Suicide Prevention Gatekeeper Agenda

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Suicide Prevention Gatekeeper Agenda

• Welcome Introductions
• The School Setting A Healthy Climate
• Emotions, Stigma and Suicide
• Myths Facts About Suicide
• Suicide Trends Statistics
• Suicide Risk Protective Factors
• Gatekeeper Training
• District/Campus Level Teams
• Clara Cáceres Contreras
• ccontreras_at_esc1.net
• 956-984-6125
• www.esc1.net

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Suicide

• When you hear the word Suicide what comes to
  mind?
• What emotions do you feel?
• Who do you think of and how old were you when It
  (suicide) happened?
• Our thoughts and emotions can impact how we
  interact with people at risk. (confusion, fear,
  denial, shock, anger)
• Understanding suicide awareness sessions makes
  a difference!

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Stigma Suicide

• Psychological autopsies has shown that 90 of
  people who died by suicide had a diagnosable
  mental illness and/or a substance use disorder.
• Suicidal individuals are usually dealing with
  multiple layers of stigma.
• What impact could this have on the person? (not
  getting help, suicide, etc)

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School Climate (Issue Brief 2- School Climate)

• School Connectedness
• Meaningful Participation
• Academic Achievement
• School Safety Security
• Training
• Respectful Discipline
• Aesthetically Pleasing-Physical Environment

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School Climate

• Help ensure that the school climate is one that
  is supportive of the at risk student.
• Fostering a feeling of connectedness between the
  students and the school,
• Proving an opportunity for students to become
  involved in school activities,
• Ensuring a safe and positive environment creates
  a climate that has potential to have a profound
  impact on adolescent suicide.

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Why the School Setting?

• Schools are in a key position to identify mental
  health problems early and to provide a link to
  appropriate services.
• More than 52 million youth attend 114,000 schools
  in the US.
• When combined with the 6 million adults who work
  a the schools, almost 1/5th of the population
  passes through schools everyday.

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Why the School Setting?

• Adolescents spend one third of their day in
  school.
• The average classroom has 3 students who have
  attempted suicide.
• School education codes mandate not only to
  educate but also to protect students.
• 5.2.2 District Improvement -Plans Strategies for
  improving student performance, including
  instructional methods, methods for addressing
  the needs (of students) for special programs
  (e.g., suicide prevention, conflict resolution,
  violence prevention, dyslexia treatment
  programs) drop out reduction discipline
  management staff development career education
  for students and accelerated education

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Why the School Setting?

• Schools have been held liable for not taking
  action to protect at-risk students.
• At school students have the greatest exposure to
  multiple helpers.
• Research has found that the schools provide an
  ideal and strategic setting for preventing
  adolescent suicide.

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The Schools Role Prevention

• Incorporate suicide prevention and intervention
  as an integral part of school-based mental health
  services
• Raise awareness of risk factors
• Bolster protective factors
• Identify students at risk
• Intervene with at risk students
• Create a culture of connectedness

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The Schools Role Prevention Planning

• Develop clear intervention and post-intervention
  protocols
• Establish a Suicide Task Force
• Develop policies and procedures
• Asses potential risk factors in school
  environment
• Identify and implement suicide prevention programs

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The Role of School StaffPrevention/Gatekeeper

• Research has found that 25 of all teachers
  sampled in a study reported that they had been
  approached by a suicidal teen.
• Research also suggests that school staff believe
  that they have a larger role in identifying
  students at risk for suicide.
• School staff can be a lifeline to a student who
  is in crisis.

