Suicide The Last Great Stigma

1. SuicideThe Last Great Stigma Judy Gabert, M.Ed., MA Counseling Suicide Prevention Action Network of Idaho 501 (c)3, only statewide suicide prevention group www.spanidaho.org

3. Information about Assessment and the Nature of Suicide are cheerfully Stolen from Dr. Thomas Joiner, FSU Dr. David Rudd, U of T, formerly U of U Most information on pre-,post- and intervention are at www.spanidaho.org

4. Objectives • Idaho and suicide • Understand what is known about suicide • Youth Suicide • Warning signs and risk and protective factors • Schools and suicide (pre-, inter-, and postvention) • Assessment • Workplace Activities • Resources

5. Myth sheet, what do you know about suicide? Take a few minutes to fill it out. When we finish, we will compare changes in your ideas about suicide. Please let us know if at any time you become too uncomfortable with this subject.

6. A psychologist returned home from a conference in Aspen, where all the psychologists were permitted to ski for free. Her husband asked her how it went. She replied, "Fine, but I've never seen so many Freudians slips."

7. General Information • Suicide is preventable. • It is a permanent solution to temporary problems. • Prevention is everyone’s responsibility. • Idaho has a Suicide Prevention Plan, available at spanidaho.org • The US rolled out its newest strategy in June, as more than 40,000 people died by suicide in 2010. • National Suicide Prevention Day is Sept. 10.

8. Idaho Suicide Data • In 2010 Idaho had the 6th highest suicide rate in the nation--49% higher than the national average. In 2009, we were 4th in the nation. • Canyon County had the highest county per capita rate for deaths by suicide in 2011 with 37 deaths. • Note that the years are different on stats as SPAN re-does stats yearly.

9. Why are Idaho’s rates high? • Generally Idaho is in the top ten for deaths by suicide as are Wyoming, Montana, Alaska, Arizona, and Nevada. In 2010, Oregon joined us at 7th. Washington no longer dwells in the top 10. Other high rate states are Colorado, Utah, and New Mexico.

10. Why? • Much rural/frontier area, aloneness • Attitude about mental health (stigma and rugged individualism) • Access to affordable mental health • High numbers of gun ownership; most lethal means (In 2011, 59% of deaths in Idaho were by firearm) • Also, tend to have more males per capita in rural areas.

11. US Suicide rates

12. Although suicide is rare--in 2011, 284 people died by suicide--it’s impacts are powerful, affecting family, friends, communities, and work places and/or schools. However, if a 747 fell from the sky once a year killing this many people, how would we respond? Idaho ranks 50th in the number of doctors per capita. From 40-45% of suicide victims see their primary care physician in the two months before they die. It’s debated that 70% see mental health clinicians in the year before they die. Idaho ranks 51st for dollars spent on mental health. All of us are more likely to know someone who has died by suicide than someone who died in a car accident; we are more likely to know someone who has made a serious attempt than someone who is seriously injured in a car accident.

13. Desire to Die Perceived burdensomeness Thwarted belongingness Acquired Ability to Self-harm(habituation to pain) Learned ability Repeated self-harm--whether accidental or intentional Witnessing repeated emotional or physical pain Abuse, especially when young Dr. Joiner’s Interpersonal Explanation of Suicide

14. Sketch of Interpersonal Explanation for Suicide Those Who Desire Suicide Those Who Are Capable of Suicide Perceived Burdensomeness Acquired Ability for Self-Harm Habituation to Physical Pain Thwarted Belongingness Serious Attempt or Death by Suicide Derived from Sketch of a Theory Power Point presentation, 2009 Thomas Joiner, PhD

15. People really don’t want to die; they want an end to pain--emotional or physical. • Most people (about 90%) who die by suicide have a treatable mental health issue, usually depression. • There are about 20-25 attempts for every death by suicide. • Although suicide is relatively rare, a family, friends, community and workplace (and/or school) are affected by a single death. • Suicide is a public health issue resolved by easily accessible, affordable, and culturally-appropriate mental health help.

