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SUICIDE PREVENTION, INTERVENTION & POSTVENTION IN SCHOOLS An Overview for School Leaders Slide 2 SUICIDE IS A DIFFICULT TOPIC Most of us have been touched, professionally and/or personally, by suicide Important to support one another as we approach this topic today.and in days following No scheduled breaks, come and go as is right for you If you would like to talk to someone, we are available to help. Slide 3 CONTEXT FOR THE PRESENTATION This presentation targets the School Mental Health Leadership Team It is designed to: Build common understanding about suicide amongst school mental health leaders Highlight helpful prevention, intervention and postvention strategies Provide recommendation actions for consideration at the school level Slide 4 SESSION OUTLINE Brief Overview of Suicide in Children and Youth Suicide Prevention, Intervention & Postvention Strategies Issues for School Leaders Recommended Actions for the MH Leadership Team Roles 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) Slide 5 CHILD AND YOUTH SUICIDE Brief Overview Slide 6 SUICIDAL BEHAVIOUR Non-Suicidal Self-Injury a deliberate attempt to cause injury to ones body without the conscious intent to die Suicidal Ideation Suicidal thoughts that include both contemplating death by suicide and planning actions that could result in death Suicide Attempt self-harming behaviour that includes an intention to die Death by Suicide self-harming behaviour that results in death Slide 7 FACTS AND FIGURES 2 nd leading cause of death after accidents, accounting for 17.3- 20.4% of adolescent mortality (but important to put this in context, death is relatively uncommon in this age group) 1.4% of all suicides occur in children under 14 years of age Death by suicide is more prevalent in males than females aged 15-19 Recent Canadian epidemiological study shows overall stable rates of suicide over the past 30 years, but trends are changing: decreasing rates for males and increasing rates for females (Skinner & McFaull, 2012) Slide 8 THE COMPLEXITY OF RISK Vulnerabilities (Distal) Triggers (Proximal) Risk Protective Factors Slide 9 VULNERABILITIES - SELF Mental illness (e.g., mood, anxiety, conduct disorders) Past suicidal behavior Substance use Unstable mood, high impulsivity Rigid thinking or coping patterns Poor physical health / chronic illness NOTE: These risk factors are correlational and not causal; typically it is a compounding of risk factors that is associated with suicidal behavior. Slide 10 VULNERABILITIES - HOME Family history of suicides / attempts Parental mental illness Alcohol / substance abuse in the home History of violence and/or abuse Divorce, separation, other losses, death Tension and aggression between parents Parental lack of time; rejection; neglect NOTE: These risk factors are correlational and not causal; typically it is a compounding of risk factors that is associated with suicidal behavior. Slide 11 VULNERABILITIES SCHOOL/COMMUNITY Learning problems Disengagement from school Lack of connectedness Marginalization Discontinuity in identity (cultural, language, gender, sexual) Some communities are at heightened vulnerability (e.g., aboriginal, LGBTQ, homeless) Negative social relationships, including bullying Slide 12 Pre-existing vulnerability Increases risk for bullying Victimization New or Exacerbated: Anxiety Depressed mood Diminished self-worth Feelings of entrapment Loneliness Withdrawal Sleep/eating problems Hopelessness Which are risk factors for: Suicidal ideation Suicide attempt Death by suicide Adapted Lenny Berman 2010 Bullying and Suicide 8doc.webinar American Association of Suicidology BULLYING AND SUICIDE Slide 13 TRIGGERS Break up with boy/girl friend Conflicts and increased arguments with parents and/or siblings Loss of close friend School related difficulties-conflicts with teachers, classmates Difficulties with the law Change in parents financial status Serious illness or injury in family member Real or perceived loss of status Slide 14 CONTAGION Occurs when suicidal behavior influences an increase in the suicidal behavior of others Multiple suicidal behaviors/suicide deaths that occur within a geographical area or fall within an accelerated time frame may represent a potential cluster Although clusters are rare, they are most common amongst adolescents Slide 15 CIRCLES OF VULNERABILITY Geographical Proximity Social Proximity Psychological Proximity Population at Risk Lahad & Cohen, 2006 Slide 16 THE ROLE OF CYBER/SOCIAL MEDIA Increasingly there are sites, chat rooms and blogs that promote suicidal ideation Methods of suicide are discussed on-line and some researchers have suggested that increases in particular methods in recent years may be related to this dialogue The rapid spread of rumours and details of deaths by suicide is difficult to manage Paradoxically, social media may hold potential benefits for suicide prevention (Skinner & McFaull, 2012) Slide 17 THE ROLE OF MEDIA Media can be helpful or harmful it is never benign and they cannot view themselves as impartial observers Contagion (mimicking of suicidal behavior) is a real phenomenon and youth are particularly vulnerable Media needs to be held accountable for adhering to safe reporting guidelines following a death by suicide Media can