

that are being met. We saw positive mental health gains across the eight-week intervention for 

both treatment conditions. Further, this preliminary evidence demonstrates that these positive 

effects are increased for older adults receiving dosages from those trained in LivingWorks 

ASIST, and manifested significantly higher positive psychological outcomes when compared to 

those not receiving treatment (i.e. control group). This has implications for training and future 

research.

Implications for Training and practice. Not all older adults receiving home and 

community-based services are at risk of suicide, however the majority have some loneliness, 

depression, and social needs risk. This stratification across risk reveals a need to (a) effectively 

assess, and (b) tailor treatment to need. The BE training may be enough to interrupt isolation 

and intervene upstream. These findings provide initial support that the BE training may be 

meaningful and appropriate with the majority of older adults, however we are currently under 

powered and while it is trending in that direction, and we expect significance by the end of the 

trial, at this time findings are promising. Since it is only 2 hours in duration, and it can be 

provided through online, zoom training platforms, it may also be easily accessible and trainable. 

ASN providers trained in BE may be able to prevent the conditions that contribute to suicide 

desire from coming into the older adults life. 

For those who are at risk of suicide, the Aging Variant of LivingWorks ASIST may be a 

tangible means for equipping ASN providers with life promoting skills to provide a life assisting 

intervention when one is needed the most. While the preliminary results reveal that older adults 

receiving call dosages from providers trained in LivingWorks ASIST experience more 

improvement in mental health, there are very real needs to identify the older adults at highest risk 

so that treatment can be tailored accordingly. 

Currently, the Aging Network does not assess for suicide desire or capability. It may 

prove useful to develop a condensed behavioral screener that could easily be implemented as 

opposed to providing 3 full measures (INQ which measures suicide desire, FAD which measures 

suicide capability, and suicide ideation/cognitions/behavioral questionnaires to assess current 

states). According to Yeates-Conwell, five variables, referred to as the “Five Ds,” are reliable 

indicators of older adult suicide risk: depression, disconnectedness, disease (mental illness), 

disability, and deadly means. It tends to be that these states are measured through different 

instruments, however behavioral screening may enable a very simple screener to identify those 

most at risk. The ASN is not only challenged to (a) identify those most at risk, but also then (b) 

match those most at risk with providers who can address their needs. 
Implications for future research. Our team is hard at work running the last wave in this 

clinical trial. While these preliminary findings are likely to be consistent across the full trial, a 

needed first step is conducting the longitudinal modeling with the total scores for each outcome 

to determine if that is the case. Next, we have more than 9,000 audio recordings of treatment 

dosages across waves. It takes significant time, training, and investment to code an audio file, 

therefore within this grant an intentional subset of these audio files will be collected for double 

coding, and further analysis. The audio files are one of the richest forms of data as we can very 

closely examine the interactions between the persons trained and the older adult mental health 

outcomes. 

We will stratify a subset of these 9,000 audio files from the highest risk baseline 

depression and suicide desire scores along with demographics for coding. Future grant funding 

will be needed to explore and study the audio files of medium and lower risk individuals, as well 

as the simulated calls with suicide interventions happening at two time points over the 8-week 

intervention. In sum, we have only scratched the surface of the very rich and intentional data we 

have collected. 

These audio files provide the opportunity for the development of a behavioral measure of 

suicide risk. While most trait measures involve lots of questions and include a good bit of 

measurement error, a behavioral measure can be derived from this dataset. We can use the total 

scores for each outcome at baseline to determine those at highest risk, evaluate the audio files of 

those in particular, and determine how their behaviors correlate with these outcomes. Such a 

behavioral screener may be a critical need in the Aging Services Network and enable very 

intentional screening of older adults who may indeed need to be matched with providers that are 

equipped to complete life assisting interventions. 

Finally, community-based research is hard and takes time, however, it has the impact to 

shift and change policy and practices. The Administration for Community Living (ACL) has 

funded one of the most rigorous and intentional suicide intervention clinical trials that has been 

attempted. This research has caught global attention as many countries struggle with preventing 

suicide and promoting life with older adults. While we have just been able to scratch the surface 

of the data we have collected, this trial has resulted in exceptional learning. Needed next steps 

include additional analysis on the data we have collected, development of a behavioral screener, 

and moving in the direction of determining how to “identify” older adults most at risk, and 

“match” them with trained ASN providers who can promote life. 

After matching strategies have been tested and proven useful, implementation research 

can be started. This clinical trial is a needed first step in garnering the evidence to get the BE 

training and the aging variant of LivingWorks ASIST on the NCOA evidence-based registry. 

While programming may be made available, more research is needed in order for that 

programming to be implemented successfully and with succession planning. 
Selected References

Joiner, T. E. (2005). Why people die by suicide. Cambridge, MA: Harvard University Press.

Fakoya, O. A., McCorry, N. K., & Donnelly, M. (2021). How do befriending interventions 

 alleviate loneliness and social isolation among older people? A realist evaluation study. 

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Fullen, M., Shannonhouse, L., Mize, M., Miskis, C. (2020) Mental health distress in 

homebound older adults: Importance of the aging network. Aging and Mental Health, 

1580-1584. doi: 10.1080/13607863.2020.1758920 

Lester, H., Mead, N., Graham, C., Gask, L., & Reilly, S. (2012). An exploration of the value and 

 mechanisms of befriending for older adults in England. Ageing and Society, 32(2), 

 307-328. doi:10.1017/S0144686X11000353 

Wiles, J., Morgan, T., Moeke-Maxwell, T., Black, S., Park, H. J., Dewes, O., Williams, L. A., & 

Gott, M. (2019). Befriending Services for Culturally Diverse Older People. Journal of 

gerontological social work, 62(7), 776–793. doi:10.1080/01634372.2019.1640333

Yousefi Z, Sharifi K, Tagharrobi Z, Akbari H. The Effect of Narrative Reminiscence on 

Happiness of Elderly Women. Iran Red Crescent Med J. 2015 Nov 7;17(11):e19612. doi: 

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