Youth Suicide

Resources:

awareness,
prevention,
intervention,
and
postvention

HANDOUT FOR TEACHERS
Warning Signs of Suicidal I deation

I. BEHAVIORS COMMON TO SUICIDAL ADOLESCENTS
TALKING OR SPECULATING ABOUT DEATH, SUICIDE, OR
FUNERALS, INVOLVEMENT WITH OCCULT PRACTICES
THREATENING SUICIDE AS REVENGE OR PUNISHMENT FOR GUILT
FASCINATION WITH DEATH IN MUSIC, ART, POETRY, AND WRITING
PUTTING ONE'S LIFE IN ORDER:
- MAKING A WILL
- WRITING GOODBYE NOTES
- GIVING AWAY PRIZED POSSESSIONS
DRAMATIC CHANGES IN :
- FRIENDS - APPEARANCE
- SCHOOL PERFORMANCE - CONTACTS WITH FAMILY/FRIENDS
- SLEEPING AND EATING PATTERNS
INTENSE INVOLVEMENT IN DRUG OR ALCOHOL ABUSE OVER
SEVERAL WEEKS
PREVIOUS SUICIDE ATTEMPTS

II. SITUATIONS COMMON TO SUICIDAL ADOLESCENTS
HISTORY OF FAMILY CONFLICT:
- ABUSE (Physical or Sexual)
- SUBSTANCE ABUSE
- SEPARATION AND DIVORCE
DEATH OR SUICIDE OF A CLOSE RELATIVE OR FRIEND
LIVING IN A HOME WHERE FIREARMS ARE AVAILABLE
INVOLVEMENT IN ANTISOCIAL BEHEVIORS OR REPEATEDCONDUCT
PROBLEMS
RECENT EMBARRASSMENT OR LOSS
PRESENCE OF AN EDUCATIONAL HANDICAP
GENDER ORIENTATION CONCERNS

III. ATTITUDES COMMON TO SUICIDAL ADOLESCENTS
LOW SELF ESTEEM
FEELINGS OF BEIN'G OVERWHELMED BY PROBLEMS WHICH MOST
TEENAGERS CAN HANDLE ("HELPLESS VICTIM ").
IMPULSIVE, POOR PROBLEM SOLVER ANGRY AT THE WORLD
DEPRESSED, HOPELESS ABOUT THE FUTURE, HAS GIVEN UP ON
THE PRESENT
POOR COMMUNICATOR, USES A "WHAT'S THE USE? APPROACH AN
OUTSIDER, NOT CONNECTED TO OTHERS, FEELS ALONE AMBIVALENT
ABOUT WANTING TO DIE; WANTS AN END TO PAIN.


PERSONALITY FACTORS COMMON TO
SUICIDAL ADOLESCENTS

* DEPRESSIVE PERSONALITY - both classic depression (apathy, lack of pleasure,
loss of energy) and reactive depression (situational)

* LOW SELF-ESTEEM - feelings of worthlessness
- includes unrealistic expectations of oneself
- loss through embarrassing set back, hypersensitivity

*HOPELESSNESS - a belief that one lacks control over one's physical and
psychological well being

- distrust of one's own resources to solve problems

- fatalistic view of life

*LONER PERSONALITY - lack of close relationships, inability to communicate

- feelings of sexual inadequacy

*DEPENDENCY - parental pressure to succeed

- high need for support coupled with inability to obtain
support from significant others

- attention seeking goals

* IMPULSIVITY - tendency to habitually react to stress without thinking
things through

- rarely thinks about consequences of suicidal attempt

*LOW FRUSTRATION - may act out of anger
TOLERANCE
- views the world as "unfair"

* ACTING OUT/AGGRESSIVE - indicative of anger in background
- desire to provoke guilt and sympathy in others

- often a mask for depression

* COGNITIVE RIGIDITY - "either-or" type of thinking, restricted problem solving
ability
Preventing Adolescent Suicide by Dave Capuzzi, Ph. D.


HANDOUT FOR TEACHERS

THE FOUR RESPONSIBILITIES OF TEACHERS
IN RESPONDING TO SUICIDAL THREATS

1. RECONGNITION OF THE WARNING SIGNS OF SUICIDAL INTENTION

2. RESPONSDING BY FINDING ANSWERS TO FOUR SPECIFIC QUESTIONS
ABOUT SUICIDAL INTENT AND/OR BEHAVIOR?

* DO YOU INTEND TO KILL YOURSELF
What did you mean when you said,..?
What has been happening to make you think about killing yourself?

