Gatekeeper Training for Suicide Prevention

Background

The rate of military suicides has been increasing in recent years. In 2010—the most recent year for which we have epidemiologic data—there were 301 suicide deaths among service members on active duty, equating to a rate of 18.0 suicides per 100,000 service members (Luxton et al., 2012). The increase in suicide within the Department of Defense (DoD), and more specifically among the Army and Marine Corps, has generated concern among policymakers, military leaders, and the public at large. This concern is evidenced by the creation in 2010 of a congressionally directed task force (Department of Defense Task Force on the Prevention of Suicide by Members of the Armed Forces, 2010), a new DoD office (the Department of Defense Suicide Prevention Office) focused specifically on suicide prevention, the Army's allocation of $50 million to study suicide within its ranks (“NIMH, U.S. Army Sign MOA to Conduct Groundbreaking Suicide Research,” 2008), and increased media scrutiny (Edwards-Stewart et al., 2011).

Each service has implemented policies and programs focused on preventing suicide within the ranks. These suicide prevention programs rely heavily on trainings for service members and their leadership that aim to train service members on how to identify individuals who may be at risk of suicide, provide immediate support, and refer them to an appropriate individual who is able to offer help. In both the Army and Marine Corps, the service members responsible for identifying and referring at-risk individuals (“gatekeepers”) are typically noncommissioned officers (NCOs) and members of the chaplaincy (including chaplains and chaplain assistants in the Army and chaplains and religious program specialists in the Navy that serve marines) (Ramchand et al., 2011).

The Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury funded the RAND Corporation, a private, nonprofit research and development organization, to conduct a research study to better understand the role and experiences of front-line military leaders and members of the chaplaincy in preventing suicide. In this article, we review the existing literature on what is known about the effectiveness of gatekeepers and of gatekeeper training. We present a theoretical model describing how gatekeeper training may influence individual characteristics that may, in turn, result in intervention behaviors. We then review the evidence supporting each of the relationships presented in this model, and conclude with recommendations for advancing research in this field.

Defining Gatekeepers and Gatekeeping

In the field of suicide prevention, the term gatekeeper refers to “individuals in a community who have face-to-face contact with large numbers of community members as part of their usual routine.” They may be trained to “identify persons at risk of suicide and refer them to treatment or supporting services as appropriate” (U.S. Department of Health and Human Services Office of the Surgeon General and National Action Alliance for Suicide Prevention, 2012). In this context, gatekeeping simply refers to performing the trained responsibilities of a gatekeeper. The military and civilian literature defines the notion of a gatekeeper similarly, although the persons designated as potential gatekeepers across populations vary. For example, gatekeeper programs in schools have focused on training teachers and school staff, but some have also trained students to act as gatekeepers to their peers (e.g., Aseltine and DeMartino, 2004; Wyman et al., 2008). In medical settings, primary care and emergency department staff have been trained to be gatekeepers (e.g., Matthieu et al., 2008; Tsai et al., 2011).

Theoretical Approach to Understand Gatekeeping

To develop a conceptual model of gatekeeping, we drew on existing research evidence. We used two database search strategies to identify relevant literature. First, we searched the National Registry of Evidence-Based Programs and Practices (NREPP) to identify those evaluation studies used to verify suicide prevention programs as evidence-based (“SAMHSA's National Registry of Evidence-Based Programs and Practices,” 2012). Second, we conducted a comprehensive literature search in databases covering health (psychology and medicine), the social sciences, and defense: PsycINFO (psychology), PubMed (medicine), New York Academy of Medicine Grey Literature Collection (medicine), Social Science Abstracts (social sciences), and Defense Technical Information Center (defense).* Fifty-three articles were identified that met criteria for inclusion in our literature review—i.e., that they be written in English; were published in peer-reviewed journals; and were empirical papers (including studies, reviews, or meta-analyses) of gatekeeping behavior to reduce or prevent suicide, which may include studies of crisis hotlines, health care providers, or suicide “postvention” efforts that also train individuals to serve as gatekeepers.** Relevant information on the domains presented in Table 1 was systematically abstracted for each study.

