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