Youth SuicideYouth Suicide

Lorna MartinLorna Martin

lormartin@gov.mb.calormartin@gov.mb.ca

Common Warning Signs ofCommon Warning Signs ofYouth SuicideYouth Suicide Suicide threats Suicide threats (written, direct, indirect)(written, direct, indirect)

Preoccupation with death Preoccupation with death (making final (making final arrangements, giving away prized possessions, talking, reading, arrangements, giving away prized possessions, talking, reading, writing, drawing about death or a dead person)writing, drawing about death or a dead person)

Changes in behaviour, physical condition, Changes in behaviour, physical condition, thoughts, or feelings thoughts, or feelings (withdrawal, isolation, increased (withdrawal, isolation, increased risk-taking, decreased performance, frequent lateness, risk-taking, decreased performance, frequent lateness, unexplained absence, crying jags, heavy use of alcohol or drugs, unexplained absence, crying jags, heavy use of alcohol or drugs, abrupt changes in appearance, appetite, sleep patterns, abrupt changes in appearance, appetite, sleep patterns, exaggerated fears, irrationality/anxiety, hopelessness, increased exaggerated fears, irrationality/anxiety, hopelessness, increased irritability, moodiness, lethargy)irritability, moodiness, lethargy)

Stress Stress (intolerable loss)(intolerable loss)

Four Indicators of Risk Four Indicators of Risk LevelsLevels• StressStress

– Critical situational events, personal lossCritical situational events, personal loss– Disruptive life eventsDisruptive life events

• SymptomsSymptoms– Changes in behaviour, physical condition, Changes in behaviour, physical condition,

thoughts/feelingsthoughts/feelings

• Thoughts of SuicideThoughts of Suicide– Direct/indirectDirect/indirect

• Loss/Lack of Social Network/SupportLoss/Lack of Social Network/Support– Healthy connections to others missing or Healthy connections to others missing or

lostlost

Assessment of RiskAssessment of Risk

• Current Suicide PlanCurrent Suicide Plan– Method, preparation, means, time frameMethod, preparation, means, time frame– The more detailed the plan, the greater the riskThe more detailed the plan, the greater the risk

• Prior Suicidal BehaviourPrior Suicidal Behaviour– Prior attempt(s) reveal(s) acceptance of suicide Prior attempt(s) reveal(s) acceptance of suicide

as an alternativeas an alternative

• ResourcesResources– Risk decreases with personal support resources Risk decreases with personal support resources

such as a place to live, caring family, friends or such as a place to live, caring family, friends or teachers, access to helpteachers, access to help

Spectrum of SuicidalitySpectrum of Suicidality

• Not all youths follow the same Not all youths follow the same trajectory towards suicidetrajectory towards suicide

• Self-harm is not necessarily a Self-harm is not necessarily a precursor to suicideprecursor to suicide

• Not all suicidal youths are depressedNot all suicidal youths are depressed

• Not all youths indicate their feelings Not all youths indicate their feelings of suicide prior to an attempt or of suicide prior to an attempt or completioncompletion

Sample 1 TrajectorySample 1 Trajectory

IDEATIONIDEATION-thoughts of death-thoughts of death-wishes never born-wishes never born-life not worth living-life not worth living-thoughts of killing -thoughts of killing

self (general self (general moving towards moving towards specific)specific)

-sees suicide as -sees suicide as retributionretribution

INTENTIONINTENTION-writing notes/will-writing notes/will-giving away -giving away

possessionspossessions-subtle/overt threats-subtle/overt threats-minor self-harm and -minor self-harm and

self-destructive self-destructive risk-takingrisk-taking

Sample 1 Trajectory (cont’d)Sample 1 Trajectory (cont’d)

ATTEMPTATTEMPT-pseudo-suicide -pseudo-suicide

attempt (in a place attempt (in a place and time when and time when interveners will be interveners will be present)present)

-minor attempt (failure -minor attempt (failure is distinct possibility)is distinct possibility)

-major attempt (failure -major attempt (failure remote)remote)

COMPLETIONCOMPLETION

Sample 2 TrajectorySample 2 Trajectory

IDEATIONIDEATION- Thoughts of killing Thoughts of killing

self (specific)self (specific)

