SOS Signs of Suicide® Prevention Program
CERTIFIED TRAINING INSTITUTE Participant Handbook 2nd Editon
A Program of Screening for Mental Health, Inc. HS 94-17M
Screening for Mental Health
®
SOS Signs of Suicide® Certified Training Institute PARTICIPANT HANDBOOK — A special thanks to the SOS Program Supporters — American Academy of Child and Adolescent Psychiatry American Academy of Nurse Practitioners American Counseling Association American School Counselor Association American School Health Association Center for Clinical Social Workers National Association of School Nurses National Association of School Psychologists National Association of Secondary School Principals National Association of Social Workers National Association of Student Councils National Student Assistance Association School Social Work Association of America United Educators Insurance — And to our SOS Program Sponsors — The Makayla Fund The Boston Foundation The Royal Bank of Canada The Will to Live Foundation
Copyright 2017 by Screening for Mental Health, Inc. All rights reserved. Printed in the United States of America. This manual is intended for non-commercial use by approved Certified SOS Program trainers. Reproduction or other use of this manual without express written consent of Screening for Mental Health, Inc. is forbidden. Screening for Mental Health, Inc. (SMH) is a non-profit organization that provides educational screening programs limited to identifying symptoms of depression, bipolar disorder, generalized anxiety disorder, post-traumatic stress disorder, eating disorders, and alcohol use. SMH does not participate in the advice or services given to users of SMH’s screening programs. SMH does not provide any medical, psychological or professional services to its customers or users. For an accurate diagnosis of a mental health disorder, participants should seek an evaluation from a qualified mental health professional. SMH employees, consultants and agents shall not be liable for any claims or damages, and expressly disclaim all liability of any nature for any action, or non-action, taken as a result of the information generated by the SMH website or any of its programs.
Acknowledgements We would like to thank the dedicated professionals who donated their time and expertise in order to help make the SOS Certified Training Institute a reality. Many of these people represent our national supporters, and all provided valuable perspectives and opinions that helped guide the creation of the SOS Certified Training Institute. We deeply appreciate their commitment to mental health outreach for adolescents and thank each of them for their time and talents. Larry Berkowitz Director Riverside Trauma Center
Joanne Meyers President Elyssa’s Mission
Pat Breaux Youth Prevention Specialist Suicide Prevention Center of New York
Jennifer Muehlenkamp Assistant Professor Psychology Department, University of Wisconsin-Eau Claire
Richard Egan Suicide Prevention Training and Outreach Facilitator, Nevada Department of Health and Human Services, Office of Suicide Prevention
Scott Poland Co-Director of the Suicide and Violence Prevention Office NOVA Southeastern University
Alan Holmlund Director Suicide Prevention Program, Massachusetts Department of Public Health
Jodie Segal Director of Education Elyssa’s Mission
Joanna Bridger Clinical Services Director Riverside Trauma Center
Jonathan Singer Associate Professor Loyola University Chicago School of Social Work
Steven Katz Coordinator of Student Services-retired Woodlake Union High School
John Trautwein President and Founder Will to Live Foundation
Nancy Kirkpatrick Youth Suicide Prevention Program Coordinator New Mexico Department of Health
Barent Walsh Executive Director Emeritus The Bridge of Central Massachusetts
Jim McCauley Associate Director Riverside Trauma Center
Janis Whitlock Director of Research Program on Self-Injury and Recovery College of Human Ecology, Cornell University
Marian & Larry McCord Founders CHADS Coalition for Mental Health
Letter from our President & Medical Director Dear Colleague, Thank you for participating in the Certified Training Institute for the SOS Signs of Suicide® Prevention Program. We are thrilled to have you! As a participant in this program, you are part of a national movement to reduce youth suicide by educating students about depression, suicide, and what to do if they are worried about themselves or a friend. The SOS Program empowers students to seek help from a trusted adult, and provides depression screening for adolescents to help schools identify students in need. As a psychiatrist in 1990, I had the idea to begin screening for depression much like my colleagues in the medical field were screening for physical diseases such as cancer and diabetes. It’s important that we screen for mental illness because it allows us to identify these illnesses early on—making treatment more effective. For more than two decades, Screening for Mental Health has developed programs to educate, raise awareness, and screen individuals for common behavioral and mental health disorders and suicide. Our education and screening programs are in middle schools, high schools, colleges and universities, community organizations, and workplaces across the country. While continuing to expand our programming, our mission remains the same: to provide innovative mental health and substance use resources, linking those in need to quality treatment options. These activities will help reduce the stigma often associated with mental health. Our work with adolescents has been especially effective. Research shows that implementing the SOS Program can effectively reduce suicide attempts. We hope that you will take the knowledge and skills you gain from this training back to your community and spread the word that suicide is preventable. The more adults and adolescents understand the signs and symptoms of depression, the more effective we can be at preventing suicide. We also hope you will continue to use Screening for Mental Health as a resource, after you have completed your training. Thank you again!
Sincerely,
Douglas Jacobs, M.D. Founder and Medical Director Screening for Mental Health, Inc.
Table of Contents Day One Part 1: Preparing for an Informative and Effective Training Section 1: Welcome and Introductions Section 2: Training Goals, Agenda, and Logistics Section 3: Overview of SOS Programs & Trainings
Part 2: Youth Suicide: Prevalence, Risk Factors, and Warning Signs Section 4: Debunking Myths and Presenting Facts Section 5: Youth Suicide: A Multifactorial Event
Part 3: SOS Program Implementation Section 6: SOS Program Educational Component Section 7: SOS Program Screening Component Section 8: School/Community Readiness & Planning Section 9: SOS Program Implementer Training
Part 4: Training Trusted Adults Section 10: Key Messages for All Trusted Adults Section 11: Training for Parents, Faculty and Staff, Community Members, and Administrators
Homework: Research and Data Collection Day Two Part 5: Developing Trainings to Meet Community Needs Section 12: Ground Rules and Safe Messaging Section 13: Special Populations Section 14: Self Injury Prevention and Programming Section 15: Postvention as Prevention
Part 6: Advocating for Suicide Prevention in Your Community Section 16: Liability and Suicide Prevention and Screening Section 17: Local and State Level Advocacy
Part 7: Time to Train Section 18: Developing your Trainings Section 19: Next Steps for Trainers
SOS Certified Training Participant Handbook Introduction Welcome and congratulations for championing the national movement for youth suicide prevention training by participating in the SOS Signs of Suicide® Prevention Program Certified Training Institute. By your participation, you have taken an important step towards protecting youth by gaining the skills and materials necessary to advocate for youth suicide prevention programming in your community, training trusted adults to support youth in need, supporting schools and youth-serving organizations to identify who may be at risk for mental health problems, and encourage help-seeking and appropriate treatment. The Certified Training Institute is designed to support the implementation of the SOS Signs of Suicide Prevention Program (SOS Program), which gives young people a “depression check-up” as well as the knowledge to recognize depression in themselves and in their peers and respond effectively. The program highlights the relationship between depression and suicide, teaching that most often suicide is a fatal response to a treatable disorder — depression. Through the SOS Program, youth-serving staff, students and their parents learn about depression, suicide and the associated risks of alcohol use. The SOS Program teaches the action steps youth should take if they experience the signs of depression or suicide within themselves or encounter these signs in a friend: ACT®: Acknowledge your friend has a problem, show the person you Care, and Tell a trusted adult. The SOS Signs of Suicide Prevention Program is the only youth suicide prevention program that has demonstrated an improvement in students’ knowledge and adaptive attitudes about suicide risk and depression, as well as a reduction in actual suicide attempts. Listed on SAMHSA’s National Registry of Evidence-based Programs and Practices, the SOS Program has shown a reduction in self-reported suicide attempts by 40-64% in randomized control studies (Aseltine et al., 2007 & Schilling et al., 2016). This handbook is designed for use during the two-day Certified Training Institute. Feel free to take notes and record your thoughts as you prepare to train others in youth suicide prevention. This handbook should serve as a reference point in your planning for future trainings. You will also have access to electronic materials, handouts, and PowerPoint presentations to utilize in future trainings. Thank you for joining Screening for Mental Health to prevent youth suicide throughout the country by serving as an advocate, trainer and trusted adult in your community.
1 Page
Part 1:
Preparing for an Informative & Effective Training
2 Page
Section 1: Welcome & Introductions Objectives: • Meet and become acquainted with your trainers and colleagues in the room • Learn the best ways to start any training • Learn about practical applications of icebreakers and energizers for future trainings
Icebreakers/Energizers Purpose of Icebreakers and Energizers • Introductions: Get a sense of who is in the room and what agencies, schools, organizations and communities they represent • Trust building: Help people feel comfortable talking with each other and participating especially when discussing sensitive topics • Mini assessment: Learn baseline level of understanding of the subject matter • Engagement: Spur on interaction with the topic and with each other to increase learning • Alignment: Orient the group to move in the same direction
3 Page
Future SOS Trainer Take Home Note: Introductions, Icebreakers, & Energizers Introductions can take time but are very important because trainers try to make personal connections with participants and build support in communities for suicide prevention programs. Further, many facilitators and program implementers may have a personal connection to suicide and need to develop a level of comfort by understanding the background of those in the room. There are many creative ways to introduce participants to each other in trainings or workshops. As training experience increases, trainers can develop a catalog of useful “icebreakers” and introductions for different situations and different groups. • Icebreakers are activities used in trainings to introduce new groups to each other—breaking through any uncomfortable first feelings some participants may have when they’re new to a group and may not know anyone. • Energizers are usually used when participants have been sitting too long, or in the morning when they are still not fully awake and ready to listen. Sometimes energizers include stretching, which helps get blood circulating through the body in a gentle way. It is important for participants not to sit all day. Breathing exercises and simple yoga techniques are also excellent ideas. Please keep in mind potential physical limitations of members of the group and the general comfort level of strangers when interacting. Icebreakers and energizers should be positive experiences for all and never lead to discomfort or embarrassment.
2-Minute Mixer (2 minutes) - Large Group This is a great way to begin a training where most people don’t already know each other. Step 1: Introduce the icebreaker as a couple of minutes where everyone can get up and meet the others in the room. Step 2: Tell everyone that they will have 2 minutes to stand up, leave their immediate vicinity and meet as many people as possible, learning their name and place of work. Step 3: Ready? Set? Go! Step 4: Bring everyone back together at their table and have a few people volunteer to share a few examples of job titles, organizations and towns/communities represented at the training. Remember: It may take some time to get folks to stop talking after they’ve started. Be kind and give them a reminder at the halfway point, and again with 30 seconds left.
4 Page
Mix & Mingle (5-10 minutes) - Large Group This is a great way to get everyone on their feet. It will also help you, as the presenter, get a better sense of the room. Step 1: Ask the group to gather in the center of the room. Step 2: Explain to the group that you will be calling out choices and that participants will move to one side of the room or the other based on their choice (examples listed below). Step 3: Call out a choice to the group, pointing at opposite sides of the room for each option. Step 4: Each of the players will then walk to the sites of the room that they either prefer or “fit-into.” Examples of choices: • Traveled far for training vs. This is my own back yard • Work directly with youth vs. Work indirectly for youth • Implemented suicide prevention vs. New to suicide prevention • Have heard of the SOS Program previously vs. This is my first exposure to the SOS Program
Candy Introductions (5-8 minutes) - Small Groups This is a great way for the people sitting at a table together to get to know each other. Step 1: Set out a small bowl of different candies on each table. Step 2: Ask participants to choose whichever candy they prefer. Step 3: Display PowerPoint slide with a question designated for each candy type. Step 4: Ask participants to share the corresponding answer to their candy question with the other participants at the table. Examples of Candy Questions: • Peppermint= How did you hear about the SOS Program? • Hershey’s= Have you implemented a suicide prevention program before? • M&M= Share a story of when you’ve interacted with a student who was at risk. • Peanut Butter Cup= How do you feel about screening students for depression? Remember: Some people may not want any candy, so have a question ready for “no candy chosen.”
Nametag Swap (8-10 minutes) - Small Groups This is a great way for the people sitting at a table together to get to know each other. Step 1: Each person turn to one person at their table, share three facts about themselves and swap nametags. Step 2: Go to another person at your table and introduce yourself as the person whose nametag you have. Step 3: Continue 3-4 times. Step 4: Have everyone go around and say their final 3 facts and have the “owner of the nametag” correct any mistakes. Remember: It may be difficult to get people to finish on time. Give them a two-minute warning, allowing them to stop where they are and give the final feedback to the whole table.
5 Page
Notes: __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ _________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________
6 Page
Section 2: Training Goals, Agenda, and Logistics Objective: • Review the agenda, expectations, goals, and objectives of the training and why they are important for future trainers
Certified Training Institute Goals • Decrease suicide and attempts by increasing knowledge and adaptive attitudes • Create local consultation and support for first time program implementers and those who face challenges along the way • Grow impact by creating suicide prevention advocates with a localized strategy that can assist in getting new schools on board by providing education on adopting appropriate policies, procedures and evidence-based programming to prevent youth suicide • Create sustainability in communities allowing for SOS programming to continue to be used over time • Provide culturally competent SOS Program delivery by engaging local trainers with community knowledge to support their own schools and communities
Certified Training Institute Objectives • Partner with local champions to increase access to suicide prevention training and education • Encourage communities to adopt universal suicide prevention programming for youth • Engage parents, school staff and community members as partners in prevention • Advocating to increase access to suicide prevention programming for all youth
Future SOS Trainer Take Home Note: Logistics Future SOS Trainers should take note of the day’s agenda and logistics and plan to provide similar information when planning trainings in their communities. Logistical issues include the following: • Bathroom and water locations • Where to step outside for a call if needed • Planned breaks (time and place) • Meals (if provided) • Parking/transportation reimbursement if applicable
Are there any other things you would share as a trainer? At any SOS Training we always acknowledge that the topic of the training is sensitive and reactions to the material are sometimes unexpected. We let participants know they are welcome and encouraged to take a moment outside of the training at any point, if they need it.
7 Page
Notes: __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________
8 Page
Section 3: Overview of SOS Objectives: • Discuss SOS Program basics and gain an understanding of SOS Program goals • Understand different levels of training available and goals of each training
The SOS Signs of Suicide® Prevention Program
The SOS Signs of Suicide Prevention Program (SOS Program) was developed to reduce the incidence of suicide among adolescents. The SOS Program is unique among suicide prevention programs as it incorporates two prominent suicide prevention strategies into a single program. The psychoeducational curriculum aims to raise awareness of suicide and its related issues, and is followed by a brief screening for depression and other risk factors associated with suicidal behavior. The SOS Signs of Suicide Prevention Program is the only youth suicide prevention program that has demonstrated an improvement in students’ knowledge and adaptive attitudes about suicide risk and depression, as well as a reduction in actual suicide attempts. Listed on SAMHSA’s National Registry of Evidence-based Programs and Practices, the SOS Program has shown a reduction in self-reported suicide attempts by 40-64% in randomized control studies (Aseltine et al., 2007 & Schilling et al., 2016). The SOS Program can be easily implemented by existing school personnel within one class period. Participating schools receive a box of materials containing everything needed to implement the program.
Program Goals • Decrease suicide and attempts by increasing knowledge and adaptive attitudes about depression • Encourage individual help-seeking and help-seeking on behalf of a friend • Reduce stigma: mental illness, like physical illness, requires treatment • Engage parents and school staff as partners in prevention through education • Encourage schools to develop community-based partnerships
SOS Program Key Message: ACT • Acknowledge that you are seeing signs of depression or suicide in a friend and that it is serious • Care: Let you friend know that you care about them and that you are concerned that s/he needs help you cannot provide • Tell a trusted adult that you are worried about your friend
9 Page
SOS Program Trainings Infographic
SOS Signs of Suicide® Prevention Programs
Certified Training Institute
As an SOS Certified Trainer, you are Each CTI creates about able to provide Trusted Adult and 30 new SOS trainers SOS Program Implementer Trainings
Trusted Adult Training
By providing Trusted Adult Training and Implementer Trainings you will:
Prepare ~20 trusted adults per training, to identify and respond to youth in need.
Implementer Training
Train school staff to implement evidence-based suicide prevention programing with ~380 students per school in addition to providing their own trusted adult trainings with ~100 parents and staff.
Screening for Mental Health
®
10 Page
SOS Program Implementer Training The Implementer Training is designed with program implementers in mind and is designed to last 4-6 hours, depending on the needs of the group and time constraints. These trainings prepare participants to work directly with students to deliver the educational and screening component of the SOS Program. In addition to learning how to deliver the SOS Program to students effectively and with fidelity to the evidence-based model, these trainings prepare implementers to educate community members, parents and school staff.
Determining an Audience The SOS Implementer Training can be done for a specific school or district as they prepare to implement the program. Another option is that the Implementer Training be open to staff from many schools/organizations so they can implement the program with the unique school/organizational structure.
SOS Implementer Training Key Components • Presenting the Facts • National and local statistics • Suicide warning signs, symptoms, risk factors • Learning how to respond to a student in need • SOS Program Implementation • SOS Program overview • SOS Educational component • SOS Screening component • School/District protocols and procedures • Planning for Implementation • Forming implementation team • Day of logistics • Planning student follow-up • Training and engaging parents and other trusted adults • Data collection and reporting Supporting Materials • • • •
SOS Implementer PowerPoint Presentation SOS Program DVD Handouts Local school/org handouts (school protocol/procedure, etc.)
NOTE: As a trainer, you gain access to an electronic portal where you can download PowerPoint slides, handouts, and more! Once you complete certification, you can use the portal to start planning your implementer training. You can customize your training by tailoring the slides to fit your community’s needs and share handouts that are most appropriate for your training attendees. * Find more training planning information and resources in section, Developing Your Trainings at the end of your handbook.
11 Page
SOS Trusted Adult Trainings As an SOS Certified Trainer, you may be asked to perform a number of introductory trainings to parents, faculty/staff and community members interested in youth suicide prevention. The goals of these trainings should be to dispel common myths surrounding suicide, provide facts about risk factors and warning signs, and to engage trusted adults in suicide prevention. Participants should feel empowered to recognize youth in need and respond to those seeking help. The SOS Trusted Adult Training is designed to last no less than one hour and does not cover the specifics of SOS Program implementation. However, all SOS Program trainings provide an overview of the program and resources for those seeking help. There are Trusted Adult Training guidelines and materials for four target audiences: parents, community members, school faculty and staff, and administrators. Key Components • Suicide signs, symptoms, risk factors and how to respond • National and local statistics • SOS Program overview • Local school/organization plan for program implementation, screening, referral and follow up Supporting Materials • Training Trusted Adults DVD and Discussion Guide • PowerPoint presentation for parents/community • Handouts for parents • Local school/org handouts (permission forms, school protocols, local mental health provider list)
12 Page
Notes: __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________
13 Page
Part 2:
Youth Suicide: Prevalence, Risk Factors & Warning Signs
14 Page
Section 4: Debunking Myths & Presenting Facts Objectives: • Learn the common myths around adolescent suicide • Understand how to debunk myths by presenting facts • Prepare to redeliver this information to participants in future trainings
Dispelling Myths and Sharing the Facts
Much of this information is drawn from Preventing Suicide: A Toolkit for High Schools, produced by the Substance Abuse and Mental Health Services Administration (http://store.samhsa.gov/product/Preventing-Suicide-A-Toolkit-for-High-Schools/SMA12-4669).
Youth Suicide
• Suicide is the 2nd leading cause of death for youth aged 11-18; young adolescents as likely to die from suicide as from traffic accidents (CDC, 2016) • 1 out of 13 high school students attempt suicide one or more times (CDC, 2012)
Depression in Adolescence
• 1 in 5 adolescents have a diagnosable mental health disorder. Approximately 1/3 of mood disorders, like depression, first emerge during adolescence (Kessler et al., 2005) • Between 20% and 30% of adolescents have one major depressive episode before they reach adulthood (Rushton, et al., 2002). Over 50% of adolescents with mental illness never receive treatment. • 90% of people who die by suicide have a diagnosable mental health disorder most commonly depression and/or substance use, which are treatable (Gould et al., 2003) • The prevalence of depression in youth and young adults increased from 8.7% in 2005 to 11.3% in 2014 (Mojtabai, 2016).
Future SOS Trainer Take Home Note: Manning Yourself with Research The most common myth surrounding suicide is that by talking about suicide you will give the idea to someone. Research shows over and over that this is untrue. When approached about this, ensure that you are sharing the appropriate research with the people you are training. A great example of this is Gould & collegues (2005) article, Evaluating Latrogenic Risk of Youth Suicide Screening Programs. American Medical Association, 293(13), 1635-1643. Also, when discussing risk factors and warning signs, an important message for parents and community members is means restriction. As you will explain, when means of suicide are restricted the number of suicides decreases. You can point individuals in the direction of research to educate themselves (see www.hsph.harvard.edu/means-matter). Means restriction is especially important for reducing access to higher lethality means, such as firearms, see research: Marzuk, P. M., Leon, A. C., Tardiff, K., Morgan, E. B., Stajic, M., & Mann, J. J. (1992). The effect of access to lethal methods of injury on suicide rates. Archives of General Psychiatry, 49, 451-458.
15 Page
Myths & Facts About Depression & Suicide Myths about depression and suicide often separate people from effective treatments and prevent people from supporting suicide prevention efforts. School staff, students, and their parents need to know the facts. Some of the most common myths are: Myth: Anyone who tries to kill him/herself must be crazy Fact: Most suicidal people are not psychotic or insane. They may be depressed or struggling with substance use and in extreme emotional pain. Extreme distress and emotional pain are signs of mental illness, but are not signs of psychosis. Myth: It’s normal for teenagers to be moody; teens don’t suffer from “real” depression. Fact: Depression can affect people at any age or of any race, ethnicity, or economic group. About 11% of adolescents have a depressive disorder by age 18 (National Institutes of Health). Myth: Teens who claim to be depressed are weak and just need to pull themselves together. There’s nothing anyone lse can do to help. Fact: Depression is not a weakness; it’s a serious health disorder. Both young people and adults who are depressed need professional treatment. A trained therapist or counselor can help them learn more positive ways to think, change behaviors, cope with problems, or handle relationships. A physician can prescribe medications to help relieve the symptoms of depression. For many people, a combination of psychotherapy and medication is beneficial. Myth: There will never be changes in the number of people who attempt suicide. The rates remain the same. Fact: While the rate of adult suicides has not changed significantly over time, the rate of suicide for youth between the ages of 15 and 24 has nearly tripled since 1960. Myth: People who talk about suicide won't really do it. Fact: Almost everyone who dies by suicide has given some clue or warning. Do not ignore suicide threats. Statements like, “You’ll be sorry when I’m dead,” or “I can’t see any way out” — no matter how casually or jokingly said — may indicate serious suicidal feelings. Myth: If a person is determined to kill themselves, nothing is going to stop them. Fact: Even the most severely depressed person has mixed feelings about death, wavering until the very last moment between wanting to live and wanting to die. Most suicidal people do not want death; they want the pain to stop. The impulse to end it all, however overpowering, does not last forever.
Myth:
People who talk about suicide won’t really do it.
16 Page
Notes: __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________
17 Page
Section 5: Youth Suicide: A Multifactorial Event Objectives: • Understand risk factors, warning signs, protective factors and precipiating events related to youth suicide • Understand the link between depression, substance use, and suicide • Prepare to educate others about the complex nature of youth suicide
Youth Suicide Statistics The Youth Risk Behavior Survey was developed in 1990 to monitor priority health risk behaviors that contribute to the leading causes of death, disability, and social problems among youth and adults in the United States. From 1991 through 2015, the YRBS has collected data from more than 3.8 million high school students. The national survey, conducted by CDC, provides data representative of 9th through 12th grade students in public and private schools in the United States. 2015 Youth Risk Behavior Survey found that: • 29.9% of students felt so sad or hopeless for 2+ weeks that they stopped doing some usual activity • 17.7% seriously considered attempting suicide • 14.6% made a suicide plan • 8.6% attempted suicide • 2.8% of those who made an attempt required medical attention Find the data for your city/state: http://www.cdc.gov/HealthyYouth/yrbs/index.htm
Risk Factor A risk factor is any personal trait or environmental quality that is associated with increased likelihood for suicide. Risk factors are NOT the same as causes. Examples: • Behavioral Health: depressive disorders, non-suicidal self-injury, substance use • Personal Features: hopelessness, low self-esteem, social isolation, poor problem-solving • Adverse Life Circumstances: interpersonal difficulties, bullying, history of abuse, exposure to peer suicide • Family Characteristics: history of family suicide, parental divorce, history of family mental health disorders • Environment: exposure to stigma, access to lethal means, limited access to mental health care, lack of acceptance
Taking a Closer Look at Risk Factors There is a clear link between mental illness and suicide. The most common psychiatric disorder associated with all people who die by suicide is depression. This is promising, in that mental illness (including depression) is treatable. If we can identify who needs help, we can get them the services they need before a crisis. • The strongest risk for suicide in youth are depression, substance use and previous attempts (NAMI, 2003) • Over 90% of people who die by suicide have at least one major psychiatric disorder (Brent et al., 1999) • Less than half of adolescents with a psychiatric disorder received any kind of treatment in a given year (Costello e al.,2013)
18 Page
Although most depressed people are not suicidal, most suicidal people are depressed. Remember, just like any health condition, depression can occur in anyone, even teens who seem to “have it all.” Major Depressive Disorder is defined by a period of at least 2 weeks when someone experiences a depressed mood or loss of interest or pleasure as well as 4 or more additional symptoms. (DSM-V, APA, 2013) Other potential symptoms include: • diminished interest or pleasure in activities • significant weight loss when not dieting or weight gain • insomnia or hypersomnia nearly every day • psychomotor agitation or retardation nearly every day (fast or slow movements) • fatigue • feelings of worthlessness or excessive or inappropriate guilt • diminished ability to think or concentrate • recurrent thoughts of death Substance use is another important risk factor to consider. Substance use is higher overall for individuals struggling with another stressor such as depression or anxiety (Schilling, et al. 2009). In fact, youth experiencing a major depressive episode were more than twice as likely to use illicit drugs than their peers. Alcohol use, drinking while down, and heavy episodic drinking are strongly associated with suicide among adolescents. Drinking is also correlated with unplanned suicides among teens (Schilling, et al. 2009). Alcohol reduces inhibition, increases impulsivity and can make teens more likely to take life threatening risks. Alcohol clouds one’s ability to find alternate coping strategies for dealing with intense emotion. Identifying youth with unhealthy substance use behavior has been shown to be a good way to reduce suicide risk (Schilling, et al. 2009)
Warning Sign • A warning sign is an indication that an individual may be experiencing depression or thoughts of suicide. Most individuals give warning signs or signals of their intentions. • Seek immediate help if someone: • Threatens to kill themselves • Is actively seeking means • Is talking and/or writing about death (Examples: “Life isn’t worth living,” “My family would be better off without me,” “I won’t be in your way much longer,” etc.)
Other warning signs to take seriously: • Risky behavior, recklessness • Increased substance use • Decreased interest in usual activities • Extreme withdrawal
Protective Factor • A protective factor is a personal trait or environmental quality that can reduce the risk of suicidal behavior. Protective factors do not imply that anyone is immune to suicidal thoughts or behaviors, but help reduce risk.
19 Page
• Examples: • Individual Characteristics: adaptive temperament, coping skills, self-esteem, spiritual faith • Family/Other Support: connectedness, social support • School: positive experience, connectedness, sense of respect • Mental Health and Health Care: access to care, support through medical and mental health relationships • Restricted Access to Means: firearms/medications/alcohol, safety barriers for bridges
Precipitating Event • A precipitating event is a recent life event that serves as a trigger, moving an individual from thinking about suicide to attempting to take his or her own life. • Precipitating events are often confused with causing suicide. No single event causes suicidality: other risk factors are typically present. Examples of precipitating events are: • A breakup • A bullying incident • The sudden death of a loved one • Getting into trouble at school
Practice: Student Bios Read the student bios and identify the risk factors, warning signs, protective factors and any precipitating events. • Margaret, a very sweet and social 8th grade student recently lost her aunt to suicide and has been treated for anxiety in the past. She is very active and competitive with the debate team. In the last month you’ve seen her grades drop dramatically, she’s missed 3 days of school (which is unusual) and she’s been seen crying in the bathroom. Today you just found out that her boyfriend broke up with her. • James is the star basketball player at your school and is president of his class. James lives in a high poverty neighborhood with his grandmother. His father is not in the picture and his mother died last year. James has missed multiple practices in the last couple weeks and was recently caught with marijuana at school. The principal suspends James from school for a week and kicks him off the basketball team for the rest of the school year.
Notes: __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________
20 Page
Part 3:
SOS Program Implementation
21 Page
Section 6: SOS Program Educational Component Objectives: • Understand SOS Program and rationale and goals • Understand the educational piece of the SOS Program • Prepare to train school/community staff to implement the SOS Program with youth
SOS Program Rationale and Goals The strongest risk factors for suicide in youth are depression, substance use, and a history of previous attempts. According to the Centers for Disease Control and Prevention, suicide is the 2nd leading cause of death for children and adolescents ages 11-18 in the United States. In 2010, 8 percent of youth (about 1.9 million people) age 12-17 in the U.S. had experienced a major depressive episode during the past year (SAMHSA, 2012). In children and adolescents, an untreated depressive episode may last 7 to 9 months, which is almost an entire academic year (U.S. Department of Health and Human Services, 1999). Depression has been linked to poor school performance, substance use, running away, feelings of worthlessness and hopelessness, and suicide. Because youth are more likely to talk to a friend about their troubles, the SOS Program uses a peer-to-peer strategy to encourage help-seeking. By training students to recognize the signs of depression and suicide, and empowering them to intervene when confronted with a friend who is exhibiting these symptoms, the SOS Program capitalizes on an important social/emotional aspect of this developmental period. For students, the program goals are to: • Help youth understand that depression is a treatable illness. • Educate youth that suicide is not a normal response to stress, but rather a preventable tragedy that often occurs as a result of untreated depression. • Inform youth of the risks associated with alcohol use/self-injury to cope with feelings. • Increase help-seeking by providing students with specific action steps to take if they are concerned about themselves or others, and identifying the resources available to them. • Encourage students and their parents to engage in a discussion about these issues. • Encourage peer-to-peer communication about the ACT help-seeking message.
22 Page
Universal Prevention Universal prevention strategies are designed to reach the entire population, without regard to individual risk factors and are intended to reach a very large audience. The program is provided to everyone in the population, such as a school or grade, with a focus on risk reduction and health promotion. Benefits include: • • • •
Reach a broad range of adolescents (at-risk/sub-clinical/clinical symptoms) Reduces stigmatization Promotes learning and resiliency in all students Overrides implementer assumptions
A Range of SOS Programs • • • • •
SOS Middle School Program – 6th-8th graders SOS High School Program – 9th-12th graders SOS Second ACT Program – 11th-12th graders Self-Injury Prevention Program – 9th-12th graders College SOS
Program Materials SOS DVD and Discussion Guide The Friends for Life DVD for high school or the Time to ACT DVD for middle school serve as the main teaching tools of the SOS Program. The aim of these DVDs is to create a supportive and responsive atmosphere for those youth who may be at risk for depression or suicide by empowering them to recognize the warning signs and seek help. The videos are approximately 25 minutes in length and are accompanied by discussion guides that includes topics for a classroom discussion led by a school health professional or counselor. The main help-seeking message of the videos is ACT: Acknowledge, Care, Tell. • Acknowledge that you are seeing the signs of depression or suicide in a friend and that it is serious. • Care: Let your friend know that you care about him or her, and that you are concerned that s/he needs help you cannot provide. • Tell a trusted adult - either with your friend or on his or her behalf. The Friends for Life DVD includes two sections: Dramatizations: Scenes feature teens who are depressed and may be contemplating suicide and the words and actions others might use to help. Each vignette includes a friend or family member who is trying to help—first the “wrong” way (i.e. trying to talk them out of it, telling them to “snap out of it,” being sworn to secrecy, etc.), and then the “correct” way (i.e. telling them that they are concerned and that they need to speak with a trusted adult to get help). Interviews with: • Real teenagers who attempted suicide and are now in treatment for depression and doing well, including some of their friends and family members • Friends and family members of suicidal teens • School-based counselors who explain how to respond to a suicidal or depressed student or to a student’s friend
23 Page
The Time to ACT DVD includes three sections: • Dramatizations: Scenes showing adolescents who are depressed and the words and actions others might use to help. Each scene includes a friend or family member who is trying to help— first the wrong way (i.e. getting angry, not taking the person seriously, or blaming them, etc.), and then the correct way (i.e. telling them that they are concerned and that they need to speak with a trusted adult). • Group Discussion: Middle school students discuss the topics of depression, suicide, bullying, self-injury and getting help. • Student Interview with a School-based Counselor: The video’s host models speaking with a trusted adult.
SOS Programs also contain: • Brief Screen for Adolescent Depression (BSAD): a 7 question, non-diagnostic, validated screening that identifies risk for depression and suicide in youth. Parent screening also available. See next section for details. • Additional Lesson Plans that build on essential knowledge and skills in suicide prevention. • Training Trusted Adults DVD for staff, parents and community members explaining the elements of the SOS Program. This is an educational tool that details the issues of depression and suicide among youth and emphasizes the important role parents and school personnel can play in helping at-risk students. • Plan, Prepare, Prevent: The SOS Online Training Module offers school professionals an online 90-minute interactive course for planning and implementing the SOS Program. Free Continuing Education credits may be available for many professionals including school social workers and school nurses. Certificates of Completion are provided for all learners. www.mentalhealthscreening.org/gatekeeper • Life Teammates® Toolkit for Coaches helps coaches reinforce the ACT messaging with student athletes and build “Life Teammates” among student athletes. • Educational materials for students, parents, faculty and staff, including Lesbian, Gay, Bisexual, Transgender & Questioning (LGBTQ) Resource Guide and Self-Injury Packet for Staff. • Wallet cards for students that can be customized to include local hotline numbers and other information about where to seek help. • Posters that reinforce the ACT message. • High School Student Newsletter, Middle School Student Newsletter using short articles, the student newsletters provide reinforcement of the ACT message, information about the warning signs of depression and suicide, the risks associated with using alcohol and drugs, strategies for dealing with bullying, and ways to enhance resilience when facing stress. • Parent Newsletter (provided in middle school programs and available for order for high school programs). Designed to increase skills and confidence among parents in recognizing and responding to signs of depression, alcohol use, bullying, self-injury, and suicidality among their children. The newsletter also serves to encourage parents to initiate a discussion about these concerns with their children and instill confidence for seeking treatment for their children, if needed. • Stickers (provided in middle school programs and available for order for high school programs). The stickers are designed to promote peer-to-peer communication by making the ACT message popular, personal and powerful, as participating students build awareness around the ACT help-seeking message among their peers. • Student Response Cards and Template provide students with an opportunity to request follow-up with an adult. • Follow-Up Form Template to reproduce for staff to enable them to track and follow-up on at-risk students. • SOS Portal: online access to all program materials, ability to stream student video and additional activities.
