Spring 2018

Suicide Postvention in Schools

Addressing an emotional issue using best available information and critical thought

Suicide is an emotionally challenging topic and the strong feelings that arise related to suicide can lead to best-intentioned interventions that may not result in best-expected outcomes.*School principals work in an environment where these emotions expressed by students, teachers, school staff, parents and the community can create pressures for decisions and action that add to the personal distress already present if a student dies by suicide.  Being pressured (both internally and externally) to do something may not result in the same outcome as doing the most helpful thing.

Currently, there is no correct, simple or clear policy, procedure or process that has substantial evidence available to guide how a school should react when a student dies by suicide.  Each school is different.  Each death occurs in a different context.  Each community in which the school is situated is different. So, a one-size-fits-all approach is not possible. Instead, decisions need to be made based on best available evidence that then need to be applied within the situation, as it uniquely exists. What follows is a synthesis of best available considerations that school administrators can think about when developing their policy, procedures and processes addressing student death by suicide.

There are four key questions to be asked when considering the development and deployment of a school-sited response to death of a student by suicide.  These are:

  1. Is the school response the same for death by suicide as it is for death by any other cause (e.g. cancer, traffic accident)?  If not, how is this different response for death by suicide justified?
  2. Is the school developing a response based primarily on emotional inputs creating external/internal pressures or on best available evidence and a critical/rational assessment of the situation?
  3. Is the response the school is considering potentially harmful – will it help decrease risk for suicide in vulnerable students or potentially increase risk for suicide in vulnerable students?
  4. Is the school responding to pressure from the suicide prevention industry or vocal crusaders in the community?  If so, why – and what are the possible costs/benefits of such response?

Building on the above considerations, schools can develop policies, plans and processes that take into account these four components of a response framework:

  1. Primum non nocere (first do no harm).
  2. Reduce the potential for suicide contagion and development of suicide clusters.
  3. Facilitate the ongoing and usual operation/activities of the school (including avoidance of memorialization).
  4. Appropriately support individuals who have been affected by a suicide death plus, identification of those who may need additional support/intervention.

Here are some key elements that should be part of the school’s policies, plans and processes related to suicide postvention. Always keep in mind that not all students and teachers will respond to the situation in the same way and that the circumstances surrounding death by suicide may vary in different situations.  Application of these elements will need to be guided by situational realities.

  1. Ensure notification of all appropriate administration and operational personnel.  Engage the school crisis response team and ensure that all members are clear about their role and understand the rationale and the process for the school-based response.  Make sure that all necessary information has been obtained and considered.  Obtain external support and advice from local mental health clinical teams, not from community based non-government organizations who do not have the expertise needed to help schools address the situation.  Develop a simple and clear “go-forward” plan and ensure all involved know what it is and their role in making it happen. Remember that a medical examiner or coroner determines the cause of death as suicide: not the school, not a member of the community and not the media.  Avoid speculation.
  2. Provide simple and factual information using well-established internal and external school communication pathways.  Avoid the use of terms/phrases such as: “crisis”, “trauma”, “epidemic”, “committed suicide” or “successful suicide” in your communications. 
  3. Avoid the creation and deployment of memorial sites or activities that glorify, vilify or stigmatize the deceased.  Avoid school wide assemblies or on-campus gatherings.  Do not create on-campus memorial sites (such as crosses, flower placements, teddy-bear placements, etc.).  Do not provide psychological debriefing, critical stress debriefing, critical stress management or similar interventions.  Not only is there no substantial evidence that they are helpful, there is evidence that they may be harmful.
  4. Do not endorse, support or summon an external service (including grief counselors) to provide student bereavement support (caveat: unless in exceptional circumstance when school internal capacity is exceeded).
  5. Do engage in an appropriate supportive memorial activity such as creating a Book of Condolences that both students and staff can write a note in. Make sure this is kept in the administration office and that the senior administrator or their designate reads the book before presenting it to the parents/guardians or others.
  6. Do have a senior administrator reach out to the family of the deceased to offer condolences. Be prepared to provide information about where memorial services being held by the family of the deceased will be held to students and teachers.
  7. Provide clear leadership, a simple message to the media (not ongoing media discussion) should the circumstances dictate and a single point of administrative contact for parents, students and the public. When informing students, parents and teachers of the death, pair the information with how to access mental health resources (including electronic access such as mental health online services and Kids Help Phone contact numbers) that are available in the school and in the community.
  8. Ensure that the usual activity of the school continues. Provide a space in the school (such as a classroom) where individual students who want to chat with school counselors, school health care providers or other trained educators can go outside of usual class time. Have this available for an hour prior to school starting, during lunch and for an hour after school ends.  Do not bring in grief counselors (there is no evidence that they are helpful and adding individuals from out-of-school settings who are not known to students will not bring comfort to those affected while it may sensationalize the situation).
  9. Do contact your local mental health services to inform them of the situation as there may be patients from the school that are being treated there and some of these patients may be more vulnerable than other members of the school community.
  10. Do “touch-base” with vulnerable or higher-risk persons in the school.  These include close friends and teachers of the deceased.  This “touch-base” can be done by a school counselor or on-site health/mental health provider as a personal reach out to “check-in”.
  11. Do acknowledge the usual and culturally appropriate grieving rituals of the community and provide support for them – for example, giving friends of the deceased and teachers/staff time to attend a community based memorial service. Provide an unobtrusive follow-up “check-in” for students, teachers, and staff some 4-6 weeks after the event to identify individuals who may be in need of additional support.
  12.  Do not endorse, create nor apply school wide “screening” for suicide ideation/intent/actions.
  13.  Do not rush into purchase of programs that purport to be able to prevent suicide in the community (no programs currently in the marketplace have ever been shown to do so). Following death of a student by suicide, it is not unusual for product vendors to approach schools promoting the sale of their products.*
  14.  Avoid creating on-campus spaces, opportunities and publicity for suicide awareness speakers and self-proclaimed experiential experts. Such activities have no research supported positive effects and may have detrimental impact on vulnerable students.