INTENTINTENT- Expresses threat in Expresses threat in

angry outburstangry outburst- Threatens to harm Threatens to harm

others others simultaneouslysimultaneously

ATTEMPTATTEMPT- Major attempt Major attempt

(selects time and (selects time and method with little method with little chance of failure)chance of failure)

COMPLETIONCOMPLETION

Sample 3 TrajectorySample 3 Trajectory

IDEATIONIDEATION

- None expressedNone expressed

INTENTINTENT

- None observedNone observed

ATTEMPTATTEMPT

- None observed- None observed

COMPLETIONCOMPLETION

Sample 4 TrajectorySample 4 Trajectory

IDEATIONIDEATION

-Morbid ideation-Morbid ideation

-Preoccupation with -Preoccupation with death and dyingdeath and dying

INTENTINTENT

-Writes songs-Writes songs

-Self-harms-Self-harms

ATTEMPTATTEMPT

- None observedNone observed

COMPLETIONCOMPLETION

-None to date-None to date

Early Family Influences on Early Family Influences on Suicidal Behaviour Suicidal Behaviour ATTACHMENTHISTORY

PSYCHOLOGICALRESPONSE

ATTACHMENTBEHAVIOUR

ASSOCIATEDBEHAVIOUR

Insecure attachment Separation anxiety ProtestDespairDetachment

FailureAlternativeattachments

Persistent anxietyDepression

Object hungerAnxiousattachmentEmotionaldetachment

AntisocialbehaviourBehaviour disorderSchool phobiaIllness behaviour

Impaired capacityto form attachments

LonelinessLow self-esteemDepression

RelationshipdifficultiesMaritaldysfunction

Personality disorderAlcohol & drugabuse

Threatenedattachments

Abandonment anxietySuicidal ideation

Suicidal threatsSuicide attempts

Alcoholic bingePromiscuityPhobic stages

Recurrentattachment failure

Chronic anxietySevere depressionPersistent suicidalideation

Repeatedsuicide attempts

Major affectivedisorderChronic alcoholism

Social isolation HopelessnessDepair

Suicide

Adam, K.S., Early family influences on suicidal behaviour

Assessing Risk LevelsAssessing Risk Levels

Ensure you are qualified to make risk decisions. If Ensure you are qualified to make risk decisions. If you have not been trained through a program you have not been trained through a program such as ASIST or LivingWorks, seek assistance such as ASIST or LivingWorks, seek assistance immediately. If you are trained, it is still immediately. If you are trained, it is still important to debrief with a qualifed colleague.important to debrief with a qualifed colleague.

• Risk levels increase as resiliency factors decreaseRisk levels increase as resiliency factors decrease• Risk levels increase withRisk levels increase with

– Current suicide planCurrent suicide plan– Prior suicidal behaviourPrior suicidal behaviour– Lack of available resources to act as a safety netLack of available resources to act as a safety net

• Risk levels further escalate if suicide plan has Risk levels further escalate if suicide plan has method, means and established timeframemethod, means and established timeframe

If you are a trained If you are a trained intervener:intervener:

• The next slides are remindersThe next slides are reminders

• The next slides are for your The next slides are for your information, to assist you providing information, to assist you providing details to a trained intervenerdetails to a trained intervener

If you are likely to be a If you are likely to be a trusted professional:trusted professional:

Seeking Assistance and Seeking Assistance and Support Support • Use the school threat assessment and/or Use the school threat assessment and/or

crisis intervention protocol to assist youcrisis intervention protocol to assist you• Access the school psychologist, social Access the school psychologist, social

worker, AFM worker or other qualified worker, AFM worker or other qualified intervener within your systemintervener within your system

• Access medical, RCMP, or mobile crisis unit Access medical, RCMP, or mobile crisis unit if there are no qualifed interveners within if there are no qualifed interveners within your system.your system.

• Contact parent(s)/guardian(s).Contact parent(s)/guardian(s).• Document your actions.Document your actions.

Acronyms to Aid in Assessing Acronyms to Aid in Assessing RiskRisk

To respond efficiently to a suicidal To respond efficiently to a suicidal youth, it is important to be calm, youth, it is important to be calm, patient, and direction.patient, and direction.

To determine the degree of risk, you To determine the degree of risk, you need to learn answers to specific need to learn answers to specific questions. Ask them. It may be a life-questions. Ask them. It may be a life-saving decision.saving decision.