24 Page
Day of Implementation • Adult introduces the SOS Program and the topic of suicide prevention • Students watch the SOS Program DVD and the program implementer leads the discussion using the accompanying discussion guide (40 minutes) • Students complete BSAD screening forms • Leader reviews Scoring Instructions with students and answers any questions they may have (5 minutes) [depending on screening option chosen] • Students score their own Student Screening Forms (5 minutes) or leader instructs students to write their names/ ID numbers to be scored by implementation team • Students complete Student Response Cards • Implementer collects completed screening forms and/or Student Response Cards • Implementer distributes the additional materials such as Student Newsletters, ACT stickers, wallet cards • After the class, designated school staff reviews all completed screening forms/Student Response Cards to determine who requires follow-up This introduction for students may be read aloud by the implementer. Use the introduction in whole or in part, or modify depending on your format.
Sample Introduction to Students Today our school is participating in the SOS Signs of Suicide Prevention Program, which is taking place throughout the country. Our goal today is to help you recognize the symptoms of depression and/or suicide in yourselves, your friends, or your loved ones. The purpose of this program is not to tell whether or not you are suffering from depression, but rather learn more about mental health and consider whether you may have symptoms that indicate a need for a further evaluation. Today’s program will include the following [this will vary depending on the screening option chosen; please make appropriate revisions]: 1. A video about depression, the signs of suicide and the steps to take if you feel a friend or loved one is at risk 2. A depression screening form for you to complete 3. Instructions on how to score the screening form 4. A student newsletter for you to read 5. Information for getting further help for yourself or a friend, if necessary
After the video: Facilitating the group discussion You can either show the video in its entirety or stop the video at opportune moments to discuss issues as they emerge. Talking about the video as a group is a way to ensure that the main teaching points of the SOS Program are learned and integrated. In the course of a discussion, ideas about the video’s message crystallize, issues are seen more clearly, different points of view are raised and the stories told take on new dimensions. With your help, they will learn what kinds of changes are red flags and what to do when their friend seems down for weeks or when their own sadness or lack of energy is seriously affecting their life.
25 Page
Utilize the discussion guide provided to facilitate a conversation with students. The discussion guide contains talking points for concepts to emphasize and questions to ask. Feel free to expand upon them, and remember, always demonstrate a positive attitude of confidence and trust. Regardless of how much time you focus on each dramatization or real life story, be sure to bring students back to the main teaching points of the program: The ACT message.
Suggestions for discussion leaders/facilitators: • • • • • • • • • • • • • • • •
• • • •
•
Consider arranging the classroom with students sitting in a circle to facilitate discussion. The discussion leader should be a facilitator and moderator rather than an “authority.” The leader provides an introduction to the SOS Program and asks questions that will guide the discussion. The leader may answer questions or provide important information, such as where to go to get help. Don’t be discouraged if students laugh during the video. Some students use humor in an effort to reduce tension around a serious topic. View brief silences as a means for students to gather their thoughts. Ask open-ended questions that focus on the DVD and open up discussion. Suggest and question rather than impose your views. Ask questions that you don’t know the answers to, such as, “Can you think of other problems that students are facing in our school that weren’t covered in the DVD that may cause them to feel depressed?” Share your observations. Encourage group members to talk to each other, not “through” you as the leader. Respond to digressions that contradict the facts presented in the DVD by asking, “Which specific section in the DVD supports the point you are making?” Try to redirect other digressions from the topic by saying, “Let’s get back to the DVD. How do you think the friend used ACT?” Interrupt private conversations and invite those speaking privately to share their thoughts openly with the group. Ensure that everyone has a chance to participate and that no one person dominates the discussion. Jump in when you must, “We’re all talking at once. Can we let each person have their say?” or, when one person dominates, “Kim, that’s very interesting. Let’s hear what some of the others have to say” or when someone is trying to break in, “Ingrid has been waiting to talk. Let’s hear what she has to say” or to bring everyone into the discussion, “Amy’s idea is similar to what Mike said earlier. Does anyone want to respond to that issue?” When Keith interrupts Sam, the leader can interrupt Keith and say, “Just a minute, I’d like to hear Sam finish what he was saying.” Try to redirect other digressions from the topic by saying, “Let’s get back to the DVD. How do you think the friend used ACT?” Interrupt private conversations and invite those speaking privately to share their thoughts openly with the group. Ensure that everyone has a chance to participate and that no one person dominates the discussion. Jump in when you must, “We’re all talking at once. Can we let each person have their say?” or, when one person dominates, “Kim, that’s very interesting. Let’s hear what some of the others have to say” or when someone is trying to break in, “Ingrid has been waiting to talk. Let’s hear what she has to say” or to bring everyone into the discussion, “Amy’s idea is similar to what Mike said earlier. Does anyone want to respond to that issue?” When Keith interrupts Sam, the leader can interrupt Keith and say, “Just a minute, I’d like to hear Sam finish what he was saying.” Remember; implementing the SOS Program is a way that schools can communicate concern and openness to discuss these issues. Invite students to ask questions and ask for help, directing them to whom they can seek help at the school.
Future SOS Trainer Take Home Note: Allowing Space for Overwhelmed Students Depression and suicide may be extremely sensitive issues for some students. If any student feels overwhelmed and needs to leave the room during the program implementation or video discussion, excuse them and make sure they have someplace safe to go where they may talk with a school professional about their feelings and have an adult accompany them.
26 Page
Time to ACT: SOS Middle School Program Discussion Talking Points 1. What does ACT stand for? • ACKNOWLEDGE the problem • CARE - Let the person know you care • TELL a responsible adult 2. How would you use these steps? • If you see signs of depression, suicide, or any other problem in someone you know: • Tell them in a caring way that you recognize that they are having a problem. • You can show you care by actively listening. This means putting aside anything else you are doing, making eye contact, sitting down, and asking questions. • Once you listen to your friend, tell him or her that it’s important that you speak with an adult, such as a parent, teacher, counselor, or someone else you trust, so that the person can get the help they need. You can figure out together who that person may be. • Offer to go with your friend to tell the adult. 3. What should you do if you are feeling depressed and need help? If you need help for yourself, ACT by telling an adult you trust how you feel so you can get help and feel better.
Dramatization #1 Sisters discussing being rejected by friends 1. In the case of the girl being rejected by her friends, why was the younger sister’s reaction considered troubling and not just a “normal” response to a bad situation? It’s not unusual for people to feel sad, upset, and angry about the loss of a relationship they value. These feelings can come and go over time. However, her reaction was much more serious and not a “typical” response to what was going on. What she experienced lasted over two weeks and involved changes in her mood, behavior, physical health, and thinking. 2. What were the signs that this girl was depressed? • She skipped play practice (an activity she usually enjoys) • She can’t sleep • She feels sick all the time • She is having negative thoughts and feeling hopeless, saying things like, “I wish I were dead.” • She says she feels, “all alone.” 3. What about the older sister’s first response made it “wrong”? • She blames her sister, saying “Just stop whining and give it some time.” • She minimizes the problem, saying, “Don’t you think you’re being a little dramatic?” • She ends the conversation abruptly by leaving the room. 4. How does the older sister use the ACT technique in the “correct” response? • Acknowledge: She makes eye contact with her sister and says, “I know you’re upset but saying that is pretty serious.” • Care: The older sister offers to go to their mother together when the younger sister seems scared. She also emphasizes her concern when she says, “I’m really worried about you.” At the end, she repeats, “I’ll be there with you.” • Tell: The older sister won’t be sworn to secrecy. When her younger sister asks to promise not to tell, she replies, “I can’t do that! I think you’re really depressed and we have to talk to somebody.” She doesn’t give up when her sibling doesn’t want to talk to their mother. She even states, “Well if you don’t, I will.” The older sister also provides reassurance that it will be okay and that her younger sister isn’t crazy, she just needs help.
27 Page
Dramatization #2 Angry Boy
1. Do you think this angry boy may be depressed? He may be. One of the main signs/symptoms of depression for adolescents can be irritability or anger, rather than a sad or down mood. Teens that are more irritable and angry are sometimes seen as troublemakers or as having behavioral problems when they may actually be depressed. These teens may have more difficulty with relationships, may be frequently absent from school, may be involved in fights, and may be doing poorly in school. Depressed youth may also be more likely to run away or have problems with the law. 2. The angry boy’s friend made the right decision to ask for help from Mr. Hull. Who else might they have turned to in this situation? School counselor, psychologist, nurse, teacher, parent, a friend’s parent, coach, etc. 3. What if the angry boy said he was suicidal? Would you feel okay to leave him alone? No. Never leave someone alone who may be at risk for suicide. Suicide is unpredictable, so don’t wait to ask for help. ACT NOW!
Dramatization #3 Girls in the bathroom discussing bullying 1. What makes you concerned for Becca, the girl being bullied? • She says she would rather be dead than put up with the bullying. • The boys are bullying her online, at home, and now in school as well. • The bullies are threatening that if she tells on them, they will get other students to participate in the bullying as well. • She has what we refer to as “tunnel vision.” She sees only one way to deal with the problem: suicide. 2. How does Becca’s friend use the ACT technique in the correct response? • Acknowledge: She seems upset by what her friend was going through. She says, “You just said you would rather be dead, I’m worried about you.” She knows that it is more than just a passing mood. • Care: She says that what Max and Adam are saying isn’t okay. She adds that asking for help is not pathetic and that Becca doesn’t have to put up with the bullying anymore. • Tell: • Becca’s friend says that she is going to talk to Mr. Michaels. When Becca says that she doesn’t want Mr. Michaels to tell her parents, her friend insists that, “If it’s so bad that you’re hiding in the bathroom, you need to get help.” • She gives Becca hope that by telling a trusted adult, she will feel better. She uses her cousin as an example of how talking to someone can help. • She added that Mr. Michaels “can help us figure this out.” 3. What are some things you could you do if you are being bullied online? • Never respond to a message or a post from a bully. • Save the message or post and show them to a parent or trusted adult, like a teacher or counselor. • Never share your password. • Think carefully about what you say online. Could what you say be taken the wrong way? • Make sure what you say is not going to hurt or scare someone. 4. What are the signs that Becca is not just angry or sad about being bullied, but may be suffering from depression? • Becca is thinking about killing herself and seems to think that is her only option to avoid further bullying. Did you know... Facts on Bullying • Both victims of bullying and bullies are at higher risk for suicide than their peers (that’s twice as many people you can help protect by reporting what you see and hear).
28 Page
• Kids who are bullied are at a higher risk of anxiety, depression, and other problems associated with suicidal behavior. • Bullying, and especially chronic bullying, has long-term effects on suicide risk and mental health that can last into adulthood.Whether it’s in-person or online, if you’re a witness to bullying, you can help: Acknowledge, Care, and Tell.
General Discussion Questions 1. What’s the difference between being sad and depressed? • Depression is more than the blues or the blahs; it is more than the normal, everyday ups and downs. When that “down” mood, along with other symptoms, lasts for more than a couple of weeks, the condition may be what’s referred to as depression. • Depression is a serious health problem that affects the whole person, mind and body. In addition to feelings, it can change or affect behavior, physical health and appearance, academic performance, thinking, social activity, and the ability to handle everyday decisions and pressures. • Depression can lead someone to isolate themselves from their friends and lose interest in activities they once enjoyed doing. • Depression can lead to thoughts of death or suicide. 2. According to the school counselor, why do people get depressed? • Depression can come from a chemical imbalance in your brain • Depression can run in families • Sometimes life stressors cause depression • Sometimes it’s a combination of reasons NOTE: Although the counselor does not say this, you may want to add: • Depression can occur in response to a recent stress or loss, such as problems at school or with the law, the death of a loved one, or relationship troubles. • Sometimes people experience depression and don’t know exactly why or what’s causing it. You don’t have to know why: if you think that you or someone you love needs help, it’s time to ACT and get help! 3. How can drugs and alcohol make things worse for someone who is depressed? • A lot of depressed people, especially teenagers, also have problems with alcohol or other drugs. (Alcohol is a drug, too). Sometimes the depression comes first and people try drugs as a way to escape it. In the long run, drugs or alcohol just make things worse. Other times, the alcohol or other drug use comes first, and depression is caused by: • the drug itself • withdrawal from it • the problems that substance use causes (academic trouble, arguments with parents, results of bad decisions) • Sometimes you can’t tell which came first...the important point is that when you have both of these problems, the sooner you get treatment, the better. • Alcohol, which initially may make people feel good, acts as a downer in the body and drinking can contribute to feelings of depression and make one’s moods unstable. • Alcohol increases the risk of suicide. Alcohol is involved in half of all suicides, murders, and accidents. • Alcohol takes away good judgment and safe behavior. Alcohol can make people do things they don’t want to do, say things they don’t want to say, and can lead to dangerous, risky behavior. • Some drugs, like alcohol or street drugs, may reduce the effectiveness of medication used to treat depression. NOTE: One warning sign of depression or suicide risk is when someone you know suddenly starts drinking alcohol. 4. What would you do if the adult you share your concerns with does not respond to you or take your concerns seriously? • Don’t give up! • State your concerns again and the reasons why you are worried until the person responds. • Share your concerns with someone else: a parent, teacher, school counselor, or other trusted adult. 5. Why should you be confident you are not betraying a friend when you tell an adult that your friend may be depressed or suicidal? • Depression can interfere with a person’s ability or wish to get help. It is an act of true friendship to share your concerns with an adult who can help.
29 Page
REMEMBER... Depression is common: if you’re struggling, you’re not alone! Depression is treatable: if you need help, help is available.
Self-Injury Discussion Questions NOTE TO DISCUSSION LEADER: Keep information about self-injury very general and within the context of seeking help from a trusted adult. Focus on: • Self-injury as a mental health problem that can be treated. • The signs of emotional stress and risk factors that can contribute to self-injury. • Those in the school who are trained to help students who self-injure. 1. What is self-injury? • Self-injury is when a person hurts their body on purpose without the intention to die. • Self-injury is a mental health problem that must be treated by a professional. 2. What should you do if you know someone who is self-injuring? • If you know someone who is hurting himself or herself on purpose, do the same thing you would do if you knew they were depressed or suicidal: ACT. Acknowledge the problem, let the person know you Care, and Tell a trusted adult. NOTE TO DISCUSSION LEADER: As a classroom exercise, ask students to recall the signs of depression and suicide to reinforce learning. Add those that are not recalled to the end of the lesson.
Military Specific Questions 1. Loss and stress are two common triggers for depression. Parental deployment places school-age children and adolescents at higher risk for a range of difficult mood and behavioral changes. What might make a student who has a deployed parent at increased risk for depression and suicide? Below are several situations that can contribute to a feeling of hopelessness: • Break-ups • Family problems • Sexual, physical, or emotional abuse • School or work problems • Feeling like you don’t belong anywhere • Drug or alcohol addiction • Mental illness • The death of a loved one • Any problem that seems hopeless 2. You notice that a friend seems to be struggling because of their parent’s pending or current deployment. They are distracted and having trouble focusing. They tell you they are constantly fighting with their mother and not doing well in school. They express that their family would “probably be a lot less stressed” if they were not here anymore. How might the ACT technique be used to support the student? • Acknowledge: You can tell them that you have “been there” and “it sounds like you’re really having a hard time with this.” • Care: Provide support: “Hang in there. I know it seems rough now, but things will get better.”, and ask “How long have you been feeling like this?” • Tell: Identify an adult that you both feel comfortable talking to and offer to talk with the adult together.
30 Page
Signs (Symptoms) of Depression • • • • • • • • • • • • • • •
Frequent sadness, tearfulness, or crying Hopelessness Decreased interest in activities; or inability to enjoy previously favorite activities Persistent boredom, low energy Social isolation, poor communication Low self esteem and guilt Extreme sensitivity to rejection or failure Increased irritability, anger, or hostility Difficulty with relationships Frequent complaints of physical illnesses, such as headaches and stomach aches Frequent absences from school or poor performance in school Poor concentration A major change in eating and/or sleeping patterns Talk of/or efforts to run away from home Thoughts or expressions of suicide or self-destructive behavior
WARNING SIGNS FOR SUICIDE • • • • • • • • • •
Talking, reading, or writing about suicide or death Talking about feeling worthless or helpless Saying things like, “I’m going to kill myself,” “I wish I were dead,” or “I shouldn’t have been born” Visiting or calling people to say goodbye Giving things away Organizing or cleaning one’s bedroom “for the last time” Developing a sudden interest in drinking alcohol Purposely putting oneself in danger Obsessing about death, violence, and guns or knives Previous suicidal thoughts or suicide attempts
31 Page
Friends for Life: SOS High School Program Discussion Being in high school can be exciting, but it can also feel overwhelming as everything changes at a fast rate and in a big way. With all that is going on, it’s normal for students to feel down or discouraged at times. This guide will help you to use the Friends for Life: Preventing Teen Suicide video to facilitate a discussion with students about knowing when a situation has gone beyond normal adjustment issues and how to respond. With your help, they will learn what kinds of changes are red flags and what to do when their friend seems down for weeks, or when their own sadness or lack of energy is seriously affecting their life. Regardless of how much time you focus on each dramatization or real life story, be sure to bring students back to the main teaching points of the program: The ACT message. ACT®: Acknowledge, Care, Tell • ACKNOWLEDGE - Note that you are seeing the signs of depression or suicide in yourself or a friend and that it is serious (review signs and symptoms). • CARE - Let your friend know that you care about them, and that you are concerned that they need help you cannot provide (review specific ways to let someone know you are concerned). • TELL - Inform a trusted adult, either with your friend or on their behalf (review specifically who students consider trusted adults in their life). NOTE: Despite some of the reluctance of the actors to tell their parents, it is important to emphasize that parents should be considered trusted adults who will help.
Notes on Jordan’s Story… There may be curiosity about Jordan’s suicide attempt and how he survived a jump out of his nine-story window. Jordan was very lucky to have survived. Most people who jump out of a building at that height will die on impact. Many survivors of this type of suicide attempt report that in the split seconds after they jump, they realize they don’t really want to die. Most people who attempt suicide don’t have the chance to change their minds. When discussing Jordan’s story with your students, it is important to keep the focus of the conversation off the method of attempt and on other aspects of this story.
Dramatization #1 Boys discussing SAT scores. Note: Some vignettes may speak to your students more than others. If you feel the vignettes in this video do not reflect your student body, ask your students to identify what does and does not resonate with them from each scenario. Consider asking your students to develop their own skits modeling the ACT message using language and scenarios reflective of the community. 1. What might make a student who thinks he/she has to be “perfect” at risk for suicide? Perfectionism often makes people overly conscientious and prone to excessive guilt when they feel they have not met their own standards or let somebody else down. These kinds of feelings, occurring when someone also has depression, may increase suicidal thoughts and/or behavior. 2. Do you see indications of depression and suicidal risk in the student’s words or behaviors? The student in this vignette exhibits multiple warning signs of depression and suicidal risk including: •
Drinking to cope with uncomfortable feelings.
• Excessive guilt: “If I don’t get a scholarship (or get into a good college), I just can’t face everybody.” • Depressed mood: “I’m so tired of always trying to keep it all together and be the best.” • Suicidal risk: “My family would be better off without me.”
32 Page
3. How did his friend react to these signs? When faced with a peer who is struggling like this, it is common for a friend to be confused about the right thing to do. Remind your students that depression is an illness that requires treatment. If their friend were suffering from another illness, like asthma, they would need to see a professional; depression is no different. Students may also think that in order to be a good friend, they should keep the situation a secret if their friend asks them to. This is not the right thing to do. In the vignette, the friend did not agree to be sworn to secrecy. He realized the situation was something he could not handle, that it was too much to take on. 4. How did the friend use the ACT technique? • Acknowledge: He acknowledges it is unusual for his friend to be drinking. Rather than tease or criticize him, he notes: “I know you’re a little stressed, but you have to talk with someone about this.” • Care: He says, “It’s really not that bad, you were doing so well and you still have all your extracurriculars.” When asked not to tell anyone he replies, “No, I can’t promise you that. It’s not going to happen.” He would not promise this because he knows his friend needs more help than he can give. • Tell: He successfully encourages his friend to reach out for help to his older sister, Beth. Again, he makes sure his friend follows through by offering to accompany him.
Dramatization #2 Girl (Laura) and her brother discussing a break-up. 1. Is it normal for people to have these kinds of feelings after a breakup with a girlfriend or a boyfriend? Yes, it’s normal for people in this situation to be sad, upset, and even angry for the loss of a relationship they valued. 2. Then what makes this girl’s reaction so concerning? Having a difficult time getting over the break-up of a relationship is not uncommon; the key is in knowing when a situation has gone beyond a normal adjustment issue. The concern for Laura is valid because her response to the end of her relationship has begun to raise red flags. Below are some specific warning signs that Laura showed in the vignette: • • • •
Having feelings this intense two months later. Saying Alex was “the only good thing in her life” (low self-esteem). Flunking classes due to a persistent sadness about the break-up. Saying “I wish I were dead.”
3. Is Alex a boy or a girl? How might that impact the situation? Lesbian, gay, bisexual, transgender, and youth questioning their sexual orientation/gender (LGBTQ) often experience additional turmoil during their adolescent years, putting them at a greater risk for depression and suicide. NOTE: This is a great time to share information about the Trevor Project with students. The Trevor Project provides crisis intervention and suicide prevention services to lesbian, gay, bisexual, transgender, and questioning (LGBTQ) young people ages 13-24. Feel free to write the website and hotline on the board for your students to take note: www.thetrevorproject.org 1 (866) 488-7386 4. Laura tells her brother, “Are you kidding, Mom and Dad wouldn’t understand.” When you think about Laura’s relationship with Alex as a girl, why might her parents be hard to talk to? If she feels like she can’t talk to her parents, what can she do? LGBTQ youth may struggle with the decision of coming out to their parents and fear that they will be rejected by their family because of their sexual orientation. Even if Laura isn’t ready to come out to her parents, she can still talk to them about her feelings of depression. If she can’t talk to her parents, she can seek out another adult to talk to.
33 Page
5. How did Laura’s brother support her, knowing that she needed to speak with someone about wishing she was dead and that it was also important the trusted adult be accepting of Laura’s sexual orientation? He is sensitive to her not wanting to talk to their parents about her feelings and he suggests, “What about Mr. Perez at school? I know he’s helped a lot of kids out with different types of problems.” 6. How did Laura’s brother use the ACT technique? • Acknowledge: He says, “It’s been two months now. You should be getting over this, but you’re not. I know you have been cutting school and not doing your work. You really need some help; I don’t know what to do.” • Care: Her brother doesn’t give up when Laura doesn’t like his idea at first to tell their mom and dad or talk to Mr. Perez. He offers to go with her to see Mr. Perez. • Tell: Laura’s brother supports her enough that she eventually agrees to “tell” someone on her own. This is usually the best way for this to happen. However, if he could not convince her to talk to a trusted adult, he would have to do so himself. Without help, his sister’s feelings could intensify into suicidal thoughts. Notes on Elyssa’s Story… Your students will likely be affected by this tragic story, particularly by the experiences described by Elyssa’s parents and friends. Students may be troubled to learn that Elyssa was sexually assaulted in fifth or sixth grade, and that things seemed to spiral down from there. Research shows that traumatic childhood experiences (especially sexual assault) are risk factors for suicide. Many young people develop mental health problems such as depression in the months and years following such a traumatic experience. It is important to note to students that Elyssa struggled with depression, and that depression can affect anyone, whether or not they have experienced a traumatic event. The key message of Elyssa’s story comes from Elyssa’s friends as they highlight the importance of seeking help for a friend and the potentially tragic consequences of keeping a secret. Remember, some secrets should be shared.
Dramatization #3 Boy (Jason) who is always being picked on; potential for violent reaction. 1. What are some things that tell you Jason may be at risk to do harm? Jason has been a victim of bullying. All situations where a student is being singled out and harassed need to be addressed. At times, starting with giving encouragement, “Hey, don’t worry about those guys; they are just a bunch of losers,” and following up with support, can be what it takes to help. In the vignette, Jason appears to be beyond this, he is very angry, he is making threats, and he may have access to guns. 2. Based on how he acts, would you think Jason might be depressed? There is not enough information about him to know for sure. However, one of the main signs/symptoms of depression for teenagers can be irritability and anger rather than a sad or down mood. Children or teens who are more irritable and angry are sometimes seen as troublemakers or as having behavioral problems when they may actually be depressed. 3. Do you think that this dramatization has anything to do with suicide? A particular incident or a series of real or perceived abuses by students (insults, rejection, constant teasing) or teachers (disciplinary actions or grading problems) can set into motion a suicide attempt in which the student plans to take others with him whom he believes caused the deep psychological pain he feels. Remind your students that Elyssa, the young girl who died by suicide, was bullied at her school. Being a victim of bullying is a risk factor for suicide. 4. Bullying can affect everyone involved. Do you think anyone else in the scene is at risk for suicide? Both victims of bullying and the bullies themselves are at increased risk for suicide. Even students who observe but do not participate in bullying report feelings of helplessness and less sense of connectedness and support from adults. If you witness bullying, it is important to ACT so that everyone involved can get the help they need.
34 Page
5. How did the girls use the ACT technique? • Acknowledge: Based on their conversation with Jason, the girls acknowledge there may be a problem that requires the attention of an adult. “Jason sounded really desperate. It sounded like he was planning on killing them, and then killing himself.” They also knew that he may have access to guns. • Care: The girls supported Jason when he was being cruelly teased: “Hey, don’t worry about them. They’re just a bunch of losers.” Then one of the girls suggested that his reaction was scaring her and said, “maybe you should talk to someone.” The girls did not assume that Jason was “just blowing off steam,” and were concerned about his safety and that of other students in the school. • Tell: The girls talked through the situation and made the right decision to involve a trusted adult (the nurse and one of their fathers) because Jason sounded “really desperate.” A suicidal individual can be very impulsive. The girls did not wait to find an adult to tell about their concerns. Notes on Sommer’s Story… Sommer’s story turns from a downward spiral into a story of hope. Some of your students will identify with the difficult challenges that Sommer faced and the self-destructive choices she made before she was able to turn her life around. She says, “All the people in my life, they kept trying to break through to me and I just wouldn’t listen. And when I finally stopped and listened, that’s when it really made a difference.” Sommer’s story highlights that when caring people consistently ACT to help someone who is struggling, a life can be saved.
Dramatization #4 Boy (Mike) in bedroom who has stopped interacting with friends. 1. What has been happening to make Mike’s friend worried about him? Mike’s friend has noticed a change in him that he cannot explain and he knows him well enough to realize that something is going on with him. Michael has withdrawn from his friends, stopped showing interest in things he used to enjoy (baseball) and his mood is irritable and grouchy (grouchiness and irritability are often key signs of depression in teens). 2. Can you find anything in this dramatization that may have caused Mike’s depression? No. A depressive episode can be triggered by an event in a person’s life, but like many other illnesses, it can also strike out of the blue. For this reason, perhaps the worst thing to say to someone with depression is that they have no reason to feel like this or that they should just “snap out of it.” This will only make them feel worse, like they are just a weak person who doesn’t have the strength to overcome some small bump in the road. Depression is like many other illnesses, it requires professional treatment to get better. You wouldn’t tell a friend with asthma or diabetes to “snap out of it” or “tough it out.” You would tell them they need to see a health professional. 3. What if Mike had said or implied he was suicidal? If Mike had implied that he was suicidal, his friend would have needed to take him to a trusted adult right away instead of making a plan with him to talk to someone the next day. Statements made about wanting to kill yourself should never be ignored and cannot wait until later, it is time to ACT! 4. How did Mike's friend use the ACT technique? • Acknowledge: Even though Mike didn’t seem to want to talk about what was going on with him, his friend persists, stating clearly, “I don’t know what it is but you’ve definitely got a problem.” • Care: Not only had the friend noticed something was wrong with Michael, he had discussed it with their mutual friends to get their input, “We are all concerned for you. You’re our friend and you really haven’t been acting like yourself lately.” His friend also offers to go with Mike to see their coach. • Tell: The friend doesn’t accept Mike’s indecisive response about going to talk to their coach together, “This is important and if you’re not there tomorrow I’m going to go by myself because I’m your best friend and you really, really need help.”
35 Page
Future SOS Trainer Take Home Note: Customizing the SOS Program for Each Group of Students The SOS Program DVDs and Discussion Guides are designed as a “jumping off point” for further discussion. It is useful to ask students whether the vignettes ring true to them. Also, it is important to engage youth in discussions of what commonly causes stress, sadness or depression in their school and community. The discussion guides contain optional military-specific questions as students in military-impacted schools face specific stressors. Encourage your training participants to consider what stressors their particular population faces.
Optional Military-Specific Questions 1. What might make a student who has a deployed parent at increased risk for depression and suicide? Loss and stress are two common triggers for depression. Parental deployment places school-age children and adolescents at higher risk for a range of difficult mood and behavioral changes. Remind your students that Sommer’s father is a Marine who has had multiple deployments. Below are additional situations that can contribute to a feeling of hopelessness: • Break-ups • Family problems • Sexual, physical, or emotional abuse • School or work problems • Feeling like you don’t belong anywhere • Drug or alcohol addiction • Mental illness • The death of a loved one • Any problem that seems hopeless 2. You notice that a friend seems to be struggling because of their parent’s pending or current deployment. They are distracted and having trouble focusing. They tell you they are constantly fighting with their mother and not doing well in school. They express that their family would “probably be a lot less stressed” if they were not here anymore. How might the ACT technique be used to support the student? • Acknowledge: You can tell them that you have “been there” and “It sounds like you’re really having a hard time with this.” • Care: Provide support: “Hang in there. I know it seems rough now, but things will get better,” and ask, “How long have you been feeling like this?” • Tell: Identify an adult that you both feel comfortable talking to and offer to talk with the adult together.
REVIEW SIGNS (SYMPTOMS) OF DEPRESSION • • • • •
Depressed mood (can be sad, down, grouchy, or irritable). Change in sleeping patterns (too much, too little, or disturbed). Change in weight or appetite (decreased or increased). Speaking and/or moving with unusual speed or slowness. Loss of interest or pleasure in usual activities.
36 Page
• • • • •
Withdrawal from family and friends. Feelings of worthlessness, self-reproach, or guilt. Feelings of hopelessness or desperation. Diminished ability to think or concentrate, slowed thinking, or indecisiveness. Thoughts of death, suicide, or wishes to be dead.
OTHER INDICATIONS OF DEPRESSION • Extreme anxiety, agitation or enraged behavior. • Excessive drug and/or alcohol use. • Neglect of physical health.
Notes: __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ _________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________
37 Page
Section 7: SOS Program Screening Component Objective: • Understand the importance of and how to use the screening component of the SOS Program • Prepare to train school/community staff to screening students for depression and signs of suicide
SOS Program Key Components • An educational DVD and guided discussion with students • The Brief Screen for Adolescent Depression- a validated depression screening tool • Student Response Cards indicating whether a student would like to speak to a trusted adult about themselves or a friend The SOS Program is included in SAMHSA’s National Registry of Evidence-Based Programs and Practices (NREPP). Please note that to use this evidence-based program to fidelity, all three aspects components must be used, including depression screening.
The SOS Screening Form: Brief Screen for Adolescent Depression (BSAD) Screening Materials The Brief Screen for Adolescent Depression (BSAD) is a validated, seven-question survey that is part of the larger Columbia DISC Depression Scale. The purpose of this tool is not to tell whether students are depressed, but rather inform them about whether they, or their friends, may have symptoms that need further evaluation. NOTE: Results from the BSAD are not diagnostic, but indicate the presence, or absence, of symptoms that are consistent or inconsistent with depression or suicide. Negative responses to the questionnaire do not rule out depression/suicide risk and positive responses do not conclusively establish depression/suicide risk. A thorough diagnostic evaluation by a healthcare professional is always necessary to determine whether or not there is the presence or absence of depression/ suicide risk. Parents should be contacted immediately by phone if a student is deemed at-risk for suicide. SOS Programs include the following screening materials: • The SOS student screening forms with scoring instructions (BSAD) • The SOS student screening form with optional alcohol use questions * • Spanish-language templates of both student and parent screenings • Parent Screening Form (BSAD) with scoring instructions. This tool is also available: • In hard copy: contact our office to order. • In PDF form: along with other program materials, in our reproducible online materials
38 Page
• Online: The Parent BSAD Online Screening Tool allows schools to provide parents with the opportunity to consider their child’s moods and behaviors from the privacy of their home or mobile device at any time. The screening is often hosted through the school’s parent portal or website where schools customize a message to parents on the screening homepage, upload their school logo, create custom demographic questions and choose from a selection of color schemes to make the site their own. Most importantly, schools customize the school and community resources provided at the end of the screening. School administrators can gain insight into student mental health through the online platform’s comprehensive reporting feature, which anonymously tracks screening data. Contact Screening for Mental Health at 781-239-0071 for more information. * As alcohol use is strongly associated with suicide in adolescents, it is recommended that you inquire about drug and alcohol use with students as you conduct your follow-up. Youth engaging in substance use while feeling down have demonstrated a threefold increase in self-reported suicide attempts (Schilling et al., 2009). Screening for alcohol use provides another avenue for early identification. A version of the BSAD including the following two questions relevant to alcohol is available for SOS Program implementers: 1. In the past year, has there been a time when you had five or more alcoholic drinks in a row? (By “drinks” we mean any kind of beer, wine, or liquor.) (yes/no) 2. In the past year, have you used alcohol because you were feeling down? (yes/no)
Screening Options The SOS Program student screening can be administered anonymously or identified. Both methods of screening provide value to students by teaching them about symptoms of depression and encouraging them to seek help based on their self-assessment. Both methods of screening allow schools to collect aggregate data to help inform their prevention efforts. Your program team and school regulations should determine which option is best for your school. Anonymous Screenings may be strictly anonymous and utilize a self-scoring method in which students complete the screening form and score it themselves, using the student scoring instructions on the back. The program leader discusses what different scores mean and what action steps should be considered depending on the scores. Students may then be advised to reach out to school counselors if needed. Identified Screening (with student name or ID number) Students complete the screening form and write their name or ID number on the form. The program leader either encourages students to self-score before collecting the forms or collects the forms for the team to score following the program. School staff follow-up with students who score high on the screening and who answer ‘yes’ to questions 4 or 5. You may also consider following up with students who are unable to identify a trusted adult.
