1. Suicide Prevention, Intervention & Postvention in Schools
An Overview for School Leaders

2. Suicide is a difficult topic…
Most of us have been touched, professionally and/or personally, by suicide Important to support one another as we approach this topic today….and in days following No scheduled breaks, come and go as is right for you If you would like to talk to someone, we are available to help.

3. Context for the presentation
This presentation targets the School Mental Health Leadership Team
It is designed to:
Build common understanding about suicide amongst school mental health leaders
Highlight helpful prevention, intervention and postvention strategies
Provide recommendation actions for consideration at the school level

4. Session Outline Brief Overview of Suicide in Children and Youth
Suicide Prevention, Intervention & Postvention Strategies
Issues for School Leaders
Recommended Actions for the MH Leadership Team
Roles and Protocols (mh leadership team, school administration, critical incident response team)
Strategies (early identification and treatment of mental health problems, youth engagement, community culture building)
Capacity-Building (information dissemination, gatekeeper training)

5. Child and youth suicide
Brief Overview
Child and youth suicide

6. Suicidal behaviour Non-Suicidal Self-Injury Suicidal Ideation
a deliberate attempt to cause injury to one’s body without the conscious intent to die
Suicidal Ideation
Suicidal thoughts that include both contemplating death by suicide and planning actions that could result in death
Suicide Attempt
self-harming behaviour that includes an intention to die
Death by Suicide
self-harming behaviour that results in death

7. Facts and Figures
2nd leading cause of death after accidents, accounting for % of adolescent mortality (but important to put this in context, death is relatively uncommon in this age group)
1.4% of all suicides occur in children under 14 years of age
Death by suicide is more prevalent in males than females aged
Recent Canadian epidemiological study shows overall stable rates of suicide over the past 30 years, but trends are changing: decreasing rates for males and increasing rates for females (Skinner & McFaull, 2012)

8. Risk The complexity of Risk Protective Factors Vulnerabilities
(Distal)
Triggers
(Proximal)
Risk

9. Vulnerabilities - self
Mental illness (e.g., mood, anxiety, conduct disorders)
Past suicidal behavior
Substance use
Unstable mood, high impulsivity
Rigid thinking or coping patterns
Poor physical health / chronic illness
Past suicidal behavior - 37% repetition rate
In more than half of suicidal attempters, there was failure at school or dropout
NOTE: These risk factors are correlational and not causal; typically it is a compounding of risk factors that is associated with suicidal behavior.

10. Vulnerabilities - home
Family history of suicides / attempts
Parental mental illness
Alcohol / substance abuse in the home
History of violence and/or abuse
Divorce, separation, other losses, death
Tension and aggression between parents
Parental lack of time; rejection; neglect
Parental divorce rate = 2x higher in suicidal patients
40% of abused children show suicidal behavior
NOTE: These risk factors are correlational and not causal; typically it is a compounding of risk factors that is associated with suicidal behavior.

11. Vulnerabilities – school/community
Learning problems
Disengagement from school
Lack of connectedness
Marginalization
Discontinuity in identity (cultural, language, gender, sexual)
Some communities are at heightened vulnerability (e.g., aboriginal, LGBTQ, homeless)
Negative social relationships, including bullying

12. Bullying and Suicide Pre-existing vulnerability
Increases risk for bullying
Victimization
New or Exacerbated:
Anxiety
Depressed mood
Diminished self-worth
Feelings of entrapment
Loneliness
Withdrawal
Sleep/eating problems
Hopelessness
Which are risk factors for:
Suicidal ideation
Suicide attempt
Death by suicide
Adapted Lenny Berman 2010 Bullying and Suicide 8doc.webinar American Association of Suicidology

13. Triggers Break up with boy/girl friend
Conflicts and increased arguments with parents and/or siblings
Loss of close friend
School related difficulties-conflicts with teachers, classmates
Difficulties with the law
Change in parents’ financial status
Serious illness or injury in family member
Real or perceived loss of status

