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

Section 25
Legal and Ethical Challenges in Counseling Suicidal Students

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Suicide rates for adolescents have risen more than 300% since the 1950s, yet the rates for the population in general have remained relatively stable (King, 2001). In 1997, the suicide rate among 15- to 24-year-olds Self-harm Teen Suicide Practical Interventions psychology continuing educationwas 11.4 per 100,000 (King, 1997). Almost 86% of all suicides by youths under the age of 20 occur in 15- to 19-year-olds (National Center for Health Statistics, 1996) and estimates of completed youth suicides range from 7,000 to 9,000 a year. Even more alarming is the fact that, for every youth suicide, there are between 100 to 200 youth suicide attempts in this country (National Center for Health Statistics, 1992). Since a teacher in a typical U.S. high school classroom can expect to have at least one young man and two young women who attempted suicide in the last year (King, 2000), many states are requiring that schools include guidelines for suicide prevention, crisis management, and postvention in their written tragedy-response plans. In addition, a number of states require that all school faculty, administration, and staff participate in workshops that address the parameters of youth suicide and provide school personnel with information about risk factors and signs and symptoms as well as direction for the protocol to be followed when youth are identified as being at risk of self-harm.

Typically, school counselors are an integral part of school-based suicide prevention, crisis management, and postvention efforts, and the increased involvement with this segment of a school's population presents a number of legal and ethical challenges to counselors as well as other school faculty, administration, and staff. What are the ethical obligations of school counselors and other school personnel once a youth has been identified as potentially suicidal or has attempted or completed suicide? What are the roles of faculty, staff, and administrators and how do their roles differ from those of the school counselor and crisis team member? How do schools work with parents and guardians of minors to ensure that an appropriate constellation of services is provided for a suicidal youth? Can the school or school district be sued by families after an attempted or completed youth suicide?

The purpose of this article is to answer these questions by addressing "best practices" in the process of providing suicide prevention programs in schools. Best practices are the aspirational standards an ethical and well-informed school counselor should strive to attain in the process of planning and implementing school-based prevention, crisis management, and postvention efforts. They can be distinguished from minimally acceptable practices which, though meeting most legal standards, may not provide maximum protection to students and their families.

Since best practices, both legal and ethical, are always informed by awareness of the guidelines that theory and research provide, a brief overview of some of the literature available to school counselors on the topics of ethnic and gender differences, methods, risk factors, precipitants of acts of self-harm, myths, and the profile of a potentially suicidal adolescent is provided. This is followed by a description of best practices for creating and implementing prevention, crisis management, and postvention programs. The article concludes by highlighting the most important legal implications for school counselors' roles.

Background
The information needed by counselors prior to planning and implementing a suicide prevention, crisis management, and postvention program for a school or school district is extensive. Such information is available to counselors through a variety of resources. Ethnic and gender differences, methods, risk factors, precipitants of attempts and completions, myths, and the possible "profile" of a suicidal youth are the topics that must be studied by school counselors interested in reaching out to this at-risk population. These topics are briefly reviewed for the purpose of providing school counselors with the background needed to meet the legal and ethical challenges they will encounter when counseling potentially suicidal students. Counselors may use the articles and books cited in this section for further study.

Ethnic and Gender Differences
Some studies on youth suicide report that the suicide rate is higher among adolescent males than among females (although adolescent women attempt three to four times as often as adolescent men). Caucasian, adolescent males complete suicide more often than any other ethnic group (Canetto & Sakinofsky, 1998; Metha, Weber, & Webb, 1998; Popenhagen & Qualley, 1998).

Although a number of explanations have been proposed to account for the differences in rates among genders and races, no clear answers have been found. Some models used to explain racial differences in suicide have suggested that the extreme stress and discrimination that African Americans in the United States confront helps to create protective factors such as extended networks of social support, that lower the risk and keep the suicide rates for African American adolescents lower than those of Caucasian adolescents (Bush, 1976; Gibbs, 1988). Despite the overall pattern suggested by the data, during the period between 1980 and 2000, the suicide rates for African American adolescent males showed an increase of over 300% in the 10-14 age group and an increase of approximately 200% in the 15-19 age group (Metha et al.; Speaker & Petersen, 2000).