Considerations when Choosing your Screening Format: Identifying Students in Need • Identified screening provides a simple way for school staff to identify students in need of follow-up. • While students may be more likely to answer screening questions honestly if they know their anonymity is protected, they must then take the next step to seek help and share their concerns with an adult. Time and Resources • Identified screening generally finds more students in need of follow-up. Staff must plan to meet this need. All screening forms should be reviewed the day of the program to ensure that students with high scores receive help.
39 Page
• However, some schools utilizing anonymous screening require all students to meet with their counselor following the SOS Program which can be a significant stretch of resources. Student Response Card Whether utilizing anonymous or identified screening, all students should complete a student response card. This tool provides an efficient and effective way for students to indicate if they would like to speak with an adult following the program. Students who seek to talk to a trusted adult about themselves or a friend identify themselves through the student response card. By having all students complete the card, the students who have concerns about themselves or a friend are not singled out. Student response cards may be customized to set expectations for when students requesting follow-up can expect to be approached by staff. Emphasize that those needing immediate assistance should approach staff immediately. Tips for Protecting Student Privacy • Collect any screening forms and student response cards individually rather than asking students to pass them forward. • Many schools find it useful to announce that a handful of students will be randomly selected to provide general program feedback. Calling a few students down for a brief interview helps create anonymity for those students who need further mental health evaluation. Ongoing Screening Schools may also choose to use the screening forms and educational materials in their nursing or counseling office throughout the school year. Students can be screened before an appointment as part of the intake process when they are seeking help in that office.
Future SOS Trainer Take Home Note: Advocating for Screening When working with schools and communities to encourage student mental health screening, please contact Screening for Mental Health so we can support your efforts. Anonymous screening along with Student Response Cards encourages many students to self-refer. It is important to maintain a balance between advocating for utilization of the full evidence-based SOS Program while allowing schools to decide what works best in their community. Schools often pilot the program with limited screening and then build capacity to screen more fully.
Screening Tool and Student Response Card FAQs Depression screening often raises a number of questions and concerns. Many first time implementers wonder how screening can work logistically and how many students they might identify through screening. It is important to encourage questions and provide as much information as possible to your audience so that people feel well prepared to screen students and follow up as needed. Some common questions are included below. Question: Aren’t students more likely to answer the screening honestly if it is conducted anonymously? Answer: No matter which screening option you choose, some students may not be ready to open up about their depression or suicide risk- but many students will. If conducting identified screening, students who are ready to seek help can use the screening form as one way to reach out. When using anonymous screening, the form can serve as way to validate a student’s concerns. The next step would be for that student to reach out through the student response card or approaching an adult.
40 Page
Question: My school uses student response cards to identify students who would like to speak to a trusted adult. Won’t students self-refer if they are suffering from depression? Answer: Screening for Mental Health collects data from schools implementing the SOS Program around the nation. Many schools report identifying students in need of immediate intervention who have replied “no” on their student response cards but scored very high on the BSAD. When school staff followed up based on the BSAD scores, they learned that some of these students had active suicide plans and required hospitalization. Only 15%-20% of students identified for follow-up in one large metropolitan area were self-referred through the student response card. Question: If students write their names on the screening forms, should I still use the student response card? Answer: Yes, when schools use both the BSAD and the student response card, the number of students identified for follow-up increases. While the screening form identifies students with symptoms consistent with depression, the student response cards encourage students to seek support for any sort of concern about themselves or a friend. Question: How many students might screen in? How many will come forward using the student response card? Answer: The number of students a school might identify following the SOS Program will vary based on individual factors. SMH collects data from schools around the country and can provide aggregate data to assist with planning. In 2015-2016, schools conducting identified screening and using the student response cards reported following up with 15% of students who received the program. Schools that did not conduct screening or did not use the student response cards followed up with fewer students. All schools implementing the SOS Program (no matter what screening option used) reported following up with a number of students. On average, schools followed up with 12% of students after the program.
SOS Program Implementation: Total Percentage of Students Needing Follow-up
Screening and Student Response Card
41 Page
Best Practices for Screening Advice on Follow Up: • Find a process that works for your team. You may consider a color coding system where scored screening forms are organized based on their level of need. • Red: need to follow-up today • Orange: need to follow up within 48 hours • Yellow: need to follow up with a week • Green: good to go Document, Document, Document: With screening comes concerns about liability. Follow best practices to reduce risk for liability • Use student follow-up form to document steps taken and recommendations made to parents/guardians. • Make team decisions when unsure what to do in any situation. • Always disclose information to parents, prompt disclosure of a sucide threat to a parent is both legal and prudent. • Confidential materials should be stored under lock and key. • Always consul with the school legal department for questions regarding policies.
ACTivity: Student Follow-up 1. As a group, review and score the screening forms you receive using the scoring instructions located on the first page of your activity packet. 2. Review both the BSAD screening form and its corresponding student response card to determine if and when you’d follow up with the student. 3. Discuss as a group your plan for follow up including the order in which you would see students. A few things to consider: a. Is the student in crisis? b. Does the student need to be seen today? c. What plan would we have for this student? Consider using the colored folder approach. Which folder would you put each student’s paperwork in? ● Red folder = needs to be seen today ● Orange folder = needs to be seen in the next 48 hours ● Yellow folder = needs to be seen in the next week ● Green folder = good to go!
42 Page
43 Page
44 Page
45
Page
46 Page
47 Page
48 Page
49 Page
50 Page
51 Page
52 Page
53 Page
54 Page
55 Page
56 Page
57 Page
Student Follow-up Form Date of Initial Contact: ___________________ Student Name: ______________________________________ How did the student come to the attention of school staff (check all that apply)? Student self-referred Student was accompanied by a friend/another student
Parent
School staff
Other (specify):_______________________________ Was this considered an emergency? Was alcohol use assessed?
Yes Yes
No No
RECOMMENDATION (Check all that apply): Needs further evaluation
Suicidal
Completed full psychiatric evaluation
With intent or plan
Without intent or plan
Does not require further evaluation
Other: __________________
PARENT/GUARDIAN NOTIFICATION AND INVOLVEMENT Was the Parent/Guardian Contacted? If Yes, Date of Contact:_____________ (Day/Month/Year) No__________ In those cases when the parent/guardian was contacted, the parent/guardian was: In agreement with the recommendation for follow up and did bring the child for follow up In agreement with the recommendation for follow up but did not bring the child for follow up Disagreed with the recommendation for follow up and did bring the child for follow up Disagreed with the recommendation for follow up and did not bring the child for follow up Other (specify): In the case when parents disagreed with the need for referral and did not follow through, was a child protective agency contacted? Yes No If yes, describe outcome: ___________________________________________________________________ REFERRAL INFORMATION Was the child referred for follow-up evaluation/treatment? If yes, was the child referred to:
Yes
No
Local Emergency Room Local Crisis Team School Counseling Staff Pediatrician School Support Group Outpatient Referral (outside of school) Inpatient Referral Partial Hospital /Intensive Outpatient Program Other (specify): _____________________________________ A follow up appointment was made (where indicated): Immediately Within a week
Within 24 hours Within a month
Within 48 hours Other (specify):
Within 72 hours
Did you have any problems making referrals for counseling or treatment?
Yes
No
If yes, what problems did you experience? (Check all that apply): Didn’t have a place to refer student to Student left the school before a referral could be made Long wait list No providers accepted insurance Other (specify): Indicate how you resolved the problem: ________________________________________________ Staff Signature: ____________________________________
Date: ___________________
FOLLOW UP Date of Follow Up: _________________ For those who followed through with treatment, was the child still in treatment within: 1 month within the referral being made Yes No Dont know 3 months of the referral being made Yes No Dont know Child terminated treatment: Against medical advice Don’t know
Completed treatment recommendations
Ran out of insurance coverage
Other (specify):
Staff Signature: ____________________________________
Date: ___________________
58 Page
Notes: __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ _________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________
59 Page
Section 8: School/Community Readiness & Planning Objective: • Prepare to support schools/communities in assessing readiness to implement universal suicide prevention programming and begin planning for program implementation. The support of administrators, teachers, and parents is crucial to the success of your program. Providing adults with the tools they need to be responsive to youth will increase the likelihood of having a positive impact on students. It is important to strike a balance between responding to the signs of a youth who may need help and the harmful effects of labeling or overreacting to a situation. Recognizing warning signs and interpreting them as indicators that a child may need assistance reduces the risk that parents, educators, and community members will react inappropriately. For this reason, materials are provided to help gain the support of parents and school staff and educate them about the warning signs of depression and suicide, and the action steps they should take if they encounter a youth who may be at-risk.
Planning to Implement the SOS Program
Future SOS Trainer Take Home Note: Helping Schools Plan This is another area in which schools and communities really appreciate the individualized advice of an SOS Program Expert. Consider taking time during trainings to troubleshoot potential planning issues and allow schools to brainstorm with colleagues about scheduling dilemmas, local referral options, and obtaining parent consent.
Assembling the SOS Program Implementation Team The best approach to school-based suicide prevention activities is teamwork. Teachers, administrators, school nurses and school mental health professionals, working in close cooperation with community-based agencies, create the best outcomes. The first step in planning to implement the SOS Program is identifying a Project Coordinator to oversee program planning and implementation. This person will champion the effort to gain support for the program, where it is needed. S/he will oversee all aspects of the program planning and implementation to ensure that all components of the program are addressed and/or delegated to others. Once the Project Coordinator is identified, s/he can recruit a team of individuals from within the school, organization, and/or local community to plan and implement a smooth, successful, and clinically sound program. The implementation team may be comprised of social workers, nurses, counselors, psychologists, health teachers, student assistance professionals, parent liaisons, and community mental health or health practitioners who can volunteer their services to help implement the program and/or serve as referral resources. Having clearly defined and agreed upon responsibilities and holding individuals accountable for following through will increase the success of the program. Some schools incorporate planning for the SOS Program into another regularly held meeting, oftentimes one that addresses other safe school activities. As a SOS Certified Trainer, attending and helping to facilitate planning meetings can greatly increase the success of the program.
60 Page
The implementation team may also choose to involve parents, students or peer-helpers in the planning process. Please note that while parents, students and peer helpers may assist in the planning stages of your program, they should not be directly involved in the program’s implementation. Parents, students and peer-helpers can, however, provide testimonials for the program and help to get more broad-based support for your prevention efforts. Scheduling and Logistics Schools should be encouraged to design a program appropriate to their school needs and resources. Screening for Mental Health provides suggestions based on program evaluation research, best practices in the field of suicide prevention, and lessons learned from partner schools implementing the program around the country from the past 15+ years. In an assembly/classroom combined option, students can view and discuss the SOS Program DVD during an assembly period in the auditorium and complete the screening forms and student response cards at a later time in a classroom setting. • It is recommended that the SOS Program be delivered in a classroom or small group setting. • Consider piloting the program with a small group of students to work out the kinks before going school-wide • Many schools implement with one grade level through a standard class (ex. 9th grade health, 10th grade literature) • Some schools implement school-wide on large screening day events or strategically throughout the school year • While SOS can be implemented in one class period, always plan for follow-up • It is not recommended that SOS be implemented during the last period of the day, Friday afternoons, right before a holiday break, etc. to minimize risk of students being sent home without access to a trusted adult immediately following the program • Alternate supervised settings must be provided for those youth who do not want to participate in the SOS Program or whose parents do not want them to participate. NOTE: Depression and suicide may be extremely sensitive issues for some teens. If any student(s) feels overwhelmed and needs to leave the room, excuse them and make sure they have someplace safe to go where they may talk with an adult about their feelings. Reviewing and Updating School Policies During the planning stages, it is important for the implementation team to find out if the school/district has a policy for suicide prevention. Having a comprehensive policy will allow educators, school administrators, parents, and community members to have a clear understanding of actions steps. If a school does have a policy, the implementation team should be encouraged to review the plan and make any needed updates or changes as they see fit. The implementation team should always receive final administrator approval of any revisions before circulating the plan. If a school does not have a policy, the implementation team should be encouraged to create a policy together. The American Foundation for Suicide Prevention (AFSP), in partnership with The American School Counselor Association, The National Association of School Psychologists, and The Trevor Project, put together a model school policy that can be used as a reference when amending or drafting a suicide prevention policy in any school. AFSP’s Model School Policy: http://www.afsp.org/preventing-suicide/our-education-and-prevention-programs/ programs-for-teens-and-young-adults/a-model-school-policy-on-suicide-prevention
61 Page
Handling Crises and Emergencies Schools should plan to have a mental health professional on site throughout the program, not only to assist with program implementation, but also to handle clinical emergencies that may arise. This person may be a school nurse, school counselor, psychologist, social worker, licensed mental health counselor, psychiatrist, or physician. The program team should be aware of, and follow, the school’s procedures for notifying parents and providing emergency health care services. Encourage program team members to notify the nearest emergency room and/or mental health facility about the program ahead of time. Staff at these facilities should be available to evaluate emergency patients. A timely notification of the program will help to ensure that they are able to handle any emergencies that may arise on the day(s) of the program. Note: Most students identified through the SOS Program will not be in a crisis state. Schools should evaluate their non-crisis policies for dealing with student mental health and plan for parent notification and referral for these students.
Preparing for Follow up • Use SAMHSA’s Find Treatment Locator to identify additional referral resources: http://findtreatment.samhsa.gov • Contact local mental health facilities and verify their referral procedures, waitlists, insurance details, etc. • Create a referral resource list to share with parents • Identify in advance who will handle emergencies • Notify the nearest crisis response center about the program in advance in order to facilitate referrals Building Bridges with Community Providers It is recommended that schools partner with local mental health providers in the community and invite them to help with program planning, implementation, and to assist with referrals. Partnering with local providers is useful for several reasons: • Some schools may not have adequate staff to conduct the program if it is being implemented on a large-scale. • Students may feel more comfortable speaking about their personal issues with an “outsider” rather than an individual with whom they interact on a daily basis. • It serves as an introduction to community-based mental health resources for those who pursue treatment outside of the school. • To gain broader support in the community for your suicide prevention efforts. • To enhance the school’s referral network for follow-up with at-risk students identified through the program. Such partnerships can be beneficial to all parties, with schools having additional resources for their prevention efforts and agencies having a consistent source of referrals. Consider contacting local and state professional and advocacy organizations. They may be natural allies in your suicide prevention efforts.
62 Page
Tips for Partnering: • When asking for assistance, offer something in return. Simply increasing visibility in the community may be an adequate benefit. • Be passionate about your efforts to reduce youth suicide. Balance urgency with success stories. • Remind potential partners of the importance of their contribution. • Make sure they know how the proposed partnership benefits them. • Be specific about what you are asking them to contribute. • Maintain regular communication and modify the relationships as needs change. • Look for creative ways to convey your gratitude to partners and thank them publicly. For example, write a story about your community partnership for your local paper, school publication or town and school websites.
63 Page
Group ACTivity: Logistics & Planning Instructions: Review the Planning Checklist below to help you think through where you are in the process of implementing SOS in your community. • If you are school staff, think about what steps are needed to plan and get ready for implementation • If you are from an outside agency, identify what areas you are able to support • In small groups discuss areas that you find challenging and work to brainstorm any barriers you foresee We will come back together as a group and debrief, sharing tips and tricks from around the room.
SOS Program Planning and Implementation Checklist Overview This document gives you a detailed checklist to help with preparing for you SOS Program implementation. Each school, district, or agency may have additional policies and procedures that can be added to this list. Initial Planning
o o o o o o o
Meet with key decision makers Meet with SOS Program Implementation Team Decide which students will get program Decide on date(s), time, and local Contact local referral resources Initial communicate with parents (consent/info sharing) Student follow-up procedure
Adult Training and Education
o o
Host staff in service training Host parent night info session
SOS Program Implementation
o
Implement the program!
Evaluation and Feedback
o o
Contact SMH for survey Complete program evaluation survey
64 Page
Initial Planning
o
Have initial meeting with key decision makers Date: ___________ • Review the Readiness Checklist with school administration • Review School Crisis Protocol • Review School Prevention Policy • Determine who will be in on SOS Program implementation team
o
Have SOS Program Implementation Team meeting. Date: ___________ • Familiarize yourself with program materials and watch DVDs • Share online training module to review www.mentalhealthscreening.org/gatekeeper • Decide on team roles and responsibilities Who is to work out date/time ____________________________________________ Who is to identify and contact key referral resources ____________________________________________ Who is coordinating parent permissions ____________________________________________ Who is coordinating parent info night ____________________________________________ Who is coordinating staff training ____________________________________________ Who are the class-room implementers ____________________________________________ Who are those doing the student follow-up _____________________________________________ • Review school crisis protocol
o
Decide who you’re implementing program with (e.g. 9th grade, entire school, etc.) Students getting Program: _____________________________________________
o
Designate date(s) and time for student implementation Date(s): _________________________ Time: ______________________ Location: ___________________________________________________
o
Contact local mental health facilities/hospitals or related organizations that help youth. Let them know you plan to implement the SOS Program, alert them of the dates and times, and verify referral procedures, waitlists, sliding scale fees and information for the uninsured.
65 Page
• Use this information to update or create your referral list so parents will have most current information. NOTES: ______________________________________________
o
Communicate with Parents: decide on and request parent permission/consent • Passive or Active consent (circle one)? Examples given in SOS Program • Send out email, letter, or other means of communication ___________ • Consider including parent newsletter, parent screening form, link to online parent screening site, referral resources, or other resources NOTES: _______________________________________________
o
Decide on follow-up procedure and share info with those involved
Where will you score screening forms/response cards? ___________________________________________________ Where will you meet with students? ___________________________________________________ Where will students go who are not participating in the program? ___________________________________________________ How will you organize the documents? Color coded folder, etc. ___________________________________________________ Who will be assigned to the hall duty and office duty during program implementation? ___________________________________________________ Where/how will you secure the documents after review? ___________________________________________________ Training and Awareness
o
Host a staff training, including all teachers and support staff. Don’t forget coaches, lunch staff, bus drivers, custodians, etc. Date/time/location: ____________________________________________________ • Ensure your mental health staff are present (social workers, school psychologists, counselors, school nurse, etc.) Yes/No • Provide general suicide prevention information on identifying students at risk • Utilize the Training Trusted Adults DVD to help introduce the topic and the SOS Program. Yes/No
o
Host a parent night Date/time/location: ____________________________________________________
66 Page
• Ensure your mental health staff are present (social workers, school psychologists, counselors, school nurse, etc.) Yes/No • Help in getting parents there: • Involve PTA/PTO in planning? Yes/No • Secure transportation? Yes/No • Secure free food? Yes/No • Secure raffle prizes? Yes/No • Child Care? Yes/No • Tack on to other event? Yes/No • Title is appealing: something like “Safeguarding our youth” “Building Resiliency in our kids” • Provide general suicide prevention information on identifying students at risk • Utilize the Training Trusted Adults DVD to help introduce the topic and the SOS Program. • Allow time for Q&A SOS Program Implementation
o o o o o o o o o o
Date/Time: __________________________ Number of students: __________________ Screening details: Anonymous/Non-anonymous (circle) Used the student response care? Yes/No Introduce SOS to students Show video Have discussion Screen student and have them fill out student response cards Follow up with students Utilize program supplemental materials to reinforce programs message (hang posters, give out wallet cards, newsletters, stickers, etc.)
Evaluation and Feedback
o
Contact Screening for Mental Health to get the most up to date feedback survey on your SOS Program implementation
o
Complete the survey
67 Page
Yes/No Date:___________________
Notes: __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ _________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________
68 Page
Section 9: SOS Program Implementer Training Objective: • Understand the goals and contents of SOS Program Implementer training • Prepare SOS Trainers to redeliver material
SOS Program Implementer Training The Implementer Training is designed with program implementers in mind and is designed to last 4-6 hours, depending on the needs of the group and time constraints. These trainings prepare program implementers to work directly with students to deliver the educational and screening component of the SOS Program. Additionally, these trainings are trainthe-trainer models, preparing implementers to train community members, parents and school staff as trusted adults in their prevention efforts. Determining an Audience • The SOS Implementer Training can be for a specific school or district, as they prepare to implement the program. The audience of this training would be anyone involved in the implementation of SOS: health teachers, social workers, school nurse, counselors, etc. • The Implementer Training can also be for an audience made up of school staff and/or staff from youth serving organization from around your community. The training will empower this audience to go back to their school and put together an implementation team and get the SOS Program going for their student body.
SOS Implementer Training Key Components • Presenting the Facts • National and local statistics • Suicide warning signs, symptoms, risk factors • Learning how to respond to a student in need • SOS Program Implementation • SOS Program overview • SOS Educational component • SOS Screening component • School/District protocols and procedures • Planning for Implementation • Forming implementation team • Day of logistics • Planning student follow-up • Training and engaging parents and other trusted adults • Data collection and reporting Supporting Materials • • • •
SOS Implementer PowerPoint Presentation SOS Program DVD Handouts Local school/org handouts (school protocol/procedure, etc.)
NOTE: As a trainer, you gain access to an electronic portal where you can download PowerPoint slides, handouts, and more! Once you complete certification, you can use the portal to start planning your implementer training. You can customize your training by tailoring the slides to fit your community’s needs and share handouts that are most appropriate for your training attendees. * Find more training planning information and resources in section, Developing Your Trainings at the end of your handbook.
69 Page
Future SOS Trainer Take Home Note: Supporting Materials for Implementer Trainings As a trainer, you gain access to an electronic portal where you can download PowerPoint slides, handouts, and more! Once you complete certification, you can use the portal to start planning your implementer training. You can customize your training by tailoring the slides to fit your community’s needs and share handouts that are most appropriate for your training attendees. * Find more training planning information and resources in section, Developing Your Trainings at the end of your handbook.
Frequently Asked Questions about Implementer Trainings Do I need to purchase the SOS Program for the schools I’m training? No, you do not. However, the goal of the SOS Implementer Training is to assist in SOS Program implementation so the school or organization will need to carry out the program with students. Refer schools to the SMH Online Shop to purchase the program: http://shop.mentalhealthscreening.org/. There may be local champions interested in purchasing the program for your school or community. Contact Screening for Mental Health for assistance with any questions regarding SOS Program funding. What slides and activities do I use? You will gain access to master PowerPoint slides and activity instructions and materials that can be customized and tailored based on your training needs. What handouts do I need for this training? You will have access to an electronic portal with all handouts needed. Handouts include activity supporting documents, trainee literature such as program brochures, planning check-lists, referral lists, school policy/protocol, etc. The handouts you choose to bring will always depend on the structure of your training. If ever unsure of what to bring please work with the SMH youth team on customization.
70 Page
Mock Agenda: A detailed agenda helps keep you organized and your audience focused. You may plan your own agenda for each training and adjust based on the content and available time. This is a sample agenda of a 4-hour training provided by SMH staff. If you have more time available, build in more activities and/or provide more detailed content.
9:30 - 9:40
Welcome and Introduction
9:40 - 10:25
Taking a Closer Look at Youth Suicide
10:25 - 10:40
Applying Our Knowledge: Identifying Students
10:40 - 10:50
BREAK
10:50 - 11:00
We Know the Facts, Now What Can We Do?
11:00 - 11:45
SOS Program in Action - DVD and Discussion
11:45 - 12:30
SOS Program in Action - Screening and BSAD Activity
12:30 - 12:40
BREAK
12:40 - 1:15
Planning for Universal Prevention
1:15 - 1:30
Q & A and Evaluations
Planning for an Implementer Training • As a trainer you will gain full access to a portal where you can download all the materials you need to facilitate a training • Download master slide deck and planning documents • You can schedule a call or meeting with SMH staff to help you prepare for the training • Tailor your slides to fit the community needs and any time constraints • Identify which handouts will be useful for your audience and print • Contact SMH staff with any questions!
Notes: __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________
71 Page
Part 4:
Training Trusted Adults
72 Page
Section 10: Key Messages for All Trusted Adults Objective: • Understand key information to share with all trusted adults in any SOS training
What is a Gatekeeper/Trusted Adult? Gatekeeper is term used in youth suicide prevention to refer to trusted adults. These are adults who are strategically positioned to recognize and refer someone at risk of suicide (e.g. parents, friends, neighbors, teachers, coaches, caseworkers, police officers). They’re “natural helpers” who can provide a link or “open a gate” to mental health treatment. In the field of suicide prevention, you may hear the term gatekeeper used instead of “trusted adult.” The SOS Program encourages the use of the term “trusted adult” because it is more clear to the general public. What do we teach Gatekeepers/Trusted Adults? As a trainer, you’ll be able to provide trusted adult trainings in your community. Much of the content included in previous sections are key components of trusted adult training. • Identify signs and symptoms: Education on risk factors, warning signs, precipitating event, and protective factors (see Section 4, Debunking Myths and Presenting Facts and Section 5, Youth Suicide: a Multifactorial Event). • Overview of the SOS Program: Include a brief introduction to the SOS Program as a part of your training so that the adults are aware of what the students are learning in class. In addition to teaching adults how to identify signs and symptoms of depression and suicide in youth the trusted adult training will also give these gatekeepers action steps on how to respond. ACT Messaging for Adults Acknowledge that you are seeing signs of depression or suicide in a student and that it is serious Care: Let the student know you care about them and you can help Tell: Follow your school protocol and tell your mental health contact Example Statement for ACTing Acknowledge: • “You sound really down. Things have gotten really tough for you.” • “I’ve noticed how you seem really quiet recently, like something major is bothering you.” • “It seems like you are dealing with some major struggles right now.” • “It sounds like you’re really hurting. Are you feeling so bad that you’ve thought about suicide?” Care: • “I’m really concerned about you trying to deal with all of this on your own.” • “I care so much about your input in my class that I want to see how I can help.” • “I would never want you to be hurting like this.” Tell: • “There are people at school who know how to help kids that are dealing with big issues like this, let’s walk down to the counseling suite together.” • “Ms. _______ will know how to get you the help you need. Let’s go see her now.”
73 Page
Reaching out to a Student in Need • Mention changes you have noticed in his or her behavior and that you are concerned and ask how he/she is doing. • Ask if they have been thinking about suicide, e.g., “Are you feeling so bad that you’ve thought about suicide?” • Be supportive, remain calm, show that you care and reassure the student that they can get help. • Escort the student to talk to their counselor. • Whether or not the student sees a mental health provider: • Continue to check in with the student • Talk to the school’s mental health contact/administrator about your concerns • Stay in touch with the school’s mental health contact/administrator Don’t: • • • • • •
Be judgmental or argue with the student about their feelings or choices. Minimize the student’s feelings. Ignore comments about suicide. Be sworn to secrecy. Forget to seek support and consultation for yourself. Try to handle the crisis alone.
ACT If You See Warning Signs We already covered how to identify signs and symptoms and what the SOS is. Let’s dig into the final piece- how to respond to youth in need, using the ACT message. If you see warning signs, take the following steps right away: • Supervise the student constantly (or make sure the student is in a secure environment supervised by caring adults) until he or she can be seen by the mental health contact. • Escort the student to see the mental health contact or administrator. • Provide any additional information to the mental health professional evaluating the student to help in the assessment process. That person will notify the student’s parents.
74 Page
ACTivity: Responding to Youth In Need Instructions: 1. Divide into pairs and choose a sample scenario. 2. One participant plays the role of the student; the other participant plays themselves (or a teacher on campus). 3. Practice responding to the student and note feedback from both participants. 4. Switch roles and try another scenario. 5. Debrief activity as a group.
Scenario 1 Lisa is an international student who you have known to be energetic and interested in many activities. For the past month, she has seemed to have little energy and often appears sad. She has always dressed casually, but recently she has looked disheveled and seems not to care as much about her appearance. You don’t know Lisa very well, but you’ve chatted several times, so you decide to approach her to ask if something is bothering her. She shrugs off the question and avoids you. You try one more time, and she breaks down in tears and says she cannot talk about it.
Scenario 2 Thomas has been sent off campus for assessment and treatment after making a suicide attempt on campus. Out of respect for Thomas’s privacy, you don’t want to share information about the attempt or his condition with the other students. However, his friends know what happened and there have been rumors flying around school. You are chatting with a group of students in the gym and are asked directly, “What happened to Thomas?”
Scenario 3 You are sitting down to read some student writing assignments during a free period in class. Many students have written emotional stories for this creative writing project, but Emma’s stands out. Emma has written a fictional story about a girl her age who attends a similar boarding school. Her character is very popular and excels in her art. Her character goes home for Christmas break and witnesses a terrible violent act. The violent story is very descriptive and graphic. It makes you uncomfortable to read as it turns sharply to focus on death.
Scenario 4 A student that you know well, Taylor, approaches you with concerns about their girlfriend. You don’t know this girlfriend, but they tell you that she is a new freshman on campus. She is described as struggling to adjust to school. She is crying all the time and has begun cutting herself because she says it helps her feel better. Taylor has been trying to help, but has finally come to you because last night she made a comment about “not even caring when I’m gone.”
Scenario 5 One of your students, Laura, used to excel in your class as well as all of her academic classes. She was one of the top students in her grade but recently her grades have begun to slip and she seems distracted. You speak to some of your colleagues and learn that her grades have been dropping across the board. When you decide to speak to her after class, she tells you that she “doesn’t care about school anymore.” You press a little to understand more and she reveals “that she doesn’t see the point in any of it anymore.”
75 Page
Notes: __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ _________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________
76 Page
Section 11: Training for Parents, Community Members, Faculty & Staff, & Administrators Objective: •
Prepare to deliver SOS Trusted Adult Trainings adapted for each audience
Future SOS Trainer Take Home Note: Preparing for a Safe Training It is important before you begin this presentation to acknowledge that you are about to discuss a sensitive and serious matter. There may be people in your audience who have a personal connection to the issues of depression and/or suicide. Some people may even be caught off-guard by their own reactions to the material. Let your audience know that they may leave the room for a few minutes if they feel they need space. You may even appoint someone from the school to stay in the hallway for people who need to talk. If this is the case, let your audience know who this is and where they can be found.
SOS Trusted Adult Training Training Overview • Audience of the training: parents/community members, faculty/staff, administrators • Purpose: Reduce stigma, educate on signs/symptoms, give action steps, gain buy-in Key Components 1. Watch Training Trusted Adults DVD and facilitate discussion including: • Myths/facts about youth suicide • Risk factors, warning signs, precipitating events, and protective factors • State/local/national stats 2. Explanation of the SOS Program and how it will be implemented 3. Sharing resources for the population (parents, staff, community, etc.) 4. Q & A Supporting Materials • Training Trusted Adults DVD and Discussion Guide • Plan, Prepare, Prevent online training module • PowerPoint presentation for trusted adult training (adapted to audience)
77 Page
• Handouts for parents, school staff, community members, see section 8 for details
o School crisis policy
o Educational material
o Local Resource list
o SOS Program info sheet
Preparing School Faculty and Staff through Training Training faculty and staff is universally advocated and supported by research as an essential component to an effective suicide prevention program. When dealing with the sensitive issues of depression and suicide, there are guidelines that all schools participating in the program need to cover with school personnel before the program. First and foremost, it is critical that all school faculty and staff understand school procedures for dealing with students who disclose suicidal intent. If planning a training in a specific school, certified trainers should familiarize themselves with school or district procedure for dealing with potentially suicidal students prior to training. This information should be distributed to all attendees with support from the school/district administration. A student may disclose the need for help to any adult in school or in the community. Therefore, it is important that all faculty, staff and adult community members be made aware that the SOS Program is being presented and why. They should know the warning signs for depression and suicide and how to effectively respond to students who may approach them for help. Research indicates that training faculty and staff to develop the knowledge, attitudes, and skills to identify students who may be at risk for suicide and make referrals can produce positive effects on an educator’s knowledge, attitudes, and referral practices. In-service training can help to educate school staff and support community wide prevention efforts. Utilize the Training Trusted Adults DVD to help familiarize staff with suicide prevention and the SOS Program. Taking time for this conversation can help educators share their concerns about youth depression, self-injury, and suicide, establish a sense of cohesion, and increase staff confidence in addressing these problems.
78 Page
Sample Lecture for Faculty/Staff Training (Adaptable for a Parent Night) 1. Present Your Plan to Implement the SOS Program Sample Introduction: “In an effort to reduce depression and suicide among our students, your school plans to implement the SOS Signs of Suicide Prevention Program (specify school-wide, in health classes, grade level, etc.) on (specify date). The goal is to help students recognize the symptoms of depression or warning signs of suicide in themselves or their friends and teach them the appropriate action steps they should take to get help. The purpose of this program is not to tell whether students are depressed, but rather inform them about whether they, or their friends, may have symptoms that need further evaluation. Through the SOS Program, school staff, students, and parents will learn about depression, suicide, and the associated risks of alcohol use. They will also learn steps for getting help through the simple acronym ACT: Acknowledge that your friend has a problem, express that you Care, Tell a trusted adult.
2. Explain Why Implementing the SOS Program is Important Sample Content: While youth suicide is uncommon, mortality from suicide increases steadily through the teens. Suicide is the second-leading cause of death for those ages 11-18. Over 90% of children and adolescents who die by suicide have a diagnosable mental disorder at the time of their death (Gould et al., 2003), yet 80% of youth with mental illness are not identified or receiving services (Merikangas et al., 2011). Adolescents who suffer from depression are at much greater risk of suicide than children without depression (U.S. Department of Health & Human Services, 1999). Overall, approximately 20% of youth will have one or more episodes of major depression by the time they become adults (NAMI, 2003). Childhood is an important time to promote healthy development, as many adult mental health disorders have related antecedent problems in childhood. Since a previous suicide attempt is the leading risk factor for adult suicide, introducing prevention early may help promote prevention throughout the lifecycle.
3. Review Suicide Risk Factors, Warning Signs, Precipitating Events, and Protective Factors 4. Summarize Sample Summary: “The goal of the SOS Program is for school staff, students, and parents to learn about depression, suicide, and the associated risks of alcohol use, and increase confidence to seek help for those who need it. Through your participation, we are taking an important step toward protecting our students by identifying mental health problems and encouraging them to seek help from trusted adults. We hope that the program will help instill confidence in you, [school name] faculty and staff, and your students about identifying the signs of depression and suicide and how to access help if someone needs it.” Note: Identify a school contact for attendees to address questions or concerns that may arise after the training.