be helpful in bringing awareness to issues of child and youth mental health more broadly Slide 18 RESPONDING TO MASS MEDIA / SOCIAL MEDIA COVERAGE Recent weeks have brought us A very tragic example of the complexity of suicidal behavior An illustration of the influence and dangers of social media Irresponsible media coverage and oversimplification of the issues in much public discourse Well-intentioned, but potentially harmful, actions Contagion A magnification of the need for district and school leadership to ensure student safety Slide 19 PROTECTIVE FACTORS Problem solving, life & communication skills Sociability Resilient Personality A sense of belonging (school, community) Secure attachment to positive parent/family Access to other caring & supportive adults Pro-social peers Appropriate discipline, limit setting & structure Opportunities to develop self-esteem Good Mental Health Slide 20 Youth suicide is complex and is often the result of many converging factors. The explanations and the solutions are equally complex. Slide 21 WHAT CAN WE DO? Reduce vulnerabilities - at school Ensure school is safe and accepting, especially for vulnerable students (enhance sense of belonging, increase connectedness and engagement, show respect for differences) Build on protective factors Provide skill-building, opportunities to build esteem, etc. Look out for triggers Identify students at risk, listen Minimize the risk for contagion Have a plan for help Slide 22 SUICIDE PREVENTION, INTERVENTION, & POSTVENTION Strategies for Slide 23 FIRST, DO NO HARM In considering various prevention, intervention, and postvention strategies, the Mental Health Leadership Team needs to understand that this area of work is not benign Some actions are more effective than others, some are risky, and many have not been evaluated rigorously This may mean taking a fresh look at existing practices to ensure alignment with the evidence base in this area Close communication with your senior administration team will be important if practice changes are required Slide 24 THROUGH THIS SECTION, CONSIDER What is your school doing consistently across the system in suicide prevention, intervention and postvention? Are these initiatives aligned with the evidence-base? Slide 25 SCHOOL RESPONSE TO SUICIDE Four components: Administrative Foundation, Prevention, Intervention & Postvention Slide 26 WHAT IS ADMINISTRATIVE FOUNDATION? The administrative foundation is the support and commitment of the school board, as articulated through the principal, to policies and procedures that address the range of needs presented by students who might be at risk for suicide. Slide 27 WHAT IS SUICIDE PREVENTION? Efforts to reduce the risk of suicidal thoughts and behavior amongst students in a systematic way Slide 28 WHAT IS INTERVENTION? Practices involved in recognizing and responding to students with suicidal ideation or behavior Practices involved in supporting vulnerable students transitioning to and from mental health care Slide 29 WHAT IS POSTVENTION? Support for school communities in responding to suspected, attempted, or death by suicide Slide 30 HELPFUL PREVENTION STRATEGIES Safe and accepting school culture Social emotional learning (coping skills, conflict resolution) Early identification and treatment of mental health problems Gatekeeper training Information dissemination (staff, parents, students) Slide 31 PREVENTION STRATEGIES TO AVOID There are risks inherent in the following strategies: Suicide awareness curriculum with students, particularly if done in a single or stand alone lesson(s) (curriculum is best delivered in the context of instruction related to mental health more generally, over a period of several lessons, with a focus on protective factorsafter adults have received gatekeeper training) Assigning suicide as a central or sole focus of study Large assemblies with guest speakers who talk about suicide Events that have the potential to glorify/glamorize suicide Peer counseling related to suicide Slide 32 Prevention StrategyEvidence Early identification and treatment of mental health problemsSolid School/community culture buildingSolid Adaptive coping skill developmentSolid Information dissemination / gatekeeper trainingPromising Screening and referralMixed Youth engagement / peer helper programsMixed Suicide awareness curricula for studentsMixed Means restrictionMixed Crisis hotlinesMixed Media education programs Insufficient Evidence Effective postvention Insufficient Evidence Slide 33 INFORMATION DISSEMINATION AND GATEKEEPER TRAINING Different 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 support Slide 34 NEEDED KNOWLEDGE For intervention to be successful, basic knowledge about warning signals can be shared with those in a position to notice changes in behavior amongst youth School 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 reference Note that 100% accurate prediction of suicide is impossible. We can only do our best. Slide 35 WARNING SIGNALS: BEHAVIOURAL Loss of interest in former activities Withdrawal from social contact Difficulty concentrating, problems with judgment and memory Dramatic shift in quality of academic performance Feelings of sadness, emptiness and hopelessness, often expressed in written assignments Sleep disturbances These signals also relate