Suicide Prevention, Intervention & Postvention in Schools

Suicide Prevention, Intervention & Postvention in SchoolsAn Overview for School LeadersSuicide is a difficult topicMost 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.

2Context for the presentationThis presentation targets the School Mental Health Leadership TeamIt is designed to:Build common understanding about suicide amongst school mental health leadersHighlight helpful prevention, intervention and postvention strategiesProvide recommendation actions for consideration at the school levelSession OutlineBrief Overview of Suicide in Children and YouthSuicide Prevention, Intervention & Postvention StrategiesIssues for School LeadersRecommended Actions for the MH Leadership TeamRoles and Protocols (mh leadership team, 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)

Child and youth suicideBrief Overview

Suicidal behaviourNon-Suicidal Self-Injurya deliberate attempt to cause injury to ones body without the conscious intent to dieSuicidal IdeationSuicidal thoughts that include both contemplating death by suicide and planning actions that could result in death Suicide Attemptself-harming behaviour that includes an intention to dieDeath by Suicideself-harming behaviour that results in deathFacts and Figures2nd 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 ageDeath by suicide is more prevalent in males than females aged 15-19Recent 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)

The complexity of RiskProtective FactorsVulnerabilities - selfMental illness (e.g., mood, anxiety, conduct disorders)Past suicidal behavior Substance useUnstable mood, high impulsivityRigid thinking or coping patternsPoor 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.Past suicidal behavior - 37% repetition rate In more than half of suicidal attempters, there was failure at school or dropout

9Vulnerabilities - homeFamily history of suicides / attemptsParental mental illnessAlcohol / substance abuse in the homeHistory of violence and/or abuse Divorce, separation, other losses, deathTension and aggression between parentsParental 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.Parental divorce rate = 2x higher in suicidal patients

40% of abused children show suicidal behavior10Vulnerabilities school/communityLearning problemsDisengagement from schoolLack of connectednessMarginalizationDiscontinuity in identity (cultural, language, gender, sexual)Some communities are at heightened vulnerability (e.g., aboriginal, LGBTQ, homeless)Negative social relationships, including bullying

Pre-existing vulnerabilityIncreases risk for bullyingVictimizationNew or Exacerbated:

Anxiety Depressed mood Diminished self-worth Feelings of entrapment Loneliness Withdrawal Sleep/eating problems HopelessnessWhich are risk factors for: Suicidal ideation Suicide attempt

Death by suicideAdapted Lenny Berman 2010 Bullying and Suicide 8doc.webinar American Association of SuicidologyBullying and SuicideTriggersBreak up with boy/girl friendConflicts and increased arguments with parents and/or siblingsLoss of close friendSchool related difficulties-conflicts with teachers, classmatesDifficulties with the lawChange in parents financial statusSerious illness or injury in family memberReal or perceived loss of status

ContagionOccurs when suicidal behavior influences an increase in the suicidal behavior of othersMultiple suicidal behaviors/suicide deaths that occur within a geographical area or fall within an accelerated time frame may represent a potential clusterAlthough clusters are rare, they are most common amongst adolescentsCircles of vulnerabilityPopulation at RiskLahad & Cohen, 2006The role of cyber/social mediaIncreasingly there are sites, chat rooms and blogs that promote suicidal ideationMethods of suicide are discussed on-line and some researchers have suggested that increases in particular methods in recent years may be related to this dialogueThe rapid spread of rumours and details of deaths by suicide is difficult to manageParadoxically, social media may hold potential benefits for suicide prevention(Skinner & McFaull, 2012)The role of media Media can be helpful or harmful it is never benign and they cannot view themselves as impartial observersContagion (mimicking of suicidal behavior) is a real phenomenon and youth are particularly vulnerableMedia needs to be held accountable for adhering to safe reporting guidelines following a death by suicideMedia can be helpful in bringing awareness to issues of child and youth mental health more broadlyResponding to mass media / social media coverageRecent weeks have brought usA very tragic example of the complexity of suicidal behavior An illustration of the influence and dangers of social mediaIrresponsible media coverage and oversimplification of the issues in much public discourseWell-intentioned, but potentially harmful, actionsContagionA magnification of the need for district and school leadership to ensure student safety

Protective factorsProblem solving, life & communication skills SociabilityResilient PersonalityA sense of belonging (school, community)Secure attachment to positive parent/family

Access to other caring & supportive adultsPro-social peers Appropriate discipline, limit setting & structure Opportunities to develop self-esteemGood Mental Health

Youth suicide is complex and is often the result of many converging factors. The explanations and the solutions are equally complex.

