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Teen Suicide: Practical Interventions for Adolescents in Crisis
10 CEUs Teen Suicide: Practical Interventions for Adolescents in Crisis

Section 26
Teen Suicide Intervention: Pre & Postvention for School Counselors

CEU Question 26 | CEU Answer Booklet | Table of Contents | Crisis CEU Courses
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Prevention
Since a growing number of legal opinions have indicated that unanticipated acts of violence in schools (and suicide is an act of violence) can be predicted (Hermann & Remley, 2000), courts, in the future, probably School Violence Teen Suicide Practical Interventions mft CEU coursewill expect schools to have prevention programs in place. If they do not, courts may hold the schools accountable for suicides. A number of steps must be taken to facilitate a successful school-community prevention effort. Communication with administrators, faculty/staff in-service, preparation of crisis teams, providing for individual and group counseling options, parent education, and classroom presentations are necessary to fulfill ethical obligations and to delineate roles.

Communication with administrators. There is a compelling need for prevention, crisis management, and postvention programs for the adolescent suicide problem to be implemented in elementary, middle, and high schools throughout the country (Metha et al., 1998; Zenere & Lazarus, 1997). One of the biggest mistakes made by counselors, educators, and coordinators' of counseling/student services is to initiate suicide prevention programs without first obtaining the commitment and support of administrators and others in supervisory positions. Building principals and superintendents must be supportive; otherwise efforts may not be effective.

In addition to the groundwork that must be done on the building level, it is also important to effect advance communication and planning on the district level. The superintendent, assistant superintendent, curriculum director, staff development director, student services coordinator, research and program evaluation specialist, must all commit their support to intervention efforts.

Faculty/staff in-service. Since teachers and other faculty and staff usually learn of a student's suicidal preoccupation prior to the situation being brought to the attention of the school counselor or another member of the crisis team (assuming such a team exists), all faculty and staff (e.g., teachers, aides, secretaries, administrators, custodians, bus drivers, food service personnel, librarians, school social workers) must be included in building or district level in-service on the topic of youth suicide. All should be taught the background information previously delineated so that they can make referrals to the school counselor. It is imperative that all adults in schools be educated about both youth suicide and building and district policies and protocols for prevention, crisis management, and postvention. They must be cautioned against attempting to provide personal counseling; their roles are to recognize risk and facilitate referrals. A growing number of publications provide excellent guidelines for elements of prevention programming focused on school faculty and staff (Davidson & Range, 1999; Metha et al., 1998; Zenere & Lazarus, 1997).

Preparation of crisis teams. Most schools have crisis teams composed of faculty, staff, and parents connected with a particular building. These teams often exist in conjunction with a program for the prevention and intervention efforts necessary to cope with the drug problem among young people in today's schools. With education beyond that which is provided during faculty/staff in-service programs discussed previously as well as additional supervision and evaluation of clinical skills, a crisis team can be taught how to facilitate prevention efforts in a school as well as how to respond to a student already experiencing a suicidal crisis or in need of postvention efforts.

Individual and group counseling options. Prior to providing students with any information about suicide and suicide prevention efforts in a school, arrangements must be made for the individual and group counseling services that will be needed by those who seek assistance for themselves or their friends. School counselors rarely have the opportunity to provide the counseling needed by students identified as potentially suicidal because of other responsibilities as well as very high student-to-counselor ratios. Unless such counseling options are available, any effort at prevention, crisis management, or postvention will be doomed to failure.

If the school district cannot make a commitment to providing counseling, then arrangements for referral to community agencies and private practitioners must be made. It is important to provide adolescents and their families with a variety of referral possibilities along with information on fee schedules. There may be some question about whether the school district will be liable for the cost of such counseling if the referral is made by the school. (This issue should be explored by whatever legal counsel is retained by the district.) The dilemma, of course, is that unless counseling takes place when a suicidal adolescent has been identified, the probability is high that an attempt or a completion will take place. If the school is aware of a teenager's suicidal preoccupation and does not act in the best interests of such a teenager, families may later bring suit against the district.

Parent education. Parents of students in a school in which a suicide prevention program is to be initiated should be involved in the school's efforts to educate, identify, and assist young people in this respect. Parents have a right to understand why the school is taking such steps and what the components of a school-wide effort will be. Evening or late afternoon parent education efforts can be constructive and engender additional support for a school or school district. Parents have the same information needs as faculty and staff with respect to the topic of adolescent suicide.