KEEP CALM AND CARRY ON

* Similar caveats should be kept in mind when considering the purchase of self-proclaimed school-based suicide prevention programs or products. Unfortunately, to date, there is no evidence that any of the products or programs marketed to schools as preventing suicide actually do prevent suicide. Some of these present participant “satisfaction” results as proof of suicide prevention – this is not proof of prevention of suicide. Others purport to be “evidence-based” and list numerous publications related to their delivery framework (such as Gatekeeper Programs). However these lists do not include studies clearly demonstrating that their program/product prevents suicide and they “cherry-pick” the publications that they list, leaving out the many that do not support their marketing pitch. Many use an “Amway” distribution model for sales of their programs/products enlisting the assistance of community based mental health agencies to do so. The pairing of fear about suicide and the false promise of hope for prevention of suicide makes a perfect marketing storm for sales. At this time, it is a buyer beware situation for school based suicide prevention programs.

AUTHOR BIO:
Dr. Stan Kutcher ONS, MD, FRCPC, FCAHS, Sun Life Financial Chair in Adolescent Mental Health at Dalhousie University and IWK Health Centre, is an international expert in adolescent mental health and leader in mental health research, advocacy, training, policy, and services innovation and has been involved in mental health work in over 25 countries.

Dr. Yifeng Wei, MA, PhD holds an Interdisciplinary PhD degree in school mental health with Dalhousie University and was awarded the Canadian Institute of Health Research Doctoral Research Award in 2011. She has worked as a researcher and school mental health lead with the Sun Life Financial Chair in Adolescent Mental Health team since 2008.
Suggested Readings related to suicide postvention:
Ontario Center of Excellence for Child and Youth Mental Health. Evidence in-sight: suicide postvention programming. (2015). Available from: http://www.excellenceforchildandyouth.ca/sites/default/files/resource/EIS_Postvention.pdf
Cox, G.R., Bailey, E, Jorm, A.F., et al. (2016). Development of suicide postvention guidelines for secondary schools: a Delphi study. BMC Public Health, 16:180 – 188.
Szumilas, M. & Kutcher, S. (2011). Post-suicide Intervention Programs: A Systematic Review. Can J Public Health, 102 (1), 18-29.
Suggested Readings related to school-based suicide prevention programs/products
Kutcher, S., Wei, Y., & Behzadi, P. (2016). School and Community Based Youth Suicide Prevention Interventions: Hot Idea, Hot Air or Sham? The Canadian Journal of Psychiatry/La Revue canadienne de psychiatrie. DOI: 10.1177/0706743716659245
National Elf Service. (2016). The vexing challenge of suicide prevention: a research informed perspective on a recent systematic review. Available from: https://www.nationalelfservice.net/mental-health/suicide/vexing-challenge-suicide-prevention-research-informed-perspective-recent-systematic-review/
National Elf Service. (2016). Suicide prevention with Stan Kutcher. Available from: https://podtail.com/podcast/national-elf-service/suicide-prevention-with-stan-kutcher/
Wei, Y., Kutcher, S., & LeBlanc, J. (2015) Hot Idea or Hot Air: A Systematic Review of Evidence for Two Widely Marketed Youth Suicide Prevention Programs and Recommendations for Implementation. Journal of the Canadian Academy of Child and Adolescent Psychiatry, 21 (1), 5-16.
McLennan, J.D. (2015). Persisting without evidence is a problem: suicide prevention and other well-intentioned interventions. J Can Acad Child Adolesc Psychiatry, 24(2): 131-132.
Teenmentalhealth.org. (2014). Critically evaluation school mental health: a pilot report. Available from: http://teenmentalhealth.org/wp-content/uploads/2014/04/Critically_evaluating_school_mental_health_pilot_report.pdf