16. It is a bit like the property of cohesion: a glass doesn’t run over even when water goes above the rim. However, one more drop (action) can make the difference. Even so, drops can be removed with help and hope. Suicide is complex; it is not the result of one action or interaction or one single factor.

17. Youth Suicide • Suicide is the 2nd leading cause of death for adolescents and young adults in Idaho, which became true nationwide in 2011. • From 2007-2011, 78 school-age children (to age 18) died by suicide in Idaho. • Nation-wide youth suicide (15-24) occurs twice as frequently as it did 50 years ago.

18. Youth Suicide in Idaho • Idaho has a 58% higher number of suicides for youth (age 10-24) per capita than the national average.[i] In the most recent five-years for which national data is available (2006-2010), the suicide rate for youth age 10-24 nationally was 7 per 100k, and Idaho’s rate was nearly 11.2. Between 2007-2011, Idaho youth suicides increased 9% over the previous five-years 2006-2010. • [i] Data are calculated from CDC WISQARS. Retrieved May 24, 2013.

19. General info • Suicide is often attributed to a mental health issue and adolescents are more at risk for suicide at the onset of these disorders.. • Every time someone is treated for a mental health or a non-specific health issue, suicide ideation should be addressed. • Most college/university mental and physical health programs do not include suicide assessment/prevention as part of the curricula. (Washington state is now a happy exception.) • Up to 70% of suicidal people had visited a mental health professional in the year before their death; about 40-45% had seen their general health practitioner for a physical ailment in the two months before their death.

20. What Youth Report • The "2011 Idaho Youth Risk Behavior Survey (YRBS): A Healthy Look at Idaho Youth" is based on a survey of 1,702 9th through 12th-graders in 48 public high schools across the state in the spring of 2011. • 27.3% of high school students reported that in the previous 12 months they felt so sad or hopeless almost every day for two weeks or more that they stopped doing some usual activities, over in in 4. • One in seven high school students and one in four 9th grade females reported seriously considering suicide in the previous 12 months • During the previous year 13.2% of high school students reported having actually made a plan about how they would attempt suicide. • 8.1% of high school females and 4.6% of high school males reported making a suicide attempt one or more times during the previous 12 months An estimated 1 in 5 adolescents suffer from serious depression.

21. Suicide Warning Signs(indicate suicide may be imminent) • Threatening to, talking or writing about suicide • Previous suicide attempt • Seeking methods to kill oneself (sudden interest in guns) • Feeling hopeless or trapped • Withdrawing from friends, family, or society • Dramatic mood changes • Increased alcohol or drug use • Inability to sleep or sleeping all the time • Nightmares

22. Warning signs, continued • Changes in weight or eating habits • Withdrawal from friends or family or activities • Agitation or anxiety or raging or risk-taking (fights) • Giving away favorite things or making final plans • Neglecting school work or personal appearance • Chronic headaches, stomach aches, fatigue (stress) • Recent loss of a friend, family member, or significant relationship • Sudden unexpected loss of freedom or fear of punishment/humilation

23. Warning Signs in Youth • Youth may exhibit depression as anger or aggression. • Sometimes risk-taking behaviors can include acts of aggression, gunplay, and alcohol/substance abuse. While teens may not act “depressed,” their behavior suggests that they are not concerned about their own safety.

24. REMEMBERAny one sign alone doesn’t necessarily indicate a person is suicidal.  However, all signs are reason for concern and several signals may be cause for concern of suicide.  Warning signs are especially important if the person has attempted suicide in the past, isn’t sleeping, or is especially agitated or anxious.

25. For Youngsters and Beyond •   Self-injury behaviors are warning signs for young children as well as teenagers. Common self-destructive behaviors include running into traffic, jumping from heights, and scratching or cutting or marking the body. (Adolescent cutters are generally no more at risk than peers for suicide but still should have their issue addressed by competent mental health clinicians.)

