CARE (Care, Assess, Respond, Empower), also called Counselors CARE (C–CARE), is a school-based, brief assessment and crisis intervention for youth at risk for suicide. The CARE protocol is designed to empower youths and engage social support by connecting youths at risk of suicide to a caring person from their personal lives or from the school environment. Parents are contacted and instructed in providing support and understanding during the suicide-risk-assessment process. The goal of CARE is to decrease suicidal behaviors and related risk factors, and increase personal and social assets, by using a standardized individual prevention approach delivered by trained staff in school.
CARE integrates brief interventions and social network support/influence approaches to reduce suicide-risk behaviors and factors. The CARE intervention introduces youths to an alternative perspective on their situation, acknowledges distress, reinforces strengths, actively interrupts suicide-risk behaviors, and provides both a connection to and mechanisms for accessing sources of help and support from caring adults at home and at school.
CARE is designed and best suited for adolescents ranging from 14 to 19 years old who are at risk of suicide.
CARE integrates principles of behavior change and maintenance by building up skill acquisitions and social support. The program teaches skills related to stress management, emotion control, coping strategies, and seeking help when needed. By teaching teens these skills and letting them know it is acceptable to seek help during stressful periods, it is believed that negative behaviors (suicide ideation) and mental conditions (depression) will be reduced.
The CARE protocol consists of three main components that are typically completed in 3½ to 4 hours. The first part is a 1½- to 2-hour, one-to-one, computer-assisted suicide assessment called the Measure of Adolescent Potential for Suicide (or MAPS). This component includes a motivational introduction and then an assessment of direct suicide risk factors (suicide attempts or threats), related risk factors (depression, high anxiety, and hopelessness), and protective factors (coping strategies and social support resources).
The assessment interview is followed by a brief 2-hour motivational counseling session conducted by trained staff—typically advanced-practice nurses, counselors, or social workers. During the counseling session, the assessment results are summarized with the youth, and shared perceptions are validated. Positive coping strategies are introduced and reinforced along with an action plan for enhancing support resources.
The third component of CARE is the social network “connection” intervention. During this intervention, each youth is personally connected with a case manager in the school (a counselor or a trained school nurse) or with the youth’s favorite teacher to foster communication between the youth and school personnel. The youth also chooses a parent/guardian to communicate with by phone to serve as another social connection. The intent of the school and parent contacts is to enhance social network connections, support, and future access to help. The CARE protocol also includes a follow-up reassessment of suicide risk and protective factors and a booster motivational counseling session, typically 9 weeks after the initial counseling session.
14 to 19
Although Hooven and colleagues (2010) report some significant findings, these are associated with attitudinal change and were not evidenced in behavioral change. As such, the preponderance of evidence demonstrates null effects in regard to affecting behavior in this study.
Care, Assess, Respond, Empower (C–CARE) was effective at reducing risk factors and increasing protective factors for suicide across all intervention groups at the postintervention assessment. All groups showed immediate and significant results in reducing suicide ideation and threats, depression, hopelessness, anxiety, and anger. Protective factors such as coping, self-efficacy, and family support increased as well.
While all the intervention groups showed significant improvements over time, the combined and intensive youth and parent interventions (P&C–CARE) group displayed greater reductions in negative behavior and greater improvement in positive factors than the Parents CARE (P–CARE) and C–CARE intervention groups, and also the minimal-intervention (MI) comparison group. Although the P&C–Care and C–CARE significantly improved more than the MI comparison group, P–CARE was not statistically significant on many measures from the comparison group. This suggests that the most effective interventions include a multifaceted approach that involved both the youths and the parents.
Similar to the short-term effects, a long-lasting decline was evident for all three intervention groups (C–CARE, P–CARE, and P&C–CARE) at 6 years from the baseline assessment. Measures of depression, anger, and suicidal behaviors showed a drop at postintervention assessment and continued a steady decline over the follow-up periods. Though the intervention groups showed a significant improvement in attitudinal change over time, these changes did not translate into behavioral changes.
Suicide Risk Behaviors
Eggert and colleagues (2002) found immediate significant reductions in suicide-risk behaviors in both intervention groups (C–CARE and Coping and Support Training [CAST]) as well as in the comparison group over time. There were significant declines in levels of suicidal ideation, threats, and attempted suicides from baseline to the first follow-up assessment at 4 weeks out; however, there were no significant differences among the groups.
All three groups also evidenced a significant decline in measures of depression. Additionally, there were significant group effects, indicating changes by intervention group. CAST and C–CARE teens had lower levels of depression than the comparison group at the 10 week follow-up.
Drug use, drug control problems, and adverse drug consequences also showed reductions across all three groups. C–CARE and CAST teens had greater declines in drug use behavior than the comparison condition, but these failed to reach statistical significance.
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