What Parents and Teachers should Know about Suicide in
Adolescents (Part 2)
(Article continued from Part I)
What can be done to help someone who may be suicidal?:
1. Take it seriously.
Myth: "The people who talk about it don't do it." Studies have
found that more than 75% of all completed suicides did things in
the few weeks or months prior to their deaths to indicate to
others that they were in deep despair. Anyone expressing
suicidal feelings needs immediate attention.
Myth: "Anyone who tries to kill himself has got to be crazy."
Perhaps 10% of all suicidal people are psychotic or have
delusional beliefs about reality. Most suicidal people suffer
from the recognized mental illness of depression; but many
depressed people adequately manage their daily affairs. The
absence of "craziness" does not mean the absence of suicide risk.
"Those problems weren't enough to commit suicide over," is often
said by people who knew a completed suicide. You cannot assume
that because you feel something is not worth being suicidal
about, that the person you are with feels the same way. It is
not how bad the problem is, but how badly it's hurting the
person who has it.
2. Remember: suicidal behavior is a cry for help.
Myth: "If someone is going to kill himself, nothing can stop
him." The fact that a person is still alive is sufficient proof
that part of him wants to remain alive. The suicidal person is
ambivalent - part of him wants to live and part of him wants not
so much death as he wants the pain to end. It is the part that
wants to live that tells another "I feel suicidal." If a
suicidal person turns to you it is likely that he believes that
you are more caring, more informed about coping with misfortune,
and more willing to protect his confidentiality. No matter how
negative the manner and content of his talk, he is doing a
positive thing and has a positive view of you.
3. Be willing to give and get help sooner rather than later.
Suicide prevention is not a last minute activity. Unfortunately,
suicidal people are afraid that trying to get help may bring
them more pain: being told they are stupid, foolish, sinful, or
manipulative; rejection; punishment; suspension from school;
written records of their condition; or involuntary commitment.
You need to do everything you can to reduce pain, rather than
increase or prolong it. Constructively involving yourself on the
side of life as early as possible will reduce the risk of
suicide.
4. Listen.
Give the person every opportunity to unburden his troubles and
ventilate his feelings. You don't need to say much and there are
no magic words. If you are concerned, your voice and manner will
show it. Give him relief from being alone with his pain; let him
know you are glad he turned to you. At times everyone feels sad,
hurt, or hopeless. You know what that's like; share your
feelings. Let the child know he or she is not alone. Avoid
arguments and advice giving. If the child's words or actions
scare you, tell him or her. If you're worried or don't know what
to do, say so.
5. ASK: "Are you having thoughts of suicide?"
Myth: "Talking about it may give someone the idea." People
already have the idea; suicide is constantly in the media. If
you ask a despairing person this question you are doing a good
thing for them: you are showing him that you care about him,
that you take him seriously, and that you are willing to let him
share his pain with you. You are giving him further opportunity
to discharge pent up and painful feelings. If the person is
having thoughts of suicide, find out how far along his ideation
has progressed.
6. If the person is acutely suicidal, do not leave him alone.
If the means are present, try to get rid of them. Detoxify the
school or home.
7. Urge professional help.
Persistence and patience may be needed to seek, engage and
continue with as many options as possible. In any referral
situation, let the person know you care and want to maintain
contact.
8. No secrets.
It is the part of the person that is afraid of more pain that
says "Don't tell anyone." It is the part that wants to stay
alive that tells you about it. Respond to that part of the
person and persistently seek out a mature and compassionate
person with whom you can review the situation. Distributing the
anxieties and responsibilities of suicide prevention makes it
easier and much more effective.
Interventions with a suicidal student:
Schools should have a written protocol for dealing with a
student who shows signs of suicidal or other dangerous behavior.
The following steps may be effective in dealing with a student
who expresses active suicidal intent.
1. Calm the immediate crisis situation. Do not leave the
suicidal student alone even for a minute. Ask whether he or she
is in possession of any potentially dangerous objects or
medications. If the student has dangerous items on his person,
be calm and try to verbally persuade the student to give them to
you. Do not engage in a physical struggle to get the items. Call
administration or the designated crisis team. Escort the student
away from other students to a safe place where the crisis team
members can talk to him. Be sure that there is access to a
telephone.
2. The crisis individuals then interview the student and
determine the potential risk for suicide. a. If the student is
holding on to dangerous items, it is the highest risk situation.
Staff should call an ambulance, the police and the student's
parents. Staff should try to calm the student and ask for the
dangerous items. b. If the student has no dangerous objects, but
appears to be an immediate suicide risk, it would be considered
a high-risk situation. If the student is upset because of
physical or sexual abuse, staff should notify the appropriate
school personnel and contact the police. If there is no evidence
of abuse or neglect, staff should contact parents and ask them
to come in to pick up their child. Staff should inform them
fully about the situation and strongly encourage them to take
their child to a mental health professional for an evaluation.
The team should give the parents a list of telephone numbers of
crisis clinics. If the school is unable to contact parents, and
if the police cannot intervene, designated staff should take the
student to a nearby emergency room. c. If the student has had
suicidal thoughts but does not seem likely to hurt himself in
the near future, the risk is more moderate. If abuse or neglect
is involved, staff should proceed as in the high-risk process.
If there is no evidence of abuse, the parents should still be
called to come in. They should be encouraged to take their child
for an immediate evaluation. d. Follow-Up: It is important to
document all actions taken. The crisis team may meet after the
incident to go over the situation. Friends of the student should
be given some limited information about what has transpired.
