denton isd august 16, 2011 dr. casey a. barrio minton, phd, ncc

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Youth Suicide Intervention

Denton ISDAugust 16, 2011

Dr. Casey A. Barrio Minton, PhD, NCC

Session OverviewUnderstanding youth suicideRecognizing warning signsFacilitating open conversationsConnecting with resourcesContinuing education resources

The Words We UseSuicide/completed suicide

Suicide attempt “potentially self-injurious behavior with a

nonfatal outcome, for which there is evidence (either explicit or implicit) that the person intended at some (nonzero) level to kill himself/herself” (Brown, 2003, p. 5).

Suicidal ideation (self)

Suicide threat (other)

The Words We UseSuicidal Act

Suicide or suicide attempt (with or without injuries)

Nonzero intent to die

Self-injurious behavior Deliberate infliction of direct physical harm Zero intent to die

Instrumental Suicide-Related Behavior Desired appearance of intending to kill self

(with or without injuries) Zero intent to die

Terminology

Self-inflictedIntent to kill self

Nonzero Zero

Actual harm to selfDesired appearance and response

Child is brought to emergency services from group home after digging into his arms with safety pin and saying that he’s “tired of life like this…”

Could it be Related to Suicide?

Adolescent takes a bottle of medications, but medications do no physical harm

Adolescent is found making cuts on her arms and legs in the school bathroom. Later, parents find diary with poetry expressing student’s loneliness and loss of hope for the future.

A Few Suicide Facts(CDC, 2006, 2009)

Leading cause of death Ages 5-14 (5th) Ages 15-24 (3rd)

Estimated 100-200 attempts per completion1 in 19 has thoughts in any 2 week period

Considerable variations among groups

2009 Dallas HS Students Overall

Felt sad or hopeless almost every day for 2+ weeks*

33.0%

Seriously considered suicide 15.6%

Made a plan* 14.4%

Attempted suicide* 12.0%

Why Suicide(Shneidman, 1985, 1999)

Perturbation

(motivation)

Lethality (thought

of Stopping)

Suicide

“Psychache”

IntolerableInterminabl

eInescapabl

e

Why Suicide(Shneidman, 1985, 1999)

Stimulus Unendurable psychological pain

Stressor Frustrated psychological needs

Purpose Solution

Goal Cessation of consciousness

Emotions Hopelessness, helplessness

Cognitions Ambivalence, restricted perception

Relational Tells of intention, egression

Serial Consistent with lifelong pattern

Common MisperceptionsSomeone who talks about it is not seriousTalking about it will increase riskAttention-seekingSuicide happens without warningSuicidal people want to die / can’t stopSuicidal people are crazy, mentally ill, insaneDanger reduced after crisis

Recognizing Warning Signs

Protective Factors for Suicide(CDC, 2009)

Access to treatment Support for help-

seeking Effective clinical

care for mental, physical, and substance abuse d/o

Support from ongoing medical and mental health care relationships

Family and community support (connectedness)

Cultural and religious beliefs

Skills in problem solving conflict resolution nonviolent ways of

handling disputes

Risk Factors for Suicide(CDC, 2009)

Family hx of suicide Family hx of child

maltreatment, conflict

Previous attempt(s) Mental disorders Alcohol/drug abuse Hopelessness Impulsive or

aggressive tendencies

Loss Isolation Physical illness

Cultural/religious beliefs

Local suicide epidemics

Barriers to accessing tx

Easy access to methods

Recent severe stressor

Unwilling to seek help because of stigma

Risk Factors for Children

Biological Impulsivity Age

Psychological Inferiority /

expendable Depression Anxiety Aggression Impulsivity Internalizing Poor coping skills

Risk Factors for Children

Cognitive Immature view of death Concrete thinking Attraction/repulsion to

life and death Substance use

Environmental Early loss Parental conflict Chaotic/inflexible family Abuse / neglect Parent mental health Isolated or alienated

from peers Poor social support Poor social skills Learning disabilities Academic failure

Risk Factors for Children

Precipitating events Psychosocial stressors, perceptions, and

ability to cope vary developmentally Recent exposure to suicide / contagion Previous coping via suicidal ideation or

behavior

Warning Signs of Suicide(American Association of Suicidology, 2003)

IdeationSubstance use

PurposelessnessAnxietyTrappedHopelessness

WithdrawalAngerRecklessnessMood change

More Warning Signs for Youth

(Suicide Prevention Lifeline; Suicide Prevention Resource Center)

Fixated on deathWorsening of school performanceUnhealthy peer relationshipsDifficulty adjusting to gender identityBullyingDepression

Danger Signs for Youth(Suicide Prevention Resource Center)

Announcing a planTalking, writing, or posting about suicide or deathHints

I wish I were dead. I'm going to end it all. You will be better off without me. What's the point of living? Soon you won't have to worry about me. Who cares if I'm dead, anyway?

