School Suicide Prevention, Intervention and Postvention

School Suicide Prevention, Intervention and Postvention
LaShante Smith, CSUS graduate student, Crystal Courtright, CSUS graduate student, Stephen E. Brock, PhD, NCSP, LEP California State University, Sacramento Professor and School Psychology Program Coordinator, CSUS Member, NEAT Member/Co-chair, PREPaRE Past Coordinator, NASP Crisis Management in the Schools IG CQ Contributing Editor, Research Reviews, Crisis Management in the Schools 18 years, School Psychologist/Lead Psychologist Developed and lead a school district crisis team Author and/or editor of multiple books, book chapters, and journal articles in the area of school crisis response 1

Presentation Outline Introduction Primary Prevention of Suicide
Suicide Statistics Primary Prevention of Suicide Secondary Prevention of Suicide General Staff Procedures Risk Assessment and Referral Protocol Suicide Postvention

National Youth Suicide Statistics
Fifth leading cause of death among 5-14 year olds in 2009 (N = 266; 0.7:100,000). Third leading cause in the age group, N = 259). Third leading cause of death among year olds in 2009 (N = 4,371; 10.1:100,000). While the rate of youth suicide suggests this act to be relatively rare (less than 10 out of every 100, to 19-year-olds committed suicide in 1996), much concern has been expressed over increases in this rate. Between1950 and 1990 there was over a 400% increase in the 15- to 19-year-old rate (2.7 to 11.1 per 100,000; per 100,000). Source: Kochanek, K. D., et al. (2011, March). Deaths: Preliminary data for National Vital Statistics Report, 59(4), Retrieved from 3

National Youth Suicide Statistics
2011 YRBS1 15.8% of high school students reported having seriously considered suicide. 12.8% reported having made a suicide plan. 7.8% of high school students reported having attempted suicide. 2.4% indicated that the attempt required medical attention. 100 to 200 attempts for each completed youth suicide. vs. 4 attempts for each completed suicide among the elderly.2 1Eaton, D. K. et al. (2012, June). Youth Risk Behavior Surveillance — United States, Morbidity and Mortality Weekly Report, 61(SS-4), Retrieved from 2McIntosh, J. L. (2011, October). USA suicide: 2008 final data. Washington, DC: American Association of Suicideology. Retrieved from 4

Other Suicide Facts: All Age Groups
Total number of deaths (N = 36,909; :100,000) 10th leading cause of death Highest rate in 15 years. More men die by suicide 3.72 male suicides (N = 29,089) for each females suicide (N = 7,820) Source: CDC. (2011). 5

Total US Suicide Rate (1981-2009)
Current = 12.02 1991 was the last time suicide rates were over 12 per 100,000 in the population (it was 12.18:100,000). Look up when FDA issued black box warning on antidepresents Suicide Rate (per 100, 000) Source: CDC (2011) 6

Other Suicide Facts: All Age Groups
50.6% of suicides are by firearms.1 Suicide by firearms rate = 6.0:100,000 N = 18,223 Highest suicide rate is among white men over 85 (48.77:100,000 vs 11.82:100,000 among white male adolescent 15-19).2 However the 2nd highest rate is among American Indian/Alaskan Native year-old males (38.9:100,000). 1McIntosh, J. L. (2011, October). USA suicide: 2008 final data. Washington, DC: American Association of Suicideology. Retrieved from 2Nantional Center for Injury Prevention and Control. (2011, December). WISQARS Injury Mortality Reports, Atlanta, GA: Centers for Disease Control and Prevention. Retrieved from 7

Suicide Rates by State (2009 Final Data)
Rank State (2008 rank) # Crude Rate Montana Alaska Wyoming Idaho Nevada Colorado New Mexico Oregon Utah Arizona 1, 42. California 3, National Total 36, Source: CDC (2011) 8

US Suicide Rates by Age & Gender
(2009 data) Suicide Rate (per 100, 000) NOTE: yrs,6 suicides in 2009, 4 males, 2 females. Source: CDC (2011) 9

Youth Risk Behavior Survey - 2011
During the 12 months before the survey, what percentage of students engaged in a variety of risky behaviors During the 12 months before the survey, 28.5% of students nationwide had felt so sad or hopeless almost every day for 2 or more weeks in a row that they stopped doing some usual activities (p. 10). Youth Risk Behavior Survey (2012), Male Total Female 10

High School Students who Felt “sad or hopeless”
Percent During the 12 months before the survey, 28.5% of students nationwide had felt so sad or hopeless almost every day for 2 or more weeks in a row that they stopped doing some usual activities (p. 10). Youth Risk Behavior Survey (2012), Male Total Female Youth Risk Behavior Survey (2012) 11

High School Students who “seriously considered attempting suicide”
Percent Nationwide, 15.8% of students had seriously considered attempting suicide during the 12 months before the survey (p. 11). Youth Risk Behavior Survey (2012), Male Total Female Youth Risk Behavior Survey (2012) 12

High School Students who “made a plan about how they would attempt suicide”
Percent During the 12 months before the survey, 12.8% of students nationwide had made a plan about how they would attempt suicide (p. 11). Youth Risk Behavior Survey (2012), Male Total Female Youth Risk Behavior Survey (2012) 13

High School Students who “attempted suicide one or more times”
Percent “Nationwide, 7.8% of students had attempted suicide one or more times during the 12 months before the survey (p.11). Youth Risk Behavior Survey (2012), Male Total Female Youth Risk Behavior Survey (2012) 14

High School Students who “made a suicide attempt that … had to be treated by a doctor or nurse”
Percent “During the 12 months before the survey, 2.4% of students nationwide had made a suicide attempt that resulted in an injury, poisoning, or overdose that had to be treated by a doctor or nurse” (p. 12). Youth Risk Behavior Survey (2012), Male Total Female Youth Risk Behavior Survey (2012) 15

High School Students who Display Suicidal Behaviors
Percent Youth Risk Behavior Survey (2012); Youth Risk Behavior Survey (2012) 16

Suicide Statistics Primary Prevention of Suicide Preventing Suicidal Ideation and Behavior Secondary Prevention of Suicide General Staff Procedures Risk Assessment and Referral Protocol Suicide Postvention

What is the School Psychologist’s role in preventing suicide in schools?
School provides ideal opportunities for quality suicide prevention messages. We are leaders in the school in developing a comprehensive crisis management system KING, K. A., STRUNK, C. M., & SORTER, M. T. (2011). Preliminary Effectiveness of Surviving the Teens® Suicide Prevention and Depression Awareness Program on Adolescents' Suicidality and Self-Efficacy in Performing Help-Seeking Behaviors. Journal Of School Health, 81(9) 18

Primary Prevention: Policy
It is the policy of the Governing Board that all staff members learn how to recognize students at risk, to identify warning signs of suicide, to take preventive precautions, and to report suicide threats to the appropriate parental and professional authorities. Administration shall ensure that all staff members have been issued a copy of the District's suicide prevention policy and procedures. All staff members are responsible for knowing and acting upon them. It is for policy setting institutions, such as school boards, that primary prevention is most important. Originally developed by Jon Sandoval, Jack Davis, and Milt Wilson, this is one example of a possible suicide prevention policy that might be employed by a school district. As you can see it emphasizes early identification of risk indicators, warning signs, and appropriate preventive precautions. It also specified that “procedures” are available. 19

Primary Prevention: Gatekeeper Training
Training natural community caregivers Advantages Reduced risk of imitation Expands community support systems Research is limited but promising Durable changes in attitudes, knowledge, intervention skills A fourth primary prevention option, and the one which receives most of my energy, is gatekeeper training. Expand the number of natural caregivers available to identify and intervene. 20

Primary Prevention: Gatekeeper Training
A Specific Training Program: Applied Suicide Intervention Skills Training Author: Ramsay, Tanney, Tierney, & Lang Publisher: LivingWorks Education, Inc Since 1985, ASIST has been delivered to over one million caregivers in more than 10 countries. Today 5,000 registered trainers deliver ASIST around the world. ASIST is a recognized exemplary program (CDC, 1992). The program has been evaluated by more than 15 independent evaluations. Training for Trainers is a five-day course that prepares local resource persons to be trainers of the ASIST workshop. Around the world, there is a network of active, registered trainers. 21

Primary Prevention: Curriculum
SOS: Depression Screening and Suicide Prevention “The main teaching tool of the SOS program is a video that teaches students how to identify symptoms of depression and suicidality in themselves or their friends and encourages help- seeking. The program's primary objectives are to educate teens that depression is a treatable illness and to equip them to respond to a potential suicide in a friend or family member using the SOS technique. SOS is an action-oriented approach instructing students how to ACT (Acknowledge, Care and Tell) in the face of this mental health emergency.” Evidenced based! Show a reduction in suicide attempts (by 40%) in a randomized controlled study (American Journal of Public Health, March, 2004). 22

Primary Prevention: Screening
School-wide Screening Very few false negatives Many false positives Requires second-stage evaluation Limitations Risk waxes and wanes Principals’ view of acceptability Requires effective referral procedures Possible Tools Suicidal Ideation Questionnaire (William Reynolds, Psychological Assessment Resources) Columbia Teen Screen (Columbia University) Beck Depression Inventory SOS Depression Screening and Suicide Prevention The third primary prevention option available to schools is that of school wide screening. 23

