Youth Suicide

1
Youth Suicide

• Lorna Martin
• lormartin_at_gov.mb.ca

2
Common Warning Signs ofYouth Suicide

• Suicide threats (written, direct, indirect)
• Preoccupation with death (making final
  arrangements, giving away prized possessions,
  talking, reading, writing, drawing about death or
  a dead person)
• Changes in behaviour, physical condition,
  thoughts, or feelings (withdrawal, isolation,
  increased risk-taking, decreased performance,
  frequent lateness, unexplained absence, crying
  jags, heavy use of alcohol or drugs, abrupt
  changes in appearance, appetite, sleep patterns,
  exaggerated fears, irrationality/anxiety,
  hopelessness, increased irritability, moodiness,
  lethargy)
• Stress (intolerable loss)

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Four Indicators of Risk Levels

• Stress
• Critical situational events, personal loss
• Disruptive life events
• Symptoms
• Changes in behaviour, physical condition,
  thoughts/feelings
• Thoughts of Suicide
• Direct/indirect
• Loss/Lack of Social Network/Support
• Healthy connections to others missing or lost

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Assessment of Risk

• Current Suicide Plan
• Method, preparation, means, time frame
• The more detailed the plan, the greater the risk
• Prior Suicidal Behaviour
• Prior attempt(s) reveal(s) acceptance of suicide
  as an alternative
• Resources
• Risk decreases with personal support resources
  such as a place to live, caring family, friends
  or teachers, access to help

5
Spectrum of Suicidality

• Not all youths follow the same trajectory towards
  suicide
• Self-harm is not necessarily a precursor to
  suicide
• Not all suicidal youths are depressed
• Not all youths indicate their feelings of suicide
  prior to an attempt or completion

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Sample 1 Trajectory

• IDEATION
• -thoughts of death
• -wishes never born
• -life not worth living
• -thoughts of killing self (general moving towards
  specific)
• -sees suicide as retribution

• INTENTION
• -writing notes/will
• -giving away possessions
• -subtle/overt threats
• -minor self-harm and self-destructive risk-taking

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Sample 1 Trajectory (contd)

• ATTEMPT
• -pseudo-suicide attempt (in a place and time when
  interveners will be present)
• -minor attempt (failure is distinct possibility)
• -major attempt (failure remote)

• COMPLETION

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Sample 2 Trajectory

• IDEATION
• Thoughts of killing self (specific)
• INTENT
• Expresses threat in angry outburst
• Threatens to harm others simultaneously

• ATTEMPT
• Major attempt (selects time and method with
  little chance of failure)
• COMPLETION

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Sample 3 Trajectory

• IDEATION
• None expressed
• INTENT
• None observed
• ATTEMPT
• - None observed

• COMPLETION

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Sample 4 Trajectory

• IDEATION
• -Morbid ideation
• -Preoccupation with death and dying
• INTENT
• -Writes songs
• -Self-harms

• ATTEMPT
• None observed
• COMPLETION
• -None to date

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Early Family Influences on Suicidal Behaviour
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Assessing Risk Levels

• Ensure you are qualified to make risk decisions.
  If you have not been trained through a program
  such as ASIST or LivingWorks, seek assistance
  immediately. If you are trained, it is still
  important to debrief with a qualifed colleague.
• Risk levels increase as resiliency factors
  decrease
• Risk levels increase with
• Current suicide plan
• Prior suicidal behaviour
• Lack of available resources to act as a safety
  net
• Risk levels further escalate if suicide plan has
  method, means and established timeframe

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If you are a trained intervener

• The next slides are reminders
• The next slides are for your information, to
  assist you providing details to a trained
  intervener

If you are likely to be a trusted professional
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Seeking Assistance and Support

• Use the school threat assessment and/or crisis
  intervention protocol to assist you
• Access the school psychologist, social worker,
  AFM worker or other qualified intervener within
  your system
• Access medical, RCMP, or mobile crisis unit if
  there are no qualifed interveners within your
  system.
• Contact parent(s)/guardian(s).
• Document your actions.

