Elderly Americans have the nation's highest rate of suicide -- a rate 50 percent greater than that for young people. Although researchers have long known the elderly are at high risk for suicide, prevention has been difficult because elders seldom seek out help.
Now, a new program involving students, alumni and faculty of the George Warren Brown (GWB) School of Social Work at Washington University in St. Louis is bringing free phone counseling and support into the homes of older Americans identified as suicide risks by friends, family and the medical community. Research based on the pilot program has shown that the telephone can be an effective tool in bringing suicide-prevention counseling into the homes of seniors at high risk for suicide -- those who are sick, lonely or isolated. An article on the research is scheduled for publication in the January 1998 issue of Research on Social Work Practice.
Known as Link Plus, the program was developed by Nancy Morrow-Howell, Ph.D., associate professor of social work, and two GWB alumni now working at Life Crisis, a well-established crisis telephone hotline program in St. Louis. Lee Judy is director of Life Crisis. Susan Becker-Kemppainen runs Link Plus and made most of the phone calls during the program's research phase, which ran July 1994 through July 1996 and was supported by a $65,000 grant from the Retirement Research Foundation in Chicago.
"Life Crisis hotline volunteers have a proven track record of providing critical counseling to people considering suicide, but only 3 percent of calls to the well-known hotline program are from people over the age of 60," Morrow-Howell said. "Older people who needed help were not coming to us, so we found a way of going to them."
Becker-Kemppainen tested the concept during the two-year research phase by making routine phone calls to a study group of 61 at-risk elders. Some clients sought assistance from Life Crisis on their own, while most were contacted and included in the study based on referrals. All were evaluated and randomly assigned to one of two study groups. Half received immediate phone counseling and other intervention, while the rest were placed in a control group and provided similar services after four months.
Becker-Kemppainen made about 60 calls per case, talking to clients, family members, doctors and other service providers, often using conference calling to coordinate communications among various caregivers. Calls continued for about eight months or as long as a client deemed necessary.
After only four months of treatment, Link Plus clients had increased social contact and fewer symptoms of depression compared to the control group. After eight months in Link Plus, clients reported less problems meeting challenges of daily living, such as making arrangements for transportation, meal preparation and money management. Nearly three-fourths of the clients reported that their life situations were "quite a bit" or "a great deal" improved.
"We feel strongly that the telephone is very much underutilized when it comes to providing therapeutic services to people, yet it remains one of the most effective ways to reach people, especially the elderly and others who can have problems with mobility," Judy said.
"It's been a surprise to us how quickly older clients open up to us on the phone," said Judy, adding that this response makes sense once you think about it: "On the phone they don't have to worry about how they look, they don't have to worry about being embarrassed or whether someone they're talking to will recognize their face in the grocery store. And they're in control of the conversation because they can always hang up at any time."
While it is difficult to determine how many of those in the study were truly on the verge of suicide, the research team found through surveys that many of the participants fit a profile for persons at risk of suicide. More than 70 percent of the clients met geriatric screening criteria for classification as "possibly" or "probably" suffering from depression. Nearly 30 percent reported having once considered suicide, and about 10 percent had thought of suicide recently.
Now that research funding for the program has expired, social work students from George Warren Brown have stepped in to continue the counseling service as a component of field education at Life Crisis. Students receive specialized training on issues facing the elderly and learn how to link older adults with resources and programs that can help them to continue living independently.
"We try to match each Link Plus client with a particular student so that the two of them can get to know each other and develop a rapport," Becker-Kemppainen said. "It really helps the students get a broad-based understanding of issues affecting the elderly and for a lot of people, it helps them determine if working with the elderly is something they want to do."
Most students work as unpaid volunteers who receive academic credit based on hours of service -- roughly one credit hour for every 100 or 120 hours of field work. All practicum students work under the close direction of trained master of social work field supervisors, some of whom are graduates of George Warren Brown who now work at Life Crisis. Field supervisors are responsible for monitoring student work with clients and providing evaluations of student progress.
Proactive approach
The study was designed to explore whether a pro-active counseling service could be effective in reaching elders at risk of suicide, but the counseling service itself is by no means limited to senior citizens who might be considering suicide.
"Anybody over the age of 60 who has unmet needs of daily living or problems with isolation and depression is let into the counseling program because our goal also is to help people not get to the point where they might consider suicide," said Becker-Kemppainen.
After spending two years on the phone with older clients, Becker-Kemppainen has plenty of personal anecdotes to illustrate the program's effectiveness in reaching once-isolated and discouraged seniors. One older man, for instance, was referred to the Link Plus because a number of seemingly small day-to-day living challenges were making his life extremely difficult and unrewarding.
During a series of phone conversations, Becker-Kemppainen learned the man was unable to find transportation to the grocery store and that a low-vision problem from diabetes had made it impossible for him to read most food labels and prepare balanced meals, an important health concern for those with diabetes.
"He couldn't drive anymore because of his low vision and he couldn't figure out what his canned foods were until after he'd opened them," Becker-Kemppainen said. "He was pretty much just eating whatever can of food he happened to open and that was not helping his diabetes problem."
She helped the man solve these problems by putting him in touch with a senior group that offers free transportation services, and by arranging for Missouri Rehabilitation Services for the Blind to visit his home and organize his pantry using a system of large, color-coded labels. She also got the man involved with a low-vision support group operated by the St. Louis Society for the Blind and Visually Impaired and arranged for him to receive newspapers, magazines and books on audio tape.
"I think a lot of people see senior citizens that are feeling sad and they fail to address it because somehow they think this is normal, that these people are old and its normal for them to be sad, but I don't believe that," Becker-Kemppainen said.
"There are resources available and people should try to help older adults get the help they need. People don't have to live their lives being sad and lonely. We should not dismiss the feelings of older adults just because they're older."
Challenge in finding those in need
Life Crisis plans to distribute information about the program to hotline operations across the country and the research team is hopeful the service will soon be making a difference in the lives of seniors nationwide.
"The people who know best about older people who are struggling most often are that person's family and friends," Judy said. "We very much would like to encourage these third-parties to call us and let us know about people who might benefit from the Link Plus service."
Life Crisis phone operators are trained to treat all calls with sensitivity, and if requested, they will preserve the anonymity of those making a referral to the service.
"We have proven that the telephone can be effective in providing counseling to older people, and now the challenge is to find those that need the service," Judy said. "We can't help them if we don't know who they are." For more information on the program and for referrals of senior citizens needing assistance, call Life Crisis at (314) 647-HELP.
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Note: For more information, refer to Morrow-Howell N, Becker-Kemppainen S and Judy L, "Evaluating an Intervention for Elders at Increased Risk of Suicide," Research on Social Work Practice, Vol. 8, No. 1, pp. 28-46, January 1998.
Journal
Research on Social Work Practice