Programs that Work
Counselors Care (CARE)
Healthy and Safe Children
Children not experiencing anxiety or mood disorders, such as depression
Age of Child
Type of Setting
Type of Service
Health Care Services
Type of Outcome Addressed
Substance Use and Dependence
Evidence Level (What does this mean?)
Counselors Care (CARE) is a school-based intervention for high-school students at risk for suicide. CARE is a two-part, four-hour program, beginning with a personalized computer-assisted assessment of risk and protective factors, and followed by a brief counseling intervention designed to enhance a youth's personal resources and social network connections.
High school students in grades 9-12 who are at risk for dropping out of school and suicidal behavior.
Randell, Eggert, and Pike (2001) and Eggert et al. (2002) studied the effects of CARE in a sample of 341 students in grades 9-12 from seven urban high schools in the Pacific Northwest. Students participated in the study in three cohorts over three academic years. The target population for the program was students at risk for dropping out. Students who were eligible for the study had the following characteristics: below expected credits for grade level, in the top 25th percentile for days absent per semester, a grade point average of less than 2.3, and/or a pattern of declining grades. Also included as eligible for the study were those students who had previously dropped out of school but later returned, or who were referred by school staff for being at high risk for dropout.
Students with parental consent completed the High School Questionnaire: Profile of Experiences (HSQ), a self-report survey instrument that screened suicide risk behaviors and related risk factors such as depression, hopelessness, anxiety, and anger. All youths with specific levels and combinations of indicators (such as prior suicide attempts, high depression, drug involvement, suicide ideation, etc.) were identified as "at suicide risk" and were entered into the study. A total of 381 youths were identified as such (38 percent of the total number of students screened on the HSQ) and were randomized to begin the study in one of three conditions: CARE only (117 students), CARE+CAST (103 students; CAST is a small peer-group life skills-training program), or the "usual care" control group (121 students).
The study condition for each school was randomly determined at the start; thereafter all three study conditions were rotated systematically through each school, as well as a "pause" condition during which no interventions were implemented (in order to minimize potential carry-over effects to other students of the interventions within the schools). The control condition was designed to simulate intervention as usual by using procedures that a high school might have in place to respond to youths at risk of suicide. In this condition, a trained interviewer conducted a minimal assessment interview (15-30 minutes) for each student. Notification of parents and designated school personnel was initiated, and immediate assistance was provided in those rare instances when the risk of suicide was imminent. In nonemergency situations, school personnel and parents/guardians identified appropriate resources and obtained assistance as warranted.
Of the total sample, 52 percent of the youths were female, 24 percent were in 9th grade, 39 percent in 10th grade, 20 percent in 11th grade, and 17 percent in 12th grade. Students' ethnic/racial representation was 40 percent Caucasian, 13 percent mixed race/ethnicity, 13 percent Asian, 12 percent African American, 7 percent Hispanic, 2 percent American Indian/Alaskan Native, 4 percent another ethnicity, and 9 percent unknown. With the exception of age (CARE+CAST students were slightly older), there were no significant baseline differences among the three groups in terms of background variables; suicide risk; or related risk, protective, and family factors.
Outcomes on the HSQ were assessed four weeks after baseline (following implementation of CARE), and ten weeks after baseline (following completion of CAST). Retention rates at ten weeks were 97 percent for the CARE+CAST group, 93 percent for the control group, and 89 percent for the CARE group. Attrition analysis indicated few significant differences among groups for study completers and noncompleters, with the exception that CARE+CAST noncompleters reported higher levels of satisfaction with their families than did CARE and control group noncompleters, and CARE noncompleters reported more suicidal ideation than noncompleters from CARE+CAST and the control group.
A second, similar study of CARE was conducted by Thompson et al. (2001) in a sample of youths from seven urban high schools in Pacific Northwest school districts. A two-step process was used to identify youths at risk for suicide. First, each school's database and referrals from school personnel were used to identify the total pool of potential high school dropouts (1,546 students). Second, youths in this pool were randomly sampled and invited to participate in the study; those who consented completed the baseline HSQ survey (1,217 students). Of the surveyed youths, 460 (38 percent) were identified as being at risk for suicide. These students were randomly assigned by the school to one of three conditions: CARE (150 students), CARE+CAST (155 students), or the "usual-care" control group (155 students, using the same minimal assessment interview described previously). The sample was 52 percent female and was ethnically diverse, with 49 percent Caucasian youths, 19 percent African American, 18 percent Asian American/Pacific Islander, 10 percent Hispanic/Latino, and 4 percent Native American.
