Student Services

Suicide Prevention and Intervention

BY RICHARD LIEBERMAN, SCOTT POLAND, AND KATHERINE COWAN
Rich Lieberman is the coordinator of the Suicide Prevention Unit of the Los Angeles Unied
School District. He is a founding member of NASPs National Emergency Assistance Teamand a
cochair of NASPs Crisis Prevention and Intervention CurriculumDevelopment Workgroup.
Scott Poland is a faculty member at Nova Southeastern University in Fort Lauderdale, FL, and
the chairman of NASPs National Emergency Assistance Team.
Katherine Cowan is Director of Marketing and Communications for NASP.
Student Services is produced in collaboration with the National Association of School Psychologists
(NASP). Articles and related handouts can be downloaded at www.naspcenter.org/principals.
T
he principal of a large suburban
high school receives a phone call
that Eric, the younger brother
of Sam, a 10th-grade student, was found
dead the night before of apparent sui-
cide. Eric had been an 8th-grade student
at the middle school situated across the
playing feld from the high school. Eric
and Sam were both fairly well-known
as popular athletes in the district. Te
boys father had been killed the year
before in an automobile accident. Tey
had missed a few weeks of school and
received some grief counseling at the
time. Sam seemed to be adjusting to the
new school year well, although he was
involved in two minor fghts. He was
also cited for underage drinking when
police broke up an unsupervised party.
Eric had withdrawn some and had been
having difculty with his schoolwork.
His mother had spoken with the school
counselor about getting Eric extra sup-
port to help him focus. Erics friends
had noticed that he seemed a little edgy
and occasionally joked that he would
rather hang himself than sit through
rates of suicidal ideation and behavior
and were more likely than other minor-
ity students to attempt suicide (Centers
for Disease Control, 2004).
Completed suicides are only part
of the picture. Other forms of suicidal
ideation and behaviors are much more
common. It is estimated that for every
youth who dies by suicide, 100200
youth attempt it. Within a typical high
school classroom, it is likely that three
students (one boy and two girls) have at-
tempted suicide in the past year. For ev-
ery three students who attempt suicide,
only one receives medical attention. Te
other two get up and go to school the
next day (Poland & Lieberman, 2002).
The Role of Schools
Given the stakes, suicide prevention
and intervention is a key responsibility
for school administrators. Educating
and protecting students is aligned with
school mandates (Kalafat &Lazarus,
2002) and should be an integral part of
school-based mental health services. Te
learning environment lends itself to pre-
vention and early intervention eforts of
all types, and programs that are designed
to reach students who are at risk of
suicide can also help reach students who
are struggling with other mental health
issues, such as depression and anxiety.
School-based programs should take
into account the unique opportunities
and limitations presented by the school
context. Schools have extensive access
another math class. His attitude had also
been afecting his participation in soc-
cer, and the coach had recently benched
him for not coming to practice.
The Hard Reality
Adolescents today face tremendous
life pressures that put them at risk for
myriad self-destructive behaviors,
and suicide is the most devastating
consequence of their inability to cope.
Although youth suicide rates have
declined slightly since 1992, it is still
the third leading cause of death among
1024 year olds (Hoyert, Heron, Mur-
phy, & Kung, 2006), following automo-
bile accidents and homicide. Alarm-
ingly, the suicide rates for 1014 year
olds increased 196% between 198398
(U.S. Department of Health and Human
Services, 1999). Equally concerning,
suicide rates among certain subpopu-
lations, such as Black males, White
females, Asian youth, American Indian
youth, and sexual minority youth have
all increased. Recent data suggest that in
2003, Hispanic students had the highest
PL October 2006 11
With appropriate attention and thoughtful planning, the risk of
student suicide can be minimized.
Student Services
individual (e.g., depression or substance
abuse) and environmental (e.g., the
presence of a frearmor poverty) risk
factors as well as a lack of protective
factors (e.g., family cohesion and con-
nections to caring adults). Ofen, situ-
ational events (e.g., the death of a loved
one or a romantic breakup) can trigger
a suicide attempt.
