Children & Adolescents: Best Practices for Suicide Prevention

1. Children & Adolescents: Best Practices for Suicide Prevention Michelle Kuchuk Manager of Clinical Technologies & Training, National Suicide Prevention Lifeline March 8, 2019

2. DISCLAIMER • The views, opinions, and content expressed in this presentation do not necessarily reflect the views, opinions, or policies of the Center for Mental Health Services (CMHS), the Substance Abuse and Mental Health Services Administration (SAMHSA), or the U.S. Department of Health and Human Services (HHS).

3. Take a moment… Take a moment to think of something that no one in the world knows about you…

4. Suicide & Youth • Suicide is the second leading cause of death in youth ages 10-24 • Relevant & effective suicide prevention and crisis response services for youth is needed • Lots of talk (and misrepresentations) about suicide – in the news, on social media, on TV, in movies • It is more important than ever to provide quality care for youth

5. How Did I Get Here? Today!

6. Working with Youth • Wide range of issues and concerns • Different ways of coping, processing • Differences in exploring emotional content: “idk” • Can present as helpless: “idk” • More likely to look for concrete advice • Common Roadblocks & Pitfalls Some Roadblocks & Pitfalls (by Adults): • The Desire to Give Advice • Belittling or patronizing statements

7. The Desire To Give Advice… • …is completely understandable! • Guide the discussion; don’t make the decisions • Advice-asking and expectation setting is especially difficult over chat, because of the ease and nature of the Internet – everything is easy to acquire … so why wouldn’t advice be any different?

8. But, what to say? (Not this) Client: Should I talk to someone about this? Counselor: It’s so understandable to want to talk to someone about this. I’m hearing that you want to talk to someone about this – do you think you will? Client: OR Counselor: Well, what do you think?

9. But, what to say? (Maybe this, instead) Client: Should I talk to someone about this? Counselor: What about talking to someone is making you hesitate? OR Counselor: It sounds confusing – on the one hand, you’d like to talk to your mom or your counselor because you feel connected to them, and on the other hand, you’re really worried that they’re going to overreact. OR Counselor: Are you worried that your mom is going to freak out if she knows?

10. Playing it out… Client: Should I talk to someone about this? Counselor: It sounds confusing – on the one hand, you’d like to talk to your mom or your counselor because you feel connected to them, and on the other hand, you’re really worried that they’re going to overreact. Client: No, they won’t overreact. Well maybe they will. But I don’t want my mom to feel worried about me all the time. She deals with a lot of stuff. Maybe I’ll tell my counselor first.

11. Belittling & Patronizing • “Children”/“kids” • “This won’t be a big deal when…” • “It’ll get better…” • “When you’re older…” Validate their experiences. They’ve probably already been told they’re overreacting.

12. But, what to say? (Not this) Client: My gf isn’t speaking to me. Counselor: It’s so understandable to feel upset. I can tell you’re hurting. This won’t be as big of a deal when you’re older, but let’s talk about what you’re going through today. Chatter/Caller:

13. But, what to say? (Maybe this, instead) Client: My gf isn’t speaking to me. Counselor: That’s so hard—when someone you care about refused to talk to you. Client: Yeah. It pretty much sucks. It’s making me feel like shit. Counselor: Can you tell me more about that? How it’s making you feel like shit? Client: I don’t know. I’m just not happy any more.

14. Working with Youth • Wide range of issues and concerns • Different ways of coping, processing • Differences in exploring emotional content: “idk” • Can present as helpless: “idk” • More likely to look for concrete advice • Common Roadblocks & Pitfalls Some Roadblocks & Pitfalls (by Adults): • The Desire to Give Advice • Belittling or patronizing statements At the end of the day, “young people” are human, too.

15. National Suicide Prevention Lifeline

16. National Network of Local Centers As of March 2019, the Lifeline had 170 affiliated call centers in 48 states. As of March 2019, 25 of those centers answer Lifeline crisis chats.

