United Nations impact on the United States National Suicide Prevention Strategy (NSPS)
by Richard Ramsay, LivingWorks Education and Faculty of Social Work University of Calgary, 2001
Introduction
In 1987 two significant but, at the time, unrelated events subsequently converged between 1995 and 2000 to have a major impact on the development of the U.S. national strategy to prevent suicide. One was the United Nations (UN) meeting of Ministers Responsible for Social Welfare in Vienna. The other was the devastating experience of the Weyrauch family in Atlanta, Georgia at the sudden and shocking suicide death of their 34-year old, physician daughter, Terri Ann.
This paper will describe the non-linear nature of the processes that eventually brought the significance of these two disparate events together.
United Nations Social Policy and Suicide
The 1987 meeting of Ministers Responsible for Social Welfare was the first global meeting of ministers and senior policy makers since 1968. This meeting produced the document, Guiding Principles for Developmental Social Welfare Policies and Programmes in the Near Future (United Nations, 1987). In 1991 the UN requested assistance from government, non-government organizations and university institutions (for the first time) to prepare a global review of progress toward the objectives of the 1987 report. The University of Calgary response largely addressed the ‘Alberta Model of Suicide Prevention’ and its objectives to develop information and training, research centre and community coordinated approach to suicide prevention (Boldt, 1985). It also elaborated on the suicide prevention innovations of four professionals (from psychiatry, psychology and social work) working as a team in collaboration with the Canadian Mental Health Association (Alberta Division), and with federal, provincial and state level government departments in Canada and the United States (Ramsay, Cooke & Lang, 1989; United Nations, 1991a, pp. 11-13).
The UN officials were impressed with the university response and acknowledged suicide as “a problem we have neglected hitherto, and we are grateful to you for having stimulated the idea that this neglect should not continue” (personal communication, Michael Stubbs, Developmental Social Welfare Unit, August 9, 1991). Immediate steps were initiated to explore the role of developmental welfare approaches to this problem, including the possibility of UN collaboration with the Canadian group to hold the first interregional ‘experts’ meeting on national strategies for the prevention of suicide in 1993 (United Nations, 1991b, p. 11).
An Alberta based Canadian group, headed by an organizing team from LivingWorks Education and Alberta’s Suicide Information and Education Centre (SIEC), were invited to host the meeting and raise the raise the required funds. The meeting was scheduled for May 25-29, 1993 at the University of Calgary and Banff Conference Centre. This first of its kind UN meeting on suicide prevention was convened with 15 members from 12 countries (Australia, Canada, China, Estonia, Finland, Hungary, India, Japan, Netherlands, Nigeria, United Arab Emirates and the United States). Representatives from WHO in Geneva and the
UN in New York attended along with observers from Sweden and Australia. The guidelines were published as the Prevention of Suicide: Guidelines for the formulation and implementation of national strategies (United Nations, 1996). The UN Guidelines were developed as a means to facilitate the development of national strategies for the prevention of suicidal behaviors. The Guidelines proposed the following Aim and Goals for a national strategy.
Aim
To promote, coordinate and support culturally appropriate inter-sectorial programs for the prevention of suicidal behaviors at national, regional and local levels.
Goals
(to support the aim of a national strategy)
1) Preventing premature death due to suicide across the life span.
2) Reducing the incidence and prevalence of other suicidal behaviors.
3) Reducing the morbidity associated with suicidal behaviors.
4) Providing opportunities and settings to enhance resiliency, resourcefulness, respect, and inter-connectedness for individuals, families and communities.
The UN Guidelines address the development of a national strategy from two perspectives.
1) a government-initiated process clearly linked to a corresponding national policy that declares suicide prevention as a public health priority.
2) a community-initiated process that acknowledges the significance of grass roots, citizen initiatives to move the importance of suicide prevention to a policy-level priority.
Both perspectives are based on the assumption that a national strategy for suicide prevention cannot be formulated and implemented until a national government adopts a policy priority in this regard.
