Youth Suicide

1. Youth Suicide Lorna Martin lormartin@gov.mb.ca

2. Common Warning Signs ofYouth Suicide • Suicide threats (written, direct, indirect) • Preoccupation with death (making final arrangements, giving away prized possessions, talking, reading, writing, drawing about death or a dead person) • Changes in behaviour, physical condition, thoughts, or feelings (withdrawal, isolation, increased risk-taking, decreased performance, frequent lateness, unexplained absence, crying jags, heavy use of alcohol or drugs, abrupt changes in appearance, appetite, sleep patterns, exaggerated fears, irrationality/anxiety, hopelessness, increased irritability, moodiness, lethargy) • Stress (intolerable loss)

3. Four Indicators of Risk Levels • Stress • Critical situational events, personal loss • Disruptive life events • Symptoms • Changes in behaviour, physical condition, thoughts/feelings • Thoughts of Suicide • Direct/indirect • Loss/Lack of Social Network/Support • Healthy connections to others missing or lost

4. Assessment of Risk • Current Suicide Plan • Method, preparation, means, time frame • The more detailed the plan, the greater the risk • Prior Suicidal Behaviour • Prior attempt(s) reveal(s) acceptance of suicide as an alternative • Resources • Risk decreases with personal support resources such as a place to live, caring family, friends or teachers, access to help

5. Spectrum of Suicidality • Not all youths follow the same trajectory towards suicide • Self-harm is not necessarily a precursor to suicide • Not all suicidal youths are depressed • Not all youths indicate their feelings of suicide prior to an attempt or completion

6. IDEATION -thoughts of death -wishes never born -life not worth living -thoughts of killing self (general moving towards specific) -sees suicide as retribution INTENTION -writing notes/will -giving away possessions -subtle/overt threats -minor self-harm and self-destructive risk-taking Sample 1 Trajectory

7. ATTEMPT -pseudo-suicide attempt (in a place and time when interveners will be present) -minor attempt (failure is distinct possibility) -major attempt (failure remote) COMPLETION Sample 1 Trajectory (cont’d)

8. IDEATION Thoughts of killing self (specific) INTENT Expresses threat in angry outburst Threatens to harm others simultaneously ATTEMPT Major attempt (selects time and method with little chance of failure) COMPLETION Sample 2 Trajectory

9. IDEATION None expressed INTENT None observed ATTEMPT - None observed COMPLETION Sample 3 Trajectory

10. IDEATION -Morbid ideation -Preoccupation with death and dying INTENT -Writes songs -Self-harms ATTEMPT None observed COMPLETION -None to date Sample 4 Trajectory

11. Early Family Influences on Suicidal Behaviour

12. Assessing Risk Levels Ensure you are qualified to make risk decisions. If you have not been trained through a program such as ASIST or LivingWorks, seek assistance immediately. If you are trained, it is still important to debrief with a qualifed colleague. • Risk levels increase as resiliency factors decrease • Risk levels increase with • Current suicide plan • Prior suicidal behaviour • Lack of available resources to act as a safety net • Risk levels further escalate if suicide plan has method, means and established timeframe

13. If you are a trained intervener: • The next slides are reminders • The next slides are for your information, to assist you providing details to a trained intervener If you are likely to be a trusted professional:

14. Seeking Assistance and Support • Use the school threat assessment and/or crisis intervention protocol to assist you • Access the school psychologist, social worker, AFM worker or other qualified intervener within your system • Access medical, RCMP, or mobile crisis unit if there are no qualifed interveners within your system. • Contact parent(s)/guardian(s). • Document your actions.

15. Acronyms to Aid in Assessing Risk To respond efficiently to a suicidal youth, it is important to be calm, patient, and direction. To determine the degree of risk, you need to learn answers to specific questions. Ask them. It may be a life-saving decision.

16. Miller (1984) Acronym 1 S - how specific is the plan of attack? The more specific the details related the higher the degree of present risk L - how lethalis the proposed method? How quickly could the person die if the plan is implemented? The greater the level of lethality, the greater the risk. A - How availableis the proposed method? If the implement to be used is readily available, the level of suicidal risk is greater. P - What is the proximity of helping resources? Generally, the greater the distance the youth would be from helping or supporting resources if the plan were implemented, the greater the degree of risk.

17. Miller (1984) Acronym 2 Four additional factors to aid in assessing the level of suicidal risk when the youth has made a previous suicidal attempt: D – Dangerous – How dangerous was the prior attempt and current plan? The greater the danger, the higher the current risk. I – Impression – Even if the danger in the attempt or plan is not significantly high, if the impression is that the danger is high and will surely cause death, the present risk is high. R – Rescue – If the opportunity for rescue was great in the prior attempt or present plan, the risk is lower than if the opportunity for rescue was remote. If the chances were or are poor that rescue will occur, the present risk is high. T – Timing – If the previous attempt was recent, the present risk is higher than if the previous attempt was long ago. If a youth may be at immediate risk, you must immediately implement any process necessary to protect that youth or to provide life-saving supports.