79 Page
Parents as Partners in Safeguarding Youth Studies have shown that as many as 86% of parents were unaware of their child’s suicidal behavior (Kashani et.al 1989; Velting et.al, 1998). For this reason, parent training is an integral part of the SOS Program. The goal is to actively engage parents in your prevention efforts, to gain their support, and to encourage discussion among parents and their children about the issues of depression and suicide. By raising parental awareness, schools/organizations partner with parents to watch for warning signs in their children and instill confidence in them to seek help for their child, if necessary. As a Certified SOS Trainer, you may be approached for your expertise in engaging parents in suicide prevention. Besides assisting with a comprehensive parent night that helps streamline safe messaging to parents, encourage schools to consider taking the following steps to increase cooperation in their prevention efforts and to broaden community support: • Inform parents about the school’s plans to implement the SOS Program. • Distribute educational materials to all parents, not just those whose children are already identified as being at-risk. • Include articles about depression, suicide, and resilience in your school newsletter, town paper, or town or school website. • Reach out to faith-based communities to offer education programs. • Conduct annual parent forums to proactively address promoting youth safety. • Include information about your youth suicide prevention efforts at health fairs. • Involve parents and the PTO early in your prevention planning and ask advocates for your efforts to get the support of other parents. • Utilize the parent version of the Brief Screen for Adolescent Depression (available in paper form and online), which helps parents to look for warning signs of depression and suicidality in their child.
Parental Consent As a SOS Certified Trainer, you will likely be asked about parental consent. Screening for Mental Health (SMH) advises schools to refer to their own school or district policies to determine requirements for gaining parental consent. SMH recommends engaging parents while obtaining parental consent before implementing a suicide prevention program, by sending out a letter introducing the program, a copy of the Parent Brief Screen for Adolescent Depression (or a link to take it online), and a list of local resources along with a permission slip to parents. Be sure to include information about who to contact at the school if parents have questions or concerns. There are two different methods of acquiring parental consent: active and passive. SMH advises using whichever option each school district requires. Active consent allows for a student’s participation only if the parent or guardian has explicitly granted either verbal or written permission. Passive consent requires either verbal or written communication to the school only if the parent or guardian does not wish to have his or her child participate. A lack of a response from the parent or guardian indicates consent for his or her child to participate. Sample parental consent letters and permission slips for both active and passive consent are included in the SOS Program. TIP: Incorporate written consent with other paperwork required for parents to sign.
Suggestions for a Parent Night If you are invited to conduct a parent night event, it can be very similar in content to the staff training. The goals of the event should be to gain support for suicide prevention efforts and provide parents with information about the signs and symptoms they should watch out for in their children, and the mental health resources in the school and the community that are available should they need them. • Plan an educational presentation for parents on ensuring the safety of youth • Entitle the parent night event in a general way, such as “Keeping Your Teen Safe” or “Safeguarding Youth”
80 Page
• Serve food and provide childcare • Combine the event with another well-attended or mandatory event, such as orientation, parent/teacher conferences, or registration for courses, special events, or sports • Show the Training Trusted Adults DVD and facilitate a discussion • Answer questions; dispel myths • Review the symptoms of depression, risk factors, protective factors, and signs of suicide • Inform parents that restricting access to lethal means, especially access to firearms, and educating them about how to limit access to lethal means can be an effective way to prevent youth suicide Prevention themes to stress with parents include: • Do not be afraid to talk to your kids about suicide • Know the risk factors and warning signs of youth suicide • Respond immediately if your child is showing warning signs • Reach out to the school for resources • Do not store guns in the home. Make any firearm in the house inaccessible to children Note on firearms in the home: A 2004 study published in the Journal of Epidemiology and Community Health found that those who stored their firearm locked, unloaded, or both were less likely to attempt suicide with it compared to those who had direct access (unlocked, loaded, or both) (Shenassa et al.). The four practices of keeping a gun locked, unloaded, storing ammunition locked, and in a separate location are each associated with a protective effect and suggest a feasible strategy to reduce risk of suicide by firearms in homes with children and teenagers where guns are stored (Grossman et al., 2005). However, whether these measures prevent firearm suicide or unintentional injury in children and adolescents is not clear. Agenda 1. Show the Training Trusted Adults DVD (clips) 2. Dispel myths & review warning signs 3. Facilitate a follow-up conversation using the discussion guide 4. Allow extra time for Q& A Differences Based on Audience • At STAFF Training: • Review the school/district’s crisis response protocol • Review/practice how to approach and/or respond to a student in need (including guidelines for handling disclosure) • At PARENT Training: • Review school policy, focusing on how and when parents/guardians will be contacted if their child needs further help • Provide school and community-based mental health resources
Best Practices in Training Trusted Adults
These best practices and key points are important to include in your gatekeeper trainigns (for parents, school staff, etc.) • Engage school’s mental health staff to discuss risk factors, warning signs and how to identify students in need • Include training on the connection between depression and suicide and dispel myths about youth suicide • Review best practices and school policy for responding to at-risk youth • Discuss confidentiality: An adult must never keep a secret for a child if there is any concern about self-harm • Review school policy for following up with at-risk students, including how and when parents/guardians will be contacted if their child needs further help
81 Page
ACTivity: Trusted Adult Training 1. Watch the adult training video. Think about watching it as a parent of a student and as a teacher in a classroom with a student who will go through SOS. 2. Decide if your group is doing a “parent night” or a “staff training”. 3. Determine one person at the table to be the SOS Program implementer (teacher, counselor, etc.) 4. The facilitator should use the discussion guide provided in this section to facilitate a discussion with the “parents” or “school staff”. 5. Everyone at the table should try to react as they think their population (audience) would react. 6. We will debrief as a large group as to what the challenges were and how we think our audience will react to an actual adult training.
82 Page
Training Trusted Adults DVD Discussion Guide Before You Start It is important, before you begin this presentation, to acknowledge that you are about to discuss a sensitive and serious matter. There may be people in your audience who have a personal connection to the issues of depression and/or suicide. Some people may even be caught off-guard by their own reactions to the material. Let your audience know that they may leave the room for a few minutes if they feel they need space. You may even appoint someone on your team to stay in the hallway for people who need to talk. If this is the case, let your audience know who this is and where they can be found.
Introduction 1. Why do you think the SOS Program is important for our community to embrace? • Many people are uncomfortable with the topic of suicide.Implementing a program like SOS can help our community discuss mental health issues, which is an important step in preventing suicide. • The SOS Program can help youth and adults differentiate between normal development and what may be a more serious mental health issue. • Suicide is the 2nd leading cause of death among people aged 11-18 (CDC, 2015). • More than 90% of youth who die by suicide have a diagnosable mental health disorder, most likely depression, which is treatable, but many youth do not receive treatment. • The SOS Program encourages students to seek help for themselves or a friend so that a trusted adult can get them the support they need.
Risk Factors, Warning Signs and Precipitating Events 1. Please review the following definitions with your Training Trusted Adults audience. They are not spelled out in detail in the video but are explained and differentiated further in the online module and in your implementation guide. • A risk factor is any personal trait or environmental quality that is associated with an increased risk of suicide. The first step in preventing suicide is to understand the risk factors. They are not necessarily causes. • A warning sign is an indication that an individual may be experiencing depression or thoughts of suicide. Most suicidal individuals give warning signs or signals of their intentions. • A precipitating event is a recent life event that serves as a trigger, moving an individual from thinking about suicide to attempting to take his or her own life. Precipitating events are often confused with causing suicide. No single event causes suicide; other risk factors are typically present. 2. What are some of the risk factors and warning signs listed in the DVD that stuck out for you? • Warning signs are changes that occur over a period of at least two weeks, including: changes in eating or sleeping patterns, increased irritability/moodiness/rapid fluctuation in mood, decreased interest in usual activities/hobbies, isolation, involvement with the law.
83 Page
• Risk factors include: history of abuse, use of drugs/alcohol, history of mental illness, previous suicide attempts, access to lethal weapons, exposure to suicidal behavior in others, family history of mental illness, history of significant loss, struggles with sexual orientation/gender identity or fears of acceptance around sexual orientation/ gender identity.
Protective Factors 1. Please review the following definition with your Training Trusted Adults audience: Protective factors are personal traits or environmental qualities that can reduce the risk of suicidal behavior. Protective factors don’t imply that anyone is immune to suicidality, but help reduce risk. 2. What are some protective factors you might find in your students? • Protective factors include: strong problem-solving skills, positive self-image, spiritual faith, close family relationships, strong peer support system, involvement in hobbies/activities, community connectedness, access to treatment, and restricted access to firearms and other means. • For a more comprehensive list of protective factors, as well as risk factors and warning signs, review the SAMHSA Toolkit at http://store.samhsa.gov/product/SMA12-4669
Guidelines for Responding to Students in Need 1. Review your school’s response protocol with your Training Trusted Adults audience. Let parents/school staff/community members know the steps your school will take to follow up with students seeking help. 2. In this section, the professionals discuss confidentiality. You also heard Melissa in Elyssa’s story say, “It’s ok to tell.” What are some steps to take if a student discloses the need for help? • Do not leave the student alone. Keep them safe until additional help can be found. • Be open. Listen and allow the student to feel comfortable sharing their feelings. • Contact a parent/guardian. If appropriate, facilitate a referral for the individual to get professional help. • Stay supportive. You may be the first person with whom this individual has discussed these feelings.
Building Bridges with the Community 1. Let your audience know that the school has a referral plan in place. If appropriate, provide a mental health resource list available to distribute. 2. Remember that you can always provide your community with the phone number for the National Suicide Prevention Lifeline for support: 1-800-273-TALK(8255)
ACT in Action 1. Hayley says, “What I would look for in a trusted adult would be somebody who could take me seriously and care about what I’m telling them and has shown an interest in the wellbeing of you and your peers.” • What qualities do you think make you a trusted adult?
84 Page
Staff Training Checklist Planning Your Staff Training Checklist: Key Steps for a Successful Training
Preview the Training Trusted Adults DVD. Make sure the disc is in working order, familiarize yourself with its content, and think about your own reactions to this video.
Read the DVD Discussion Guide. Consider key questions and talking points.
Review risk factors and warning signs of depression and suicidality as well as protective factors. Print copies of corresponding handouts to distribute during the training. Be prepared to answer questions and clarify information.
Understand myths and corresponding facts about depression and suicide. Print related handouts.
Work with school administration and mental health staff to review protocol for how staff should respond when approached for help by a student. This process may mean referring the student to you or another point person in the school. Have printed guidelines ready.
Review specific school/youth serving organization’s policy for following up with at-risk students. Be prepared to give detailed information.
If applicable, inform staff of date, time and setting of program implementation.
Handouts • Risk Factors and Warning Signs • Protective Factors • Myths about Depression and Suicide • Disclosure Template for School Staff to Use When Approached by Students Asking for Help • Specific school/district’s policy and protocol for handling at-risk students* *Coordinate with school administration
85 Page
Parent Night Checklist Planning Your Parent Meeting Checklist: Key Steps for a Successful Training
Preview the Training Trusted Adults DVD. Make sure the disc is in working order, familiarize yourself with its content, and think about your own reactions to this video.
Read the DVD Discussion Guide. Consider key questions and talking points.
Review risk factors and warning signs of depression and suicidality as well as protective factors. Print copies of corresponding handouts to distribute during the training. Be prepared to answer questions and clarify information for parents.
Understand myths and corresponding facts about depression and suicide. Print related handouts.
Work with school administration and mental health staff to review each school’s policy for following up with at-risk students, including how and when parents/guardians will be contacted if their child needs further help.
Provide parents with school and community-based mental health resources in your community.
Prevention themes to stress with parents include:
• Do not be afraid to talk to your kids about suicide • Know the risk factors and warning signs of youth suicide • Respond immediately if your child is showing warning signs • Reach out to the school for resources • Make all firearms in the house inaccessible to children
If applicable, inform parents of date, time and setting of program implementation.
Handouts for Parent Night • Risk Factors and Warning Signs • Myths about Depression and Suicide • Parent Brief Screen for Adolescent Depression Screening Form • Referral list of school and community-based mental health resources* • Specific school’s policy and protocol for handling at-risk students* *To be provided by the school
86 Page
Homework Objectives: • Practice gathering data and information relevant to your community as you prepare to redeliver trainings • Familiarize yourself with how to find information related to suicide prevention in your area
Activity: • Complete the worksheet on the following page by following the steps outlined below: 1. Research the items outlined 2. Summarize all information discovered and additional information gathered 3. Print/write notes about your community to share with the group 4. Prepare to discuss your community’s risk factors, resources, and climate for suicide prevention on Day 2
87 Page
Homework State and National Legislation related to youth suicide prevention: ___________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ Local Partners in youth suicide prevention: __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ State and Local Suicide Prevention Coalition Chairs and Other Key Contacts: __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ Youth Risk Behavior Survey (YRBS) stats for your state related to youth self-injury/suicide: __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ School Level Data regarding risk factors, student demographics, special populations: __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ School/Community Climate (what makes it unique, what particular challenges does it face?): __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________
88 Page
Part 5:
Developing Trainings to Meet Community Needs
NOTE: Day two of the training will focus on how we can customize our trainings based on the communities we serve. We will look at cultural considerations, recent events, and common concerns in communities. The last few hours of the day will be dedicated to practicing planning and presenting this information.
89 Page
Section 12: Ground Rules & Safe Messaging Objectives: • Learn the importance of safe messaging and practice using proper vocabulary to ensure future trainings are clear, informative, and emotionally safe for all participants • Consider ground rules that will be helpful for creating an open, productive training environment in your own community
Future SOS Trainer Take Home Note: Discussing Sensitive Topics • Discussion of suicide raises strong emotions for many people. When training adults in the SOS Program, working directly with students around issues of suicide, and discussing suicide in any setting, be aware of the impact of your words. • Always encourage participants to take a break and step outside of the room as needed. • Always practice safe messaging and encourage your audience to use proper vocabulary and safe messaging with their students and parents.
Ground Rules It is best to start each training with some ground rules. You want to establish a way to work together openly and productively over the time of the training. You may want to ask the group what they would like the ground rules to be. Consider asking everyone to: • Assume that all participants have the best intentions • Silence phones • Side conversations to happen outside of the room • Use as few abbreviations/jargon as possible, etc. All SOS trainings should start with an acknowledgement that this is a heavy topic and anyone who needs to can step outside at any time for a breather.
90 Page
Proper Vocabulary It is best practice to use safe messaging and proper vocabulary in any training or presentation you’re providing. Here you’ll find key definitions for words that will come up in your trainings. Suicide: Death caused by self-directed injurious behavior with any intent to die as a result of the behavior. Note: The term “committed” suicide is discouraged because it connotes the equivalent of a crime or sin. The CDC has also deemed “completed suicide” and “successful suicide” as unacceptable. Preferred terms are “death by suicide” or “died by suicide.” Suicide attempt: A non-fatal self-directed potentially injurious behavior with any intent to die as result of the behavior. A suicide attempt may or may not result in injury. Suicide attempt survivor: Someone who has lived through a suicide attempt. Suicidal ideation: Thoughts of suicide. These thoughts can range in severity from a vague wish to be dead to active suicidal ideation with a specific plan and intent. This term may sound unnecessarily clinical to your audience. “Suicidal thoughts” is a clear way to discuss this concept. Suicide loss survivor: Someone who has lost a loved one to suicide. Unintentional injury: A fatal or non-fatal injury that was unplanned and not intended to happen. Causes include a motor vehicle crash, poisoning, fall, fire, and drowning. Unintentional injuries are sometimes referred to as “accidents,” but this term is discouraged since it implies the injury was not preventable. Universal prevention: Universal prevention strategies are designed to reach the entire population, without regard to individual risk factors and are intended to reach a large audience. Universal prevention overrides implementer assumptions, reduces mental health stigma across the population, and promotes learning in all participants. Prevention: Interventions designed to stop suicidal behavior before it occurs. These interventions involve reducing the factors that put people at risk for suicide and suicidal behaviors. They also include increasing the factors that protect people or buffer them from being at risk. Treatment: The care of suicidal people by licensed mental health caregivers, health care providers, and other caregivers with individually tailored strategies designed to change the self-injurious or self-directed violent thoughts, behaviors, mood, environment, or chemistry of individuals that increase the risk for engaging in suicidal behaviors, and help them identify and address their emotional, psychological, and physical needs without engaging in self-destructive behaviors.
91 Page
Postvention: Actions taken after a suicide has occurred largely to help persons affected by the suicide loss, such as family, friends, classmates, and co-workers of the deceased. Self-Injury: Intentional, non-life threatening, self-inflicted bodily harm or disfigurement of a socially unacceptable nature, performed to reduce and/or communicate psychological distress. Depression: Criteria for Major Depressive Episode: DSM-5 A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure. (Note: Do not include symptoms that are clearly due to a general medical condition, or mood-incongruent delusions or hallucinations.) • Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful). Note: In children and adolescents, can be irritable mood. • Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others). • Significant weight loss when not dieting, or weight gain (e.g., a change of more than 5 percent of body weight in a month), or decrease or increase in appetite nearly every day. Note: In children, consider failure to make expected weight gains. • Insomnia or hypersomnia nearly every day. • Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down). • Fatigue or loss of energy nearly every day. • Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick). • Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others). • Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide. B. The symptoms cause clinically significant distress or impairment in social, occupational or other important areas of functioning. C. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism).
92 Page
Future SOS Trainer Take Home Note: The Facts and Safe Messaging Suicide impacts most people at some point in their professional, social, family or personal life. No matter your audience, you never know who may be struggling with their own mental health concerns or suicidal thoughts. Using safe messaging ensures that your training encourages all learners that prevention works and that help is always available. Whenever speaking about suicide, it is important that all messages are strategic, safe, positive, emphasizing hope and prevention. Certain types of messaging about suicide death may increase risk among vulnerable individuals. Suicide should never be presented as hopeless or unsolvable. Positive and safe messaging can help individuals in crisis find the help they need and educate the public about how they can be involved in preventing suicide.
Best Practices • Emphasize help-seeking and provide information on finding help. Always provide a concrete resource for help seeking such as the National Suicide Prevention Lifeline (1-800-273-TALK[8255]). Supplement with any local resources you are aware of. • Emphasize prevention. Reinforce the fact that there are preventative actions individual can take if they are having thoughts of suicide or know others who are or might be. • Highlight effective treatment for underlying mental health problems which correlate to 90% of all suicides. • Teach the warning signs, as well as risk factors and protective factors for suicide. Teach people how to tell if they or someone they know may be thinking of suicide. Cautions • Avoid phrases like “commit” “succeed” or “complete” – instead use “died by suicide” “took their life” etc. • Avoid details about method. It’s okay to share the facts but there Is no need to go into details • Avoid simplifying suicide. We know suicide is very complex, there are many risk factors involved. We do not want to misinform by insinuating that it happened for this reason or another. Remember- no one thing causes someone to take their life. • Avoid glorifying suicide. We do not want to trigger anyone by implying any positive outcomes after the death. Suicide is a tragedy and should be talked about as such. • Avoid portraying suicide as an option. Suicide is never an option and by making that clear we are avoiding any triggering language for those in our audience. • Avoid providing extensive statistics about suicide without solutions or action steps making suicide seem too overwhelming to address. Only use statistics along with specific messaging about the power of prevention to avoid normalizing suicide or implying that nothing can be done about it.
93 Page
Introduction of Local Suicide Loss Survivors Introduce a guest speaker to tell his/her story as a suicide loss survivor in the community. A guest speaker should share: 1. Name 2. How long and WHY I have been involved with suicide prevention 3. Why I came to this workshop/training 4. How I expect this training will support shared mission to prevent youth suicides
Survivor Story/Self-Disclosure Many trainings include a survivor story or self-disclosure. This is a powerful tool in helping your audience bring a face/experience to the topic of suicide prevention. It helps us see that depression and suicide can affect anyone at any point in their life. It is vital that the speaker be prepared to safely and effectively get the messaging across. They should: • Be in a safe place in their recovery • Define key messages • Practice • Present the narrative • Know their audience • Be honest and comprehensive • Provide mental health resources
Future SOS Trainer Take Home Note: Survivors Allowing participants to hear directly from family members impacted by suicide enforces our shared goal to encourage suicide prevention programming. When planning your trainings be sure to connect with your local suicide prevention coalitions, nonprofit agencies, hospitals, churches, and schools to seek support from suicide loss survivors. When inviting survivors to speak, clarify the goal of the speaking request: to encourage audience members to become engaged in suicide prevention by providing personal context. Please use the handout “Speaking about Suicide” in the trainer’s online portal to help your speaker prepare.
94 Page
Notes: __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________
95 Page
Section 13: Special Populations Objectives: • Understand the specific risk and protective factors for a diverse youth population • Prepare to present a culturally competent training that represents the youth in your community
Cultural Competence Cultural competence refers to the ability to interact effectively with people of different cultures and socio-economic backgrounds, particularly in the context of the helping professions (teaching, social work, medicine, etc.). Cultural competence comprises four components: (a) Awareness of one’s own cultural worldview, (b) Attitude towards differences, (c) Knowledge of different practices and worldviews, and (d) Cross-cultural skills. Developing cultural competence results in an ability to understand, communicate with, and effectively interact with people across cultures. Cultural competence is critical to reducing mental health disparities and improving access to high-quality mental health care, and services that are respectful of and responsive to the needs of diverse individuals.
Suicide Prevention with Special Populations Differences in cultural background can affect how people respond to problems, the way they talk about death and dying, their attitudes toward suicide, as well as how they feel about sharing personal information and seeking help. It is important to be aware of these possible differences and tailor your responses accordingly. For example, individuals from some cultures may not be open to seeing a mental health provider, but they may be willing to talk with a faith community leader. Risk and protective factors from research on specific populations may be helpful background information, however participants should be cautious about applying population-wide information to individual young people. Because the majority of the U.S. population is White (77.4%), most research on risk and protective factors for suicide has been done with samples comprised mainly of Whites. So, the risk and protective factors that have been identified as most important across all U.S. populations are especially relevant for Whites. The following section includes prevalence, risk factors and strengths/protective factors for populations that fall outside of the majority including: • American Indian and Alaska Natives • Asians, Pacific, Islanders and Native Hawaiians • Blacks/African Americans • Hispanics • Arab Americans • Youth Living In Poverty • Youth Experiencing Homelessness or Living in Out-of-Home • Recent Immigrants • Youth Facing Academic Pressure • Youth Living with Medical Conditions and Disabilities • LGBTQ Youth • Bullies, Bullied Youth, and Bully-Victims
96 Page
Other demographic/cultural/historical factors should be considered when preparing a training for a specific region or community: • What are the socio-economic conditions in the community? • Are many young people recent immigrants or first generation Americans? • What language barriers might exist? • What religions are common in the community? • Is there a history of discrimination for particular groups specific to this community? • Do community members have access to mental health care?
Future SOS Trainer Take Home Note: Having Difficult Conversations Sometimes dividing populations by ethnicity, gender, or socioeconomic background could feel divisive rather than empowering. Be careful not to reinforce negative stereotypes, myths, or stigma related to mental health and certain groups of people. Remember, the goal of pointing out variations in risks and strengths or statistics regarding certain populations is to encourage culturally competent interventions for all students.
American Indian and Alaska Natives Prevalence American Indian/Alaska Native (AI/AN) high school students report higher rates of suicidal behaviors than the general population of U.S. high school students. Lifetime rates of suicidal ideation were significantly higher among youth raised on reservations (32.6%) compared to youth raised in urban areas (21%).
Strengths and Protective Factors Two studies found that for AI/AN youth, strengthening protective factors may be more important than reducing risk factors in addressing suicide risk. In addition to the common protective factors across populations, research has shown the following to be among the most significant protective factors in AI/AN populations: Cultural identification: Two studies of Native American youth in the Midwest found that those who had a stronger ethnic/cultural identity were better able to cope with acculturative stress and less likely to have suicidal thoughts. Spirituality: Commitment to tribal cultural spirituality (forms of spirituality deriving from traditions that predate European contact) is significantly associated with a reduction in suicide attempts. People with a high level of cultural spiritual orientation have a reduced prevalence of suicide compared with those with low levels of cultural spiritual orientation.
97 Page
Family connectedness: Connectedness to family and discussing problems with family and friends are protective against suicide attempts among AI/AN youth.
Risk Factors In addition to the common risk factors across populations, research has shown the following to be among the most significant risk factors in AI/AN populations: Alcohol and drug use: In a small 2007–2010 study of White Mountain Apache youth ages 15-24, 64% were “drunk or high” when they died by suicide, 75.7% were “drunk or high” during a suicide attempt, and 49.4% during suicidal ideation. Alienation: In an analysis of suicide notes to determine motivation, alienation among Native Americans was double that of Whites. Alienation causes a loss of well-being when the individual feels emotionally disconnected from his or her family of origin or culture. Acculturation: Alaska Native tribal members with greater adaptation to the mainstream culture reported increased psychosocial stress, less happiness, and greater use of drugs or alcohol to cope with the stress of navigating the differences between two cultures. In less traditional American Indian tribes, there is more pressure to acculturate, greater conflict regarding traditional cultural practices, and a high suicide rate among adolescents and young adults. Discrimination: Studies of American Indian youth found that discrimination was as important a predictor of suicidal ideation as poor self-esteem and depression. This association may be more common among reservation youth than their urban counterparts. Community violence: AI/AN youth are 2.5 times more likely to experience trauma than non-AI/AN youth. Much of this trauma involves victimization from non-AI/AN perpetrators or from family violence and abuse. Mental health services access and use: Only 10% to 35% of American Indian adolescents and young adults use professional health services during a suicidal episode. There are many reasons for not seeking help. In one study, youth reported that internal factors, such as embarrassment, not realizing they had a problem, a belief that nobody could help, and self-reliance, affected their decisions not to seek help. There is also a lack of American Indian mental health professionals. In addition, significant numbers of AI/AN live in rural, isolated areas where it is difficult to get to the few mental health professionals of any racial/ethnic background that are located within a reasonable distance. Many AI/AN people do not trust mental health professionals because they see mental health services as part of White culture and not sensitive to their culture. The underlying assumptions driving psychological intervention can neglect the social, societal, and historical issues that many AI/AN people associate with suicide. Contagion: Many suicide deaths occur on reservations where AI/AN youth have considerable exposure to suicide. Suicide contagion has been observed among both AI/AN adults and youth, and there is evidence that youth may be at particular risk.
Section adapted from: Suicide Prevention Resource Center. (2013). Suicide among racial/ethnic populations in the U.S.: American Indians/Alaska Natives. Waltham, MA: Education Development Center, Inc.
98 Page
Asians, Pacific Islanders and Native Hawaiians Prevalence Asian, Native Hawaiian and other Pacific Islander high school students report higher rates of suicidal behaviors than the general population of U.S. high school students. In a national population-based study, about 62% of Asians who attempted suicide reported that their first suicide attempt occurred when they were under 18 years of age. In a survey of students attending high schools in Hawaii, Native Hawaiians had a significantly higher lifetime prevalence rate for suicide attempt (12.9%) than non-native Hawaiian students (9.6%). Another survey of Hawaiian high school students found that Native Hawaiians (11.5%) and Filipinos (13.6%) had more than twice the rate of suicide attempts in the past 12 months than Whites (5.6%).
Strengths and Protective Factors In addition to the common protective factors across populations, research has shown the following to be among the most significant protective factors in Asian, Native Hawaiian and other Pacific Islander populations: Cultural identification: Among Asians, higher levels of identification with Asian culture, such as a sense of belonging and affiliation with spiritual, material, intellectual, and emotional features of Asian culture, have been associated with a 69% reduction in the risk of suicide attempt. Family relationship: Among Native Hawaiian and other Pacific Islander youth, strong and supportive family relationships and higher levels of family cohesion, family organization, and parental bonding have been related to lower risk of lifetime suicide attempt. Among Asians, family cohesion and parental support were associated with lower levels of suicidal ideation. Help seeking with native healers: Although Native Hawaiian youth do not seek help for their mental health problems from physicians as often as other groups, they do seek help from traditional Native Hawaiian healers more often than other groups.
Risk Factors In addition to the common risk factors across populations, research has shown the following to be among the most significant risk factors in Asian, Native Hawaiian, and Other Pacific Islander populations: Family conflict: High levels of family conflict, such as witnessing family violence or experiencing low levels of family support, have been associated with suicide risk in Asian and Native Hawaiian populations. Among Asian youth and college students, family problems and conflict, especially parent-child conflict, play a very significant role in increasing risk for suicidal ideation. Family conflict created greater risk for suicidal behavior among less acculturated Asian adolescents compared to those who were highly acculturated. Acculturation: A study of Native Hawaiian youth found a small but statistically significant risk for attempting suicide in adolescents who had greater affiliation with Hawaiian culture. This may be due to increased cultural conflict and stress of being culturally Hawaiian in a Western environment.
99 Page
One longitudinal study of high school youth found that the high rate of suicidal behavior among Pacific Islanders, including Native Hawaiians may be related to cultural conflict and stress in acculturating. Non-Hawaiian Pacific Islanders living in the United States have had to deal with cultural barriers that cause loss of ethnic identity. Native Hawaiians have had to deal with colonialism similar to other native peoples, which has led to a significant change in values and a negative effect on family structure, health, and wellbeing. Discrimination: Asians reporting that they are racially discriminated against have been found to be more likely to have a psychiatric disorder. Asian college students who perceive discrimination report higher rates of suicidal ideation and suicide attempts. Mental health services access and use: Due in large part to their cultural beliefs and values, Asians are less likely to seek professional help for psychological distress, and they are less likely to disclose suicidal thoughts. Two studies found that Asian adults and college students were less likely than other racial groups to seek professional psychological help for suicidal ideation. In a national survey, Asians/Pacific Islanders who reported suicidal thoughts or attempts were less likely than Hispanics, Blacks, or Whites to seek or receive psychiatric services. Asians are more likely to use informal support systems than formal services for help with mental health problems. When they do obtain professional help Asians generally drop out of treatment sooner than whites. Lack of access to treatment that is sensitive to their culture is also a barrier. Immigrant Asian populations may be hampered in the U.S. mental health system by discriminatory attitudes and language proficiency issues. Poor academic achievement: Two studies of Asian college students in the U.S. found that poor academic performance and anxiety about performing well enough was a major risk factor for suicidal ideation.
Section adapted from: Suicide Prevention Resource Center. (2013). Suicide among racial/ethnic populations in the U.S.: Asians, Pacific Islanders, and Native Hawaiians. Waltham, MA: Education Development Center, Inc.
100 Page
Blacks and African Americans Prevalence Black high school students report slightly lower rates of certain suicidal behaviors, except for attempts, than the general population of U.S. high school students. Although Black suicide rates are lower than the overall U.S. rates, suicide affects Black youth at a much higher rate than Black adults. Suicide is the third leading cause of death among Blacks ages 15-24. Since the Black community in the United States is disproportionately young, the number of deaths among youth may have a particularly strong impact on the Black community.
Strengths and Protective Factors In addition to the common risk factors across populations, research has shown the following to be among the most significant risk factors in Black and African American populations: Religion: Orthodox religious beliefs and personal devotion have been identified as protective against suicide among Blacks. Participation in organized religious practices, such as church attendance, is linked to lower suicide risk in African Americans. Among Blacks with psychiatric disorders, religiosity has been found to delay age of onset of ideation as well as decrease the number of psychiatric disorders. Social and emotional support: Family support, peer support, and community connectedness have been shown to help protect Black adolescents from suicidal behavior. Although emotional support from family decreased the risk of suicide attempts for both Caribbean Blacks and African Americans, the impact was stronger for Caribbean Blacks than for African Americans.
Risk Factors In addition to the common risk factors across populations, research has shown the following to be among the most significant risk factors in Black and African American populations: Family Conflict: One study noted that Black adolescents reporting parental conflict were 6.4 times more likely to attempt suicide than Black adolescents who did not report parental conflict. Hopelessness, racism, and discrimination: Among Black youth, perceived racism and discrimination along with social and economic disadvantage may lead to having no hope for the future, which is a risk factor for suicide. Mental health services access and use: In a study using a nationally representative sample, Black youth were substantially less likely than White youth to have used a mental health service in the year during which they seriously thought about or attempted suicide.
Section adapted from: Suicide Prevention Resource Center. (2013). Suicide among racial/ethnic populations in the U.S.: Blacks. Waltham, MA: Education Development Center, Inc.
101 Page
Hispanics/ Latinos Prevalence Hispanic high school students report higher rates of suicidal behaviors than the general population of U.S. high school students. Studies have consistently shown that since 1995 Hispanic adolescent females have higher rates of suicidal thoughts and behavior (but not deaths) than Black or White females.
Strengths and Protective Factors In addition to the common protective factors across populations, research has shown the following to be among the most significant protective factors in Hispanic populations: Familism: Hispanics have scored high on measures of familism, which has been described as the strong feelings of commitment, loyalty, and obligation to family members that extends beyond the nuclear family. The interdependent nature of family includes making family needs a priority over individual needs and being able to turn to family for support. Youth reporting strong, supportive relationships with their parents are less likely to attempt suicide. Ethnic affiliation: Latina adolescents with greater involvement in Hispanic culture have more positive relationships with their mothers and fewer withdrawn-depressive behaviors and suicide attempts. In addition, ethnic identity is positively associated with self-esteem among Latino/Latina adolescents, and has been shown to moderate the relationship between perceived discrimination and depression. Religiosity and moral objections to suicide: Individuals identifying themselves as Hispanic report higher scores on measures of moral objections to suicide and on measures of religiosity compared to people who are not Hispanic. They are also more likely than other racial/ethnic groups to belong to religious denominations that have strong beliefs prohibiting suicidal thoughts and behaviors. Caring from teachers: One recent national study found that perceived caring from teachers was associated with a decreased risk of suicide attempts by Latina adolescents.
Risk Factors In addition to the common risk factors across populations, research has shown the following to be among the most significant risk factors in Hispanic populations: Alcohol: According to the National Violent Death Reporting System 2003–2009, of the Hispanic suicide decedents tested for alcohol, about 28% were legally intoxicated at the time of death. Of the four racial/ethnic minority groups studied, Hispanics had the second highest rate of alcohol use during an attempt. Mental health services access and use: Compared to non-Hispanic Whites, Hispanics underutilize mental health services, are less likely to receive care that follows recommended guidelines, and are more likely to rely on informal supports (e.g., family) and primary care providers than on mental health specialists for mental health services. In a national survey, Hispanic adults who reported suicidal thoughts or attempts were less likely than non-Hispanic White adults to seek or receive psychiatric services. In a recent survey, Hispanics were less likely than other racial/ethnic groups to call a suicide crisis line during a suicidal crisis.