14. Contagion
Occurs when suicidal behavior influences an increase in the suicidal behavior of others
Multiple suicidal behaviors/suicide deaths that occur within a geographical area or fall within an accelerated time frame may represent a potential cluster
Although clusters are rare, they are most common amongst adolescents

15. Circles of vulnerability
Geographical Proximity
Social Proximity
Psychological Proximity
Population at Risk
Lahad & Cohen, 2006

16. The role of cyber/social media
Increasingly there are sites, chat rooms and blogs that promote suicidal ideation
Methods of suicide are discussed on-line and some researchers have suggested that increases in particular methods in recent years may be related to this dialogue
The rapid spread of rumours and details of deaths by suicide is difficult to manage
Paradoxically, social media may hold potential benefits for suicide prevention
(Skinner & McFaull, 2012)

17. The role of media
Media can be helpful or harmful – it is never benign and they cannot view themselves as impartial observers
Contagion (mimicking of suicidal behavior) is a real phenomenon and youth are particularly vulnerable
Media needs to be held accountable for adhering to safe reporting guidelines following a death by suicide
Media can be helpful in bringing awareness to issues of child and youth mental health more broadly

18. Responding to mass media / social media coverage
Recent weeks have brought us…
A very tragic example of the complexity of suicidal behavior
An illustration of the influence and dangers of social media
Irresponsible media coverage and oversimplification of the issues in much public discourse
Well-intentioned, but potentially harmful, actions
Contagion
A magnification of the need for district and school leadership to ensure student safety

19. Protective factors Problem solving, life & communication skills
Sociability
Resilient Personality
A sense of belonging (school, community)
Secure attachment to positive parent/family
Access to other caring & supportive adults
Pro-social peers
Appropriate discipline, limit setting & structure
Opportunities to develop self-esteem
Good Mental Health

20. Youth suicide is complex and is often the result of many converging factors. The explanations and the solutions are equally complex.

21. What can we do? Reduce vulnerabilities - at school
Ensure school is safe and accepting, especially for vulnerable students (enhance sense of belonging, increase connectedness and engagement, show respect for differences)
Build on protective factors
Provide skill-building, opportunities to build esteem, etc.
Look out for triggers
Identify students at risk, listen
Minimize the risk for contagion
Have a plan for help

22. Suicide prevention, intervention, & postvention
Strategies for
Suicide prevention, intervention, & postvention

23. First, do no harm
In considering various prevention, intervention, and postvention strategies, the Mental Health Leadership Team needs to understand that this area of work is not benign
Some actions are more effective than others, some are risky, and many have not been evaluated rigorously
This may mean taking a fresh look at existing practices to ensure alignment with the evidence base in this area
Close communication with your senior administration team will be important if practice changes are required

24. Through this section, Consider…
What is your school doing consistently across the system in suicide prevention, intervention and postvention?
Are these initiatives aligned with the evidence-base?

25. SCHOOL RESPONSE TO SUICIDE
Four components:
Administrative Foundation, Prevention, Intervention & Postvention

26. What is Administrative foundation?
The administrative foundation is the support and commitment of the school board, as articulated through the principal, to policies and procedures that address the range of needs presented by students who might be at risk for suicide.

27. What is Suicide Prevention?
Efforts to reduce the risk of suicidal thoughts and behavior amongst students in a systematic way

28. What is intervention?
Practices involved in recognizing and responding to students with suicidal ideation or behavior
Practices involved in supporting vulnerable students transitioning to and from mental health care

29. What is postvention?
Support for school communities in responding to suspected, attempted, or death by suicide

30. Helpful Prevention strategies
Safe and accepting school culture
Social emotional learning (coping skills, conflict resolution)
Early identification and treatment of mental health problems
Gatekeeper training
Information dissemination (staff, parents, students)