17. Lifeline Crisis Chat • The Lifeline manages a network of Crisis Chat Centers (current Crisis Call Centers) • Accredited by Contact USA/Online Emotional Support (OES) • National coverage (not localized)

18. How Chat Works • User enters zip code on Lifeline Chat homepage  chat is routed to available center  center answers

19. Chat Interactions vs. Calls • Closing the Conversation • Chats last longer than calls • Longer pauses between responses • Lack of auditory cues • Younger population • More non-suicidal self-injury • More people who are actively suicidal • Greater tendency for counselors to rush on Chat • Counselors need to make more of an effort not to sound robotic • Unique language/behavior • Risk Assessment • Safety Planning & Means Restriction • Emergency services and Active Rescues

20. How to Sound Human • Incorporate Ourselves More • Match Language Used by the Chatter • Intensifiers/Maximizers • Use Validation to Show That YOU Think What They’re Going Through is Normal • Use ALL Active Listening Tools • Reflection • Clarify & Paraphrase • Get Meta and Talk About It • Responding to THE Question • Call It Out

21. Incorporate Ourselves More Match the language used by the chatter • Try using the same terms — e.g. mom/mother, gf/girlfriend. Using abbreviations and emojis are sometimes ok, but shouldn’t be a replacement. Intensifiers/Maximizers • Since we don’t have our voices to convey warmth, intensity, or emphasis, we can express empathy by using intensifiers such as: “Jane, I can hear that you feel SO very hurt…” Use validation to show that YOU think what they’re going through is normal • This lets chatters know that their feelings are normal, natural, and importantly – that YOU think so. You can say, “You are not alone. I’m here to listen” or “that makes sense” or simply, “I see.”

22. Use ALL Active Listening Tools Reflection • “It seems like you’re feeling terrified after learning that your dad is angry at you again” or “It sounds like it’s incredibly overwhelming to face her at school, without having anyone to talk to.” Paraphrase & Clarify • Digest, interpret, and paraphrase to demonstrate understanding – or that at the very least, you’re trying to. Don’t be afraid to make mistakes! Chatters will see … that we’re human! Focus on what they are feeling. • “I get the feeling that you wish you could tell your dad how you feel when he yells at you. I’m wondering if you have thought about what you might say…”

23. Get Meta and Talk About It Responding to THE question • If a chatter asks, “Is this a ‘Bot?” You can first try to counter this by something like:  “I am a real person, my name is… and I work as a crisis counselor at…” Call it out! • If a chatter mentions that they’re frustrated because they feel as though they’re talking to a robot, or to a counselor following a script, ask about it! Validate their feeling, and remind yourself that any feeling a chatter brings up is grounds for a (nonjudgmental) discussion.

24. Long Pauses & IDK Long Pauses • The trajectory of a chat or text conversation is different than a phone call • Check in a few times, every five minutes or so • Then, empathetically close the conversation with an invitation to return IDK • Remain calm • Do not underestimate the skill of sitting together in silence • Open-ended questions and reflection (no interrogating!) • If you “take a leap” and reflect the wrong thing, it’ll be okay. At the end of the day, you’re talking to a human being.

25. Communication Modes Traditional • Listener listens to speak (focus on yourself) • Each agenda sent back and forth Crisis Prevention/Active-Listening • Listener listens to listen (focus on the other) • Receive first, before we send Suicide-Prevention • Tends toward “Traditional…” • Focus on “why”/something to be “solved” Talking about suicide can be scary. Often, people don’t know where to start/what to look for/how to sit with people in pain.

26. Don’t Try To Fix People • People are not problems to be solved, or mysteries to be unraveled. • There is no magic pill. • How often are we confusing even to ourselves? How often do we ask “why did I do that?!”

27. Suicide Myths • Myth: If you talk about suicide, you’re just putting the idea of suicide into that person’s mind and increasing their risk of suicide. • Fact: The reality is, talking openly about suicide opens up communication, allowing the discussion of painful things to come out into the open instead of staying deeply buried within the person. • Myth: People who talk about suicide or attempt suicide don’t actually want to kill themselves—they just want attention. • Fact: The majority of people who die by suicide, or attempt suicide, do or say something to indicate their state of mind and intentions before they act. It’s not that they “want” attention. They need attention. • Myth: Once someone decides to complete suicide, there is nothing anyone can do to stop it. • Fact: In fact, the majority of people who have attempted suicide go on to live long lives. Wanting to die is different than dying.