Miller (1984) Acronym 1Miller (1984) Acronym 1SS -- how how specificspecific is the plan of attack? The more is the plan of attack? The more

specific the details related the higher the degree of specific the details related the higher the degree of present riskpresent risk

LL -- how how lethallethal is the proposed method? How is the proposed method? How quickly could the person die if the plan is quickly could the person die if the plan is implemented? The greater the level of lethality, the implemented? The greater the level of lethality, the greater the risk.greater the risk.

AA -- How How availableavailable is the proposed method? If is the proposed method? If the implement to be used is readily available, the the implement to be used is readily available, the level of suicidal risk is greater.level of suicidal risk is greater.

PP -- What is the What is the proximityproximity of helping resources? of helping resources? Generally, the greater the distance the youth would Generally, the greater the distance the youth would be from helping or supporting resources if the plan be from helping or supporting resources if the plan were implemented, the greater the degree of risk.were implemented, the greater the degree of risk.

Miller (1984) Acronym 2Miller (1984) Acronym 2Four additional factors to aid in assessing the level of suicidal Four additional factors to aid in assessing the level of suicidal

risk risk when the youth has made a previous suicidal attempt:when the youth has made a previous suicidal attempt:D – DangerousD – Dangerous – How dangerous was the prior attempt – How dangerous was the prior attempt

and current plan? The greater the danger, the higher the and current plan? The greater the danger, the higher the current risk.current risk.

I – ImpressionI – Impression – Even if the danger in the attempt or plan – Even if the danger in the attempt or plan is not significantly high, if the impression is that the danger is not significantly high, if the impression is that the danger is high and will surely cause death, the present risk is high.is high and will surely cause death, the present risk is high.

R – RescueR – Rescue – If the opportunity for rescue was great in the – If the opportunity for rescue was great in the prior attempt or present plan, the risk is lower than if the prior attempt or present plan, the risk is lower than if the opportunity for rescue was remote. If the chances were or opportunity for rescue was remote. If the chances were or are poor that rescue will occur, the present risk is high.are poor that rescue will occur, the present risk is high.

T – TimingT – Timing – If the previous attempt was recent, the – If the previous attempt was recent, the present risk is higher than if the previous attempt was long present risk is higher than if the previous attempt was long ago.ago.

If a youth may be at immediate risk, you must If a youth may be at immediate risk, you must immediately implement any process necessary to immediately implement any process necessary to protect that youth or to provide life-saving supports.protect that youth or to provide life-saving supports.

Safety ContractsSafety Contracts

• Many low to moderate risk youths Many low to moderate risk youths respond positively and reliably to a respond positively and reliably to a safety contract.safety contract.

• The contract should includeThe contract should include– A specific plan that prevents immediate riskA specific plan that prevents immediate risk– A commitment to not engage in self-harm A commitment to not engage in self-harm

for an agreed-upon timeframefor an agreed-upon timeframe– Crisis support, including names and Crisis support, including names and

telephone numberstelephone numbers

• Ensure you have a ‘back-up’ plan in Ensure you have a ‘back-up’ plan in addition to a safety contractaddition to a safety contract

Sample Safety ContractSample Safety ContractPERSONAL SAFETY CONTRACT

Date:________________________ Time: ________________

I, (name), promise to keep myself safe until (date and time) when I see my counsellor. I will not harm myself or others in any way. If I feel like I cannot control myself or start to feel worried, or anxious, or that I might not keep this promise, I will call:

(insert youth’s choice of trusted friend or family member and telephone number) or

(insert youth’s alternative choice and telephone number) or(insert name of hospital/RCMP/nursing station and telephone number)

_______________________ _______________________Signature of Youth Signature of Counsellor

Ensure you have a ‘back-up’ plan in addition to a personal safety contract. Contact resources.

Assisting Low Risk YouthsAssisting Low Risk Youths

• Listening empathicallyListening empathically

• Obtaining a specific, written promise to Obtaining a specific, written promise to seek help when neededseek help when needed

• Providing a promise of continued Providing a promise of continued supportsupport

““Will you be safe until Tuesday?” Will you be safe until Tuesday?”

““I’ll stay with you while you tell your parent how you’re I’ll stay with you while you tell your parent how you’re feeling.”feeling.”

““Can you promise me that you will follow the Can you promise me that you will follow the instructions we have agreed to in this contract?”instructions we have agreed to in this contract?”

