PROVO — When school administrators ask Greg Hudnall if his teen suicide prevention program is “evidence-based,” he doesn’t hesitate.

Yes, he tells them. It is.

Hudnall's Hope Squads have become increasingly common in Utah schools, backed by state dollars as the teen suicide rate has risen to crisis levels.

Hudnall says Hope Squads, which train students to spot warning signs of suicide and refer their classmates to care, are informed by regular surveys of participants, as well as industry best practices and a cadre of local suicide prevention experts.

There are Hope Squads in 31 of Utah’s 41 school districts, he said, with nearly 7,000 student members. And that’s just in Utah. Hudnall said there soon will be Hope Squads at nearly 100 schools in a dozen other U.S. states and seven in Canada.

There are high school Hope Squads, junior high Hope Squads and elementary Hope Squads; Hudnall believes there should be college and corporate Hope Squads, too.

For those seeking a solution as suicide claims the lives of more Utah youths than car accidents do, Hope Squads may seem to be an answer. There's just one catch: There’s no solid proof that Hope Squads actually reduce suicides.

Researchers from the Centers for Disease Control and Prevention announced in November that Hope Squad programs were expanding without “rigorous” study to show that they're effective — or that they do “not produce unintended harmful or negative effects.”

The Utah programs — which include another educational effort called Hope for Tomorrow — have “a relatively narrow focus,” the CDC researchers wrote, and they fail to address suicide contributors like social environments, bullying and mental health treatment.

“No evidence was found for their effectiveness in preventing suicidal behaviors or addressing key risk and protective factors for suicide,” the CDC said.

To Hudnall, who had never been asked to speak to CDC researchers, it was a slap in the face. Privately, administrators demanded that he explain his data or emailed his lead national researcher to ask if they should dump their Hope Squads.

“The phone calls I got were like, ‘Holy mackerel!’” he said.

Doug Gray, a professor of psychiatry and a suicide expert at the University of Utah who has advised Hudnall for the better part of two decades, said the CDC’s language felt “pretty critical,” with “no appreciation for using sound principles of what we know about suicide prevention, creating a program and working like hell to get it researched.”

The CDC’s critique came at the January 2017 invitation of state officials, though, as they grappled with a dramatic spike in youth suicides that has alarmed lawmakers and baffled researchers.

Utah’s rate increased nearly fourfold between 2007 and 2015 and has since plateaued, yet the rate at which youths in Utah kill themselves is still more than 2 1/2 times the 2015 national average.

Forty-two Utahns between 10 and 17 died by suicide in 2017, according to preliminary state data, and five students enrolled at a single Wasatch Front High School have taken their own lives within the last year.

Gov. Gary Herbert recently created a dedicated suicide task force, and the state Legislature allocated more than $7 million in new funding to address suicide.

Yet Utah continues to place its faith in Hope Squads, even without a controlled, randomized trial to definitively prove their worth to data scientists.

With federal funding for such research in short supply, can Utah policymakers and educators be certain that the leading school suicide responses are based on more than anecdotal successes and good intentions?

Why Hope Squads?

It’s been 20 years since Hudnall first dedicated himself to preventing suicide, having been called to identify the body of a 14-year-old boy in a public park and made sick by the experience.

Then a principal at a Provo high school, Hudnall, 59, now works out of offices near the mouth of Provo Canyon, with a whiteboard full of to-dos and the random assortments of pens and markers you only find on an educator's desk.

He is a breathless free associator who will sometimes stop midthought to queue up a video testimonial, and he recently finished writing a book: “The Hope Squad: The Successful Suicide Prevention Program for Students,” for release in August by a local publisher.

One day, he wants to see Hope Squads in at least 10,000 U.S. schools.

Studies show teens in distress will often talk to their peers before they approach an adult, and those peer confidants often keep their secret. Hudnall's foundational idea was to empower groups of students to get help for their peers.

Beginning in 2004, he launched teams of particularly empathetic and approachable students who were nominated by peers to become a school’s “eyes and ears,” scanning classrooms and hallways for comments or behaviors that might hint at thoughts of suicide.

But Hope Squad members weren't expected to act as amateur counselors or therapists when they found a peer in crisis. They were trained to talk about their concerns with an adult adviser or persuade their peers to go to an adult.

Hudnall says he never intended to take Hope Squads beyond the Provo School District. It wasn’t until 2014, 10 years after the first Hope Squad, that the program began to spread rapidly.

Growth was spurred by three factors: first, the rapidly increasing rate of youth suicide; second, reports that after seven suicides at Provo schools between 1999 and 2004, there had been none in nine years after the launch of Hudnall’s peer support teams, and third, legislation that gave each Utah school $500 annually for suicide prevention, which Hudnall agreed to accept as payment for a Hope Squad.