to problems in mental health more generally Slide 36 Strong and overt expressions of anger and rage Excessive use of drugs and/or alcohol Promiscuous behaviour Uncharacteristic delinquent, thrill-seeking behaviour Self-mutilation Occurrence of previous suicidal gestures or attempts Planning for death; making final arrangements; giving away favourite possessions WARNING SIGNALS: BEHAVIOURAL Slide 37 WARNING SIGNALS: COMMUNICATION Statements revealing a desire to die, or a preoccupation with death Nihilistic comments: life is meaningless, filled with misery, whats the use of it all? Verbal or written threats Sudden cheerfulness after prolonged depression may be relief because decision has been taken Slide 38 HELPFUL INTERVENTION STRATEGIES Identification and Referral Ensure staff aware of warning signals Ensure clear protocol at school level Provide immediate and calm support to the student Ensure safety and supervision Facilitate assessment and care Contact parent/guardian Document actions Slide 39 HELPFUL INTERVENTION STRATEGIES Supporting Vulnerable Students Ensure staff understand role and limits of competence Support staff with caring adult role Identify vulnerable students Work with clinical staff, when involved Create a school safety plan for each student, as needed Implement and monitor plans, as needed Slide 40 INTERVENTION STRATEGIES TO AVOID Peer intervention models with inadequate adult supervision and monitoring Recruitment of gatekeepers who are uncomfortable / unready for the role Counseling of high risk students by unqualified professionals Slide 41 HELPFUL POSTVENTION STRATEGIES Understand the phases of postvention Have a plan for who does what at each phase of postvention First 24 hours Next 48-72 hours During the first month Planning for the future Practice deliberate self- and team-care Slide 42 WORKING THROUGH PHASES The accompanying presentation for the School Mental Health Team articulates considerations for the postvention period, through these phases This difficult work is usually led by the school admin team, with support from the Superintendent, Crisis Response Team, MH leadership team, and corporate communications, as needed Main message have a plan for who does what at each phase of postvention Slide 43 FIRST 24 HOURS Verify 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 indicated In 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, how Inform 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) Slide 44 NEXT 48-72 HOURS Restore school to regular routines Liaise with bereaved/affected family Consider involvement with funeral/memorials Avoid on-campus memorials that could glorify suicide Monitor staff well-being Keep school community informed Involve community partners in postvention support Document actions Slide 45 DURING THE FIRST MONTH Monitor all staff and student well-being Plan for school events of relevance (year book, award nights, graduation) Conduct a critical incident review Consider offering information sessions for parent community with mental health agency Continue documentation of actions Response Team Debriefing Slide 46 PLANNING FOR THE FUTURE Continue support and monitoring of students and staff Plan for anniversaries, birthdays and significant events Implement recommendations from the critical incident review, in consultation with SO and MH Leadership Team Assess current suicide prevention strategies and enhance as needed Share the postvention plan with new staff members Continue to work with community to refine response for future Slide 47 Information for All Schools in board, with support for vulnerable schools Information for Parents/Guardians and the wider school community Information for All Students, with support as needed Information for All Staff, with Support for Vulnerable Members Support for Vulnerable Students Support for Students in Crisis and their Families Media Social Media Slide 48 TAKE CARE OF EACH OTHER Death by suicide is a special kind of school crisis that impacts us in significant ways, professionally and personally The School Team needs to work together, to debrief often, and to reach out when members are struggling Members need to practice self-care deliberately The Board Team can provide support in this regard the School Team is not alone Slide 49 Documentation of Ontario community mobilization response following a suicide cluster Slide 50 A COMPREHENSIVE SUICIDE PREVENTION STRATEGY INCLUDES: Proactive, universal strategies that promote a sense of belonging at school (reaching out to vulnerable students) Wide-spread instruction in adaptive coping skills, like problem solving and conflict resolution Knowledge and skills for early identification of mental health problems (with clear connections to service) Gatekeeper training, with protocols for students at risk Effective postvention, with protocols Other strategies? Evaluate!! Slide 51 ISSUES FOR SCHOOL LEADERS Child and Youth Suicide Slide 52 IT TAKES A VILLAGE Many players needed, to assume different roles Suicide Strategy Planning and Communication E.g., Board Mental Health Leadership Team, Senior Administration Team, Corporate Communications / Public Relations, Community Partners Suicide Prevention and Intervention E.g., Board Mental Health Leadership Team, School Mental Health Professionals, School