Primary Prevention: Screening
Middle & High School Age Youth Parent Consent and Participant Assent Screening Questionnaire Clinical Interview Parent Notification, Referral and Crisis Management Consent Screening = short set of questions regarding depression/suicide Sx Teens that answer yes to more than a certain number of these questions advance to a short one-on-one interview with a mental health professional to follow-up on the symptoms the teen endorsed and determine if they are experiencing any impairment. Only teens that indicate they might have a problem on the screening questionnaire and are deemed to be at risk by a mental health professional are considered to have “screened positive.” The parents of these teens are informed of the results and are offered a referral for a complete mental health evaluation. Accurately identifies youth who are suffering from mental illness or are at risk of suicide. In a study of approximately 2,000 high school students who participated in TeenScreen, 74% of students who were contemplating suicide and 50% of students who had made a prior suicide attempt were not previously known to be having problems by school personnel. In addition, 69% of students found to be suffering from depression were also unknown. Only 1.6% of suicidal teens identified by TeenScreen in one study who also meet criteria for a clinical diagnosis were already in treatment with a mental health professional. The national Suicide Prevention Resource Center listed the TeenScreen Program as a “Promising Program” on its list of Evidence- Based Practices in Suicide Prevention Programs. Debriefing No Referral 24

Primary Prevention: Suicide Prevention & Crisis Hotlines
Rationale Suicidal ideation is associated with crisis Suicidal ideation is associated with ambivalence Special training is requires to respond to “cries for help” Likely benefit those who use them Limitations Limited research regarding effectiveness Few youth use hotlines Youth are less likely to be aware of hotlines Highest risk youth are least likely to use Logistics of hotlines and the schools may be problematic 25

Primary Prevention: Suicide Prevention & Crisis Hotlines
26

Primary Prevention: Risk Factor Reduction
Restriction of Lethal Means Media Education Postvention Skills Training Restrictions on guns can reduce the overall suicide rate. Restrictive gun laws have their greatest impact on adolescents and young adults. Gun legislation does have an impact on suicide mortality. Given the evidence regarding contagion recent efforts have been undertaken to educated the media Media guidelines for news reporting in Austria = 7% in first year, 20% after 4 years, reduction in suicide rates In the US the CDC recommendations (things to avoid e.g., front page, picture, using the word suicide in the caption). Not studied, but given Austria’s research… Postvention is a topic I will be addressing in detail later. Although, for the purposes of this discussion I will be classifying it as a tertiary prevention strategy, it can also be consider primary prevention in that it aim at preventing suicide. Does not address suicide per se, but rather it focuses on areas that are typically deficient among suicidal youth (e.g., problem solving, coping, and cognitive skills). Communication skills, drug abuse prevention, self-awareness, conflict management are all examples of curricula that may prevent suicide by given youth new skills (or alternatives to suicidal behavior). Ask audience for other examples. Research regarding such skills based prevention curricula is promising 27

Primary Prevention: Risk Factor Reduction
Restriction of Lethal Means: Gun Control Source: 28

Protective factors in preventing suicide
Family support and cohesion, including good communication. Peer support and close social networks. School and community connectedness. Cultural or religious beliefs that discourage suicide and promote healthy living. Adaptive coping and problem-solving skills, including conflict-resolution. General life satisfaction, good self-esteem, sense of purpose. Easy access to effective medical and mental health resources. Source: 29

Suicide Statistics Primary Prevention of Suicide Secondary Prevention of Suicide Suicide Intervention General Staff Procedures Risk Assessment and Referral Protocol Suicide Postvention

Duty to Warn When a student is a danger to self or others there is a duty to warn. Tarasoff v. Regents of the University of California Duty to warn refers to the responsibility to breach confidentiality if a student is in danger. In situations where there is clear evidence of danger to the student or others, the counselor must determine the degree of seriousness of the threat and notify the person in danger and others who are in a position to protect that person from harm. For example, if a student tells the school counselor that another student is planning to commit suicide, the counselor is obliged to investigate and should not leave the indicated student alone until the parents or guardians have arrived. The legal precedent of this concept was set in the case of Tarasoff v. Regents of the University of California (1976). In this case, a University of California student was seeing a psychologist at the university's health center because a young woman named Tatiana Tarasoff had spurned his affections. The psychologist, reasoning that Poddar was dangerous because of his pathological attachment to Tarasoff and because he intended to purchase a gun, notified the police both verbally and in writing. The police questioned Poddar and found him to be rational; they made Poddar promise to stay away from Tarasoff. Two months later, however, Poddar killed Tarasoff. When Tarasoff's parents attempted to sue the University of California, health center staff members, and the police, the courts dismissed the case. The Tarasoff family appealed to the Supreme Court of California, asserting that the defendants had a duty to warn Ms. Tarasoff or her family of the danger and that they should have persisted to ensure [Poddar's] confinement. In a 1974 ruling, the court held that the therapists indeed did have a duty to warn Ms. Tarasoff. When the defendants and several amici curiae [literally, "friends of the court," or entities who file a brief with the court even though they are not parties to the suit] petitioned for a rehearing, the court took the unusual step of granting one. In their second ruling, the court released the police from liability without explanation and more broadly formulated the duty of therapists, imposing a duty to use reasonable care to protect third parties against dangers posed by patients. "The case of Tarasoff v. Regents of the University of California (1976) imposed an affirmative duty on therapists to warn a potential victim of intended harm by the client, stating that the right to confidentiality ends when the public peril begins. This legal decision sets an affirmative duty precedent in cases of harm to others that is generally accepted within the social work profession." According to Davis and Ritchie (1993), this case indicates that "notifying police is not sufficient action to protect the counselor from a lawsuit if the client's threat is carried out" (p. 27).

General Staff Procedures
Responding to a Threat of Suicide. A student who has threatened suicide must be carefully observed at all times until a qualified staff member can conduct a risk assessment. The following procedures are to be followed whenever a student directly or indirectly threatens to commit suicide. Secondary prevention (or suicide intervention) involves more than just being able to identify risk factors and warning signs of suicidal thinking and behavior. It also involves knowing what to do when such indicators are observed. This is were suicide Intervention procedures (such as those alluded to during our discussion of suicide prevention policy) come into play. We will now review a set of procedures which I have developed for responding to suicidal thinking and behaviors. These include both general staff and risk assessment protocols. We begin with a review of the general staff procedures. A threat would include any statement or communication indicating a desire to cause physical harm to oneself. Such threats might include suicide notes, indirect threats, and direct threats. A potential place for students to write suicide notes and reveal suicidal thoughts is in their journals. Written assignments in general are often the sources of suicide notes as well as direct and indirect suicide threats. English teachers need to be especially sensitive to such communications.Indirect threats of suicide often take the form of wishes or desires. However, they clearly indicate that the student feels he or she would be better off if he or she were not alive. Such threats might include the following: "I wish I were dead.", "Everyone would be better off if I weren't around any more.", "If only I could go to sleep and never wake up again.", etc. Direct threats are clear unequivocal statements that the student is considering suicide as a solution to problems. A student making a direct suicide threat might say, "I'm going to kill myself".

Stay with the student or designate another adult staff member to supervise the youth suspected to be at risk for suicide constantly until help arrives. If the student has the means to carry out suicide on his or her person, determine if he or she will voluntarily relinquish it. Do not force the student to do so or place yourself in danger. If the student refuses to relinquish lethal means: Protect yourself and your students. Have the school office call 911. Unless doing so would put yourself or your students in danger do not allow the student to leave the school. 1. Stay with the student or designate another staff member to supervise the youth constantly and without exception until help is obtained. Visual contact with a student who has threatened suicide should be maintained at all times. If at all possible this contact should be maintained by a staff member and not a student. 2. Under no circumstances should you allow the student to leave the school. A student who has threatened suicide should not leave school before the appropriate school professionals have had the opportunity to assess the degree of suicide risk and have ensured that appropriate supervision has been provided. 3. Do not agree to keep a student's suicidal intentions a secret. All staff members have a legal and professional responsibility not to honor confidentiality in any situation where maintaining the confidence might result in harm to a student. No matter how much a student implores you to do so, do not keep a suicide plan a secret. It is clearly better to have a student mad at you for betraying a confidence, than dead because you maintained a confidence. A teacher in this state has been sued by the parents of a 12-year-old student after the teacher was allegedly told by the student that he intended to commit suicide. The teacher did not inform the parents of the students suicidal intent and the suit was brought against the teacher after the student committed suicide. 4. If the student has the means to carry out the threatened suicide on his or her person, determine if he or she will voluntarily relinquish it. Do not force the student to do so. This procedure is in reaction to a court case (Kelson v. City of Springfield, Oregon; 1985 ). This law suite was generated in part by the fact that a student who shot himself at school was never asked to relinquish the gun used in the suicide. Staff members apparently knew that this student was highly suicidal and that he had a gun in his possession. It should, however, be made clear that staff members should never use force to attempt to remove the means of a potential suicide. If a student refuses to voluntarily relinquish the means of his or her threatened suicide, call the police and let them handle the situation. Never put self in danger.