The literature on youth suicide continues to document the fact that Native Americans also have high adolescent suicide rates in the United States. There is considerable variability across tribes. The Navajos, for example have suicide rates close to the national average of 11 to 13 per 100,000 of the population; some Apache groups have rates as high as 43 per 100,000 (Berlin, 1987). The high suicide rates in the Native American population have been associated with factors such as alcoholism and substance abuse, unemployment, availability of firearms, and child abuse and neglect (Berman & Jobes, 1991). In general, less traditional tribes have higher rates of suicide than do more traditional tribes (Wyche, Obolensky, & Glood, 1990). Suicide rates for both Asian-American and Hispanic-American adolescents continue to be lower than those for African-American and Native-American youth even though the 1980-1994 time period bore witness to much higher rates than previously recorded (Metha et al, 1998).

Methods
The use of firearms outranks all other methods of completed suicides; firearms are used by both genders. Studies in the United States show that availability of guns increases the risk of adolescent suicide (Brent et al., 1993; King, 2000). The second most common method is hanging and the third most common is gassing. Males use firearms and hanging more often than do females, but females use gassing and ingestion more often than do males for completed suicides (Berman & Jobes, 1991). The most common method used by suicide attempters is ingestion or overdose of medicine.

Risk Factors
As noted by Garland and Zigler (1993) and Shaffer and Craft (1999), the search for the etiology of suicide spans many areas of study. Studies of counselor awareness of risk factors continue 'to take place (King, 2000). Examples of risk factors that have been studied include neurotransmitter imbalances and genetic predictors, psychiatric disorders, poor self-efficacy and problem-solving, skills, sexual or physical abuse, concerns over sexual identity or orientation, availability of firearms, substance abuse, violent rock music, divorce in families, unemployment and labor strikes, loss, disability, giftedness, and, interestingly, phases of the moon. It is important for school counselors to note that almost all adolescent suicide victims have experienced some form of psychiatric illness. The most prevalent psychiatric disorders among adolescents who have completed suicide appear to be affective disorders, conduct disorders or antisocial personality disorders, and substance abuse disorders (Shaffer, 1988: Shaffer & Craft). Among affective disorders, particular attention should be paid to bipolar illness and depressive disorder with comorbidity such as attention deficit disorder, conduct disorder, or substance abuse disorders (Rohde, Lewinsohn, & Seeley, 1991).

The suicide of a family member or a close friend of the family can also be a risk factor for youth suicide. Prior attempts also escalate risk and are still the best single predictors (Shaffer, Garland, Gould, Fisher, & Trautman, 1988). An adolescent experiencing a physical illness that is chronic or terminal can also be at higher risk (Capuzzi, 1994). Many researchers have studied cognitive and coping-style factors (e.g., generalized feelings of hopelessness and poor interpersonal problem-solving skills) as risk factors for youth suicide (Garland & Zigler, 1993). High neuroticism and low extraversion, high impulsiveness, low self-esteem, giftedness, disability, and an external locus of control have also been studied and can be used to predict risk (Beautrais, Joyce, & Mulder, 1999).

Precipitants
Often, attempted or completed suicide is precipitated by what, to the adolescent, is interpreted as a shameful or humiliating experience (e.g., failure at school or work, or interpersonal conflict with a romantic partner or parent). Mounting evidence indicates that adolescents who do not cope well with major and minor life events and who do not have family and peer support are more likely to have suicidal ideation (Mazza & Reynolds, 1998). The humiliation and frustration experienced by some adolescents struggling with conflicts connected with their sexual orientation may precipitate suicidal behavior (Harry, 1989; McFarland, 1998), although being gay or lesbian in and of itself may not be a risk factor for suicide (Blumenthal, 1991). Hoberman and Garfinkel (1988) found the most common precipitant of suicide in a sample of 229 youth suicides to be an argument with a boyfriend, a girlfriend, or a parent (19%), followed by school problems (14%). Other humiliating experiences such as corporal punishment and abuse also serve as precipitants; the experience of sexual or physical assault seems to be a particularly significant risk factor for adolescent women (Hoberman & Garfinkel).

Myths
One of the biggest problems connected with youth suicide is the fact that parents, teachers, mental health professionals, and the adolescent population itself are not made aware of a variety of myths and misconceptions associated with this topic. Since subsequent discussion of best practices for prevention, crisis management, and postvention in this article is based on prior awareness of this topic, the reader is referred to Capuzzi and Gross (2000) for a more complete discussion of the following myths:
• Suicide is hereditary
• Suicide happens with no warning
• Adolescents from affluent families attempt or complete suicide more often than adolescents from poor families
• Once an adolescent is suicidal, he or she is suicidal forever
• If an adolescent attempts suicide and survives, he or she will never make an additional attempt
• Adolescents who attempt or complete suicide always leave notes
• Most adolescent suicides happen late at night or during the pre-dawn hours
• Never use the word suicide when talking to adolescents because using the word gives some adolescents the idea
• Every adolescent who attempts suicide is depressed.