Planning and Prevention
In addition to developing the capacity
to identify and intervene with students
at risk, a key underpinning of school
prevention eforts is creating a culture of
connectedness in which students, both
those at risk and their peers who may
know something, trust and seek the help
of school staf members. Specifcally,
school suicide prevention programs
should include awareness education and
screening, crisis and mental health team
coordination, collaboration with com-
munity services, reliance on evidence-
based strategies, and clear intervention
and postvention protocols.
Suicide task force. Every school
should have a suicide task force to
coordinate prevention and intervention
activities. Te task force should include
school mental health professionals, a
school administrator, and representa-
tives from local mental health and
suicide prevention crisis centers. Te
purpose of the task force is to develop
policies and procedures, assess potential
risk factors within the school environ-
ment (e.g., bullying), identify and imple-
ment appropriate prevention programs,
train staf members, assess and provide
interventions for students who are iden-
tifed as being at risk, and coordinate
with community providers. All concerns
of suicide risk should be relayed to a
member of the task force who acts as
the designated reporter. Depending on
to and infuence over students, allowing
staf members to raise awareness of risk
factors, bolster protective factors, and
identify and intervene with students at
risk. However, many of the forces con-
tributing to suicide risk and the resources
for intensive intervention fall outside
school control. Te challenge for princi-
pals is to establish procedures that both
safeguard students and are appropriate to
school resources and legal authority. Te
foundation of this process must be the
recognition that suicide is preventable and
that preventing it requires the conscious
commitment of school administrators
and staf members.
Suicidal Youth
Suicidal adolescents feel deep emotional
pain and isolation. Feelings of hopeless-
ness, sadness, worthlessness, anger, and
loneliness are ofen compounded by the
belief that no one else can understand
or helptheir pain. Although some
youth self-refer, most either attempt to
keep their decision a secret (but usually
give warning signs anyway) or cry for
help indirectly by making reference to
their plans, usually to peers. Adolescent
girls have higher rates of depression
and are twice as likely to carefully plan
and attempt suicide. Boys, however,
are more likely to act impulsively and
almost fve times as likely as females to
die by suicide (Brock, Sandoval, & Hart,
2006). Adolescents can understand the
concept of death cognitively. However,
it is not clear that they internalize the
end of their own lives, particularly
younger adolescents. It would not be
uncommon for students even as old as
16 to view death as magical, temporary,
and reversible (Lieberman, Poland, &
Cassel, in press). Typically, a combi-
nation of factors compels a youth to
attempt suicide. Tis includes both
1 PL October 2006
Warning signs
Verbal and written statements
about death and dying
Dramatic changes in behavior
or personality
Fascination with death and
dying
Giving away prized possessions
or making out a will
Interpersonal conflicts or loss
Triggers
Getting into trouble with
authorities
Breakup with a boyfriend
or a girlfriend
Death of a loved one or
significant person/loss
Knowing someone who
died by suicide
Bullying or victimization
Family conflict/dysfunction
Academic crisis or school
failure
Disappointment or rejection
Abuse
Trauma exposure
Serious illness or injury
Anniversary of the death
of a loved one
Forced or extended separation
from friends or family.
Source: Kalafat, J., & Lazarus, P. J.
(2002). Suicide prevention in schools.
In S. E. Brock, P. J. Lazarus, & S. R.
Jimerson, Best practices in school
crisis prevention and intervention.
Bethesda, MD: National Association of
School Psychologists.
Warning Signs and Triggers
PL October 2006 13
the size of the school, more than one
designated reporter may be required.
Gatekeeper training. Teaching
the warning signs of suicide to school
personnel is referred to as gatekeeper
training. Te goal is to ensure that
school personnel recognize suicidal be-
havior, take it seriously, and inform the
appropriate staf member immediately.
Gatekeeper training should be provided
for paraprofessionals, coaches, bus driv-
ers, and so forth, and should emphasize
working as a part of a team, never keep-
ing knowledge of suicidal behavior a
secret, and knowing the warning signs.
Depression screening. Te Cen-
ters for Disease Control has identifed
depression screening as a promising
strategy for youth suicide prevention.