Do not agree to keep a student's suicidal intentions a secret. Take the student to the prearranged room. Notify the Designated Reporter (e.g., school psychologist or counselor). Notify the School Principal (or other designated administrator). Inform the youth that outside help has been called and describe what the next steps will be. 5. Take the suicidal student to the prearranged room. As soon as is possible take the suicidal student to the prearranged, non-threatening room away from other students where there is another adult and a telephone close by. Typically, this room would be the Referral Coordinator's office. 6. Notify the Crisis Intervention Coordinator immediately. Share all relevant information regarding the suicide threat with the CI Coordinator. This individual is usually a school psychologist or a school counselor. The CI Coordinator is the individual responsible for receiving and acting upon all reports from teachers and others about students who may be considering suicide. 7. Notify the Crisis Response Coordinator immediately. It is also important to share all relevant information regarding the suicide threat with the CR Coordinator. This individual is usually the school principal. The CR Coordinator is responsible for notifying the student's parents or legal guardians and describing the problem to them. When appropriate this responsibility may be delegated to someone else (such as the CI Coordinator). 8. Inform the suicidal youth that outside help has been called and describe what the next steps will be. Let the student know that you have informed the CI & CR Coordinators and explain who these individuals are. Tell the student that these individuals will assist in finding help to deal with suicidal thoughts and impulses. Also let the student know that his or her parents/guardians will in all likelyhood need to be contacted. If the student is resistant to the idea of such a contact make sure that this information is relayed to the CR & CI Coordinator's. If you suspect the students resistance to parental contact to be a result of child abuse, a referral to CPS may need to be made While you will not be able to promise that parents will not be informed of the suicidal threats, let the student know his or her concerns regarding parental knowledge have been understood.

Requires that school staff members have… Knowledge of the risk factors the increase the odds of suicide. Variables that should direct our attention. Been trained to identify direct and indirect threats (or warning signs) that indicate the presence of suicide. Variables that should direct our action.

Risk Factors for Suicide Biological Reduced serotongenic activity Situational 40% have identifiable precipitants A firearm in the home By themselves are insufficient Disciplinary crisis most common Biological risk factors. Neurochemical research has found that persons who commit suicide and violent suicide attempters often have a deficit in the functioning of the neurotransmitter serotonin. However, the relationship between reduced serotongenic activity and suicidal behavior is not clear. Situational risk factors. While situational factors are most typically associated with suicidal behavior, they are, by themselves, insufficient to cause this behavior. When combined with other risk factors they create conditions that may lead to suicide. One of the strongest situational risk factors in the United States is the presence of a firearm in the home. Among youth, the most frequent stresses include interpersonal loss or conflict (particularly in romance), economic problems, and legal problems. Incarceration is also a frequent factor in youth suicide . Frequently, a precipitating event will push the teenager "over the edge." As many as 40% of youth suicidal behaviors appear to have identifiable precipitants (e.g., rejection, unwanted pregnancy, poor school performance, fights with friends, dispute and/or break-up with a romantic partner, or problems with parents). The most common event of this type is a disciplinary crisis. 36

Risk Factors for Suicide Psychopathology Associated with 90% of suicides Prior suicidal behavior the best predictor Substance abuse increases vulnerability and can also act as a trigger Familial History Stressor Functioning Biological risk factors. Neurochemical research has found that persons who commit suicide and violent suicide attempters often have a deficit in the functioning of the neurotransmitter serotonin. However, the relationship between reduced serotongenic activity and suicidal behavior is not clear. Situational risk factors. While situational factors are most typically associated with suicidal behavior, they are, by themselves, insufficient to cause this behavior. When combined with other risk factors they create conditions that may lead to suicide. One of the strongest situational risk factors in the United States is the presence of a firearm in the home. Among youth, the most frequent stresses include interpersonal loss or conflict (particularly in romance), economic problems, and legal problems. Incarceration is also a frequent factor in youth suicide . Frequently, a precipitating event will push the teenager "over the edge." As many as 40% of youth suicidal behaviors appear to have identifiable precipitants (e.g., rejection, unwanted pregnancy, poor school performance, fights with friends, dispute and/or break-up with a romantic partner, or problems with parents). The most common event of this type is a disciplinary crisis. 37

Risk Factors for Suicide Adolescence and late life Bisexual or homosexual gender identity Criminal behavior Cultural sanctions for suicide Delusions Disposition of personal property Divorced, separated, or single marital status Early loss or separation from parents Family history of suicide Hallucinations Homicide Hopelessness Hypochondriasis In one study, about half the kids who were at-risk had a parent (same sex) who had attempted also When interviewing for possible suicide, also ask about homicidal thoughts Hopeless and impulsivity are two major things for kids Living alone is especially important if male Most of the reputable researchers do not feel that the scales are very good – use them only as a guide 38

Warning Signs for Suicide Verbal Most individuals give verbal clues that they have suicidal thoughts. Clues include direct ("I have a plan to kill myself”) and indirect suicide threats (“I wish I could fall asleep and never wake up”). Behavioral Knowledge of warning signs is a suicide intervention prerequisite. Effective school intervention plans need to ensure that students, parents, and school personnel are knowledgeable of warning signs and instructed on how to refer the individual for appropriate assessment. Specific warning signs of youth suicide include the following: Individual who are thinking about suicide usually give signals. Four out of five suicide victims display warning signs, often providing verbal clues. Elementary students provide clues to their intentions through their behavior. 39

Verbal Warnings Signs of Suicide “Everybody would be better off if I just weren’t around.” “I’m not going to bug you much longer.” “I hate my life. I hate everyone and everything.” “I’m the cause of all of my family’s/friend’s troubles.” “I wish I would just go to sleep and never wake up.” “I’ve tried everything but nothing seems to help.” “Nobody can help me.” “I want to kill myself but I don’t have the guts.” “I’m no good to anyone.” “If my (father, mother, teacher) doesn’t leave me alone I’m going to kill myself.” “Don’t buy me anything. I won’t be needing any (clothes, books).” Warning signs that suicidal students may verbalize to staff or other adults. Staff should be trained to watch for these particular warning signs. 40

Behavioral Warning Signs of Suicide Writing of suicidal notes Making final arrangements Giving away prized possessions Talking about death Reading, writing, and/or art about death Hopelessness or helplessness Social Withdrawal and isolation Lost involvement in interests & activities Increased risk-taking Heavy use of alcohol or drugs In addition to notes and threats, additional, specific warning signs are presented in this overhead, with the most dangerous warning signs listed first. Notes Making funeral arrangements, writing a will, paying debts, saying good-bye, etc. could be signs a youth is suicidal. In effect, the youth is executing a will. This could be a sign the youth is exploring death as a solution to problems. Sometimes warnings include writing death poems or filling sheets of paper with macabre drawings. A youth who feels there is no hope problems will improve and who feels helpless to change things may consider suicide. These behaviors may be a sign of depression, and may be a precursor of suicide. Withdrawal and isolation may be a sign of depression A youth who is considering suicide may see no purpose in continuing previously important interests and activities. Youths who choose high-risk sports, dare-devil hobbies, and other unnecessarily dangerous activities may be suicidal. Substance abusers have a 6 times greater risk for suicide than the general population. 41

Behavioral Warning Signs of Suicide (cont.) Abrupt changes in appearance Sudden weight or appetite change Sudden changes in personality or attitude Inability to concentrate/think rationally Sudden unexpected happiness Sleeplessness or sleepiness Increased irritability or crying easily Low self esteem Youths who no longer care about their appearance may be suicidal. These changes may be a sign of depression that can increase the risk of suicide. The shy youth who suddenly becomes a thrill- seeker or the outgoing person who becomes withdrawn and unfriendly may be giving signals that something is seriously wrong. This inability may be a sign of depression or other mental illness and may increase the risk of suicide. Sudden happiness, especially following prolonged depression, may indicate the person is profoundly relieved after having made a decision to commit suicide. This behavior may be a sign of depression and may increase the risk of suicide. Depressed, stressed, and potentially suicidal youths demonstrate wide mood swings and unexpected displays of emotion. Youths with low self esteem consider suicide. 42

Behavioral Warning Signs of Suicide (cont.) Dwindling academic performance Abrupt changes in attendance Failure to complete assignments Lack of interest and withdrawal Changed relationships Despairing attitude Question unexpected and sudden decrease in performance Remain alert to excessive absenteeism in a student with a good attendance record, particularly when the change is sudden. Sudden failure is often seen in depressed and suicidal students. One of the first signs of a potentially suicidal youth is withdrawal, disengagement, and apathy. A sudden lack of interest in extra-curricular activities may be seen. Evidence of personal despair may be abrupt changes in social relationships. Students may make comments about being unhappy, feeling like a failure, not caring about the future, or even not caring about living or dying. 43

Suicide Statistics Primary Prevention of Suicide Secondary Prevention of Suicide Preventing Suicidal Behavior General Staff Procedures Risk Assessment and Referral Protocol Suicide Postvention

Risk Assessment and Referral Protocol
Whenever a student judged to have some risk of engaging in self-directed violence or suicide, a school-based mental health professional should conduct a risk assessment and make the appropriate referrals. Identify Assess Consult Refer Goal: To prevent the immediate risk of injury by a person who has conscious thoughts of violence. A form of first aid, thus an appropriate tool for any caregiver. Has 4general steps…. Identify violent thoughts. Assesses risk of engaging in a behavior. Consult with others about assessment findings. Make appropriate referrals to address violent thinking and any associated risk of violent behavior.

