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Does Practice Make Perfect? A Randomized Control Trial of Behavioral Rehearsal on Suicide Prevention Gatekeeper Skills

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Abstract

Suicide is the third leading cause of death among 10–24-year-olds and the target of school-based prevention efforts. Gatekeeper training, a broadly disseminated prevention strategy, has been found to enhance participant knowledge and attitudes about intervening with distressed youth. Although the goal of training is the development of gatekeeper skills to intervene with at-risk youth, the impact on skills and use of training is less known. Brief gatekeeper training programs are largely educational and do not employ active learning strategies such as behavioral rehearsal through role play practice to assist skill development. In this study, we compare gatekeeper training as usual with training plus brief behavioral rehearsal (i.e., role play practice) on a variety of learning outcomes after training and at follow-up for 91 school staff and 56 parents in a school community. We found few differences between school staff and parent participants. Both training conditions resulted in enhanced knowledge and attitudes, and almost all participants spread gatekeeper training information to others in their network. Rigorous standardized patient and observational methods showed behavioral rehearsal with role play practice resulted in higher total gatekeeper skill scores immediately after training and at follow-up. Both conditions, however, showed decrements at follow-up. Strategies to strengthen and maintain gatekeeper skills over time are discussed.

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Acknowledgments

We acknowledge the generous collaboration of the Spencerport School District administration. We thank Ms. Pamela Robinson for serving as a trainer and the staff and parents who participated in the study. We gratefully acknowledge Emma Forbes-Jones, Ph.D., and Erin Hunter, Ph.D., coders on the study, and Heather McGrane-Minton, B.S., who assisted with data entry. This project was supported by an NIMH K23 grant and ARRA supplemental funding (MH073615; MH073615-03S1; PI: Cross) as well as a P20 Developing Center for Public Health and Population-Based Approaches to Suicide Prevention (MH071897; PI: Caine). Dr. Forbes-Jones’s participation was supported by an NIMH Institutional T32 grant (MH018911; PI: Caine).

Author information

Authors and Affiliations

  1. Department of Psychiatry, Box Psych, University of Rochester Medical Center, 300 Crittenden Blvd, Rochester, NY, 14642, USA

    Wendi F. Cross, Danette Gibbs, Karen Schmeelk-Cone & Eric D. Caine

  2. Center for the Study and Prevention of Suicide, University of Rochester Medical Center, Rochester, NY, USA

    Wendi F. Cross & Eric D. Caine

  3. Family Support Center, Spencerport Central School District, Spencerport, NY, USA

    David Seaburn

  4. Office of Mental Health Promotion, University of Rochester Medical Center, Rochester, NY, USA

    Ann Marie White

Authors
  1. Wendi F. Cross
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  2. David Seaburn
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  3. Danette Gibbs
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  4. Karen Schmeelk-Cone
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  5. Ann Marie White
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  6. Eric D. Caine
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Corresponding author

Correspondence to Wendi F. Cross.

Appendices

Appendix 1-Practice Role Play Materials

  

Student role

Your name is Josh/Judy. You’re a fourth grader. You’re being bullied a lot at school this year. Yesterday, you got so mad you kicked the wastebasket in class and yelled at everyone, “Stop looking at me!”

• You've cried a lot at home in your room.

• No one knows how awful you feel inside. And alone.

• Your dog, Abby, is your only friend.

• You sometimes wonder if your uncle's hunting rifle is still in his basement. Would anyone miss you?

Some comments you are likely to say:

• "Everyone is against me."

• "I wish everyone would leave me alone."

• "It's so unfair!"

• "No one cares what I think."

• "Would anyone miss me?"

You like your teacher. She/he is friendly and pays attention to you. You feel like you could talk to her/him. She/he has asked you to stay back at recess to talk.

Teacher/Staff Role

Yesterday, Judy/Josh, one of your fourth grade students, kicked the wastebasket in her/his class and slammed the door as he left. S/He’s been sent to the office in the past, but this is out of character for Judy/Josh. You worry about her/him being suspended. You like her/him. You and s/he have talked a lot. You want to talk with her/him at recess today and see if you can be helpful. You are comfortable with her/him and begin the conversation, “Hey, Judy/Josh. How’s it going?”

Have a conversation with Judy/Josh to learn about how s/he’s feeling and thinking and any need for intervention.

Observer role

Observe the interaction between the student and staff/teacher and take notes using the attached scoring sheet. This sheet will be collected. Be prepared to give the teacher some feedback as follows:

1. Say 2 things the teacher/staff role player did well.

2. Say 2 things the student role player did well.

3. Based on the form, what might the ‘gatekeeper’ improve upon or practice?

Appendix 2-Actor Script 1

  

ACTOR: I don’t know, I’m ok I guess. I didn’t really want to come… (AVOIDING)

 [PAUSE for question about what’s going on.]

ACTOR: I don’t feel like talking, you know? (SLOW TO DISCLOSE)

 [PAUSE for encouragement to talk]

ACTOR: It’s just some stuff going on… (WARMING UP)

 [PAUSE for encouragement to talk/inquiry.]

ACTOR: Ok, yeah, well, I guess I’ve been feeling bad, you know? Everything is just pissing me off, I don’t know… (DEPRESSION)

 [PAUSE to see if the participant asks clarifying questions about what is going on with you.]

ACTOR: Ok, well, my so called friends have turned against me.some kids started passing around messages about me… it’s like everyone is turning against me.” (EVENT)

 [PAUSE to let the participant respond to your statement or ask questions about how you are feeling.]

ACTOR: Nothing I do is going to make any difference. I might as well not even be around.

(HOPELESSNESS)

 [PAUSE to see if participant asks you directly about suicide, thoughts of wanting to die or plans to kill yourself.]

ACTOR: You know, I feel really weird, on edge, ready to fight about everything. (FEELING—IRRITABILITY)

ACTOR: I can’t seem to concentrate on anything—my mind keeps jumping around.

 (THOUGHTS)

ACTOR: You know, it would be real easy to end it. Like, I think about the pills I’ve got at home…you know? (PLAN)

ACTOR: [If/When participant attempts to persuade you to get some help from a counselor, mental health professional, doctor, clergy/priest/minister, etc. (PERSUADE) respond:] Do you really think I need to see someone? [if doesn’t suggest you should see someone go on to…] I don’t have anyone to talk to. (HELP 1)

 [PAUSE to see if the participant makes a specific referral to a named mental health professional or department where help is offered.] ACTOR: What do you think I should do? (HELP 2)

ACTOR: [Make note of who or where they refer you to and repeat that information here.] Ok, I’ll go talk to (whomever they referred you to) at the (wherever they mentioned to go) now. Thanks for listening. (REFERRAL)

ACTOR: [If you still DO NOT get a referral, end the conversation with:] Well, ok, thanks for listening. (CONCLUSION)

ACTOR: [IF/WHEN you get a direct question about suicide, respond with affirmation of the SUICIDE question:] Well, yeah, I guess I am feeling like I want to die. [And continue…]

ACTOR: [If you get a question about Wanting to hurt yourself’ respond with:] I don’t want to cut myself or anything; I just want this all to be over. [And continue…]

  1. Based on Cross et al. 2010

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Cross, W.F., Seaburn, D., Gibbs, D. et al. Does Practice Make Perfect? A Randomized Control Trial of Behavioral Rehearsal on Suicide Prevention Gatekeeper Skills. J Primary Prevent 32, 195 (2011). https://doi.org/10.1007/s10935-011-0250-z

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