When the Unthinkable Happens

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When the Unthinkable Happens

• Suicide Prevention and Postvention for Schools

John E. Landers, Ph.D. Clinical
Psychologist doctorlanders_at_gmail.com
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Content of Presentation

• Laws, Rules, Standards, and Expectations
• Scope of the Concern
• Myths and Stigma
• Best Practice in Prevention
• Best Practice in Postvention
• Additional Discussion

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Laws, Rules, Standards, and Expectations
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Idaho Statutes

• TITLE 33
• EDUCATION
• CHAPTER 5
• DISTRICT TRUSTEES
• 33-512.Governance of schools. The board of
  trustees of each school district shall have the
  following powers and duties
• (4) To protect the morals and health of the
  pupils

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Idaho Statutes

• TITLE 33
• EDUCATION
• CHAPTER 5
• DISTRICT TRUSTEES
• 33-512B.Suicidal tendencies -- Duty to warn. (1)
  Notwithstanding the provisions of section
  33-512(4), Idaho Code, neither a teacher nor a
  school district shall have a duty to warn of the
  suicidal tendencies of a student absent the
  teachers knowledge of direct evidence of such
  suicidal tendencies.
• (2) "Direct evidence" means evidence which
  directly proves a fact without inference and
  which in itself, if true, conclusively
  establishes that fact. Direct evidence would
  include unequivocal and unambiguous oral or
  written statements by a student which would not
  cause a reasonable teacher to speculate regarding
  the existence of the fact in question it would
  not include equivocal or ambiguous oral or
  written statements by a student which would cause
  a reasonable teacher to speculate regarding the
  existence of the fact in question.
• (3) The existence of the teachers knowledge of
  the direct evidence referred to in subsections
  (1) and (2) of this section shall be determined
  by the court as a matter of law.

This statute was enacted in 1996 as a result of
the Idaho Supreme Courts decision in Brooks v.
Logan, 132 Idaho 484, 903 P.2d 73 (1005) (Brooks
I).
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Idaho Administrative Rules

• IDAPA 08.02.03.160 SAFE ENVIRONMENT AND
  DISCIPLINE
• Each school district will have a comprehensive
  district wide policy and procedure encompassing
  the following
• School Climate
• Discipline
• Student Health
• Violence Prevention
• Gun-free Schools
• Substance Abuse - Tobacco, Alcohol, and Other
  Drugs
• Suicide Prevention
• Student Harassment
• Drug-free School Zones
• Building Safety including Evacuation Drills
• Districts will conduct an annual review of these
  policies and procedures.

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IDAHO CONTENT STANDARDSHEALTH EDUCATION(Health
Education Standards Approved by Legislature
January 2010 for Fall 2010 School District
Adoption)

• Mental, Emotional Social Health (Grades 6-12)
• Mental, emotional and social wellbeing is a
  foundation for building good health and includes
  a sense of security, identity, belonging, purpose
  and competence in order to strive toward a
  healthy and productive life. Knowledge and skills
  may include emotional intelligence, suicide
  prevention, stress management, communication
  skills, conflict resolution, and mental illness.

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Idaho School Counselors Study

• Completed in April 2010
• Study done as part of the graduate research of
  two students at NNU
• 109 participants (professional school counselors,
  and social workers that are members of ISCA)

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Does your school/district have a written plan to
reduce the likelihood of student suicide?
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Does your school/district have a written plan to
respond to a completed student suicide?
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Have you ever had a student referred to you as
potentially suicidal?
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Scope of the Concern
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Idaho Youth (YRBS Idaho, 2009)

• 28 of Idaho high school students report
  experiencing depression (1 in 3)
• 14 report seriously considering suicide (1 in 7)
• 13 said they made a plan for how they would
  attempt suicide (1 in 7)
• 7 report making at least one attempt (1 in 14)

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Idaho Youth (YRBS Idaho, 2009)

• If you are a high school teacher with 30 children
  in your classroom
• 10 have been depressed this year
• 4 have seriously considered suicide this year
• 4 have developed a plan to attempt suicide this
  year
• 2 have made at least one attempt at suicide this
  year
• Can you name these children?