Identify suicidal thoughts. Conduct a risk assessment and make appropriate referrals. Consult with fellow school staff members regarding the risk assessment and referral options. Consult with County Mental Health regarding the risk assessment and referral options. As indicated, consult with local law enforcement about referral options.

Use risk assessment information and consultation guidance to develop an action plan. Action plan options are as follows: A. Extreme Risk If the student has the means of his or her threatened suicide at hand, and refuses to relinquish such then follow the Extreme Risk Procedures. B. Crisis Intervention Referral If the student's risk of suicide is judged to be moderate to high, but means of violence are not at hand, then follow the Crisis Intervention Referral Procedures. C. Mental Health Referral If the student's risk of suicide is judged to be low and means of violence are not at hand, then follow the Mental Health Referral Procedures.

A. Extreme Risk Have school administration call the police. If it is judged safe to do so, attempt to calm the student by talking and reassuring him or her until the police arrive. If it is judged safe to do so, continue to request that the student relinquish the means his or her threatened suicide and try to prevent the student from harming self or others. Call the parents and inform them of the actions taken.

B. Crisis Intervention Referral Determine if the student's distress is the result of parent or caretaker abuse, neglect, or exploitation. Meet with the student's parents or caregivers. Determine what to do if the parents or caregivers are unable or unwilling to assist with the crisis. Make appropriate referrals.

C. Mental Health Referral Determine if the student's distress is the result of parent or caretaker abuse, neglect, or exploitation. Meet with the student's parents or caregivers. Make appropriate referrals. Protect the privacy of the student and family. Follow-up with the referral resources (e.g., hospital or clinic).

Suicide Risk Assessment
Asking the “S” Question The presence of suicide warning signs, especially when combined with suicide risk factors generates the need to conduct a suicide risk assessment. Risk assessment begins with asking if the student is having thoughts of suicide.

Its Your Turn…. Imagine you are working with a student that may be suicidal. How you would ask the question.

Identification of Suicidal Intent Be direct when asking the “S” question. BAD  You’re not thinking of hurting yourself, are you? Better  Are you thinking of harming yourself? BEST  Sometimes when people have had your experiences and feelings they have thoughts of suicide. Is this something that you’re thinking about? How did you do? This typically involves asking a direct question about the person-at-risk’s conscious thoughts of suicide. Overwhelming stressors that generate reported feelings of helplessness and hopelessness provide the caregiver with the reason for asking the “S question.” In asking the “S question” it is critical to be direct.

Predicting Suicidal Behavior (CPR++): Current Factors Current plan (greater planning = greater risk). How (method of attempt)? How soon (timing of attempt)? How prepared (access to means of attempt)? Pain (unbearable pain = greater risk) How desperate to ease the pain? Person-at-risk’s perceptions are key Resources (more alone = greater risk) Reasons for living/dying? Can be very idiosyncratic Information obtained from the risk assessment is critical in developing a plan of action. C P R Source: Ramsay, R. F., Tanney, B. L., Lang, W. A., & Kinzel, T. (2004). ASIST Trainer’s Manual. Calgary, AB: LivingWorks Education, Inc. Ramsay, Tanney, Lang, & Kinzel (2004)

Predicting Suicidal Behavior (CPR++): Historical Factors (+) Prior Suicidal Behavior? of self (40 times greater risk) of significant others An estimated 26-33% of adolescent suicide victims have made a previous attempt (American Foundation or Suicide Prevention, 1996). (+) Mental Health Status? history mental illness (especially mood disorders) linkage to mental health care provider Source: Ramsay, R. F., Tanney, B. L., Lang, W. A., & Kinzel, T. (2004). ASIST Trainer’s Manual. Calgary, AB: LivingWorks Education, Inc. Ramsay, Tanney, Lang, & Kinzel (2004)

Standardized Risk Screening Tools Beck Scale for Suicidal Ideation (BSI) 21 item self-report for adolescents Best to detect and measure severity of ideation One of only scales to assess active and passive ideation Suicidal Ideation Questionnaire (SIQ) Severity or seriousness of ideation Two version for 7-9th and 10-12th grades Draw-back: No item regarding past or current suicide attempts

Suicide Risk Assessment Summary

Responding to At-Risk Youth
Teach appropriate behavior and social problem-solving skills in the classroom or in a small group setting. Additional problems or risk factors are addressed through determining student and family needs. Referrals made to appropriate support systems. Protective factors for student are analyzed and provisions made to continue or to add to these factors, which provide support for the at-risk student. For example, provide an adult mentor who meets periodically with the student. Based on the survey or screenings, the following could be used to respond to suicidal youth who are at risk, or high risk What is the difference between “at-risk” and “high risk?” Appearance vs. Behavior Interventions will depend upon assessed risk level.

Responding to High Risk Youth
Determine if there are any imminent warning signs. If there are, then refer student for an immediate suicide and/or homicide risk assessment. If imminent warning signs are not present, then give the student a high priority for a Student Success Team Meeting. Assign a Student Success Team member (e.g., principal, school psychologist, or teacher) to provide informal consultation until a formal meeting may be scheduled. At the SST meeting, develop recommendations for responding to high-risk youth and consider the need for a referral for Special Education services. Consider a referral to school site mental health and community-based mental health services. Determine if there are any imminent warning signs (the high risk factors discussed earlier). If there are, then refer student to the Risk Assessment Team for an immediate suicide and/or homicide risk assessment. 2If imminent warning signs are not present, then give the student a high priority for a Student Support Meeting. Assign a Student Support Team member (e.g., principal, mental health specialist, or master teacher) to provide informal consultation until a formal meeting may be scheduled. At the formal meeting, develop recommendations for responding to high-risk youth and consider the need for a referral for Special Education services. Consider a referral to school site mental health and community-based mental health services.

Responding to High Risk Youth
Consider the need to revise student’s behavior contract and/or to conduct a more in-depth functional assessment. Obtain parental permission to exchange information with the appropriate community agencies to determine if student is eligible for additional services. If available, call a meeting with other agency personnel to focus on provisions for wrap-around intervention and support for the student and family. Develop an action plan for immediate interventions that includes provisions for increased supervision. Consider the need to revise student’s behavior contract and/or to conduct a more in-depth behavioral analysis. Obtain parental permission to exchange information with the appropriate community agencies to determine if student is eligible for additional services. If available, call a meeting with other agency personnel to focus on provisions for wrap-around intervention and support for the student and family. Develop an action plan for immediate interventions that includes provisions for increased supervision. Note. Adapted from Dwyer and Osher

Suicide Statistics Primary Prevention of Suicide Secondary Prevention of Suicide General Staff Procedures Risk Assessment and Referral Protocol Suicide Postvention

School Suicide Postvention
“… the largest public health problem is neither the prevention of suicide nor the management of suicide attempts, but the alleviation of the effects of stress on the survivors whose lives are forever altered.” E.S. Shneidman Forward to Survivors of Suicide Edited by A. C. Cain Published by Thomas, 1972

Key Terms and Statistics Suicide postvention … is the provision of crisis intervention, support and assistance for those affected by a completed suicide. Affected individuals includes both “survivors” and other persons who were “exposed” to the death. Andriessen, K., & Krysinska, K. (2012). Essential questions on suicide bereavement and postvention. International Journal of Environmental Research and Public Health, 9, doi: /ijerph Andriessen & Krysinska (2012)

Key Terms and Statistics Survivors of suicide “the family members and friends who experience the suicide of a loved one” (McIntosh, 1993, p. 146). “a person who has lost a significant other (or a loved one) by suicide, and whose life is changed because of the loss” (Andriessen, 2009, p. 43). “… someone who experiences a high level of self-perceived psychological, physical, and/or social distress for a considerable length of time after exposure to the suicide of another person” (Jordan & McIntosh, 2011, p. 7). McIntosh, J. Control group studies of suicide survivors: A review and critique. Suicide Life Threat. Behav. 1993, 23, Andriessen, K. Can postvention be prevention? Crisis 2009, 30, Jordan, J.R.; McIntosh, J.L. Suicide Bereavement: Why Study survivors of Suicide Loss? In Grief after Suicide; Jordan, J.R., McIntosh, J.L., Eds.; Routledge: New York, NY, USA, 2011; pp

Key Terms and Statistics How many survivors of suicide are there? Estimates vary greatly Shneidman (1969) = 6 per suicide Wrobleski (2002) = 10 per suicide Berman (2011) = per suicide X , = N of Survivors per suicide Completed Suicides Suicide Survivors (U.S. 2009) Berman, A.L. Estimating the population of survivors of suicide: Seeking an evidence base. Suicide Life Threat. Behav. 2011, 41, The first systematic estimation of the number of suicide survivors, a survey among members of suicide survivor support groups [4], found that the number varied considerably depending on the type of the relationship, the frequency of contact between the deceased and the bereaved, and the age of the deceased. For example, parents who lost a child by suicide estimated that the death has left 80 suicide survivors behind, the spouses and/or partners of the suicides estimated the number at 60, while siblings and/or friends at 45–50. Shneidman, E. Prologue: Fifty-Eight Years. In On the Nature of Suicide; Shneidman, E.S., Ed.; Jossey-Bass: San Francisco, CA, USA, 1969; pp Wrobleski, A. Suicide Survivors: A Guide for Those Left Behind; SAVE: Minneapolis, MN, USA, 2002. N = 6 = 221,454 in 2009 N = 10 = 369,090 N = 80 to 45 = 2,953,720 to 1,660,905 (according to this survey of suicide survivor support group members. 288 x 80 = 23,040 OK in the decade who can be considered survivors of youth (15-19 years) suicide.

