Suicide Awareness, Prevention and Intervention: Everyone Plays a Role … What is Yours? Paula S. McCommons, Ed.D.

Suicide Awareness, Prevention and Intervention: Everyone Plays a Role … What is Yours?
Paula S. McCommons, Ed.D

As We Move Forward … A Lesson From Loss:
Let us not look backward in anger or forward in fear but around us in awareness. James Thurber

Today’s Goals Review factors that impact prevention and intervention efforts Identify what we know about how youth suicide happens – risk factors and warning signs Explore our role in prevention and intervention of youth at risk Describe resources and self-care strategies for youth , families and caregivers/ourselves 2003

My underlying premise…
You are the “human tool.”

Looking in a mirror… are you looking back at a caring adult in a child’s life?
One of the wonderful things we now see in adulthood is that these children really remember one or two teachers who made the difference. They mourn some of those teachers more than they do their own family members because what went out of their lives was a person who looked beyond outward experience, their behavior and often unkempt appearance, and saw the promise. (Werner , 1992)

When individuals are in distress consider…
Being kind. Offering choice. Modeling Self-care.

Refer to NAMI handout on Mental Health Facts
To Talk About Suicide Prevention Need to Talk About Mental Illness/Behavioral Health & Treatment Refer to NAMI handout on Mental Health Facts

What Do You Already Know?
Please take a moment to complete the “Suicide Awareness Quiz”

Mental Health Awareness and Treatment
1/5 youth meet the criteria for a mental health dx. and yet only 1/5 ever get the help they need Mental health issues tend to run in families Diagnosis (dx) are often co-occurring, meaning you will have more than one diagnosis at a time Self-medicating often becomes another dx. A lot of hurting kids - just because on the radar may have… Wrong insurance, non-compliance – “I stopped taking it 3 weeks ago because it made me feel funny but I didn’t want you to be mad at me.” or “I’ll take my meds mon- fri but the week-ends are mine.” Diabetes, curly hair, hot tempers Pharmaceutical commercials – great education normalizing depression as a medical condition like diabetes and heart disease but set folks up to think it is “cured” with a purple, yellow pill. Still have to go to school, still living with your family still have to go to therapy Often have anxiety as a child, goes unchecked become depressed and then self-medicate Experience a traumatic event, develop PTSD no treatment becomes depressed and start to self-injure

Challenges of Diagnosing & Treating Mental Illness Among Youth:
Behavior is complex – not like an x-ray of a broken bone Health parity does not always play out – many blocks to appropriate treatment Caregivers may also be in need of treatment and/or support Stigma -

Other Factors Impacting Prevention and Intervention Efforts
Mental Health Awareness and Treatment “Normal” Development Brain Development Sleep Hygiene Previous Loss and Trauma Visual Exposure and Uncensored Technology – Information Overload Family Strains and Discord

“Normal” teen and young adult development may lead to …
Non-compliance with treatment Self-medication Teens confiding in peers rather than adults Vulnerability to peer influences and behaviors

A Dose of Empathy: How many of you would pick your teen years as the “best years of your life”?

Causes of Mental Illness (MI): A Combination of Factors
Heredity (genetics) – a predisposition but not a guarantee Biology – Chemical imbalances among neurotransmitters may cause brain communication errors/difficulties .Brain Injury or defects may alter functioning and mood. Psychological Trauma – i.e abuse, neglect, loss Environmental Stressors –i.e. witnessing violence, may trigger a mi in those who are already vulnerable to a mi

Diagnosis of Mental Illness Among Youth:
Rule out physical causes – meet with pediatrician Evaluation – gather “data” from youth, parent, teacher and other caregivers Behavioral Health Specialists – psychiatrist, psychologist, clinical social worker, and licensed counselor

Treatment of Mental Illness Among Youth:
Medication – especially given the connection with bio-chemical imbalances in the brain Psychotherapy -CBT (cognitive behavioral therapy), group and family are common A combination of meds and therapy Creative therapies - i.e. art, equestrian and play

Prognosis of Youth with Mental Health Disorder:
With appropriate treatment youth may experience recovery from or at least a successful management of their symptoms. If untreated youth may become adults at greater risk for substance abuse, and self-injury, including suicide.

A Guide to Campus Mental Health Action Planning

Informed Trauma Care: Creating a Community Meeting
Not therapy Instill sense of community – “We” Increase self-awareness & help seeking Re-enforce safety Offer hope

A “Grounding Conversation/Meeting: All members answer 4 ?’s”:
My name is __________________. I am feeling ____________________. My goal for today is _______________. I know I can get _________________to help me with my goal. Remember replace “What is wrong with you? with “What has happened to you?”

A Primer on Suicide from SPRC

2013 National Youth Behavior Survey Results: In the past 12 months…
Nearly 30% of students reported feeling so sad or hopeless almost every day for 2 weeks or more that they stopped some usual activities * this was not a significant increase from 2011 17% seriously considered suicide (more females (22%) than males (11% 13% made a plan 8% attempted at least 1 x (10% female & 5% male) Nearly 3% of attempts required medical treatment

2013 College and University Student Health Survey and Research
More than half of college student reported feeling so overwhelmed, anxious or depressed that it impacted their daily functioning Majority of suicides did not occur on campus and often involved older/graduate aged students Overwhelming majority of students who died by suicide were not involved with the college campus counseling services

Jed Foundtion and MTV “Half of Us” Campaign

To Talk About Suicide Prevention We Need to Look at the “Causes”:
The connection between depression and suicide. Refer to NIMH handout on teens and depression.