Program Description	Evaluation Design	Constructs and Measures
Program name Type of program (crisis hotline, gatekeeper training, screening program, provider training, treatment intervention, social/policy interventions, systems approaches) Population Hours or elements of training	Brief description of evaluation design Time points for data collection Sample size Experimental (control group, comparison group) Analytic strategy Brief description of evaluation findings	Gatekeeper self-efficacy, attitudes, past experiences, constructs (and measures), etc. Dependent variables other than pre/post changes in knowledge, attitudes, etc. (and measures). This includes intentions to intervene and intervention/referral behavior. Measurement of suicide attempts or completions
Aspects Relevant to Model	Relevant Hypotheses	Other
Training focus areas examined (education about suicide/mental health, knowledge of risk factors, risk assessment, communication skills, information about resources, referral process/skills) Gatekeeper characteristics examined in analyses (age, sex, job type, previous experience, education/degree) Other barriers/facilitators examined (beliefs or attitudes about suicide/mental health, motivation, reluctance, comfort, self-efficacy, training quality, social and organizational support, competing job demands)	Tested main effects of hours spent training a specific aspect (e.g., risk assessment) on intentions to intervene or intervention behavior Tested main effects of demographics/beliefs/self-efficacy on intentions to intervene or intervention behavior Tested interactions between elements of training and self-efficacy/demographics/past experience variables Tested any other interactions	Results relevant to factors that facilitate or hinder gatekeeper behaviors Questions/issues/use for the current study

Guided by this literature, RAND developed a conceptual model of gatekeeping that describes the pathways between training and intervention behaviors. The model also accounts for factors that may hinder or enhance the effectiveness of such trainings or of intervention behaviors. The model is consistent with Bandura's social cognitive theory, which posits that interactions between environmental and personal factors influence the learning of new behavior (Bandura, 2001). The model is depicted in Figure 1.

In the model, “training” is a generic concept that encompasses training on suicide prevention broadly or on specific gatekeeper skills. While not every gatekeeper must be specifically trained in how to intervene and care for persons at potential risk of suicide, most of the literature to date stems from evaluations of training programs. Furthermore, the Marine Corps and Army both provide gatekeeper training to NCOs as a key component of their service-wide approach to suicide prevention, and thus including that factor in the model is particularly relevant. The box on the far right, “intervention behavior,” is considered to be the main mechanism to reduce the ultimate outcome, rates of suicide completions and attempts. It refers to any action that involves asking another individual about mental health issues, suicidal thoughts or plans, and/or escorting or encouraging those at risk to seek help.

As the model shows, there are four factors that may influence an individual's decision to intervene with a person at risk of suicide and that can be affected by effective gatekeeper training:

1. Knowledge about suicide, which includes declarative and perceived knowledge about suicide, depression, and resources available for at-risk individuals.
2. Beliefs and attitudes about suicide prevention refers to whether individuals believe suicide is considered preventable, whether it is important or appropriate to intervene with at-risk individuals, and whether seeking help for mental illness is a form of self-care.
3. Reluctance to intervene refers to perceptions individuals may have that it is not their responsibility or that it is inappropriate to intervene; stigma of mental illness is one reason for gatekeeper reluctance.
4. Self-efficacy to intervene reflects the extent to which the individual feels comfortable and competent to identify, care for, and facilitate referral for a person at risk of suicide.

By placing the model within a circle representing the individual, we purport that each factor's influential strength on intervention behavior may differ from person to person. In addition, there may be systematic differences across individuals on how training influences these factors, as well as how changes in these factors may influence intervention behavior. Such individual characteristics are personal attributes that include demographic information (e.g., sex, age, race) and professional background (e.g., job type, education, prior suicide prevention training). The circle containing these individual characteristics is dashed and within a square that represents the social context in which a person acts or is expected to act as a gatekeeper. Systemic factors at this level influence gatekeeping constructs in the same way as individual characteristics, and may describe the extent to which one's organization, supervisor, or coworkers support the role of gatekeepers to prevent suicide or impose competing demands that limit the ability of persons to act as gatekeepers. Because both organizational and individual factors may influence the amount and type of gatekeeper training a person receives, the box depicting training purposely spans both the individual and social contexts.

In what follows, we present an overview of the scientific literature on each of these factors. For each factor (knowledge, beliefs, reluctance, and self-efficacy), we describe (1) the evidence on how training impacts the factor, (2) how changes or differences in the factor itself are related to intervention behavior, and (3) whether changes in this factor are related to changes in suicides or suicide attempts. Then, we examine the literature describing how individual and systemic characteristics are associated with each of the four factors, as well as how they may modify the effect of training on the factor. As we indicate, the evidence is well developed in some areas, while in others there are significant gaps.