The Profile
The suicidal profile has been analyzed from the perspectives of both the practicing counselor or mental health practitioner and that of the empirically based researcher. Although no constellation of traits and characteristics has been identified as predictive of suicidal attempts, a number of experts (Beautrais et al., 1999; Capuzzi, 1994; Capuzzi & Golden, 1988; Capuzzi & Gross, 2000; Curran, 1987; Davis; 1983; Hafen & Frandsen, 1986; Hussain & Vandiver, 1984; Johnson & Maile, 1987; Mazza & Reynolds, 1998) believe that about 90 percent of the adolescents who complete suicide (and lethal first attempts can result in completions) give cues to those around them in advance. Whether these cues are limited or numerous will depend on the adolescent, since each adolescent has a unique familial and social history. It is important for school counselors and other school personnel to recognize the signs and symptoms to facilitate prevention efforts. One of the essential components of the best practices discussed in a subsequent section of this article is teaching the profile of the suicidal or potentially suicidal youth so that referral and intervention can take place. Behavioral verbal, and cognitive cues and personality traits are the four areas around which counselors can make observations to base their assessments of the extent of suicidal ideation and risk. They are presented below in abridged form. The reader is referred to Capuzzi and Gross (2000) for more extensive description and discussion.

Behaviors
A number of common behaviors can be noted by counselors and other practitioners as possible cues: lack of concern about personal welfare; changes in social patterns; a decline in school achievement; altered patterns of sleeping and eating; attempts to put personal affairs in order or to make amends; use or abuse of alcohol or drugs; unusual interest in how others are feeling; preoccupation with death and violence themes; sudden improvement after a period of depression; and sudden or increased promiscuity.

Verbal Cues
As noted by Schneidman, Farbverow, and Litman (1976), verbal statements can provide cues to self-destructive intentions. Such statements should be assessed and considered in relation to factors such as behavioral signs, changes in thinking patterns, motivations, and personality traits. There is no "universal" language or "style" for communicating suicidal intention. Some adolescents will openly and directly say something like "I am going to commit suicide" or "I am thinking of taking my life." Others will be far less direct and make statements such as "I'm going home," "I wonder what death is like," "I'm tired," "She'll be sorry for how she has treated me," or "Someday I'll show everyone just how serious I am about some of the things I've said."

Thinking Patterns and Motivations
In addition to behavioral and verbal cues, thinking patterns and motivations of suicidal adolescents can also be assessed and evaluated. For such an assessment to occur, it is necessary to encourage self-disclosure to learn about changes in an adolescent's cognitive set and distortions of logic and problem-solving ability. As noted by Velkoff and Huberty (1988), the motivations of suicidal adolescents can be understood more readily when suicide is viewed as fulfilling one of three primary functions: (a) an avoidance function that protects the individual from the pain perceived to be associated with a relationship or set of circumstances; (b) a control function that enables an adolescent to believe he or she has gained control of someone or something thought to be out of control, hopeless or disastrous; and (c) a communication function that lets others know that something is wrong or that too much pain or too many injuries have been accumulated.

Personality Traits
As previously noted, it would be ideal if the research on the profile of the suicidal youth provided practitioners with such a succinct profile of personality traits that youth at risk for suicide could be identified far in advance of any suicidal risk. Adolescents who fit the profile could then be assisted through individual and group counseling or other means. Although no consensus has yet been reached on the "usual," "typical," or "average" constellation of personality traits of the suicidal adolescent, researchers have agreed on a number of characteristics that seem to be common to many suicidal youth. Among these are low self-esteem, hopelessness/helplessness, isolation, high stress, need to act out, need to achieve, poor communication skills, other directedness, guilt, depression, and poor problem-solving skills.

Best Practices
At the end of the introduction to this article, four questions were posed that relate to the legal and ethical challenges in counseling suicidal students. The first three of these questions (What are the ethical obligations of school counselors and other school personnel once a youth has been identified as potentially suicidal or attempted or completed suicide?, What are the roles of faculty, staff, and administrators, and how do their roles differ from those of the school counselor or crisis team member?, and How do schools work with parents and guardians to ensure that an appropriate constellation of services is provided for a suicidal youth?) are addressed through brief descriptions of school preparedness for prevention, crisis management, and postvention.
-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 #11
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 25
What are three myths and misconceptions about suicide that parents, teachers, mental health professionals, and the adolescent population itself are not made aware of? Record the letter of the correct answer the CEU Answer Booklet.

 
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