31. Prevention Strategies to avoid
There are risks inherent in the following strategies:
Suicide awareness curriculum with students, particularly if done in a single or stand alone lesson(s) (curriculum is best delivered in the context of instruction related to mental health more generally, over a period of several lessons, with a focus on protective factors…after adults have received gatekeeper training)
Assigning suicide as a central or sole focus of study
Large assemblies with guest speakers who talk about suicide
Events that have the potential to glorify/glamorize suicide
Peer counseling related to suicide

32. Insufficient Evidence
Prevention Strategy
Evidence
Early identification and treatment of mental health problems
Solid
School/community culture building
Adaptive coping skill development
Information dissemination / gatekeeper training
Promising
Screening and referral
Mixed
Youth engagement / peer helper programs
Suicide awareness curricula for students
Means restriction
Crisis hotlines
Media education programs
Insufficient Evidence
Effective postvention

33. Information Dissemination and Gatekeeper training
Different audiences have different knowledge needs
AWARENESS - Classroom teachers can benefit from as little as a 2-hour session that provides information about risk factors, warning signs, and what to do if one of their students appears to be at risk for suicide
LITERACY - More in-depth gatekeeper training can be offered for select individuals in a school who are in a position that makes is more likely that students will approach them for help (e.g., admin team, guidance, student success), and who are willing to provide consultation and support when crises occur
EXPERTISE - School mental health professionals should maintain strong knowledge and skills with respect to suicide assessment and support

34. Needed Knowledge
For intervention to be successful, basic knowledge about warning signals can be shared with those in a position to notice changes in behavior amongst youth
School staff, parents, students, youth-involved community members
Can be shared in a variety of ways (brochures, workshops, fact sheets, trusted websites, media)
Key warning signals are described here as a handy reference
Note that 100% accurate prediction of suicide is impossible. We can only do our best.

35. WARNING SIGNALS: Behavioural
Loss of interest in former activities
Withdrawal from social contact
Difficulty concentrating, problems with judgment and memory
Dramatic shift in quality of academic performance
Feelings of sadness, emptiness and hopelessness, often expressed in written assignments
Sleep disturbances
These signals also relate to problems in mental health more generally

36. WARNING SIGNALS: BEHAVIOURAL
Strong and overt expressions of anger and rage
Excessive use of drugs and/or alcohol
Promiscuous behaviour
Uncharacteristic delinquent, thrill-seeking behaviour
Self-mutilation
Occurrence of previous suicidal gestures or attempts
Planning for death; making final arrangements; giving away favourite possessions

37. WARNING SIGNALS: Communication
Statements revealing a desire to die, or a preoccupation with death
Nihilistic comments: life is meaningless, filled with misery, what’s the use of it all?
Verbal or written threats
Sudden cheerfulness after prolonged depression may be relief because decision has been taken

38. Helpful intervention strategies
Identification and Referral
Ensure staff aware of warning signals
Ensure clear protocol at school level
Provide immediate and calm support to the student
Ensure safety and supervision
Facilitate assessment and care
Contact parent/guardian
Document actions

39. Helpful intervention strategies
Supporting Vulnerable Students
Ensure staff understand role and limits of competence
Support staff with caring adult role
Identify vulnerable students
Work with clinical staff, when involved
Create a school safety plan for each student, as needed
Implement and monitor plans, as needed

40. Intervention strategies to avoid
Peer intervention models with inadequate adult supervision and monitoring
Recruitment of gatekeepers who are uncomfortable / unready for the role
Counseling of high risk students by unqualified professionals

41. Helpful postvention strategies
Understand the phases of postvention
Have a plan for who does what at each phase of postvention
First 24 hours
Next hours
During the first month
Planning for the future
Practice deliberate self- and team-care

42. Working through phases
The accompanying presentation for the School Mental Health Team articulates considerations for the postvention period, through these phases
This difficult work is usually led by the school admin team, with support from the Superintendent, Crisis Response Team, MH leadership team, and corporate communications, as needed
Main message – have a plan for who does what at each phase of postvention

