When the Unthinkable Happens

1. When the Unthinkable Happens Suicide Prevention and Postvention for Schools John E. Landers, Ph.D. Clinical Psychologist doctorlanders@gmail.com

2. Content of Presentation • Laws, Rules, Standards, and Expectations • Scope of the Concern • Myths and Stigma • Best Practice in Prevention • Best Practice in Postvention • Additional Discussion

3. Laws, Rules, Standards, and Expectations

4. Idaho Statutes TITLE 33 EDUCATION CHAPTER 5 DISTRICT TRUSTEES 33-512.Governance of schools. The board of trustees of each school district shall have the following powers and duties: (4) To protect the morals and health of the pupils;

5. Idaho Statutes TITLE 33 EDUCATION CHAPTER 5 DISTRICT TRUSTEES 33-512B.Suicidal tendencies -- Duty to warn. (1) Notwithstanding the provisions of section 33-512(4), Idaho Code, neither a teacher nor a school district shall have a duty to warn of the suicidal tendencies of a student absent the teacher’s knowledge of direct evidence of such suicidal tendencies. (2) "Direct evidence" means evidence which directly proves a fact without inference and which in itself, if true, conclusively establishes that fact. Direct evidence would include unequivocal and unambiguous oral or written statements by a student which would not cause a reasonable teacher to speculate regarding the existence of the fact in question; it would not include equivocal or ambiguous oral or written statements by a student which would cause a reasonable teacher to speculate regarding the existence of the fact in question. (3) The existence of the teacher’s knowledge of the direct evidence referred to in subsections (1) and (2) of this section shall be determined by the court as a matter of law. This statute was enacted in 1996 as a result of the Idaho Supreme Court’s decision in Brooks v. Logan, 132 Idaho 484, 903 P.2d 73 (1005) (Brooks I).

6. Idaho Administrative Rules IDAPA 08.02.03.160 – SAFE ENVIRONMENT AND DISCIPLINE • Each school district will have a comprehensive district wide policy and procedure encompassing the following: • School Climate • Discipline • Student Health • Violence Prevention • Gun-free Schools • Substance Abuse - Tobacco, Alcohol, and Other Drugs • Suicide Prevention • Student Harassment • Drug-free School Zones • Building Safety including Evacuation Drills • Districts will conduct an annual review of these policies and procedures.

7. IDAHO CONTENT STANDARDSHEALTH EDUCATION(Health Education Standards Approved by Legislature January 2010 for Fall 2010 School District Adoption) Mental, Emotional & Social Health (Grades 6-12) Mental, emotional and social wellbeing is a foundation for building good health and includes a sense of security, identity, belonging, purpose and competence in order to strive toward a healthy and productive life. Knowledge and skills may include emotional intelligence, suicide prevention, stress management, communication skills, conflict resolution, and mental illness.

8. Idaho School Counselors Study • Completed in April 2010 • Study done as part of the graduate research of two students at NNU • 109 participants (professional school counselors, and social workers that are members of ISCA)

9. Does your school/district have a written plan to reduce the likelihood of student suicide?

10. Does your school/district have a written plan to respond to a completed student suicide?

11. Have you ever had a student referred to you as potentially suicidal?

12. Scope of the Concern

13. Idaho Youth (YRBS Idaho, 2009) • 28% of Idaho high school students report experiencing depression (1 in 3) • 14% report seriously considering suicide (1 in 7) • 13% said they made a plan for how they would attempt suicide (1 in 7) • 7% report making at least one attempt (1 in 14)

14. Idaho Youth (YRBS Idaho, 2009) • If you are a high school teacher with 30 children in your classroom: • 10 have been depressed this year • 4 have seriously considered suicide this year • 4 have developed a plan to attempt suicide this year • 2 have made at least one attempt at suicide this year • Can you name these children?

15. Indicators for Educators • Many adults view youth who are irritable or who act out as behavior-problem youth, without being aware that a very treatable underlying cause such as depression may be affecting the youth • While youth must be held accountable for their actions, it is equally important that their depression, if present, be recognized, evaluated and treated

16. Indicators for Educators • Miller and Taylor (2000) analyzed high risk behaviors in 9th-12th graders and found a correlation with suicide ideation and attempts • High Risk Sex (multiple partners, before age 14) • Binge Drinking (5 or more in several hours) • Drug Use • Disturbed eating patterns • Smoking • Violence

17. Indicators for Educators • The 17% of youth with more than three problem behaviors accounted for 60% of medically treated suicidal acts • Compared to adolescents with zero problem behaviors, the odds of a medically treated suicide attempt were • 2.3 times greater among adolescents with one • 8.8 with two • 18.3 with three • 30.8 with four • 50.0 with five • 227.3 with six • A count of problem behaviors may offer a reliable way to identify suicide risk