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Indicators for Educators

• Many adults view youth who are irritable or who
  act out as behavior-problem youth, without being
  aware that a very treatable underlying cause such
  as depression may be affecting the youth
• While youth must be held accountable for their
  actions, it is equally important that their
  depression, if present, be recognized, evaluated
  and treated

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Indicators for Educators

• Miller and Taylor (2000) analyzed high risk
  behaviors in 9th-12th graders and found a
  correlation with suicide ideation and attempts
• High Risk Sex (multiple partners, before age 14)
• Binge Drinking (5 or more in several hours)
• Drug Use
• Disturbed eating patterns
• Smoking
• Violence

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Indicators for Educators

• The 17 of youth with more than three problem
  behaviors accounted for 60 of medically treated
  suicidal acts
• Compared to adolescents with zero problem
  behaviors, the odds of a medically treated
  suicide attempt were
• 2.3 times greater among adolescents with one
• 8.8 with two
• 18.3 with three
• 30.8 with four
• 50.0 with five
• 227.3 with six
• A count of problem behaviors may offer a reliable
  way to identify suicide risk

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Myths and Stigma
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• Suicide is a whispered word, inappropriate for
  polite company. Family and friends often pretend
  they do not hear the word's dread sound even when
  it is uttered. For suicide is a taboo subject
  that stigmatizes not only the victim but the
  survivors as well.
• - Earl A. Grollman - Author of Suicide

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Stigma and Suicide Prevention

• Suicide has become the Last Taboo we can talk
  about AIDS, sex, incest, and other topics that
  used to be unapproachable. We are still afraid of
  the S word
• Overcoming stigma and talking openly about
  suicide is the key to prevention
• Suicide is the leading cause of death for Idaho
  youth after unintentional injury
• Suicide is preventable through treatment
• Educators spend more time with our youth than any
  other adults and have a key role to play in
  detection and referral for treatment

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Myth vs. Fact

• 1.Talking about suicide might cause a person to
  act
• False it is helpful to show the person you take
  them seriously and you care. Most feel relieved
  at the chance to talk
• 2. A person who threatens suicide wont really
  follow through
• False 80 of suicide completers talk about it
  before they actually follow through
• 3. Only crazy people kill themselves
• False - Crazy is slang for psychotic, which means
  to have lost touch with reality. Few who kill
  themselves have lost touch with reality they
  feel hopeless and in terrible pain (90 of those
  completing suicide meet criteria for depression)

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Myth vs. Fact

• 4. No one I know would do that
• False - suicide is an equal opportunity killer
  rich, poor, successful, unsuccessful, beautiful,
  ugly, young, old, popular and unpopular people
  all complete suicide
• 5. Theyre just trying to get attention
• False They are trying to get help. We should
  recognize that need and respond to it
• 6. Suicide is a city problem, not in the country
  or a small town
• False rural areas have higher suicide rates
  than urban areas

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Myth vs. Fact

• Once a person decides to die nothing can stop
  them - They really want to die
• False - most people want to be stopped if we
  dont try to stop them they will certainly die -
  people want to end their pain, not their lives,
  but they no longer have hope that anyone will
  listen, that they can be helped
• Taking antidepressants increases risk of suicide
• False Yes the FDA has put a label on SSRIs
  stating that use may increase suicidal agitation
  however, A 2003 WHO study in over 15 countries
  found a significant reduction, averaging about
  33, in the youth suicide rate that coincided
  with the introduction of SSRI's