Linking the UN Guidelines to United States Initiatives
Lloyd Potter, the U.S. CDC representative, provided Jerry (Weyrauch) with a draft copy of the UN document. At the 1994 AAS meeting in New York, Weyrauch met with Mort Silverman and David Clark about the UN Guidelines document. Silverman had presented the keynote address to the interregional meeting: Approaches to Suicide Prevention: A Focus on Models. Their reaction was “it is a ‘doable’ plan but they had no idea who would/could do it” (personal communication, Jerry Weyrauch, February 24, 2001).
From his study of the document and consultations with Silverman, Clark and Potter, Weyrauch concluded that the “grass roots” process outlined in the community-initiated option was needed in the United States. He was convinced that the “silent segment of our society, i.e. survivors of suicide [were] an obvious force to energize and lead the efforts to create a national policy on suicide.” Out of this came the idea for Suicide Prevention Advocacy Network (SPAN) to empower survivors to become this force for change. Weyrauch’s belief in this process was motivated in part by an Abraham Lincoln quote,
“Public opinion is everything. With public sentiment, nothing can fail. Without it, nothing can succeed. Therefore, he who molds public opinion goes deeper than he who enacts statutes or pronounces decisions.”
He concluded that if Lincoln was correct, “then the survivors of suicide in the U.S. have the potential to mold public opinion about the need for a national policy on suicide” (Weyrauch, 1995, p. 1).
I first met Weyrauch at the annual AAS meeting in Phoenix (May 1995). He was a one-person exhibit supported by a SPAN banner and a draft copy of the UN Guidelines. His dream, outlined to me a few months later, was to have a National Survivors Day at the Capitol on May 10, 1996. The morning would be survivor meetings with elected representatives that would deliver, for the first time, advocacy letters from constituents asking for a national suicide prevention strategy. In the afternoon there would be a press conference to highlight the national problem of suicide. The evening would be devoted to a candle light memorial service to remember those who died from suicide. “Survivors from across the U.S. would be invited to come and be seen as well as be heard. The seeds for this are being sown. I will let you know if any of them germinate” (personal communication, J. Weyrauch, September 9, 1995).
Beginnings of a Community-Initiated Process
The two seemingly unrelated events that occurred in 1987 were about to converge on to a common pathway leading to the advancement of a national suicide prevention strategy in the United States. After Terri Ann’s death personal support came from many sources, including Iris Bolton, co-author of My Son, My Son: A Guide to Healing after Death, Loss or Suicide (Bolton and Mitchell, 1984). At the time Iris offered what turned out to be a prophetic vision that “there’s a hidden gift in this. You may find it somewhere down the road” (Ernst, 2001, p. 23).
The first National Awareness Day for Suicide: A National Problem happened as dreamed on Mother’s Day weekend in 1996. Advocacy letters from 43 states were hand-delivered to a congressional delegation by SPAN persons. Close to 150 SPAN supporters, from California to Florida, marched on Capitol Hill.
Advancing the National Suicide Prevention Strategy
Prior to the publication of the UN Guidelines, the formulation and implementation of national strategies for suicide prevention was primarily left to the initiative of individual countries (Taylor, Kingdon and Jenkins, 1997). These researchers used the key elements of the UN Guidelines (i.e. government policy, model, general aims and goals, measurable objectives, monitoring and evaluation) to conduct a survey of several countries and their involvement in suicide prevention. From nine responding countries (60% response rate), they
found three groups: nations with comprehensive strategies (or setting them up); nations with national preventative programs; and nations without national action. The countries of Finland, Norway, Australia, New Zealand and Sweden were in the first group. The U.S. was in the second group along with the Netherlands, England, France and Estonia. Canada was in the third group with Japan, Denmark, Austria and Germany.
