Suicide Prevention, Intervention & Postvention in - SMH

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SUICIDE PREVENTION,
INTERVENTION &
POSTVENTION IN SCHOOLS
An Overview for School Leaders
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.
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
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)
Brief Overview
CHILD AND YOUTH SUICIDE
SUICIDAL BEHAVIOUR
 Non-Suicidal
Self-Injury
 a deliberate attempt to cause injury to one’s 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
FACTS AND FIGURES
 2nd
leading cause of death after accidents, accounting for 17.320.4% 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)
THE COMPLEXITY OF RISK
Vulnerabilities
(Distal)
Triggers
(Proximal)
Protective
Factors
Risk
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.
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.
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
BULLYING AND SUICIDE
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
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
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
CIRCLES OF VULNERABILITY
Geographical
Proximity
Psychological
Proximity
Social
Proximity
Lahad & Cohen, 2006
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)
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
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
PROTECTIVE FACTORS

Problem solving, life &
communication skills

Access to other caring &
supportive adults

Sociability

Pro-social peers

Resilient Personality


A sense of belonging
(school, community)
Appropriate discipline,
limit setting & structure

Secure attachment to
positive parent/family
Opportunities to develop
self-esteem

Good 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 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
Strategies for
SUICIDE PREVENTION,
INTERVENTION, & POSTVENTION
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
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?
SCHOOL RESPONSE TO SUICIDE
 Four
components:
 Administrative Foundation, Prevention, Intervention &
Postvention
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.
WHAT 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 behavior
 Practices 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 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)
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
factors…after 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
Prevention Strategy
Evidence
Early identification and treatment of mental health problems
Solid
School/community culture building
Solid
Adaptive coping skill development
Solid
Information dissemination / gatekeeper training
Promising
Screening and referral
Mixed
Youth engagement / peer helper programs
Mixed
Suicide awareness curricula for students
Mixed
Means restriction
Mixed
Crisis hotlines
Mixed
Media education programs
Insufficient Evidence
Effective postvention
Insufficient Evidence
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
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.
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
WARNING SIGNALS: BEHAVIOURAL
 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: COMMUNICATION
Statements revealing a desire to die, or a preoccupation
with death
Nihilistic comments: life is meaningless, filled with
misery, what’s the use of it all?
Verbal or written threats
Sudden cheerfulness after prolonged depression may be
relief because decision has been taken
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
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
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
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
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
FIRST 24 HOURS

Verify the death, confirm the facts, talk with the student’s 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)
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
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
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
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
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
Documentation of
Ontario community
mobilization
response following a
suicide cluster
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!!
Child and Youth Suicide
ISSUES FOR SCHOOL LEADERS
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
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
SUICIDAL BEHAVIOR IS A REALITY IN YOUR SCHOOLS
BE PROACTIVE,
BE PREPARED
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
An effective strategy builds common
 Parent education
understanding across the board &
community, and signals a systematic,
proactive approach
School Leaders
RECOMMENDED ACTIONS
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 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.
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
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?
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
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
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
CAPACITY - BUILDING
When possible, sequence capacity-building:
 School
Leaders
 School Staff
 Gatekeeper Training
 Parents
 Students
Different audiences
will have different
knowledge needs
COMMUNICATE WITH STAFF
 Communicate
the protocol and related tools and
templates
 Board
MH Team
 School Leaders
 Some
School Leaders
School Staff
messages may need to go directly from the Board
MH Team to all Staff and to media
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
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
CONTACT
SCHOOL MENTAL HEALTH ASSIST
Kathy Short, Ph.D., C.Psych.
Director, School Mental Health ASSIST
[email protected]
905-527-5092, x2634
School Mental Health
ASSIST
Équipe d’appui en santé mentale pour les écoles

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