Risk Factors for Youth Suicide
Depression or bipolar disorders Hopelessness Drug or alcohol abuse Availability of firearms High suicidal intent Previous attempt Co-existing condition Suicidal behaviors Insomnia Self-harm behavior Behavior problems Involvement with bullying as target and/or aggressor Current or past abuse Legal or disciplinary crisis Lack of treatment Family history of suicidal behavior Unsupported GLBTQ youth

Suicidality and Depression
Depression is the strongest and most common correlate with suicidal ideation and behavior 60% of suicide victims had a mood disorder and up to 80% of suicide attempters do Depression in combination with other comorbidities (anger/impulsivity, anxiety or distress) greatly increase risk for suicide attempt Depression is a treatable illness Educate teen and family on the illness and be realistic about the often lengthy road to recovery Offer HOPE and remind all of innate resiliency that can be strengthened

Statistics and Research
8.3 % of adolescents; 2.5 % of children Depression occurring earlier than in previous decades Early onset depression often persists, recurs and may predict more severe illness in adulthood Associated with an increased risk for suicidal behaviors

Myths About Depression
It will go away on its own Everyone feels this way Having depression or seeking help is a sign of weakness If a depression is mild, you don’t have to worry about suicide People or events “cause” depression Children don’t get depressed Moodiness in adolescents is normal

Symptoms of Depression
Low self-esteem Excessive guilt Difficulty concentrating/making decisions Social isolation Increased aches and pains with no physical cause Persistent thoughts of death/suicide Depressed mood/Irritability Loss of interest/pleasure (anhedonia) Changes in sleeping patterns Changes in eating patterns/weight Increased agitation or a slowing down of thought, speech or movement Fatigue/loss of energy

Types of Depression Major Depression Bipolar Disorders (I and II)
Dysthymic Disorder Seasonal Affective Disorder Depression, Not Otherwise Specified

Other Factors for College Students:
The following factors may exacerbate mental health conditions such as depression and anxiety: Major life transitions – i.e., leaving home, family and peer supports Pressures to succeed Uncertainties about the future job market Increased financial burdens, especially for graduate students Increased drug and alcohol use Insomnia - “all nighters”

Causes of Depression Genetic/Familial Factors
Research shows that depression tends to run in families. Parents are not to “blame” if their teen becomes depressed Biochemical Factors Research supports that some depressions are caused by a chemical imbalance in the brain. This is why medications may help Genetic: Depression tends to run in families. Children of depressed parents tend to become depressed even when raised by non-depressed adoptive parents. Biochemical: Several years ago physicians noted that certain medications had strong mood altering effects, leading to the idea that mood disorders could be a function of biochemical disturbance that could be stabilized by drugs. Imbalances in neurotransmitters: serotonin and norepinephrine Cognitive and Social Skills: This theory suggests that “distorted, negative thinking” patterns developed early in life are central to clinical depression. Views the world as cruel, the self as deficient and unworthy and the future as hopeless. When under stress, a person with a tendency to negative thinking is more likely to become depressed which often leads to worsening self-esteem and social interaction problems. There is evidence that parental and child cognitive style are related which could be due to either modeling or genetics. Environmental/Other: A number of studies have shown more “exit” events (divorce, loss), more undesirable events, more “severely threatening” events and more uncontrollable events in the 6 months prior to the onset of depression.

Causes of Depression Cognitive and Social Skills
A tendency toward negative thinking and/or problems interacting with others are often factors in teen depression. This is where psychotherapy can help Environmental Factors Loss, stress, life events, and chronic illness can “trigger” depression

Types Of Treatment Psychotherapy: Individual, Group, Family, Maintenance Plan Coping skills Emotion regulation skills Communication skills Social skills Medication Treatment Non-addictive Potential side effects Combination psychotherapy and medication treatment often works best

Risk Factors for Adolescent Suicide
Depression or bipolar disorders Hopelessness Drug or alcohol abuse Availability of firearms High suicidal intent Previous attempt Co-existing condition Suicidal behaviors Insomnia Self-harm behavior Behavior problems Involvement with bullying as target and/or aggressor Current or past abuse Legal or disciplinary crisis Lack of treatment Family history of suicidal behavior Unsupported GLBTQ youth

Non-suicidal self-injury
Suicide Continuum Passive death wish Suicidal ideation no method Suicidal ideation with plan Suicide Attempt Completed Suicide Suicidal Ideation Non-suicidal self-injury Brent et al., 1988

Precipitating Events to Suicidal Behavior:
Perceived overwhelming distress following an “critical” event: Break up Impending legal and/or disciplinary action Academic decline Being “outted” NOTE: The event does NOT cause the individual to become suicidal. Suicide is the result of a complex set of factors.