26. Early Trauma May Increase Risk • Trauma disrupts development of the brain • Changes in ability to handle stress Overreaction to situations: fight or flight Underreact: seem numb or paralyzed seek ways to hide • Disruption of trust in adults or others

27. Extra Concern for Teens • Continued trouble at school or work • Incarceration or court-related problems • Inability to deal with problems or disappointment (low emotional intelligence) • Raging or extremely angry reactions • Shame or embarrassment within peer groups or public settings

28. Bio-psychosocial Risk Factors • Mental disorders • Alcohol and other substance use disorders • Impulsive and/or aggressive tendencies • Hopelessness • History of trauma or abuse • Some major physical illnesses • Previous suicide attempt • Family history of suicide

29. Environmental Risk Factors • Job or financial loss • Relationship or social loss • Easy access to lethal means • Local clusters of suicide that have a contagious influence

30. Psycho-social Risk Factors • Lack of social support • Sense of isolation • Stigma associated with seeking help • Barriers to accessing mental health care and substance abuse treatment • Certain cultural and religious beliefs (those that believe suicide is noble) • Exposure to, and influence of others who have died by suicide

31. Harvard Study Information • Adolescents (36% in the study) are more likely to die the same day of a crisis. Number lowers to 24% for those in twenties. • In postmortem of 76% of decedents, only 4% of youth had drug/alcohol in system; 36 % for adults. (This study is being replicated, and these numbers seem to be holding close) • In 41% of cases, death investigation reports noted the youths had either made a prior attempt (21%) and/or told someone they were thinking of suicide in the days preceding their death (31%).

32. Youth and Means • Nationally, 45% of suicide deaths in young adults (to age 24) are by firearm, and 43% are by strangulation (biggest means in Idaho for youth) • Most young people who die by firearm use one found in the home, stored unlocked, though death reports show that adolescents often knew where to find the key or the combination numbers or broke the glass on the gun storage.

33. Most people die by firearms; women generally choose pills.

34. People who die by suicide are ambivalent until the last second. (bridge stories) • Often when the means are taken out of the suicide plan, the person chooses to live. • People who were restrained from jumping off the Golden Gate Bridge rarely went on to die by suicide. Ninety-four percent never attempted suicide again; 99% are still alive. • When barriers were placed on a Washington DC bridge, suicides did not go up at the sister bridge a mile away.

35. Humor time • My therapist told me the way to achieve true inner peace is to finish what I start. So far today, I have finished two bags of chips and a chocolate cake. I feel better already.

36. A 2010 study of Idaho high school and Jr. high school counselors and social workers showed that while 97% of respondents had experienced a potentially suicidal student, only 55% felt well prepared to handle such a student. The same study stated that 64% of school counselors felt ill prepared to deal with the aftermath of a student suicide, or postvention. 

37. Administrative Rules IDAPA 08.02.03.160 – SAFE ENVIRONMENT AND DISCIPLINE • Each school district will have a comprehensive district wide policy and procedure encompassing the following: ƒ School Climate ƒ Discipline ƒ Student Health ƒ Violence Prevention ƒ Gun-free Schools ƒ Substance Abuse - Tobacco, Alcohol, and Other Drugs ƒ Suicide Prevention ƒ Student Harassment ƒ Drug-free School Zones ƒ Building Safety including Evacuation Drills • Districts will conduct an annual review of these policies and procedures.

38. TITLE 33 • EDUCATION • CHAPTER 5 • DISTRICT TRUSTEES • 33-512B.Suicidal tendencies -- Duty to warn. • (1) Notwithstanding the provisions of section 33-512(4), • Idaho Code, neither a teacher nor a school district • shall have a duty to warn of the suicidal • tendencies of a student absent the teacher’s • knowledge of direct evidence of such suicidal • tendencies.