Limitations of the Existing Literature

Before reviewing the evidence, it is important to note study limitations that effect the conclusions we can draw from the studies as a whole. First, in terms of design, most of the studies in the existing literature are either single-group (n = 24) or had a non-equivalent control group (i.e., quasi-experimental design, n = 21); only eight of the 53 studies in this review used an experimental design. Thus, the causal relationship between training and each factor and ultimately on behavior is difficult to discern. Second, most of the existing evidence comes from pre- and post-training comparisons of gatekeeper behavior. Forty-four studies in this review had at least two measurement occasions, and nine studies were cross-sectional. Only a few studies included an additional measurement occasion six months or one year after training to examine more long-term effects of training. Thus, we are limited in our ability to discern whether the effects of training persist or, alternatively, whether effects emerge over time. Third, the existing literature does not contain many studies of gatekeeper training programs specifically with military personnel. Our search identified only four studies in the military context. The efficacy of gatekeeper programs in the military is not well established, and there was minimal existing literature to inform this review. The existing literature regarding gatekeeper programs for suicide prevention has almost exclusively been in educational (high school or college), community, or workplace settings. Finally, the specific methods and content of gatekeeper training can vary extensively from one training program to the next. As the programs are quite heterogeneous, it is challenging to draw strong conclusions regarding exactly how gatekeeper training affects intervention behavior.

1. Knowledge About Suicide

Knowledge about suicide includes declarative and perceived knowledge about suicide, depression, and resources available for at-risk individuals. Declarative knowledge is the ability of individuals to accurately recall relevant information (e.g., risk factors for suicide). Perceived knowledge is the extent to which individuals believe they know about a particular area (e.g., “do you know how to ask someone if they are considering suicide?”). Knowledge about suicide is expected to impact gatekeeping behavior by either enabling potential gatekeepers to identify those at risk of suicide and/or enabling potential gatekeepers to assist at-risk individuals in seeking help.

Does training affect knowledge? There is substantial evidence that training can increase both declarative and perceived knowledge about suicide (Abbey, Madsen, and Polland, 1989; Aseltine and DeMartino, 2004; Bean and Baber, 2011; Cross et al., 2007; Cross et al., 2011; Gordana and Milivoje, 2007; Matthieu et al., 2008; Shim and Compton, 2010; Tompkins, Witt, and Abraibesh, 2010; Tsai et al., 2011; Wyman et al., 2008). Those who receive gatekeeper training are generally better able to recognize warning signs of suicide and choose effective intervention strategies compared with those who have not received training. For example, Aseltine and DeMartino (2004) examined high school students who were randomly assigned to either participate in Signs of Suicide (SOS), a two-day training that teaches students to recognize the signs of suicide in themselves and others, or to a control group. SOS is a school-based gatekeeper training for students that incorporates suicide awareness with a brief screening for depression and other risk factors associated with suicidal behavior. The didactic component of the program is based on the action steps “acknowledge, care, and tell” (ACT), through which youths are taught to acknowledge the signs of suicide that others display and take them seriously, demonstrate care for the at-risk individual, and tell a responsible adult. Three months after the intervention, students who received training had significantly higher declarative knowledge about depression and suicide than those in the control group.

Further, interactive training methods may improve knowledge gains from training compared with self-study methods from educational pamphlets. Abbey, Madsen, and Polland (1989) found that participants who received lectures plus educational handouts had significantly higher post-training knowledge scores than the randomly assigned handouts-only group or the control group. Another study, by Cross and colleagues (2007), found that QPR (Question, Persuade, and Refer) training plus a standardized role-play exercise helped participants practice gatekeeping skills such as the ability to ask directly about suicide, persuade the at-risk individual to accept help, and refer appropriately both after the training and six weeks later. Participants who took part in the role-play exercise felt it was a worthwhile experience and that it enhanced their training of gatekeeper knowledge and skills, though the lack of a control group in this study weakens the conclusions we can make about the effects of the treatment.