Key Terms and Statistics There is a distinction between “suicide survivorship” and “exposure to suicide.” Survivor applies to bereaved persons who had a personal/close relationship with the deceased. Exposure applies to persons who did not know the deceased personally, but who know about the death through reports of others or media reports or who has personally witnessed the death of a stranger. Andriessen, K., & Krysinska, K. (2012). Essential questions on suicide bereavement and postvention. International Journal of Environmental Research and Public Health, 9, doi: /ijerph There is a distinction between “suicide survivorship” and “exposure to suicide” [2-5]. The former applies to the bereaved who had a personal and close relationship with the deceased (e.g., a friend or a family member), the latter reflects a situation of a person who did not know the deceased personally but who knows about the death through reports of others or media reports (e.g., suicide of a celebrity) or who has personally witnessed the death of a stranger (e.g., train drivers or police). The metaphor of a stone thrown into a lake reflects well the wide-reaching impact of suicide. It causes many ripples which turbulently affect the water’s surface. The big challenge for effective postvention is ensuring that every survivor, from the close family members and friends to those indirectly exposed to suicide, can receive help and support they need. Provision of timely and adequate services for the bereaved requires also a good understanding of the bereavement process and the needs of the survivors as a group as well as acknowledging the individual differences between the bereaved. Andriessen & Krysinska (2012)

Key Terms and Statistics Both survivors and educators need support. Survivors need… support groups. support from outside of the family. to be educated about the complicated dynamics of grieving. to be contacted in person (instead of by letter or phone). Grad et al. (2004)

Special Issues in Postvention
Factors that make the postvention response a special and unique form of crisis intervention. Suicide contagion A special form of bereavement Social stigma Developmental differences Cultural differences Suicide contagion “…a process by which exposure to the suicide or suicidal behavior of one or more persons influences others to commit or attempt suicide.” “The effect of clusters appears to be strongest among adolescents.” Sonneck et al. (1994). “Surveyed all suicide cases in Vienna, Austria that were reported in major daily newspapers and analyzed them in connection with subway suicide. …. The number of subway suicides in Vienna increased dramatically between 1984 and mid Based on the hypothesis that there was a connection between the dramatic way in which these suicides were reported and an increase in suicides and suicide attempts, the Austrian Association for Suicide Prevention developed media guidelines and initiated discussions with the media that culminated with an agreement to abstain from reporting on cases of suicide. Following the implementation of these guidelines in mid-1987, there was a 75% decrease in subway suicides that has been sustained for 5 yrs. Suicide rates increase when … The number of stories about individual suicides increases A particular death is reported at length or in many stories The story of an individual death by suicide is placed on the front page or at the beginning of a broadcast The headlines about specific suicide deaths are dramatic Survivors report … Guilt and shame More depression and complicated grief Less vitality and more pain Social stigma, isolation, and loneliness Poorer social functioning, and physical/mental health Searching for the meaning of the death Being concerned about their own increase suicide risk Multiple levels of grief reactions Common grief reactions e.g., sorrow, yearning to be reunited Unexpected death reactions e.g., shock, sense of unreality Violent death reactions e.g., traumatic stress Unique suicide reactions e.g., anger at deceased, feelings of abandonment Both students and staff members may be uncomfortable talking about the death. Survivors may receive (and/or perceive) much less social support for their loss. Viewed more negatively by others as well as themselves. There may exist a reluctance to provide postvention services. American Foundation for Suicide Prevention (2001); Cain (1972); De Groot et al. (2006); Jordan & McIntosh (2011); Jordan (2001); Mishara (1999); O’Carroll & Potter (1994); Ramsay et al. (1999); Roberts et al. (1998); Sonneck et al. (1994)

Suicide Clusters Suicide contagion
Number of Suicides Population Suicide contagion CA youth committed suicide (ages 15-19) A state-wide average of 140 suicides per year Among year olds, a state-wide average annual rate of 5 per 100,000 individuals. A 1,000 student high school can expect a completed suicide once every 20 years. A 2,000 student high school can expect a completed suicide once every 10 years. x selected proportion of population = Rate 140 2,823,940 x 100,000 = 5 140 2,823,940 x 1,000 = A suicide cluster may be defined as a group of suicides or suicide attempts, or both, that occur closer together in time and space than would normally be expected in a given community. A statistical analysis of national mortality data indicates that clusters of completed suicide occur predominantly among adolescents and young adults, and that such clusters account for approximately 1%-5% of all suicides in this age group (1). Suicide clusters are thought by many to occur through a process of "contagion," but this hypothesis has not yet been formally tested (2,3). Nevertheless, a great deal of anecdotal evidence suggests that, in any given suicide cluster, suicides occurring later in the cluster often appear to have been influenced by suicides occurring earlier in the cluster. Ecologic evidence also suggests that exposure of the general population to suicide through television may increase the risk of suicide for certain susceptible individuals (4,5), although this effect has not been found in all studies (6,7). Gould MS, Wallenstein S, Kleinman M. A Study of time-space clusteing of suicide. Final report. Atlanta, Georgia: Centers for Disease Control, September 1987; (contract no. RFP ). A statistical analysis of national mortality data indicates that clusters of completed suicide occur predominantly among adolescents and young adults, and that such clusters account for approximately 1%-5% of all suicides in this age group US Census Beuro Took the last five years of year old suicides (150 in 2006, 122 in 2007, 134 in 2008, 144 in 2009, and 150 in 2010) and added them together and then divided by 5 to get the five year average. Then divided that number by the 2010 US Census Bureau figures for year-olds in CA (2,823,940) Then multiplied that by a given number = annual rate of expected suicides 140 = 5 year average ( ) 2,823,940 (2010 pop ages 15-19) 15-19 OK Males, = 248 suicides (population = 1,486,820) 15-19 OK Females, = 40 suicides (population = 1,388,440) 288/2,875,260 = x 100,000 = average annual suicide rate (per 100,000 teens) 288/2,875,260 = x 1,000 = 0.1 average annual suicide rate (per 1,000 teens). (0.1 X 10 = 1) 288/2,875,260 = x 2,000 = 0.2 average annual suicide rate (per 1,000 teens). (0.2 X 5 = 1) 140 2,823,940 x 2,000 = 0.1 Kidsdata.org (2012); US Census Bureau (2012)

Suicide Clusters Suicide contagion
Percent of CA high school students with a self- reported attempt (in the 12 months prior to survey) that required medical attention. 3.35% of population = overall average of attempts in these areas in 2011 Just more that 3 serious attempts (in a 12 month period) for every 100 CA high schoolers. For every 100 students in a school’s population one might expect a serious attempt every 4 months. For every 100 student in a school’s population one might expect at least 3 serious attempts every 12 months For every 1000 students in a school’s population one might expect at least 33 serious attempts every 12 months (or about 3, 2.79 to be exact, attempts per month). Bottom line…. More than one completed suicides in a given year -or- More than 33 serious suicide attempts per year (or more than 3 per month, 33/12=2.79) in a typical 1,000 student high school ( x 1,000). or 67 serious suicide attempts per year (or more than 6 per month, 67/12= 5.5) in a typical 2,000 student high school ( x 2,000) in a given year -may be- an indication of a suicide cluster/contagion. CDC (2012, June 8)

Postvention Protocol 1. Verify the death 2. Mobilize the Crisis Team
3. Assess impact & determine response 4. Notify affected school staff members 5. Contact the deceased’s family 6. Determine what to share 7. Determine how to inform others 8. Identify crisis intervention priorities 9. Faculty planning session 10. Provide crisis intervention services 11. Ongoing daily planning sessions 12. Memorials 13. Debrief American Foundation for Suicide Prevention et al. (2011).

