SUICIDE PREVENTION INTERVENTION POSTVENTION IN SCHOOLS An Overview

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 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 & Mc. Faull, 2012)

THE COMPLEXITY OF RISK Vulnerabilities (Distal) Triggers (Proximal) Protectiv e Factors Ris k

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 Suicidal ideation Which are risk factors for: Suicide attempt Death by suicide Adapted Lenny Berman 2010 Bullying and Suicide 8 doc. 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 Geographic al Proximity Psychologic al Proximity Social Proximity n io t a l u p Po sk Ri at 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 & Mc. Faull, 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 Sociability Pro-social Resilient Appropriate Personality A sense of belonging (school, community) Secure attachment to positive parent/family to other caring & supportive adults peers discipline, limit setting & structure Opportunities self-esteem Good to develop 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 evidencebase?

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

ed ia M So ci al 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 M ed ia

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 Other strategies? Evaluate!! risk Effective postvention, with protocols

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, skillbuilding and caring school cultures Staff education and training Media education An effective strategy builds Parent education common 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 Many school have teams and tools in place. For these schools, it is a matter of confirming thatand these refine resourcesthe are aligned with the wider board strategy, ensure Monitor, evaluate strategy 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. * These may be existing leadership teams at the Team board and school level, or subgroups within these Crisis Response § Support staff and students in need of immediate support individually or in small groups

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 Kathy. Short@hwdsb. on. ca 905 -527 -5092, x 2634 School Mental Health ASSIST Équipe d’appui en santé mentale pour les écoles