Youth Suicide Intervention

1. Youth Suicide Intervention Denton ISD August 16, 2011 Dr. Casey A. Barrio Minton, PhD, NCC

2. Session Overview Understanding youth suicide Recognizing warning signs Facilitating open conversations Connecting with resources Continuing education resources

3. The Words We Use • Suicide/completed suicide • Suicide attempt • “potentially self-injurious behavior with a nonfatal outcome, for which there is evidence (either explicit or implicit) that the person intended at some (nonzero) level to kill himself/herself” (Brown, 2003, p. 5). • Suicidal ideation (self) • Suicide threat (other)

4. The Words We Use • Suicidal Act • Suicide or suicide attempt (with or without injuries) • Nonzero intent to die • Self-injurious behavior • Deliberate infliction of direct physical harm • Zero intent to die • Instrumental Suicide-Related Behavior • Desired appearance of intending to kill self (with or without injuries) • Zero intent to die

5. Terminology • Self-inflicted • Intent to kill self • Nonzero • Zero • Actual harm to self • Desired appearance and response

6. Could it be Related to Suicide? Child is brought to emergency services from group home after digging into his arms with safety pin and saying that he’s “tired of life like this…” Adolescent takes a bottle of medications, but medications do no physical harm Adolescent is found making cuts on her arms and legs in the school bathroom. Later, parents find diary with poetry expressing student’s loneliness and loss of hope for the future.

7. A Few Suicide Facts(CDC, 2006, 2009) • Leading cause of death • Ages 5-14 (5th) • Ages 15-24 (3rd) • Estimated 100-200 attempts per completion • 1 in 19 has thoughts in any 2 week period • Considerable variations among groups

8. Why Suicide(Shneidman, 1985, 1999) “Psychache” Intolerable Interminable Inescapable

9. Why Suicide(Shneidman, 1985, 1999)

10. Common Misperceptions Someone who talks about it is not serious Talking about it will increase risk Attention-seeking Suicide happens without warning Suicidal people want to die / can’t stop Suicidal people are crazy, mentally ill, insane Danger reduced after crisis

11. Recognizing Warning Signs

12. Protective Factors for Suicide(CDC, 2009) • Access to treatment • Support for help-seeking • Effective clinical care for mental, physical, and substance abuse d/o • Support from ongoing medical and mental health care relationships • Family and community support (connectedness) • Cultural and religious beliefs • Skills in • problem solving • conflict resolution • nonviolent ways of handling disputes

13. Risk Factors for Suicide(CDC, 2009) • Family hx of suicide • Family hx of child maltreatment, conflict • Previous attempt(s) • Mental disorders • Alcohol/drug abuse • Hopelessness • Impulsive or aggressive tendencies • Loss • Isolation • Physical illness • Cultural/religious beliefs • Local suicide epidemics • Barriers to accessing tx • Easy access to methods • Recent severe stressor • Unwilling to seek help because of stigma

14. Risk Factors for Children • Biological • Impulsivity • Age • Psychological • Inferiority / expendable • Depression • Anxiety • Aggression • Impulsivity • Internalizing • Poor coping skills

15. Risk Factors for Children • Cognitive • Immature view of death • Concrete thinking • Attraction/repulsion to life and death • Substance use • Environmental • Early loss • Parental conflict • Chaotic/inflexible family • Abuse / neglect • Parent mental health • Isolated or alienated from peers • Poor social support • Poor social skills • Learning disabilities • Academic failure

16. Risk Factors for Children • Precipitating events • Psychosocial stressors, perceptions, and ability to cope vary developmentally • Recent exposure to suicide / contagion • Previous coping via suicidal ideation or behavior

17. Withdrawal Anger Recklessness Mood change Warning Signs of Suicide(American Association of Suicidology, 2003) Ideation Substance use Purposelessness Anxiety Trapped Hopelessness

18. More Warning Signs for Youth(Suicide Prevention Lifeline; Suicide Prevention Resource Center) Fixated on death Worsening of school performance Unhealthy peer relationships Difficulty adjusting to gender identity Bullying Depression

19. Danger Signs for Youth(Suicide Prevention Resource Center) • Announcing a plan • Talking, writing, or posting about suicide or death • Hints • I wish I were dead. I'm going to end it all. You will be better off without me. What's the point of living? Soon you won't have to worry about me. Who cares if I'm dead, anyway? • Meaninglessness • Giving away prized possessions • Dropping out of school, activities • Obtaining a weapon

20. Facilitating Open Conversations

21. Roadblocks to Discussing Youth’s biases and fears Our biases and fears Our desire to fix, change, or convince otherwise Leakage myth