Postvention Protocol Verify that a death has occurred
Confirm the cause of death Confirmed suicide Unconfirmed cause of death Confirm the Cause of Death The school’s principal or superintendent should first check with the coroner and/or the medical examiner’s office (or, if necessary, local law enforcement) to ascertain the official cause of death. If the death has been ruled a suicide, the school can proceed to communicate as described in the crisis response section. If the Cause of Death Is Unconfirmed If the body has not yet been recovered or if there is an ongoing investigation, schools should state that the cause of death is still being determined and that additional information will be forthcoming once it has been confirmed. Acknowledge that there are rumors (which are often inaccurate), and remind students that rumors can be deeply hurtful and unfair to the missing/ deceased person, their family, and their friends. If there is an ongoing investigation, schools should check with local law enforcement before speaking about the death with students who may need to be interviewed by the authorities. Brock (2002)

Postvention Protocol Mobilize the crisis response team Brock (2002)
Preparedness is essential. Once a suicide death has been confirmed, the school should immediately implement a coordinated crisis response in order to effectively manage the situation, provide opportunities for grief support, maintain an environment focused on normal educational activities, help students cope with their feelings, and minimize the risk of suicide contagion. What follows can be used by any school, regardless of whether there is a pre-existing Crisis Response Plan in place. KEY CONSIDERATIONS The Crisis Response Team Leader (usually the school psychologist or counselor) has overall responsibility for the duration of the crisis. She or he should immediately assemble a Crisis Response Team, which will be responsible for implementing the various elements of the crisis response. The Crisis Response Team should be composed of at least five or six (but no more than 15) people chosen for their skills, credentials, and ability to work compassionately and effectively under pressure—ideally a combination of administrators, counselors, social workers, psychologists, nurses, and/or school resource officers. It can also be useful to include a member of the school’s information technology or computer lab staff. The Crisis Response Team Leader should designate one individual as the Team Coordinator. Crisis Response Team Leader’s Checklist • Inform the school superintendent of the death. • Contact the deceased’s family to offer condolences, inquire what the school can do to assist, discuss what students should be told, and inquire about funeral arrangements. • Call an immediate meeting of the Crisis Response Team to assign responsibilities. • Establish a plan to immediately notify faculty and staff of the death via the school’s crisis alert system (usually phone or ). • Schedule an initial all-staff meeting as soon as possible (ideally before school starts in the morning). • Arrange for students to be notified of the death in small groups such as homerooms or advisories (not by overhead announcement or in a large assembly) and disseminate a death notification statement for students to homeroom teachers, advisors, or others leading those groups. • Draft and disseminate a death notification statement for parents. • Disseminate handouts on Facts About Suicide and Mental Disorders in Adolescents and Talking About Suicide to faculty. • Speak with school superintendent and Crisis Response Team Coordinator throughout the day. • Determine whether additional grief counselors, crisis responders, or other resources may be needed from outside the school. Team Coordinator’s Checklist The tasks below may be delegated as appropriate to specific staff or faculty in the school. • Conduct initial all-staff meeting. • Conduct periodic meetings for the Crisis Response Team members. • Monitor activities throughout school, making sure teachers, staff, and Crisis Response Team members have adequate support and resources. • Plan parent meeting if necessary. • Assign roles and responsibilities to Crisis Response Team members in the areas of Safety, Operations, Community Liaisons, Funeral, Media Relations, and Social Media. Safety • Keep to regular school hours. • Ensure that students follow established dismissal procedures. • Call on school resource officers or plant manager to assist parents and others who may show up at the school and to keep media off of school grounds. • Pay attention to students who are having particular difficulty, including those who may be congregating in hallways and bathrooms, and encourage them to talk with counselors or other appropriate school personnel. Operations • Assign a staff or faculty member to follow the deceased student’s schedule to monitor peer reactions and answer questions. • If possible, arrange for several substitute teachers or “floaters” from other schools within the district to be on hand in the building in case teachers need to take time out of their classrooms. • Arrange for crisis counseling rooms for staff and students. • Provide tissues and water throughout the building and arrange for food for faculty and crisis counselors. • Work with administration, faculty, and counselors to identify individuals who may be having particular difficulty, such as family members, close friends, and teammates; those who had difficulties with the deceased; those who may have witnessed the death; and students known to have depression or prior suicidality; and work with school counseling staff to develop plans to provide psychological first aid to them. • Prepare to track and respond to student and/or family requests for memorialization. Community Liaisons • Several Team members will be needed, each serving as the primary contact for working with community partners of various types, including: ❍ coroner/medical examiner, to ensure accuracy of information disseminated to school community ❍ police, as necessary, to ensure student safetyAFSP & SPRC: A F T E R A S U I C I D E | A T o o l k i t f o r S c h o o l s ❍ mayor’s office and local government, to facilitate community-wide response to the suicide death ❍ mental health and medical communities, as well as grief support organizations, to plan for service needs ❍ arranging for outside trauma responders and briefing them as they arrive on scene Funeral • Communicate with the funeral director about logistics, including the need for crisis counselors and/or security to be present at the funeral. Encourage family to consider holding the funeral off school grounds and outside of school hours if at all possible. • Discuss with the family the importance of communicating with clergy or whomever will be conducting the funeral to emphasize the importance of connecting suicide to underlying mental health issues (such as depression) and not romanticizing the death in ways that could risk contagion. • Depending on the family’s wishes, help disseminate information about the funeral to students, parents and staff, including: ❍ location ❍ time of the funeral (keep school open if the funeral is during school hours) ❍ what to expect (for example, whether there will be an open casket) ❍ guidance regarding how to express condolences to the family ❍ policy for releasing students during school hours to attend (i.e., students will be released only with permission of parent, guardian, or designated adult) • Work with school counselors and community mental health professionals to arrange for counselors to attend the funeral. • Encourage parents to accompany their child to the funeral. Media Relations • Prepare a media statement. • Designate a media spokesperson who will field media inquiries utilizing Key Messages for Media Spokesperson document. • Advise staff that only the media spokesperson is authorized to speak to the media. • Advise students to avoid interviews with the media. • Refer media outlets to Reporting on Suicide: Recommendations for the Media. Social Media • Oversee school’s use of social media as part of the crisis response. • Consider convening a small group of the deceased’s friends to work with school administration to monitor social networking sites and other social media. Brock (2002)

Postvention Protocol Assess the suicide’s impact on the school and estimate the level of response required. The importance of accurate estimates. Make sure a postvention is truly needed before initiating this intervention. Temporal proximity to other traumatic events (especially suicides). Timing of the suicide. Physical and/or emotional proximity to the suicide. Ironically those at greatest risk for developing psychiatric disturbances (e.g., PTSD), don’t appear to be at greater risk than others for becoming a part of a suicide cluster. It has been speculated that emotional proximity increases awareness of the negative effects of suicide on survivors. Brock (2002)

Postvention Protocol Notify other involved school staff members.
Deceased student’s teachers (current an former) Any other staff members who had a relationship with the deceased Teachers and staff who work with suicide survivors. Brock (2002)

Brock (2002); American Foundation for Suicide Prevention et al. (2011)
Postvention Protocol Contact the family of the suicide victim. Purposes include... Express sympathy and offer support. Identify the victim’s friends/siblings who may need assistance. Discuss the school’s response to the death. Identify details about the death could be shared with outsiders. If the Family Does Not Want the Cause of Death Disclosed While the fact that a student has died may be disclosed immediately, information about the cause of death should not be disclosed to students until the family has been consulted. If the death has been declared a suicide but the family does not want it disclosed, someone from the administration or counseling staff who has a good relationship with the family should be designated to contact them to explain that students are already talking about the death amongst themselves, and that having adults in the school community talk to students about suicide and its causes can help keep students safe. If the family refuses to permit disclosure, schools can state, “The family has requested that information about the cause of death not be shared at this time” and can nevertheless use the opportunity to talk with students about the phenomenon of suicide: “We know there has been a lot of talk about whether this was a suicide death. Since the subject of suicide has been raised, we want to take this opportunity to give you accurate information about suicide in general, ways to prevent it, and how to get help if you or someone you know is feeling depressed or may be suicidal.” p. 9 Brock (2002); American Foundation for Suicide Prevention et al. (2011)