What can we do?Reduce vulnerabilities - at schoolEnsure school is safe and accepting, especially for vulnerable students (enhance sense of belonging, increase connectedness and engagement, show respect for differences)Build on protective factorsProvide skill-building, opportunities to build esteem, etc.Look out for triggersIdentify students at risk, listenMinimize the risk for contagionHave a plan for helpSuicide prevention, intervention, & postventionStrategies for

First, do no harmIn considering various prevention, intervention, and postvention strategies, the Mental Health Leadership Team needs to understand that this area of work is not benignSome actions are more effective than others, some are risky, and many have not been evaluated rigorouslyThis may mean taking a fresh look at existing practices to ensure alignment with the evidence base in this areaClose communication with your senior administration team will be important if practice changes are requiredThrough this section, ConsiderWhat is your school doing consistently across the system in suicide prevention, intervention and postvention?

Are these initiatives aligned with the evidence-base?SCHOOL RESPONSE TO SUICIDEFour components: Administrative Foundation, Prevention, Intervention & Postvention

25What 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.

26What is Suicide Prevention?Efforts to reduce the risk of suicidal thoughts and behavior amongst students in a systematic way

What is intervention?Practices involved in recognizing and responding to students with suicidal ideation or behaviorPractices involved in supporting vulnerable students transitioning to and from mental health care

What is postvention?Support for school communities in responding to suspected, attempted, or death by suicide

Helpful Prevention strategiesSafe and accepting school culture Social emotional learning (coping skills, conflict resolution)Early identification and treatment of mental health problemsGatekeeper trainingInformation dissemination (staff, parents, students)

Prevention Strategies to avoidThere 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 factorsafter adults have received gatekeeper training)Assigning suicide as a central or sole focus of studyLarge assemblies with guest speakers who talk about suicideEvents that have the potential to glorify/glamorize suicidePeer counseling related to suicide

Prevention StrategyEvidenceEarly identification and treatment of mental health problemsSolidSchool/community culture buildingSolidAdaptive coping skill developmentSolidInformation dissemination / gatekeeper training PromisingScreening and referral MixedYouth engagement / peer helper programsMixedSuicide awareness curricula for studentsMixedMeans restrictionMixedCrisis hotlinesMixedMedia education programs Insufficient EvidenceEffective postvention Insufficient EvidenceInformation Dissemination and Gatekeeper trainingDifferent audiences have different knowledge needs

AWARENESS - Classroom teachers can benefit from as little as a 2-hour session that provides information about risk factors, warning signs, and what to do if one of their students appears to be at risk for suicide

LITERACY - More in-depth gatekeeper training can be offered for select individuals in a school who are in a position that makes is more likely that students will approach them for help (e.g., admin team, guidance, student success), and who are willing to provide consultation and support when crises occur

EXPERTISE - School mental health professionals should maintain strong knowledge and skills with respect to suicide assessment and supportNeeded KnowledgeFor intervention to be successful, basic knowledge about warning signals can be shared with those in a position to notice changes in behavior amongst youthSchool staff, parents, students, youth-involved community members Can be shared in a variety of ways (brochures, workshops, fact sheets, trusted websites, media)Key warning signals are described here as a handy referenceNote that 100% accurate prediction of suicide is impossible. We can only do our best.WARNING SIGNALS: Behavioural Loss of interest in former activitiesWithdrawal from social contactDifficulty concentrating, problems with judgment and memoryDramatic shift in quality of academic performanceFeelings of sadness, emptiness and hopelessness, often expressed in written assignmentsSleep disturbances