Sleep and Self-Injurious Behavior: NSSI and Suicidal
Insomnia was strongest depressive symptom in the week prior to suicide (Goldstein et al., 2008) Insomnia also associated with increased risk of self-harm and suicidal ideation even when controlled for depression (Wong et al., 2011, 2012) Treatment for depression does NOT necessarily improve sleep and some medication can make it worse Again, we need to educate teen and family and be realistic about progress and emphasize sleep hygiene

How 2 Talk with UR Kid/Student: Suggestions From Teens

A pneumonic device to assess suicidal acute risk.
Is the Path Warm?: A pneumonic device to assess suicidal acute risk.

A Word Of Caution... The prediction of future suicidal behavior is NOT measurable; however research does identify risk factors and “favorable” conditions for a completed suicide.

Protective Factors Identified for Reducing Suicidal Behavior: None Identified for NSSI
Family and school connectedness (Kaminski et al., J Youth Adol, 2010) Reduced access to firearms (Grossman et al., JAMA, 2005) Safe schools (Eisenberg et al., J Ped, 2007) Self-esteem (Sharaf et al., JCAPN, 2009) Academic achievement (Borowsky et al., Pediatrics, 2001) (Refer to Youth Suicidal Behavior Fact Sheet, National Center for the Prevention of Youth Suicide)

More Protective Factors…
Family meal times Regular exercise and sleep Parent supervision Support and treatment for parent stress/illness Address school issues such as bullying, attendance and missing school work

Reflection: Ask yourself these questions. . .
Could one prevention approach meet the needs of these young people? Why do we need to ask prevention program developers, “What is your model for how suicide occurs?” What are the prevention approaches that address the risk factors and precipitating events identified in the literature? Given your experience and role (s), what would you suggest? 2003

Some illustrations and scenarios
A teenager has experienced repeated episodes of depression and feels hopeless, despite some sessions with a school counselor. Her parents have refused to let her see a psychiatrist. When her parents leave for a weekend of partying with their friends at a football game, she concludes that she would be better off dead and overdoses. 2003

A scenario A graduating senior returns from Spring break only to receive news that her fifty-two year old father has died by suicide . He had suffered a heart attack when she was in high school but seemed to recover. After twenty plus years of service her Dad had recently been laid off. He had also served in the Gulf War.

Another scenario On the way to school Friday morning the bus driver hears Taylor tell Olivia , her best friend, the following, “My Mommy and Daddy are getting a divorce and my Daddy wont live with us anymore. I don’t want to live without my Daddy. My Mommy is going to visit my grandma this week-end and I am going to take her pills from the medicine cabinet.” After the students unload the bus driver tells you what he heard.

Another illustration A gifted teenager has experienced severe anxiety for several years. Treatment has helped, but he continues to be self-critical and overly concerned about his performance and others’ approval of him. When he is caught parking his car on school campus without a student permit, he faces a one-day suspension. Panicked about his parents’ reaction, he drives the car to a bridge and jumps. 2003

And another Diagnosed at age 8 with Conduct Disorder and ADHD, this 14 year-old struggles academically. He compensates for his poor academic status by being the class clown and taking risks to gain the attention of his friends. One night at a friend’s house, he drinks with the other kids and then plays a fatal game of Russian Roulette. 2003

One more A young woman experiences a romantic break-up and becomes depressed. She encounters her former boyfriend on the street with a new partner. She returns to her college dorm and hangs herself. 2003

Reflection: Ask yourself these questions. . .
Could one prevention approach meet the needs of these young people? Why do we need to ask prevention program developers, “What is your model for how suicide occurs?” What are the prevention approaches that address the risk factors and precipitating events identified in the literature? Given your experience and role (s), what would you suggest? 2003

Suicide Prevention in the USA : A Brief Recent History
1999 Surgeon General declares suicide a public health threat Each state charged with formulating a comprehensive across the life span plan 2011 National Prevention Strategy outlined nation’s plan for promoting health & wellness 2012 National Action Strategy for Suicide Prevention released four strategic directions – joint efforts of Surgeon General & National Action Alliance for Suicide Prevention

Four Strategic Directions
Create supportive environments Enhance clinical and community preventative services Promote availability of treatment and supportive services in a timely manner Improve suicide prevention surveillance collection, research and evaluation

National and Legislative Updates cont.
2014 Action Alliance released Effective Suicide Messaging Guidelines covering the: Strategy – Who is the audience? What is the intended outcome? How will it be measured? Safety – Does content and delivery follow best practice guidelines – Positive Narrative – Are hope, recovery and resources/support emphasized?