18. Myths and Stigma

19. “Suicide is a whispered word, inappropriate for polite company. Family and friends often pretend they do not hear the word's dread sound even when it is uttered. For suicide is a taboo subject that stigmatizes not only the victim but the survivors as well.” - Earl A. Grollman - Author of Suicide

20. Stigma and Suicide Prevention • Suicide has become the Last Taboo – we can talk about AIDS, sex, incest, and other topics that used to be unapproachable. We are still afraid of the “S” word • Overcoming stigma and talking openly about suicide is the key to prevention • Suicide is the leading cause of death for Idaho youth after unintentional injury • Suicide is preventable through treatment • Educators spend more time with our youth than any other adults and have a key role to play in detection and referral for treatment

21. Myth vs. Fact 1.Talking about suicide might cause a person to act • False – it is helpful to show the person you take them seriously and you care. Most feel relieved at the chance to talk 2. A person who threatens suicide won’t really follow through • False – 80% of suicide completers talk about it before they actually follow through 3. Only “crazy” people kill themselves • False - Crazy is slang for psychotic, which means to have lost touch with reality. Few who kill themselves have lost touch with reality – they feel hopeless and in terrible pain (90% of those completing suicide meet criteria for depression)

22. Myth vs. Fact 4. No one I know would do that • False - suicide is an equal opportunity killer – rich, poor, successful, unsuccessful, beautiful, ugly, young, old, popular and unpopular people all complete suicide 5. They’re just trying to get attention • False – They are trying to get help. We should recognize that need and respond to it 6. Suicide is a city problem, not in the country or a small town • False – rural areas have higher suicide rates than urban areas

23. Myth vs. Fact • Once a person decides to die nothing can stop them - They really want to die • False - most people want to be stopped – if we don’t try to stop them they will certainly die - people want to end their pain, not their lives, but they no longer have hope that anyone will listen, that they can be helped • Taking antidepressants increases risk of suicide • False – Yes the FDA has put a label on SSRI’s stating that use may increase suicidal agitation; however, A 2003 WHO study in over 15 countries found a significant reduction, averaging about 33%, in the youth suicide rate that coincided with the introduction of SSRI's

24. Other Myths • Suicide is generally completed without warning • Listening to certain types of music (e.g., “heavy metal”) or engaging in certain activities (e.g., watching particular movies) causes people to become suicidal • Preventing access to lethal means will not prevent suicide - students will simply choose another method • Suicide rates are higher for impoverished people • Membership in some religions protects against suicide more than in others • The motives for suicide are easily established • A person with a terminal physical illness is likely to complete suicide • There is a very low correlation between alcohol abuse and suicide • Males have the highest rate of suicidal behavior • Improvement in emotional state means lessened risk of suicide • Severe mental illness is particularly associated with youth suicide

25. Best Practice in Prevention

26. Education Components • UNIVERSAL PREVENTION: Prevention for all students via curricula and activities to boost resiliency and protective factors, while preventing and/or mitigating potential risk behaviors. Staff training is designed to create awareness, help identify students with risk behaviors or warning signs, and communicate the risk to school mental health professionals. • Administrative Consultation • Gatekeeper Training for all Staff • Parent Training (similar to gatekeeper) • Community Resource Training • Student Training • SELECTED INTERVENTION: Identification and intervention efforts that target students with vulnerabilities such as depression, a recent loss experience, bullying behaviors or other risk factors. • INDICATED INTERVENTION: Crisis-response assessment and intervention services for students having suicidal thoughts or behaviors, or demonstrating other self-injurious acts.

27. Model Program – Miami Dade County Public School District • Program emphasizes recognizing risk and warning signs, help-seeking, self-awareness, conflict resolution, anger management, problem solving, relationship building, coping skills, stress management and more. • Results of the Miami-Dade Youth Suicide Prevention and Intervention Program, or YSPIP, include a 75% reduction in the suicide rate among 15-19-year-old students since program inception in 1989. • The suicide rate is well below levels of same-age students in Florida and across the United States.

28. Idaho Resources from State Dept. of Education and SPAN-Idaho • There are resources on prevention and postvention as well as legal considerations available on the SPAN Idaho website • These have been designed with best-practices in mind and are free for your district to access, modify, and utilize • Access resources via http://www.spanidaho.org/ and click on the Schools link to the right

29. Free Best-Practice Prevention Program • Two fathers who lost adolescent children to suicide have collaborated with the nation’s top experts in implementing and evaluating school-based suicide-prevention programs. • The result is a top-notch two-hour online training module in suicide prevention for school teachers called “Making Educators Partners in Youth Suicide PreventionTM.” • Available through a not-for-profit organization formed by the two fathers, Scott Fritz and Don Quigley of New Jersey, this interactive training program can be accessed at www.sptsnj.org. • Its content is applicable across states and school systems, and has been lauded nationwide. To learn more about this designated best-practice program, email talkback@wellawaresp.org.