*DO YOU HAVE A PLAN?
How specific is it?
How realistic is it?

*IN WHAT WAY WOULD YOU TAKE YOUR LIFE?
How deadly is the means?
Does he have access to a means of self destruction?

*WHAT CAN I DO TO DISSUADE YOU?
How determined is he to hurt himself? Where is he on the scale?
I s there anything or anyone who could prevent him from suicide?

3. ACCEPTING RESPONSIBILITY TO OBTAIN HELP FOR ONE WHO IS SUICIDAL

I t is safer to presume that a student is serious when he threatens suicide than to
dismiss it as an angry outburst or attention-seeking behavior.

Parents must be involved in the process of obtaining help.

I t is a common experience that parents may initially resist the idea that their child is
suicidal. Explain your professional concerns to them Suicidal behaviors must be
taken seriously; the alternative is unthinkable.

4. MAKING REFERRALS TO RESOURCES IN YOUR SCHOOL COMMUNITY FOR
IMMEDIATE ASSESSMENT AND COUNSELING

The school counselor, in-school crisis team personnel, and parents

What are the mental health resources in your community?

Confirm that student has obtained help.


HANDOUT FOR TEACHERS

SUICIDE PREVENTION AWARENESS FOR EDUCATORS

YOU HAVE A RESPONSI BI LI TY TO TAKE ACTI ON.
If one of your students threatened suicide or showed other signs of being
suicidal your reaction and subsequent course of action, could make the difference
between life and death.

In our American society, suicide has always been viewed as a shameful,
dishonorable act. The person who has suicidal thoughts knows this, is ashamed, and
is reluctant to tell anyone how he feels. At the time he needs somebody most, he
fears he will be treated like an outcast if he asks for help. When he fina1ly does reveal
the way he feels, he is very sensitive to the reactions of the person in whom he has
confided. Often he will reveal his intentions indirectly through: warning signs of
distress.

WHAT DO YOU SAY TO A SUI CI DAL YOUNGSTER?
The best thing to do when someone makes suicidal statements is to show
concern and to ask questions in a straightforward and calm manner. .

T ell him you are taking his threat very seriously .
Ask what feelings have prompted the desire to suicide.
Ask about recent home situations or relations with friends.
Ask if the person bas talked with anyone else about suicide.
Ask if he or she bas thought about the means of suicide and, if so, if any steps have
been taken to procure those means.
Tell him you will help him through this difficult period.
Ask if he or she would be interested in speaking confidentially with someone
additionally who is also very helpful in such situations.

Your questions accomplish three important goals:
They show that you are willing to discuss the subject and that you are not appalled or
disgusted by it.
They will open lines of communication, allowing the student to talk about the way he
feels, which alone may help him to feel better and to believe that someone will help him.
The questions will help you, and subsequently others, to evaluate the seriousness of
the problem. (lethality assessment).

HOW DO YOU KNOW THE LETHALI TY 0F HI S I NTENT?
In evaluating the probability that a suicide attempt will be made, be aware
that as a general rule: "The more specific the plan, the greater and more imminent the
danger. If detailed plans have been made and the means of suicide obtained, the danger is not
only great- it is immediate!


HANDOUT FOR TEACHERS, P.2

The presence of any suicidal intention should be considered with caution. This does not mean
that someone with only vague suicidal notions should not be taken seriously; he or she may be in
the early stages of planning, or indeed the act may be carried out impulsively without the
carefully detailed plans that characterize many adult suicides. It doesn't take much planning to
grab a gun, jump out a window, or drive into a highway abutment.

WHAT I S THE COURSE OF ACTI ON I F I SUSPECT A STUDENT MAY BE SUI CI DAL?

Your responsibility, even when you receive a third hand report of a suicidal threat, is to report
what you have heard to a school counselor, school psychologist, or agency-based professional
and the school principal. The parents must be immediately involved in a plan of action.
Treatment will be based an the level of risk the student seems to present. The following
recommended interventions are commonly used strategies for those who deal with suicidal
youth.