It is important to note that while most studies show evidence that training increases knowledge, at least one study found no such effect. Specifically, Mishara, Houle, and Lavoie (2005) found that training did not significantly improve knowledge about suicide or the utilization of resources for gatekeepers or the suicidal individual six months after the training. Thus, gatekeepers were not effectively encouraging those who were at risk of suicide to utilize resources. Also important is that individual characteristics, such as sex, job type, and educational background, have been found to moderate knowledge acquisition from training (see the Differences in Individual Characteristics section later in this article).

Does knowledge impact intervention behavior? While there is substantial evidence that suicide prevention training positively impacts participants' knowledge about suicide, the relationship between knowledge about suicide and actual intervention behavior (i.e., gatekeeping) remains unexamined.

Does greater knowledge result in fewer suicides or suicide attempts? There is limited evidence that gains in knowledge about suicide are related to fewer suicides and/or suicide attempts. One experimental study found that high school student gatekeepers who received training had more knowledge about suicide and fewer suicide attempts after training compared with the control group (Aseltine and DeMartino, 2004). The study concluded that greater knowledge of depression and suicide was significantly associated with a lower probability of self-reported suicide attempts in the three months following program implementation, though it is not clear that gatekeeper training or associated behaviors, per se, were the reason that suicide attempts decreased.

A study by Gordana and Milivoje (2007) evaluated a gatekeeper training program in the army of Serbia and Montenegro that was implemented in 2003. The authors tracked suicide rates, as well as knowledge and attitudes about depression and suicide, yearly from 1999 to 2005 (before and after program implementation). The program, based on the U.S. Air Force strategy (Knox et al., 2003), consisted of four levels of gatekeeping, starting with soldiers themselves being trained to recognize the signs of suicide, and followed by three layers of mental health service providers: the primary mental health team in a military unit (physicians, psychologists, and officers); the secondary mental health team, situated in the Military Medical Center (psychiatrists and psychologists); and the tertiary mental health team, situated in the Military Medical Academy (psychiatrists and psychologists who refer soldiers to treatment). After the implementation of the suicide prevention program in 2003, knowledge about suicide had improved and deaths by suicide had decreased among army personnel (Gordana and Milivoje, 2007). This study is particularly noteworthy because it was one of very few studies identified in our literature search that focused on a suicide prevention program implemented in a military context. However, interpretation of the results must be made cautiously: As opposed to the experimental high school study by Aseltine and DeMartino (2004), the findings of the Serbian and Montenegrin army evaluation are based on an observational study, meaning that findings are correlational and it is impossible to determine whether the program caused the increase in knowledge or reduction in suicide attempts.

2. Beliefs and Attitudes About Suicide Prevention

Beliefs and attitudes about suicide prevention cover a broad spectrum, but mostly tend to focus on whether suicide is considered preventable, whether it is important or appropriate to intervene with at-risk individuals, and whether seeking help for mental illness is a viewed as a form of self-care.

Does training affect beliefs and attitudes about suicide prevention? There is limited evidence that training helps develop more adaptive, or desirable, beliefs and attitudes about suicide prevention. Three studies among high school and university students found that individuals who received training had more adaptive attitudes post-training (Aseltine and DeMartino, 2004; Aseltine et al., 2007; Indelicato, Mirsu-Paun, and Griffin, 2011). For example, an evaluation of implementing the QPR gatekeeper training among university staff and students found significant self-reported increases from pre- to post-training in participants' belief that it is appropriate to ask someone about suicide, and in the likelihood they would do so (Indelicato, Mirsu-Paun, and Griffin, 2011). Furthermore, the effects of training did not deteriorate from one to three months post-training, indicating some lasting changes in beliefs about suicide prevention, though this study has no control group for comparison.

In a study that administered a gatekeeper training program to students at three schools and withheld training at two schools, students who received training did not display more adaptive attitudes about prevention than the students at schools where the training was withheld (Spirito et al., 1988). Students who participated in the program showed slight but not statistically significant improvements in their attitudes about the efficacy of mental health treatment or whether suicidal ideation should be kept to oneself. It is important to note that the suicide prevention program did not negatively affect attitudes toward suicide, which is one of the primary concerns of opponents of suicide education in schools (Spirito et al., 1988).

Do beliefs and attitudes about suicide prevention impact intervention behavior? Although there is some evidence that gatekeeper training positively impacts participants' beliefs about suicide prevention, the relationship between attitudes about suicide prevention and gatekeeping behavior remains unexamined.