43. First 24 hours
Verify the death, confirm the facts, talk with the student’s family personally (usually the principal, with support from the Board Team)
Mobilize the critical incident response team
Assess the impact of the death and level of response required
If parents do not wish the suicide to be disclosed, and students are unlikely to find out the cause of death, large scale suicide postvention is not indicated
In contrast, high impact events that will involve media would call for support from the board response team and enacting of postvention protocols
Identify vulnerable students and provide support
Determine what information to share, with whom, how
Inform Superintendent, notify school staff, inform students simultaneously in their classrooms (not through announcements or a large assembly) using prepared scripts
Manage the media, using one designated liaison person with media training (may be a member of the board team)

44. Next 48-72 hours Restore school to regular routines
Liaise with bereaved/affected family
Consider involvement with funeral/memorials
Avoid on-campus memorials that could glorify suicide
Monitor staff well-being
Keep school community informed
Involve community partners in postvention support
Document actions

45. During The first month Monitor all staff and student well-being
Plan for school events of relevance (year book, award nights, graduation)
Conduct a critical incident review
Consider offering information sessions for parent community with mental health agency
Continue documentation of actions
Response Team Debriefing

46. Planning for the future
Continue support and monitoring of students and staff
Plan for anniversaries, birthdays and significant events
Implement recommendations from the critical incident review, in consultation with SO and MH Leadership Team
Assess current suicide prevention strategies and enhance as needed
Share the postvention plan with new staff members
Continue to work with community to refine response for future

47. Information for All Schools in board, with support for vulnerable schools
Information for Parents/Guardians and the wider school community
Information for All Students, with support as needed
Information for All Staff, with Support for Vulnerable Members
Support for Vulnerable Students
Support for Students in Crisis and their Families
Social Media
Media

48. Take care of each other
Death by suicide is a special kind of school crisis that impacts us in significant ways, professionally and personally
The School Team needs to work together, to debrief often, and to reach out when members are struggling
Members need to practice self-care deliberately
The Board Team can provide support in this regard – the School Team is not alone

49. Documentation of Ontario community mobilization response following a suicide cluster

50. A Comprehensive suicide prevention strategy includes:
Proactive, universal strategies that promote a sense of belonging at school (reaching out to vulnerable students)
Wide-spread instruction in adaptive coping skills, like problem solving and conflict resolution
Knowledge and skills for early identification of mental health problems (with clear connections to service)
Gatekeeper training, with protocols for students at risk
Effective postvention, with protocols
Other strategies? Evaluate!!

51. Issues for school leaders
Child and Youth Suicide
Issues for school leaders

52. It takes a village… Many players needed, to assume different roles
Suicide Strategy Planning and Communication
E.g., Board Mental Health Leadership Team, Senior Administration Team, Corporate Communications / Public Relations, Community Partners
Suicide Prevention and Intervention
E.g., Board Mental Health Leadership Team, School Mental Health Professionals, School Administration, School Staff, Community Partners
Postvention
E.g., Initial team may include: Principal/Vice-Principal(s), Critical Incident Response Team, Superintendent, Board Mental Health Leadership Team, Corporate Communications, Community Partners

53. Pertinent issues for school leaders
Determining a coordinated school-wide approach
Establishing systematic and proactive suicide prevention initiatives within the context of wider mental health promotion and prevention efforts
Ensuring clear protocols and roles for intervention with students exhibiting suicidal behavior
Developing or updating postvention protocols in light of new realities (consistent with established board protocols)
Communicating the suicide strategy and related supports and expectations with staff

54. Suicidal behavior is a reality in your schools Be proactive, Be Prepared

55. Components of an effective Suicide strategy
Protocols for students at risk
Protocols following a death by suicide
Broad focus on mental health promotion, skill-building and caring school cultures
Staff education and training
Media education
Parent education
An effective strategy builds common understanding across the board & community, and signals a systematic, proactive approach