““Will you keep your appointment with me tomorrow?”Will you keep your appointment with me tomorrow?”

Assisting Moderate Risk Youths Assisting Moderate Risk Youths without a specific planwithout a specific plan• Require more intervention and directionRequire more intervention and direction• Written and verbal commitment requiredWritten and verbal commitment required• Refer to school psychologistRefer to school psychologist• Contact parent(s)Contact parent(s)““I’m not positive you’re going to be okay after you leave here.”I’m not positive you’re going to be okay after you leave here.”““Will you keep the promises you made in our contract?”Will you keep the promises you made in our contract?”““Here’s a telephone number where I can be reached, the Here’s a telephone number where I can be reached, the

suicide crisis line and the clinic number. Promise me now suicide crisis line and the clinic number. Promise me now that you will call me or any of these other numbers for help that you will call me or any of these other numbers for help before you decide to take any action that might harm you. before you decide to take any action that might harm you. Even when the idea enters your head and you’re not Even when the idea enters your head and you’re not sure….phone. Can you promise?”sure….phone. Can you promise?”

““Can I telephone you this evening to make sure you’re all right? Can I telephone you this evening to make sure you’re all right? I’m very concerned and I want us to talk again to make I’m very concerned and I want us to talk again to make things better for you.”things better for you.”

““Will you be safe if you leave here now? Are you positive?”Will you be safe if you leave here now? Are you positive?”

Assisting High Risk YouthsAssisting High Risk Youths• Youth is in crisisYouth is in crisis• Do not leave the youth unsupervised.Do not leave the youth unsupervised.• Support cannot be withdrawn for any reasonSupport cannot be withdrawn for any reason• Be assertive and directive.Be assertive and directive.““I can’t leave you here alone. I want you to come with me now I can’t leave you here alone. I want you to come with me now

so we can get you more help than I can give you here.”so we can get you more help than I can give you here.”““You can’t promise that you won’t kill yourself and that You can’t promise that you won’t kill yourself and that

concerns me. Let’s go together to the hospital where we can concerns me. Let’s go together to the hospital where we can get more support.”get more support.”

• Do not take ‘no’ for an answer. Follow Do not take ‘no’ for an answer. Follow school protocol for threat assessment/crisis school protocol for threat assessment/crisis intervention. intervention.

• Contact parent(s). Dial 911 if necessary.Contact parent(s). Dial 911 if necessary.

Summary of Typical Risk Summary of Typical Risk FactorsFactors• Recent attemptsRecent attempts

• Recent lossesRecent losses

• Critical incidentsCritical incidents

• Prior traumasPrior traumas

• Isolation/Isolation/withdrawalwithdrawal

• Substance abuseSubstance abuse

• Destructive coping Destructive coping stylesstyles

• Poor problem Poor problem solving skillssolving skills

• DisorientationDisorientation

• Inadequate supportInadequate support

• Hopelessness/ Hopelessness/ helplessnesshelplessness

Summary of Protective Summary of Protective FactorsFactors• Support from family Support from family

and friendsand friends• Perceived connection Perceived connection

to family and friendsto family and friends• Strong cultural tiesStrong cultural ties• Good physical and Good physical and

mental healthmental health• Strong spiritual tiesStrong spiritual ties• Positive self-esteemPositive self-esteem• Early identification Early identification

and treatment of and treatment of psychiatric illnesspsychiatric illness

• Good school Good school performanceperformance

• Positive attitude Positive attitude towards schooltowards school

• Skills in stress Skills in stress management, management, communication, communication, problem-solvingproblem-solving

• Fear of suicide and Fear of suicide and objections to suicideobjections to suicide

• Sense of Sense of belongingnessbelongingness

Risk vs Imminent DangerRisk vs Imminent DangerPHASE ONEPHASE ONEIs there a plan and means?Is there a plan and means?Risk factors – five of the following (1-4=risk, Risk factors – five of the following (1-4=risk,

5 or more=danger):5 or more=danger):a)a) MaleMaleb)b) Past attemptPast attemptc)c) More than one attemptMore than one attemptd)d) Antisocial behaviourAntisocial behavioure)e) Friend or family who has committed suicideFriend or family who has committed suicidef)f) Drug and/or alcohol abuseDrug and/or alcohol abuseg)g) DepressionDepressionh)h) Difficulty socially, especially family problemsDifficulty socially, especially family problems