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Suicide Nomenclature Activity(definitions)

• Completed Suicide/ Death by Suicide
• Gatekeeper
• Suicide Attempt
• Suicide Threat
• Suicide Ideation
• Deliberate Self-Harm
• Unintentional Injury or Accident

• Suicide Attempt Survivors
• Suicide Survivors
• Suicidology
• Prevention
• Intervention/Treatment
• Postvention

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Suicide in the US

• 13.7 million children in the US have a mental
  health disorder
• 2/3 of them are not getting help they need
• Neglecting mental health can lead to serious life
  threatening consequences such as school failure,
  family conflicts, drug abuse, violence and suicide

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Suicide in the US

• Suicide is the third leading cause of death for
  youth ages 15-24
• Suicide rates for ages 10-14 have increased by
  51 between 1981 and 2004
• Approximately 1 in 5 teenagers seriously consider
  suicide
• 1 in 12 attempt suicide yearly in the US with
  700,000 requiring medical attention

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Methods of SuicideTexas Children Ages 10-14
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Texas YRBS

• Made a plan about how they would attempt suicide
  in the last 12 months.
• Total-12.2
• Females-15.1
• Males-9.4

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Texas YRBS

• Attempted suicide one or more times in the last
  12 months.
• Total-9.4
• Females-12.5
• Males-6.1
• Highest overall rate was in Hispanic females
  (15.8)

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True / False

• Adolescent suicide is an increasing problem in
  the United States.

(True) While the suicide rate for the general
population has remained relatively stable since
the 1950s, the suicide rate for adolescents has
more than tripled.
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True / False Answers

• Most teenagers will reveal that they are suicidal
  or have emotional problems for which they would
  like emotional help.(True) Most teens will
  reveal that they are suicidal and although
  studies have shown that they are more willing to
  discuss suicidal thoughts with a peer than a
  school staff member, this disposition that most
  teens have towards expressing suicidal ideations
  could be used for screening adolescents through
  questionnaires and/or interviews.

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True / False Answers

• Adolescents who talk about suicide do not attempt
  or commit suicide.(False) One of the most
  ominous warning signs of adolescent suicide is
  talking repeatedly about ones own death.
  Adolescents who make threats of suicide should be
  taken seriously and provided the help they need.
  In this manner, suicide attempts can be averted
  and lives can be saved.

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True / False Answers

• Educating teens about suicide leads to increased
  suicide attempts, since it provides them with
  ideas and methods about killing themselves.
  (False) When issues concerning suicide are
  taught in a sensitive, educational context they
  do not lead to, or cause, further suicidal
  behaviors.

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True / False Answers

• Talking about suicide in the classroom will
  promote suicidal ideas and suicidal behavior.
  (False) Talking about suicide in the classroom
  provides adolescents with an avenue to talk about
  their feelings, thereby enabling them to be more
  comfortable with expressing suicidal thoughts and
  increasing their chances of asking help from a
  friend or school staff member.

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True / False Answers

• Parents are often unaware of their childs
  suicidal behavior. (True) Studies have shown
  that as much as 86 of parents were unaware of
  their childs suicidal behavior.

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True / False Answers

• The majority of adolescent suicides occur
  unexpectedly without warning signs. (False)
  Nine out of ten adolescents who commit suicide
  give clues to others before their suicide
  attempt. Warning signs for adolescent suicide
  include depressed mood, substance abuse, loss of
  interest in once pleasurable activities,
  decreased activity levels, decreased attention,
  distractibility, isolation, withdrawing from
  others, sleep changes, appetite changes, morbid
  ideation, offering verbal cues, offering written
  cues, and giving possessions away.

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True / False Answers

• Most adolescents who attempt suicide fully intend
  to die.(False) Most suicidal adolescents do not
  want suicide to happen. Rather, they are torn
  between wanting to end their psychological pain
  through death and wanting to continue living,
  though only in a more hopeful environment. Such
  ambivalence is communicated to others through
  verbal statements and behavior changes in 80 of
  suicidal youths.

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True / False Answers

• There is a significant difference between male
  and female adolescents regarding suicidal
  behavior. (True) Adolescent females are
  significantly more likely than adolescent males
  to have thought about suicide and to have
  attempted suicide.

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True / False Answers

• The most common method for adolescent suicide
  deaths is drug overdose. (False) Guns are the
  most frequently used method for deaths by suicide
  among adolescents. In 1994, guns accounted for
  67 of all adolescent deaths by suicide while
  strangulation (via hanging), the second most
  frequently used method for adolescent suicide
  deaths, accounted for 18 of all adolescent
  deaths by suicide.