The analysis by Taylor and colleagues acknowledged that the Bush administration in the 1980s had identified suicide as an important public health problem within an overall national strategy for disease prevention and health promotion. During this administration, the Department of Health and Human Services published the 4-volume Report of the Secretary’s Task Force on Youth Suicide. The fourth of these ‘white volumes’ recommended a “group of important consensus-based strategies to guide prevention and intervention levels at the national level in the United States” (Tanney, 2000, p. 16). “Except for the landmark contributions that were made concerning the cost of suicide and the identification of gay, lesbian and transsexual youth as populations at significant risk of suicidal acts” (Tanney, p. 17), the Secretary’s Report had little impact on national strategy development. On the positive side, the Task Force “opened our eyes” to the diverse constituency of stakeholders who are concerned and committed to the cause of suicide prevention. However, by 1994 there had been little expansion of the process by the Clinton administration. As Tanney reported “the core recommendations of the U.S. Task Force remain[ed] as unfilled promises” throughout most of the 1990s (p. 17). Several important deficits were identified “but [it] offered no organized plan or strategy for change” (p. 18) and there were no key advocates pushing for implementation of the recommendations.
Progress in getting the U.S. initiative from the second to the first group, got a big boost in 1997 through the tireless efforts of Senator Harry Reid (D-NV). History was made on May 6, 1997 when he introduced and obtained unanimous support in the first session of 105th Congress for Senate Resolution #84 on suicide and suicide prevention. Major support for this success was credited to SPAN members who delivered 20,000 advocacy letters (more than 3 times the inaugural number in 1996) to Capitol Hill legislators calling for action. In the same year, Representative John Lewis (D-5th-GA) introduced House Resolution #212 and with almost single-handed persistence stayed focused on the importance of this resolution until it was unanimously passed in October 1998, just before the 105th Congress adjourned. Lewis, an African-American colleague of Dr. Martin Luther King, is known for his repeated inspirational charges to SPAN to “Don’t give up, Don’t give out and Don’t give in – Keep On, Keep On.” Both resolutions specifically urged the development of “an effective national strategy for the prevention of suicide” (AAS, 1997b, p. 1; SPAN USA, 1999, p. 3). The impact of the UN Guidelines through the determined efforts of SPAN advocates resulted in the approval of a national policy priority – a critical step on the road to the formulation of a national strategy for suicide prevention.
Senator Reid’s office was also working on an appropriation request to support focused programs to implement the goals of Resolution 84. The success of his work was announced in July 1997 with a $2.5 million increase to the 1998 fiscal budget of the Centers for Disease Control and Prevention, which was subsequently ratified by the Senate and House of Representatives. The appropriation included $1 million to establish two new injury control research centers, one to focus specifically on suicide. The other $1.5 million was dedicated for a “CDC evaluation of interventions focused on the prevention of suicide among the elderly.” (AAS, 1997b, p.1).
By November 1997, a SPAN Steering Committee (composed of representatives of a broad spectrum of suicide prevention initiatives) met to begin the development of the National Suicide Prevention Strategy. The committee was co-sponsored with the National Center for Injury Prevention (NCIPC) of the Centers for Disease Control (CDC). The committee was encouraged by NCIPC Director, Dr. Mark Rosenberg, to follow the new public health model to “test, learn, improve and test again and again” instead of the old approach of “plan, plan, plan and test” (Weyrauch, 1998, page 1). The objective of the committee through a six sub-committee structure was to set the stage for a National Summit Meeting in Reno, Nevada in October 1998 to endorse the specifics of a national strategy. The National Strategy would be taken to each State’s legislative leaders for endorsement and appropriate efforts for implementation. The actual implementation would be the responsibility of the local grassroots professionals in partnership with community leaders.
In the run up to the National Summit in 1998, SPANUSA did not limit its scope to the United States. With financial support from Solvay Pharmaceuticals, Weyrauch proposed, organized and co-chaired with Maila Upanne from Finland, a 5th year reunion of the 1993 meeting in consultation with the Calgary team to assess progress and look to the future. The meeting was held at the 1998 international injury control conference in Amsterdam with representatives from the12 countries that drafted the UN Guidelines in Calgary. The intertwining of UN and U.S. efforts was consolidated, and allowed SPANUSA to ‘gift’ the healing power of its Lifekeeper quilt concept to international colleagues.