Risk vs Imminent Danger Risk vs Imminent Danger (cont’d)(cont’d)

PHASE TWOPHASE TWOCan the youth complete tasks incompatible with suicidal Can the youth complete tasks incompatible with suicidal

states?states?1.1. Written promise to abstain from suicidal behaviour Written promise to abstain from suicidal behaviour

for specified timefor specified time2.2. Ability to compliment self and othersAbility to compliment self and others3.3. Ability to assess their own emotional state (e.g, Ability to assess their own emotional state (e.g,

develop hierarchy of situations that would raise develop hierarchy of situations that would raise suicidal thoughts)suicidal thoughts)

4.4. Capacity to plan ahead (e.g., being prepared for Capacity to plan ahead (e.g., being prepared for stressors, positive imagery, relaxation, develop stressors, positive imagery, relaxation, develop social support systemsocial support system

(Inability to accomplish these four tasks indicates (Inability to accomplish these four tasks indicates possible imminent danger)possible imminent danger)

ReferralsReferrals

• Report suicidality and refer to a trained Report suicidality and refer to a trained professional (e.g., psychologist, medical professional (e.g., psychologist, medical doctor, Salvation Army Mobile Crisis Unit). doctor, Salvation Army Mobile Crisis Unit). While awaiting the professional,While awaiting the professional,

• Remove access to means of suicideRemove access to means of suicide• Use protocols for threat assessments/crisis Use protocols for threat assessments/crisis

interventionintervention• Inform parent that referral has been madeInform parent that referral has been made• Maintain supervision of youthMaintain supervision of youth

Formal AssessmentsFormal AssessmentsThere are several instruments available There are several instruments available

to trained professionals to detect to trained professionals to detect suicidality. Some of the most suicidality. Some of the most commonly used are:commonly used are:

• Suicide Probability Scale (SPS)Suicide Probability Scale (SPS)• Suicidal Ideation Questionnaire (SIQ)Suicidal Ideation Questionnaire (SIQ)• ISO-30ISO-30• Children’s Depression Rating Scale Children’s Depression Rating Scale • Beck Hopelessness Scale (BHS)Beck Hopelessness Scale (BHS)• Index of Potential SuicideIndex of Potential Suicide

Making the ConnectionMaking the Connection• You’ve recognized the signs and symptoms.You’ve recognized the signs and symptoms.

• You’ve asked the questions directly.You’ve asked the questions directly.

• You’ve documented the interview and your You’ve documented the interview and your actions.actions.

• You’ve made a connection with the youth.You’ve made a connection with the youth.

• You may be the difference between You may be the difference between recovery and imminent death.recovery and imminent death.

• The youth is trusting you to be a reliable, The youth is trusting you to be a reliable, responsible adult.responsible adult.

Keeping the ConnectionKeeping the Connection• Stay focused. Stay focused. • Stay calm. Stay calm. • Stay with the youth.Stay with the youth.• Err on the side of caution. Err on the side of caution. • Trust your ‘gut’.Trust your ‘gut’.• Get help. Create a helping network with Get help. Create a helping network with

the youth.the youth.• Document events.Document events.• Debrief with a trusted colleague following Debrief with a trusted colleague following

the initial resolution of the event.the initial resolution of the event.

This presentation has been an This presentation has been an overview of commonly held overview of commonly held principles and practices when principles and practices when dealing with suicidal clients. dealing with suicidal clients.

It is intended as an information It is intended as an information session only.session only.

This presentation does not This presentation does not provide training for suicide provide training for suicide intervention.intervention.

For information on training in For information on training in intervention and postvention, please intervention and postvention, please contact:contact:

Centre for Suicide PreventionCentre for Suicide PreventionSuite 320, 1202 Centre Street S.E.Suite 320, 1202 Centre Street S.E.Calgary, Alberta Canada T2G 5A5Calgary, Alberta Canada T2G 5A5Phone: 403 245-3900 Fax: 403 245-Phone: 403 245-3900 Fax: 403 245-0299 0299 sptp@suicideinfo.casptp@suicideinfo.ca

ororLorna MartinLorna Martin Manitoba Education, Citizenship and Manitoba Education, Citizenship and Youth Youth Phone: 204 945-7964 Fax: 204 948-2291Phone: 204 945-7964 Fax: 204 948-2291lormartin@gov.mb.calormartin@gov.mb.ca