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True / False Answers

• Because female adolescents die by suicide at a
  lower rate than male adolescents, their attempts
  should not be taken seriously.(False) One of
  the most powerful predictors of death by suicide
  is a prior suicide attempt. Adolescents who have
  attempted suicide are 8 times more likely than
  adolescents who have not attempted suicide to
  attempt again.

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True / False Answers

• Not all adolescents who engage in suicidal
  behavior are mentally ill.(True) Studies
  involving psychological autopsies of adolescents
  who completed suicide suggest that most
  adolescents are relatively rational and coherent
  at the time of their death. However, other
  research does suggest that identifying at-risk
  youth, by utilizing depression scales and
  psychopathology inventories, through screening
  and treating those individual who test positive
  for mental illness can benefit from counseling.

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True / False Answers

• Suicidal behavior is inherited.(False) There is
  no specific suicide gene that has ever been
  identified.

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True / False Answers

• Adolescent suicide occurs only among poor
  adolescents.(False) Adolescent suicide occurs
  in all socioeconomic groups. Socioeconomic
  variables have not been found to be reliable
  predictors of adolescent suicidal behavior.
  Instead of assessing adolescents socioeconomic
  backgrounds, school professionals should assess
  their social and emotional characteristics (i.e.,
  affect, mood, social involvement, etc.) to
  determine if they are at increased risk.

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True / False Answers

• The only one who can help a suicidal adolescent
  is a counselor or a mental health
  professional.(False) Most adolescents who are
  contemplating suicide are not presently seeing a
  mental health professional. Rather, most are
  likely to approach a family member, peer, or
  school professional for help. Displaying concern
  and care as well as ensuring that the adolescent
  is referred to a mental health professional are
  ways paraprofessionals can help.

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True / False Answers

• Adolescents cannot relate to a person who has
  experienced suicidal thoughts.(False) Data from
  the 1997 Youth Risk Behavior Surveillance Survey
  (YRBS), which surveyed 16,262 high school
  students, found that one in five students (24.1)
  had seriously considered attempting suicide in
  the previous year.

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True / False Answers

• If an adolescent wants to commit suicide, there
  is nothing anyone can do to prevent its
  occurrence.(False) One of the most important
  things an individual can do to prevent suicide is
  to identify the warning signs of suicide and
  recognize an adolescent at increased risk for
  suicide. School professionals should, therefore,
  be aware of these risk factors and know how to
  respond when a student threatens or attempts
  suicide. The existence of a school crisis
  intervention team may assist with this process.

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Self-Mutilation Versus Suicide

• The intent of self-mutilation is different than
  suicide-some use it as a form of
• Emotion regulation
• It calms me down.
• Releases endorphins and changes the serotonin
  levels in the brain
• The relief is within seconds

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Self-Mutilation Versus Suicide

• Self mutilation is not done with the intent to
  die.
• The suicidal person usually views death as the
  only way to stop the internal psychic pain. So
  death is usually the intent of their behavior.
• However, those who self-mutilate are at an
  increased risk for suicide. They need to be
  monitored and assessed for suicidality.

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Risk Factors(Issue Brief 3b- How Can a School
Identify a student At-Risk for Suicide)
Suicide Awareness Curriculum Importance of
curriculum length Exemplary programs Mental
health approach Gatekeeper Training Screening
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Lunch
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Gatekeeping Three Easy Steps You Take Every Day

• QuestionNotice signs ask
• PersuadeAsk facts permission to get them help
• Refer Identify needs-reach out for help

Remember to keep it simple like CPRwill provide
assistance until you hand them over to qualified
staff!
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Gatekeeping

• Is not intended to be a form of counseling or
  treatment
• Is intended to offer hope through positive action
• Is intended to teach those who are in a position
  to recognize warning signs, clues suicidal
  communications of people in trouble to ACT
  vigorously to prevent a possible tragedy.