These signals also relate to problems in mental health more generallyStrong and overt expressions of anger and rageExcessive use of drugs and/or alcoholPromiscuous behaviourUncharacteristic delinquent, thrill-seeking behaviourSelf-mutilationOccurrence of previous suicidal gestures or attemptsPlanning for death; making final arrangements; giving away favourite possessionsWARNING SIGNALS: BEHAVIOURAL

WARNING SIGNALS: CommunicationStatements revealing a desire to die, or a preoccupation with deathNihilistic comments: life is meaningless, filled with misery, whats the use of it all?Verbal or written threatsSudden cheerfulness after prolonged depression may be relief because decision has been taken

Helpful intervention strategiesIdentification and Referral

Ensure staff aware of warning signalsEnsure clear protocol at school level

Provide immediate and calm support to the studentEnsure safety and supervisionFacilitate assessment and careContact parent/guardianDocument actions

Helpful intervention strategiesSupporting Vulnerable Students

Ensure staff understand role and limits of competenceSupport staff with caring adult role

Identify vulnerable students Work with clinical staff, when involvedCreate a school safety plan for each student, as neededImplement and monitor plans, as needed

Intervention strategies to avoidPeer intervention models with inadequate adult supervision and monitoringRecruitment of gatekeepers who are uncomfortable / unready for the roleCounseling of high risk students by unqualified professionals

Helpful postvention strategiesUnderstand the phases of postventionHave a plan for who does what at each phase of postventionFirst 24 hoursNext 48-72 hoursDuring the first monthPlanning for the futurePractice deliberate self- and team-careWorking through phasesThe accompanying presentation for the School Mental Health Team articulates considerations for the postvention period, through these phasesThis 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 neededMain message have a plan for who does what at each phase of postventionFirst 24 hoursVerify the death, confirm the facts, talk with the students family personally (usually the principal, with support from the Board Team)

Mobilize the critical incident response team

Assess the impact of the death and level of response required If parents do not wish the suicide to be disclosed, and students are unlikely to find out the cause of death, large scale suicide postvention is not indicatedIn contrast, high impact events that will involve media would call for support from the board response team and enacting of postvention protocols

Identify vulnerable students and provide support

Determine what information to share, with whom, howInform Superintendent, notify school staff, inform students simultaneously in their classrooms (not through announcements or a large assembly) using prepared scripts

Manage the media, using one designated liaison person with media training (may be a member of the board team)Next 48-72 hoursRestore school to regular routinesLiaise with bereaved/affected familyConsider involvement with funeral/memorialsAvoid on-campus memorials that could glorify suicideMonitor staff well-beingKeep school community informedInvolve community partners in postvention supportDocument actionsDuring The first monthMonitor all staff and student well-beingPlan for school events of relevance (year book, award nights, graduation)Conduct a critical incident reviewConsider offering information sessions for parent community with mental health agencyContinue documentation of actionsResponse Team DebriefingPlanning for the futureContinue support and monitoring of students and staffPlan for anniversaries, birthdays and significant eventsImplement recommendations from the critical incident review, in consultation with SO and MH Leadership TeamAssess current suicide prevention strategies and enhance as neededShare the postvention plan with new staff membersContinue to work with community to refine response for future

MediaSocial MediaTake care of each otherDeath by suicide is a special kind of school crisis that impacts us in significant ways, professionally and personallyThe School Team needs to work together, to debrief often, and to reach out when members are strugglingMembers need to practice self-care deliberatelyThe Board Team can provide support in this regard the School Team is not alone

Documentation of Ontario community mobilization response following a suicide clusterA 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 resolutionKnowledge and skills for early identification of mental health problems (with clear connections to service)Gatekeeper training, with protocols for students at riskEffective postvention, with protocolsOther strategies? Evaluate!!Issues for school leadersChild and Youth Suicide