Do more adaptive beliefs and attitudes result in fewer suicides or suicide attempts? As with knowledge about suicide, there is limited evidence that development of more adaptive beliefs about suicide prevention are related to fewer suicides and suicide attempts. Again, Aseltine and DeMartino (2004) found that more adaptive attitudes about suicide and intervention were significantly associated with a lower probability of self-reported suicide attempts in the three months following program implementation. Furthermore, more adaptive attitudes toward suicide partially mediated the effect on treatment group (training versus control) on suicide attempts in the three-month period following training. That is, the effects of training on suicide attempts were partially explained by gains in attitudes youth had about suicide prevention (Aseltine and DeMartino, 2004), though again, this universal training encompassed more than just training on gatekeeping strategies.

In addition, Gordana and Milivoje (2007) found that after implementing a suicide prevention program in the army of Serbia and Montenegro in 2003, attitudes toward suicide prevention had improved and deaths by suicide had decreased among army personnel. Again, these findings were correlational, and it is impossible to determine whether the program caused the improved attitudes or reduction in suicide attempts.

3. Reluctance to Intervene and Stigma

Potential gatekeepers may be reluctant or unlikely to intervene with an at-risk individual because they feel that it is not their responsibility or that it is inappropriate to intervene. The stigma of mental illness is one reason for gatekeeper reluctance. Here, stigma refers to negative stereotypes and discriminatory behavior against someone who has or is thought to have a mental illness (Corrigan, 2004). The most common type of discriminatory action is socially avoiding a person who is thought to have a mental illness (Corrigan, 2004). Potential gatekeepers may not feel comfortable interacting with individuals in distress or at risk of suicide, and may avoid them as a result. Further, potential gatekeepers may avoid the topic of depression and suicide in conversation to avoid attributing the label of mental illness to another individual, which they fear could cause further distress (Mishara, Houle, and Lavoie, 2005).

Does training affect reluctance to intervene? Three studies of gatekeeper training programs found that training reduced reluctance to intervene when compared with a control group (Bean and Baber, 2011; Tompkins and Witt, 2009; Wyman et al., 2008). Tompkins and Witt (2009) evaluated the impact of the QPR gatekeeper training on college resident advisors.*** Advisors who received the QPR training showed reductions in reluctance after the training was complete, and these reductions were maintained at the five-month follow-up. In addition, intentions to intervene increased from pre- to post-training and were maintained at five-month follow-up (Tompkins and Witt, 2009).

The second study was the only one of the three that used randomized assignment to construct a control group, and it did so to evaluate QPR training for middle and high school personnel (including teachers, administrators, and health and social service staff) (Wyman et al., 2008). Using as-treated analyses, gatekeeper reluctance was significantly lower at one-year follow-up for those in the QPR training group, but reluctance did not differ as a result of training using intent-to-treat analyses**** (Wyman et al., 2008). Finally, Bean and Baber (2011) examined the impact of the National Alliance on Mental Illness–New Hampshire's (NAMI-NH's) “Connect” program, a three-hour suicide prevention training session for youth and key adults in the community (e.g., police officers, educators, and mental health care providers). This study found that perceived stigma related to youth suicide and mental health care significantly decreased from pre- to post-training for both youth and adults who participated in gatekeeper training.

Does less reluctance affect intervention behavior? Limited evidence exists to date regarding the influence of reluctance to intervene on gatekeeping behaviors. In the study of college resident advisors, though the training reduced reluctance and increased self-reported intentions to intervene, training did not translate into a significant behavioral change in terms of self-reported gatekeeper behaviors (e.g., asking about suicidal thoughts, escorting a peer to professional help) (Tompkins and Witt, 2009).

Additional insight on how reluctance to intervene affects gatekeeping behavior can be gained from a study by Mishara, Houle, and Lavoie (2005). The authors evaluated the effects of gatekeeper training provided to friends and families of men who had already attempted suicide, or who were suffering from a major psychological or substance abuse problem. In a free response question, some gatekeepers reported that the main reason they did not directly ask about suicide was because they did not want to further upset the suicidal person or they were embarrassed to bring it up (Mishara, Houle, and Lavoie, 2005). Therefore, caregivers who act as potential gatekeepers may avoid the topic of suicide in conversation because of the stigma associated with mental illness, a label that would presumably cause further distress.

Does less reluctance result in fewer suicides or suicide attempts? No study to date has related improvements in or lower levels of reluctance with reduced rates of suicides or suicide attempts.