Classroom presentations. Debate continues surrounding the safety of adolescent suicide prevention programs 'that contain an educational component presented to adolescents. This debate is similar to the one that emerged years ago when schools initiated staff development and classroom presentations on the topic of physical and sexual abuse. In conjunction with this debate, a number of advocates of education and discussion efforts are focused on students in a school-wide suicide prevention effort (Capuzzi, 1988, 1994; Capuzzi & Golden, 1988; Curran, 1987; Ross, 1980; Sudak, Ford, & Rushforth, 1984; Zenere & Lazarus, 1997). These advocates recommend providing an appropriate forum in which adolescents can receive accurate information, ask questions, and learn about how to obtain help for themselves and their friends. They believe that doing so does not precipitate suicidal preoccupation or attempts (Capuzzi; Capuzzi & Gross, 2000).

A carefully prepared and well-presented classroom presentation made by a counselor or member of the school's crisis team is essential. Such a presentation should include both information on causes, myths, and symptoms as well as information about how to obtain help through the school. Under no circumstances should media be used in which adolescents are shown a suicide plan.

On the elementary level, school faculty should not present programs on the topic of suicide prevention. Their efforts are better focused on developmental counseling and classroom presentations directed at helping children develop resiliency and overcome traits (e.g., low self-esteem or poor communication skills) that may put them at risk for suicidal behavior at a later time. Although these efforts should be continued through secondary education, middle and high school students are better served through presentations that address adolescent suicide directly.

Crisis Management
School counselors often receive student referrals from other adults in the building when the student is thought to be experiencing a suicidal crisis. The principles delineated below are shared for the purpose of providing succinct guidelines for a suicide-risk assessment so that steps can be taken to prevent a possible attempt. Any assessment, phone call, or step taken in this context should be documented in case notes.

Remember the meaning of the term crisis management. When thinking of crisis management, it is important to understand the meaning of the word crisis as well as the word management. The word crisis means that the situation is not usual, normal, or average; circumstances are such that a suicidal adolescent is highly stressed and in considerable emotional discomfort. The word management means that the professional involved must be prepared to apply skills that are different than those required for preventive or postvention counseling. An adolescent in crisis must be assessed, directed, monitored, and guided for the purpose of preventing an act of self-destruction.

Be calm and supportive. A calm, supportive manner on the part of the intervener conveys respect for the perceptions and internal pain of an adolescent preoccupied with suicidal thoughts. Remember that such an adolescent usually feels hopeless and highly stressed. The demeanor and attitude of the helping person are pivotal in the process of offering assistance.

Be nonjudgmental. Statements such as "You can't be thinking of suicide, it is against the teachings of your church," or "I had a similar problem when I was your age and I didn't consider suicide" are totally inappropriate during a crisis situation. An adolescent's perception of a situation is, at least temporarily, reality and that reality must be respected.

Encourage self-disclosure. The very act of talking about painful emotions and difficult circumstances is the first step in what can become a long-term healing process. A professional helper may be the first person with whom such a suicidal adolescent has shared and trusted in months or even years, and it may be difficult for the adolescent to confide simply because of lack of experience with communicating thoughts and feelings. It is important to support and encourage self-disclosure so that an assessment of lethality can be made early in the intervention process.

Acknowledge the reality of suicide as a choice but do not "normalize" suicide as a choice. It is important for professionals to let adolescents know that they are not alone and isolated with respect to suicidal preoccupation. It is also important to communicate the idea that suicide is a choice, a problem-solving option, not a good choice, and that there are better choices and options.

Actively listen and positively reinforce. It is important, during the initial stages of the crisis management process, to let the adolescent who is potentially at risk for suicide know you are listening carefully and really understanding how difficult life has been. Being listened to, heard, and respected are powerful and empowering experiences for anyone who is feeling at a loss for how to cope.

Do not attempt in-depth counseling. Although it is very important for a suicidal adolescent to begin to overcome feelings of despair and to develop a sense of control as soon as possible, the emotional turmoil and stress experienced during a crisis usually makes in-depth counseling impossible.

Developing a plan to begin lessening the sense of crisis an adolescent may be experiencing is extremely important, however, and should be accomplished as soon as possible. Crisis management necessitates the development of a plan to lessen the crisis; this plan should be shared with the adolescent so that it is clear that circumstances will improve. In-depth counseling cannot really take place during the height of a suicidal crisis.