Administration, School Staff, Community Partners Postvention E.g., Initial team may include: Principal/Vice-Principal(s), Critical Incident Response Team, Superintendent, Board Mental Health Leadership Team, Corporate Communications, Community Partners Slide 53 PERTINENT ISSUES FOR SCHOOL LEADERS Determining a coordinated school-wide approach Establishing systematic and proactive suicide prevention initiatives within the context of wider mental health promotion and prevention efforts Ensuring clear protocols and roles for intervention with students exhibiting suicidal behavior Developing or updating postvention protocols in light of new realities (consistent with established board protocols) Communicating the suicide strategy and related supports and expectations with staff Slide 54 SUICIDAL BEHAVIOR IS A REALITY IN YOUR SCHOOLS BE PROACTIVE, BE PREPARED Slide 55 COMPONENTS OF AN EFFECTIVE SUICIDE STRATEGY Protocols for students at risk Protocols following a death by suicide Broad focus on mental health promotion, skill-building and caring school cultures Staff education and training Media education Parent education An effective strategy builds common understanding across the board & community, and signals a systematic, proactive approach Slide 56 RECOMMENDED ACTIONS School Leaders Slide 57 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) Slide 58 GETTING ORGANIZED Identify Existing/Needed Teams (Board, School, Critical Incident Response) Clarify Roles, as needed Develop/update protocols for intervention & postvention Develop/update tools/templates for intervention & postvention Select and implement prevention strategies Stage capacity-building efforts Communicate the suicide strategy to staff Monitor, evaluate and refine the strategy Many 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. Slide 59 IDENTIFY TEAMS* Board Suicide Strategy Team protocol development, strategy selection, etc. Suicide Response Team support school team, work with media, etc. School Suicide Strategy Team protocol development, strategy selection Suicide Response Team support students, staff, community, etc. Crisis Response Team Support staff and students in need of immediate support individually or in small groups * These may be existing leadership teams at the board and school level, or subgroups within these Slide 60 CLARIFY ROLES Leadership and Planning Teams Who will be involved in confirming our school protocols for intervention and postvention? Who will be involved in selecting prevention approaches? Response Teams Who will support the school and the school team during the crisis? Following the crisis? Who does what? For example, Who will contact the family, communicate with staff, students, etc. Who will support the school response team? Who will work with media? Who will work with community? Who will link with mental health partners? Slide 61 DEVELOP/UPDATE PROTOCOLS Obtain information about any board-wide protocols for intervention and postvention Consult with colleagues in developing/updating protocols for your school, particularly those who have worked through postvention Where 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 Slide 62 ACCESS TOOLS Access 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 crisis Intervention Fact sheets / warning signals At a glance protocol or flowchart More detailed protocol with rationale Postvention Letters for school community Scripts for students Key messages for media Support documents for staff Documentation outline Critical incident review form Slide 63 SELECT AND IMPLEMENT PREVENTION STRATEGIES If you have a mental health strategy that includes universal promotion and skill-building, you are already doing some of this work Work with caring and accepting schools professionals to enhance sense of belonging in schools Prepare information for dissemination with key groups Work towards mobilization of community Slide 64 CAPACITY - BUILDING When possible, sequence capacity-building: School Leaders School Staff Gatekeeper Training Parents Students Different audiences will have different knowledge needs Slide 65 COMMUNICATE WITH STAFF Communicate the protocol and related tools and templates Board MH Team School Leaders School LeadersSchool Staff Some messages may need to go directly from the Board MH Team to all Staff and to media Slide 66 MONITOR, EVALUATE, REFINE Documentation and debriefing of actions and enablers/challenges is important; for prevention, intervention, and especially postvention Postvention is emotionally-charged, and the more that our actions can be routinized the better While every situation is unique, each offers learning opportunities that can be used in future Slide 67 SOURCES, WITH THANKS MH Leader Suicide Subgroup Ian Manion, Ontario Centre of Excellence for Child and Youth Mental Health Ian Brown, School Mental Health ASSIST Stephan Roggenbaum & Katherine Lazear, University of South Florida Key Resources: SAMHSA Toolkit, Suicide Postvention Guidelines South Australia, Principal Leadership 2009, NASP Postvention Strategies for School Personnel, Kutcher 2008 Slide 68 CONTACT SCHOOL MENTAL HEALTH ASSIST Kathy Short, Ph.D., C.Psych. Director, School Mental Health ASSIST Kathy.Short@hwdsb.on.ca 905-527-5092, x2634 School Mental Health ASSIST quipe dappui en sant mentale pour les coles