LOW RISK FOR SUICIDAL ACTION:
CALM CONCERN, CONFIDENCE BUILDING
NOTIFICATION OF PRINCIPAL AT EVERY LEVEL
DISCUSS CONCERNS WITH PARENTS; RECORD RESULTS
WRITTEN CONTRACT WITH STUDENT
ONGOING CONTRACT WITH YOU/PEER
MEDIUM RISK FOR SUICIDAL ACTION:
NOTIFICATION AND INVOLVEMENT OF PARENTS
RECOMMEND OUTSIDE AGENCY RESOURCE
MANAGEMENT PLAN AT SCHOOL FOR STUDENT
FOLLOW-UP CONTACT WITH PARENTS
HIGH RISK FOR SUICIDAL ACTION:
CONSTANT SUPERVISION AT SCHOOL AND HOME
IMMEDIATE INVOLVEMENT OF PARENTS
CONFIRMATION OF REFERRAL RESOURCES INVOLVEMENT
REMOVAL OF MEANS OF SELF DESTRUCTION

WHAT PRECI PI TATES SUI CI DAL THOUGHTS?

It may be helpful to keep in mind that in any crisis situation the stress process has three parts:

? an embarrassing public setback or a traumatic loss; (e.g. Loss of a girlfriend or death of a
friend)

? troubling negative thoughts about self or others (e.g. Im worthless.; They hate me.,
Nobody cares.)


? attempting to cope with a temporary crisis (e.g. An auto accident) by an impulsive, and at
times permanent, act of self destruction.

Adapted from Suicide in Youth and What to Do About It.
San Mateo County, California
HANDOUT

HOW EDUCATORS CAN HELP SUICIDAL CHILDREN

Be aware of your responsibilities to know warning signs to protect a suicidal youngster.

Identify potentially suicidal children using warning signs and referral to school counselors ("high
risk category students.}

Use proactive strategies to teach children better coping and problem - solving skills through
realistic problem situations, role plays, and videos.

Take any suicide attempt, regardless how non- lethal, as a very serious sign that a child has taken
desperate measures to let someone know of his distress.

Alert parents when their children make suicidal threats and direct them to seek appropriate
mental health resources.

Consult with parents to seek remedial assistance to improve communication among family
members and address dysfunctional behavior.

Let the child know that you understand their hurtful feelings. Encourage them to discuss what
they are experiencing that has influenced them to consider suicide.

If you are not able to maintain a relationship with a "high risk" category student, make certain
that the child has a supportive relationship with another adult in the school.

Work with self destructive middle school aged students to help them assess repetitious,
alienating behaviors (e.g., Absenteeism, rebelliousness in class, apathy toward work completion,
deliberately provocative behavior towards others in the class, etc.). Help them understand how
these behaviors involve them in problems over and again.

Use a self- structuring response when faced with suicidal behavior.

"You do not have to hurt yourself to tell me that something is wrong. "

Set limits when you hear suicidal threats, no matter how causal the intent.

" Billy, we take it very seriously around here when someone threatens to kill
himself. Tell me straight out what is wrong. Don't try to get my attention by making
threats to hurt yourself. Say instead, Mr. Savage, I have a problem, Can you help me?


D-I-R-T
ASSESSMENT of PREVIOUS SUICIDE ATTEMPTS
by YOUNG PEOPLE

Use the D-I-R-T test to weigh the risk factors of previous suicide attempts:










S-L-A-P
LETHALITY ASSESSMENT
for YOUNG PEOPLE

Have you been thinking of harming yourself?

If answered in the affirmative, is followed by:

How would you harm yourself?

From this point you are assessing lethality of intentions by the use of the S-L-A-P test:











Youth Suicide
Barbara Hicks (1990)
D How dangerous was the previous attempt?

I What impression did the individual have about the risk of the
previous attempt?

R Was the opportunity for rescue possible or remote?

T Was the previous attempt recent or long ago?

S How specific is the plan?

L How lethal is the proposed method?

A How available is the proposed method?

P What is the proximity of helping resources?

SUICIDE INTERVENTION SCREENING

When to assess.

When the counselor hears counselees say,

"I can't handle it."

"Id be better off dead.

"I just don't know what to do or where to turn."

"I've had it. "

**** Or if you notice any significant combination of suicidal warning signs.

How to assess.

The counselor needs to explore these themes by asking,

1. How much are you thinking about killing yourself? Are you thinking
about hurting yourself?

2. What is your method or plan?

3. Is that method or plan available to you?

4. Where/when would you do this?

5. Who would be most affected by your death or to whom would you
address a suicide note?

6. On a scale of 1 to 10, one being very unlikely and ten being certain that you will do it,
where are you on that scale in your plan to kill yourself?

7. Who, in addition to me, needs to know how you're feeling right now?
What would you want to tell them so that they could understand you better?

8. Is my being with you helping not at all, a little, or a lot? What would I need to know
about you in order to help you more ?



