Youth in Crisis: Competency Check-In Indiana Youth Institute December 2010

Youth Suicide InterventionDenton ISDAugust 16, 2011

Dr. Casey A. Barrio Minton, PhD, NCCSession OverviewUnderstanding youth suicideRecognizing warning signsFacilitating open conversationsConnecting with resourcesContinuing education resourcesThe Words We UseSuicide/completed suicide

Suicide attemptpotentially self-injurious behavior with a nonfatal outcome, for which there is evidence (either explicit or implicit) that the person intended at some (nonzero) level to kill himself/herself (Brown, 2003, p. 5).

Suicidal ideation (self)

Suicide threat (other)TCA - 12/01/2006Casey A. Barrio, PhD, NCC3The Words We UseSuicidal Act Suicide or suicide attempt (with or without injuries)Nonzero intent to die

Self-injurious behaviorDeliberate infliction of direct physical harmZero intent to die

Instrumental Suicide-Related BehaviorDesired appearance of intending to kill self (with or without injuries)Zero intent to dieTCA - 12/01/2006Casey A. Barrio, PhD, NCC4TerminologySelf-inflictedIntent to kill selfNonzero ZeroActual harm to selfDesired appearance and response

TCA - 12/01/2006Casey A. Barrio, PhD, NCC5Child is brought to emergency services from group home after digging into his arms with safety pin and saying that hes tired of life like thisCould it be Related to Suicide?Adolescent takes a bottle of medications, but medications do no physical harmAdolescent is found making cuts on her arms and legs in the school bathroom. Later, parents find diary with poetry expressing students loneliness and loss of hope for the future.A Few Suicide Facts(CDC, 2006, 2009)Leading cause of deathAges 5-14 (5th)Ages 15-24 (3rd)Estimated 100-200 attempts per completion1 in 19 has thoughts in any 2 week period

Considerable variations among groups2009 Dallas HS StudentsOverallFelt sad or hopeless almost every day for 2+ weeks*33.0%Seriously considered suicide15.6%Made a plan*14.4%Attempted suicide*12.0%TCA - 12/01/2006Casey A. Barrio, PhD, NCC7Why Suicide(Shneidman, 1985, 1999)Psychache

IntolerableInterminableInescapable8Why Suicide(Shneidman, 1985, 1999)StimulusUnendurable psychological painStressorFrustrated psychological needsPurposeSolutionGoalCessation of consciousnessEmotionsHopelessness, helplessnessCognitionsAmbivalence, restricted perceptionRelationalTells of intention, egressionSerialConsistent with lifelong pattern9Common MisperceptionsSomeone who talks about it is not seriousTalking about it will increase riskAttention-seekingSuicide happens without warningSuicidal people want to die / cant stopSuicidal people are crazy, mentally ill, insaneDanger reduced after crisis

Recognizing Warning SignsProtective Factors for Suicide(CDC, 2009)Access to treatmentSupport for help-seeking Effective clinical care for mental, physical, and substance abuse d/oSupport from ongoing medical and mental health care relationshipsFamily and community support (connectedness)Cultural and religious beliefs

Skills in problem solvingconflict resolutionnonviolent ways of handling disputes

Risk Factors for Suicide(CDC, 2009)Family hx of suicideFamily hx of child maltreatment, conflictPrevious attempt(s)Mental disordersAlcohol/drug abuseHopelessnessImpulsive or aggressive tendenciesLossIsolationPhysical illnessCultural/religious beliefsLocal suicide epidemicsBarriers to accessing txEasy access to methodsRecent severe stressorUnwilling to seek help because of stigma

Risk Factors for ChildrenBiologicalImpulsivityAge

PsychologicalInferiority / expendableDepressionAnxietyAggressionImpulsivityInternalizingPoor coping skills

Risk Factors for ChildrenCognitiveImmature view of deathConcrete thinkingAttraction/repulsion to life and deathSubstance useEnvironmentalEarly lossParental conflictChaotic/inflexible familyAbuse / neglectParent mental healthIsolated or alienated from peersPoor social supportPoor social skillsLearning disabilities Academic failure

Risk Factors for ChildrenPrecipitating eventsPsychosocial stressors, perceptions, and ability to cope vary developmentallyRecent exposure to suicide / contagionPrevious coping via suicidal ideation or behavior

Warning Signs of Suicide(American Association of Suicidology, 2003)IdeationSubstance use

PurposelessnessAnxietyTrappedHopelessnessWithdrawalAngerRecklessnessMood change

Dr. Casey A. Barrio, PhD, NCC17More Warning Signs for Youth(Suicide Prevention Lifeline; Suicide Prevention Resource Center)Fixated on deathWorsening of school performanceUnhealthy peer relationshipsDifficulty adjusting to gender identityBullyingDepression

Danger Signs for Youth(Suicide Prevention Resource Center)Announcing a planTalking, writing, or posting about suicide or deathHintsI wish I were dead. I'm going to end it all. You will be better off without me. What's the point of living? Soon you won't have to worry about me. Who cares if I'm dead, anyway?MeaninglessnessGiving away prized possessionsDropping out of school, activitiesObtaining a weapon