4. Self-Efficacy to Intervene

Self-efficacy to intervene is defined as an individual's belief that he or she will be able to identify, care for, and facilitate treatment for a person at risk of suicide.

Does training affect self-efficacy to intervene? There is mixed evidence that training can have a direct, positive impact on self-efficacy. Three single-group studies (i.e., studies without a comparison group) found that self-efficacy increased from pre- to post-training (Clark et al., 2010; Cross et al., 2007; Shim and Compton, 2010). One study with a randomly constructed control group found that those who participated in QPR training had higher mean levels of self-efficacy (controlling for baseline levels) than the control group (Wyman et al., 2008); however, another study did not find differences in self-efficacy post-training between the intervention and control group (LaFromboise and Howard-Pitney, 1995). In addition, Tompkins and Witt (2009) used a non-equivalent control group and found that self-efficacy to intervene increased for both the training and control groups over the course of the study. So, although the most rigorous of the studies does suggest that training can increase self-efficacy to intervene, the others raise a question about the impact of training versus raising awareness. The limited evidence, especially from studies using comparison groups, means that questions remain about whether training can in fact improve participants' beliefs that they can identify, care for, and facilitate treatment for a person at risk of suicide.

One study found that the number of years since receiving training affected one's self-efficacy to intervene. King and Smith (2000) found that those who had attended suicide training within the past three years were more likely to report self-efficacy to intervene than those who had completed training longer than three years prior. The study consisted of a one-time survey of school counselors who had participated in suicide gatekeeper training at some point in the previous 13 years, thus testing differences in self-reported knowledge, declarative knowledge, and self-efficacy based on years since training. It did not include a comparison group that did not receive training, but findings nonetheless suggest that training boosters may be helpful to maintain preparedness to intervene after training.

Does increased self-efficacy affect intervention behavior? Evidence on the link between self-efficacy and gatekeeping behavior remains limited. For example, though self-efficacy improved (along with knowledge and reluctance to intervene) in the study by Tompkins and Witt (2009), there were no apparent improvements in gatekeeper behaviors (i.e., asking about suicide or referring those at risk of suicide to appropriate resources).

Does increased self-efficacy result in fewer suicides or suicide attempts? The connection between gatekeeper self-efficacy and suicide attempts and completions remains unstudied. It is unknown whether improvements in self-efficacy as a result of training are associated with reduced suicide rates.

Differences in Individual Characteristics

Individual characteristics of gatekeepers have also been found to relate to suicide knowledge, beliefs, attitudes, and intentions to intervene, as well as to how gatekeeper training can affect each of these. Individual characteristics refer to a person's age, sex, ethnic or racial background, prior experiences, health status, and so forth. Researchers have found that some of the key individual characteristics of relevance to suicide gatekeeping preparedness include sex, job type, and prior training in the field of mental health, as described below.

Sex. The most extensive evidence is on the impact of sex; females appear to be more knowledgeable, have more adaptive beliefs, and be more likely to intervene than males both before and after receiving gatekeeper training (Aseltine and DeMartino, 2004; Aseltine et al., 2007; Clark, 2010; Overholser et al., 1989; Spirito et al., 1988). Overholser and colleagues (1989) found that females had more previous experience intervening with suicidal individuals than males. Further, relative to male student gatekeepers, female students were more likely to seek help when personally depressed, intervene on behalf of friends, and report personal suicidal ideation or attempts in the three-month period following study completion (Aseltine and DeMartino, 2004).

In addition to the main effects of sex, there is mixed evidence regarding sex as a moderator of the benefits of gatekeeper training. Spirito and colleagues (1988) found that the effect of treatment group (training versus control) varied according to sex: Those who received gatekeeper training had significantly less reliance on maladaptive coping regarding suicide intervention than the control group, but this effect was only true for females. Thus, sex moderated the effect of training on maladaptive coping mechanisms. In contrast, a quasi-experimental study of gatekeeper training for high school students found no moderating effect of training, and that in aggregate, participants who received training had more adaptive attitudes toward suicide post-training regardless of sex (Ciffone, 2007). Aseltine and colleagues (2007) also found that the effect of training on suicide knowledge, attitudes, help-seeking, or personal suicidal ideation or attempts at three-months post-training did not differ according to sex.