What to say to a potentially suicidal counselee:

1. Tell the person that you don't want him/her to do it.

2. Don't tell the person that "everything will be all right - you have so much to
live for." This invalidates 'the individual's feelings. Also, you have no guarantee that
the person's concern I can be easily fixed or is within his/her control. Try to join with
the individual in a discussion about feelings related to the problem. I can understand
how things might seem so bad that you might have such thoughts. Tell me a bit more
about them" THEN SHUT UP AND LISTEN!!!

3. When you have 1istened, respond by focusing on cognition rather than affect.
Go for problem-solving - try to defuse and calm strong emotions. "Let's figure
out what your first step could be." or "Let's see if we can find a way to take
care of one part of this problem."

What to do:

1. Suggest a suicide intervention contract, counselee's verbal or written promise
not to hurt oneself while help is being obtained with a specific time to see the
counselor again the following day.
2. Consult with school principal, school counselor, or psychologist.
3. Contact parent/guardian.
4. Recommend family contact with therapist or the community mental health
center for a lethality assessment.
5. Recommend family involvement of doctor or caseworker.
6. Provide youth with hotline phone number 1-800-422-0009.
7. Check out necessity and criteria far hospitalization.

Adapted from:
Milcinski, T.C. (1993). Counselor Self: Efficiency and Suicide Intervention. Unpublished doctoral dissertation, The University of
Kansas, Lawrence.

SUICIDAL ADOLESCENT'S MINDSET
Suicidal people are predisposed toward looking for anything which will support their
negative views of themselves, their situation, those around them, and the world in general They
anticipate that no one will hear them despite their attempts to make others attend to their pain,
confusion, and anger.

SUICIDAL ADOLESCENT'S PROCESSING DEFICIENCIES
Primitive Thinking:
absolutistic
irreversible
fatalistic
anecdotal logic

Therefore...... COUNSELORS MUST TAKE OVER DECISON-MAKING
FOR SUICIDAL COUNSELEES

Emergency Counseling with Suicidal Youth
1. Carefully understand the precipitating situation or factors.

2. Assess the degree of hopelessness

3. Work with tunnel vision," i.e. the person having reduced himse1f to very rigid and
limited ways of viewing a situation and/or seeing only a very limited number of
options.

4. Does the individual have a suicidal plan? How specific is it? Risk rises with the specificity of
the plan.

5. Are the means of suicide available? Is there a gun in the home?

6. Does the person use drugs or alcohol?

7. Has the person made previous attempts? If so, what were the circumstances? Are these
previous circumstances similar to the current precipitating events?

8. Is there a family history of suicide and/or depression?

9. Bargain for a delay.

10. Make a non-suicide contract. Make it specific, have the youngster sign it, and sign it
yourself as a witness. Make copies for the youngster, yourse1f, and perhaps others.

11. Increase signal awareness; sensitize the person to cues that he may need to take specific
actions to compete with suicidal feelings.

12. Remove the person from the provocative situation.

13. Draw significant others into the situation; community resources.










Name of Student Date of Initial Report


School School Counselor's Name

A. Basic Information

1. History of Concerns

2. Family Systems Information

3. Interventions (include dates)
School Counselor

Agency/Doctor/Therapist

Medications

4. School Related Issues

B. Follow-up Case Management

1. Collaboration with Mental Health Providers

2. Direct Services to Student
Counseling Issues to Address
8 Cognitive
8 Effective
8 Behavioral

Support Services
8 Group
8 Team

3. Consultation with Teachers

4. Consultation with Family

5. Peer Involvement



Case Management Template
(Suicidal Threats, Gestures, Attempts)

NO SUICIDE CONTRACT


I, a student at
Name School

take the responsibility for my welfare and agree not to harm myself in any way. I understand that if I am having

suicidal thoughts that I agree to call my counselor
Name

at .
Phone No.

If I cannot reach them, I will call the Crisis Hotline at or I will tell an adult and
Phone No.

get help for myself.













Student Witness


Parent Notification

Actual Sample of a letter used in a Middle School

Dear Parents/Guardian:

It was brought to our attention that your child was expressing thoughts of doing harm to.
himself/herself. When this occurs, it is our school system's procedure to have that child remain in
our physical presence until that child can be released directly to his/her parent or guardian. We
take every occurrence of a suicidal threat seriously and strongly encourage you to have your
child evaluated by a certified mental health professional or community mental health agency.
The purpose of this evaluation is to determine the lethality of your child's thoughts and to
provide recommendations and assistance.