Safe Reporting and Effective Messaging on Suicide
Refer to handouts for examples and recommendations

Student PSA Winners Posters, 30 and 60 second audio and video PSA Needed faculty sponsor and follow media guidelines on reporting on suicide Review winners at: Club founded at Calico High School If depression were as easy to spot in the hallway as a banana…

National and PA Legislative Updates cont.
Act 71 passed in June 2014 to go into effect school year. PA becomes one of only twenty states requiring some type of staff education on suicide prevention. Schools… Must have a comprehensive suicide policy Must, in conjunction with the Dept. of Ed., offer 4 hrs. of suicide prevention training every 5 yrs. May incorporate an age appropriate suicide awareness and prevention curriculum PA Youth Suicide Prevention Initiative to provide no cost resources for schools –

More Good News… In 2015 PA received 5 yr SAMHSA grant to focus on suicide prevention in schools and higher education. We now have an interactive state calendar for suicide prevention activities at a county, regional and state level Visit –

PA Higher Education Suicide Prevention Coalition
Collaborative formed to enable colleges, community colleges, and universities across Pennsylvania to discuss efforts toward suicide prevention on campuses Currently just over 50% of campuses are participating in the coalition Participation includes monthly web-based video meetings, as well as one face-to-face meeting each of the five years of the project. For more information or to participate contact

Refer to “Preventing Suicide : A Toolkit for High Schools”
Download your free copy at :

SPRC and Resources for Colleges and Universities

Six Steps to Comprehensive Suicide Prevention in Schools
Identification & Response Screening Postvention Student Education & Advocacy Staff Education Parent Education SAMHSA, 2012

In Other Words, Schools Need...
Policy and procedures to govern suicide prevention, intervention and postvention efforts Training of specialized staff to respond to identified youth who may be at risk or in imminent danger “Gatekeeper training” of school personnel regarding identification , referral and resources for at-risk youth Parent education on referral resources and prevention strategies including enhancing protective factors Student education around peer referral Screening for behavioral health issues Postvention procedures to address a death by suicide

Six Steps to Comprehensive Suicide Prevention in Schools (SAMHSA)
1. Protocols for helping students at risk of suicide, including: »»A protocol for helping students who may be at risk of suicide »»A protocol for responding to students who attempt suicide at school »»Agreements with community providers to provide behavioral health services to students

Working with Students At-Risk for Suicide
Immediate evaluation – Every PA County must have a emergency services system. Call 211 Parents are notified and asked to come and take the child to evaluation If student refuses, parent can do a 201 If parent and student refuses and child is in imminent danger, conduct a 302 Work with solicitor for best practice on transporting students to hospital or on a case by case basis

2. Protocols for responding to suicide death (Postvention), including: »»Steps to take after the suicide of a student or other member of the school community »»Staff responsible for taking these steps »»Agreements with community partners to help in the event of a suicide

3. Staff education and training, including: »»Information about the importance of suicide prevention for all staff »»Training, for all staff, on recognizing and responding to students who may be at risk of suicide. »»Training, for appropriate staff, on assessing, referring, and following up with students identified as at risk of suicide.

QPR Gatekeeper Training for Suicide Prevention
Educational program designed to teach "gatekeepers"--those who are strategically positioned to recognize and refer someone at risk of suicide (e.g., parents, friends, neighbors, teachers, coaches, caseworkers, police officers)--the warning signs of a suicide crisis and how to respond by following three steps: Question the individual's desire or intent regarding suicide Persuade the person to seek and accept help Refer the person to appropriate resources The 1- to 2-hour training is delivered by certified instructors in person or online, and it covers (1) the epidemiology of suicide and current statistics, as well as myths and misconceptions about suicide and suicide prevention; (2) general warning signs of suicide; and (3) the three target gatekeeper skills (i.e., question, persuade, refer). The training includes a short video that shows interviews with people who have experienced suicide in their families, schools, and neighborhoods, and it provides standardized role-play dialogue for use in a behavioral rehearsal practice session. For participants whose focus is on schools and youth, the training also reviews local rates of students' suicidal behavior and the school district's protocol for responding to suicidal students. Once trained, the participants, or gatekeepers, receive a booklet that contains an overview of the didactic presentation and a review of the gatekeeper role. Wallet cards also are distributed for use as a review and resource tool, with prompts to recall the gatekeeper skills emphasized in the training and information about local referral resources.

4. Parent education, including: »» Information for parents about suicide and related behavioral health issues »» Strategies to engage parents in suicide prevention programs 5. Student education, including: »»One or more programs to engage students in suicide prevention »»Integration of suicide prevention into other student healthy behavioral health initiatives

Student Education & Prevention Programs
Suicide Prevention Resource Center -Best Practice Registry The purpose of the Best Practices Registry (BPR) is to identify, review, and disseminate information about best practices that address specific objectives of the National Strategy for Suicide Prevention. The BPR is a collaborative project of the Suicide Prevention Resource Center (SPRC) and the American Foundation for Suicide Prevention (AFSP). It is funded by the Substance Abuse and Mental Health Services Administration (SAMHSA). Many of the best practice resources listed have to be purchased.

NREPP: prevention, screening, gatekeeper education, postvention

Who Should Do Suicide Prevention Curricula with Students?
Student Education & Advocacy

In Other Words, Comprehensive Suicide Prevention Includes…
Policy and procedures to govern suicide prevention, intervention and postvention efforts Training of specialized staff to respond to identified youth who may be at risk or in imminent danger “Gatekeeper training” of personnel regarding identification , referral and resources for at-risk youth Parent education on referral resources and prevention strategies including enhancing protective factors Youth education around peer referral Screening for behavioral health issues Postvention procedures to address a death by suicide

Elements of a Comprehensive Suicide Prevention Program for Colleges and Universities

To talk about prevention need to talk about cause.
Suicide is the result of a complex set of variables but prevention is possible when some of these variables are effectively addressed.