102 Page
Alienation: In an analysis of suicide notes to determine motivation, reported alienation among Hispanics was double that of non-Hispanic Whites. Alienation causes a loss of well-being when the individual feels emotionally disconnected from his or her family of origin or society. Acculturative stress and family conflict: Differences between the level of acculturation in parents and their children can create conflict and stress in the relationship, especially with Hispanic adolescent girls, given the high value placed on the family. This conflict and stress appears to play a pivotal role in Hispanic girls’ suicide attempts. Hopelessness and fatalism: In a four-year analysis of a nationally representative sample, Hispanic adolescents and young adults had the highest rates of hopelessness and fatalism among all racial/ethnic groups. Discrimination: Perceived racial discrimination is associated with suicide attempts among Hispanic college students.
Future SOS Trainer Take Home Note: Enhancing Your Knowledge There are many great resources for Certified Trainers to read and distribute. Throughout your training, alert participants to literature that supports their efforts. One great resource is included specifically for this section. Until 2012, the protective role of teacher support had not previously been emphasized in the literature. Strengthening connections to teachers and other adults may reduce suicidal behavior in adolescent Latinas. De Luca, S. M., Wyman, P., & Warren, K. (2012). Latina adolescent suicide ideations and attempts: Associations with connectedness to parents, peers, and teachers. Suicide and Life-Threatening Behavior, 42(6), 672–683.
Section adapted from: Suicide Prevention Resource Center. (2013). Suicide among racial/ethnic populations in the U.S.: Hispanics. Waltham, MA: Education Development Center, Inc.
103 Page
Other Special Populations to Consider Recent Immigrants Despite limited research on the topic of suicide risk for recent immigrants, some studies have shown adolescent immigrants are at an elevated risk for suicide compared to adult immigrants (Ratkowski & De Lio 2013). Identified risk factors include acculturation (similar to specific ethnic groups outlined above), family conflict, low socio-economic status, and substance use. Protective factors that have been identified for recent immigrants include integration into the community and strength of family bonds. Family bonds play a key role in risk for suicide in immigrants. One study found that adolescents living with both parents was a strong protective factor and immigrants with divorced parents were two times more likely than non-immigrants to take their life (Ratkowski & De Lio, 2013)
Future SOS Trainer Take Home Note: Barriers for Recent Immigrants As a trainer, you’ll want to talk about some of the biggest challenges faced by youth and families that are recent immigrants. Language barriers and a lack of culturally competent clinicians can limit access to mental health services. Encourage your audience to dispel misconceptions and discuss solutions to common barriers. As a trainer, you may feel discouraged by the fact that controlling for depression and substance use does not decrease risk. When presenting this information to schools it is important to focus on the ways we can make an impact in these kids’ lives by building protective factors, creating a stable and supportive environment within school, and working to improve access to mental health services.
Youth Living in Poverty Youth living in low-income neighborhoods are at a significantly higher risk for suicide and are twice as likely to think seriously about suicide and four times more likely to attempt suicide. Unfortunately, when we control for known risk factors, such as depression and substance use, the risk does not decrease. It is hypothesized that this is due to magnification of individual risk factors in low-income neighborhoods. These neighborhoods more commonly have elevated violence, higher rates of suicide (due to exposure to both violence and suicide), and schools in these neighborhoods are less likely to have adequate mental health services within or outside of schools. (Dupere et.al 2009)
104 Page
Youth Experiencing Homelessness or Living in Out-of-Home Settings Homeless young people have higher rates of mood disorders, conduct disorders, post-traumatic stress disorder, and suicide attempts. One study found that more than half of runaway and homeless youth have had some thoughts of suicide. Youth involved in the juvenile justice or child welfare systems often have many risk factors for suicide. Young people involved in the juvenile justice system die by suicide at a rate about four times greater than the rate among youth in the general population. Though comprehensive suicide data on youth in foster care does not exist, one researcher found that youth in foster care were more than twice as likely to have considered suicide and almost four times more likely to have attempted suicide than their peers not in foster care. Academic Pressure The media often portrays high achieving youth in competitive schools as at increased risk for suicide. Although research does not support a link between academic pressure and suicide, we know that life stressors can contribute to suicide risk for people who are struggling with other risk factors. It is important to teach students what to do if academic pressure (or any life stressor) seems to be causing concern beyond normal stress. Screening for depression is critical in helping to identify students who may be more impacted by life stressors. Youth Living with Medical Conditions and Disabilities A number of physical conditions are associated with an elevated risk for suicidal behavior. Some of these conditions include chronic pain, loss of mobility, disfigurement, cognitive styles that make problem-solving a challenge, and other chronic limitations. Adolescents with asthma are more likely to report suicidal thoughts and behavior than those without asthma. Additionally, studies show that suicide rates are significantly higher among people with certain types of disabilities, such as those with multiple sclerosis or spinal cord injuries.
LGBTQ (Lesbian, Gay, Bisexual, Transgender, and Questioning) Youth Prevalence Studies that compare the rate of suicide attempts and ideation among LGB youth with those among heterosexual youth show significantly higher rates for LGB youth. Furthermore, most suicide attempts among LGB people occur during adolescence and young adulthood (SPRC 2008). Suicide attempts by LGB youth may be more serious, with one study finding that 58% of LGB people who attempted suicide reported they really hoped to die compared to 33% of heterosexual people (SPRC 2008). Suicide attempts by LGB youth may be more lethal, with one-fifth of LGB youth who attempted suicide needed hospitalization (SPRC 2008).
105 Page
National Youth Risk Behavior Survey Results (2015) Reported Behaviors
LGB Students
Heterosexual Students
Increased Risk for LGB Students
Felt sad or hopeless almost every day for 2+ weeks they stopped doing usual activities Bullied on school property in the past 12 months
60.4%
26.4%
>2 times
34.2%
18.4%
~2 times
Used heroin one or more times during their life
6%
1.3%
>4 times
Seriously considered attempting suicide during the past 12 months Attempted suicide one or more times in the past 12 months
42.8%
14.8%
~3 times
29.4%
6.4%
>4 times
Risk Factors Psychosocial Stressors: The risk factors that apply to youth overall also apply to LGB youth. One study suggests that the elevated risk of suicide attempts among LGB adolescents is a consequence of the psychosocial stressors associated with being lesbian, gay, or bisexual, including gender nonconformity, victimization, lack of support, dropping out of school, family problems, and suicide attempts by acquaintances and homelessness. While heterosexual adolescents also experience these stressors, they are more prevalent among LGB adolescents. LGB young people also have an elevated risk for both depression and substance use. Victimization and Violence: According to the 2009 Gay, Lesbian & Straight Education Network National School Climate Survey, 86% of LGBTQ youth surveyed experienced harassment at school, 60% felt unsafe at school because of their sexual orientation, and about one-third of LGBTQ youth skipped a day of school in the past month because they felt unsafe. Most LGBTQ youth are the victims of physical or verbal assault. Family Problems: Lack of family support and connectedness, conflict, and rejection play an important role in suicide risk for LGB youth. Abuse within the family (whether psychological, verbal, physical, or sexual) elevates the risk of suicidal behavior by LGB young people. Homelessness: Family conflict is also a contributing factor to high rates of homelessness of LGBT youth. Life on the street represents risks for all homeless youth. Homeless and runaway youth have elevated rates of mental illness, violence, sexual exploitation, and substance use. They also have a high rate of suicide attempts: one study found that 76% of homeless youth reported attempting suicide at least once, and 86% of that group reported more than one attempt. Disclosure: Stress related to the awareness, discovery, and disclosure of being gay (i.e. “coming out”) are unique risk factors for LGB youth. LGB youth experience a rise in suicide attempts and ideation around the time of disclosure or “coming out.” More than one-third of LGBTQ youth will lose friends through coming out. LGB youth who had disclosed their sexual orientation to their families were more than four times as likely to have attempted suicide as LGB youth who had not disclosed.
106 Page
Strengths and Protective Factors The majority of research related to protective factors for LGBTQ youth focuses on a lack of risk factors. Interventions can be designed to reduce risk factors and to build protective factors that are valuable for all youth. Family support: Research findings generally agree that family and parental support are important protective factors against LGB youth suicide. LGB youth with strong family connectedness are half as likely to experience suicidal ideation as those with low family connectedness. Improving the ability of parents to support adolescents grappling with issues of sexual identity may be critical in protecting these young people. Support from other adults and school safety are characteristics that are amenable to change, and would be appropriate targets for interventions aimed at protecting young people from suicidality. Lower levels of these protective factors in LGB youth account for much of the increased risk of suicidal ideation and attempts. Encouraging non-parental influential adults to connect with LGBTQ adolescents and creating safe school environments for LGBTQ youth may be crucial elements in suicide prevention. Transgender Youth While little research exists on transgender people and suicidal behavior, it is reasonable to hypothesize that transgender youth—in common with LGB youth—have elevated risk and lower protective factors for suicidal behavior. Transgender youth often exhibit gender nonconformity and are presumed by others to be LGB even if they do not identify as such. Transgender youth also experience high rates of rejection and physical and verbal abuse at the hands of their parents. Transgender youth commonly experience higher rates of victimization by their peers, negative parental reactions, substance use, and family violence—similar to those of their LGB counterparts, who have higher rates of suicidal behavior.
107 Page
Suggested Reading and Resources for Educators, Students, & Parents The Trevor Project: A nonprofit organization providing suicide prevention, education, and crisis response services to LGBTQ youth. http://www.thetrevorproject.org/ http://www.thetrevorproject.org/educatorslocalresources Family Acceptance Project: A community research, intervention, education, and policy initiative aimed at decreasing health and other related risks for LGBTQ youth in the context of their families. http://familyproject.sfsu.edu/ It Gets Better Project: Support site for LGBTQ youth, documenting that despite the challenges of youth, life for LGBTQ individuals does, in fact, get better. http://www.itgetsbetter.org/ Suicide Prevention Resource Center (SPRC): Provides prevention resources, support, and training to individuals and organizations dedicated to suicide prevention. http://www.sprc.org/library/SPRC_LGBT_Youth.pdf Gay, Lesbian and Straight Education Network (GLSEN): A leading educational organization that strives to create a safe school environment for all students by emphasizing acceptance, individual contributions, and student diversity. http://www.glsen.org/ Gay-Straight Alliance Network: Youth leadership organization empowering youth activists to fight homophobia by connecting school-based Gay-Straight alliances to each other and community resources. www.gsanetwork.org/ Parents, Families, and Friends of Lesbians and Gays (PFLAG): A national organization that celebrates diversity and embraces all individuals, regardless of sexual orientation and gender identity. www.pflag.org Gay & Lesbian Alliance Against Defamation (GLAAD): A media monitoring organization that promotes understanding, acceptance, and equality by holding the media accountable for their words and images while also encouraging the LGBT voice in the community. http://www.glaad.org/ Center for Disease Control: Providing articles, resources, and support for related to LGBT health. http://www.cdc.gov/lgbthealth/ American Psychological Association: Lesbian, Gay, Bisexual, and Transgender Office of Concerns dedicated to improving the health and well-being of LGBT people by increasing understanding and tolerance of gender identity and sexual orientation. http://www.apa.org/pi/lgbt/ National Gay and Lesbian Task Force: National organization dedicated to securing equality for LGBTQ individuals by encouraging activism and campaigning for advancement of pro-LGBTQ legislation. http://www.thetaskforce.org/issues/youth Advocates for Youth: Nonprofit organization whose mission of rights, respect, and responsibility helps young people make informed and responsible decisions about their sexual and reproductive health. www.advocatesforyouth.org Trans Alliance Society: British Columbian nonprofit organization dedicated to supporting transgender education, outreach, and advocacy. http://www.transalliancesociety.org/
108 Page
Bullying and Suicide Risk What we know about bullying • Youth with disabilities, learning differences, sexual/gender identity differences, or cultural differences are often vulnerable to being bullied. • Involvement in bullying in any way –as a bully, bully-victim, or as a witness – has serious long lasting negative consequences for youth. • Youth who report witnessing a bully incident have greater feelings of helplessness and less sense of connectedness to school than youth who did not report witnessing a bullying incident. What we know about suicide • Youth who feel connected to their school are less likely to engage in suicide-related behaviors. • Suicide-related behavior is complicated and rarely the result of a single source of trauma or stress. • The vast majority of those who die by suicide suffered from a mental illness. What we know about bullying AND suicide • Most youth who experience a bullying incident do NOT become suicidal. • Youth who are able to cope with problems in healthy ways and solve problems peacefully are less likely to engage in suicide and bullying related behaviors. • Youth who report frequently bullying others are at high, long-term risk for suicide-related behavior. • Youth who report both being bullied and bullying others (sometimes referred to as bully-victims) have the highest rates of negative mental health outcomes, including depression, anxiety, and thinking about suicide. • Youth who report being frequently bullied by others are at increased risk of suicide-related behaviors, and negative physical and mental health outcomes. Adapted from the CDC report The Relationship Between Bullying and Suicide: What we know and what it means for schools. For more information: https://www.cdc.gov/violenceprevention/pdf/bullying-suicide-translation-final-a.pdf
Future SOS Trainer Take Home Note: Building School Connectedness Building school connectedness is a great protective factor for students and combats issues of bullying and suicidal related behaviors in youth. Although it is a nice complement to universal suicide prevention programming, bullying prevention cannot be the sole source of our prevention efforts.
109 Page
Notes: __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ _________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________
110 Page
Section 14: Self-Injury Prevention & Programming Thank you to our partners, experts in the field of non-suicidal self-injury, Barry Walsh from the Bridge of Central Massachusetts and Janis Whitlock from Cornell University for their contribution to Section 14 of this handbook.
Objectives: • Learn current research, myths and facts, vocabulary and best practices when providing self-injury prevention programming • Prepare to implement the SOS Signs of Self-Injury Program and train others in program implementation • Prepare to deliver SOS Self Injury Training for parents and faculty and staff for self-injury prevention
Myths & Facts Myth: Self-injury, such as wrist-cutting, should be considered a suicide attempt. Fact: Self-injury is generally not about suicide. 98.2% of youth who die by suicide use a method other than cutting (Walsh, 2014). Methods of self-harm that should be considered suicidal are use of gun, hanging, overdose, ingestion of poison such as carbon monoxide, and jumping from a height. Myth: Self-injury is unexplainable. Fact: Many studies have found explanations for self-injury. These reasons include: • To reduce emotional distress such as anxiety, sadness, anger, or shame • To “feel” something after bouts of emotional numbness known as dissociation • To communicate distress to others and to change their behavior Myth: Individuals who self-injure are separate and distinct from suicidal people. Fact: Self-injurious behavior is distinct from suicidal behavior but the two behaviors can and do occur in the same individual. Recent research has shown that persistent self-injury is a strong predictor for suicide attempts (but not death by suicide). Myth: Self-injury is mostly about attention-seeking or manipulating others. Fact: “Attention-seeking” or “manipulation” is not an adequate explanation for self-injury. There are far more effective ways to gain attention than to physically hurt one’s body. Use of language such as “manipulative” or attention-seeking” usually suggests caregiver frustration with the self-injuring person. Myth: Self-injury is mostly a problem in females. Fact: Various studies show rates of self-injury in school populations to be almost equal in across the sexes: 60-65% female; 35-40% male. Myth: Most individuals who self-injure have been sexually abused. Fact: Studies of clinical samples have shown larger percentages of self-injuring individuals with histories of sexual abuse. This does not appear to be true in selective community samples of middle school, high school, and university students. Myth: Self-injury is just a fad. Ignore it and kids will grow out of it. Fact: Self-injury should not be minimized or referred to as “a fad.” Self-injury involves real tissue damage and potential scarring. Self-injury is indicative of serious distress that requires assessment and treatment by a professional. There is no evidence that most people who self-injure spontaneously “grow out of the behavior.”
111 Page
Myth: Most who self-injure are mentally ill and probably won’t get better. Fact: Self-injury is now occurring in highly accomplished, high functioning individuals who are doing well in school/work and have stable relationships. Self-injury should not be equated with mental illness. The behavior is treatable and the prognosis for a full recovery is very good – regardless of pre-existing mental illness. Myth: Professional tattoos and piercings are the same as self-injury. Fact: Body modification obtained from professionals (i.e., tattoos and piercings) is generally considered separate and distinct from self-injury. Body modification is a deliberate, planned, and public act lacking aspects of emotion regulation. Self-injury tends to be a more private behavior that at its core is about regulating painful emotions. However, people who inflict their own tattoos or piercings may be employing such behavior as a form of self-injury. Myth: Self-injury is not a problem in my school. Fact: Based on considerable research, self-injury is occurring at high rates in many middle and high schools throughout the United States. Rates of 10 to 20% in school settings have been commonly reported. The large majority of middle and high schools in the United States report some type of self-injury, especially self-cutting.
Defining Self-Injury Self-injury is when people intentionally hurt their bodies, generally without suicidal intent, in order to reduce psychological distress (Walsh, 2014). Data from the 2013 Massachusetts Youth Risk Behavior Survey indicates that 14% of high school students and 14% of middle school students self-injured during the previous year. Recent Rresearch showed 7.3% of American adolescents self-injuring over a 12-month period (Taliaferro et al., 2012) and an 18% lifetime prevalence of self-injury for adolescents internationally (Muehlenkamp et al., 2012). While middle school students are known to engage in self-injury, the average age of onset is around 15 (Whitlock & Selekman, 2014). While individuals with major psychiatric diagnoses continue to have high rates of self-injury, a new generation of selfinjuring individuals is emerging from the general population. The core problem for these individuals appears to be a combination of intense stress, inadequate coping skills, and an influential peer group endorsing self-injury. The most common examples of self-injury are cutting (e.g., wrist, arm, and legs), hitting, burning, scratching, hair-pulling, and skin-picking. Individuals who self-injure do so in order to reduce intense emotional distress (i.e., anxiety, tension, panic, frustration, contempt, anger, sadness, depression, or shame) and often rely on it as a preferred way of managing and reducing emotional pain. Often, they have started self-injuring as early as age 11 and many hurt themselves hundreds of times over multiple years. Self-injury is generally not about suicide - it is an emotion-regulation technique that has the major disadvantage of causing bodily harm (Walsh, 2014). The forms of self-injury recounted above (e.g. cutting, self-hitting, skin picking) have in common that they generally pose little risk to life. Suicide involves high lethality methods such as the use of a gun, ingesting pills, hanging, jumping, and ingesting poison. Suicide is about permanently ending misery; whereas self-injury is about temporarily reducing emotional distress. Self-injury is often referred to as NSSI (non-suicidal self-injury) in order to distinguish it from self-harm related to suicidal thoughts and behaviors. However, recent research has shown that self-injury, if it persists, is a strong predictor for suicide attempts (note: not death by suicide; Victor & Klonsky, 2014). These findings point to why it is important to intervene with self-injury early to prevent the emergence of subsequent suicidal behavior. One reason those who self-injure may become suicidal is when their self-injurious actions fail to provide their usual distress-reducing effect, they do not feel the same relief. The absence of relief may catapult them into a suicidal crisis. In such instances, youth may begin to feel hopeless, helpless, and then panicked when the pain seems inescapable. Another concern for youth who self-injure is that they may become more capable of damaging their body if they begin to have suicidal thoughts. Damaging one’s body is not easy for most people to do. If a young person who has been self-injuring without suicidal intent becomes suicidal, they may find it easier to carry out a suicidal act because they have already practiced crossing the boundary of hurting their body.
112 Page
Forms of self-injury include: Most common • Severely scratching or pinching skin with fingernails or other objects • Cutting wrists, arms, legs, torso or other areas of the body • Banging or punching objects to the point of bruising or bleeding • Punching or banging oneself to the point of bruising or bleeding • Biting to the point that bleeding occurs or marks remain on skin • Abrading the skin (burning with an object, such as with an eraser) Less common • Ripping or tearing skin • Pulling out hair, eyelashes, or eyebrows with the overt intention of hurting oneself • Intentionally preventing wounds from healing • Burning wrists, hands, arms, legs, torso or other areas of the body • Rubbing glass into skin or embedding sharp objects such as needles, pins, and staples into the skin (Whitlock et al., 2011) Other behaviors that might indicate self-injury in an individual include: • Spending time on websites, message boards, or chat rooms devoted to self-injury. Consuming books, movies, and other popular media focused on self-injury • Frequently exchanging texts devoted to self-injury topics • Exchanging photos of self-injury wounds • Talking about self-injurious behaviors in general or about self-injurious thoughts
Developing School Self-Injury Protocols Why support schools to develop a self-injury protocol? • Protocols guide responses to situations with which staff members may be unfamiliar, staff members may find uncomfortable, and/or staff members find difficult to manage. • Protocols provide a means of assuring that a school’s legal responsibilities and liabilities are addressed even in situations in which personnel may not have this as their primary concern. • Protocols encourage staff members to respond systematically to all situations of self-injury. It is essential to note that although a self-injury protocol may be similar to one used to manage suicide-related behavior, it is not the same. The two types of protocols may, however, share common elements and suicide-related protocols are often a good starting point for development of non-suicidal self-injury protocols. Functional school protocol for addressing self-injury incidents should include steps for the following processes: • Identifying self-injury. • Assessing self-injury. • Designating individuals to serve as the point person or people at the school for managing self-injury cases and next steps. • Determining under what circumstances parents should be contacted. • Manage active student self-injury (with self-injurious student, peers, parents, and external referrals). • Determining when and how to issue an outside referral.
113 Page
• Identifying external referral sources and contact information. • Educating staff and students about self-injury.
Future SOS Trainer Take Home Note: Developing a Self-Injury Protocol A template school self-injury protocol is located on the trainer portal. Please share it with schools as needed.
Utilizing and Encouraging the School Crisis Team Responsibility for developing a self-injury protocol most often resides with the school crisis team. If a school does not have a crisis team in place, the first step would be to assemble a team of diverse individuals (typically some combination of guidance counselors, nurses, school social workers, school psychologists, administrators and/or teachers) best positioned to address issues related to detecting and managing self-injurious students. It is also important to identify a point person from this team to serve as the main liaison between the student, his/her parents, and the school. Certified Trainers can provide training on general knowledge and advise on school policy and protocol however, Tthe crisis team should seek in-depth training from local self-injury or mental health experts. If this training is unavailable locally, the crisis team should can look to national organizations such as S.A.F.E. Alternatives (www.selfinjury. com), The Bridge (www. thebridgetraininginstitute.org), and the Cornell Research Program on Self-injury and Recovery (www.crpsib.com) for more information. The crisis team/point person (or both) is responsible for: • Responding to any disclosures of self-injury. • Serving as a resource for faculty/staff who may suspect a student is injuring but do not know for sure. • Making contact with the student and directing him or her to the nurse for an assessment and care of wounds. • Assuring that a self-injurious student is assessed for suicidality at the point of identification and later as indicated by symptom changes. • Acting as a liaison between the student, parents, affected faculty/staff and peers, and outside referral agents associated with the student as a result of the disclosure. • Establishing a productive and supportive relationship with the self-injurious student or finding someone else who can be in this role. In order for the crisis team or point person to operate effectively, it is important for faculty and staff to refer all suspected or confirmed self-injury cases directly to the crisis team or point person. All faculty and members of the school staff should be trained in the finalized self-injury protocol. The most important part of faculty/ staff training is learning how to identify signs and symptoms of self-injury. Staff must be able to recognize the full range of self-injury behaviors. It is also imperative that faculty/staff members are trained to recognize the difference between self-injury and suicidal behavior, and to be aware of the conditions under which self-injury requires immediate attention, such as severe wounds that need stitches or other medical care. Staff should be aware of the designated point person for managing self-injury on campus. Although the designated point person may well be the individual to first initiate conversation with the student, all staff should be trained to comfort- ably respond to students who discloses self-injury. Learning how to respond with what Dr. Barent Walsh calls “respectful
114 Page
curiosity” and how to keep the door open for conversation with a student who denies or shuts down conversation is an important skill for anyone who may be in contact with self-injurious students.
Future SOS Trainer Take Home Note: Helping to Craft School Protocol The SOS Signs of Self-injury Prevention Program supports a school’s efforts to train all faculty and staff in self-injury prevention and response. As a SOS Certified Trainer, consider how you can add value to a school’s self-injury prevention efforts by ensuring that there is an effective response protocol in place and that all faculty and school staff understand the protocol.
Responding to Self-Injury Contagion in Student Populations While self-injury is generally about emotion regulation, social contagion can also play a role. Some individuals self-injure in order to communicate with or influence others. Peer group influences can include: • Modeling (i.e., imitation of high-status peers) • Disinhibition (i.e., self-control of behavior is undermined by observing same behavior in others) • Competition (as to who is “best” at self-injuring) • The role of peer hierarchies (status related to degree of self-injury) • Desire for group cohesiveness (“blood brother/ sister” phenomenon) • Electronic media contagion influences: websites, chat rooms, message boards devoted to self-injury • Movies, music videos with self-injury (many have exceptionally triggering content) Strategies for Managing and Preventing Self-Injury Contagion Epidemics or contagion episodes of self-injury occur in schools when students who know each other self-injure within short periods of time. In such situations, students communicate frequently about, trigger, and sometimes encourage selfinjurious behavior in each other. The following four strategies can be helpful to curb contagion: 1. Identify the primary high-status peer models. Point persons may need to consult with teachers for this information. 2. Reduce communication about self-injury among members of the peer group. Point persons explain to students that by talking about self-injury with their peers they may be unintentionally hurting their friends. Self-injurers are encouraged to talk with the school point persons, family, and therapists, but are instructed not to talk with peers about self-injury as such talk is “triggering.” Eliciting the cooperation of high-status peer models can be helpful in this effort. 3. Reduce the public exhibition of scars or wounds in the school. Students should be asked to cover visible wounds, scars, or bandages in school as these visible reminders can also be very triggering. Point persons involve parents, when appropriate, to address the behaviors of peer communication or wound exhibition outside of school. Some students may need to have extra sets of clothing in school to cover wounds or scars. In rare cases, students may have to be dealt with disciplinarily, such as when one student provides a razor to another or actively encourages another to “try self-injury” or if students do not comply with expectations outlined above.
115 Page
4. Treat the behavior using individual counseling methods. Discussion of self-injury details in group therapy can trigger social contagion. Group methods can be used to teach skills, but discussion of the details of selfinjury should not be allowed in group settings.
Future SOS Trainer Take Home Note: Responding to Self-Injury A handout on responding to self-injury is located on the trainer portal. Please share it with schools as needed.
SOS Signs of Self-Injury Program Screening for Mental Health developed the Signs of Self-Injury Prevention Program in collaboration with national experts in the field of self-injury. Program Goals The overall goal of the Signs of Self-Injury Prevention Program is to reduce the incidence of self-injury in the adolescent population. In order to do so, the program has several intermediate goals and objectives for each of the three primary stakeholder groups comprising the school community (students, school staff, and parents) as well as the school community itself. Student Goals • Learn about the issue of self-injury including: signs and symptoms, appropriate peer responses, importance of adult intervention, and positive outcomes to seeking help. • Assess personal risk for adopting self-injurious behaviors. • Develop strategies designed to replace self-injurious thoughts and behaviors with more adaptive coping skills. • Practice help-seeking (ACT) for oneself, or on behalf of a friend, when facing self-injury. • Adopt responsible and health conscious attitudes towards self-injury and mental health.
116 Page
School Staff Goals • Learn about the issue of self-injury including: signs and symptoms, important risk factors associated with self-injury, appropriate responses, and treatment options. • Learn the key distinction between self-injury and suicide. • Engage parents as partners in prevention by educating them about self-injury, including: signs of self-injury in youth, effective responses to self-injury, and awareness of community resources. • Adopt responsible and health conscious attitudes towards self-injury and mental health. Parent Goals • Learn about the issue of self-injury including: signs and symptoms, appropriate responses, and treatment options. • Adopt responsible attitudes towards self-injury and mental health. School Community Goals • Develop community-based partnerships with stakeholders sharing the mission of ensuring the safety, well-being, and good mental health of youth. • Foster positive attitudes towards mental illness prevention and treatment within the school community. • Develop a school protocol for responding to self-injury that is strategic, compassionate, and effective.
Theoretical Underpinnings of the Program Developmental Appropriateness - The Role Peers Play in Teaching Youth to ACT Research indicates that youth in crisis are more likely to turn to their peers, rather than adults, for help (Gould et al., 2002). By training students to recognize the signs of self-injury, and by educating them to appropriately respond to a friend who self-injures, the Signs of Self-Injury Prevention Program capitalizes on an important social/emotional aspect of an adolescent’s development. The program strives to: 1. Educate youth that self-injury is not a healthy response to stress but one that involves bodily harm, potential scarring, and stigma. 2. Help youth understand that self-injury is a problem that is responsive to treatment. 3. Teach youth about signs/definition of self-injury. 4. Provide youth with specific action steps for help-seeking, either for themselves or others. 5. Help youth identify clinical resources available to them in their school and community. 6. Encourage students to discuss issues of self-injury and the ACT help-seeking message with their peers, their parents, and trusted adults Supportive Environment – The Role Adults Play in Teaching Youth to ACT People often know how to behave in the most healthiest and safest manner but are unable to act on these behaviors if not appropriately supported by their environment. Ensuring a successful prevention program in a school environment requires support from the groups operating within that environment: administrators, counselors, teachers, and peers. It also helps to have support from people who can impact the school environment, such as family and community members. Persons who are informed about self-injury are more apt to have a positive impact on at-risk students than those who are not. The response to self-injury should be compassionate, not judgmental or over-reactive. The ability to recognize and interpret warning signs as indicators that an adolescent may need help, can reduce the risk that parents, educators, and community members will misinterpret student behavior or react inappropriately.
117 Page
Modeling Appropriate Behavior - The Role Video Plays in Teaching Youth to ACT By educating peers and adults about self-injury, the program is intervening at an interpersonal behavioral health level. The program also intervenes at the individual level through the use of its main teaching tool, the Signs of Self-Injury DVD. The DVD uses modeling, in the form of acted scenarios and personal testimony, to show students appropriate coping skills/behavioral responses to use when confronted with real-life situations of self-injury. The DVD also reinforces healthier attitudes towards self-injury by depicting positive outcomes resulting from help-seeking and treatment. Personal Risk Appraisal – The Role Self-Assessment Plays in Teaching Youth to ACT Another individually-focused intervention strategy used by the program is that of risk perception. In order for people to want to change health behaviors they must be abvle to appropriately assess their own risk of engaging in those behaviors. The Signs of Self-Injury Prevention Program includes a short questionnaire for students assessing whether they have considered or engaged in self-injury and whether they utilize alternate coping mechanisms to deal with emotional distress. Students are also reminded about the distinction between non-suicidal self-injury and self-harm with suicidal intent. Students who answer “yes” to questions about suicidal intent or bhehavior are advised to seek help immediately.
Program Implementation The program includes a video and accompanying discussion guide and implementation guide, brief self-assessment tool and student response cards. The discussion guide includes questions to help facilitate a conversation with students about self-injury after watching the student portion of the video. The implementation guide includes chapters on program implementation for students, as well as how to educate parents and staff about self-injury. The brief self-assessment tool and student response cards are used to help identify students who need follow-up and referral to a mental health professional. The Signs of Self-Injury video is the main teaching tool of the program. It uses the help-seeking message used in the SOS Programs, ACT: Acknowledge, Care, and Tell. Program implementation should take approximately 50-60 min. The steps include: • Introduction (5 minutes) • Video (18 minutes) • Discussion (15 minutes) • Self-assessment (5 minutes) • Help-seeking (5 minutes) Chapter 1 of DVD: for School Personnel and Faculty (11 minutes): This chapter serves as an introduction to the problem of self-injury. It is relevant for school staff, administrators, parents, psychologists, teachers, coaches, maintenance staff, and any other adult who comes in contact with students. The chapter includes: • Information about self-injury and treatment; differentiating between self-injury and suicide, the functions of self-injury, and guidelines for responding to self-injury • A modeled dramatization that demonstrates how to respond to a student disclosing self-injury, using “low-key dispassionate demeanor” (Walsh, 2006) • Interviews with self-injury expert Barent Walsh, Ph.D. as well as a school administrator and a school counselor • An interview with Amy, a true success story of someone who recovered from self-injury
118 Page
Chapter 2 of DVD: for Students (18 minutes): This chapter models supportive attitudes and behavioral responses for youth who may be at risk for self-injury, may already be self-injuring, or may be observing self-injury in others. This chapter has three components: • Dramatizations showing adolescents dealing with a friend who self-injures. Scenarios depict a friend who is trying to help - first the “wrong” way (i.e., getting angry, discussing their own self-injury, or keeping the disclosure a secret), and then the “correct” way (i.e., telling them that they are concerned and that they need to speak with a trusted adult). • Interview with a clinician in which a student actor discloses self-injurious behaviors to a counselor and agrees to get help. • Amy: A real life success story where Amy shares her personal experience of engaging in self-injury to cope with strong feelings. She discusses how treatment helped her identify new ways of coping that helped her stop injuring herself.
SOS Self-injury Training for Trusted Adults – Overview The Goal of a Certified Self-injury Training is to educate school faculty and staff, parents and community members about self-injury prevention and intervention, and to prepare staff members to train students in self-injury prevention and intervention. Often students will come to school staff to disclose self-injury. The primary responsibility of the staff person is to refer self-injuring students to the school’s point persons. Point persons are usually staff with mental health training such as social workers, guidance counselors, psychologists, or nurses. It is important for all school staff to know how to, and how not to, respond to self-injury in students. A Certified Self-Injury Training includes: 1. Overview of the Signs of Self-Injury Prevention Program to be implemented with students 2. Myth and facts about self-injury 3. The warning signs for self-injury 4. How to effectively respond to students who may approach them for help 5. School procedures for dealing with students disclosing self-injurious behavior Some staff may be apprehensive or uncomfortable with involvement in mental health prevention programs. Small group discussions allow staff to share their concerns and increase confidence in addressing self-injury. School personnel should leave a staff training with a good comfort level for talking with students about self-injury.
