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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.
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.
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.
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
Reflection Exercise #12