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Other Myths

• Suicide is generally completed without warning
• Listening to certain types of music (e.g., heavy
  metal) or engaging in certain activities (e.g.,
  watching particular movies) causes people to
  become suicidal
• Preventing access to lethal means will not
  prevent suicide - students will simply choose
  another method
• Suicide rates are higher for impoverished people
• Membership in some religions protects against
  suicide more than in others
• The motives for suicide are easily established
• A person with a terminal physical illness is
  likely to complete suicide
• There is a very low correlation between alcohol
  abuse and suicide
• Males have the highest rate of suicidal behavior
• Improvement in emotional state means lessened
  risk of suicide
• Severe mental illness is particularly associated
  with youth suicide

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Best Practice in Prevention
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Education Components

• UNIVERSAL PREVENTION Prevention for all students
  via curricula and activities to boost resiliency
  and protective factors, while preventing and/or
  mitigating potential risk behaviors. Staff
  training is designed to create awareness, help
  identify students with risk behaviors or warning
  signs, and communicate the risk to school mental
  health professionals.
• Administrative Consultation
• Gatekeeper Training for all Staff
• Parent Training (similar to gatekeeper)
• Community Resource Training
• Student Training
• SELECTED INTERVENTION Identification and
  intervention efforts that target students with
  vulnerabilities such as depression, a recent loss
  experience, bullying behaviors or other risk
  factors.
• INDICATED INTERVENTION Crisis-response
  assessment and intervention services for students
  having suicidal thoughts or behaviors, or
  demonstrating other self-injurious acts.

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Model Program Miami Dade County Public School
District

• Program emphasizes recognizing risk and warning
  signs, help-seeking, self-awareness, conflict
  resolution, anger management, problem solving,
  relationship building, coping skills, stress
  management and more.
• Results of the Miami-Dade Youth Suicide
  Prevention and Intervention Program, or YSPIP,
  include a 75 reduction in the suicide rate among
  15-19-year-old students since program inception
  in 1989.
• The suicide rate is well below levels of same-age
  students in Florida and across the United States.

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Idaho Resources from State Dept. of Education and
SPAN-Idaho

• There are resources on prevention and postvention
  as well as legal considerations available on the
  SPAN Idaho website
• These have been designed with best-practices in
  mind and are free for your district to access,
  modify, and utilize
• Access resources via http//www.spanidaho.org/
  and click on the Schools link to the right

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Free Best-Practice Prevention Program

• Two fathers who lost adolescent children to
  suicide have collaborated with the nations top
  experts in implementing and evaluating
  school-based suicide-prevention programs.
• The result is a top-notch two-hour online
  training module in suicide prevention for school
  teachers called Making Educators Partners in
  Youth Suicide PreventionTM.
• Available through a not-for-profit organization
  formed by the two fathers, Scott Fritz and Don
  Quigley of New Jersey, this interactive training
  program can be accessed at www.sptsnj.org.
• Its content is applicable across states and
  school systems, and has been lauded nationwide.
  To learn more about this designated best-practice
  program, email talkback_at_wellawaresp.org.

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Best Practice in Postvention
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• The single best predictor of how students will
  respond to a frightening event is how the adults
  around them are reacting. Being able to work
  through the effects of a suicidal death with
  caring, supportive adults will decrease the
  contagion. Any kind of death is hard for
  adolescents, but it is especially hard if adult
  guidance and support is withheld.
• Ruof, S.R. Harris, J.M. (1988). Suicide
  contagion Guilt and modeling. A series on
  suicide prevention. NASP Communique, 16(7), 8.

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Goals of Postvention

• Prevent other suicides.
• Reduce the onset and degree of debilitation by
  psychiatric disorders (e.g., PTSD).
• Reduce feelings of isolation among suicide
  survivors.

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Postvention Checklist Included in Resources

• Verification of suicide
• Mobilize the crisis intervention team
• Assess the suicides impact and level of services
  needed
• Notify other school personnel
• Contact the family of the suicide victim
• Determine what and how to share information
• Staff Planning Session
• Intervention services
• Memorials and funerals
• Dealing with the media
• Debriefing

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Additional Discussion
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Universal Prevention First-Responders

• Proper implementation of universal prevention
  program means anyone and everyone is a
  first-responder
• What would you do if you saw someone in physical
  pain, being physically injured, or unconscious?
• If you needed to administer CPR or first-aid,
  could you?