It takes a villageMany players needed, to assume different rolesSuicide Strategy Planning and CommunicationE.g., Board Mental Health Leadership Team, Senior Administration Team, Corporate Communications / Public Relations, Community PartnersSuicide Prevention and InterventionE.g., Board Mental Health Leadership Team, School Mental Health Professionals, School Administration, School Staff, Community PartnersPostventionE.g., Initial team may include: Principal/Vice-Principal(s), Critical Incident Response Team, Superintendent, Board Mental Health Leadership Team, Corporate Communications, Community PartnersPertinent issues for school leadersDetermining a coordinated school-wide approach Establishing systematic and proactive suicide prevention initiatives within the context of wider mental health promotion and prevention effortsEnsuring clear protocols and roles for intervention with students exhibiting suicidal behaviorDeveloping or updating postvention protocols in light of new realities (consistent with established board protocols)Communicating the suicide strategy and related supports and expectations with staff

Suicidal behavior is a reality in your schools

Be proactive, Be Prepared

Components of an effective Suicide strategyProtocols for students at riskProtocols following a death by suicideBroad focus on mental health promotion, skill-building and caring school culturesStaff education and training Media educationParent education

An effective strategy builds common understanding across the board & community, and signals a systematic, proactive approachRecommended actionsSchool Leaders

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)

Getting organizedIdentify Existing/Needed Teams (Board, School, Critical Incident Response)Clarify Roles, as neededDevelop/update protocols for intervention & postventionDevelop/update tools/templates for intervention & postventionSelect and implement prevention strategiesStage capacity-building effortsCommunicate the suicide strategy to staffMonitor, evaluate and refine the strategyMany school have teams and tools in place. For these schools, 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.Identify Teams*BoardSuicide Strategy Team protocol development, strategy selection, etc.Suicide Response Team support school team, work with media, etc.

SchoolSuicide Strategy Team protocol development, strategy selectionSuicide Response Team support students, staff, community, etc.

Crisis Response TeamSupport 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 theseClarify rolesLeadership and Planning TeamsWho will be involved in confirming our school protocols for intervention and postvention? Who will be involved in selecting prevention approaches?

Response TeamsWho 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? Develop/update protocolsObtain information about any board-wide protocols for intervention and postventionConsult with colleagues in developing/updating protocols for your school, particularly those who have worked through postventionWhere appropriate to do so at the school level, work with local agencies to plan for community mobilization during postvention (note that this may be worked out at a system level)

Develop/update your Intervention Protocol (clearly state what to watch for, what to do, who in involve, where to document)

Develop/update your Postvention Protocol

Access toolsAccess pertinent tools and templates available at the board level and ensure the School Mental Health Team knows how to access these in the event of a suicidal crisisInterventionFact sheets / warning signalsAt a glance protocol or flowchartMore detailed protocol with rationalePostventionLetters for school communityScripts for studentsKey messages for mediaSupport documents for staffDocumentation outlineCritical incident review form

Select and implement prevention strategiesIf you have a mental health strategy that includes universal promotion and skill-building, you are already doing some of this workWork with caring and accepting schools professionals to enhance sense of belonging in schoolsPrepare information for dissemination with key groupsWork towards mobilization of community

Capacity - buildingWhen possible, sequence capacity-building:

School LeadersSchool StaffGatekeeper TrainingParentsStudents

Different audiences will have different knowledge needsCommunicate with staffCommunicate the protocol and related tools and templates

Board MH Team School LeadersSchool LeadersSchool Staff

Some messages may need to go directly from the Board MH Team to all Staff and to mediaMonitor, evaluate, refineDocumentation and debriefing of actions and enablers/challenges is important; for prevention, intervention, and especially postventionPostvention is emotionally-charged, and the more that our actions can be routinized the betterWhile every situation is unique, each offers learning opportunities that can be used in future Sources, with ThanksMH Leader Suicide SubgroupIan Manion, Ontario Centre of Excellence for Child and Youth Mental HealthIan Brown, School Mental Health ASSISTStephan 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 2008Contact School Mental Health ASSISTKathy Short, Ph.D., C.Psych.Director, School Mental Health ASSISTKathy.Short@hwdsb.on.ca905-527-5092, x2634

School Mental Health

ASSISTquipe dappui en sant mentale pour les coles