28. (Major) Risk Factors & Warning Signs Disclaimer: Though the majority of people who die by suicide or attempt suicide do or say something to indicate their state of mind and intentions before they act, there are still many people who have attempted suicide who report not knowing they were going to do so until hours before the attempt. That being said... Risk Factors & Warning Signs • Family history of suicide • Previous suicide attempts • History of mental illness, especially depression • Feelings of shame, hopelessness, loss • IDs as LGBTQIA • History of substance abuse • School recently experienced a suicide • Lack of social support • Increasing isolation • Easy access to/familiarity with lethal means (especially guns) • Recent stressors such as breakups/arguments with family or friends • Any event that leads to loss or humiliation

29. Explore Pain + Ask About Suicide • Explore feelings of overwhelmedness, high stress, loneliness, isolation • Befriend, and establish trust. Allow the person to open up about recent losses, or sleep problems, or substance abuse • Really listen for references to feeling hopeless, or trapped, or the suffering of unbearable pain, or having no reason to live. • Ask about suicide, especially if you notice phrases like: • I just don't have a reason to go on living • I've basically just cut myself off from the world • I feel like I can't trust anyone • I can't stop crying I seriously hate my life • I really feel like I have nothing to live for • I can't stop crying I don't know what I'm supposed to do • I just want to die seriously • How am I supposed to live my life like this • I see no reason for me to live • No one cares • Notice that most of these do not reference dying directly • Sit and shoulder the pain with them (empathetically, and not sympathetically)

30. Risk Assessing Lifeline Suicide Risk Assessment Standards: • Are you thinking of suicide? • Have you thought about suicide in the last two months? • Have you ever attempted to kill yourself? Additionally: • Ask about means, and ask about time. Transcript Example Client: I don't want to be here anymore. :( Counselor: The stuff with your dad has been so difficult for you. Mike: when people say they don’t want to be here anymore they sometimes mean they want to end their life. Is that what you mean? Client: I don’t know. Counselor: I am here to listen about what you’re going through.You were saying that you didn’t want to be here anymore – can you tell me about what you mean? Client: It’s just been shitty for a while. Counselor: Yeah. Through everything that you’ve been going through – have you had any thoughts of suicide in the last few months? Client: Yeah I have. Counselor: Thank you for telling me. I know it can be tough to talk about.

31. Risk Assessing Lifeline Suicide Risk Assessment Standards: • Are you thinking of suicide? • Have you thought about suicide in the last two months? • Have you ever attempted to kill yourself? Additionally: • Ask about means, and ask about time. Transcript Example (cont.) Client: It’s fine. Counselor: You said you feel like things are pointless, and you mentioned how overwhelmed and worthless you’ve been feeling. Are you have any thoughts of suicide today? Client: Yeah I think I am. Counselor: I’m glad you told me that. Do you think about how you would do this? Client: I was thinking of taking some pills and just going to sleep … Counselor: Thanks for being honest with me. It’s brave of you to talk about it. You mentioned pills – do you know which pills you would take? Client: yeah, tylenolpms i have Counselor: Have you thought of a time when you would take those pills? I want you to know that I am here for you, through every step of this conversation. Client: ty. no, not a time. Just thinking about the pills.

32. Some Don’ts… Don’t… • Interrogate • Say “I’m glad to hear that” • Behave as though the goal is to have the person not have suicidal thoughts anymore. (What kind of message does that send?) Transcript Example (Poor) Client: I don't want to be here anymore. :( Counselor: Are you thinking of suicide? Client: I don’t know. Counselor: Have you thought about suicide in the last three months? Client: Yeah. Counselor: Have you ever attempted to kill yourself? Client: No. Counselor: So you said you were thinking of suicide? Client: No I don’t think so. Counselor: I’m glad to hear that.

33. After Assessment • Explore options • Friend? Tell them you’re there for them. Explore feelings re: seeking professional help, feelings re: calling/chatting with a hotline. • Professional? Explore their support network. Explore feelings re: calling/chatting with a hotline; other services? Safety plan.