For $500 per year, Hope Squad schools in Utah receive trainings for advisers, students, parents and teachers, as well as three years' worth of curriculum on mental health and suicide prevention.

The most similar program that is considered evidence-based by the CDC and national registries is a North Dakota-based program called Sources of Strength. And, on paper, it’s pretty similar.

Sources of Strength students are trained as peer leaders who, with the help of advisers, have conversations with friends and produce posters, videos, social network posts and other presentations to share a message of hope, help and strength.

There are some differences in curriculum and emphases, but the major difference from the perspective of data scientists is that Sources of Strength boasts a randomized trial conducted by university researchers that showed, among other findings, “trained peer leaders in larger schools were four times as likely as were untrained peer leaders to refer a suicidal friend to an adult.”

It’s a good program, said Gray, who is widely acknowledged as a top Utah authority on youth suicide and who has participated in "psychological autopsies" of suicide deaths — speaking to parents, friends and other associates after a youth suicide — that showed the possible value of such "gatekeeper" trainings.

“So the question is why don't we just take a program that works and just use that?" he asked.

Hudnall and Hope Squad researchers think their program may be more effective because of its robust curriculum and focus on peer interventions. But it's also cheaper for Utah schools. Whereas Hope Squads only cost each Utah school $500 annually that the state will reimburse, the startup cost for the trainings and materials involved in the Sources of Strength program runs $5,000, per the organization’s website.

"There just isn't the money” in Utah, Gray said. “So the thought I've always had is, 'We've got (Hudnall's program), which is based on very sound principles.’ The people who run that want it to be studied. They strongly desire to have a spotlight on it and study it."

‘Supported,’ but not ‘evidence-based’

Both Hope Squad and Hope for Tomorrow have been deemed “supported” by the Division of Substance Abuse and Mental Health's Evidence-Based Workgroup, which keeps a list of prevention programs that meet Utah's statutory requirements.

By law, the group must always include at least one social scientist with experience researching prevention methods, as well as urban and rural prevention specialists and public health officials. Together, they give approved programs one of four grades.

"Supported" is the state's third-highest grade, a tier above “promising” and below “well-supported.” To be "supported," like Hope Squads, a program must have consistently demonstrated a positive result, which can include effects on participants' knowledge, beliefs, attitudes or behavioral intentions.

To be "well-supported," a program would need to show at least one behavioral outcome, or behavior.

It's difficult to measure a suicide program's most important outcome — total suicides — because so few die by suicide even at crisis levels (11 out of 100,000 Utah teens in 2015). One school might have zero suicides for five years and three another year, without any one cause it can point to definitively.

So even the leading national prevention program registries offer some leeway when it comes to outcomes. In the aforementioned Sources of Strength trial, it was enough that university researchers showed increases in students' connectedness to adults, school engagement and peer referrals.

Hope Squads haven't had that level of scientific study, but they have tracked their effectiveness in two key ways.

Hudnall keeps a tally of students who have been referred to adults by their peers, which he says is now over 3,000 since the program began, resulting in more than 300 hospitalizations.

Hope Squad members and advisers are also asked to complete surveys before and after each year, and students are asked a range of questions that cover their comfort with suicide-related topics, their willingness to take actions such as going to an adult and the number of times they helped a peer.

The surveys have been analyzed by Rodney Hopkins, a research assistant professor in social work at the University of Utah. More than 9 out of 10 Hope Squad members reported helping other students in 2014-15, and all advisers said their school's Hope Squad had contributed “to a safe, healthy and positive school climate."

Those numbers are “very positive,” Hopkins said.

In fact, the CDC report said Hope Squads and Hope for Tomorrow showed “some preliminary positive results.”

“But,” Hopkins added, “you can’t raise a new flag and say this is the best thing in the world, because you don’t have that big study that has everything controlled for.”

In prevention circles, the term “evidence-based” means a program has undergone a randomized trial and been compared to another group that didn’t have the program. And such studies aren’t cheap.

Hope Squad researchers have applied for funding from the federal Substance Abuse and Mental Health Services Administration and the nonprofit American Foundation for Suicide Prevention, or AFSP. But neither selected them.

A Department of Education innovation grant created last year — sponsored in the Senate by Utah's Orrin Hatch — would have provided millions of dollars for a five-year study that had the potential to be expanded for up to 10 years.

A team of Hope Squad researchers from the University of Utah, Brigham Young University, the University of Cincinnati and Old Dominion spent countless hours on conference calls and in Google documents, writing and rewriting a proposal. But not only did the DOE decide to pass, it didn’t fund a single suicide prevention program anywhere in the nation.