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Acronyms to Aid in Assessing Risk

• To respond efficiently to a suicidal youth, it is
  important to be calm, patient, and direction.
• To determine the degree of risk, you need to
  learn answers to specific questions. Ask them. It
  may be a life-saving decision.

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Miller (1984) Acronym 1

• S - how specific is the plan of attack? The more
  specific the details related the higher the
  degree of present risk
• L - how lethal is the proposed method? How
  quickly could the person die if the plan is
  implemented? The greater the level of lethality,
  the greater the risk.
• A - How available is the proposed method? If the
  implement to be used is readily available, the
  level of suicidal risk is greater.
• P - What is the proximity of helping resources?
  Generally, the greater the distance the youth
  would be from helping or supporting resources if
  the plan were implemented, the greater the degree
  of risk.

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Miller (1984) Acronym 2

• Four additional factors to aid in assessing the
  level of suicidal risk when the youth has made a
  previous suicidal attempt
• D Dangerous How dangerous was the prior
  attempt and current plan? The greater the danger,
  the higher the current risk.
• I Impression Even if the danger in the
  attempt or plan is not significantly high, if the
  impression is that the danger is high and will
  surely cause death, the present risk is high.
• R Rescue If the opportunity for rescue was
  great in the prior attempt or present plan, the
  risk is lower than if the opportunity for rescue
  was remote. If the chances were or are poor that
  rescue will occur, the present risk is high.
• T Timing If the previous attempt was recent,
  the present risk is higher than if the previous
  attempt was long ago.
• If a youth may be at immediate risk, you must
  immediately implement any process necessary to
  protect that youth or to provide life-saving
  supports.

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Safety Contracts

• Many low to moderate risk youths respond
  positively and reliably to a safety contract.
• The contract should include
• A specific plan that prevents immediate risk
• A commitment to not engage in self-harm for an
  agreed-upon timeframe
• Crisis support, including names and telephone
  numbers
• Ensure you have a back-up plan in addition to a
  safety contract

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Sample Safety Contract

• PERSONAL SAFETY CONTRACT
• Date________________________ Time
  ________________
• I, (name), promise to keep myself safe until
  (date and time) when I see my counsellor. I will
  not harm myself or others in any way. If I feel
  like I cannot control myself or start to feel
  worried, or anxious, or that I might not keep
  this promise, I will call
• (insert youths choice of trusted friend or
  family member and telephone number) or
• (insert youths alternative choice and telephone
  number) or
• (insert name of hospital/RCMP/nursing station and
  telephone number)
• _______________________ _______________________
• Signature of Youth Signature of Counsellor

Ensure you have a back-up plan in addition to a
personal safety contract. Contact resources.
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Assisting Low Risk Youths

• Listening empathically
• Obtaining a specific, written promise to seek
  help when needed
• Providing a promise of continued support
• Will you be safe until Tuesday?
• Ill stay with you while you tell your parent
  how youre feeling.
• Can you promise me that you will follow the
  instructions we have agreed to in this contract?
• Will you keep your appointment with me tomorrow?

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Assisting Moderate Risk Youths without a specific
plan

• Require more intervention and direction
• Written and verbal commitment required
• Refer to school psychologist
• Contact parent(s)
• Im not positive youre going to be okay after
  you leave here.
• Will you keep the promises you made in our
  contract?
• Heres a telephone number where I can be
  reached, the suicide crisis line and the clinic
  number. Promise me now that you will call me or
  any of these other numbers for help before you
  decide to take any action that might harm you.
  Even when the idea enters your head and youre
  not sure.phone. Can you promise?
• Can I telephone you this evening to make sure
  youre all right? Im very concerned and I want
  us to talk again to make things better for you.
• Will you be safe if you leave here now? Are you
  positive?