The National Summit Meeting was organized as a Consensus Development Conference (NIH, 1993): Advancing the National Strategy for Suicide Prevention: Linking Research and Practice. The challenge was daunting. Few believed that it could be done in such a short time period. Others were skeptical that a strong collaboration between government, agencies, private and national non-profit organizations, health professionals, educators, survivors, and attempters could be achieved. The idea of asking 450 people with diverse interests working in a conference atmosphere for 3 days to formulate national strategy recommendations was considered impossible. In contrast the UN Guidelines were developed over 6 days with only 15 participants from 12 different countries. It took the visionary dedication of individuals like Lucy Davidson to make it happen. Davidson was a key architect of the National Summit and a significant player in the earlier Bush administration efforts to recognize the problem of
suicide (J. Wyerauch, personal communication, April 16, 2001). It happened through the strong leadership of Davidson and many others, and key roles played by U.S. participants at the UN interregional meeting in 1993 – Morton Silverman, Chair of the Expert Panel, responsible for the final report and Lloyd Potter, a key member of the Conference Planning Committee. A comprehensive report was presented to the Surgeon General David Satcher at the close of the conference on October 18, 1998. More than 450 participants furnished 290 ideas for recommendations to the Expert Panel chaired by Dr. Silverman, who gleaned a draft preamble and 81 recommendations for the National Suicide Prevention Strategy (SPAN, 1999, p. 4). The Preamble highlighted the following points:
1) recognition and affirmation of the value, dignity and importance of each person;
2) suicide is not solely the result of illness or inner conditions; it can stem from societal conditions and attitudes;
3) everyone concerned with suicide prevention shares a responsibility to help change attitudes and eliminate conditions of oppression, racism, homophobia, discrimination and prejudice against diverse populations who are disproportionately affected by these conditions; and the
4) need for collaboration at all levels of a community.
Impact of the UN Guidelines on the U.S. National Suicide Prevention Strategy
The impact that the UN Guidelines had on the success of the Nevada conference was offered by Dr. Potter in a personal note to the author on the final day of the consensus conference, “Without you, this would never have happened. We all owe you so much, most don’t even know.” (personal communication, October 18, 1998). The impact was formally recognized in a letter from the Surgeon General in the Surgeon General’s Call to Action in 1999. He acknowledged that the UN document, Prevention of Suicide: Guidelines for the Formulation and Implementation of National Strategies that was drafted at the 1993 meeting in Canada “motivated the creation of an innovative public/private partnership to seek a national strategy for the United States” (Satcher, 1999, p. 1). In the Call to Action document, Satcher noted that the recommendations and their supporting conceptual framework were essential steps toward a comprehensive National Suicide Prevention Strategy. He reaffirmed the need for the other core elements that the UN Guidelines recommended – constructive health policy, measurable overall objectives, and ways to monitor and evaluate progress toward these objectives, a provision of resources for groups and agencies identified to carry out the recommendations. He called on the nation “to move forward with these crucial recommendations and support continued efforts to improve the scientific bases of suicide prevention” (p. 2). He was straightforward about “the most well-considered plan accomplishes nothing if it is not implemented. To translate AIM [Awareness, Intervention, Methodology] into action, each of us, whether we play a role at the federal, state, or local level, must turn these recommendations into programs best suited for our own communities” (p. 2).
Progress toward a comprehensive National Suicide Prevention Strategy (NSPS) was significant in 2000. In February 2000 a U.S. Senate Appropriations Subcommittee on Labor, Health and Human services, Education and related Agencies held a Hearing on Suicide, which was the first time that a hearing on all aspects of suicide had been held. Experts were convened in March 2000 to provide consultation on further development. They concluded that the NSPS scope should:
1) ‘articulate the framework’ to legitimize and empower state and local prevention efforts,
2) strike a balance between universal and targeted interventions,
5) demonstrate a sensitivity to being overly prescriptive, and
6) recognize that some objectives may have international or cross-cultural implications for effective prevention (AAS, 2000, p. 1).