Designated staff should follow up with the student and parents
to determine whether the student is receiving appropriate mental
health services. Follow-up is crucial, because most suicides
occur within three months of the beginning of improvement in
depressive symptoms, when the youth has the energy to carry out
plans conceived earlier. Regularly scheduled supportive
counseling should be provided to teach the youth coping
mechanisms for managing stress accompanying a life crisis, as
well as day-to-day stress.
In a counseling situation, a contract can be an effective
prevention technique. The suicidal adolescent can be made to
sign a card which states that he or she agrees not to take the
final step of suicide while interacting with the counselor.
Role of the teachers:
Teachers play an especially important part in prevention,
because they spend so much time with their students. Along with
holding parent-teacher meetings to discuss teenage suicide
prevention, teachers can form referral networks with mental
health professionals. They can increase student awareness by
introducing the topic in health classes.
Some schools have automatic expulsion policies for students who
engage in illegal or violent behavior. It is important to
remember that teens who are violent or abuse drugs may be at
increased risk for suicide. If someone is expelled, the school
should attempt to help the parents arrange immediate and
possibly intensive psychiatric and behavioral interventions.
Role of the peers:
Peers are crucial to suicide prevention. According to one
survey, 93% of the students reported that they would turn to a
friend before a teacher, parent or spiritual guide in a time of
crisis. Peers can form student support groups and, once educated
themselves, can train others to be peer counselors.
Adolescents often will try to support a suicidal friend by
themselves. They may feel bound to secrecy, or feel that adults
are not to be trusted, and this may delay needed treatment.
Ideally, a teenage friend should listen to the suicidal youth in
an empathic way, but then insist on getting the youth immediate
adult and professional help.
Role of the parents:
Parents need to be as open and as attentive as possible to their
adolescent children's difficulties. The most effective suicide
prevention technique parents can exercise is to maintain open
lines of communication with their children. Sometimes teens hide
their problems, not wanting to burden the people they love. It
is extremely important to assure teens that they can share their
troubles, and gain support in the process. Parents are
encouraged to talk about suicide with their children, and to
educate themselves by attending parent-teacher or
parent-counselor education sessions and from nearby libraries or
the internet. Once trained, parents can help to staff a crisis
hotline in their community. Parents also need to be involved in
the counseling process if a teen has suicidal tendencies. These
activities may both alleviate parents' fears of the unknown and
assure teenagers that their parents care.
Postvention:
The rationale for school-based postvention/crisis intervention
is that a timely response to a suicide is likely to reduce
subsequent morbidity and mortality in fellow students, including
suicidality, the onset and exacerbation of psychiatric
disorders, and other symptoms related to pathological
bereavement.
An attempted or completed suicide can have a powerful effect on
the staff and on the other students. One study found an
increased incidence of major depression and posttraumatic stress
disorder 1.5 to 3 years after the suicide. There have been
clusters of suicides in adolescents, and some feel that media
sensationalization or idealized obituaries of the deceased may
contribute to this phenomenon.
The school should have plans in place to deal with a suicide or
other major crisis in the school community. The administration
or the designated individual should try to get as much
information as soon as possible. He or she should meet with
teachers and staff to inform them of the suicide. The teachers
or other staff should inform each class of students. It is
important that all of the students hear the same thing. After
they have been informed, they should have the opportunity to
talk about it. Those who wish should be excused to talk to
crisis counselors. The school should have extra counselors
available for students and staff who need to talk. Students who
appear to be the most severely affected may need parental
notification and outside mental health referrals. Rumor control
is important. There should be a designated person to deal with
the media. Refusing to talk to the media takes away the chance
to influence what information will be in the news. One should
remind the media reporters that sensational reporting has the
potential for increasing a contagion effect. They should ask the
media to be careful in how they report the incident. Media
should avoid repeated or sensationalistic coverage. They should
not provide enough details of the suicide method to create a
"how to" description. They should try not to glorify the
individual or present the suicidal behavior as a legitimate
strategy for coping with difficult situations.
It is imperative for crisis interventions to be well planned and
evaluated; otherwise, not only may they not help survivors, but
they may potentially exacerbate problems through the induction
of imitation.
COMMUNITY BASED PREVENTION PROGRAMS
Crisis Services (hotlines):
Crisis centers and hotlines are based on the premise that
suicide is often associated with a critical stress event, it is
usually approached with ambivalence, and the wish to commit
suicide is seen as a way to solve an immediate problem. Crisis
centers and hotlines are designed to deal with the immediate
crisis, and use the individual's ambivalence to convince them
that there are other means of solving the problem other than
suicide.
Restricting access to lethal means:
The underlying rationale for means restriction is that suicidal
individuals are often impulsive, they may be ambivalent about
killing themselves, and the risk period for suicide is
transient. Restricting access to lethal methods during this
period may prevent suicides. The following steps may be useful:
* Safe storage of guns
* Fences on bridges
* Restricting drugs/poisons
* Other restrictions on guns
Educating the media:
This includes educating media professionals about contagion, in
order to yield stories that minimize them, and encouraging the
media's positive role in educating the public about risks for
suicide and shaping attitudes about suicide.
CONCLUSION
Suicide attempts and completed suicides among adolescents are
problems of increasing significance. School staff, parents, and
health professionals should be sensitized about the risk factors
and warning signs of suicide, and about the ways to deal with
suicidal adolescents.
FURTHER READING
* Gould, M.S., Greenberg, T., Velting, D.M. & Shaffer, D. (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.
* Hawton, K. & James, A. (2005) Suicide and deliberate self harm
in young people. British Medical Journal, 330, 891-894.
* www.depts.washington.edu/hiprc/practices/topic/suicide
* www.baltimorepsych.com/suicide.htm
* www.metanoia.org/suicide/