1. SUICIDE PREVENTION, INTERVENTION & POSTVENTION IN SCHOOLS An Overview for Board 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 Board Mental Health Leadership Team  It is designed to:  Build common understanding about suicide amongst board mental health leaders  Highlight helpful prevention, intervention and postvention strategies  Provide recommendation actions for consideration at the system level  The accompanying presentation for School Mental Health Leaders mirrors this content, but adds specific detail relevant for schools

4. SESSION OUTLINE  Brief Overview of Suicide in Children and Youth  Suicide Prevention, Intervention & Postvention Strategies  Issues for Board Leaders  Recommended Actions for the MH Leadership Team  Roles and Protocols (mh leadership team, senior administration, 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, media education)

5. CHILD AND YOUTH SUICIDE Brief Overview

6. SUICIDAL BEHAVIOUR  Non-Suicidal Self-Injury  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  2 nd leading cause of death after accidents, accounting for 17.3- 20.4% 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 15-19  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. THE COMPLEXITY OF RISK Vulnerabilities (Distal) Triggers (Proximal) Risk Protective Factors

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 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 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. 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 BULLYING AND SUICIDAL BEHAVIOR

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

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 board doing consistently across the system in suicide prevention, intervention and postvention?  Are these initiatives aligned with the evidence-base?  Review the companion School Mental Health Leaders’ presentation and determine if this is the right time to share this information with school administrators in your board

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. Prevention StrategyEvidence Early identification and treatment of mental health problemsSolid School/community culture buildingSolid Adaptive coping skill developmentSolid Information dissemination / gatekeeper trainingPromising Screening and referralMixed Youth engagement / peer helper programsMixed Suicide awareness curricula for studentsMixed Means restrictionMixed Crisis hotlinesMixed Media education programs Insufficient Evidence Effective postvention Insufficient Evidence

33. 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

34. 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

35. 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

36. HELPFUL POSTVENTION STRATEGIES  Understand the phases of postvention  Have a plan for who does what at each phase of postvention  First 24 hours  Next 48-72 hours  During the first month  Planning for the future  Practice deliberate self- and team-care

37. 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

38. 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 Media Social Media

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

40. 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!!

41. ISSUES FOR BOARD LEADERS Child and Youth Suicide

42. 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

43. PERTINENT ISSUES FOR BOARD LEADERS  Determining a coordinated board-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  Communicating the suicide strategy and related supports and expectations

44. SUICIDAL BEHAVIOR IS A REALITY IN YOUR SCHOOLS BE PROACTIVE, BE PREPARED

45. 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

46. RECOMMENDED ACTIONS Board Leaders

47. 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, media education)

48. 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 boards have teams and tools in place. For these boards, 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.

49. IDENTIFY TEAMS*  Board  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

50. CLARIFY ROLES  Leadership and Planning Teams  Who will be involved in protocol development, strategy selection, training, communication, etc.?  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?

51. DEVELOP/UPDATE PROTOCOLS  Consult with school leaders in developing/updating protocols, particularly those who have worked through postvention  Work with local agencies to plan for community mobilization during postvention  Work with media to educate and reinforce safe reporting guidelines  Develop/update your Intervention Protocol  Develop/update your Postvention Protocol

52. DEVELOP/UPDATE TOOLS  Create/select/adapt/update pertinent tools and templates  Make tools available to School Mental Health Teams  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

53. 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

54. CAPACITY - BUILDING When possible, sequence capacity-building:  Senior Leaders  School Leaders  School Staff  Gatekeeper Training  Parents  Media  Students Different audiences will have different knowledge needs

55. COMMUNICATE WITH STAFF  Communicate the protocol and related tools and templates  Board MH Team School Leaders  School LeadersSchool Staff  Some messages may need to go directly from the Board MH Team to all Staff and to media

56. 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

57. 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

58. CONTACT SCHOOL MENTAL HEALTH ASSIST Kathy Short, Ph.D., C.Psych. Director, School Mental Health ASSIST Kathy.Short@hwdsb.on.ca 905-527-5092, x2634 School Mental Health ASSIST Équipe d’appui en santé mentale pour les écoles