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Assisting High Risk Youths

• Youth is in crisis
• Do not leave the youth unsupervised.
• Support cannot be withdrawn for any reason
• Be assertive and directive.
• I cant leave you here alone. I want you to come
  with me now so we can get you more help than I
  can give you here.
• You cant promise that you wont kill yourself
  and that concerns me. Lets go together to the
  hospital where we can get more support.
• Do not take no for an answer. Follow school
  protocol for threat assessment/crisis
  intervention.
• Contact parent(s). Dial 911 if necessary.

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Summary of Typical Risk Factors

• Recent attempts
• Recent losses
• Critical incidents
• Prior traumas
• Isolation/withdrawal
• Substance abuse

• Destructive coping styles
• Poor problem solving skills
• Disorientation
• Inadequate support
• Hopelessness/ helplessness

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Summary of Protective Factors

• Support from family and friends
• Perceived connection to family and friends
• Strong cultural ties
• Good physical and mental health
• Strong spiritual ties
• Positive self-esteem
• Early identification and treatment of psychiatric
  illness

• Good school performance
• Positive attitude towards school
• Skills in stress management, communication,
  problem-solving
• Fear of suicide and objections to suicide
• Sense of belongingness

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Risk vs Imminent Danger

• PHASE ONE
• Is there a plan and means?
• Risk factors five of the following (1-4risk,
• 5 or moredanger)
• Male
• Past attempt
• More than one attempt
• Antisocial behaviour
• Friend or family who has committed suicide
• Drug and/or alcohol abuse
• Depression
• Difficulty socially, especially family problems

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Risk vs Imminent Danger (contd)

• PHASE TWO
• Can the youth complete tasks incompatible with
  suicidal states?
• Written promise to abstain from suicidal
  behaviour for specified time
• Ability to compliment self and others
• Ability to assess their own emotional state (e.g,
  develop hierarchy of situations that would raise
  suicidal thoughts)
• Capacity to plan ahead (e.g., being prepared for
  stressors, positive imagery, relaxation, develop
  social support system
• (Inability to accomplish these four tasks
  indicates possible imminent danger)

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Referrals

• Report suicidality and refer to a trained
  professional (e.g., psychologist, medical doctor,
  Salvation Army Mobile Crisis Unit). While
  awaiting the professional,
• Remove access to means of suicide
• Use protocols for threat assessments/crisis
  intervention
• Inform parent that referral has been made
• Maintain supervision of youth

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Formal Assessments

• There are several instruments available to
  trained professionals to detect suicidality. Some
  of the most commonly used are
• Suicide Probability Scale (SPS)
• Suicidal Ideation Questionnaire (SIQ)
• ISO-30
• Childrens Depression Rating Scale
• Beck Hopelessness Scale (BHS)
• Index of Potential Suicide

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Making the Connection

• Youve recognized the signs and symptoms.
• Youve asked the questions directly.
• Youve documented the interview and your actions.
• Youve made a connection with the youth.
• You may be the difference between recovery and
  imminent death.
• The youth is trusting you to be a reliable,
  responsible adult.

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Keeping the Connection

• Stay focused.
• Stay calm.
• Stay with the youth.
• Err on the side of caution.
• Trust your gut.
• Get help. Create a helping network with the
  youth.
• Document events.
• Debrief with a trusted colleague following the
  initial resolution of the event.

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• This presentation has been an overview of
  commonly held principles and practices when
  dealing with suicidal clients.
• It is intended as an information session only.
• This presentation does not provide training for
  suicide intervention.
• For information on training in intervention and
  postvention, please contact

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• Centre for Suicide PreventionSuite 320, 1202
  Centre Street S.E.Calgary, Alberta Canada T2G
  5A5
• Phone [phone] Fax [phone]
  sptp_at_suicideinfo.ca or
• Lorna Martin
• Manitoba Education, Citizenship and Youth
• Phone [phone] Fax [phone]
• lormartin_at_gov.mb.ca