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First-Responders

• Brain death occurs 4-6 minutes after sudden
  cardiac arrest without implementing CPR. That is
  why even if an AED is not available, providing
  simple CPR until the paramedics arrive can have a
  huge impact on the outcome. By continuing to
  manually pump blood throughout the body the brain
  and other organs are kept alive.
• The American Heart Association states that when
  CPR and defibrillation are administered within
  eight minutes of a cardiac arrest, the victim's
  chance of survival increases to 20. When these
  steps are provided within four minutes and the
  paramedics arrive within eight minutes, the
  likelihood of survival increases to over 40.
• Until everyone is properly trained in CPR and
  first aid, surviving a cardiac arrest is really
  about being in the right place at the right time.
  
• Since most cardiac arrests statistically happen
  in the home, becoming CPR trained might just mean
  you will one day save the life of a good friend
  or loved one!
• Why are we talking about CPR and
  First-Responders?

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Psychological First-Responders

• Who is the most likely individual to be in the
  presence of an adolescent experiencing a
  psychological crisis?
• Who is an adolescent experiencing a psychological
  crisis most likely going to turn to for help?
• Who is going to provide an initial assessment,
  build rapport, and referral for further
  assessment and treatment?
• First responder or Licensed mental health
  professional?

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Barriers to First-Responders

• Bystander Effect (Kitty Genovese) - presence of
  others inhibits helping
• conclude from the inaction of others that help is
  not needed
• assume that someone else is going to intervene
• Comfort
• Confidence
• Competence
• Training can alleviate these concerns!

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When Do I Intervene?

• If you believe that someone may be thinking about
  harming themselves, for whatever reason
• Dont allow any barrier to get in the way (e.g.,
  time, fear, attitudes, etc)
• Ask the Question

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Initiating the Assessment

• It seems things havent been going so well for
  you lately. I know that recently _______ has
  happened. Most people would find that upsetting.
• Have you felt upset, maybe some sad or angry
  feelings youve had trouble talking about? Maybe
  I could help you talk about these feelings and
  thoughts?
• Do you feel like things can get better, or are
  you worried things will just stay the same or get
  worse?
• Are you feeling unhappy most of the time?

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Identifying Suicidal Ideation

• Others Ive talked to have said that when they
  feel that sad or angry, they thought for a while
  that things would be better if they were dead.
  Have you ever thought that? What were your
  thoughts?
• Is the feeling of unhappiness so strong that
  sometimes you wish you were dead?
• Do you sometimes feel that you want to take your
  own life?
• How often have you had these thoughts? How long
  do they stay with you?

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Risk Assessment

• Current Plan
• Prior Behavior
• Resources

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Current Plan

• Have you thought about how you might make
  yourself die?
• Do you have a plan?
• On a scale of 1 to 10, how likely is it that you
  will kill yourself?
• When do you think you might do this?
• Do you have the means with you now, at school, or
  at home?
• Where are you planning on killing yourself?
• Have you written a note?
• Have you put things in order?

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Prior Behavior

• Has any one that you know of killed or attempted
  to kill themselves? Do you know why?
• Have you every threatened to kill yourself
  before? When? What stopped you?
• Have you ever tried to kill yourself before? How
  did you attempt to do so?

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Resources

• Is there anyone or anything that would stop you?
• Is there someone whom you can talk to about these
  feelings?
• Have you or can you talk to your family or
  friends about suicide?

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C P R
Current Plan
Prepared
Prior Behavior
Acceptable
Resources
Alone
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Next Steps

• What will you do now?

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Contact Us

• Matt McCarter
• Safe and Drug-Free Schools Coordinator
• Idaho State Department of Education
• mamccarter_at_sde.idaho.gov
• John Landers, Ph.D.
• Clinical Psychologist
• Eastern Idaho Regional Medical Center
• doctorlanders_at_gmail.com