Four strategically located national public hearings in the Fall of 2000 provided valuable public input to the Goals and Objectives for the NSPS that was to be released in the Spring of 2001. The highlight of 2000 was the enactment into law on October 17th that authorized “consideration by congressional appropriations to provide $75 million for suicide prevention programs specific to children and adolescents” (SPAN, 2001, p.1). The next step is to get the $75 million approved. The community-initiated process of the UN Guidelines is nearing completion. The U.S. national strategy is progressing toward final development. The Goals and Objective are ready for public release. Next in this stage is to approve the activities needed to achieve the goals and objectives, and to see the appointment of an active and effective coordinating body. As these steps are completed, implementation of a comprehensive national strategy will be ready to proceed in cooperation with a growing number of State-level suicide prevention initiatives that are in various stages of development and implementation.
Sustaining the Gains
With the remarkable progress that has occurred since the founder of SPAN first received a draft copy of the UN Guidelines in 1994, the development of the U.S. national strategy has moved through several stages of the community–initiated process. The process in now at the stage where the national government is poised to designate a national coordinating body for suicide prevention to complement the national level policy priority that has been given to the prevention of suicide. The UN Guidelines outline the following steps that must be taken to support this kind of policy priority.
1) A coordinating body responsible for the implementation of the national strategy needs to be appointed. The formulation of the strategy has been effectively developed and serves as possible model for others to follow.
2) The mandate of the coordinating body must be broad enough to include responsibilities for promoting, implementing and coordinating to advance progress toward achievement of national strategy objectives.
3) The coordinating body is provided with executive, financial and technical resources to ensure effective and efficient implementation of the national strategy.
The U.S. effort to evolve a national suicide prevention strategy since 1995 provides an excellent case study of a community-initiated process. The grass roots movement that the founders of SPANUSA patterned after the UN Guidelines complements the well-developed government-initiated strategy in Finland that was highlighted in the UN Guidelines document (Jenkins and Singh, 2000). However, the community-initiated process in the U.S. is still to be completed. It will not be complete until the necessary government-initiated steps of this process are firmly in place. The activation of these steps is crucial for the continued advancement of the national strategy for suicide prevention. If the remaining steps are not completed it will soon be apparent that “all the progress in the U.S. will be largely for naught if we are not able to create and implement this National Coordinating Body” (personal communication, J. Weyrauch, February 24, 2001). There is both concern and optimism as development of the U.S. national strategy moves toward the implementation phase, federally as well as at the state level. This desired partnership is not easily guaranteed. There remains a concern that representatives in federal government departments will not want to share authority, responsibilities or funding with others. Optimism, on the other hand, lies in the involvement of state planning groups and the work that is going on at this level to implement community-initiated plans and programs. The U.S. community-initiated process has almost come full circle since 1996. The circle will be complete when the development of the national strategy is completed and when statewide implementation plans are common place and actively evolving throughout the country. Once this happens a tighter circle can begin to continue advocacy, awareness and make revisions to unfolding plans. This process will be facilitated through rigorous evaluation, sharing of results and modifications to achieve “best practice” approaches in all States. SPANUSA has conceptualized a holistic framework to guide this process that includes an Affirmation of Life vision, supported by Research and Collaborative Processes, and encouraged through passionate and caring Leadership (See Appendix I).
Beyond the impact of the UN Guidelines on the U.S. national strategy, the U.S. example is now available for others to follow. A recent report claims “The endorsement by both the World Health Organization and the United Nations of the framing of national strategies has put particular onus on governments to respond in an area of health in which they traditionally have had little interest” (Jenkins and Singh, 2000, p. 613). These endorsements and the tremendous impact of grass roots organizations like SPANUSA, has considerably increased activities by national governments in suicide prevention. Jenkins and Singh suggest the growing impact of these developments “augurs well for continuing progress in trying to prevent one of the most tragic events in the life of a family and a community (p. 614).