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Risk Factors(Issue Brief 3a-Risk Protective
Factors and Warning Signs)Multifactorial
Causation-9 out of 10 youth that engage in
suicidal behavior give clues

• Risks
• Previous suicide attempt
• Substance abuse disorder
• Feeling hopelessness, isolation, living alone, or
  runaways
• Parental Psychopathology (depressive
  disorder/mood disorder)
• Access to firearms
• Physical/sexual abuse
• School difficulties (grades, attendance, conduct
  disorder or disruptive, aggressive, impulsive
  behaviors, juvenile delinquency)
• Life stressors/interpersonal losses,
  relationships, legal disciplinary problems
• Sexual orientation (homosexual, bisexual,
  trans-gender youth, identity issues)
• Chronic physical illness
• Contagion or imitation (exposure to media,
  friends, or acquaintances)

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Protective Factors(Issue Brief 3a-Risk
Protective Factors and Warning Signs)Multifactor
ial Causation-9 out of 10 youth that engage in
suicidal behavior give clues

• Protective
• Family cohesion
• Good coping skills
• Good academics
• Impulse control
• Feeling connected to school
• Good peer relationships
• Lack of access to means suicidal behavior
• Advise seeking/help seeking behaviors
• Problem solving/conflict resolution
  skills/abilities
• Opportunities for meaningful participation/social
  integration
• Sense of worth/confidence
• Stable environment
• Access to care, mental, physical, substance
  disorders
• Responsibility/accountability for others/pets
• Religiosity

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• Early Warning Signs
• (Issue Brief 3a-Risk Protective Factors and
  Warning Signs)

• Withdraw from friends and family
• Preoccupation with death
• Marked personality change serious mood changes
• Difficulty concentrating
• Difficulties in school (decline in quality of
  work)
• Change in eating sleeping habits
• Loss of interest in once pleasurable things
• Frequent complaints about physical symptoms,
  often related to emotions, such as stomachaches,
  headaches, fatigue, etc.
• Persistent boredom
• Loss of interest in things one care about

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Late Warning SignsIssue Brief 3a-Risk
Protective Factors and Warning Signs)

• Openly talking about suicide or a plan
• Exhibiting impulsivity such as violent actions,
  rebellious behavior, or running away
• Refusing help, feeling beyond help
• Statements of hopelessness, helplessness or
  worthlessness
• Giving away favorite possessions,
• Complaining of being a bad or rotten person
• Inability to tolerate praise or rewards
• Verbal statements, hints, such as, you will not
  need to worry about me much longer or I wish I
  were dead
• Suddenly cheerful after a period of depression
  may mean student has already made up his mind to
  his problems by ending his life

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Direct Verbal Clues

• I am going to end it all.
• I have decided to kill myself.
• If_______happens or doesnt happen,
• I am going to kill myself.
• I wish I were dead

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In-Direct Verbal Clues

• They/she/he would be better off without me.
• I want to go to sleep and never wake up.
• I cant take it anymore!
• You wont have to worry about me anymore.
• Nobody cares if I am dead or alive.
• I am going to put an end to all of this soon.
• If this is how life is, I want out.
• I am tired of life. Whats the point of going on?
• I am calling it quits, living is useless.
• You are going to regret how you have treated me.

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Behavioral Clues

• Purchasing a gun
• Relapse into drug or alcohol use after recovery
• Giving away prized possession
• Changes in behavior

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Situational Clues

• Flare up/rejection by loved ones
• Recent unwanted move
• Death/loss of friend/loved one
• Loss of freedom
• In trouble with the law or authorities

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Intervention StrategiesResponding to a Student
Crisis(Issue Brief 6c-Responding to a Student
Crisis)

• What NOT to do
• Promise confidentiality
• Debate the issue of suicide (right or wrong?)
• Panic, rush or act shocked
• Judge or dare
• Minimize the situation (we all go through this)
• Leave the student alone!!
• Preach or manipulate
• If a student does have a weapon do not attempt to
  take the weapon by force

• What to DO
• Assess situation
• Ensure student safety
• Stay with youth
• Send someone for help
• Listen, listen, listen
• Be empathic
• Be direct (dont be afraid to say suicide)
• Inform parents
• Take the student seriously