Said Gray: “We shut down our life for a month and we didn’t even have a chance. Don’t fund us? Don’t fund us. Fund somebody.”

Jennifer Wright-Berryman, an assistant professor of social work at the University of Cincinnati, thinks the team may have another opportunity for a trial as Hudnall rolls out new Hope Squads at schools in multiple states.

By asking some schools to wait for their Hope Squads while collecting data that researchers can compare with schools that already have Hope Squads, researchers might get the control data they need to put the CDC's concerns to rest.

Such a study might cost between $150,000 and $250,000 over three to five years, Wright-Berryman said. But “that’s a lean budget.”

Funding remains scarce. The AFSP reported that in 2013, suicide prevention received $37 million in federal research funding, while HIV/AIDS got nearly $3 billion — even as AIDS deaths decreased and suicide deaths increased.

“We just haven’t seen the required level of investment that we need to really get a handle on this issue,” said Kim Myers, suicide prevention coordinator for the state Department of Human Services. “At the very highest level, we are not investing meaningfully in understanding strategies that are effective for suicide prevention.”

Rep. Steve Eliason, R-Sandy, said he considered running a bill to allocate state funding during this year's session, but there were too many other priorities on the suicide prevention front, including mobile crisis outreach teams, elementary school counselors and improved suicide hotline resources.

Ideally, Gray said, a "do-gooder" donor would invest in the research, sparing researchers the time and money involved in applying for more highly competitive grants.

“We can't keep shutting down for a month and working on stuff that's almost futile in terms of the percentage chance of getting — it'd be better to go up to Idaho and just get a lottery ticket every week.”

Eyes and ears

Among nonscientists, the most common question about Hope Squads is whether they place too much responsibility on overstressed, inexperienced teenagers.

Gray, an unpaid adviser to the program, said he wondered the same thing when he first heard Hudnall describe his peer teams.

But then Gray took the notion to the aspiring psychiatrists he trains at the U. His students told him they had always been confidants for their peers, long before they went to medical school for professional training on how to appropriately respond. Come to think of it, Gray realized, he had been like that when he was younger, too.

“And I'm like, ‘Oh, wow.’”

Emmeline Grimmer, an 18-year-old senior in her third year as a Hope Squad member, said it was daunting when she was first invited to join the program as a 10th-grader entering Lone Peak High School in northern Utah County.

Several recent suicides had earned Lone Peak the nickname “Suicide High.” But Grimmer said she learned that her job was simply to be “extra-sensitive about how everyone is doing" — “not to be the counselors and give them therapy.”

A Hope Squad's monthly training program begins with a curriculum called Question, Persuade and Refer, which is listed in leading evidence-based registries and teaches students to recognize signs of suicide, intervene appropriately and refer their peers to care.

(Hudnall stresses to schools that it is vital to partner with local mental health providers who can provide fast access to care in times of crisis.)

“If something ever happens — like, we did have a suicide this year — then it’s not our fault, and we’ve done everything we can,” said Grimmer, who plans to study health psychology at BYU in the fall.

Lizzy Brailsford, a 16-year-old sophomore at Lone Peak, said she has been mature for her age ever since her father died when she was 9, and friends have always confided in her.

“My friends sometimes call me the mom of the group,” she said.

Now she feels more confident speaking to her peers — even strangers — about difficult topics. That comes with pressure, she said, but she knows she can rely on support from her Hope Squad adviser and other adults.

Hudnall’s 2014-15 year-end survey found that 96 percent of students either reported “no stress,” “very little stress” or “manageable” stress as a result of their role in Hope Squads.

At Lone Peak, the Hope Squad has been supported this year by a regular class taught by Emily Cox — a trained school counselor who had spent two years leading the Hope Squad as a club.

“It’s not the end of the world’s problems by any means,” Cox said. “All I can say is that this is what’s working for our school. It’s working because the students are into it, the administration is fully supportive and the community almost rioted to have something like this.”

Pleasant Grove City Councilwoman Cyd LeMone said that after local schools saw three suicides in 2012, she doesn’t know of any since Hudnall implored community leaders to set up Hope Squads.

Christy Hutchinson, prevention coordinator for Davis School District for the past four years, said two high schools that had several suicides before implementing Hope Squads have had similar results. Davis has even installed Hope Squads in eight elementary schools, where they focus on character development, empathy and inclusion.

“What it’s really boiling down to is connectedness," Hutchinson said. "They do random acts of kindness. They do ‘No one eats alone’ days. They host a lot of things that just overall boost morale in a school and help kids feel OK and welcome.”

But while Hudnall advocates for a community-involved model that layers in involvement from advisers, administrators, parents and mental health providers, he admits that not all Hope Squads are created equally. And, generally, they require two to three years to change a school’s culture, he said.