Job type or educational background. Job type and educational background have been widely examined in relation to suicide knowledge, beliefs, intentions to intervene, and the extent to which gatekeeper training can improve these. Not surprisingly, mental health professionals are more knowledgeable about suicide compared with other occupations, regardless of gatekeeper training (Cross et al., 2011; Matthieu et al., 2008). Cross and colleagues' (2011) study of QPR training with high school teachers, staff, and parents found that training improved knowledge about suicide for school staff and parents, but not for trained mental health professionals (Cross et al., 2011). However, two studies in a medical setting found that gatekeeper training improved knowledge about suicide and self-efficacy to intervene for both clinical and non-clinical staff (Matthieu et al., 2008; Tsai et al., 2011). In a study of Veterans Administration (VA) staff members, clinical and non-clinical staff members showed improvements from pre- to post-training, but non-clinical staff had greater gains (Matthieu et al., 2008). A study of gatekeeper training among nurses found that training improved risk assessment knowledge for both psychiatric nurses and nurses from other specialty areas, but did not report whether the increase was greater for one group than the other (Tsai et al., 2011).

The impact of gatekeeper training among school staff in various roles in an educational setting has also been examined. Gatekeeper QPR training did not affect actual intervention behavior among school personnel serving in a primarily surveillance role (i.e., administrators and support staff). In contrast, those serving in a direct communication role (i.e., teachers) who received the training were more likely to show notable changes in identifying suicidal behaviors in students compared to those in a surveillance role (Wyman et al., 2008). Training did not affect the frequency of asking about suicide and other intervention behaviors for support staff members. Tompkins, Witt, and Abraibesh (2010) also found that training improved high school teachers and administrators' knowledge and attitudes about suicide, but support staff either showed no change or negative shifts from pre- to post-training. One explanation may be that teachers and administrators already had relationships with distressed students and enhanced their conversations with students after training, whereas support or administrative staff may not have established those relationships.

Systemic Support and Competing Demands

Systemic support refers to the extent to which one's organization, supervisor, or coworkers support the role of gatekeepers to prevent suicide. This includes making resources and training available for gatekeepers. Competing demands refers to job-related roles and responsibilities that may interfere with fulfilling one's role as a gatekeeper. This includes the perception that job-related tasks require so much time at work that there is not enough time to adequately perform gatekeeper duties. Thus, although not the focus of gatekeeper training, these factors are part of the gatekeeping environment and are expected to influence intervention behavior.

Little attention has been given to how support and demands influence gatekeeping behavior. Our search identified one study that examined these factors: a cross-sectional, single-group study by Moore and colleagues (2011). The authors reported that supervisor and organizational support for gatekeepers was positively related to intervention behavior post-training. Additionally, organizational constraints (e.g., time demands) were negatively related to intervention behavior. Coworker support of gatekeeper behaviors did not affect using the intervention skills learned during training. Notably, the authors identified a trend whereby supervisor and organizational support buffered against the negative effects of organizational constraints in relation to intervention behavior (Moore et al., 2011). Thus, even in presence of organizational demands, individuals who were more supported in their gatekeeping role were more likely to intervene with individuals at risk of suicide.

Conclusions

Our theoretical model of gatekeeping, based on a comprehensive review of the literature, theorizes that gatekeeper training can impact four important factors—knowledge, perceptions about suicide prevention, reluctance, and self-efficacy—and that changes in these factors can influence intervention behavior. Though the research is scant, we can draw three general conclusions.

There is some evidence from the literature that gatekeeper training can improve knowledge, beliefs/attitudes, self-efficacy, and reluctance to intervene. The strongest evidence to date is that gatekeeper training can improve knowledge about suicide, but there is emerging research to suggest that it also can foster more adaptive beliefs about suicide prevention and decrease people's reluctance to intervene. The relationship between training and self-efficacy to intervene is more tenuous. These relationships have been shown in a number of settings and with different individuals. However, noticeably absent from this literature are studies of the U.S. armed forces, which rely critically on gatekeeping programs in their suicide prevention activities.