22. Preparing for Conversations(Shea, 2002) • Tune in to own responses • Be direct – kill, suicide, dead • Tune in to hesitancy • Investigate “not really” • Look for nonverbals • Get out from behind the desk • Take your time • Don’t try to fix or give advice • Prepare to be persistent and creative • Focus on relationship over details … but get details if the time seems right

23. Skills for Opening(Shea, 2002) • Ask questions regarding concrete behavioral facts or thoughts • “When you ‘threw a fit,’ what exactly did you do?” “Did you put the razor blade up to your wrist?” “What happened next?” • Ask question so not as threatening • “Sometimes drinking can lead people to have thoughts of killing themselves that they normally wouldn’t have. Has that ever happened to you?”

24. Skills for Opening(Shea, 2002) • Assume suspected behavior is occurring and frame a ? based on assumption • “What other ways have you thought of killing yourself?” “How often do you cut?” • Normalize the experience • “Some people tell me that, at times, living is so painful that they have thoughts of wanting to kill themselves. Have you had any thoughts like that?”

25. Adapting Skills for Children • Communicate caring and comfort • Specific reason for interview • Not in trouble • Safe to tell truth • No right or wrong answers • Caretaking w/in interview • Determine who is present for interview • Beware of limits to language, leading language, and repeated questions  adapt language, integrate drawing • Attend to developmental understanding of death

26. Key Assessments • Precipitating events, stressors, triggers • inescapable • intolerable • interminable • Suicidal • Ideation • Plans • Means • Intent • Supporting assessments • Warning signs • Prior history • Reasons for dying • Reasons for living • Supports

27. Asking “The Question” • Summarize situation and reflect feelings • Use owning statements • Be very direct • You sound , are you thinking of suicide? • Sometimes when people , they are thinking of suicide. Are you thinking of suicide? • Honor choice to share • Let him or her tell you way

28. Assessing Ideation • After giving child room to share • Summarize content and reflect feelings • Restate thoughts of suicide • Use owning statement regarding needing to know more • Elicit details regarding ideation • (see guidelines handout)

29. Assessing Means, Method, Plan, Intent • Plan - How • Means - Could he/she? Access • Methods - Lethality • Intent - Timeline, action taken • Consider • Level of specificity (more specific  ↑ risk) • Degree of access • Level of lethality • Action already taken • Degree of commitment

30. Supports & Deterrents • Look for • Strength/nature of deterrents • Any hope? Change in feeling? • Family, spiritual beliefs can be critical “What has kept you from…” (details vip) “Who/what is a source of support for you…” “What are the pros and cons of your plan?”

31. Withdrawal Anger Recklessness Mood change Assessing Warning Signs(American Association of Suicidology, 2003) Ideation Substance use Purposelessness Anxiety Trapped Hopelessness

32. Assessing Other Risk Factors • History • Prior suicide attempts • Prior violence • Prior diagnoses / treatment • Mental status • Behavior changes

33. Determining Level of Risk

34. Confounds to the “Risk Grid” Is risk grid a dangerous myth? Counselor/client relationship Perceived pain Perceived resources Previous attempts Mental health history & disorders Balance of reasons for living and dying

35. Connecting with Resources

36. Next Steps • Follow organizational protocols for youth crisis • Do not leave the youth alone • Notify caregivers and/or emergency providers • Empower youth to share himself/herself • Arrange for mental health assessment and services • Follow-up with youth

37. Professional Care for Suicide (Lee & Bartlett, 2006) • Comprehensive suicide assessment • Appropriate management plan • Family involvement • Consultation with professionals • Implementation of plan

38. Professional Care for Suicide • Emergency/crisis services (24/7) • Hotlines • Inpatient hospitalization • Intensive outpatient/Partial hospitalization • Outpatient services

39. Continuing Education Resources

40. Organizational Resources • Standardized Trainings • ASIST (Applied Suicide Intervention Skills Training) • safeTALK (suicide alertness for everyone) • QPR • SOS (Signs of Suicide) • Trevor Project Lifeguard Workshop • Crisis response planning • www.ed.gov/emergencyplan

41. Crisis / Referral Resources United Way’s 211 (or www.211.org) Suicide Prevention Lifeline (800/273-TALK) The Trevor Project

42. Key Websites • National Suicide Prevention Lifeline • 800-273-TALK • Suicide Prevention Resource Center • American Association of Suicidology • Suicide Prevention Action Network • The Trevor Project • American Foundation for Suicide Prevention • SAMHSA NREPP

43. Questions & Discussion