Nor does Hudnall claim that Hope Squads can prevent suicides altogether. The Provo City School District confirmed that there were no suicides in the nine-year stretch after Hope Squads began in 2004, but there have been four suicides in five years since 2013.

Students at Herriman High, where five enrolled students have died by suicide since last summer, started a Hope Squad in the fall.

Erin Preston, the mother of a Herriman sophomore, said she doesn’t want to discourage Hope Squad participation, but she wonders if “we’re putting too much responsibility and pressure on kids to solve issues that need to be solved at least in conjunction with adults.”

“If they’re part of the puzzle, that’s great, but if they for instance identify a kid that’s suicidal … what do they do with that? Who do they take it to, and what happens at that point? What then occurs?”

Preston said the selection process, in which students are nominated to become Hope Squad members by their peers, may also exclude students who are better able to reach some pockets of the student population.

Her son told her that “sometimes you need some kids who are the rule-breakers, or who see the world differently.”

What’s next?

Kimball Gardner said that, like Hope Squad officials, he too “would have loved to have had the opportunity to tell the CDC team more about Hope for Tomorrow.”

Gardner is a director at the Utah office of the National Alliance on Mental Illness — which advocates for people affected by mental illness — and said the Hope for Tomorrow program was started to raise students' awareness of mental health issues and eliminate the stigma surrounding mental illness.

NAMI Utah added suicide prevention to its Hope for Tomorrow curriculum about six years ago, he said. It's often taught in health classes.

And, like Hope Squad officials, Gardner said he's “very confident that our outcomes would be very, very strong” in a rigorous evaluation.

But Gardner said even if other states might benefit from a Hope for Tomorrow-like program, he has “never pretended that we’re going to get a national designation.” They can't afford the study, he said.

“We’ve got two unique programs in Utah that were initially designed for Utah,” he said. “Let’s support those programs.”

The CDC said in statements to the Deseret News that a majority of risk factors and precipitating circumstances in recent Utah suicide deaths "were not being directly addressed" by Utah's leading programs and that "in general, few state programs are comprehensive in the way we suggest."

But it also said that “the choice of suicide prevention strategy by a state or a local jurisdiction depends on several factors such as the target population, known risk factors, funding, etc., and it’s totally at the discretion of (the) jurisdiction.”

State leaders, at least, have backed the local programs.

The state task force wrote in its February recommendations that it was “encouraged by the promise of peer-to-peer programs like Hope Squads and would encourage schools throughout the state to consider implementing such programs with strong oversight and fidelity.”

And Eliason, the task force co-chairman, passed a bill that increased school suicide prevention reimbursements from $500 to $1,000, which Hudnall said he hopes to collect in full so he can hire additional trainers and create more resources for parents.

Said Eliason: “That comes at a cost because, generally, these programs were funded at a cost of 50 cents a student. To raise that up to a buck is a small price to pay for preventing suicide.”

Hudnall currently charges out-of-state schools $5,000 for the first four years of a Hope Squad program and $500 annually thereafter, but he said he plans to hold Utah costs to the amount the state will reimburse.

Myers said it “certainly is not a Utah phenomenon” to have suicide prevention programs that lack rigorous evaluation, but the state will keep trying to find resources for research.

“We have culpability here,” she said. “We have to make sure that it gets evaluated.”

Some school districts won't implement Hope Squads until they're in a national registry, Hudnall said. But that in itself is a murky subject at the moment, given that the NREPP — which was run by a contractor — saw its funding eliminated earlier this year by the Trump administration, slammed by a top Health and Human Services Department official for “a skewed presentation of evidence-based interventions.”

In the meantime, Hope Squad researchers have written two scholarly papers about the program's promise. One was published in February by the Children & Schools journal, stating that “pilot data suggest training is effective in equipping Hope Squad members to help peers in distress," but that "more research and evaluation needs to be done to understand the impact on suicide-related outcomes.”

Cox said she is “very confident” in the effectiveness of Lone Peak's Hope Squad, at least, “because I have seen the number of referrals that go to the counselors and the therapists."

Asked if Hudnall's Hope Squad program would withstand more rigorous scrutiny, Grimmer said, “Absolutely.”

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Added Brailsford: “100 percent.”

If not evidence, there's an abundance of enthusiasm, at least.

Help available

If you or somebody you know is experiencing suicidal thoughts, you can call the 24-hour National Suicide Prevention Lifeline at 1-800-273-TALK or text “HOME” to the Crisis Text Line at 741-741. Utahns with smartphones can also download the SafeUT app for around-the-clock counseling and crisis intervention.

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