56. School Leaders
Recommended actions

57. Consider…. Roles and Existing/Needed Protocols
Existing/Needed Strategies (e.g., early identification and treatment of mental health problems, youth engagement, community culture building)
Existing/Needed Capacity-Building (e.g., information dissemination, gatekeeper training)

58. Getting organized
Identify Existing/Needed Teams (Board, School, Critical Incident Response)
Clarify Roles, as needed
Develop/update protocols for intervention & postvention
Develop/update tools/templates for intervention & postvention
Select and implement prevention strategies
Stage capacity-building efforts
Communicate the suicide strategy to staff
Monitor, evaluate and refine the strategy
Many school have teams and tools in place. For these schools, it is a matter of confirming that these resources are aligned with the wider board strategy, ensure capacity, and meet your needs within the current context.

59. Identify Teams* Board School Crisis Response Team
Suicide Strategy Team – protocol development, strategy selection, etc.
Suicide Response Team – support school team, work with media, etc.
School
Suicide Strategy Team – protocol development, strategy selection
Suicide Response Team – support students, staff, community, etc.
Crisis Response Team
Support staff and students in need of immediate support individually or in small groups
* These may be existing leadership teams at the board and school level, or subgroups within these

60. Clarify roles Leadership and Planning Teams Response Teams
Who will be involved in confirming our school protocols for intervention and postvention?
Who will be involved in selecting prevention approaches?
Response Teams
Who will support the school and the school team during the crisis? Following the crisis? Who does what? For example,
Who will contact the family, communicate with staff, students, etc.
Who will support the school response team?
Who will work with media?
Who will work with community?
Who will link with mental health partners?

61. Develop/update protocols
Obtain information about any board-wide protocols for intervention and postvention
Consult with colleagues in developing/updating protocols for your school, particularly those who have worked through postvention
Where appropriate to do so at the school level, work with local agencies to plan for community mobilization during postvention (note that this may be worked out at a system level)
Develop/update your Intervention Protocol (clearly state what to watch for, what to do, who in involve, where to document)
Develop/update your Postvention Protocol

62. Access tools
Access pertinent tools and templates available at the board level and ensure the School Mental Health Team knows how to access these in the event of a suicidal crisis
Intervention
Fact sheets / warning signals
At a glance protocol or flowchart
More detailed protocol with rationale
Postvention
Letters for school community
Scripts for students
Key messages for media
Support documents for staff
Documentation outline
Critical incident review form

63. Select and implement prevention strategies
If you have a mental health strategy that includes universal promotion and skill-building, you are already doing some of this work
Work with caring and accepting schools professionals to enhance sense of belonging in schools
Prepare information for dissemination with key groups
Work towards mobilization of community

64. Capacity - building When possible, sequence capacity-building:
School Leaders
School Staff
Gatekeeper Training
Parents
Students
Different audiences will have different knowledge needs

65. Communicate with staff
Communicate the protocol and related tools and templates
Board MH Team School Leaders
School Leaders School Staff
Some messages may need to go directly from the Board MH Team to all Staff and to media

66. Monitor, evaluate, refine
Documentation and debriefing of actions and enablers/challenges is important; for prevention, intervention, and especially postvention
Postvention is emotionally-charged, and the more that our actions can be routinized the better
While every situation is unique, each offers learning opportunities that can be used in future

67. Sources, with Thanks MH Leader Suicide Subgroup
Ian Manion, Ontario Centre of Excellence for Child and Youth Mental Health
Ian Brown, School Mental Health ASSIST
Stephan Roggenbaum & Katherine Lazear, University of South Florida
Key Resources:
SAMHSA Toolkit, Suicide Postvention Guidelines South Australia, Principal Leadership 2009, NASP Postvention Strategies for School Personnel, Kutcher 2008

68. Contact School Mental Health ASSIST
Kathy Short, Ph.D., C.Psych.
Director, School Mental Health ASSIST
, x2634
School Mental Health
ASSIST
Équipe d’appui en santé mentale pour les écoles