39. (2) "Direct evidence" means evidence which directly • proves a fact without inference and which in itself, • if true, conclusively establishes that fact. Direct • evidence would include unequivocal and • unambiguous oral or written statements by a • student which would not cause a reasonable • teacher to speculate regarding the existence of the • fact in question; it would not include equivocal or • ambiguous oral or written statements by a student • which would cause a reasonable teacher to • speculate regarding the existence of the fact in • question. • (3) The existence of the teacher’s knowledge of the • direct evidence referred to in subsections (1) and • (2) of this section shall be determined by the court • as a matter of law.

40. Prevention • Everyone learns the warning signs • All staff and interested parents trained as gatekeepers and have protocols for reporting • Students learn that the code of silence doesn’t apply • School climate of inclusion and opportunity to succeed • Curriculum delivered as part of mental health unit in small groups is best with at least two adults • Parents are forewarned and know warning signs

41. No assemblies presented by previously suicidal youth; no work done on prevention other than gatekeeper training within a year of death by suicide in the school community • Always have hope messages and ways for students to have easy access to help • Message that suicide is rare and result of easily treated mental health issue

42. Intervention • Know easily accessible, competent mental health (tip off mental health clinician about the student) • Protocols to include community actions (EMT/police), how parents will be notified, what to do if parent/guardian cannot be located, and pre-screened mental health professionals • Student never left alone nor sent home • Home cleared of means • Culturally-appropriate and confidentiality protocols • Documentation of all actions taken • De-briefing of those involved • Follow up with parent and mental health (permission)

43. Postvention • Use the protocols on website (IMPORTANT for liability) • School teams are available • Students are especially vulnerable after a death of a classmate • The school day should be kept as normal as possible; do not let students leave unless their parents come to pick them up (not advisable)

44. Remember to monitor social media • Announcement made within classrooms • Be very aware of students’ reactions and offer safe place to talk • Prescreen close friends and vulnerable youth • No memorial at locker • Counselor or other professional to monitor classrooms throughout the day and bus after school

45. De-brief and self-care meetings for staff during the days after the death • Continue to monitor friends of deceased and other vulnerable students/staff • No permanent memorials; ask students to write notes to the family (pre-read), take up a collection for flowers or for the family, or other such activities • Contact family about coming to get personal items after the funeral • Have at least one school representative at the funeral; have mental health people available after • Encourage the family to have the funeral after school

46. Laughter as Medicine •  APsychology Today article entitled “Happily Ever Laughter” cites a study which shows that the average child in kindergarten laughs some 300 times a day whereas the typical adult laughs a measly 17 times a day. If you haven’t laughed in awhile maybe it is time you did. There is much research to show that laughter really is the best medicine for a lot of different types of maladies including depression.

47. Humor Time • A young woman took her troubles to a psychiatrist. "Doctor, you must help me," she pleaded. "It's gotten so that every time I date a nice guy, I end up in bed with him. And then afterward, I feel guilty and depressed for a week." "I see," nodded the psychiatrist. "And you, no doubt, want me to strengthen your will power and resolve in this matter." "For goodness sake, NO!" exclaimed the woman. "I want you to fix it so I won't feel guilty and depressed afterward."

48. For Clinicians: 1. Complete a comprehensive assessment for every patient where suicidality is an issue. 2. A thorough diagnostic interview and history must be completed as a part of the assessment process. 3. Always cover the targeted domains identified including: precipitant(s), suicidal thinking and past behavior, symptom presentation, hopelessness, impulsivity and self-control, and protective factors. 4. The use of simple 1-10 patient ratings are useful to gauge the patient--not only current severity across identified symptoms but also can be used to monitor a patient's functioning. 5. Be sure to consider co-morbidity.

49. Liability Issues • DOCUMENT, DOCUMENT, DOCUMENT • Write the client’s words specifically as you can. • CONFER, COLLABORATE • Interview collateral sources • Read and memorize Dr. Rudd’s The Assessment and Management of Suicidality available by pdf request to Linda Haroldson or me.

50. Be Aware • Many people kill themselves in the first few days after an emergency room evaluation for suicide or after getting out of in-patient treatment or after a mental health diagnosis • Provide a crisis plan to your clients ahead of time for this occurrence