18. Safety Contracts • Many low to moderate risk youths respond positively and reliably to a safety contract. • The contract should include • A specific plan that prevents immediate risk • A commitment to not engage in self-harm for an agreed-upon timeframe • Crisis support, including names and telephone numbers • Ensure you have a ‘back-up’ plan in addition to a safety contract

19. Sample Safety Contract PERSONAL SAFETY CONTRACT Date:________________________ Time: ________________ I, (name), promise to keep myself safe until (date and time) when I see my counsellor. I will not harm myself or others in any way. If I feel like I cannot control myself or start to feel worried, or anxious, or that I might not keep this promise, I will call: (insert youth’s choice of trusted friend or family member and telephone number) or (insert youth’s alternative choice and telephone number) or (insert name of hospital/RCMP/nursing station and telephone number) _______________________ _______________________ Signature of Youth Signature of Counsellor Ensure you have a ‘back-up’ plan in addition to a personal safety contract. Contact resources.

20. Assisting Low Risk Youths • Listening empathically • Obtaining a specific, written promise to seek help when needed • Providing a promise of continued support “Will you be safe until Tuesday?” “I’ll stay with you while you tell your parent how you’re feeling.” “Can you promise me that you will follow the instructions we have agreed to in this contract?” “Will you keep your appointment with me tomorrow?”

21. Assisting Moderate Risk Youths without a specific plan • Require more intervention and direction • Written and verbal commitment required • Refer to school psychologist • Contact parent(s) “I’m not positive you’re going to be okay after you leave here.” “Will you keep the promises you made in our contract?” “Here’s a telephone number where I can be reached, the suicide crisis line and the clinic number. Promise me now that you will call me or any of these other numbers for help before you decide to take any action that might harm you. Even when the idea enters your head and you’re not sure….phone. Can you promise?” “Can I telephone you this evening to make sure you’re all right? I’m very concerned and I want us to talk again to make things better for you.” “Will you be safe if you leave here now? Are you positive?”

22. Assisting High Risk Youths • Youth is in crisis • Do not leave the youth unsupervised. • Support cannot be withdrawn for any reason • Be assertive and directive. “I can’t leave you here alone. I want you to come with me now so we can get you more help than I can give you here.” “You can’t promise that you won’t kill yourself and that concerns me. Let’s go together to the hospital where we can get more support.” • Do not take ‘no’ for an answer. Follow school protocol for threat assessment/crisis intervention. • Contact parent(s). Dial 911 if necessary.

23. Recent attempts Recent losses Critical incidents Prior traumas Isolation/withdrawal Substance abuse Destructive coping styles Poor problem solving skills Disorientation Inadequate support Hopelessness/ helplessness Summary of Typical Risk Factors

24. Support from family and friends Perceived connection to family and friends Strong cultural ties Good physical and mental health Strong spiritual ties Positive self-esteem Early identification and treatment of psychiatric illness Good school performance Positive attitude towards school Skills in stress management, communication, problem-solving Fear of suicide and objections to suicide Sense of belongingness Summary of Protective Factors

25. Risk vs Imminent Danger PHASE ONE Is there a plan and means? Risk factors – five of the following (1-4=risk, 5 or more=danger): • Male • Past attempt • More than one attempt • Antisocial behaviour • Friend or family who has committed suicide • Drug and/or alcohol abuse • Depression • Difficulty socially, especially family problems

26. Risk vs Imminent Danger (cont’d) PHASE TWO Can the youth complete tasks incompatible with suicidal states? • Written promise to abstain from suicidal behaviour for specified time • Ability to compliment self and others • Ability to assess their own emotional state (e.g, develop hierarchy of situations that would raise suicidal thoughts) • Capacity to plan ahead (e.g., being prepared for stressors, positive imagery, relaxation, develop social support system (Inability to accomplish these four tasks indicates possible imminent danger)

27. Referrals • Report suicidality and refer to a trained professional (e.g., psychologist, medical doctor, Salvation Army Mobile Crisis Unit). While awaiting the professional, • Remove access to means of suicide • Use protocols for threat assessments/crisis intervention • Inform parent that referral has been made • Maintain supervision of youth

28. Formal Assessments There are several instruments available to trained professionals to detect suicidality. Some of the most commonly used are: • Suicide Probability Scale (SPS) • Suicidal Ideation Questionnaire (SIQ) • ISO-30 • Children’s Depression Rating Scale • Beck Hopelessness Scale (BHS) • Index of Potential Suicide

29. Making the Connection • You’ve recognized the signs and symptoms. • You’ve asked the questions directly. • You’ve documented the interview and your actions. • You’ve made a connection with the youth. • You may be the difference between recovery and imminent death. • The youth is trusting you to be a reliable, responsible adult.

30. Keeping the Connection • Stay focused. • Stay calm. • Stay with the youth. • Err on the side of caution. • Trust your ‘gut’. • Get help. Create a helping network with the youth. • Document events. • Debrief with a trusted colleague following the initial resolution of the event.

31. This presentation has been an overview of commonly held principles and practices when dealing with suicidal clients. It is intended as an information session only. This presentation does not provide training for suicide intervention. For information on training in intervention and postvention, please contact:

32. Centre for Suicide PreventionSuite 320, 1202 Centre Street S.E.Calgary, Alberta Canada T2G 5A5 Phone: 403 245-3900 Fax: 403 245-0299 sptp@suicideinfo.ca or Lorna Martin Manitoba Education, Citizenship and Youth Phone: 204 945-7964 Fax: 204 948-2291 lormartin@gov.mb.ca