Postvention Protocol Determine what information to share about the death Several different communications may be necessary When the death has been ruled a suicide When the cause of death is unconfirmed When the family has requested that the cause of death not be disclosed Templates provided in After a Suicide: A Toolkit for Schools” keeping in mind that long delays in sharing facts will fuel harmful rumors. Option 1 – When the death has been ruled a suicide It is with great sadness that I have to tell you that one of our students, _________, has taken [his/her] own life. All of us want you to know that we are here to help you in any way we can. A suicide death presents us with many questions that we may not be able to answer right away. Rumors may begin to circulate, and we ask that you not spread rumors you may hear. We’ll do our best to give you accurate information as it becomes known to us. Suicide is a very complicated act. It is usually caused by a mental disorder such as depression, which can prevent a person from thinking clearly about his or her problems and how to solve them. Sometimes these disorders are not identified or noticed; in other cases, a person with a disorder will show obvious symptoms or signs. One thing is certain: there are treatments that can help. Suicide should never, ever be an option. Each of us will react to _____’s death in our own way, and we need to be respectful of each other. Feeling sad is a normal response to any loss. Some of you may not have known ______very well and may not be as affected, while others may experience a great deal of sadness. Some of you may find you’re having difficulty concentrating on your schoolwork, and others may find that diving into your work is a good distraction. We have counselors available to help our school community deal with this sad loss and to enable us to understand more about suicide. If you’d like to talk to a counselor, just let your teachers know. Please remember that we are all here for you. Option 2 – When the cause of death is unconfirmed It is with great sadness that I have to tell you that one of our students, _________, has died. All of us want you to know that we are here to help you in any way we can. The cause of death has not yet been determined by the authorities. We are aware that there has been some talk about the possibility that this was a suicide death. Rumors may begin to circulate, and we ask that you not spread rumors since they may turn out to be inaccurate and can be deeply hurtful and unfair to _______ as well as [his/her] family and friends. We’ll do our best to give you accurate information as it becomes known to us. Each of us will react to _____’s death in our own way, and we need to be respectful of each other. Feeling sad is a normal response to any loss. Some of you may not have known _____ very well and may not be as affected, while others may experience a great deal of sadness. Some of you may find you’re having difficulty concentrating on your schoolwork, and others may find that diving into your work is a good distraction. We have counselors available to help our school community deal with this sad loss. If you’d like to talk to a counselor, just let your teachers know. Option 3 – When the family has requested that the cause of death not be disclosed The family has requested that information about the cause of death not be shared at this time. We are aware that there has been some talk about the possibility that this was a suicide death. Rumors may begin to circulate, and we ask that you not spread rumors since they may turn out to be inaccurate and can be deeply hurtful and unfair to ______ as well as [his/her] family and friends. We’ll do our best to give you accurate information as it becomes known to us. Since the subject has been raised, we do want to take this opportunity to remind you that suicide, when it does occur, is a very complicated act. It is usually caused by a mental disorder such as depression, which can prevent a person from thinking clearly about his or her problems and how to solve them. Sometimes these disorders are not identified or noticed; in other cases a person with a disorder will show obvious symptoms or signs. One thing is certain: there are treatments that can help. Suicide should never, ever be an option. Each of us will react to _____’s death in our own way, and we need to be respectful of each other. Feeling sad is a normal response to any loss. Some of you may not have known ______very well and may not be as affected, while others may experience a great deal of sadness. Some of you may find you’re having difficulty concentrating on your schoolwork, and others may find that diving into your work is a good distraction. We have counselors available to help our school community deal with this sad loss. If you’d like to talk to a counselor, just let your teachers know. Brock (2002); American Foundation for Suicide Prevention et al. (2011)

Postvention Protocol Determine what information to share about the death Avoid detailed descriptions of the suicide including specific method and location. Avoid over simplifying the causes of suicide and presenting them as inexplicable or unavoidable. Avoid using the words “committed suicide” or “failed suicide.” Always include a referral phone number and information about local crisis intervention services Emphasize recent treatment advances for depression and other mental illness. keeping in mind that long delays in sharing facts will fuel harmful rumors. Avoid detailed descriptions of the suicide including specific method and location. Detailed descriptions increase the risk of a vulnerable individual imitating the act. Avoid over simplifying the causes of suicide and presenting them as inexplicable or unavoidable. Doing so may cause vulnerable individuals to think of it as a common response. Research shows that more that 90% of suicide victims have a mental illness. Present it as a poor choice that was preventable. Avoid using the words “committed suicide” or “failed suicide.” The verb “committed” is usually associated with sins or crimes. Suicide is better understood in a behavioral health context. Consider the phrase “died by suicide” or “non-fatal suicide attempt.” Always include a referral phone number and information about local crisis intervention services The National Suicide Prevention Lifeline toll-free number, TALK, is available 24/7. It connects the caller to a certified crisis center near where the call is placed. Emphasize recent treatment advances for depression and other mental illness. This is likely associated with decreasing trends in suicide since 1990. Brock (2002); American Foundation for Suicide Prevention et al. (2011)

Postvention Protocol Determine how to share information about the death. Reporting the death to students... Avoid tributes by friends, school wide assemblies, sharing information over PA systems that may romanticize the death Positive attention given to someone who has died (or attempted to die) by suicide can lead vulnerable individuals who desire such attention to take their own lives. Provide information in small groups (e.g., classrooms). Brock, 2002

Brock, 2002; American Foundation for Suicide Prevention et al. (2011)
Postvention Protocol Determine how to share information about the death. Reporting the death to the media... It is essential that the media not romanticize the death. The media should be encouraged to acknowledge the pathological aspects of suicide. Photos of the suicide victim should not be used. “Suicide" should not be placed in the caption . Include information about the community resources. Sample media statement provided in “After a Suicide: A Toolkit for Schools” Sample Media Statement To be provided to local media outlets either upon request or proactively. School personnel were informed by the coroner’s office that a [__]-year-old student at [________] school has died. The cause of death was suicide. Our thoughts and support go out to [his/her] family and friends at this difficult time. The school will be hosting a meeting for parents and others in the community at [date/time/location]. Members of the school’s Crisis Response Team [or mental health professionals] will be present to provide information about common reactions following a suicide and how adults can help youths cope. They will also provide information about suicide and mental illness in adolescents, including risk factors and warning signs of suicide, and will address attendees’ questions and concerns. A meeting announcement has been sent to parents, who can contact school administrators or counselors at [number] or [ address] for more information. Trained crisis counselors will be available to meet with students and staff starting tomorrow and continuing over the next few weeks as needed. Suicide Warning Signs These signs may mean someone is at risk for suicide. Risk is greater if a behavior is new or has recently increased in frequency or intensity, and if it seems related to a painful event, loss, or change. • Talking about wanting to die or kill oneself • Looking for ways to kill oneself, such as searching online or buying a gun • Talking about feeling hopeless or having no reason to live • Talking about feeling trapped or in unbearable pain • Talking about being a burden to others • Increasing the use of alcohol or drugs • Acting anxious or agitated, or behaving recklessly • Sleeping too little or too much • Withdrawing or feeling isolated • Showing rage or talking about seeking revenge • Displaying extreme mood swings Local Community Mental Health Resources [To be inserted by school] National Suicide Prevention Lifeline TALK (8255) [Local hotline numbers to be inserted by school] Recommendations for Reporting on Suicide Research has shown that graphic, sensationalized, or romanticized descriptions of suicide deaths in the news media can contribute to suicide contagion (“copycat” suicides), particularly among youth. Media are strongly encouraged to refer to the document “Reporting on Suicide: Recommendations for the Media,” which is available at and Media Contact NAME: TITLE: SCHOOL: PHONE: ADDRESS: Brock, 2002; American Foundation for Suicide Prevention et al. (2011)

Brock (2002); World Health Organization (2000)
Postvention Protocol Determine how to share information about the death. Reporting the death to the media: Guidelines from the World Health Organization Suicide is never the result of a single incident Avoid providing details of the method or the location a suicide victim uses that can be copied Provide the appropriate vital statistics (i.e., as indicated provide information about the mental health challenges typically associated with suicide). Provide information about resources that can help to address suicidal ideation. World Health Organization. (2000). Preventing suicide: A resource fro media professionals. Geneva, Switzerland: Author. Retrieved from Brock (2002); World Health Organization (2000)

Postvention Protocol Identify students significantly affected by the suicide and initiate referral procedures. Risk Factors for Imitative Behavior Facilitated the suicide. Failed to recognize the suicidal intent. Believe they may have caused the suicide. Had a relationship with the suicide victim. Identify with the suicide victim. Have a history of prior suicidal behavior. Have a history of psychopathology. Shows symptoms of helplessness and/or hopelessness. Have suffered significant life stressors or losses. Lack internal and external resources Brock (2002); Brock & Sandoval (1996)

Postvention Protocol Conduct a faculty planning session. Share information about the death. Allow staff to express their reactions and grief.. Provide a scripted death notification statement for students. Prepare for student reactions and questions Explain plans for the day. Remind all staff of the role they play in identifying changes in behavior and discuss plan for handling students who are having difficulty. Brief staff about identifying and referring at-risk students as well as the need to keep records of those efforts. Apprise staff of any outside crisis responders or others who will be assisting. Remind staff of student dismissal protocol for funeral. Identify which Crisis Response Team member has been designated as the media spokesperson and instruct staff to refer all media inquiries to him or her. Sample Agenda for Initial All-Staff Meeting This meeting is typically conducted by the Crisis Response Team Leader and should be held as soon as possible, ideally before school starts in the morning. Depending on when the death occurs, there may not be enough time to hold the meeting before students have begun to hear the news through word of mouth, text messaging, or other means. If this happens, the Crisis Response Team Leader should first verify the accuracy of the reports and then notify staff of the death through the school’s predetermined crisis alert system, such as or calls to classroom phones. Remember that information about the cause of death should be withheld until the family has been consulted. Goals of Initial Meeting Allow at least one hour to address the following goals: • Introduce the Crisis Response Team members. • Share accurate information about the death. • Allow staff an opportunity to express their own reactions and grief. Identify anyone who may need additional support and refer them to appropriate resources. • Provide appropriate faculty (e.g., homeroom teachers or advisors) with a scripted death notification statement for students. Arrange coverage for any staff who are unable to manage reading the statement. • Prepare for student reactions and questions by providing handouts to staff on Talking About Suicide and Facts About Suicide and Mental Disorders in Adolescents. • Explain plans for the day, including locations of crisis counseling rooms. • Remind all staff of the important role they may play in identifying changes in behavior among the students they know and see every day, and discuss plan for handling students who are having difficulty. • Brief staff about identifying and referring at-risk students as well as the need to keep records of those efforts. • Apprise staff of any outside crisis responders or others who will be assisting. • Remind staff of student dismissal protocol for funeral. • Identify which Crisis Response Team member has been designated as the media spokesperson and instruct staff to refer all media inquiries to him or her. End of the First Day It can also be helpful for the Crisis Response Team Leader and/or the Team Coordinator to have an all-staff meeting at the end of the first day. This meeting provides an opportunity to take the following steps: • Offer verbal appreciation of the staff. • Review the day’s challenges and successes. • Debrief, share experiences, express concerns, and ask questions. • Check in with staff to assess whether any of them need additional support, and refer accordingly. • Disseminate information regarding the death and/or funeral arrangements. • Discuss plans for the next day. • Remind staff of the importance of self-care. • Remind staff of the importance of documenting crisis response efforts for future planning and understanding. Brock (2002); American Foundation for Suicide Prevention et al. (2011)

