Suicide Intervention: The Pathway to Assisting Life

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September 12, 2019

By Jeremy D. Howard, MS, LAT, ATC

What if you were told that an at-capacity Boeing 737-200 airplane crashed and killed 130 people every day? Would this be enough to drive serious change in the Airline industry? You can bet it would make the news—but what if I told you this is exactly how many Americans die each day from suicide?

Suicide is devastating, there is no way to sugarcoat this concept. When someone dies by suicide, those closest are deeply affected and often find themselves wondering what could have been done. While it may seem like a dark and taboo topic in the sports medicine field, we as Athletic Trainers and licensed health care professionals need to address the proverbial elephant in the room. We need to understand potential warning signs and be prepared to intervene in order to assist.

According to The National Institute of Mental Health, the Center for Disease Control collected data on suicide in the United States and the reported statistics were staggering. The most shocking series of statistics are as follows:

1. Suicide has climbed to be the tenth leading cause of death in the United States with 47,173 (~130 per day) people dying from suicide each year.

2. Suicide is reported to be the second leading cause for those in the age range of 10-years-old to 34-years-old.

3. Incidents of suicide are over two times more common than homicide.

4. Suicide rates in the United States have climbed from 10.7 percent of the population in 2001 to 14 percent of the population in 2017.

5. The midwestern states and Alaska experience the highest suicide rates

With regard to athletics, A.L. Rao reported in “Athletic suicide – Separating fact from fiction and navigating the challenging road ahead” published in Current Sports Medicine Reports in 2018, that high school students who are ‘highly involved’ in athletics are shown to have lower suicide rates. Rao’s findings were based on a youth behavior risk survey. Further, Rao cited that collegiate athletes also demonstrated decreased suicidality at a rate of 0.93 per 100,000 when compared to age-matched non-athlete college students at a rate of 7.5 per 100,000. While this data does suggest some inherent resilience for the athletic population, it does not mean invulnerability to suicidality. Thus, we as health care professionals who develop close working relationships to the student-athlete/patient must be aware of what potential triggers or suicidal correlates exist in our patient population to ensure we can effectively intervene when necessary.

Pain is a known cause of depression. However, K. Konietzny, O. Chehadi, C. Levenig, M. Kellmann, J. Kleinert, T. Mierswa, and M.I. Hasenbring in the article “Depression and suicidal ideation in high-performance athletes suffering from low back pain: The role of stress and pain-related though suppression” published in the European Journal of Pain in 2019, discussed a concern linking pain-related thought suppression to increased perception of depression and suicidal ideations in athletes. Pain-related thought suppression in lay terms is essentially trying not to think about the pain, think of the adages like “pain doesn’t hurt” or “ignore the pain.” Understand this is a very lay explanation of the concept, but what Konietzny discovered was that this method of pain suppression actually increased reported perception of depression and suicidal ideations in athletes.

Further, when comparing an athletic population to non-athletes, researchers found that athlete suicide is more commonly linked to the correlate of social relationships while non-athlete suicide is more commonly correlated to perception of stress according to K. Anchuri, A.K. Davoren, A. Shanahan, M. Torres and H.C. Wilcox, H.C in. “Nonsuicidal self-injury, suicidal ideation, and suicide attempt among collegiate athletes: Findings from the National College Health Assessment” published in the Journal of American College Health in 2019. To generalize, it is worth implementing a potential suicidal intervention with athletes demonstrating major changes in personality when coupled with social separation and/or injury.

Now, let’s talk about the intervention process. The Army trains and certifies their Suicide Intervention Officer (SIOs) using the Pathway to Assisting Life (PAL) model as supported by the Applies Suicide Intervention Skills Training (ASIST) workshop governed by Living Works. The PAL model is very useful and the ASIST training on its implementation is extremely valuable. The two most common issues seen when teaching suicide intervention are first the intervener’s willingness to ask the hard question “Are you thinking of killing yourself?” over more ambiguous questions such as, “Are you thinking of hurting yourself?” or “Are you okay?” Secondly, the intervener jumps model from ‘Connecting with Suicide,’ skipping over ‘Understanding Choices’ and landing on ‘Assisting Life.’

At first glance, this jump to immediately protect the patient may seem appropriate, but by failing to understand the why, we have only temporarily prevented the patient’s suicide attempt. It is truly the act of understanding the rationale and reasons behind why the patient has chosen to die by suicide that allows us to effectively intervene, get the patient the necessary resources and referrals, and to prevent death by suicide in the long term.

These concepts may seem obvious to caregivers. However, it is challenging all the same. In athletic training education, many students take a course on Sports Psychology, but one maybe two courses in the psychology realm amongst every other aspect of the profession may not have thoroughly prepared every AT to deal with suicide intervention. Broadly speaking, many athletic training students focus their educational endeavors on the orthopedic side, learning special tests, evaluations and common injuries. It is highly recommended that ATs seek out formal advanced training through organizations like Living Works and other similar entities to be guided through the intervention process. Just as ATs must be trained in emergency cardiac care, they should make every effort to learn appropriate suicide intervention.It may one day save a life.


National Institute of Mental Health. (2019). Mental health information.Retrieved from

Rao, A.L. (2018). Athletic suicide – Separating fact from fiction and navigating the challenging road ahead. Current Sports Medicine Reports, 17(3), 83-84. doi: 10.1249/JSR.0000000000000462.

Konietzny, K., Chehadi, O., Levenig, C., Kellmann, M., Kleinert, J., Mierswa, T., & Hasenbring, M.I. (2019). Depression and suicidal ideation in high-performance athletes suffering from low back pain: The role of stress and pain-related though suppression. European Journal of Pain, 23(6), 1196-1208. doi: 10.1002/ejp.1387.

Anchuri, K., Davoren, A.K., Shanahan, A., Torres, M., & Wilcox, H.C. (2019). Nonsuicidal self-injury, suicidal ideation, and suicide attempt among collegiate athletes:Findings from the National College Health Assessment.Journal of American College Health, Jun 18, 1-9. doi: 10.1080/07448481.2019.1616743.


About the Author

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Jeremy Howard is the State Health Promotion Officer for Florida Army National Guard under the Resilience, Risk Reduction, and Suicide Prevention Program. Howard graduated with a Bachelor of Science in Athletic Training from Florida Gulf Coast University (#DunkCity) and from the University of Saint Augustine for Health Sciences’ Master of Health Science in Athletic Training programs. He is currently pursuing an Educational Doctorate in Health Sciences at the same institution. In 2002, Howard enlisted in the Florida Army National Guard and is still currently serving; he is also a veteran of Operation Enduring Freedom-Afghanistan. His professional interests include Concussion/TBI, Injury Prevention Programs and Manual Therapy.

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