Within schools, the three study conditions were rotated systematically such that each school received each condition, as well as a "pause" semester during which no interventions were implemented. Outcomes on the HSQ were measured four weeks after baseline following completion of CARE, ten weeks after baseline following CAST, and nine months after baseline. Retention at nine-month follow-up was 86 percent for CARE, 93 percent for CARE+CAST, and 90 percent for the control group. Analyses indicated no significant differences among groups for most of the background variables, although CARE+CAST youths were slightly older than youths in the other two groups, and CARE youths had significantly lower baseline problem-solving coping scores.
Key Evaluation Findings
Eggert et al. (2002) and Randell, Eggert, and Pike (2001) reported the following results:
- Youths in all three groups showed a significant decreasing trend over time in suicide risk behaviors (thoughts, threats, attempts), with no significant differences among groups. Further inspection of findings showed that while reductions in suicide risk behaviors occurred between baseline and four-week assessment (after CARE implementation) for all three groups, effects were sustained at ten-week assessment (after CAST implementation) for youths in the CARE and control conditions (i.e., for youths not in CARE+CAST).
- Changes in suicidal threats showed a significant effect of gender on treatment for female students only. For females, CARE youths showed declining trends from four-week to ten-week assessments, compared with a slight rebounding for those in the control group.
- All three groups showed significant declines in depression over time. Further analyses showed that only CARE+CAST youths had significantly less depression than controls at four-week assessment. At ten-week assessment, both CARE and CARE+CAST youths exhibited significantly lower levels of depression than controls, with controls demonstrating a slight rebound effect.
- A steady decline in anger control problems over time was found for all three groups, with no significant differences among groups.
- Significant reductions were found for youth in all three groups in use of alcohol, marijuana, and hard drugs, drug-use control problems, and adverse drug-use consequences. No significant differences were found among groups.
- Compared with the usual-care control group, both CARE+CAST and CARE were associated with faster rates of decline in favorable attitudes toward suicide. No significant differences were found between youths in CARE+CAST and CARE.
- There were no significant differences among groups for suicide threats or attempts within the month preceding the posttest; however the baseline rates for suicide threats or attempts were low and are thus limited as outcome measures.
- For depression, both CARE+CAST and CARE groups showed significantly lower levels of depression at ten weeks and nine months than did the control group.
- Declines in hopelessness were sustained within groups across all time points for the CARE+CAST and CARE groups, with significant effects found for the majority of comparisons between both treatment groups and the control group.
- Following the four-week assessment, the control groups rebounded in reported levels of hopelessness and then showed a decline.
- For CARE+CAST versus controls, hopelessness was significantly lower at the ten-week assessment but not at the nine-month assessment.
- For CARE versus the control group, hopelessness was significantly lower at both the ten-week and the nine-month assessments.
- Significant effects for declines in anxiety were found for females in both CARE+CAST and CARE when compared with controls, but not for males.
- For both CARE and CARE+CAST females, significantly larger declines in anxiety were found at the ten-week and the nine-month assessments when compared with controls.
- Differences in the rates of decline in anger for females in CARE+CAST and CARE were statistically significant when compared with controls. Again, no significant differences were found among groups for males.
- Group comparisons showed significant treatment effects regarding anger for CARE and CARE+CAST females compared with control females at the ten-week but not at the nine-month assessment.
Public and private high schools
Previous studies of the CARE program have been supported in part by the National Institute of Nursing Research.
CARE is a two-part prevention protocol delivered in two sessions. The first is a two-hour, one-to-one computer-assisted suicide assessment called the Measure of Adolescent Potential for Suicide (MAPS), which provides a comprehensive and individualized assessment of direct suicide risk factors, related risk factors, and protective factors. The MAPS includes a motivational introduction followed by an assessment of the youths' stressors, depression, hopelessness, anxiety, suicidal behaviors, risky behaviors, drug involvement, personal skills and coping strategies, and social support resources.
The second part of CARE is a two-hour motivational counseling and social network intervention designed to
- deliver empathy and support
- provide personalized information
- reinforce coping skills and help-seeking behaviors
- increase access to help
- enhance access to social support.
CARE leaders are specially trained, advanced level clinicians; generally a master's level high-school teacher, counselor, or nurse.