Postvention Protocol Initiate crisis intervention services
Initial intervention options… Individual psychological first aid. Group psychological first aid. Classroom activities and/or presentations. Parent meetings. Staff meetings. Walk through the suicide victim’s class schedule. Meet separately with individuals who were proximal to the suicide. Identify severely traumatized and make appropriate referrals. Facilitate dis-identification with the suicide victim… Do not romanticize or glorify the victim's behavior or circumstances. Point out how students are different from the victim. Parental contact. Psychotherapy Referrals. Brock (2002)

Center for Suicide Prevention (2004)
Postvention Protocol Consider memorials “A delicate balance must be struck that creates opportunities for students to grieve but that does not increase suicide risk for other school students by glorifying, romanticizing or sensationalizing suicide.” Note. From “School Memorials After Suicide: Helpful or Harmful” by the Centre for Suicide Prevention (2004, May). Retrieved January 2006 from Center for Suicide Prevention (2004)

Postvention Protocol Do NOT . . . Consider memorials
send all students from school to funerals, or stop classes for a funeral. have memorial or funeral services at school. establish permanent memorials such as plaques or dedicating yearbooks to the memory of suicide victims. dedicate songs or sporting events to the suicide victims. fly the flag at half staff. have assemblies focusing on the suicide victim, or have a moment of silence in all-school assemblies. Note. From “Suicidal Ideation and Behaviors,” by S. E. Brock & J. Sandoval. In C. G. Bear, K. M. Minke, & A. Thomas, Children’s Needs II: Development, Problems, and Alternatives, 2006, Bethesda, MD: National Association of School Psychologists. Copyright 2006 by the National Association of School Psychologists. Brock & Sandoval (2006)

Postvention Protocol DO . . . Consider memorials
something to prevent other suicides (e.g., encourage crisis hotline volunteerism). develop living memorials, such as student assistance programs, that will help others cope with feelings and problems. allow students, with parental permission, to attend the funeral. Donate/Collect funds to help suicide prevention programs and/or to help families with funeral expenses encourage affected students, with parental permission, to attend the funeral. mention to families and ministers the need to distance the person who committed suicide from survivors and to avoid glorifying the suicidal act. Note. From “Suicidal Ideation and Behaviors,” by S. E. Brock & J. Sandoval. In C. G. Bear, K. M. Minke, & A. Thomas, Children’s Needs II: Development, Problems, and Alternatives, 2006, Bethesda, MD: National Association of School Psychologists. Copyright 2006 by the National Association of School Psychologists. Brock & Sandoval (2006)

Postvention Protocol Debrief the postvention response.
Goals for debriefing will include… Review and evaluation of all crisis intervention activities. Making of plans for follow-up actions. Providing an opportunity to help intervenors cope. Brock (2002)

Concluding Observation
“… the person who commits suicide puts his psychological skeleton in the survivor’s emotional closet; he sentences the survivor to deal with many negative feelings and more, to become obsessed with thoughts regarding the survivor’s own actual or possible role in having precipitated the suicidal act or having failed to stop it. It can be a heavy load” (p. x). Shneidman (1972)

Selected References American Foundation for Suicide Prevention and Suicide Prevention Resource Center. (2011). After a suicide: A toolkit for schools. Newton, MA: Education Development Center. Retrieved from American Foundation for Suicide Prevention, American Association of Suicideology, & Annenberg Public Policy Center. (2001). Reporting on suicide: Recommendations for the media. Retrieved from Andriessen, K. (2009). Can postvention be prevention? Crisis, 30, Andriessen, K., & Krysinska, K. (2012). Essential questions on suicide bereavement and postvention. International Journal of Environmental Research and Public Health, 9, doi: /ijerph Berman, A. L. Estimating the population of survivors of suicide: Seeking an evidence base. Suicide & Life Threatening Behavior, 41, Brock, S. E. (2002). School suicide postvention. In S. E. Brock, P. J. Lazarus, & S. R. Jimerson (Eds.), Best practices in school crisis prevention and intervention (pp ). Bethesda, MD: National Association of School Psychologists. Brock, S. E. (2003, May). Suicide postvention. Paper presented at the DODEA Safe Schools Seminar. Retrieved from 2 Brock, S. E., Sandoval, J., & Hart, S. R. (2006). Suicidal ideation and behaviors. In G Bear & K Minke (Eds.), Children’s needs III: Understanding and addressing the developmental needs of children (pp ). Bethesda, MD: National Association of School Psychologists

Selected References Cain, A. C. (Ed.). (1972). Survivors of Suicide. Springfield, IL, Thomas: Springfield, IL. Centers for Disease Control and Prevention. (2012, March 9). Web-based injury statistics query and reporting system (WISQARS). Leading causes of death reports. Atlanta, GA: National Center for Injury Prevention and Control. Retrieved from Centers for Disease Control and Prevention. (2012, June 8). Youth risk behavior surveillance – United States, 2011, MMWR, 61(4), Retrieved from Center for Suicide Prevention. (2004, May). School memorials after suicide: Helpful or harmful? Retrieved from Davis, J. M., & Brock, S. E. (2002). Suicide. In J. Sandoval (Ed.), Handbook of crisis counseling, intervention and prevention in the schools (2nd ed., pp ). Hillsdale, NJ: Lawrence Erlbaum Associates. de Groot, M. H., de Keijeser, D., & Neeleman, J. (2006). Grief shortly after suicide and nautral death: A comparative study among spouses and first-degree relatives. Suicide and Life-Threatening Behavior, 36, Grad, O. T., Clark, S., Dyregrov, K., & Andriessen, K. (2004). What helps and what hinders the process of surviving the suicide of somebody close? Crisis, 25, Jordan, J. R. (2001). Is suicide bereavement different: A reassessment of the literature. Suicide & Life- Threatening Behavior, Jordan, J. R. & McIntosh, J. L. (2011). Suicide bereavement: Why study survivors of suicide loss? In J. R. Jordan, J. L. McIntosh (Eds.), Grief after Suicide (pp. 3-17). New York, NY: Routledge.

Selected References Jordan, J. R. (2001). Is suicide bereavement different: A reassessment of the literature. Suicide & Life-Threatening Behavior, Jordan, J. R. & McIntosh, J. L. (2011). Suicide bereavement: Why study survivors of suicide loss? In J. R. Jordan, J. L. McIntosh (Eds.), Grief after Suicide (pp. 3-17). New York, NY: Routledge. McIntosh, J. (1993). Control group studies of suicide survivors: A review and critique. Suicide Life & Threatening Behavior, 23, Mishara, B. L. (1999). Concepts of death and suicide in children ages 6-12 and their implications for suicide prevention. Suicide & Life-Threatening Behavior, 29, O’Carroll, P. W., & Potter, L. B. (1994, April 22). Suicide contagion and the reporting of suicide: Recommendations form a national workshop. MMWR, 43(RR-6), Retrieved from Ramsay, R. F., Tanney, B. L., Tierney, R. J., & Lang, W. A. (1996). Suicide intervention workshop (6th ed.). Calgary, AB: LivingWorks Education. Roberts, R. L., Lepkowski, W. J., & Davidson, K. K. (1998). Dealing with the aftermath of a student suicide: A T.E.A.M. approach. NASSP Bulletin, 82, Scocco, P., Frasson, A., Costacurta, A., & Pavan, L. (2006). SPRPoxi: A research-intervention project for suicide survivors. Crisis, 27, Shneidman, E. (1969). Prologue: Fifty-eight years. In E. S. Scneidman (Ed.) On the nature of suicide (pp. 1-30). San Francisco, CA: Jossey-Bass. Shneidman, E. (1972). Forward. In A. C. Cain (Ed.), Survivors of Suicide. Springfield, IL: Thomas. Sonneck, G., Etzersdorfer., & Nagel-Kuess, S. (1994). Imitative suicide on the Viennese subway. Social Science & Medicine, 38(3), doi: / (94) Wrobleski, A. (2002). Suicide survivors: A guide for those left behind. Minneapolis, MN: SAVE.

School Suicide Prevention, Intervention and Postvention

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