Your child may return to school as soon as possible. W e ask that a report from the
mental health professional who saw your child be shared with his/her school counselor at the
time your child returns to school.

Thank you for taking this matter seriously. If we can be of any assistance, please call us
at .

Sincerely,



Additional issues
Encourage parents to sign a release at agency or mental health treatment
provider so that counselor has permission to contact same and discuss
case.
Have a list of mental health referral resources, addresses, and telephone
numbers to provide to parents/guardians. Include local ER.
Record on counselor's calendar/schedule contact with parent/guardian,
date and time, and results of discussion.
Share actions taken with an administrator. Ask him/her to document
conversation, date, time.
Arrange follow- up meeting with student. It is advisable to continue to
involve family in follow-up plans. Case conference may be appropriate
especially for a student returning from institution after a serious suicide
attempt.
Use case management template to guide treatment plan.


WHAT ARE PARASUICIDAL BEHAVIORS?

Parasuicidal behaviors are self-destructive acts which, while there is no conscious attempt to kill
oneself, place the young person in danger of being killed by the high risk nature of the act or by
relating to individual who are capable of bringing harm to the individual. Engaging in
parasuicidal behavior is seen as a prelude to an overt act of suicide. Voluntarily placing one's
life in harm's way is a nonverbal declaration that one considers his/her life cheap, a throw-
away. Such behavior extends to placing oneself in a dangerous situation through refusing to
consider how vulnerable one becomes when under the influence of drugs and alcohol.






















Faced with the presence of the reality that these acts or choices could result in bodily harm, it is
important for the helper to inquire of the individual whether these potential dangers were
considered. Find out if the individual's response to your question is a suicidally focused response
such as, "Who would really miss me? Find out about related behaviors such as polydrug abuse
or heavy drinking and drugging at the same time. Such behaviors tell you that the individual has
crossed the line between substance abuse and life abuse.
Rowland L. Savage Governor's Conference on Child Abase November, 1997









Suicide Prevention Handbook
P R E V E N T I N G S U I C I D E

Teach children how to express emotions and feelings.

Allow children to share feelings and emotions without fear of embarrassment and show that you
respect their feelings.

Help children to learn to put differences into perspective and to respect differences in people.

Anticipate when situations or events may be overwhelming to children and help them to deal
with their concerns.

Help them to understand that life is full of ups and downs and that down periods are normal and
temporary.

Teach them how to make and keep friends and to value friendship.

Help them to understand that relationships between people change and teach them to deal with
such changes.

Help them to understand that everyone makes mistakes and that learning from mistakes is the
most important part.

Teach them that asking for help is a sign of strength, not weakness, and that help is available for
all problems.

Teach them how to make decisions and to take responsibility for such decisions. Be sure to teach
them to explore choices and solutions and to examine the possible consequences of actions.

Accept them for what they are and learn to change your expectations rather than expecting them
to change.

Let them know that they are unique and special, and most importantly that they are loved.
WHAT ARE THE ISSUES IN POSTVENTION?


Purpose: The objective is to reduce possible contagion among
young people after a suicide of an agemate.

The loss of a close friend introduces a sense of doubt to once confident young people.

They may experience a loss of control over once stable feelings and thoughts:
8 Anxiety and fear for their own safety can be implied.
8 Why did he choose to die? I have just as many problems.
8 Questions about their own self worth are raised.

Suicide may be looked upon in a new light -- a possibility for them too.

The closer the friendship ties and/or the more alienated the students are to the adult world the
greater is their risk. Postvention plans should identify those students and provide more
intensive counseling intervention for them.

All students can benefit from a postvention talk; death reminds many of related loses in their
lives.

Intervention following a suicide is to:

8 convince students that their loss is recognized.
8 convey a sense of understanding for the pressures they experience.
8 open up channels of communication about their concerns.

Communication themes to use during a postvention are:

8 Feelings of anger, guilt, fear, confusion, shame, indifference, disbelief, blame, and
unrelated grief are normal bereavement themes.
8 There are no answers to" why" except he made a terrible choice when there were many
others open to him.
8 No one makes" another commit suicide; he "chooses" his death.
8 We all feel abandoned and cheated by a suicide.

R.L. Savage 10/99 Archdiocesan Response Team Postvention Fldr


SUICIDE PREVENTION MODEL FOR
ELEMENTARY AGED STUDENTS




































SUICIDE PREVENTION MODEL
FOR ADOLESCENTS AND PREADOLESCENTS