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Preparing for the question

• Plan a time and place to ask the question
• Try to secure a private setting
• Give yourself plenty of time
• Be prepared to listen

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How to Ask the Question

• Less Direct Approach
• Sometimes people that feel the way you do want
  to kill themselves are you thinking of doing
  that or are you feeling that way
• Do you feel so unhappy you wished you were dead
• More Direct Approach
• Are you thinking about suicide/killing yourself
• (Practice, Practice, Practicemake it you)

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What to Say Persuade they get Help

• Listen
• Give your full attention
• Speak only when the person has finished
• Dont judge, condemn or rush
• Be calm, watch your fears
• Sample
• Will you let me help you make an appointment
  with?
• Will you go with me to the counselor/nurse?
• Will you promise not to harm yourself ?

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What to do-Referral

• Personally take the child to the appropriate
  person, counselor, social worker, or nurse.
• Reach out for help, dont wait, do something
• Hope begins with you!

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Practice Session Role Play

• The Gatekeeper could the following steps to
  briefly intervene
• Greet student, state the facts ( _____________ I
  noticed that you (fact, fact)).
• Make a statement about the students mood (You
  seem _______________).
• Ask the question (___________, are you thinking
  about killing yourself?).
• Thank the student for being truthful
  (__________I really appreciate your telling me
  the truth about this.).
• Start the student toward help (Lets get you
  some help.).
• Start moving slowly, (walk with me..).

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Practice SessionRole Play

• Scenario 1--Aimee, 15, has started being late to
  class.--She is not turning in work, and you
  notice cuts on her wrist.--She has poor eye
  contact, and she is suddenly not social. --A
  friend of Aimees comes to you worriedshe got an
  email in which Aimee refers to just
  Disappearing forever.
• Scenario 2--Prakash, 10, is normally quiet and
  studious. -- He gets in trouble for bringing a
  knife to school and gets into a fight.--You are
  his math teacher and math is his favorite
  subject. He likes you. Today, he sits at the
  back of the classroom and is the last to leave,
  as if he wants to talk.
• Scenario 3--Marta,13 is a student who talks often
  in class, and gets into trouble for clowning
  around and laughing. --Today she has a bruise on
  her face that she is trying to hide. --She is
  sullen and withdrawn and makes no eye contact.
• (One person plays the Gatekeeper, the other the
  student, than switch roles with next scenario of
  their choice or make up your own scenario)

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Practice SessionRole Play

• Scenario 1--Robert, 16, is the class clown, but a
  wizard on the football field. His personality
  has been shifting.--You are the coach. You
  notice he is losing weight. You know his parents
  recently divorced.--He is normally on time to
  practice. He comes late, doesnt make eye
  contact, and says he cannot stay to play today.
  Football has been his life.
• Scenario 2--Nakeeta,17, is captain of her debate
  team. You are her English teacher. She has been
  making plans to attend a competitive all-girls
  college. You are recommending her. She fails
  to turn in a key assignment. --She starts
  keeping to herself and is avoiding her
  friends--When you talk to her about it, she tells
  you with tears in her eyes not to bother with the
  recommendationshe has no future.
• Scenario 3--Mien Tsu, 6, is one of 8 children.
  He is painfully quiet, but loves your music
  classroom. --Every class he volunteers to help
  you pass out rhythm instruments. --Today he is
  crying and sits in a ball on the floor. --His
  father has been in and out of the hospital for
  weeks. --When class is over, he doesnt leave,
  but sits silently crying and hits his fists
  repeatedly on his legs.
• (One person plays the Gatekeeper, the other the
  student, than switch roles with next scenario of
  their choice or make up your own scenario)

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General Gatekeeping Team Roles and Tasks
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Suicide Prevention Sample Level 1 Gatekeeping
Documentation Form (Remember to edit this to meet
your district/campus needs) Staff
Name_____________________________Date______Time___
__ Student Name__________________________________
_Grade_____ What I noticed What I asked the
student What the student said What I did

• Note If he/she is thinking about killing
  himself/herself
• Ask if they have a plan
• Ask them to describe their plan
• Ask if they have initiated their plan
• If yes, take appropriate action immediately,
  including calling 911 if necessary
• Be aware that the student may not be truthful.
  If your intuition is that they are not truthful,
  refer the student to the next level.