The transfer of knowledge, beliefs, and skills learned in training to actual intervention behavior is largely unstudied. Though there is increasing evidence that training affects knowledge, beliefs, and reluctance, research on how improvements in these factors translate to intervention behavior is lagging. In this instance, research is strongest linking reluctance to intervene to intervention behavior. Similarly, research has shown in one instance that a gatekeeper training program was causally associated with changes in suicides or suicide attempts. Specifically, Aseltine and DeMartino (2004) showed that those exposed to gatekeeper training had improved knowledge and more adaptive beliefs about suicide prevention that, in turn, were associated with fewer suicide attempts at three-months post-training. This study thus remains the strongest evidence to date suggesting that gatekeeper trainings can reduce suicide, though observational studies (e.g., Gordana and Milivoje, 2007) are also useful and have provided suggestive evidence to this effect.

Recommendation. Continued research is needed as to how knowledge, beliefs, self-efficacy, and reluctance are related to both intervention behavior and changes in suicide rates. Ideally, such research would be experimentally based, in which groups are randomized to receive or not receive a gatekeeper training. This could occur in the Army and Marine Corps, where such training is already omnipresent, by focusing on new recruits. However, observational research and case studies could still provide evidence that both services could use to enhance or inform their current training programs.

Individual and contextual factors are associated with how effective gatekeeping programs will be. There is strong evidence that females have more knowledge about suicide, have more adaptive beliefs about suicide prevention, and are more likely to intervene with someone who may be at risk of suicide. However, there is mixed evidence that gatekeeper training differentially affects females and males. Job duties are also important, with gains of gatekeeper training effective for all—but perhaps more pronounced for those without prior mental health training—and changes in intervention behaviors seen primarily among those already interacting regularly with individuals at risk (e.g., teachers versus other school staff). There is also emerging evidence that contextual factors, such as organizational support of gatekeeping programs or competing demands placed on individuals, influence gatekeeping.

Recommendation. Future evaluation studies of gatekeeper training programs should examine the influence of support and competing demands. Institutional support and competing demands may affect the transfer of knowledge and skills acquired in training to actual changes in intervention behavior. This may be particularly relevant for NCOs, who take on gatekeeping as a “collateral” duty in addition to a myriad of other responsibilities.

Gatekeeping programs are heterogeneous. Though our review synthesized research findings from multiple studies, the gatekeeper trainings studied varied widely. For some, gatekeeper training was part of an overarching suicide prevention strategy; sometimes, the training was offered to specific groups and focused exclusively on gatekeeping, while at other times, gatekeeping was targeted universally to all participants in addition to recommendations for self-care. In addition to varying target audiences, trainings also differed in their duration and the methods used to convey the information.

Recommendation. Research should examine the components and features of gatekeeper trainings that yield the most promising effects. There is variability in the trainings offered in DoD, particularly for chaplains, and research may be able to exploit this variation to understand what training components and delivery methods are most likely to yield desired changes in specific populations.

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Notes

* This literature search was conducted as part of a corresponding product that evaluated suicide prevention programs (Acosta et al., 2013). Each study labeled as a gatekeeper suicide prevention program was included in the current study. In addition, novel searches were conducted to identify studies of gatekeeping behavior that were not necessarily program evaluations. Four separate search strategies were conducted in PsycINFO and PubMed: (1) (SU=suicide) AND (SU=prevention OR awareness OR intervention) AND (SU=gatekeeper OR training), (2) (SU=suicide AND prevention AND gatekeeper); (3) (SU=suicide AND prevention AND gatekeeper AND training); and (4) (SU=suicide) AND (SU=prevention) AND (SU=gatekeeper). These novel searches yielded two additional papers not identified by Acosta et al. (2013).

** Articles were excluded that (a) discussed suicide prevention programs that do not include gatekeeper training (e.g., marketing campaigns, mental health interventions, screening with standardized instruments, restricted access to lethal means, and coping skills/self-referral training); (b) focused on the epidemiology of suicide; (c) were published in a language other than English; or (d) were editorials, letters, commentaries, or case studies.

*** QPR is a widely used gatekeeper training that teaches people “how to recognize the warning signs of a suicide crisis and how to question, persuade, and refer someone to help” (QPR Institute, 2011).

**** The intent-to-treat analyses used the training status that was assigned to the individual's school at the time of baseline measurement as each staff member's training status, whether the staff member fully participated in the training or not. The as-treated analyses used each individual's true training status by follow-up and also included random effects of the staff member's current school at follow-up to allow for potential variation in impact at the school level (Wyman et al., 2008).

The research presented here was sponsored by the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury and conducted within the Forces and Resources Policy Center of the RAND National Defense Research Institute (NDRI).