Do not do an assessment alone. It is a good idea to enlist the assistance of another professional, with expertise in crisis management, when an adolescent thought to be at risk for suicide is brought to a school counselor's attention. School counselors should ask a colleague to come into the office and assist with assessment. It is always a good idea to have the support of a colleague who understands the dynamics of a suicidal crisis; in addition, the observations made by two professionals are more likely to be more comprehensive. Since suicidal adolescents may present a situation that, if misjudged or mismanaged, could result in a subsequent attempt or completion, it is in the best interests of both the professional and the client for professionals to work collaboratively whenever possible. It should also be noted that liability questions are less likely to become issues and professional judgment is less likely to be questioned if assessment of the severity of a suicidal crisis and associated recommendations for crisis management have been made on a collaborative basis.

Ask questions to assess lethality. A number of dimensions must be explored to assess lethality. This assessment can be accomplished through an interview format (a crisis situation is not conducive to the administration of a written appraisal instrument). Readers are referred to Capuzzi and Gross (2000) for a complete description of the assessment process and a list and explanation of the questions. It is important to understand that the role of the school counselor and crisis team is to determine if a student is potentially suicidal. Once this determination has been made, the student should be reassessed by the agency identified by the school district to make the final decision about the degree of risk for a suicide attempt or completion.

Make crisis management decisions. If, as a result of an assessment made by at least two professionals, the adolescent is thought to be potentially suicidal, the student should be seen by an outside agency. Under no circumstances should the student be left alone or asked to return home or meet with a mental health counselor without being accompanied by a parent or guardian.

Notify parents. Parents of minors must be notified and asked for assistance when an adolescent is determined to be at risk for a suicide attempt. Often, adolescents may attempt to elicit a promise of confidentiality from a school counselor who learns about suicidal intent. Such confidentiality is not possible or required (Remley & Herlihy, 2001); the welfare of the adolescent is the most important consideration.

Sometimes parents do not believe that their child is suicidal. At times, parents may be adamant in their demands that the school or mental health professional withdraw their involvement. Although some professionals worry about liability issues in such circumstances, liability is higher if such an adolescent is allowed to leave unmonitored with no provision for follow-up assistance. Schools should confer with legal counsel to understand liability issues and to make sure that the best practices are followed in such circumstances. It may be necessary to refer the student to protective services for children and families when parents or guardians refuse to cooperate.

Consider hospitalization. Hospitalization can be the option of choice during a suicidal crisis, if the parents are not cooperating, when the risk is high. An adolescent who has not been sleeping or eating, for example, may be totally exhausted or highly agitated. The care and safety that can be offered in a psychiatric unit of a hospital is often needed until the adolescent can experience a lowered level of stress, obtain food and rest, and realize that others consider the circumstances painful and worthy of attention. The protocol in the school and school district's written tragedy response plan should be followed in such circumstances. School counselors and crisis team members should not take it upon themselves to transport a student to the psychiatric unit of a local hospital; this should be facilitated by the staff of the agency the school collaborates with when such circumstances arise.

Refuse to allow the youth to return to school without an assessment by a mental health counselor, psychologist, psychiatrist, or other qualified professional. An increasing number of school districts are adopting this policy. Although it could be argued that preventing a suicidal youth from returning to school might exacerbate suicidal ideation and intent, this policy increases the probability that the youth will receive mental health counseling and provides the school with support in the process of preventing the youth from engaging in self harm. Acquiring a release from a third party for a student's return also provides an element of protection in the event that an attempt or completion takes place at a later time and the family files a lawsuit.