MeaninglessnessGiving away prized possessionsDropping out of school, activitiesObtaining a weapon

Facilitating Open

Conversations

Roadblocks to Discussing

Youth’s biases and fearsOur biases and fearsOur desire to fix, change, or convince otherwiseLeakage myth

Preparing for Conversations(Shea, 2002)

Tune in to own responses Be direct – kill, suicide, dead Tune in to hesitancy Investigate “not really” Look for nonverbals Get out from behind the desk Take your time Don’t try to fix or give advice Prepare to be persistent and

creative

Focus on relationship over details … but get details if the time seems right

Skills for Opening(Shea, 2002)

Ask questions regarding concrete behavioral facts or thoughts

“When you ‘threw a fit,’ what exactly did you do?” “Did you put the razor blade up to your wrist?” “What happened next?”

Ask question so not as threatening “Sometimes drinking can lead people to

have thoughts of killing themselves that they normally wouldn’t have. Has that ever happened to you?”

Skills for Opening(Shea, 2002)

Assume suspected behavior is occurring and frame a ? based on assumption

“What other ways have you thought of killing yourself?” “How often do you cut?”

Normalize the experience “Some people tell me that, at times,

living is so painful that they have thoughts of wanting to kill themselves. Have you had any thoughts like that?”

Adapting Skills for Children

Communicate caring and comfort Specific reason for interview Not in trouble Safe to tell truth No right or wrong answers Caretaking w/in interview

Determine who is present for interviewBeware of limits to language, leading language, and repeated questions adapt language, integrate drawingAttend to developmental understanding of death

Key AssessmentsPrecipitating events, stressors, triggers

inescapable intolerable interminable

Suicidal Ideation Plans Means Intent

Supporting assessments

Warning signs Prior history Reasons for dying Reasons for living Supports

Asking “The Question”Summarize situation and reflect feelingsUse owning statements

Be very direct You sound , are you thinking of suicide? Sometimes when people , they are

thinking of suicide. Are you thinking of suicide?

Honor choice to shareLet him or her tell you way

Assessing IdeationAfter giving child room to share

Summarize content and reflect feelings Restate thoughts of suicide Use owning statement regarding needing to

know more

Elicit details regarding ideation (see guidelines handout)

Assessing Means, Method, Plan, Intent

Plan - HowMeans - Could he/she? AccessMethods - LethalityIntent - Timeline, action taken

Consider Level of specificity (more specific ↑ risk) Degree of access Level of lethality Action already taken Degree of commitment

Supports & Deterrents“What has kept you from…” (details vip)“Who/what is a source of support for you…”“What are the pros and cons of your plan?” Look for

Strength/nature of deterrents

Any hope? Change in feeling?

Family, spiritual beliefs can be critical

Assessing Warning Signs(American Association of Suicidology, 2003)

Ideation

Substance use

Purposelessness

Anxiety

Trapped

Hopelessness

Withdrawal

Anger

Recklessness

Mood change

Assessing Other Risk Factors

History Prior suicide attempts Prior violence Prior diagnoses / treatment

Mental statusBehavior changes

Determining Level of Risk

Ideation

Plan Lethality Intent

None No -- -- --

Mild Some No -- --

Moderate Yes Vague Low --

Severe Yes Specific High --

Extreme Yes Specific High Yes

Confounds to the “Risk Grid”

Counselor/client relationshipPerceived painPerceived resourcesPrevious attemptsMental health history & disordersBalance of reasons for living and dying

Is risk grid a

dangerous myth?

Connecting with Resources

Next StepsFollow organizational protocols for youth crisisDo not leave the youth alone

Notify caregivers and/or emergency providers

Empower youth to share himself/herself

Arrange for mental health assessment and services

Follow-up with youth

Professional Care for Suicide (Lee & Bartlett, 2006)

Comprehensive suicide assessmentAppropriate management planFamily involvementConsultation with professionalsImplementation of plan

Professional Care for Suicide

Emergency/crisis services (24/7)Hotlines

Inpatient hospitalizationIntensive outpatient/Partial hospitalizationOutpatient services

Continuing Education Resources

Organizational Resources

Standardized Trainings ASIST (Applied Suicide Intervention Skills

Training) safeTALK (suicide alertness for everyone) QPR SOS (Signs of Suicide) Trevor Project Lifeguard Workshop

Crisis response planning www.ed.gov/emergencyplan

Crisis / Referral Resources

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

Key WebsitesNational Suicide Prevention Lifeline

800-273-TALKSuicide Prevention Resource CenterAmerican Association of SuicidologySuicide Prevention Action NetworkThe Trevor ProjectAmerican Foundation for Suicide PreventionSAMHSA NREPP

Questions & Discussion

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