Things to consider when planning SOS Self-Injury Training for trusted adults: Who to Invite Invite all individuals who routinely interact with students, including teachers, clinicians, health staff, coaches, bus drivers, office support staff, and any other paraprofessionals who are a regular part of students’ daily lives. Choosing a Setting Create a comfortable learning environment where people will be encouraged to share and discuss their apprehensions, concerns, confidence levels, and ideas around dealing with student needs and behaviors after implementation of the Signs of Self-Injury Prevention Program. For example: • Provide food/refreshments or other thank you gestures for attending the training.
119 Page
• Group seating arrangements that are conducive to discussion. • Conduct the training during another mandatory or highly attended event (i.e., faculty meeting or in-service training day). • Provide a short written introduction to the topic/program so that attendees will know what to expect ahead of time. • • • •
Future SOS Trainer: Sample Introduction for Self-Injury Training for Faculty/Staff “As a Certified SOS Signs of Self-Injury Trainer, I have been invited to provide training and support to your school/community as you implement the Signs of Self-Injury Prevention Program (specify school-wide, in health classes, class-wide etc.) on (specify date). Our goal is to help students recognize the symptoms of self-injury in themselves, or their friends, and teach them the appropriate action steps they should take to get help. The purpose of this program is to inform students that if they, or their friends, are self-injuring, they can benefit from getting help. Through the Signs of Self-Injury Prevention Program, school staff, students, and parents will learn about self-injury. They will know the action steps needed for students to get help by learning the simple acronym “ACT”: Acknowledge that your friend has a problem, express that you Care, and Tell a trusted adult. Staff participation is an important step toward identifying mental health problems and maladaptive coping behaviors – a step that helps us protect our students. Encouraging student help-seeking from trusted adults is an important prevention measure in addressing future self-injurious behaviors in our school. We hope that the program will help instill confidence in you, our staff, and students about identifying the signs of self-injury and how to access help if someone needs it.”
Schedule of Activities • Introduce the Signs of Self-Injury Prevention Program and the topic of self-injury • Show both chapters of the SOS Signs of Self-Injury DVD • Facilitate a discussion about the DVD that includes a review of the educational materials entitled: “Defining Self-Injury,” “Guidelines for Responding to Students Disclosing Self-Injury,” and “Responding to Self-Injury Contagion in Student Populations.” In particular, discuss the possibility for contagion. Hand out the corresponding educational materials for staff to keep as references • Use the “Myths and Facts” handout to structure a question/answer period to clear up any misperceptions about self-injury • Coordinate with school staff to present the implementation plan for students that summarizes who will be implementing the program, if/how community-based partnerships will be employed, how emergencies will be handled, how to secure parent consent, if/how parents will be involved in program planning, how to ensure follow-up for at-risk youth, and how referrals will be made • Coordinate with school staff to review school protocol for handling students disclosing self-injury. If there is not one in place, support school staff to create one using the handout “School Protocol Template for Responding to Individual Cases of Self-Injury” • Encourage staff to review school and community mental health resources • Summarize key aspects of training • Identify a resource person that training participants can contact regarding future questions or concerns that may arise
120 Page
SOS Self-Injury Training for Parents – Overview Certified SOS Signs of Self-Injury Trainers may be called upon to deliver self-injury prevention training for parents. If a school decides to conduct a parent event, it can be very similar in content to the staff training. The goals of the event should be: to gain parental support for the program, to educate parents about the signs and symptoms of self-injury (so that they know what to watch for, and how to respond to, self-injury in their child), and to offer support for those parents already confronting self-injury with their child. Parents may also need professional help to deal with a self-injuring child, so having a clinical expert on self-injury in attendance (to present or just field questions) can be of great help. Clinical professionals should remind parents that a self-injuring child does not signify “bad parenting.” Parents also need to know they are not alone - many parents struggle with their child’s self-injury. Setting and Logistics • Plan an educational presentation for parents on ensuring youth safety and give the parent event a general title, such as “Keeping Your Teen Safe” or “Safeguarding Youth.” • Serve food. Offer a raffle or other incentives/thanks for attending. • Combine the event with another well-attended or mandatory event, such as orientation, parent/teacher conferences, registration for courses, special events, or sporting events.
Future SOS Trainer: Sample Introduction for Self-Injury Parent Training “As a Certified SOS Signs of Self-Injury Trainer, I have been invited to provide training and support to your school/community as your school implements the Signs of Self-Injury Prevention Program (specify school-wide, in health classes, class-wide etc.) on (specify date). Our goal is to help students recognize the symptoms of self-injury in themselves, or their friends, and teach them the appropriate action steps they should take to get help. The purpose of this program is to inform students that if they, or their friends, are self-injuring, they can benefit from getting help. Through the Signs of Self-Injury Prevention Program, school staff, students, and parents will learn about self-injury. Everyone will learn the action steps needed for students to get help by learning the simple acronym “ACT”: Acknowledge that your friend has a problem, express that you Care, and Tell a trusted adult. That trusted adult may be you! We want parents to be prepared to help prevent self-injury in their children and their friends. We hope that the program will help instill confidence in you, our parents, about identifying the signs of self-injury and how to access help if someone needs it.”
Schedule of Activities • Introduce the Signs of Self-Injury Prevention Program and the topic of Self-Injury. • Show both chapters of the Signs of Self-Injury DVD and facilitate a discussion. • Review the symptoms of self-injury and protective factors. • Be prepared to field questions. Summary of Education/Communication Activities for Families Adolescence presents many challenges for parents as well as teens. Dealing with an adolescent who self-injures can be very difficult, overwhelming, and frightening for parents. Parents are important partners in safeguarding youth. The way in which parents respond to self-injury can make a difference in the treatment outcomes for their children. For example, some parents blame themselves for their child’s self-injury. When these feelings of guilt and shame are communicated to
121 Page
the child, they can exacerbate the situation and cause the young person to alienate him/herself. If parents are educated on self-injury and the reasons why young people self-injure, they may be able to respond more helpfully by seeing beyond the behavior itself. Three factors primarily affect Parent/Guardian responses to self-injury: interpretation of the behavior, perception of the child’s risk for such behaviors, and perceived ability to effectively respond to the self-injuring child (self-efficacy). Prevention Themes to Stress with Parents/Guardians: • Do not be afraid to talk to your kids about self-injury. • Know the risk factors and warning signs of self-injury. • Respond immediately if your child is showing warning signs. • Reach out to the school for resources. Print Materials for Distribution to Parents/Guardians: • Letter of introduction/consent to the program - describing the goals of the program and the date it will be implemented • Referral Resource List for Parents - a list of resources available in the school and community for students and parents seeking help • Handout: “Defining Self-Injury” • Handout “Myths and Facts About Self-injury” • Handout “Helping Youth Who Self-Injure: Suggestions for the Family”
Future SOS Trainer Take Home Note: Use of Empathetic Language Remember that self-injury can be an uncomfortable, even jarring topic for adults with little education on the topic. It is best to frame self-injury in a way that is educational, supportive and, when possible, uplifting. Remind your audience that self-injury comes from a natural desire to feel better (a concept that we all can understand) and that it is a form of coping or self-soothing that is not unlike other maladaptive coping skills that society is more accustomed to (i.e. alcohol use). It can be helpful to explain that we have all experienced emotions intensely in certain points of our lives. We can relate to the experience of wanting to control intense emotions in adolescence even if we cannot relate to the behavior of self-injury.
Self-Injury Resources Check out the Cornell University Self-Injury and Recovery Research and Resources (SIRRR) for more great resources on Self-Injury: www.selfinjury.bctr.cornell.edu.
122 Page
ACTivity: SOS Signs of Self-Injury Program Trusted Adult Training • • • •
After you watch part of the video break up into groups Decide if your group is a parent night or a staff professional development training Use your handbook to determine the structure of the training based on the population you choose. For a few minutes, in small groups use the Self-Injury Video discussion guide (in your handbooks) have a discussion as you would at an adult training
Signs of Self-Injury Program Discussion Guide Before You Begin Whether you are presenting this DVD to students or adults, it is important to acknowledge that you are discussing a sensitive topic. There may be people in your audience who have a personal connection to self-injury or other serious mental health concerns. Some people may be caught off guard by their reaction to the material. Let your audience know that they are welcome to take a break and leave the room for a few minutes if they need some space. When presenting to students, identify a location/contact person for students to access if they choose to leave the room. Overview of DVD The entire DVD is approximately 29 minutes and includes two chapters - one to be shown to students and the other designed to train school personnel. NOTE: Staff should familiarize themselves with both DVD chapters in preparation for program implementation. Chapter 1 of DVD For School Personnel and Faculty (11 minutes): This chapter serves as an introduction to the problem of self-injury. It is relevant for school staff, administrators, parents, counselors, teachers, coaches, maintenance staff, and any other adult who comes in contact with students. The chapter includes: • Information about self-injury and treatment; differentiating between self-injury and suicide, the functions of self-injury, and guidelines for responding to self-injury • A modeled dramatization that demonstrates how to respond to a student disclosing self-injury, using “low-key dispassionate demeanor” (Walsh, 2006) • Interviews with self-injury expert Barent Walsh, Ph.D. as well as a school administrator and a school counselor • An interview with Amy, a true success story of someone who recovered from self-injury Sample Introduction to Staff “In an effort to reduce self-injury among our students, we plan to implement the Signs of Self-Injury Prevention Program (specify school-wide, in health classes, class-wide etc.) on (specify date). Our goal is to help students recognize the symptoms of self-injury in themselves, or their friends, and teach them the appropriate action steps they should take to get help. The purpose of this program is to inform students that if they, or
123 Page
their friends, are self-injuring, they can benefit from getting help. Through the Signs of Self-Injury Prevention Program, school staff, students, and parents will learn the action steps needed for students to get help using the simple acronym “ACT”: Acknowledge that your friend has a problem, express that you Care, Tell a trusted adult. Staff participation is an important step toward identifying mental health problems and maladaptive coping behaviors – a step that helps us protect our students. Encouraging student help-seeking from trusted adults is an important prevention measure in addressing future self-injurious behaviors in our school. We hope that the program will help instill confidence in you, our staff, and students about identifying the signs of self-injury and how to access help if someone needs it. NOTE: Identify a school contact for attendees to address questions or concerns that may arise after the training.
Self-Injury Staff Discussion Guide Questions
Q. Who does self-injury affect? A. 10-20% of middle/high school/college students of all genders and socio-economic and racial groups. Q. What is self-injury generally used for by teens? A. It’s generally not about suicide. Instead, teens use self-injury as a coping mechanism to reduce powerful emotions such as anxiety, anger, sadness, depression, and shame. Q. Who are examples of point persons in your school? A. Staff with mental health training such as guidance counselors, psychologists, nurses and social workers. Q. Why is it important to encourage students to refrain from talking about self-injury with their friends? A. Self-injury can be “contagious.” Students should understand that talking about their self-injury may unintentionally hurt their friends by triggering the behavior in others. Q. In terms of your reaction, what is the best way to respond to youth when finding out about self-injury? A. It’s best to respond to youth with a low-key dispassionate demeanor. It is important to not judge, condemn, or overreact. You want to validate their feelings, and offer help. Q. Under what circumstances would your school contact the parent or guardian of a self-injuring student? A. Parents should always be contacted so that they can access treatment for their child. It is recommended that school mental health staff contact the parents with the student present to help explain the behavior to the parent and recommend next steps. Q. Why is creating a “safety contract” ill-advised? A. Asking a student to give up self-injury immediately may be unrealistic for a student who is using this coping mechanism. It may lead students to hide the behavior or avoid seeking help. Q. Identify and explain the steps to treatment for self-injury. A. The video identifies two steps: 1. Identifying and reducing the triggers to the behavior 2. Teaching effective alternate coping skills • Relaxing breathing • Calming visualization • Non-competitive exercise • Journaling • Expressive art
124 Page
Amy’s Story Q. What did Amy use to cope with her feelings? A. Amy utilized a number of strategies: • Breathing exercises • Visualizations of places that made her feel safe (the beach, the woods) • Focus on senses for distraction (good smells- candles, perfume) • Exercise (jogging) • “Safety kit” to help distract and provide an alternative to self-injury (nail polish, pictures of family and friends). Q. Self-injury is generally not about suicide, but school staff should always assess for suicide when self-injury is disclosed. If a student indicates that they self-injured with suicidal intent, how should the school manage this incident? A. If the behavior is identified as an emergency, the crisis protocol should be followed. Chapter 2 of DVD For Students (18 minutes) This chapter models supportive attitudes and behavioral responses for youth who may be at risk for self-injury, may already be self-injuring, or may be observing self-injury in others. This chapter has three components: 1. Dramatizations showing adolescents dealing with a friend who self-injures. Scenarios depict a friend who is trying to help - first the “wrong” way (i.e. getting angry, discussing their own self-injury, or keeping the disclosure a secret), and then the “correct” way (i.e., telling them that they are concerned and that they need to speak with a trusted adult) 2. Interview with a clinician in which a student actor discloses self-injurious behaviors to a counselor and agrees to get help 3. Amy: A real life success story where Amy shares her personal experience of engaging in self-injury to cope with strong feelings. She discusses how treatment helped her identify new ways of coping that helped her stop injuring herself Sample Introduction for Students: “Today our school is participating in the Signs of Self-Injury Prevention Program. Our goal is to help you recognize the signs of self-injury in yourselves, your friends, or your loved ones. The purpose of this program is to reduce self-injury by educating individuals about the signs of self-injury, appropriate responses to self-injury, and how to seek treatment for self-injury. Please be aware that although the DVD outlines the steps to take if you are worried about a friend, those who are struggling with self-injury should ask for help directly or ask a friend for support in getting help. After we watch the DVD, which is approximately 18 minutes long, we will discuss the lessons of the program and you can ask questions. Anyone who feels unable to stay for the entire DVD should ask to be excused. You will be escorted to (fill this in according to specific plan) until next class. We will ask each of you to complete a student response card after the discussion. These cards will be collected by school staff and reviewed, to determine who may want to further discuss their concerns about self-injury – in private with an adult. Any questions?”
125 Page
Self-Injury Student Discussion Questions Note to discussion leader: Keep information about self-injury very general and within the context of seeking help from a trusted adult. Focus on: • Self-injury as a mental health problem that can be treated • The signs of emotional stress and risk factors that can contribute to self-injury • Those in the school who are trained to help students who self-injure Opening Points: Q: What is self-injury? A: Self-injury is when a person hurts their body on purpose without the intention to die. Self-injury is a mental health problem that must be treated by a professional. Q: What does ACT stand for? A: Acknowledge the problem, Care-Let the person know you care, and Tell a trusted adult. Q: What should you do if you know someone who is self-injuring? A: If you know someone who is hurting himself or herself on purpose, do the same thing you would do if you knew they were depressed or suicidal: ACT. Acknowledge: If you see signs of self-injury, tell him or her in a caring way that you recognize that s/he is having a problem. Care: Show the person how much you care. You can show you care by actively listening. This means putting aside anything else you are doing, making eye contact, sitting down, and asking questions. Tell: Once you listen to your friend, tell him or her that it’s important that you speak with an adult, such as a parent, teacher, counselor, or someone else they trust so that the person can get help. You can figure out together who that adult should be. Offer to go with your friend to tell an adult, for support. Dramatization #1 Male friends at lockers, discussing burns on legs Q: What were the signs that Victor has been self-injuring? A: David noticed the burns on Victor’s legs at basketball practice. Burning yourself is self-injury. Q: What about David’s first response to his friend, Victor, made it “wrong”? A: • David got angry • David walked away • David called Victor “stupid” Q: How did David use the ACT technique in the “correct” response? A: Acknowledge: He made eye contact with Victor and said, “It looks like you’re hurting yourself on purpose.” When Victor tried to pass it off as “nothing,” David said, “It’s not just nothing.” Care: David took the time to actively listen and express concern. David said, “Okay, I’m sorry. I’m just trying to help.” He also said, “I just think something’s wrong,”… and “it’s weighing you down,” and “it’ll do you good to unload, get if off your chest.” David offered to go with Victor to get help, demonstrating his support for his friend. Tell: David insisted that Victor needs to “talk with someone who gets it.” David reminded Victor that he had successfully talked to his guidance counselor, Mr. Gonzales, in the past. David didn’t give up. When Victor said that he had talked
126 Page
with Mr. Gonzales too many times already, David emphasized that frequency was not the point. Talking with someone who “gets it” is the point. David also insisted they go together to guidance, making sure that Victor would meet with Mr. Gonzales and to support him in getting help. Dramatization #2 Girl and boy in a gym, talking about self-injury Q: How do you know that the boy, Simon, is self-injuring? A: He covers up his arms when Brandy approaches and doesn’t deny it when she asks, “do you cut yourself too?” Q: In the scene, Brandy is about to tell Simon how she used to self-injure, but this is interrupted by a “WRONG” message. Why is it wrong to discuss the details of self-injury with peers? A: Discussing self-injury with peers or showing wounds can trigger the behavior in others. That’s why Brandy says her counselor told her, “it makes things worse.” Q: If you shouldn’t talk with peers about self-injury, who should you talk to? A: • A trusted adult at school such as a guidance counselor, social worker, nurse, teacher, coach • A parent or some other supportive adult family member Q: What did Brandy say influenced her to stop self-injuring? A: She said her boyfriend “put a lot of pressure on her” to stop and she “saw a counselor to get help.” Dramatization #3 Two girls discussing a play and then self-injury Q: Why does Michelle ask about Sarah’s costume in the play in the dramatization? A: Because she noticed the cuts on Sarah’s arm and wants to bring up the topic of self-injury in a sensitive way. Q: Sarah tries to avoid admitting that she self-injured saying her cat scratched her. How does Michelle deal with that? A: She doubted the truth of her statement. She is persistent. She challenges her friend’s unlikely explanation. Q: Why is promising to keep information secret about self-injury the WRONG response? A: People who self-injure are in distress and need help from trained adults. A caring friend is important, but peers aren’t equipped to give professional help for self-injury. Q: How did Michelle demonstrate the ACT approach in the CORRECT response? A: Acknowledge: Michelle brought up self-injury and didn’t give up when Sarah tried to change the subject or avoid it. Care: She showed she cared when she said, “If you can’t talk to me, who can you talk to?” She also said, “I’m worried that you’re hurting yourself,” and “maybe I can help.” Tell: • Michelle insisted they talk with “someone with experience.” • She walked with Sarah to the guidance office to support her friend in getting help. She may also be trying to make sure that Sarah meets with the counselor. • Michelle didn’t allow Sarah to postpone going to see the counselor. She convinced her to go right away and offered to go with her. Q: Sarah makes it clear that it is hard for her to talk about self-injury. What makes it so hard for people to talk about? A: People may feel ashamed or afraid to discuss self-injury. They may fear being judged, punished, condemned, or rejected.
127 Page
Q: Why is Sarah afraid she “will get in trouble” because she is self-injuring? A: Some schools and/or parents may respond to self-injury with anger, horror, shock, and even punishment. NOTE: It’s important to emphasize that your school does not respond in this way. The school policy is to be supportive and to help the student get help. Amy: A True Success Story Q: What does Amy say contributed to starting to self-injure? A: Pressure at school, being away from home for the first time, breaking up with a boyfriend, conflicts with family. Q: What emotions did Amy say self-injury helped her deal with? A: She refers to depression, anxiety, stress, anger, feeling “overwhelmed,” and “out-of-control.” Q: Was Amy’s self-injury about wanting to die? A: No, she clearly states that she and, in fact, most people who self-injure don’t want to die, but do want to reduce their emotional distress. Q: How did Amy say she was able to stop self-injuring? A: She says she learned new, healthier ways to deal with her emotions such as breathing exercises, calming visualizations, exercise, distracting herself including using her senses to relax herself, such as smelling something pleasant. She also carried with her what she called a “safety kit” in a make-up bag, containing reminders of those who support her (photos) and contact information for those who she can turn to for help (phone numbers). The kit also included items that helped distract her. Q: What could students who self-injure use that would be an alternative to a safety kit? A: Solicit class discussion on this question. An example is a list of healthy, effective activities/coping skills, stored perhaps on a smartphone, or written on a note card, carried in a wallet, school notebook or backpack. Q: What other skills are useful to manage and reduce upsetting emotions? A: Have the class brainstorm healthy techniques that they already use to manage emotions. Examples might include: reading, listening to music, using the computer, playing a video game, watching a funny movie, journaling, talking with a friend, creating expressive artwork, taking a walk, going shopping, exercising, cleaning, cooking, or baking. Closing Points: Q: What is self-injury? A: • Self-injury is when a person hurts his or her body on purpose, generally without the intention to die. • Self-injury is an unhealthy way to cope with strong feelings/emotions. • Self-injury can be influenced by peers. Discussing details of self-injury with peers can trigger the behavior in others. Q: What’s the difference between self-injury and a suicide attempt? A: By definition, those who self-injure do not intend to die. However, a person’s intention behind his/her behavior is not always clear. If you know someone who is self-injuring, the action step remains the same: ACT. Q: Why is self-injuring a problem? A: • It involves deliberately hurting one’s body. • There is immediate tissue damage that can result in scars. • Peers may judge, condemn, or avoid the self-injuring person. Parents and school staff can be alarmed by the behavior. • It interferes with the development of healthier, more effective coping skills.
128 Page
Q: According to the DVD, why do people self-injure? A: Some people use self-injury as a way to cope with intense feelings, like anger, anxiety, sadness, shame, etc. Others may harm themselves to communicate a need for help. Q: What should you do if you know someone who is self-injuring? A: If you know someone who is hurting himself or herself on purpose: ACT. Acknowledge the problem; let the person know you Care, and Tell a trusted adult. Q: You can show you care by actively listening to the person. How can you show that you are “actively listening” to someone? A: • Look at the person who is talking • Put aside anything else you are doing • Sit down with the person, lean forward, with arms not crossed • Ask mostly “what” and “how” questions; avoid persistent “why” questions • Don’t interrupt, but nod your head to show you are listening • Keep your focus on the person who is talking Q: What do you do if a person rejects your attempts to help them and refuses to discuss it? A: • Be persistent, convey your concerns again • Use active listening techniques • Turn the tables: Ask them what they would do if you had a problem and needed help. Michelle was able convince her friend • to get help by turning the tables and asking her friend if she was self-injuring, wouldn’t her friend want to help her? • Tell a trusted adult about the self-injury on your own. Recognize that your friend may be upset that you shared this information with an adult in the short-term, but is likely to understand in the long-term. Explain to the friend you told the adult in order to be supportive and get them help with a serious problem. Q: What should you do if you self-injure, or are thinking of it, and need help? A: If you self-injure, or are thinking of it, tell a trusted adult about your feelings of self-injury, so you can get help and feel better. You don’t have to suffer alone – there is hope and there is help. Ask a friend to help you approach an adult if you need additional support. Q: Why should you be confident you are not betraying a friend when you tell an adult that your friend may be selfinjuring? A: Self-injury can interfere with a person’s ability or wish to get help. It is an act of true friendship to share your concerns with an adult who can help. Q: What would you do if the adult you share your concerns with does not respond to you or take your concerns seriously? A: Don’t give up! State your concerns and the reasons why you are worried again. If the person still doesn’t respond, share your concerns with someone else: a parent, teacher, school counselor, or other trusted adult. Note to Discussion Leader: As a classroom exercise, ask students to recall the signs of depression and suicide to reinforce learning. Add those that are not recalled to the end of the lesson.
129 Page
Signs (Symptoms) of Depression • • • • • • • • • • • • • • •
Frequent sadness, tearfulness, crying Hopelessness Decreased interest in activities or inability to enjoy previously favorite activities Persistent boredom, low energy Social isolation, poor communication Low self-esteem and guilt Extreme sensitivity to rejection or failure Increased irritability, anger, or hostility Difficulty with relationships Frequent complaints of physical illnesses, such as headaches and stomachaches Frequent absences from school or poor performance in school Poor concentration A major change in eating and/or sleeping patterns Talk of/or efforts to run away from home Thoughts or expressions of suicide or self-destructive behavior
Warning Signs for Suicide • • • • • • • • • •
Talking, reading or writing about suicide or death Talking about feeling worthless or helpless Saying things like, “I’m going to kill myself,” “I wish I were dead,” or “I shouldn’t have been born” Visiting or calling people to say goodbye Giving things away Organizing or cleaning one’s bedroom “for the last time” Developing a sudden interest in drinking alcohol or drug use Purposely putting oneself in danger Obsessing about death, violence and guns or knives Previous suicidal thoughts or suicide attempts
130 Page
Suggested Reading on Non-Suicidal Self-Injury Batejan, K., Jarvi, S., & Swenson L. (2014): Sexual Orientation and Non-Suicidal Self-Injury: A Meta-Analytic Review, Archives of Suicide Research, DOI: 10.1080/13811118.2014.957450 Daine, K., Hawton, K., Singaravelu, V., Stewart, A., Simkin, S., & Montgomery, P. (2013). The Power of the Web: A Systematic Review of Studies of the Influence of the Internet on Self-Harm and Suicide in Young People. Plos ONE, 8(10), 1-6. doi:10.1371/journal.pone.0077555 Gratz, K.L. & Chapman, A.L. (2009). Freedom from self-harm: Overcoming self-injury with skills from DBT and other treatments. Oakland, CA: New Harbinger. Hollander, M. (2008). Helping teens who cut. New York: Guilford. Hyman, J. (1999). Women living with self-injury. Philadelphia: Temple University Press. Joiner. T. (2007). Why people die by suicide. Cambridge, MA: Harvard University Press. Joiner, T. (2010). Myths about suicide. Cambridge, MA: Harvard University Press. Kettlewell, C. (1999). Skin game: A Cutter’s Memoir. New York: St. Martin’s Press. Klonsky, D. E. (2007). The functions of deliberate self-injury: A review of the evidence. Clinical Psychology Review, 27, 226-239. Klonsky, E.D., May, A.M. & Glenn, C.R. (2013). The relationship between nonsuicidal self-injury and attempted suicide: Converging evidence from four samples. Journal of Abnormal Psychology, 122, (1), 231-237. Martin, G., Swannell, S., Hazell, P. & Taylor, A. (2010). Australian National Epidemiological Study of Self-Injury (ANESSI). Brisbane, Australia: Center for Suicide Prevention Studies. Michelmore, L. & Hindley, P. (2012), Help-Seeking for Suicidal Thoughts and Self-Harm in Young People: A Systematic Review. Suicide and Life-Threat Behavior, 42: 507–524. doi: 10.1111/j.1943-278X.2012.00108.x Muehlenkamp, J. J. (2006). Empirically supported treatments and general therapy guidelines for non-suicidal self-injury. Journal of Mental Health Counseling, 28, 166-185. Muehlenkamp, J.J., Claes, L. Havertape, L. & Plener, P.L. (2012). International prevalence of adolescent non-suicidal selfinjury and deliberate self-harm. Child & Adolescent Mental Health, 6:10. http://www.capmh.com/content/6/1/10 Nixon, M.K. & Heath, N.L. (2008). Self-injury in youth. New York: Routledge. Nock, M. (Editor). (2009). Understanding non-suicidal self-injury: Origins, assessment, and treatment. Washington, DC: American Psychological Association. Nock, M.K. & Kessler, R.C. (2006). Prevalence of and risk factors for suicide attempts versus suicide gestures: Analysis of the National Comorbidity study. Journal of Abnormal Psychology, 115(3), 616-623. Nock, M.K. & Kessler, R.C. (2006). Prevalence of and risk factors for suicide attempts versus suicide gestures: Analysis of the National Comorbidity study. Journal of Abnormal Psychology, 115(3), 616-623.
131 Page
Nock, M. K. & Prinstein, M. J. (2004). A functional approach to the assessment of self-mutilative behavior. Journal of Consulting and Clinical Psychology, 72(5), 885-890. Plener, P.L., Libal, G. & Nixon, M.K. (2009). In Nixon, M.K. & Heath, N.L. (2009). Self-injury in youth: The essential guide to assessment and intervention. New York: Routledge. Sandman, C.A. (2009). Psychopharmacologic treatment of nonsuicidal self-injury (2009). In Nock, M. K. (Editor), (2009a). Understanding non-suicidal self-injury: Origins, assessment, and treatment. Washington: APA Press. Swannell, S.V., Martin, G.E., Page, A., Hasking, P., & St. John, N.J. (2014). Prevalence of nonsuicidal self-injury in nonclinical samples: Systematic review, meta-analysis and meta-regression. Suicide and Life-Threatening Behavior, 2, 1-31. Taliaferro, L.A., Muehlenkamp, J.J., Borowsky, I.W., McMorris, B.J. &Kugler, K.C. (2012). Risk factors, protective factors, and co-occurring health-risk behaviors distinguishing self-harm groups: population-based sample of adolescents. Academy of Pediatrics, 12(3), 205-213. Walsh, B. & Doerfler, L. (2009). Residential treatment of self-injury. In Nock, M. (Editor). Understanding non-suicidal selfinjury: Origins, assessment, and treatment. Washington, DC: American Psychological Association. Walsh, B. (2012). Treating self-injury: A practical guide, 2nd Edition. New York: Guilford. Whitlock, J., Eckenrode, J., & Silverman, D. (2006b). Self-injurious behaviors in a college population. Pediatrics, 117(6), 1939-1948. Whitlock, J. L., Powers, J. L., & Eckenrode, J. (2006a). The virtual cutting edge: The internet and adolescent self-injury. Developmental Psychology, 42(3), 1-11. Whitlock, J., Muehlenkamp, J., Eckenrode, J., Purington, A., Barrera, P., Baral-Abrams, G., Kress, V., Grace Martin, K, Smith, E., (2013). Non-suicidal self-injury as a gateway to suicide in adolescents and young adults. Journal of Adolescent Health, 52(4), 486-492. Whitlock, J.L. & Selekman, M. (2014). Non-suicidal self-injury (NSSI) across the lifespan. In Oxford Handbook of Suicide and Self-Injury, edited by M. Nock. Oxford Library of Psychology, Oxford University Press.
132 Page
Notes: __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ _________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________
133 Page
Section 15: Postvention as Prevention Thank you to our partner, Riverside Trauma Center, for contributing Section 14 to this handbook. To learn more about Riverside Trauma Center, visit www.riversidetraumacenter.org
Objective: • Introduce the concept of postvention, share postvention resources, and encourage best practices.
Postvention as Prevention The term postvention was coined by Edwin Shneidman (1972), the founder of contemporary suicidology, to describe planned interventions with those affected by a suicide death that would facilitate the grieving process. Over the last several decades, others have expanded the goals to include stabilizing the environment and reducing the risk of negative behaviors, most notably the risk of contagion. Shneidman and many others have gone on to say that, because we know that exposure to suicide can be a significant risk factor for suicide, effective and timely suicide postvention efforts are a key to suicide prevention. There are many competing priorities for schools after the suicide death of a community member. It is centrally important to consider how to best balance the need for commemoration activities while still addressing the need to reduce the possible contagion effect. It is also important to address the need to provide some trauma response for students and community members who experience the death as traumatic. This need has been highlighted by research which has demonstrated increased rates of PTSD in youth up to three years after the suicide death of a peer (Brent et al., 1996). After a suicide death in a school, resources are often stretched by these competing priorities combined with the reality that staff themselves are often grieving and overwhelmed by anxiety about their students. Administration and guidance staff, in particular, end up balancing the significant needs of their existing work/caseloads, grieving students, students at-risk, and anxious and grieving parents and staff, while simultaneously experiencing their own grief reactions. Often bringing in outside resources is necessary, whether staff from other schools or an external agency. External support for school staff can enable them to attend to the needs of the students (and model healthy help seeking behavior). Much of how people make meaning, grieve, and construct the narrative of a suicide death is impacted by what happens after the death. While every death and every school community are unique, there are some general guidelines that have been developed over many years of seeing what has generally worked well for schools and communities and what has not worked well and can be learned from.
Postvention Goals 1. At the organizational level, to help restore equilibrium and functioning to stabilize the environment within the school and to get teachers back to their primary jobs of teaching and students back to their primary jobs of learning. 2. To promote healthy grieving, and commemorate the deceased for all members of the community who have been impacted. 3. To provide comfort to those who are distressed, minimize adverse personal outcomes (depression, PTSD, complicated grief), and reduce the risk of suicide imitation or contagion. 4. To identify those most likely to need support. These are likely to include, but are not limited to: • Those who were psychologically close to the deceased (e.g., friends and family members). • Those who were already depressed and possibly suicidal themselves before the death. • Those who have had other recent losses or traumas. • Those who might psychologically identify with the deceased as being similar in lifestyle, values, or life circumstances.
134 Page
• Those who may have felt responsible for the well-being of the deceased, and by extension, for preventing the suicide. For example, in a school setting, teachers, coaches, and counselors who were closely involved with an adolescent who has died of suicide are at risk. 5. Use the experience/tragedy as a “teachable” moment to consider how to talk about suicide prevention, crisis planning, school connectedness, etc. 6. Increase empowerment and mutual support for all members of the school community.
Postvention Guiding Principles 1. Avoid oversimplifying the causes of suicide, murder-suicides, or suicide pacts. Emphasize that suicide is not the result of a single factor or event in the life of the deceased (e.g., the break-up of a relationship); rather it is a complex and complicated interplay of events. Also avoid presenting the causes as inexplicable or unavoidable. Emphasize that there are alternatives to suicide when one is feeling distressed or hopeless, and make clear what resources are available for getting help. It can be useful to characterize the act of suicide as a serious mistake in judgment on the part of the deceased, in which their recognition of alternatives and resources for help was impaired by the psychological pain from which they suffered. 2. Emphasize the correlation between depression, mental illness, and suicide, and stress that help or treatment is available. Reducing the stigma of mental illness and help-seeking behavior enhances the likelihood that people will seek help, particularly if they learn the pathways through which help can be accessed. 3. Avoid romanticizing or glamorizing someone who has died by suicide. That is, do not portray the deceased as a hero or having died a noble or romantic death (as in Romeo and Juliet). Conversely, do not portray the deceased as selfish or worthy of contempt. Emphasize that almost all suicide is associated with psychiatric disorder, and the impairment in judgment that accompanies this disorder. 4. Discourage a focus on the method of the suicide, which is often the subject of gossip and sensationalization. Report the method factually (e.g., he hung himself), but emphasize that the important information is that the person mistakenly felt unable to get help for his or her problems, when in fact help was possible. 5. Provide a structure that facilitates ongoing suicide prevention efforts (Gould & Kramer, 2001; Graham, Reser, Scuderi, Zubrick, Smith, & Turley, 2000; Suicide Prevention Resource Center [SPRC], 2008).