What Do You Already Know?
Please take a moment to complete the “Suicide Awareness Quiz”

How does youth suicide happen?
Researchers have pinpointed (1) a set of risk factors that can lead to completed suicide. Researchers have also described (2) precipitating events that contribute to completed suicides. (3) Other researchers are investigating a “suicide gene”. 2003

(1) Risk Factors for Completed Suicide
Mental illness such as depression, bipolar disorder, anxiety/mood disorder, disruptive or conduct disorder. These often are associated with hopelessness and previous suicide attempts. Family history of suicidal behavior and/or mental illness/ Extreme family discord Alcohol or other drug abuse Types of Depression Major Depression Bipolar Disorders (Manic-Depression) Dysthymic Disorder Cyclothymic Disorder Seasonal Affective Disorder Depression, Not Otherwise Specified 2003

(2) Precipitating Events for Completed Suicide
Exposure to another's suicide Legal or disciplinary crisis Availability of firearms 2003

(3) A Suicide Gene May Be Linked to Some Suicides
Bakish, et al.,( 2000) – investigating a genetic trait or mutation Mann (2001, 2011) – suggests individuals may not only “inherit the illnesses that trigger suicidal feelings, but that they may also inherit a predisposition to act on their feelings”; they may inherit a “variant gene” that makes them more prone to attempts Not to be confused with suicide genes used in some cancer therapies 2003

Risk Factors: Mental Illness
In over 80% of community and referred cases of suicide attempts, there are associated mental illnesses, most often depressive, anxiety, conduct or substance abuse disorder disorders. Psychiatric diagnoses (most often mood disorders, substance abuse disorder, conduct disorder, bipolar disorder w/ mixed state), often in combination, are present in about 90% of teen deaths by suicide. In over 80% of community and referred cases of suicide attempts, there are associated psychopathological conditions, most often depressive, anxiety, conduct or chemical dependency disorders. These psychopathologies, coexisting with personality conditions (especially borderline, antisocial, histrionic), also appear to increase the risk of both suicide attempts and completions. Identifying Depression Depression is a mood disorder. The depressive disorders are among the most prevalent of the mental illnesses. Depression is an illness characterized by: a decline in one’s health or functioning with symptoms that follow a predictable course. The depressive disorders are very responsive to treatment. Prevalence 8.3 % of adolescents; 2.5 % of children Depression occurring earlier than in previous decades Early onset depression often persists, recurs and may predict more severe illness in adulthood Associated with an increased risk for suicidal behaviors 2003

Anxiety Disorders Co-existing with a mood disorder, these conditions can interfere with a person’s treatment and recovery. If not identified and targeted, these disorders can increase the risk for suicidal thoughts and/or behaviors in depressed individuals. Separation Anxiety Disorder Social or Specific Phobias Panic Disorder Stress Disorders (Acute or Post Traumatic) Obsessive-Compulsive Disorder Generalized Anxiety Disorder 2003

Depression in the Family
Children of depressed parents appear to be at substantially increased risk for death by suicide. (Brent, et al., 1994) 2003

Family Discord The most common precipitant for suicidal behavior and suicide is parent-child discord. Discordant, hostile family interactions predisposed [youth] to suicidal thoughts. (Kosky et al., 1986, p. 527) Suicide victims had less frequent and less satisfying communications with their parents. (Gould et al., 1996) 2003

Risk Factors: Drug and Alcohol Abuse
Children of substance-abusing parents appear to be at substantially increased risk for completed suicide. Alcohol acts as a disinhibitor to suicidal behavior. A link seems to exist between alcohol abuse and suicide by firearms. Adolescents who are depressed and use alcohol are more than 5x more likely to use a firearm (Brent, et al., 1994) 2003

Risk Factors: Exposure to the Suicidality of Others
Exposure to a classmate’s suicide attempt may prompt suicidal behavior in other students. Those most vulnerable to “contagion” are more isolated, were not close to the suicide victims, and have other associated risk factors. Among close friends and acquaintances of adolescent victims, exposure does increase the incidence of depression, anxiety and PTSD. Exposure to TV programs and news stories on suicide may prompt suicidal behavior in vulnerable adolescents. 2003

Risk Factors: Disciplinary Action
A pending disciplinary crisis might precipitate suicidal behavior. Discipline should occur as soon as possible after misbehavior to decrease the feelings of anticipatory anxiety. Involve parents and be sure and emphasize the behavior does not define who they are or will be. Offer a way out. 2003

Juvenile Suicide in Confinement: National Survey (Hayes, 2009)
23% of suicides involved youth who also engaged in previous non suicidal self-injury Only 35% of suicide victims who completed during time in a detention facility received a mental health evaluation Less than half of all victims had never been assessed by a mental health professional or had not been assessed within 30 days of their death Less than 20% of those who completed were on suicide precaution status at the time of their death; those who were died within 15 minutes of their last observation

Precipitating Events to Suicidal Behavior:
Perceived overwhelming distress following an “critical” event: Break up Impending legal and/or disciplinary action Academic decline or not attending school Being “outed” NOTE: The event does NOT cause the individual to become suicidal. Suicide is the result of a complex set of factors. Many of these factors can be mitigated and may save a life.