Postvention
When an adolescent has attempted or completed a suicide, it is imperative, particularly in a school setting, for the counselors to be aware of the impact of such an event on the "system." Usually within just a few hours, the fact that an adolescent has attempted or completed suicide has been chronicled through the peer group. This could present a problem to the faculty and staff in a given school building since not answering questions raised by students can engender the sharing of misinformation or rumors. The following guidelines should prove helpful to school counselors in the process of planning and implementing postvention efforts:
• The principal of the building in which a student has attempted or completed suicide (even though such an incident most likely occurred off the school campus) should organize a telephone network to notify all faculty and staff that a mandatory meeting will take place prior to school the next morning. The principal should share information and answer questions about what happened during such a meeting. In the case of a suicide completion, it is recommended that the principal provide all faculty and staff with an announcement that can be read in each class rather than over a public address system, so that everyone in the school receives the same information. The announcement should confirm the loss and emphasize the services the school and community will be providing during the day and subsequent days. Details about the circumstances or the family of the deceased should not be given so that confidentiality is maintained in that regard.
• Faculty and staff should be instructed to answer student questions that spontaneously arise.
• Faculty and staff should be told to excuse students from class if they are upset and need to spend time in the office of the building counselor or another member of the crisis team.
• Parents who are upset by the suicidal incident should be directed to a designated individual to have questions answered. Parents should also be provided with options for counseling, whether this counseling is provided by school personnel or referred to members of the mental health community.
• At times, newspaper and television journalists contact the school for information about both the attempt or the completion and the school's response to the "aftermath." It is important to direct all such inquiries to a designated individual to avoid the problems created by inconsistency or sharing inaccurate information.
• Be alert to delayed or enhanced grief responses on the part of students prior to the anniversary of a suicide completion. Often students will need opportunity to participate in a support group with peers or individual counseling prior to and, perhaps, beyond the anniversary date.
• Do not conduct a memorial service on the school campus after a suicide because doing so may provide reinforcement to other students preoccupied with suicidal ideation. This means that it is unwise to conduct an on-campus memorial service after a death for any reason--it is difficult to explain why a student who has suicided is not being remembered when another student, faculty or staff has been memorialized previously. Excuse students to attend the off campus memorial or funeral. Do the same thing for deaths for other reasons.
• Early in the sequence of events, one or two individuals from the school should contact the family and ask if there is any support it might need that the school can provide. It is a good idea to offer such assistance periodically, since so many families are left alone with their grief once the memorial or funeral has taken place.

Additional Considerations
The fourth question posed in the beginning of this article is Can the school or school district be sued by families after an attempted or completed suicide? In a pertinent review of the results of school violence litigation against educators, Hermann and Remley (2000) noted that, even though school personnel are expected to exert reasonable care to prevent harm to students, courts have been reluctant to hold educators liable for injuries related to-violence or self-harm. Usually state law claims fail because so much of today's school violence (and suicide attempts and completions are components of school violence) results from what can be termed spontaneous acts of violence. This statement should not, however, lull school personnel into a false sense of security, since a growing number of legal opinions have indicated that an unanticipated act of violence can be predictable and thus actionable under state law. Counselors, teachers, administrators, and other members of school staffs can protect themselves by writing and implementing prevention, crisis-management, and postvention policies and procedures for protecting youth from self-harm.

These policy and procedural documents should mandate in-service for school personnel so that all adults in the school environment recognize risk factors, myths, and possible behavioral, verbal, cognitive, and personality indicators as well as role responsibilities and limitations. Best practices are more likely to be followed if schools take a proactive rather than a reactive stance to this growing epidemic in our nation's schools.

Concluding Comments
Because of the legal and ethical considerations delineated in this article, counselors and other school personnel who are interested in learning how to identify potentially suicidal youth must obtain more extensive information than that provided here. In addition, since school counselors may need to provide follow-up supportive counseling once a suicidal youth returns to school, school counselors should obtain supervision from professionals who are experienced in working with suicidal youth after a suicidal crisis or a suicide attempt. Generally, prevention, crisis management, and postvention activities should not be attempted by anyone who has not completed a 2-year CACREP accredited or CACREP equivalent graduate program. Membership in the American Association of Suicidology or the American Foundation of Suicidology, participation in workshops and conferences focused on the topic of youth suicide, and consistent reading of the Journal of Suicide and Life Threatening Behavior and other books and journals is imperative so that best practices are followed in a way that ensures that legal and ethical standards are integrated into the prevention, crisis management, and postvention efforts of school counselors.

A youth who becomes suicidal is communicating the fact that he or she is experiencing difficulty with issues such as problem-solving, managing stress, and expressing feelings. It is important for school counselors to respond in constructive, safe, informed ways, because the future of their communities is dependent upon individuals who are positive, functional, and able to cope with the complex demands of life.
-Capuzzi, David, Professional School Counseling, Oct2002, Vol. 6, Issue 1
The article above contains foundational information. Articles below contain optional updates.

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Personal Reflection Exercise #12
The preceding section contained information about legal and ethical challenges in counseling suicidal students.  Write three case study examples regarding how you might use the content of this section in your practice.

Online Continuing Education QUESTION 26
According to Capuzzi, what is the first step in what can become a long-term healing process? Record the letter of the correct answer the CEU Answer Booklet.

 
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