Postvention Tasks What follows is a list of postvention tasks for schools in which a suicide has occurred. It is our recommendation that a postvention plan be in place at all schools/organization in preparation for an event like a suicide. The postvention plan should be based on these tasks and sequenced generally as follows: 1. Verification of death and cause All responsible postvention efforts begin with verification of the death: who died, when, the circumstances, location, and whether or not the death was a suicide. Most officials – school superintendents, CEOs, community leaders – will be initially swamped with information and rumors from students, parents, colleagues, and the press asking if they have heard that a given person has died. In an age of cell phones, social networking sites, and Twitter, responsible leaders should assume much of the information will be inaccurate and that rumors will prevail. No official release of information should be distributed until the circumstances of the death have been confirmed by the appropriate authority: police chief, medical examiner, immediate family member. Even if a family member requests secrecy about the cause of death, it may not be possible to keep the circumstances a secret. In many states the cause of death is public information, though in the United States, federal FERPA and HIPPA laws take precedence. We suggest gently helping the family to think through the “pros and cons” of trying to keep the cause of death a secret, and the difficulty in doing so. If the family still does not want to disclose this information, then the institution must uphold their wishes. However, Hollingsworth (2007, p. 53) notes, “not disclosing the cause of death as a suicide leads to
135 Page
confusion, rumors, speculation, decreases trust among staff and students, puts school supportive staff in the position of not discussing this openly with students, puts other students’ parents in a position of not knowing how to support their sons and daughters, and increases the likelihood of contagion.” 2. Coordination of external and internal resources It is important to quickly mobilize and organize internal and external resources. The superintendent or principal should immediately notify his or her crisis response team and plan for an initial meeting within hours or early on the next day. Most crisis teams have written protocols delegating actions and responsibilities in case of sudden traumatic death. Schools with working relationships with local mental health agencies and neighboring school districts and other local resources will often invite these partners to the crisis response meeting. Ideally this will not be the first time school personnel and community programs have met. Although some school systems are inclined to handle a crisis on their own with staff familiar to the students, these local resources can provide valuable consultation for school administrators and teachers who may be unfamiliar with how to handle this devastating loss, and who may themselves be grieving the death of the student. Nearby school systems can send additional counselors to cover students who are in acute grief and the nearby school system may also be able to provide back up to teachers and school staff who might want to attend the wake or funeral. Perhaps the most important reason for utilizing outside resources is to ensure that school personnel who are on the frontlines of postvention efforts are themselves being supported throughout the entire postvention effort. 3. Dissemination of information The most effective strategy for providing known details of the death is a written statement that can be distributed to everyone in the school. It should include factual information about the death and acknowledgement that it was suicide, condolences to family and friends, plans to provide support for those impacted, information about funeral plans if known, or acknowledgement that the information will be provided once known, and any changes in schedule during the upcoming days. It is also strongly advised that an announcement not be read over a public address system. Conducting this conversation in smaller groups (like homerooms) gives responders a chance to gauge individual and group reactions. When everyone in the community gets exactly the same information – teachers reading the statement in the classroom; emails to parents or employees; press release to local media – then rumors will begin to subside. Templates for letters and scripts are available in the American Foundation for Suicide Prevention (AFSP) and the Suicide Prevention Resource Center (SPRC)’s toolkit, After a Suicide: A Toolkit for Schools: http://www.sprc.org/sites/sprc.org/files/library/AfteraSuicideToolkitforSchools.pdf 4. Support for those most impacted by the death Close friends, fellow team or club members, or neighbors in the community may have a particularly hard time and need extra support for a period of time. Those who need support might also include a student or faculty member who recently argued with the deceased or a boy/girlfriend who initiated a breakup. Counselors will frequently follow the schedule of the deceased student. A neighbor may host a gathering for families on the same block. The emphasis in these activities is on mourning the loss. Although traditionally postvention counselors have tried to minimize discussions about the details and means of the death, trying to divert grieving friends and colleagues away from such discussion may be counterproductive. People struggle to make sense of the question, “Why did my friend/ classmate/student die by suicide?” and they will wrestle with that question for a very long time. Indeed, this question may be the lead-in to a “teachable moment,” in which key points can be emphasized in discussions: Suicide is never the result of one thing, but rather the convergence of multiple factors; one of those factors is almost always a psychiatric disorder. Important information to share includes evidence that 90 percent of those who die from suicide have an underlying depression, substance abuse problem, anxiety disorder, or other psychiatric issues that contributed to their deaths (Moscicki, 2001).
136 Page
5. Identification of those at risk and prevention of contagion After a suicide death some attention must be devoted to identifying whether close friends or others in the school community might be at risk for suicide attempts or other risky behaviors. Those at risk could include individuals having a history of suicidal behavior or depression, a history of tragic loss or suicide in their family, peers who start to identify with the deceased even though the connection was quite remote, and students, coworkers or staff who are likely to have felt responsible for somehow contributing to or preventing the suicide. Generally, in a school someone on the crisis team should keep a master list of the students and staff that may be at risk. These individuals may need someone who knows them well to check in with them or their family. Most of those identified will not need an immediate referral or evaluation but may be encouraged to ask for support and asked to identify who can be of most help to them if they are feeling scared, overwhelmed, or depressed. 6. Commemoration of the deceased Although the original purpose of postvention activity was to facilitate grief (Shneidman, 1972), over the years the focus of postvention activities has shifted to reducing the possibility of contagion. This has sometimes led to misguided efforts to maintain secrecy after a suicide death, blaming or stigmatizing the deceased. Little effort has focused on facilitating healthy grieving as a necessary form of prevention. School officials can take the lead in offering public condolences to family and friends, encouraging appropriate commemorative activities, and allowing flexibility in work or class schedules so that members of the community can attend memorial services. Generally our experience has been that in schools, large all-community events during the school day, requiring the participation of students, are not ideal. When commemoration activities and funerals are held after school hours, participation is voluntary. It is also more likely that parents may accompany their children or teenagers to the funeral or wake, a practice that should be encouraged. The school can also play a role in helping students know what to expect, as for many adolescents, this may be their first funeral, so knowledge about specific details can be extremely helpful: Will the casket be open or closed? Has the family decided on cremation or burial? Who will preside over the funeral? Are there religious rituals that can be explained ahead of time? It is also important to be aware of online memorials, such as a memorialized Facebook page. This page can become a place for friends to visit and post comments to the deceased, raising the issue of how to respond to comments posted there indicating someone is considering suicide. There is considerable controversy about memorializing a student who dies of suicide for fear that glorification will lead to contagion. We believe that commemoration activities should be the same for any death of a student or colleague, regardless of the cause of death. The CDC (1988) discourages permanent memorials such as planting of trees and placement of benches in a student’s memory. As is supported by others in the field (Kerr et al., 2003; Poland, 2003), our experience has been that it is preferable to memorialize those lost to suicide by encouraging and supporting suicide prevention activities of local or national organizations, raising scholarship money through activities or becoming involved in helping other suicide survivors. Encouraging such “mobilizing” activities is also consistent with approaches to helping survivors deal with the potentially traumatic experience of a suicide loss by supporting a sense of agency rather than helplessness (Brymer et al., 2006). When developing policies, it is important to assure consistency of the response, regardless of the type of death. Similar questions arise about how to handle memorials in a yearbook or related publication. Again, the recommendation is to make it consistent with how any other death would be recognized, and to make mention of those attributes and activities about the person that will be remembered, rather than focus on the cause of death. 7. Psychoeducation on grieving, depression, PTSD, and suicide The goals of this task are to provide individuals with an understanding of the grieving process, as well as to provide education about signs and symptoms of depression, PTSD, and suicidal thoughts or behaviors. For younger people who may not have experienced a prior loss, understanding that their reactions are normative may be comforting. Regarding education on signs and symptoms of depression and suicide, the underlying assumption is that we might prevent further suicide deaths by detecting depressive symptoms or suicidal tendencies in others, or help individuals recognize such symptoms in themselves. Appropriate psychoeducation may counter such risks by reinforcing important social messages and by encouraging adaptive coping and problem-solving strategies, such as help-seeking.
137 Page
If, as postulated, familiarity with suicidal behavior as a coping strategy increases the risk of modeling of this behavior (de Leo & Heller, 2008; Insel & Gould, 2008; Rubinstein, 1983), then it is appropriate in to provide education about other options for coping with difficulties. This is where evidence –based curriculum like SOS come in. 8. Screening for depression and suicidal thoughts and behaviors Because we know there is a possibility of copycat deaths or contagion, especially following a suicide death among adolescents or young adults, we believe that postvention efforts have a responsibility to screen others for depression or suicidal risk. This imperative is bolstered by the 2013 National Youth Risk Behavior Survey (CDC, 2008) findings indicating that 29.9% of students met screening indicators for depression, and 17% seriously considered suicide. Additionally, case finding is consistent with a public health approach to preventing an illness. 9. Provision of services in the case of a second or subsequent suicide Depending upon the size of the setting or community, a second suicide death in a short period of time or within the same peer group may increase the risk that a cluster is developing within the community. While it is our experience that many communities may wait until a third or fourth suicide to take action, we recommend beginning to form a “community coordinating committee” (CDC, 1988) following a second death. The role of a coordinating committee is to elevate suicide prevention to a community level, and to include a wide range of school, community, and regional or state leaders in the prevention plan. Such a committee should include school officials, public safety, community leaders, local mental health agencies, local media, and clergy, and should be linked to the state or regional coalition for suicide prevention as well as the state’s strategic plan for suicide prevention (See for example, Massachusetts Coalition for Suicide Prevention, 2009). 10. Linkage to resources An important part of responding to any potentially traumatic event is linking individuals and groups to resources for continued, local support as needed. Ideally, we recommend providing individuals, family members and school personnel with a list of local mental health resources, including contact information for emergency mental health assessment. As noted above, when multiple suicide deaths occur in a given locale, a crucial part of the response includes ensuring that the many local community professionals are collaborating with a single vision and plan. Community coalitions should also be linked to statewide and federal organizations that focus on suicide prevention and postvention. 11. Evaluation and review of lessons learned On-going feedback should be sought from all involved in the postvention process: students, staff, those involved with implementing the plan, as well as management and local officials, if appropriate. Even if the postvention is a onetime event, plans should include follow-up support and the development of on-going organizational and community structures to respond in the event of future suicide deaths. Plans should address potentially sensitive milestones like anniversaries or graduation, and those occasions may again be used as opportunities to evaluate and review the process. If the postvention is a larger, ongoing project, involving a planning or organizing committee, the committee should build in periods for review and soliciting feedback from all constituents, and the results of the feedback be built into the ongoing plan. 12. Development of a system-wide prevention plan Many school districts that have a suicide death will respond to the tragedy determined to do anything they can to prevent further deaths from suicide. They may form a task force or a community coalition and begin looking at strategies for suicide prevention. Excellent resources exist to guide such efforts (See the Suicide Prevention Resource Center, www.sprc.org). There are a few strategies that are common to most of these prevention efforts:
138 Page
A. Identification and promotion of protective factors In the case of a community-wide effort, part of the work of a school is to identify and promote factors that are likely to mitigate further suicide deaths. Schools can include curricula that teach effective coping and problem-solving strategies, and can teach or encourage frustration tolerance. B. Reduction of means Reducing access to the methods by which suicide may occur is an essential component of postvention. The Harvard Injury Control Research Center has reviewed dozens of research studies demonstrating that under certain circumstances, decreasing access to lethal means of suicide also decreases the suicide deaths in a given area (see www.hsph.harvard.edu/means-matter). This is particularly true for reducing access to higher lethality means, such as firearms (Marzuk, Leon, Tardiff, Morgan, Stajic, & Mann, 1992). For example, information provided to parents of at-risk peers and students following the suicide death of a peer should include suggestions that families secure or remove weapons from the home. Similarly, families should be encouraged to purge their medicine cabinets (in an environmentally safe manner) of unused medications. Medication prescribed for individuals considered to be at risk should be provided in safe, that is, small, quantities. Similar precautions should be considered for other means, for example with architectural and physical barriers on bridges and buildings. Balancing this recommendation, however, is the importance of exercising care to not draw excessive attention to a specific method following a suicide death.
Common Dilemmas in Postvention “We don’t think it was a suicide.” There are many times when the family of the deceased, for a wide variety of reasons may not choose to say that the death was a suicide. While it is incredibly important that the school respect the family’s wishes because we would not want to do anything that would add to the grief of a family who has just lost a child to suicide, it is important that the school find a way to have honest conversations within the community. One place to start is by talking to the family. We always recommend that someone from the school go as soon as possible in-person to offer condolences to the family. There are many reasons why this is important, but among other reasons it opens the lines of communication with the family. In our experience many, although not all, families, eventually give permission for the school to acknowledge the death as a suicide when they come to understand that the school being able to respond to the death and talk openly about suicide can help keep other students safe. However, even when permission is not given by the family, if the students are talking or asking about the death having been a suicide, it is imperative that school personnel are able to find a way to have open and honest conversations about suicide. Many school personnel default to lying or shutting the conversation down, saying “No. It was an accident.” or “I don’t know.” Students generally have radar for authenticity but even more so when they are in pain. Avoiding the truth or shutting down the conversation communicates to them that it is not ok to talk about suicide or how they are feeling. This is the opposite of the goal of effective postvention and of SOS. We want students to know that they can talk to the trusted adults in their lives about these issues. We encourage school personnel to find a way to respond to students that feels authentic to them, respects the wishes of the family, and still encourages the conversation. For example, if a student asks, “Is it true that ____ killed himself?” a possible response could be, “That’s not what we are hearing from the family, but a lot of students seem to be talking about that. If that were the case, let’s talk about what that would mean.” There are certainly cases where the cause of death is unclear or where it is clearly not a suicide. It is important to note that sudden deaths by causes other than suicide can also increase distress and suicidal thoughts and behaviors among students. One study found higher increases in peer groups’ suicidal ideation and behavior after an auto accident death than after a suicide death. Any death in the student community should be considered when implementing SOS. And, again, the school policy and response should be consistent regardless of cause of death. Large Meetings/Assemblies As mentioned in task #3 (Dissemination of Information), we discourage the use of assemblies for notification or discussions about the death. Conducting these conversations in smaller groups (like homerooms) gives responders a chance to gauge individual and group reactions. This includes reactions of students who may be particularly distraught by the news, but also of those who may be joking around or not paying attention. This is important because this type of
139 Page
reaction, while perhaps a coping mechanism, can be particularly triggering for other students who are responding to the death. Smaller groups can also allow students to feel more comfortable asking questions. The “empty chair/desk” This dilemma refers to any space like a desk or a locker where the physical void is a reminder or the person’s absence, but also has the danger of becoming a reminder/glorification of death. Depending on the grade or the structure of a particular school, this may be more or less of an issue. It is advisable to consider the particular needs of the class and the school, balancing the need for commemoration with the need to return to the school’s primary job of teaching and the need to be aware of students who may be at risk. We recommend that desks and lockers not be left indefinitely vacant or unassigned, that, to the extent possible, they not be the site of commemorative memorials (see “Memorials” below). Many schools have left desks empty for the rest of the year and found students staring glassily at the desk unable to concentrate in class. While in other cases, students have arrived at school one day to find their friend’s desk gone and have been angry and felt like this is a violation and yet another loss. When possible and appropriate plans to (re)move or change the desk, etc. should be made with the students’ input, when this is not possible or appropriate at minimum, students should be informed what the plan is in advance. Memorials Memorials are discussed at more length above in task #6 Commemoration of the Deceased. General guidelines include: • Having consistent policies for all student deaths regardless of the cause of death. • Discouraging permanent memorials (benches, planting trees, etc.) which could be construed by other students at-risk as glorifying the death (although there is much contention in the field and little evidence either way regarding this). • Encouraging proactive and prevention related forms of memorialization like participating in Out of Darkness suicide prevention walks. • Memorials are likely to spring up in the school. We recommend that the school plan for this and provide space and materials (like paper and markers) for this, ideally somewhere where school staff have a view of them, perhaps outside of the guidance offices. Most importantly, we suggest that there be a clear plan for when the memorial will be removed, e.g. “please leave messages, condolences, etc. through next Friday at which point everything will be taken and given to _____’s family”). Services Also discussed in more detail above in Task #6, Commemoration of the Deceased, are general guidelines about wakes/ funerals, including: • Providing as much information as possible regarding when, where, and what will happen to students and faculty who want to attend (open casket, what to expect, etc.). • Not closing school. We know that funerals and wakes are very helpful for some people in their grieving process, for others they need the structure and routine of school, for others they may not have known the student who died and are not personally grieving. • Not sending buses from the school. We want to encourage parents to go with their children. Even if the children do not want them to, even if they just stand in the back while their child sits with his/her friends. We have heard repeatedly how students have realized, after the fact, how important it was to have their parents there for them, and that there are few moments as powerful as the ride home. • To the extent possible, allowing those who want to attend the services to do so. For many schools it is a significant challenge to keep the school and classes running when many of the staff are grieving and very much want to attend the funeral/memorial. With planning there are generally ways to make this viable.
140 Page
Rumors The best way to minimize rumors which are often rampant after a suicide death (for more discussion on this, see Task #1, Verifying the death and cause), is to provide accurate, factual, timely, and - to the extent possible and appropriate complete information. If there is a lack of information forthcoming, people are more likely to invent things to fill the void. The Media We recommend that one staff person be assigned to be the media coordinator and that all staff be advised that any requests from the media should be directed to that individual. Have the media coordinator familiarize him or herself (ideally in advance) with the safe reporting guidelines for suicide, http://www.sprc.org/sites/sprc.org/files/library/at_a_ glance.pdf, and provide the guidelines to any media sources interested in reporting on the death. These guidelines can also be provided to students and staff who may be posting information or thoughts about the death on social media. “We were about to start reading Romeo and Juliet. Should we still do that?” There are many considerations in terms of how to approach the curriculum and other school activities (plays involving suicide, etc.) in the immediate aftermath of a suicide death and in the curriculum going forward. While there are certain cases where, due to timing or other circumstances, continuing with a planned activity may be ill-advised, in general the school has to move forward with providing the structure, curriculum, and overall education that it believes is best for students. There are many ways of doing this in a supportive, safe, and trauma-informed way. We believe that it is important to be striving to do this across potentially difficult issues for all students regardless of whether there has been a death in the community. For example, one school was about to read The Kite Runner and wondered if they should still do so because there is a suicide attempt at the end. We commented that the traumatic incident that most people remember from the The Kite Runner is brutal rape scene near the beginning, and while it is likely that there are students in the class who are struggling with thoughts of suicide right now, it is almost certain that there are students in the class who have been sexually assaulted. When teaching this kind of material we encourage always being sensitive to the fact that students will have had some of these types of thoughts and experiences and to encourage help seeking and problem solving. The example that comes up most commonly for schools is Romeo and Juliet. This story is so often told from the perspective of the romance of star-crossed lovers. Consider talking about problem solving and help seeking behaviors by encouraging discussions about whether their plan was a good one even if the message hadn’t gone awry. What other options could they have come up with? Reframe the narrative to talk about the idea that the real tragedy is that they didn’t know that there were other options. They didn’t know that they could ask for help.
Considerations for Implementing SOS as Part of a Postvention Response Timing: The SOS Program curriculum fits in perfectly with tasks 7 and 8 – psychoeducation and screening for depression and suicide. However, while we recommend that some pieces of education regarding depression and suicide be included in the conversations immediately following the death, the broad focus during this time has to be on allowing the students time and space to grieve. There are varying opinions on the exact right amount of time recommended before introducing a formal curriculum. We generally recommend waiting at least 3-4 months after the death. Again, this does not mean waiting this long to have conversations about suicide, but only before implementing a classroom-based curriculum. We also recommend that if school administrators knows that they will be implementing SOS to inform the students, parents, and staff that it will be happening as soon as possible. This is helpful both in assuring the community that there will be formal, universal suicide prevention education (some communities may be concerned that it seems like nothing is being done), and in giving students, parents, and staff time to prepare themselves for the program and get answers to any questions they might have. It is also important to consider timing in terms of the school calendar and important dates that might be related to the death. One school we worked with conducted the SOS Program curriculum four months to the day from a student’s death. Students were very angry and felt like this was a violation of the anniversary day and of the student’s memory. Considerations such as the time of year and grade (e.g. freshmen in the Fall just starting high school may be so
141 Page
overwhelmed, not feel comfortable, or have anyone that they can talk to yet and so may have more difficulty engaging with material/discussion). School calendar considerations of standardized testing dates and impending vacations are always important, but should be given extra thought in a postvention situation, as students who are grieving may be experiencing increased stress related to such events. Each specific group of students may have different needs as well, and we encourage the school to use their judgment and knowledge of the dynamics of a specific class in planning the curriculum. Explicit Preparation: In implementing the SOS Program in schools where there has been a suicide death, it is important to acknowledge that there may be increased anxiety about the program on the part of students, parents, administration, staff implementing the program, and the staff at large. When using screening it is often the case that more students may screen in and planning and preparing for who can help with triaging these students and to where necessary referrals can be made. In addition to the parents’ forum and staff training, which are always recommended with SOS implementation, we also recommend considering writing a letter to students explaining the program and what to expect. We also recommend considering a more active or hybrid permission process (some schools have used passive permission for the curriculum and active for the screening). While there is a strong possibility that seeking active permission may decrease the number of students able to participate, it is especially important to have buy-in and understanding from the community of what the school is trying to achieve by using the SOS Program. Additional Discussion Components/Curriculum Considerations: Prior to beginning the program and showing the video we strongly recommend that an introduction be made that: Acknowledges the death; e.g. We are going to be talking about a serious and sensitive subject - Signs of Suicide. We have had a hard year with the loss of _____. You may also have other personal connections to issues of depression and suicide. This presentation is about taking care of you and your friends. • Tells the students exactly what is going to happen during the period; e.g. Today’s program will include the following: o A video about depression and the signs of suicide along with the steps to take if you feel a friend or loved one is at risk o A discussion about the video, your reactions, and your thoughts about depression and suicide o A newsletter for you to look at, which I will hand out shortly o A brief screening form to check how you are doing o A transitional activity (if possible) • Mitigates potential guilt brought up by the video; E.g. The information you will hear is true for most people, however, there is a small group of people that may not show signs and symptoms of depression or suicidal urges. Please also remember as we go through this program that we are all doing the best we can to help and watch out for each other. As you watch, don’t worry if you didn’t know what to do in the past. We are participating in this program to learn more effective ways to help each other now, and in the future. • Letting the students know that they may have strong or unexpected reactions to this material, and that that is ok. And giving them some sort of plan for what to do if they become overwhelmed. Consider modifications that might help specific groups of students such as discussion breaks during the video, structured questions, small group discussions, or transition activities (so as to allow students to reregulate themselves before heading to their next class).
142 Page
Consider including a conversation about why grief after suicide can be so complicated in the discussion piece of the SOS curriculum (this can be connected easily by talking about the experiences of Elyssa’s family and friends). This may be overwhelming for some students (and so may not be indicated depending on the group), but for other groups it may feel insensitive not to address it. Consider also discussing ways to support/talk to a friend who has lost a loved one to suicide.
Future SOS Trainer Take Home Note: Sharing Local Resources Calling on national and local community resources is critical in postvention response. When preparing for a training, contact local resources to determine postvention services and resources provided. Consult with your state’s Department of Public Health and local suicide prevention coalitions to find out what resources are available for postvention support in your community. National Resources: • The American Foundation for Suicide Prevention and Suicide Prevention Resource Center’s After a Suicide: A Toolkit for Schools: http://www.sprc.org/sites/sprc.org/files/library/ AfteraSuicideToolkitforSchools.pdf • Erbacher, T., Singer, J. & Poland, S. (2014) Suicide in Schools: A Practitioner’s Guide to Multi-level Prevention, Assessment, Intervention, and Postvention (School-Based Practice in Action). Routledge: New York. Massachusetts Resource: Riverside Trauma Center, funded through the Massachusetts Department of Public Health, provides suicide postvention to schools throughout the state. If you are located in Massachusetts and experience a suicide death (or other trauma) in your school community, please call the 24 hour critical incident line at 1-888-851-2451, press option #1 and ask to speak to a trauma center manager.
Notes: __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________
143 Page
Part 6:
Advocating for Suicide Prevention in your Community
144 Page
Section 16: Liability & Suicide Prevention & Screening Objective: • Understand best practices for protecting schools and individuals from legal action
Addressing Liability Concerns about Suicide Prevention, Assessment and Intervention School administrators and community leaders have an obligation to protect their schools and communities from litigation and rightly seek to adhere to laws and regulations when managing suicide prevention, assessment and intervention. However, concerns about legal action can paralyze large bureaucracies (such as schools) from taking any action for fear that attempts to support students will be misconstrued negatively. As a SOS Certified Trainer, it is important to encourage all attendees to engage in best practices when implementing suicide prevention policies. Attendees should understand that delivering evidence-based suicide prevention programming is one of the best ways to ensure that a suicide never occurs and that a school is not found liable in the unfortunate event of a suicide. There have been a number of court cases in which schools were sued following a student suicide. Suicide in Schools: A Practitioner’s Guide to Multi-level Prevention, Assessment, Intervention, and Postvention by Terri Erbacher, Jonathan Singer, and Scott Poland reviews court cases to illustrate lessons learned and explain the meaning of the key legal terms. One of the key issues in legal cases has been failure to train school staff in suicide prevention. The following content is adapted from Suicide in Schools: A Practitioner’s Guide to Multi-level Prevention, Assessment, Intervention, and Postvention.
Legal terms and key legal issues for schools Negligence is a breach of duty owed to an individual involving injury or damage (suicide) that finds a causal connection between a lack of or absence of duty to care for the student and his/her subsequent suicide. Foreseeability is a situation in which a reasonable person would have been able to recognize that a student was in an acute emotional state of distress and that self-harm or danger, in some way, could and should have been anticipated. Foreseeability may relate to the absence of appropriate supervision or the lack of appropriate policies/procedures used when a student’s suicide was deemed likely and imminent. State-created danger is found when a school is in violation of legal responsibility based on the constitutional rights of the victims. The argument states that through enacting or failing to enact/follow through with certain policies and procedures, the school caused danger to the student who attempted/died by suicide. Immunity Schools and school districts are rarely found liable for failing in their duty to protect students. Unless the school board or administration is found to have enacted or failed to enact policies and procedures that violate their duty to protect (state-created danger), the school maintains governmental immunity for the wrongful actions of the individual school employees. It is important to note that individual school staff can be sued for failing to protect students even if the school district has been determined to have immunity from such a lawsuit. In loco parentis is a Latin term for “in the place of a parent” and refers to the legal responsibility of a school perform the responsibilities of a parent for a student while at school. In other words, schools may be mandated to look out for the student’s best interest as they see fit. Schools assume the control and supervision of the children as stand-in parents while they are attending.
145 Page
Intervening force is a common defense for schools and their personnel, which state that suicide is an intervening force that breaks the direct connection between the school’s actions and the injury to a student. For instance, schools may argue that a number of events occurred between the time when the school was negligent (such as by failing to notify parents when they knew a student to be suicidal) and the actual suicide of the student. There was an intervening force between the negligence and the suicide.
Professional Ethical Standards for Key School Personnel Do no harm For any school mental health professional to uphold his/her ethical standards, that person must do no harm, which should include suicide prevention efforts. Whether there is a legal mandate to provide suicide prevention or not, school mental health professionals always have an ethical obligation to prevent harm to the student and protect that student from potential danger. Competence Mental health professionals are obliged to maintain competence by staying up to date on the risk factors and warning signs of suicide. This can be ensured by mandating trainings on suicide prevention, assessment, and intervention. Limits to confidentiality Mental health professionals must be aware of the limits of confidentiality when working with youth. The suspicion of suicidal behavior is a reason one must break confidentiality. Just as students often worry about breaking their friend’s trust, mental health professionals often feel bound by confidentiality and their strong relationship with the student. It must be clear to all adults working with young people, that confidentiality can never be promised if there is concern that a child may harm themselves. Notifying parents Failure of the school to notify a student’s parent or guardian when there is reason to suspect that the student is suicidal is the most common source for lawsuits (Berman et al., 2009). When there is reason to believe that a student is contemplating suicide, confidentiality must be broken and parents immediately notified. Even if a student denies suicidal thoughts or intent, it is the duty of the school to notify the parents if information available implies that the student may be suicidal. There is one exception when notifying parents may not be possible. If the team decides that there may be increased risk to the child due to suspected neglect or abuse at home, school staff should call local child protective services or the police instead of the parents. Even this exception requires that a call be made outside of the school. If a parent or guardian refuses to ensure the safety of their child, refuses to seek additional mental health services for the child, or does not take the suicide risk seriously, school personnel should call local child protective services. Transfer of responsibilities to parents Once parental notification is accomplished and properly documented, school personnel have fulfilled their legal duty to transfer responsibility to the parents through notification. Throughout this process, school staff should use an emergency notification form for documentation. An emergency notification form asks parents to sign and acknowledge that they have been notified of the suicidal emergency with their child and have been informed about needed treatment and supervision. If a parent refuses to sign, a second school employee should note their refusal on the form and protective services should to be called. The school should keep the form to document that it notified the parents and made appropriate recommendations in case any legal action is taken against the school by the parents. Providing appropriate postvention response Schools should implement a robust postvention response in the aftermath of a suicide in order to support grieving students and prevent a contagion effect from occurring.
146 Page
ACTivity: Review of Key Legal Case and Consider Implications for Schools Review the case study below and think about the key legal terms and professional ethical standards we reviewed and how they relate to this example. Wyke v. Polk County School Board (1997) Key points in the case: • In 1989, 13-year-old Shawn Wyke killed himself in his own home after two prior attempts on school property. • The school did not notify Shawn’s guardians of his two prior attempts on the school campus during school hours (school officials were aware of these attempts). Shawn’s mother affirmed that, had she known about her son’s suicidality, he would have received more care and supervision at home. • Shawn’s guardians were not informed of either suicide attempt at school; however, they were aware of Shawn’s behavioral and emotional issues. They had made an appointment for him to see a mental health counselor, but he killed himself prior to the appointment date. • Another boy witnessed one of Shawn’s attempts to hang himself in the school bathroom, and the boy informed his mother. When his mother immediately informed the school, the dean of students said he would “take care of it.” The dean of students then called Shawn into his office and read bible verses to him, believing this to be the best way to handle the situation. The dean of students also stated that he was not allowed to call parents. • A school custodian testified that after she heard a boy discussing conflict with his grandmother, she walked into the bathroom and the boy told her he would have killed himself had she not walked in. After the boy left, she found a coat hanger and cord hanging from the ceiling, which she threw out. She then reported notifying the vice principal of this event without being asked to identify the boy and then being asked if she did not have anything else to be doing. The vice principal denied having this conversation. Two days later, Shawn died by suicide. The jury felt as though Shawn’s attempts on the school’s campus would cause any sensible person to reasonably assume that he needed help/care or he would be in imminent danger to himself and attempt once more. As a result, the court determined that Shawn’s suicide was foreseeable. In the end, the school board was found liable for: • Not offering suicide prevention programs (failure to train) • Not providing adequate supervision of a student • Failing to notify Shawn’s parents that he was suicidal This case affirmed that the Polk County School Board was guilty in their negligence to take appropriate steps to prevent Shawn’s suicide, and this litigation can be used as a reference in present and future lawsuits against schools for similar situations. Additionally, since this lawsuit occurred, much more research has been published regarding youth suicide, warning signs, and the steps schools should be taking to implement prevention programs/strategies.
147 Page
How School Leaders Can Best Protect Their Schools: 1. Recognize that a student in their school could die by suicide, and there are students thinking about it right now. Work to prevent this tragedy 2. Provide and document suicide prevention training for all staff 3. Develop guidelines to ensure that parents are promptly notified of suicidal behavior 4. Implement and document suicide prevention programming, appropriate interventions and postvention efforts Schools that implement solid suicide prevention programs and procedures, greatly reduce risk of liability, follow their legal duty to care for students, and have the best chance at saving lives. (Poland, 2015) How school personnel can best protect themselves from liability issues: 1. Maintain liability insurance: Nurses, social workers, psychologists, and counselors in schools should each carry individual malpractice insurance. 2. Seek supervision from colleagues: Always consult with others to gain another perspective and ensure the best care is being taken of the student. 3. Keep good records: Prioritize thorough documentation as without records, there is no evidence. 4. Provide mandatory crisis training to all personnel and document the dates and those in attendance. 5. Provide best practices responses: A school should be implementing suicide prevention programming, appropriate intervention as needed, and postvention response should a suicide occur.
148 Page
Notes: __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ _________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________
149 Page
Section 17: Local & State Level Advocacy Objective: • Learn about advocacy at the state and local level and how to use trainings as a form of advocacy • Learn best practices in media outreach
What is Advocacy?
Advocacy is the act or process of supporting a cause, proposal or policy. How to Advocate • Take a stand on an issue, creating a vision for a solution • Identify the people who can be involved in making your vision come true • Create or attend a forum where your voice can be heard • Discuss, argue, provide evidence to support your argument
Advocacy Activities • Communicate with administrators, elected officials and local contacts • Actively participate in local coalitions and prevention groups • Use SOS Trainings to empower grassroots advocates • Get involved with local government, assist in development of legislation and/or testify at hearings • Get involved with district planning by presenting at school meetings or assisting with development of policy Having a Clear Message To be the most effective in your advocacy efforts you need a clear message. What is the issue and why is important? Why is prevention necessary and who should be involved? What does research indicate? And what is the best way to educate people? Helping schools adopt evidence-based youth suicide prevention programming will create the most impact in your community. Many schools that adopt the SOS Program do so because they have a champion or an advocate- someone who has been affected by suicide- or the school has experienced a tragedy. Certified SOS Trainers can use trainings to advocate for schools to adopt prevention programs BEFORE there is a crisis. By inspiring, educating, and engaging schools and organizations in youth suicide prevention, we can prevent tragedy! Training buy-in can sometimes be difficult to secure. This section will outline different avenues of outreach, who your allies and partners are, and how to engage the media.
Advocacy Strategies as a Certified SOS Trainer There are two advocacy strategies you can implement as a trainer: school-level and community/grassroots. Schoollevel advocacy refers to engagement of specific schools and/or districts, working to support their youth suicide prevention program implementation. Community/grassroots advocacy refers to larger scale outreach, working to get multiple schools and organizations involved in youth suicide prevention. School-level Advocacy Many schools need support in gaining buy-in to begin suicide prevention programming. Certified SOS Trainers can help with school-level advocacy.