The Truth About Suicide Real Stories of Depression in College

Implications For School And Mental Health Professionals
Suicidal intent must be assessed with any student who engages in self-harming behavior. If there is a bleeding or seeping wound the nurse/medical staff should evaluate and treat. Contagion may play a factor in the increase in the number of students who self-injure. The media, internet, videos and music are mediums for school personnel to monitor.

What Is The School’s Response?
Include self-harming behaviors in policies on student safety. Establish procedures for school personnel to follow in identifying, reporting, monitoring and supporting youth who self-harm in and out of school. Conduct annual crisis response training for appropriate staff reviewing 302 procedures, utilizing Act 147, and intervening with student’s who experience safety concerns.

What Is The School’s Response? (cont’d)
In-service all staff on the nature of self-harming behaviors. Inform parents of at-risk behaviors including SIB. Utilize the Student Assistance Program. Know your personal and professional limits when intervening. Include the School Nurse in the evaluation of any wound/injury. Involve parents through out the intervention and management of the student. Obtain releases with clinician to share info. & treatment strategies. Consider need for 504 accommodations.

Recommended Policies and Procedures for Schools
302 Procedures for students who can not keep themselves safe Comprehensive suicide prevention programs focusing on students, staff and parents addressing mental health awareness, appropriate interventions, and resources Postvention procedures in the event of a suicide or other tragic loss Memorial policy Visit for sample policies and procedures

Youth Mental Health Issues Impact on the Family
Changes in routines for the family Increased anger, frustration and irritability Guilt and blame among family members Shame and resentment about the illness Anxiety and fear about the illness Feeling the need to “walk on eggshells” around the depressed person Mental health issues of other family members may become more apparent 1. Changes in routines for the family due to the depressed persons impaired functioning 2. Increase in anger, frustration and irritability for family members because of the disruption 3. Feelings of guilt and blame occur for family members 4. Feeling resentful and ashamed of the depressed person and what is happen ing in the family 5. Experiencing anxiety and fear about the illness, wondering when it will go away or who else will become depressed 6. Feeling the need to “walk on eggshells” around the depressed person Common Sense Solutions: Reassuring the person that the depression will go away Giving the person advice to become more active Ignoring the problem Advising the depressed person to use “logic” Don’t usually work because the depression blocks the process! Emergencies/Suicidality 1. Recognize symptoms of depression and risk factors for suicidality 2. If teen reports thoughts of death/suicide, consult with a MH provider 3. Know how to talk to a teen about a “No Suicide Contract” 4. If suicidality is a factor, remove available methods, especially firearms 5. Suicidality as “manipulation”: pay attention, teen may “up the ante” Coping Strategies 1. Be hopeful - depression can be treated 2. Encourage teen to begin or remain in treatment 3. Encourage consistent use of medication - even if teen begins to feel better 4. Take care of yourself 5. Be direct in communicating 6. Provide positive feedback about changes you notice 7. Always take suicide talk seriously - let MH provider know if this is a factor 8. Make school aware of what is occurring - they can be supportive 9. Avoid taking angry comments personally 10. Look for gradual improvement 11. Encourage the person toward goals; avoid “overdoing” or “overprotecting” 12. Get support/treatment for yourself

Approaching Parents Voice concerns and observations.
Educate parents about self-injuring behaviors. Address concerns of parents. Assist with referrals for evaluation, treatment, crisis and support . Collaboratively plan with teen, family and mental health provider.

What To Do If You Suspect A Youth Has Mental Health Issues
SEEK HELP from a mental health professional ENCOURAGE teen to follow his/her treatment plan BE PATIENT – most mental health issues are very treatable but results are often gradual EXPLORE support resources for the child at school and community

One Teen’s Story of Survival, Recovery and Hope: Meet Jordan

Moving From Risk Factors Impacting Youth Health to the Promotion of Resiliency Among Youth and Ourselves

Skills to Help Teens Decrease Self Injury: Refer to STAR Manuals
Emotion Education The Freeze Frame Technique Emotion Regulation Skills Distress Tolerance Sensory Soothing Communication Skills Download “Emotional Regulation, Distress Tolerance and Interpersonal Skill Development” manual at

If the student has given any verbal or behavioral indicators of self-harm or harm to others, follow your school or agency crisis plan!

If there is a crisis situation. . .
Be familiar with 302 procedures or know how to reach who does. Keep the student near you. Keep the student talking. Reach the student’s parents. Limit contact with other teens.

General tips for starting a conversation with a teen.
Developed by Dr. Mary Margaret Kerr

1. If the student hesitates, gently offer an example of the worrisome behavior.
“You seem to have lost your interest in the track meet.” “I’ve noticed that you seem more excited than usual.” “You look as if you have dropped a lot of weight recently.” “I notice you’ve been sleepy a lot lately.”

2. Resist the urge to explain the symptom and/or offer advice.
Don’t say. . . “I guess your track team is not doing as well this year. No wonder you’re less excited.” “Maybe you should eat more.” “Kids sometimes sleep too much when they’re bored. Maybe you need to……”

3. Be a good listener so the student feels comfortable talking.
Pay attention to how much you are actually listening versus counseling.