34. Safety Plan • A safety plan is a written list of various coping strategies of sources of support for people who are at high risk for suicide. The safety plan’s purpose is to provide a list of personal triggers or warning signs and personal resources and coping strategies that are pre-determined before the crisis occurs. • “Sometimes a crisis hits and people who are already struggling may suddenly experience strong suicidal feelings. Those feelings often go away in a matter of hours or days, but it can feel like it’ll last forever. I’m not saying this is likely to happen, but if it does, I want to be sure you make it through safely and call for help. Can we talk over a plan, just in case?” • 3rd party: “Lots of people have guns at home. What some families in your situation do is store their guns away from home until the person is feeling better, or lock them and ask someone they trust to hold onto the keys. If you have guns at home, I’m wondering if you’ve thought about a strategy like that.”

35. Means Restriction • Youth suicides are higher in states with high gun ownership • Household gun ownership: the single biggest predictor of youth suicide rate in a state • Every day, an average of three youth between ages 10 and 19 years die by firearm-related suicide • States where many people own guns should be aware of the association and the risk to youth Means Restriction Training • Suicide Prevention Resource Center’s (SPRC) Counseling on Access to Legal Means (CALM) Training • Free, online course (training.sprc.org)

36. Youth & The Internet

37. Viral Challenges/Scares • Momo, Blue Whale… • Check validity before sharing/spreading fear • The main problem is that parents and caregivers are distracted from the real issues of teaching children how to safely thrive online (while chasing viral shock-fads) • Sharing panic means more vulnerable individuals have access; kids sometimes participate ironically Staying Safe Online • Don’t contact strangers online, regardless of the method • Set privacy systems together • Talk to kids: teach good practice instead of focusing on the big red button they shouldn’t push • Foster openness and transparency with your child, and check-in if you sense secrecy • Utilize shared family spaces for YouTube watching and video-gaming • Let your (Internet-savvy) kids educate you!

38. AAS’ Guide to Suicide & Social Media Tips for Adults • Parents’ education: social media trends, platforms using and how many accounts, how are they being used? • Monitoring access & use: when, why, and how much is dependent on child’s age & mental health status • Not good for anyone to be constantly consuming images of violence (self-directed or upon others) • Some children will be more vulnerable than others • Parents & pediatricians should be asking kids about their digital lives, social media experience, and how it impacts their day-to-day • Behavioral healthcare providers should include social media/digital lives in safety plans • Explore positives and negatives • Consult with experts Parental Control Tools: cell phone plan carriers, hardware, internet filters

39. Resources & Best Practices • Don’t be a referral service • Resources/referrals are not a magic fix • Be extremely wary of “passing off”/ “volleying” • Specific Tips • Visit the resource/referral together • Save link/write it down/etc.

40. A Crisis Continuum • Pre-crisis • The pre-crisis stage is the time to divert an individual from crisis trajectory. Peer support, family, case management, and in-home supports can be effective. Most individuals resolve pre-crisis situations on their own, but some lack resources or resilience. • Crisis • The crisis stage presents an opportunity to mobilize the support system to manage a stressful life event before it affects wellness. Most individuals deal effectively with crises by using their strengths and supports. Provider-based resources would be used sparingly at this stage. Self-help and/or peer-based responses (e.g., warm lines) may be sufficient. • Mental Health Crisis • A mental health crisis calls for a response to prevent the situation from rising to the level of a psychiatric emergency. This level of crisis threatens one’s sense of control. Symptoms may be exacerbated and recurrence may follow. These situations generally require provider involvement. Serious cases may require psychiatric hospitalization. • Psychiatric Emergency • A psychiatric emergency requires an emergency response by the crisis response system, often on an involuntary basis, and often other community resources such as the police and hospital emergency departments. It may overtake an individual despite their best efforts and those of the support system. Inpatient psychiatric care is usually indicated.

41. Resources

42. Being Supportive Everyday • Be there —“invisible support” • Share in the weight of their pain (get under the rock!) • Researchers have (preliminarily) shown that one of the best possible interventions for high-risk teens is for the caring adults in their lives to get education in suicide prevention

43. Remember that thing… (About an hour ago, you took a moment to think of something that no one in the world knows about you…)

44. Thank You!! Michelle Kuchuk, M.S. Manager of Clinical Technologies & Training National Suicide Prevention Lifeline mkuchuk@vibrant.org