Looking back to the UN meeting in 1987 and Terri Ann Weyrauch’s suicide, no one could have imagined that Iris Bolton’s ‘hidden gift’ prediction would materialize as far as it has
toward a comprehensive U.S. National Suicide Prevention Strategy that is expected to be released in May 2001.
References
AAS (Summer 1997a). Senate Resolution 84 passes unanimously. NewsLink, vol. 23, 2, Washington, DC: American Association of Suicidology, p. 1.
AAS (Fall 1997b). Appropriations request passed by Senate and House: $2.5 million sought for suicide prevention. NewsLink, vol. 23, no.3, Washington, DC: American Association of Suicidology, p. 1.
AAS (Summer 2000). National suicide prevention strategy moves ahead. NewsLink, Vol.26, no. 2, Washington, DC: American Association of Suicidology, p. 1.
Boldt, M. (1985). Towards the development of a systematic approach to suicide prevention: The Alberta model. Canada’s Mental Health, 33, 2-4.
Bolton, I. and Mitchell, C. (1984). My Son, My Son. Atlanta, GA: Bolton Press.
Davidson, L., Potter, L., and Ross, V. (Writers) (1999). The Surgeon General’s Call to Action to Prevent Suicide 1999 (1-2). Washington, DC: Department of Health and Human Services, U.S. Public Health Service.
Ernst, H. (March, 2001). ‘The hidden gift’: Grief over their daughter’s suicide inspires prevention work. The Lutheran, pp. 23-24.
NIH (1993). Guidelines for the planning and management of NIH Consensus Development Conferences. Bethesda, MD: National Institutes of Health, Office of the Director, Office\ of Medical Applications of Research; 1993. 13p.
Jenkins, R. and Singh, B. (2000). General population strategies of suicide prevention. In K, Hawton and K. van Heeringen (Eds.), The International Handbook of Suicide and Attempted Stuicide (597-615). London: John Wiley and Sons, Ltd.
Ramsay,R. Cooke, M. and Lang, W. (1989). Alberta’s suicide prevention programs. Suicide and Life Threatening Behavior, 20, 335-351.
Ramsay, R. and Tanney, B. (1996). Global Trends in Suicide Prevention: Toward the development of national strategies for suicide prevention. Mumbai: Tata Institute of Social Sciences.
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Satcher, D. (1999). A letter from the Surgeon General. The Surgeon General’s Call to Action to Prevent Suicide 1999 (1-2). Washington, DC: Department of Health and Human Services U.S. Public Health Service.
SPAN (February, 1999). It CAN be done . . . . and YOU DID IT! SPANUSA, Issue 7, Marietta, GA: Suicide Prevention Advocacy Network, p. 1.
SPAN (January, 2001). Landmark legislation . . . Products of the power of the people. SPANUSA, Issue 12, Marietta, GA: Suicide Prevention Advocacy Network, p. 1.
Tanney, B. (Spring 2000). What can we learn from the White Volumes? SIEC Current Awareness Bulletin, AAS, Newslink, 26(1), 16-18.
Taylor, S., Kingdom, D., Jenkins, R. (1997). How are nations trying to prevent suicide? An analysis of national suicide prevention strategies. Acta Psychiatrica Scandinavica, 95, 457-463.
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United Nations (1996). Prevention of Suicide: Guidelines for the formulation and implementation of national strategies. New York: Department for Policy Coordination and Sustainable Development.
Weyrauch, J. (1995). Suicide Prevention Advocacy Network (SPAN) founded. SPANUSA, Issue 1, Marietta, GA: Suicide Prevention Advocacy Network, p. 5, 8.
Weyrauch, J. (Summer, 1996). Some of the things that happened because of the . . . First Annual National Awareness Day for Suicide: A National Problem Friday, May 10, 1996. Surviving Suicide, Vol. 8, no. 2, p. 4.
Weyrauch, J. (February, 1998). National suicide prevention strategy: Progress report. SPANUSA, Issue 5, Marietta, GA: Suicide Prevention Advocacy Network, p.1.
Appendix I
(Insert SPAN Affirmation of Life chart)