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Suicide Prevention Sample Level 2 Campus
Screening Form Student Name______________________
______________Date ________Time____ Student
stated (in the students words) As reported by
_________________________________________ Frequenc
y of thoughts ____________________________________
______________ (months, weeks, days, hours,
minuteshow often) (ask how often are you
thinking about killing yourself? Once a week??
Etc.) Intensity of thoughts
1 2 3 4 5 6 7 8 9
10 (ask on a scale of 1 to 10, ten being ready
to kill yourself, how intense are your
thoughts?) Duration of thoughts (write an
amount) (ask when you think about it, how long
do you think about it each time?) History of
Attempts (ask have you ever tried to kill
yourself in the past? When? Where? What
triggered it? What happened?) History of
Methods (ask what methods did you
use?) Drug/Alc. Use (ask about this past and
present, related to the attempts) Current
Medications/Counseling (ask are you currently
taking medication? Are you seeing a counselor?
Have you in the past?) Plan (ask what is your
plan, when/where do you plan to do
this?) Method (ask how are you going to do
thiswhat method?) Other statements
Check when completed
Parent/Guardian notified
Administrator notified
SPED counselor/LSSP notified MHMR
Called
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Suicide Prevention Sample Level 2 Campus
Screening Form Parent Statement I have had
explained to me the seriousness of the situation
and agree to accept responsibility to keep my
child safe. I agree to take my child for further
evaluation today. Further, I understand to make
our home safe I must remove any guns, knives,
other weapons, medication and other possible
means from my home. In the event of an
emergency, we will call (the local suicide
hotline phone number) immediately. Local
Hotline ______________________ Contact Name
_____________________ Parent Signature____________
_____________Date/time________________ Student
statement I agree to keep myself safe today and
go to get help, and tell my parent if I feel like
killing myself Student Signature_______________
________Date/time_________________ School
Screener signature______________________
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Possible Actions for your District/Campus

• ? 1. Choose a district leader for the
  gate-keeper team.
• ? 2. Develop a team of key team members that
  might include counselors, administrators,
  nurses, school board member, a SHAC team member,
  school safety officers, SDFS federal program
  director, and other members that you want
  represented on the team.
• ? 3. Review the gate-keeping training
  objectives and concepts.
• ? 4. Decide who on each campus will be the
  lead go to personthe campus team leader.
• ? 5. Establish a district-wide campus
  training plan.
• ? 6. Break into subcommittees to do the
  following
• The campus go to team leaders will develop a
  list of team members on each campus.
• Counselors will revise the screening forms to
  meet the districts needs/approval.
• SHAC representative/safety officer/board
  member/SDFS director/administrators will review
  the laws, student handbook, school safety
  policies and legal matters and update as needed.

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Possible Actions for your District/Campus

• ? 7. Have gate-keeper team discuss district
  policies and procedures related to
• a. Students running off campus
• b. Students with a weapon on campus
• c. Students over-dosing on campus and the
  reporting process of such occurrences.
• d. Any other issues that might be of
  importance to discuss before training
• ? 8. Assign break-out groups any follow-up to
  include
• a. Typing, editing and compiling any
  district-wide procedures.
• b. Typing and editing the screening forms and
  training materials to reflect district
  needs/campus needs.
• c. Campus teams review new training
  documentation and finalize for training
• ? 9. Make adjustments to the district plan
  based on input received from
• the gate-keeping team.
• ? 10. District team designee (contact local MHMR
  to share information and the district plan.
  Develop the local notification process with MHMR
  when students need emergency assessment.
• ? 11. SHAC team member informs parents about the
  district plan to help inform parents and gain
  parental support.
• ? 12. Determine if your school district has a
  suicide postvention protocol. If not, raise this
  issue with appropriate personnel.