Facilitating Open ConversationsRoadblocks to DiscussingYouths biases and fearsOur biases and fearsOur desire to fix, change, or convince otherwiseLeakage myth

Preparing for Conversations(Shea, 2002)Tune in to own responsesBe direct kill, suicide, deadTune in to hesitancyInvestigate not reallyLook for nonverbalsGet out from behind the deskTake your timeDont try to fix or give advicePrepare to be persistent and creative

Focus on relationship over details but get details if the time seems right

Skills for Opening(Shea, 2002)Ask questions regarding concrete behavioral facts or thoughts When you threw a fit, what exactly did you do? Did you put the razor blade up to your wrist? What happened next?

Ask question so not as threateningSometimes drinking can lead people to have thoughts of killing themselves that they normally wouldnt have. Has that ever happened to you?Dr. Casey A. Barrio, PhD, NCC23Skills for Opening(Shea, 2002)Assume suspected behavior is occurring and frame a ? based on assumptionWhat other ways have you thought of killing yourself? How often do you cut?

Normalize the experienceSome people tell me that, at times, living is so painful that they have thoughts of wanting to kill themselves. Have you had any thoughts like that?

Dr. Casey A. Barrio, PhD, NCC24Adapting Skills for ChildrenCommunicate caring and comfortSpecific reason for interviewNot in troubleSafe to tell truthNo right or wrong answersCaretaking w/in interview

Determine who is present for interviewBeware of limits to language, leading language, and repeated questions adapt language, integrate drawingAttend to developmental understanding of deathKey AssessmentsPrecipitating events, stressors, triggersinescapableintolerableinterminable

SuicidalIdeationPlansMeansIntent

Supporting assessmentsWarning signsPrior historyReasons for dyingReasons for livingSupports

Asking The QuestionSummarize situation and reflect feelingsUse owning statements

Be very directYou sound , are you thinking of suicide?Sometimes when people , they are thinking of suicide. Are you thinking of suicide?

Honor choice to shareLet him or her tell you wayAssessing IdeationAfter giving child room to shareSummarize content and reflect feelingsRestate thoughts of suicideUse owning statement regarding needing to know more

Elicit details regarding ideation(see guidelines handout)

Assessing Means, Method, Plan, IntentPlan-HowMeans-Could he/she? AccessMethods-LethalityIntent-Timeline, action taken

ConsiderLevel of specificity (more specific risk)Degree of accessLevel of lethalityAction already takenDegree of commitmentSupports & DeterrentsWhat has kept you from (details vip)Who/what is a source of support for youWhat are the pros and cons of your plan?

Look forStrength/nature of deterrentsAny hope? Change in feeling?Family, spiritual beliefs can be critical

Assessing Warning Signs(American Association of Suicidology, 2003)IdeationSubstance use

PurposelessnessAnxietyTrappedHopelessness

WithdrawalAngerRecklessnessMood change

Dr. Casey A. Barrio, PhD, NCC31Assessing Other Risk FactorsHistoryPrior suicide attemptsPrior violencePrior diagnoses / treatment

Mental statusBehavior changes

Determining Level of RiskIdeationPlanLethalityIntentNoneNo------MildSomeNo----ModerateYesVagueLow--SevereYesSpecificHigh--ExtremeYesSpecificHighYes

Dr. Casey A. Barrio, PhD, NCC33Confounds to the Risk GridCounselor/client relationshipPerceived painPerceived resourcesPrevious attemptsMental health history & disordersBalance of reasons for living and dyingIs risk grid a dangerous myth?Casey Barrio Minton, PhD, NCC34Connecting with ResourcesNext StepsFollow organizational protocols for youth crisisDo not leave the youth alone

Notify caregivers and/or emergency providersEmpower youth to share himself/herself

Arrange for mental health assessment and services

Follow-up with youthProfessional Care for Suicide (Lee & Bartlett, 2006)Comprehensive suicide assessmentAppropriate management planFamily involvementConsultation with professionalsImplementation of plan

Professional Care for SuicideEmergency/crisis services (24/7)Hotlines

Inpatient hospitalizationIntensive outpatient/Partial hospitalizationOutpatient services

Dr. Casey A. Barrio, PhD, NCC38Continuing Education ResourcesOrganizational ResourcesStandardized TrainingsASIST (Applied Suicide Intervention Skills Training)safeTALK (suicide alertness for everyone)QPRSOS (Signs of Suicide)Trevor Project Lifeguard Workshop

Crisis response planningwww.ed.gov/emergencyplan Crisis / Referral ResourcesUnited Ways 211 (or www.211.org)Suicide Prevention Lifeline (800/273-TALK)The Trevor ProjectKey WebsitesNational Suicide Prevention Lifeline 800-273-TALKSuicide Prevention Resource CenterAmerican Association of SuicidologySuicide Prevention Action NetworkThe Trevor ProjectAmerican Foundation for Suicide PreventionSAMHSA NREPPQuestions & Discussion