Issues to Consider
This program received a "promising" rating. The evaluations of CARE found that the program resulted in faster rates of decline in risk factors for suicide and lower levels of depression and hopelessness among participants when compared with a usual-care control group. In addition, the treatment group resulted in lower levels of anxiety and anger for female students. Although studies have been limited to the Pacific Northwest, the CARE interventions were evaluated in schools with diverse ethnic populations. Findings across the evaluations were mixed, however, with the treatment groups demonstrating significant, positive effects compared with the control group for some outcome measures and time periods but not for others.
Several limitations should be noted for this program. The results for specific suicide-related behaviors showed few differences between the treatment group and the usual-care control group. For both ethical and legal reasons, the use of a no-intervention control group was not possible, so the CARE participants were compared with a group who underwent a brief assessment interview along with usual-care follow-up that would be expected in schools dealing with students at risk of suicide. Many of the comparisons did not find significant differences between groups for the suicide-related outcomes, and the authors conclude that even the briefest of suicide-risk assessments and provisions of support (as in the control group) produce reductions in suicide risk. While this may be true, an alternate explanation might be that the lack of significant differences coupled with significant declines over time for all groups may have been because neither of the interventions or the usual-care control were responsible for a significant impact on the participants, but that these high-risk students would have demonstrated improved outcomes over time regardless of their participation in the study. Establishing causal effects of the programs is even more difficult given the voluntary basis for program enrollment, which may have resulted in a self-selection bias; i.e., students who were more interested in addressing negative feelings and risky behaviors may have been more likely to sign up for the interventions than students with less interest in change.
Few differences were found between the CARE and CARE+CAST groups, and the only differences that emerged favored the CARE-only group. This suggests that the positive outcomes evidenced by the treatment participants were primarily the result of the four-hour CARE intervention, with the added six-week CAST program having little effect. Further support for the benefits of a brief intervention is found in studies of a semester-long and two semester-long early version of CAST (Eggert, Seyl, and Nicholas, 1990; Eggert et al., 1994; and Eggert et al., 1995), which found that the MAPS assessment protocol was just as effective as the longer programs.
While CARE and CARE+CAST were found to lower youth substance use, so too did the usual care, and no significant differences were found among groups.
Finally, it should be noted that the program developers also served as the evaluators of the program.
Reconnecting Youth Inc.
P.O. Box 20343
Seattle, WA 98122
None at this time
Eggert, Leona L., Christine D. Seyl, and Liela J. Nicholas, "Effects of a School-Based Prevention Program for Potential High School Dropouts and Drug Abusers,"
The International Journal of the Addictions,
Vol. 25, No. 7, 1990, pp. 773-801.
Eggert, Leona L., Elaine A. Thompson, Brooke P. Randell, and Kenneth C. Pike, "Preliminary Effects of Brief School-Based Prevention Approaches for Reducing Youth Suicide-Risk Behaviors, Depression, and Drug Involvement," Journal of Child and Adolescent Psychiatric Nursing, Vol. 15, No. 2, 2002, pp. 48-64.
Eggert, Leona L., Elaine A. Thompson, Jerald R. Herting, and Liela J. Nicholas, "Erratum: Reducing Suicide Potential Among High-Risk Youth: Tests of a School-Based Prevention Program," Suicide and Life-Threatening Behavior, Vol. 29, No. 1, 1999, p. 96.
Eggert, Leona L., Elaine A. Thompson, Jerald R. Herting, and Liela J. Nicholas, "Reducing Suicide Potential Among High-Risk Youth: Tests of a School-Based Prevention Program," Suicide and Life-Threatening Behavior, Vol. 25, No. 2, 1995, pp. 276-296.
Eggert, Leona L., Elaine A. Thompson, Jerald R. Herting, Liela J. Nicholas, and Barbara Garii Dicker, "Preventing Adolescent Drug Abuse and High School Dropout Through an Intensive School-Based Social Network Development Program," American Journal of Health Promotion, Vol. 8, No. 3, 1994, pp. 202-215.
Randell, Brooke P., Leona L. Eggert, and Kenneth C. Pike, "Immediate Post Intervention Effects of Two Brief Youth Suicide Prevention Interventions," Suicide and Life-Threatening Behavior, Vol. 31, No. 1, 2001, pp. 41-61.
Thompson, Elaine Adams, Leona L. Eggert, Brooke P. Randell, and Kenneth C. Pike, "Evaluation of Indicated Suicide Risk Prevention Approaches for Potential High School Dropouts," American Journal of Public Health, Vol. 91, No. 5, 2001, pp. 742-752.