4. Do not badger! Here are some ways we badger:
“I took time to talk with you, and this is all you have to say?” “Why don’t you face facts; something is wrong with you.” “If you don’t want help now, then don’t come to me later.” “Stop making excuses and get your work done.”

5. If the student does not want to talk, try another option.
“Maybe this isn’t a good time. We could meet after school.” “I know you and Dr.. Robb are close. Do you feel you might want to talk with him? I can check to see when he is available.” “If you ever want to talk, just let me know.” “Sometimes students are more comfortable expressing their problems in writing. Would that make things easier for you?”

6. Be patient! Students with problems are not always articulate. It may take a little while for them to explain how they feel. Do not interrupt. Show the student that you are interested by looking at him and nodding your head.

7. Avoid Judgments. This is no time to evaluate the student’s perceptions. “Well, that is nothing to worry about.” “How did you ever get into such a mess anyway?” “I hope you learned your lesson.”

8. Next, name some action that you can take with the student.
If you cannot immediately think of a plan, at least show your acceptance and willingness to help. “I am not sure how to tackle this problem, but we can think it through.” “Gee, his is a real problem. Let me give it some thought. We’ll talk Wednesday, okay?” “Now I see. How about if I share some of this with the counselor? I think she could help.” “I’d like to help you through this. How would you like to proceed?”

Some students need information to view their situations more hopefully
Some students need information to view their situations more hopefully. If this is the case, offer it. “I see why you were so worried about this quiz. You did not realize that everyone did poorly. I have decided to adjust everyone’s grades.” “Suspension is serious, but no, it does not mean you fail the course.” “I know the seniors said they could vote you off the team, but that decision is made only by the coach.”

Additional Talking Points…
9. Close the conversation with reassurance – even if you can not genuinely show acceptance of the student’s views. 10. Follow up on your commitment to seek help on behalf of the student. This will most likely involve a member of the crisis/SAP team and the parent/guardian. 11. Know the limits of your confidentiality and be honest with the student.

Specific Guidelines for Talking with a Suicidal Teen
Remember the “SAD ADOLESCENT” Mnemonic tool developed by Dr. Mary Margaret Kerr

Remember the “SAD ADOLESCENT:
Sex – females more likely to attempt, males more likely to choose more lethal means Age – 24 most at risk among youth Depression – a major risk factor especially if untreated Availability of means – especially firearms in the home but suffocation nearly as often Discord in family or parent mental health issues

The “SAD ADOLESCENT” cont.
Organized - plan/intent/prepared Do not hesitate to ask about suicidal thoughts and plans. Be gently persistent in seeking details about suicidal thoughts. Ask about frequency, duration, and intensity of these thoughts. Lack of social supports – loss of friends; peer conflicts

Earlier suicide ideation or attempts Do not hesitate to ask about previous suicide attempts. Substance abuse or chemical dependency – especially an increased use Cognitive distortions, hopelessness, perceived burdensome

Not agreeable to a safety plan to keep from acting upon suicidal thoughts. Safety plan involves: Youth agreeing not to act on suicidal thoughts Identifying distraction strategies that involve others and those that involve no one else Identify trusted adults they will call if the thoughts become urges and they are in distress Numbers of crisis contacts Identifying triggers and reviewing the plan with the youth’s parents/guardians Temper, aggression, homocidality

How to help: Know warning signs and what your can do or who you can tell. Be familiar with local and national resources. Offer hope and follow up. Maintain and model your own self-care.

Aevidum Club founded at Calico High School
Student PSA Winners Posters, 30 and 60 second audio and video PSA Needed faculty sponsor and follow media guidelines on reporting on suicide Review winners at: Aevidum Club founded at Calico High School If depression were as easy to spot in the hallway as a banana…

Re-enforcing Healthy Stress Reduction and Symptom Mitigating Strategies
Educate student on connection between their lifestyle and their stress symptoms Many stress reactions can be mitigated by self management choices Many stress management techniques can have an impact if they are only visualized e.g. taking a bath, sitting at the beach Each student needs their own “bag of tricks” Refer to handout - H.E.A.R. M.E. and Improving Sleep