150 Page
Meet with local partners: Local partners are helpful for you in understanding what strategies have and have not worked when navigating prevention in schools. Connecting with these contacts can help bridge communication gaps between schools and their community partners. Leaders in prevention/youth programming to consider • • • • •
Local organizations advancing “controversial” programming in schools such as sex education, LGBTQ support Local bully prevention programs Youth-serving organizations Supportive churches and faith-based organizations Suicide prevention coalition members
Engage parents and families: Attend PTO/PTA meetings and present or set up an information table about suicide prevention. Remember always to provide resources for people in need of support Engage school staff: Ask to present at a staff meeting to give a brief introduction to the topic of youth suicide. Provide data: Many people are unaware of the prevalence of depression and suicidal thoughts/behaviors in youth. By sharing local data with staff, parents and administrators you help educate and destigmatize the topic, while creating a sense of urgency. The Youth Risk Behavior Survey (YRBS) is a great tool to find local data, visit: http://www.cdc.gov/ healthyyouth/data/yrbs/index.htm Provide examples from neighboring schools or districts: Identify area schools or districts using SOS or a similar program to share success stories and lessons learned from these schools. Offer to host an SOS Trusted Adult Training: you can offer to provide a training to parents and/or staff to introduce the topic and gain buy in. *Check to see if you have local youth suicide prevention legislation to see if there is a training requirement for school personnel. Offer to host an SOS Implementer Training: if the school is interested in implementing the program, but concerned about the specifics, offer to host a training to walk school staff through planning, day of implementation and follow up with students. Community/Grassroots Advocacy Host an SOS Implementer Training: Although working directly with schools to bring prevention programming can be successful, hosting an SOS Implementer training for a variety to schools and organization can help you reach the community at large. Research state and national legislation: Knowing your state laws regarding youth suicide prevention will clarify the demand for trainings in your state. For example, if state law requires suicide prevention training for all school staff, there will be many people seeking training at any given time and you may consider using the legislation as a marketing tool to get people at your training. When a bill is proposed, or a piece of legislation is passed related to youth suicide prevention in your state, there is a good chance a training requirement is included. In addition to helping you understand the demand, knowing the ins and outs of local legislation will help you understand who is/will be responsible for regulation oversight at the state level. This information will help you identify any funding associated with the legislation and what agency is available for questions.
151 Page
Look to local partners & coalition leaders: Local partners and suicide prevention coalition leaders are often your greatest allies in thinking through the logistics of trainings; spreading the word for the training, assisting in finding a location, and potentially helping with funding. It’s important to consider local suicide prevention/mental health advocacy champions in your community and to begin connecting with these allies. Many of these partners and contacts will already have plans for youth suicide prevention in your state. It’s important to gain a fuller understanding of what they are doing and how universal suicide prevention for youth fits into the larger plan. Using the media: Engaging your local media can be helpful for a number of reasons. Putting out a press release can help recruit attendees for a training and show neighboring schools/districts what you are doing in your community all while destigmatizing the topic of depression and suicide. Use the SOS Training Media Guide provided below and in your trainer’s portal to plan your media outreach. Organizations and agencies to consider to help you find an audience for training: • State membership organizations (State level school nurse, school social work, school counselor organizations) • Local prevention non-profit organizations • Local youth-serving organizations • State/regional suicide prevention coalitions/task forces • Hospitals • Community mental health providers • State departments (Dept. of Public Health, Dept. of Behavioral Health, Dept. of Public Instruction, etc.) The SOS Implementer Training provides your attendees with information on how to implement the SOS Program within their schools’ structure. Many schools will be able to go back to their school/organization and implement the program without further support while other schools may want help with buy-in, logistical planning, etc. Certified SOS Trainers have the skills to provide this support however, if you cannot accommodate, please connect these schools with SOS Program staff for follow-up.
Working With Your Local Media to Highlight Your Suicide Prevention Efforts The media plays a vital role in shaping public opinion and raising awareness for important public health issues, such as suicide prevention. Working with the media is an excellent way to promote programs, initiatives and events, and increase visibility in your community. The following guide offers tips and information that will help you identify and work with reporters, create materials, and garner coverage. Prior to the Training Event: Build a Media List Identify the appropriate reporters, editors, producers, news directors, and departments in local newspapers and broadcast stations that focus on local, community news or health. You may also want to do an internet search of past stories to see if anyone has covered suicide prevention or other mental health topics and add them to your list. Contact the Media Once you’ve created your media list, you’ll know which reporters you plan to contact but before you email them or pick up the phone, you’ll want to take some time to get to know what they cover and topics that are frequently covered by the media outlet. If possible, take some time to read through some of their previous articles to see if there’s a way to tie the current message of your training to their past reporting. Additionally, most news and radio shows have social media channels you can look at to get to know more about the topics they find compelling and want to cover.
152 Page
Reaching out to a reporter to have them cover your event is called a pitch. Keep in mind that that a newspaper pitch and a radio/TV pitch should be different. They have different goals and audiences, and your pitch should reflect that. If the reporter is interested in attending or covering the event, they will contact you. They are inundated with requests to cover events and organizations every day. It’s important to provide new, timely, and accurate information to help build a relationship with the reporter as a trustworthy source of news. You want to reach out to reporters about a week to two weeks prior to the event. Your pitch on the event should include the following information: • • • •
Date, time, and location of the event Who will be in attendance at the event (note if any elected officials will attend/speak) Who will speak at the event What is the goal of the event
If you are interested in having the public attend your event, you’ll want to post information on the event on your social media channels. Day of the Training Event: Prepare a Media Kit The day of the training event, you’ll want to prepare a media kit, which provides information for journalists that attend the event. Below are some examples of what to include. The rest of this guide also includes language, descriptions, and templates for your media kit. A media kit is usually a folder that includes the following information: • Event Agenda • Facts (and citations) about youth suicide • A press release about the event • Bios for each speaker • Sponsor Information (If applicable) • Contact information (feel free to share our contact info) • SOS brochure or fact sheet • Safe message guidelines for media Include Facts About Youth Suicide To draw attention to the need for youth suicide prevention efforts you always want to share key statistics and facts about youth suicide with your media contact. Below you will find some national statistic. Please feel free to also use local or regional statistics. • Suicide is the 2nd leading cause of death for 11-18 year olds in the US (CDC 2015) • The prevalence of depression in adolescents and young adults increased from 8.7% in 2005 to 11.3% in 2014 (Mojtabai et.al 2016) • 17.7% of high school students in the US seriously consider attempting suicide (CDC, YRBS 2015) • 8.6% of high school students have attempted suicide in the past year (CDC, YRBS 2015)
153 Page
Sample Trainer Bio Jane Adams, LCSW, is a Certified SOS Trainer at Chicago Youth Services. She is the Training Manager and oversees prevention programming for the south loop of Chicago. In this role, Jane works with schools and community organizations to provide prevention training for substance use, suicide prevention, and character development. She is a frequent speaker at conferences and provides prevention trainings to groups nationally. Jane received her Master of Social Work from the University of Chicago and a Bachelor of Arts from the University of Michigan. About Screening for Mental Health Screening for Mental Health (SMH), the pioneer of large-scale mental health screening for the public, provides innovative mental health and substance use resources, linking those in need with quality treatment options. Our programs offered online and in-person, educate, raise awareness, and screen individuals for common mental health disorders and suicide. For more information about Screening for Mental Health, visit http://mentalhealthscreening.org. Make sure to include information on the speaker’s organization and contact information with each bio. Contact Info Sheet In your media kit you want to provide contact information for anyone involved in the training. This would include the trainer, any speakers and their organizations, and any sponsoring organizations. If you would like, you can provide them with contact information for Screening for Mental Health: Screening for Mental Health 1 Washington St. Ste 304 Wellesley Hills, MA 02481 Office Phone: 781.239.0071 Email:
[email protected] Information about The SOS Program You may also want to provide information on the SOS Program. We are happy to provide you with pdf copies of fact sheets, brochures, etc. This information should also be available on your online portal. Contact us with any questions! Safe Messaging Guidelines for Media One of the biggest challenges for media reporting on suicide prevention is doing so with safe messaging. We want the media to cover issues of mental health and suicide prevention to help fight stigma but we also want them to eliminate triggering language to help fight contagion. When providing any information to the media regarding your trainings, it is recommended to also include literature on safe reporting. You want to provide the media with as many resources as possible. It is our suggestion that you let them know you are including the information with a statement like this, “I’m sure you already know this information but it’s standard for us to include this information in any of our press kits.” This way you bring attention to the fact that it is in the media/press kit but also acknowledge that you are not challenging their ability to report safely. Here are some resources we recommend sharing: • http://www.sprc.org/keys-success/safe-messaging-reporting • http://www.sprc.org/sites/default/files/migrate/library/SafeMessagingrevised.pdf • http://reportingonsuicide.org/ Tips for Talking to the Media Your media kit will provide journalists that attend your event with vital information but most reporters will want to speak with someone at the event to get a unique quote to add to their story. The best way to prepare for this is to have some talking points that you review prior to the event. You do not want to provide the talking points to the press but instead, speak to them when they are asking you questions.
154 Page
You want your talking points and answers to reporter questions to be concise, free of jargon and to focus on the impact of the event. Below are some standard talking points for Screening for Mental Health and the SOS Program. (You can also use this exact language in any follow up emails with press regarding details of your training). • Screening for Mental Health, Inc. (SMH) is a national nonprofit organization. Its mission is to provide innovative mental health and substance use resources, linking those in need with quality treatment options. • The SOS Signs of Suicide® Prevention Program, a program of Screening for Mental Health, is the only youth suicide prevention program that has demonstrated an improvement in students’ knowledge and adaptive attitudes about suicide risk and depression, as well as a reduction in actual suicide attempts. • Listed on SAMHSA’s National Registry of Evidence-based Programs and Practices, the SOS Program has shown a reduction in self-reported suicide attempts by 40-64% in randomized control studies (Aseltine et al., 2007 & Schilling et al., 2016). • SOS is unique among school-based suicide prevention programs as it incorporates two prominent suicide prevention strategies into a single program: an educational curriculum that raises awareness about suicide and depression, and a brief screening for depression. • The SOS Programs use a simple and easy-to-remember acronym, ACT® (Acknowledge, Care, Tell), to teach students action steps to take if they encounter a situation that requires help from a trusted adult. • SOS is offered for both middle and high school aged youth and can be implemented in one class period by existing faculty and staff. Photos If possible, designate someone to take photos at the event of speakers providing the training. After the event, you can use the photos on your social media channels to highlight the event. After the Training Event: Contact reporters who covered the event to see if they need additional information or quotes to complete their stories. Call reporters who did not attend the event to offer additional information, including elements of the media kit, in case they intend to publish an article on the event. • Reporters may not always tell you when they will run a story. You’ll want to monitor the media sites you reached out to see if they covered the story.
155 Page
Sample Press Releases Press Release for Trusted Adult Trainings Suicide Prevention, Trusted Adult Training for [Parents/School Administrators/Community/School Staff] to be held [DATE] in [CITY] The Training is Sponsored by [insert sponosor if applicable] [AUDIENCE] in the [CITY/TOWN] area are invited to attend a training on recognizing and responding to symptoms of youth depression and suicide risk. Suicide is the second leading cause of death for youth between the ages of 11 and 18, after accidents and unintentional deaths, according to the Centers for Disease Control. The free training will be held [DATE], from [TIME] at [LOCATION]. [NAME OF ORGANIZATION, is sponsoring the training. MISSION/VISION] School staff and other adult community members will be trained to identify and respond to youth who show signs of depression or suicidal tendencies. They will learn about the use of Screening for Mental Health’s SOS Signs of Suicide® Prevention Program in the middle and high schools. The SOS Programs use the acronym, ACT® (Acknowledge, Care, Tell), to teach students action steps to take if they notice the signs of depression or suicide in a friend or themselves.. [INFORMATION ABOUT THE SPONSORING ORGANIZATION, IF APPLICABLE] The SOS Signs of Suicide® Prevention Program was developed to reduce suicide among adolescents and has demonstrated its effectiveness. Research showed a 64 percent reduction in self-reported suicide attempts among youth who received the program. The SOS middle and high school programs are listed on the Substance Abuse and Mental Health Services Administration’s (SAMHSA) National Registry of Evidence-based Programs and Practices. To learn more about the SOS Program please visit https://mentalhealthscreening.org/programs/sos-signs-of-suicide. To learn more about Screening for Mental Health please visit https://mentalhealthscreening.org/ Contact [YOUR CONTACT INFO]
156 Page
Press Release for Implementer Trainings Training for School Staff Implementing Suicide Prevention Programming to be held [DATE] in [CITY] The Training is Sponsored by [insert sponosor if applicable] School staff in the [CITY/TOWN] will attend a training on recognizing and responding to risk factors and symptoms of youth depression and suicide. Suicide is the the second leading cause of death for youth between the ages of 11 and 18, after accidents and unintentional deaths, according to the Centers for Disease Control. The free training will be held [DATE], from [TIME] at [LOCATION] is being presented by [NAME OF ORGANIZATION, MISSION/VISION] Experts will train school staff to implement Screening for Mental Health’s SOS Signs of Suicide® Prevention Program for middle and high school youth, and to provide gatekeeper training to other adults in their schools and communities. The SOS Programs use the acronym, ACT® (Acknowledge, Care, Tell), to teach students action steps to take if they notice the signs of depression and suicide in a friend or themselves.The program can be implemented in one class period by school faculty and staff. [INFORMATION ABOUT THE SPONSORING ORGANIZATION, IF APPLICABLE] The SOS Signs of Suicide® Prevention Program was developed to reduce suicide among adolescents and has demonstrated its effectiveness with a new study showing a 64 percent reduction in self-reported suicide attempts among youth who received the program. The SOS middle and high school programs are listed on the Substance Abuse and Mental Health Services Administration’s (SAMHSA) National Registry of Evidence-based Programs and Practices. To learn more about the SOS Program please visit https://mentalhealthscreening.org/programs/sos-signs-of-suicide. To learn more about Screening for Mental Health please visit https://mentalhealthscreening.org/ Contact [YOUR CONTACT INFO]
157 Page
Notes: __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ _________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________
158 Page
Part 7
Time to Train
159 Page
Section 18: Developing your Trainings Objective: • Discuss how to prepare for your trainings How to prepare Each training you facilitate is going to be different, depending on the type of training, the plan for implementation, and the community you are working with. Prior to each training, work with the training host to clarify expectations, audience, and plans for program implementation. Use the questions outlined in the Training Planning Checklist to help you customize your trainings for your audience. What to do with this information • SOS Trainings are meant to be customized to meet the needs of each audience. Certified trainers have access to the SOS Trainer’s Portal containing PowerPoint slides, handouts and other training materials. The side decks contain all SOS training slides available for each training type. While SOS trainings must contain key messages about youth suicide prevention and the SOS Program, you are encouraged to: • Remove slides to fit time constraints/audience needs • Adjust slides with local statistics and resources • Create additional slides specific to your audience (ex. Local school protocol) • SOS trainings are most effective when they are designed with the audience in mind. Feel free to contact the SMH training program team for support as you customize your trainings!
Notes: __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________
160 Page
Pre-Training Questions and Logistics Training Host • Who are they? • What is my or SMH’s history/relationship with the host? If none, how did they learn about SOS? • Have they implemented SOS before (MS, HS, both?) or any another universal suicide prevention program? • If yes: which grades, how many students, for how many years, who are the implementers, how do they train staff, do they host parent nights, etc, etc. • If they’ve used SOS previously, are they using all the components? If not, why not? • Are there any concerns they/their community have about SOS or suicide prevention work? Training • What is their goal/hope for the training? • What type of training do they want? • # of hours, including time for breaks • Start time • End time • Training location address • What time does the training location open/close? • Can the trainer arrive early to set-up? Attendees • # of attendees • Who are the attendees? • What is their relationship to the training host? • What is their relationship to other attendees (i.e. same school/agency)? • Have attendees had prior suicide prevention training? • Are attendees new to SOS or are they experienced implementers? • Is there any information that should be especially emphasized with attendees? • Have there been any recent suicides in the schools/community? If so, is postvention underway? • Do students in the school struggle with Non-Suicidal Self-Injury (NSSI)? Is there a NSSI policy in place? • What are your local demographics? • Do the students face any particular risk factors? A/V Needs and Supplies • Small table for laptop/projector/speakers • Laptop • Projector • Screen • Speakers • Few pieces of flip chart paper (or chalkboard/whiteboard) • Markers • Tape for flip charts (if applicable) • Nametags Other Nitty Gritty Details • Day-of contact’s name, email address, and cell number • Is lunch being given to attendees…or will they be a hungry/de-caffeinated? Should you build in extra time for them to get food off-site?
161 Page
On-Site Prep Check List • Arrange space as needed • Room/chairs/tables • My space: water, clicker, timeline/agenda, pen • Nearby space: store my bag/notes and extra handouts • Set-up A/V with PowerPoint • Test movie and speakers • Unpack my handouts • Distribute PowerPoint slides (if applicable) • Distribute pre-tests • Put candy on each table (if doing candy icebreaker) • Distribute or put out any additional handouts • Ready my handouts/activities in bunches • Pre-tests • DVD facilitator guides (if doing) • BSAD Acticity (if doing) • Logistics activity (if doing) • Post-tests • Prep my flipchart and/or dry erase board • Schedule for Today • Ground Rules • Resource sharing space
162 Page
Section 19: Next Steps for Certified Trainers Objective: • Understand the opportunities and responsibilities for SOS Trainer Certification
The Certification Once you have completed the two-day training, you will receive an email with your certification exam. Successfully complete this test and you will receive a certificate, showing your completion of this course. The certificate will have an expiration date one year following the training. You will be added to our list of trainers and contacted if there is a need in your community that SMH cannot fulfill. In the future you may be listed as a trainer on our website as a resource for those in the community looking for trainings. Note: If you would not like to be listed on our website as a Certified SOS Trainer please contact our office at 781-239-0071.
Access to Training Materials As a Certified SOS Trainer you will have access to a web-based platform where you can download and print for your trainings. If, at any time, you cannot access these materials please contact our office.
Posting Training Opportunities All trainings hosted by a Certified SOS Trainer can be posted on the Screening for Mental Health training website. The date, time, location, and target audience are always to be communicated to SMH staff and we can share this info our training website. Even if you are providing a training that is closed to the public (for instance, an in-school training), contact SMH so that we may publicize your suicide prevention work in the community.
Communication with Screening for Mental Health What to expect from us Screening for Mental Health (SMH) can provide any technical and/or logistical support for your trainings. Our marketing team can assist you with training flyers and advertisements. We will post your trainings publicly on our training website to assist with recruitment of participants and publicize your suicide prevention work. We will contact you when any updates are made to training content. Examples may include: training website updates, additions and subtractions of PowerPoint slides, additions of handouts and suggested reading, and SOS Program updates. We will be sure to contact you directly to share this information. There may be cases in which SMH is contacted by a school/organization with a training need. If SMH staff is unable to fill the need and the school/community is in your area, we may contact you to see if you could assist in training. SMH can handle your registration needs. Participants can register for your trainings on the SMH training page, allowing both SMH and the trainer to collect this information. If you are interested in learning more, contact our office at 781-239-0071. Note: We will never sell your contact information and we will only share it with schools/organizations/individuals with your permission.
163 Page
What we expect from you • Prior to each training, please send us the following information: • Date/Location/Training Type (trusted adult or implementer) • List of registrants (template spreadsheet on trainer’s portal) Within a week of completing a training please: • Complete electronic form with training description (link on trainer’s portal) • Upload list of all attendees in the training description survey (template on trainer’s portal) • Send your attendees the appropriate training evaluation link to everyone you train (link on trainer’s portal)
Recertification There will be an annual recertification for Certified SOS Trainers. Within a year of certification, Certified SOS Trainers must: Complete at least one SOS Program training and do the following: • Complete electronic training description form for each training o Link on trainer’s portal • Submit training attendee list for each training o Template on trainer’s portal and can be submitted in the training description survey described above) • Encourage training attendees to complete electronic training evaluation measuring knowledge gains o Links for each training type found on trainer’s portal • Complete online recertification form o Will be emailed to you at time of recertification Once you have passed recertification you will receive anew certificate with an updated expiration date for the following year. This annual process will continue as long as you continue to recertify yourself. Our goal is for all Certified SOS Trainers to maintain their certification by continually offering trainings. If you do not pass recertification we will no longer be a Certified SOS Trainer. Trainers are eligible to be recertified by attending another Certified Training Institute to refresh knowledge and committing to providing SOS trainings going forward. Note: Recertification is always at the discretion of Screening for Mental Health. SMH reserves the right to withhold recertification for any reason.
164 Page
Notes: __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ _________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ _________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________
165 Page
References American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Washington, DC. Aseltine, R., et al. (2007). Evaluating the SOS suicide prevention program: A replication and extension. BMC Public Health 7(161). Baber, K., & Bean, G. (2009). Frameworks: A community-based approach to preventing youth suicide. Journal of Community Psychology, 37, 684-696. Brent, D. A, Moritz, G., Bridge, J., Perper, J., & Canobbio, R. (1996). Long-term impact of exposure to suicide: A three-year controlled follow-up. Journal of the American Academy of Child and Adolescent Psychiatry, 35, 646-653. Brent DA, Baugher M, Bridge J, Chen T, Chiappetta L (1999), Age- and sex related risk factors for adolescent suicide. J Am Acad Child Adolesc Psychiatry 38:1497–1505 Brymer, M., Jacobs A., Layne C., Pynoos, R., Ruzek J., Steinberg, A., Vernberg, E., & Watson, P. (2006). Psychological first aid field operations guide (2nd ed.). Rockville, MD: National Child Traumatic Stress Network and National Center for PTSD. Available for download at http://ncptsd.va.gov/ncmain/ncdocs/manuals/ PFA_2ndEditionwithappendices.pdf Bubrick, K., Goodman, J. & Whitlock, J. (2010). Non-suicidal self-injury in schools: Developing and implementing school protocol. [Fact sheet] Cornell Research Program on Self-Injurious Behavior in Adolescents and Young Adults. Retrieved from http://crpsib.com/userfiles/NSSI-schools.pdf Centers for Disease Control. (1988). CDC recommendations for a community plan for the prevention and containment of suicide clusters. Morbidity and Mortality Weekly Report, 37(Suppl. S-6). Retrieved from http://www.cdc.gov/mmwr/preview/mmwrhtml/00001755.htm Centers for Disease Control and Prevention. (2008). Youth Risk Behavior Surveillance-United States, 2007. Surveillance Summaries. MMWR, 57 (Whole No. SS-4). Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. (2014). The Relationship Between Bullying and Suicide: What We Know and What it Means for Schools. Retrieved February 3, 2015 from: http://www.cdc.gov/violenceprevention/pdf/bullying-suicide-translation-final-a.pdf Centers for Disease Control and Prevention. (2014). Youth Risk Behavior Surveillance –United States, 2013. Surveillance Summaries. MMWR, 63, No. 4. Retrieved on February 3, 2015 from http://www.cdc.gov/mmwr/pdf/ss/ss6304.pdf Centers for Disease Control. (2016). QuickStats: Death Rates for Motor Vehicle Traffic Injury, Suicide, and Homicide Among Children and Adolescents aged 10–14 Years — United States, 1999–2014. MMWR Morb Mortal Wkly Rep 2016;65:1203. DOI: http://dx.doi.org/10.15585/mmwr.mm6543a8 De Leo, D., & Heller, T. (2008). Social modeling in the transmission of suicidality. Crisis: International Journal of Crisis Intervention and Suicide Prevention, 29(1), 11-19.
166 Page
De Luca, S. M., Wyman, P., & Warren, K. (2012). Latina adolescent suicide ideations and attempts: Associations with connectedness to parents, peers, and teachers. Suicide and Life-Threatening Behavior, 42(6), 672–683. Dupere V., Leventhal T., Lacourse E., (2009). Neighborhood poverty and suicidal thoughts and attempts in late adolescents. Psychological Medicine. 39, 1295-1306. Erbacher, T. A., Singer, J. B., Poland, S. (2015). Suicide in Schools: A Practitioner’s Guide to Multi-level Prevention, Assessment, Intervention, and Postvention. New York: Routledge. Gender Spectrum. (2015). Understanding Gender. Retrieved from https://www.genderspectrum.org/quick-links/under standing-gender Gould, et al. (2005). Evaluating Iatrogenic Risk of Youth Suicide Screening Programs. American Medical Association, 293(13), 1635-1643. Gould, M., et al. (2003). Youth suicide risk and preventive interventions: A review of the past 10 years. Journal of the American Academy of Child and Adolescent Psychiatry, 42 (4), 386-405. Gould, M. S., & Kramer, R. A. (2001). Youth suicide prevention. Suicide and Life-Threatening Behavior, 31(Suppl.), 6-31. Graham, A., Reser, J., Scuderi, C., Zubrick, S., Smith, M., & Turley, B. (2000). Suicide: An Australian Psychological Society discussion paper. Australian Psychologist, 35, 1-28. Hollingsworth, J. (2007). Oregon youth suicide prevention. Youth suicide prevention, intervention, & postvention guidelines: A resource for school personnel (2nd revision) [A modification for Oregon of the May 2002 edition of Youth suicide prevention, intervention and postvention guidelines: A resource for school personnel. Augusta: The Maine Youth Suicide Prevention Program.]. Eugene, OR: Looking Glass Youth and Family Services. Retrieved from http://www.oregon.gov/DHS/ph/ipe/ysp/docs/yspipg.pdf Insel, B. J., & Gould, M. S. (2008). Impact of modeling on adolescent suicidal behavior. Psychiatric Clinics of North America, 31, 293-316. Kataoka, S.; Zhang, L.; & Wells, K. (2002). Unmet need for mental health care among U.S. children: Variation by ethnicity and insurance status. American Journal of Psychiatry, 159 (9), 1548-1555. Kerr, M. M., Brent, D. A., McKain, B., & McCommons, P. S. (2003). Postvention Standards Manual: A guide for a school’s response in the aftermath of sudden death (fourth ed.). Pittsburgh: University of Pittsburgh Medical Center. Retrieved from http://www.starcenter.pitt.edu/files/document/Postvention.pdf Kessler, R. C., Berglund, P., Demler, O., Jin, R., Walters, E. E. 2005. Life-time prevalence and age-of-onset distribution of DSM-IV disorders in the national co-morbidity survey replication. Archives of General Psychiatry, 62, 593-602. Marzuk, P. M., Leon, A. C., Tardiff, K., Morgan, E. B., Stajic, M., & Mann, J. J. (1992). The effect of access to lethal methods of injury on suicide rates. Archives of General Psychiatry, 49, 451-458. Merikangas, KR et al. Service Utilization for Lifetime Mental Disorders in U.S. Adolescents: Results of the National Comorbidity Survey-Adolescent Supplement (NCS-A). Journal of the American Academy of Child & Adolescent Psychiatry. Vol. 50 No. 1 (Jan. 2011).
167 Page
Moscicki, E. K. (2001). Epidemiology of completed and attempted suicide: toward a framework for prevention. Clinical Neuroscience Research, 1, 310-323. Mojtabai, R., Olfson, M., Han, B. (2016). National Trends in the Prevalence and Treament of Depression in Adolescents and Young Adults. American Academy of Pediatrics, 138 (6), Retrieved on 11/17/2016 http://pediatrics. aappublications.org/content/early/2016/11/10/peds.2016-1878 Muehlenkamp, J. J., Claes, L., Havertape, L., & Plener, P. L. (2012). International prevalence of adolescent non-suicidal self-injury and deliberate self-harm. Child and Adolescent Psychiatry and Mental Health, 6(1), 1 - 9. doi:10.1186/1753-2000-6-10 National Alliance for Mental Illness, New Hampshire. (2010). Connect Suicide Prevention Program (website home). Retrieved February 1, 2010 from www.naminh.org/frameworks.php (formerly called “Frameworks”). National Alliance of Mental Illness (NAMI). (2003). Depression in Children and Adolescents. Retrieved on February 3, 2015 from http://www.nami.org/Template.cfm?Section=By_Illness&template=/ ContentManagement/ContentDisplay.%20cfm&ContentID=17623 Poland, S. (2003). After a suicide: Answering questions from students. National Association of School Psychologists Resources website. Retrieved from www.nasponline.org/resources/principals/aftersuicide.aspx. Ratkowski, K., De Lio D. (2013). Suicide in Immigrants: An Overview. Open Journal of Medical Psychology, 2013, 2, 124 133 Rubinstein, D. H. (1983). Epidemic suicide among Micronesian adolescents. Social Science and Medicine, 17, 657-665. Rushton, J. L., Forcier, M., Schectman, R. M. (2002). Epidemiology of depressive symptoms in the national longitudinal study of adolescent health. Journal of the American Academy of Child and Adolescent Psychiatry, 4, 199-205. Schilling, E. A., Aseltine, R. H., Glanovsky, J. K., James, A., & Jacobs, D. (2009). Adolescent alcohol use, suicidal ideation, and suicide attempts. Journal of Adolescent Health, 44, 335-341. Schilling, E.A., Aseltine, R.H., James, A. (2016). The SOS Suicide Prevention Program: Further Evidence of Efficacy and Effectiveness. Prevention Science. Shaffer, D., Scott, M., Wilcox, H., Maslow, C., Hicks, R., Lucas, C., Garfinkel, R. & Greenwald, G. (2004). The Columbia SuicideScreen: Validity and reliability of a screen for youth suicide and depression. Journal of the American Academy of Child and Adolescent Psychiatry, 43(1), 71-79. Shenassa, E.D., Rogers, M.L., Spalding, K.L. & Roberts, M.P. (2004). Safter storage of firearms at home and risk of suicide: a study of protective factors in a nationally representative sample. Journal of Epidemiology and Health, 58. 841-848. Shneidman, E. S. (1972). Foreword. In A. C. Cain (Ed.), Survivors of suicide (pp. ix-xi). Springfield, IL: Charles C. Thomas. Substance Abuse and Mental Health Services Administration. (2012). Results from the 2010 National Survey on Drug Use and Health: Mental Health Findings, NSDUH Series H-42, HHS Publication No. (SMA) 11-4667. Rockville, MD: Substance Abuse and Mental Health Services Administration.
168 Page
Suicide Prevention Resource Center. (2008). Assessing and managing suicide risk: Core competencies for mental health professionals [A workshop and program developed by SPRC and the American Association of Suicidology]. Webpage description available at www.sprc.org/traininginstitute/amsr/clincomp.asp. Retrieved in 2008. Suicide Prevention Resource Center. (2008). Suicide risk and prevention for lesbian, gay, bisexual, and transgender youth. Newton, MA: Education Development Center, Inc. Suicide Prevention Resource Center. (2013). Suicide among racial/ethnic populations in the U.S.: Blacks. Waltham, MA: Education Development Center, Inc. Suicide Prevention Resource Center. (2013). Suicide among racial/ethnic populations in the U.S.: Hispanics. Waltham, MA: Education Development Center, Inc. Suicide Prevention Resource Center. (2013). Suicide among racial/ethnic populations in the U.S.: Asians, Pacific Islanders, and Native Hawaiians. Waltham, MA: Education Development Center, Inc. United States Census Bureu. 2014. Population Estimates Program (PEP). Retrieved from http://quickfacts.census.gov/ qfd/states/00000.html U.S. Department of Health and Human Services. Mental Health: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health, (1999). U.S. Public Health Service, Report of the Surgeon General’s Conference on Children’s Mental Health: A National Action Agenda. Washington, D.C., Department of Health and Human Services, (2000). UCLA Center for Mental Health in Schools. School community partnerships: a guide. Retrieved from http://smhp.psych.ucla.edu/pdfdocs/guides/schoolcomm.pdf Underwood, M., & Dunne-Maxim, K. (1997). Managing sudden traumatic loss in the school: New Jersey adolescent suicide prevention project. Piscataway, NJ: University Behavioral Health Care. Walsh, B. (2014). Treating self-injury: A practical guide, 2ND Edition. (paperback edition). New York: Guilford. Whitlock, J, Muehlenkamp, J., Purington, A., Eckenrode, J., Barreira, J., Abrams, G.B., Marchell, T., Kress, K., Girard, K., Chin, C., Knox, K. (2011). Non-Suicidal Self-Injury in a College Population: General Trends and Sex Differences. Journal of American College Health, 59(8), 691-698 Whitlock, J.L. & Selekman, M. (2014). Non-suicidal self-injury (NSSI) across the lifespan. Oxford Handbook of Suicide and Self-Injury, edited by M. Nock. Oxford Library of Psychology, Oxford University Press. Wyman, P. A., Brown, C. H., Inman, J., Cross, W., Schmeelk-Cone, K., Guo, J., et al. (2008). Randomized trial of a gatekeeper program for suicide prevention: 1-year impact on secondary school staff. Journal of Consulting and Clinical Psychology, 76, 104-115.
169 Page
About Screening for Mental Health, Inc. Screening for Mental Health, Inc. (SMH) is a non-profit 501(c)(3) organization that develops evidence-based mental health education and screening programs for use by members of the public. The mission of SMH is to provide innovative mental health and substance use resources, linking those in need to quality treatment options. BOARD OF DIRECTORS Douglas G. Jacobs, M.D. Associate Clinical Professor of Psychiatry Harvard Medical School Founder and Medical Director Screening for Mental Health, Inc.
Shari I. Lusskin, M.D. Clinical Professor of Psychiatry, Obstetrics, Gynecology, and Reprodutive Science Attending in Psychiatry at Mount Sinai Medical Center Icahn School of Medicine at Mount Sinai
Leonard Freedberg, M.D. Private Practitioner Newton-Wellesley Psychiatry
Daryl DeKarske, MPH Senior Director, Global Regulatory Affairs Shire Pharmaceuticals
Jefferson Bruce Prince, M.D. Child Psychiatry North Shore Children’s Hospital Harvard Medical School
Matthew D. Anthes Founder and Managing Partner Union Square Strategic
Saul Levin, M.D., MPA CEO and Medical Director American Psychiatric Association
SCREENING FOR MENTAL HEALTH, INC. One Washington Street, Suite 304 Wellesley Hills, MA 02481 Tel: 781-239-0071 Fax: 781-431-7447 www.MentalHealthScreening.org
170 Page