Te most widely recognized programs
are Signs of Suicide (SOS) and Teen
is liability. Schools have been sued
and found liable for failing to take
proper action, particularly for failing
to notify parents, when a student was
thought to be suicidal. Te key issues
in court cases have been forseeability
and negligence and have included
cases in which schools did not warn
parents about both verbal and writ-
ten statements about suicide as well
as cases in which the school failed to
provide supervision and counseling
for suicidal students. Schools have also
been sued over more-complex issues,
such as school climate and failure to
reduce bullying, that were claimed to
contribute to the suicide of a student.
It is important to keep records of train-
ing given to school staf members and
to strictly adhere to intervention and
reporting protocols.
Screen, developed at Harvard and Co-
lumbia Universities. Te SOS program
combines a training video for gatekeep-
ers with a brief screening for depression.
Some very promising research shows
that student participants increased their
knowledge about depression and suicide;
engaged in more adult-seeking behavior;
and most important, decreased their
suicide attempts. Teen Screen is designed
to screen youth for depression and other
mental disorders associated with suicidal
behaviors. Unfortunately, secondary
schools have been slow to implement
screening. Te reasons seemto be denial
of the scope of the problem, reluctance
to take time away fromacademics, and
the cost. However, screening takes very
little time and money.
Legal issues. A major concern
for principals in prevention eforts
Activate the school crisis team. Verify the death and assess the impact on the school community
(including staff members and parents).
Contact the victims family to offer support and determine their preferences for student outreach,
expressions of grief, and funeral arrangements/attendance.
Determine what and how information is to be shared. Tell the truth.
Inform students through discussion in classrooms and smaller venues, not assemblies or schoolwide
announcements.
Identify at-risk youth. Provide support and referral when appropriate. Those at particular risk to imitate
suicidal behavior are those who might have facilitated the suicide, failed to recognize or ignored warning
signs, or had a relationship or identify with the victim.
Focus on survivor coping and efforts to prevent further suicides. This is a time for key prevention
information. Emphasize that no one thing or person is to blame and that help is available.
Advocate for appropriate expressions of memorialization. Do not dedicate a memorial (e.g., tree, plaque,
or yearbook). Do contribute to a suicide prevention effort in the community or establish a living memorial
(student assistance programs).
Evaluate the crisis response.
Media representatives should be encouraged to follow American Association of Suicidology guidelines.
These guidelines recommend not making the suicide front page news or publishing a picture of the
deceased, but instead emphasizing suicide prevention, recognition of warning signs, and where to go
for help.
After the Fact
Student Services Student Services
14
Intervention
When a student is identifed as poten-
tially suicidal, he or she needs to be
seen by a school mental health profes-
sional immediatelyno exceptions. If
there is no mental health professional
in the building, the designated school
administrator will need to fll this role
until a mental health professional can be
brought in. Te goals of intervention are
to ensure student safety, assess and re-
spond to the level of risk, determine the
services needed, and ensure appropriate
care (Brock et al., 2006).
Assessing risk. Te designated
reporter should be trained to determine
the students level of risk and empow-
ered to seek administrative support as
the designated reporter and the student
work through the following steps. Tere
are three key questions that must be
included in any interview:
1. Have you ever thought of commit-
ting suicide? One in four students think
about suicide at some time; this alone
indicates low risk.
2. Have you ever attempted suicide
before? Tis is an important question
because the young person who has
attempted before is at moderate risk to
attempt again.
3. Do you have a plan to harm yourself
now? Te student who has a plan and
the means at his or her disposal would
be classifed at highest risk. He or she
must be supervised every moment until
transferred to the care of his or her
parents or a treatment facility.
When a student is assessed at any
level of risk for suicide, the school has a
duty to supervise the student, warn his
or her parents, and provide appropriate
referrals and follow-up.
Warning parents. Te parents of
the student must be notifed, regard-
less of the information obtained in the
interview. Information provided by
the students parents may be needed
during to the assessment process. Te
only exception to contacting parents is
when it appears that the student might
be a victim of parental abuse, in which
case an immediate referral should be
made to protective services. School staf
members should try to meet with the
parents and the student together before
releasing the student to parental care.