Self-Soothing Through the Five Senses
Accessible and easily taught self-soothing/distress tolerance skills is to use the 5 senses Vision, hearing, smell, taste, touch Usually at least 2-3 of the five senses are engaged or capable of being engaged at any given moment as a distraction from distress. “Observe, Describe and Experience” EXAMPLE OF TEACHING KID THE 5 SENSES LET’S TAKE THE SITUATION IN WHICH A DISTRESSED TEEN MUST WAIT 50 MINUTES UNTIL THE END OF CLASS BEFORE SHE WILL BE ABLE TO TAK TO A FRIEND WITH WHOM SHE IS ANGRY. THAT IS, SHE CANNOT YET RESOLVE THE CONFLICT WITH HER FRIEND NOR CAN SHE RESOLVE HER ANGER. SO, SHE MUST FIND A WAY TO TOLERATE HER DISTRESS. ASSUMING SHE WAS UNABLE TO CONCENTRATE ON THE TEACHER’S LESSON, WHAT SENSES COULD SHE ENGAGE TO SELF-SOOTHE? VISION IS THE MOST OBVIOUS..SHE COULD FOCUS ON A POSTER ON THE CLASSROOM WALL, ON A CEILING TILE, OR ON A COLORFUL PIECE OF CLOTHING WORN BY ANOTHER STUDENT. USING HER HEARING SHE COULD FOCUS ON THE HUM OF THE AIR CONDITIONING OR THE BUZZ OF THE FLORESCENT LIGHTS. USING TASTE, SHE COULD SUCK ON A PIECE OF HARD CANDY, BEING MINDFUL OF HOW THE FLAVOR CHANGES DEPENDING ON WHAT PART OF THE TONGUE THE CANDY TOUCHES, FOCUSING ON THE DIFFERENT SENSATIONS CREATED BY THE CHANGING SIZE OF THE CANDY. USING SMELL, THE DISTRESSED STUDENT MIGHT FOCUS ON THE ODOR OF A PLEASNAT PERFUME THAT EITHER SHE OR A PEER IS WEARING. FINALLY, EMPLOYING TOUCH, THE STUDENT MIGH FOCS ON THE SOFTNESS AND TEXTURE OF A PIECE OF CLOTHING SHE IS WEARING, OR ON THE VARYING TACTILE QULITIES OF HER BOOK BAG.

Life isn’t the way it is supposed to be. Life is the way it is
Life isn’t the way it is supposed to be. Life is the way it is. It is how we cope that makes the difference. Anonymous Adolescent

Lets Review Your Quiz And Practice Some Self-Care
P.S. The answers are all true and exhaling is a great start to self-care!

Modeling Our Own Self-Care: Lessons from Geese

Key Resources AFSP – American Foundation for Suicide Prevention PAYSPI – Pennsylvania Youth Suicide Prevention Initiative SPRC – Suicide Prevention Resource Center SAMHSA – Substance Abuse and Mental Health Services Administration (US DEPT of Health and Human Services)

Key Resources Maine Youth Suicide Prevention Program National Action Alliance for Suicide Prevention National Suicide Prevention Lifeline – 273-TALK

College Resources The JED Foundation – a nonprofit public charity committed to reducing youth suicide and improving the mental health safety net for college students: Ulifeline – Among other programs, The Jed Foundation created Ulifeline, an anonymous Internet based resource that provides students with a supportive link to their college mental health or counseling center:

Selected Resources Aevidum – www.aevidum.com
Suicide Prevention Resource Center – Safety Planning Guide for Clinicians and Template

Selected Resources (cont.)
Cornell Research Program on Self-Injurious Behavior in Adolescents and Young Adults National Institutes of Mental Health National Center for the Prevention of Youth Suicide

References American Psychiatric Association. (2003) Practice guidelines for the assessment and treatment of patients with suicidal behavior. Am J Psychiatry, 160(11): 1 – 60. Brent DA, Poling KD, Goldstein TR (2011). Treating depressed and suicidal adolescents. New York: Guilford Press. Goldstein TR and Poling KD (2011). SIB Institute, STAR Conference, Pgh., PA Hayes, L. (2009) Juvenile suicide in confinement: A national survey. US Dept. of Justice, OJJDP. Download at

References (cont.) Kaffenberger & Seligman (2007). Helping students with mental and emotional disorders, In Erford (ed.)Transforming the school counseling profession(2nd ed.), , Upper Saddle River, NJ: Pearson. Lewis Lm. (2007). No-harm contracts: a review of what we know. Suicide Life Threat Behav.,37,50-57.

References (cont.) Peterson et al., (2010). Adolescents who harm: How to protect them from themselves. Current Psychiatry, 9, Spirito A & Overholser J, editors (2003). Evaluating and treating adolescent suicide attempters. San Diego, CA: Elsevier Science. Wexler DB (1991). The adolescent self: Strategies for self-management, self-soothing, and self-esteem in adolescents. New York, NY: Norton and Co.

Selected Resources National Suicide Prevention Lifeline
TALK Suicide Prevention Resource Center – Safety Planning Guide for Clinicians and Template

Selected Resources (cont.)
Cornell Research Program on Self-Injurious Behavior in Adolescents and Young Adults National Institutes of Mental Health National Center for the Prevention of Youth Suicide

STAR-Center Resources
STAR-Center website Manuals include: Dialectical Behavior Therapy with Teenagers Managing Anxiety Living with Depression Teenage Depression Postvention

Life isn’t the way it is supposed to be. Life is the way it is
Life isn’t the way it is supposed to be. Life is the way it is. It is how we cope that makes the difference. Anonymous Adolescent

All Rights Reserved, 2005, 2009, 2013, and 2014.
We acknowledge with gratitude the Pennsylvania Legislature for its support of STAR-Center and our outreach efforts. This presentation was developed by Services for Teens At Risk and may not be reproduced without written permission from: STAR-Center Outreach, Western Psychiatric Institute and Clinic, 3811 O’Hara Street, Pgh., PA (412) All Rights Reserved, 2005, 2009, 2013, and 2014.

Suicide Awareness, Prevention and Intervention: Everyone Plays a Role … What is Yours? Paula S. McCommons, Ed.D.

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Suicide Awareness, Prevention and Intervention: Everyone Plays a Role … What is Yours? Paula S. McCommons, Ed.D.

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