30. Best Practice in Postvention

31. “The single best predictor of how students will respond to a frightening event is how the adults around them are reacting. Being able to work through the effects of a suicidal death with caring, supportive adults will decrease the contagion. Any kind of death is hard for adolescents, but it is especially hard if adult guidance and support is withheld.” Ruof, S.R. & Harris, J.M. (1988). Suicide contagion: Guilt and modeling. A series on suicide prevention. NASP Communique, 16(7), 8.

32. Goals of Postvention • Prevent other suicides. • Reduce the onset and degree of debilitation by psychiatric disorders (e.g., PTSD). • Reduce feelings of isolation among suicide survivors.

33. Postvention Checklist – Included in Resources • Verification of suicide • Mobilize the crisis intervention team • Assess the suicide’s impact and level of services needed • Notify other school personnel • Contact the family of the suicide victim • Determine what and how to share information • Staff Planning Session • Intervention services • Memorials and funerals • Dealing with the media • Debriefing

34. Additional Discussion

35. Universal Prevention & First-Responders • Proper implementation of universal prevention program means anyone and everyone is a first-responder • What would you do if you saw someone in physical pain, being physically injured, or unconscious? • If you needed to administer CPR or first-aid, could you?

36. First-Responders • Brain death occurs 4-6 minutes after sudden cardiac arrest without implementing CPR. That is why even if an AED is not available, providing simple CPR until the paramedics arrive can have a huge impact on the outcome. By continuing to manually pump blood throughout the body the brain and other organs are kept alive. • The American Heart Association states that when CPR and defibrillation are administered within eight minutes of a cardiac arrest, the victim's chance of survival increases to 20%. When these steps are provided within four minutes and the paramedics arrive within eight minutes, the likelihood of survival increases to over 40%. • Until everyone is properly trained in CPR and first aid, surviving a cardiac arrest is really about being in the right place at the right time. • Since most cardiac arrests statistically happen in the home, becoming CPR trained might just mean you will one day save the life of a good friend or loved one! • Why are we talking about CPR and First-Responders?

37. Psychological First-Responders • Who is the most likely individual to be in the presence of an adolescent experiencing a psychological crisis? • Who is an adolescent experiencing a psychological crisis most likely going to turn to for help? • Who is going to provide an initial assessment, build rapport, and referral for further assessment and treatment? • First responder or Licensed mental health professional?

38. Barriers to First-Responders • Bystander Effect (Kitty Genovese) - presence of others inhibits helping • conclude from the inaction of others that help is not needed • assume that someone else is going to intervene • Comfort • Confidence • Competence Training can alleviate these concerns!

39. When Do I Intervene? • If you believe that someone may be thinking about harming themselves, for whatever reason • Don’t allow any barrier to get in the way (e.g., time, fear, attitudes, etc…) • Ask the Question

40. Initiating the Assessment • It seems things haven’t been going so well for you lately. I know that recently _______ has happened. Most people would find that upsetting. • Have you felt upset, maybe some sad or angry feelings you’ve had trouble talking about? Maybe I could help you talk about these feelings and thoughts? • Do you feel like things can get better, or are you worried things will just stay the same or get worse? • Are you feeling unhappy most of the time?

41. Identifying Suicidal Ideation • Others I’ve talked to have said that when they feel that sad or angry, they thought for a while that things would be better if they were dead. Have you ever thought that? What were your thoughts? • Is the feeling of unhappiness so strong that sometimes you wish you were dead? • Do you sometimes feel that you want to take your own life? • How often have you had these thoughts? How long do they stay with you?

42. Risk Assessment Current Plan Prior Behavior Resources

43. Current Plan • Have you thought about how you might make yourself die? • Do you have a plan? • On a scale of 1 to 10, how likely is it that you will kill yourself? • When do you think you might do this? • Do you have the means with you now, at school, or at home? • Where are you planning on killing yourself? • Have you written a note? • Have you put things in order?

44. Prior Behavior • Has any one that you know of killed or attempted to kill themselves? Do you know why? • Have you every threatened to kill yourself before? When? What stopped you? • Have you ever tried to kill yourself before? How did you attempt to do so?

45. Resources • Is there anyone or anything that would stop you? • Is there someone whom you can talk to about these feelings? • Have you or can you talk to your family or friends about suicide?

46. C P R Current Plan Prepared Prior Behavior Acceptable Resources Alone

47. Next Steps… What will you do now?

48. Contact Us Matt McCarter Safe and Drug-Free Schools Coordinator Idaho State Department of Education mamccarter@sde.idaho.gov John Landers, Ph.D. Clinical Psychologist Eastern Idaho Regional Medical Center doctorlanders@gmail.com