Te conference should focus on how
everyone can work together to obtain
the treatment and supervision needed.
If the student has mentioned a specifc
suicide method, steps need to be taken
to remove access to it.
Providing referrals. It is impor-
tant to collaborate with community
mental health resources and consider
cultural, developmental, and sexuality
issues when making referrals. Some-
times students are asked to sign a no
harm agreement, although there is no
research data to prove the efectiveness
of such contracts. However, helping
the student identify caring adults at
home and at school, appropriate coping
strategies, and community resources can
be empowering. When used, no harm
agreements should be viewed as only a
small part of the treatment and safety
plan and not as a substitute for supervi-
sion and treatment.
Documenting and following up.
Te staf member needs to document
the conference and, ideally, have the
parents sign a form indicating they have
been notifed of the suicidal emergency
of their child and have received refer-
ral information. It is very important
that follow-up services be provided at
school, regardless of whether or not
parents obtain community services. A
re-entry planning meeting should be
held whenever a student returns from
mental health hospitalization.
Aftermath
A suicide death is generally followed
by a complicated grief process and has
a powerful impact on a school com-
munity. It is absolutely essential that
principals are prepared to cope with the
afermath. In the case scenario at the be-
ginning of the article, students and staf
members in both the middle and the
high schools are likely to be afected by
Erics death, perhaps placing some other
students at risk. Providing leadership in
times of crisis is facilitated by having a
plan in place.
Follow-up. Te principal needs to be
in close communication with counsel-
ing personnel to ensure that appropriate
services are provided. Tere is ofen an
anniversary date associated with youth
suicide, and collaboration between
schools, agencies, and parents is essen-
tial. It is also not unusual for students to
want to memorialize the suicide victim
with plaques or permanent markers at
school. Te literature and experts cau-
tion against such remembrances and in-
Resources on the Web
American Association of Suicidology www.suicidology.org
American Foundation for Suicide Prevention www.afsp.org
Signs of Suicide (SOS) www.mentalhealthscreening.org
Teen Screen Program www.teenscreen.org
Centers for Disease Control www.cdc.gov
National Suicide Hotline: 800.SUICIDE
14 PL October 2006
PL Octoberr 2006 15
stead recommend projects and services
for the living, such as scholarships in the
students memory.
Care for the Caregivers
Tere is nothing easy about suicide or
suicide prevention. However, addressing
the issue directly and openly through
prevention and intervention eforts
can greatly contribute to student safety.
Safeguarding students is an integral part
of an educators role, but the complex
and potentially tragic consequences of
suicide can strain even the most sea-
soned professional. Principals should
not underestimate the impact on staf
members of either a rash of suicide refer-
rals or an actual suicide. In addition to
ensuring the necessary resources to sup-
port students, principals must be vigilant
to the needs of staf members and create
a school culture in which students and
staf members alike recognize when they
are struggling and feel comfortable seek-
ing appropriate help. PL
References
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(2006). Suicidal ideation and behaviors.
In G. G. Bear, K. M. Minke, & A. Tomas
(Eds.), Childrens needs II: Development,
problems and alternatives (pp. 361374).
Bethesda, MD: National Association of
School Psychologists.
n Centers for Disease Control and Pre-
vention. (2004). Youth risk behavior sur-
veillanceUnited States, 2003. MMWR,
53(SS-2), 196.
n Hoyert, D. L., Heron, M. P., Murphy,
S. L., & Kung, H. C. (2006) Deaths: Final
data for 2003. National Vital Statistics
Report, 54(13). Hyattsville, MD: National
Center for Health Statistics. (DHHS
Publication No. (PHS) 2006-1120.)
n Kalafat, J., &Lazarus, P. J. (2002).
Suicide prevention in schools. In S. E.
Brock, P. J. Lazarus, &S. R. Jimerson, Best
practices in school crisis prevention and
intervention. Bethesda, MD: National As-
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(Eds.), Best practices in school psychology
V. Bethesda, MD: National Association of
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