02 Developing A Suicide Management Plan in Schools

The framework for this Workbook was created by Thomas C. Barrett in ‘Youth in Crisis: Seeking Solutions to Self-Destructive Behavior”, 1987. The process of intervention has been changed to conform with the attribution based crisis theory of Saikeu as described in his book “Crisis Inte rvention: a Handbook for Practice and Research”, 1990.

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INTRODUCTION

The school may be the most logical place for a comprehensive suicide intervention effort because it is the common element that all communities share, regardless of their size, and all children must attend. Every state has laws that mandate school attendance and, it is fair to say that, with the exception of the home, children spend more time in schools than any other place.

The logic behind a school suicide intervention effort is strengthened when the resources of school systems are considered. Schools generally maintain a high professional to student ratio, and, in most situations, schools have access to individuals with training in counseling and guidance. In addition, students themselves are key resources in the suicide intervention process. Obviously, schools provide the most common opportunity for large numbers of youngsters to interact on a day-to-day basis.

Schools are in a strong position to establish and maintain key liaison functions. All schools have formal communication channels with parents or guardians and open communication with families is of utmost importance in dealing with the potentially suicidal youngster. Most schools also maintain some degree of communication with various key community resources such as social service agencies, police departments and mental health centers.

Finally, schools are places of learning and the question of suicide has to do with a type of learning about why things happen. If the school can develop a culture of positive attribution, reduce cognitive error and enhance emotional literacy, it can create a milieu of suicide prevention as well as addressing suicide management. This approach is based on a fundamental assumption that people are the sum total of their thoughts and that they cannot behave other than as they think. It follows, therefore, that changing the way people think about themselves, others and future prospects can have a profound effect on how they function in life. While our thoughts are personal and unique, they are shaped by the input and responses of those around us. Present responses to suicidal ideation or attempts are often counterproductive in the long term although they may meet the immediate criteria of keeping the person alive.

The degree to which a school system can undertake a comprehensive suicide intervention effort is contingent on the commitment of the school and the community toward the effort. This workbook is oriented toward the development of a suicide management program that is based on cognitive behavior management.

The degree of commitment of the planning team to the principles embodied in the Cognitive Behavior Protocol #06 will determine the ultimate decision to proceed.

ATTRIBUTION THEORY

A necessary part of any plan of intervention is to define and implement a process that is philosophically coherent and based on a sound theoretical base. This paper is based on the Cognitive Behavior Protocol #06, which outlines the background information about suicide and the training requirements of Psychological First Aid [PFA] as a crisis intervention strategy. The PFA process is based on attribution theory and we will provide a brief overview of that theory here.

Attribution theory developed as an approach to social perception and is concerned with analyzing the cognitive processes that underlie causal explanations. It is a theory of the ways people try to ‘make sense’ of events by setting them in a causal framework.

When individuals engage in an activity, they may attribute their outcomes to the operation of one or more causal factors. A growing body of research has focused on the conditions that influence the tendency to ascribe responsibility to personal forces (e.g., ability and effort) or to impersonal forces over which the individual has little control (e.g., situation and bad luck).

One personality dimension that would appear to play a major role in influencing the nature of causal attribution is internal-external control of reinforcement (I-E). The I-E variable represents a generalized interpretation of how reinforcement is causally related to one’s own behavior. At one end of the I-E dimension are individuals who believe that reinforcement is contingent upon their behavior (internals), while those at the other extreme believe that reinforcement is independent of their actions and is controlled by luck, chance or powerful others (externals).

It has been suggested that some individuals who obtain external scores on the I-E scales may have developed this expectancy for defensive reasons. By adopting an external orientation, these individuals are able to maintain self-esteem by attributing negative events to forces beyond their control. It is suggested that externals have less need to resort to forgetting and denial as defensive strategies since they can readily account for failures by attributing them to impersonal forces.

If an external orientation does serve as a defensive function then it might
be expected that the relationship between I-E and attribution of responsibility would be mediated by the nature of the outcome in an activity. Specifically, externals, following failure, would be more inclined to rationalize this outcome by attributing it to forces beyond their control. In contrast, successful task performance would engender little or no threat and, therefore, differences between internals and externals in assigning responsibility to outside forces would be diluted.

These issues aside, anecdotal and case-study evidence indicates that procedures can be designed to successfully change undesirable attributions and the emotional behavior associated with them. Experimental work lends further support to the feasibility of altering undesirable emotional behavior through attributional change.

In this presentation, we will focus on the attributional implications of crises intervention. Because of the emphasis upon ‘engagement’ in the training focus, crisis intervention has particular significance.

AN ATTRIBUTIONAL ANALYSIS OF CRISIS INTERVENTION

An initial distinction needs to be drawn between attributions about a) the source of the crisis, and b) the attributions about the source of the crisis resolution, as these are perceived by the person in crisis.

An attributional dilemma – an uncertainty about the cause to which an event is attributable – is faced when the person in crisis attempts to identify the source of crisis arousal: to what should the feelings of crisis be attributed? A second attributional dilemma is faced later when the person attempts to attribute the resolution of the crisis: to what should the relief from crisis disturbance be attributed?

The crisis intervention should provide the individual with the kind of information that will help answer these two attributional questions in ways that minimize the emotional disturbance and maximize the internalization of constructive changes made in resolving the crisis.

A second distinction is to be drawn between the process of crisis intervention and its structure.

STRUCTURAL FEATURES

Easy Access And Non-Psychiatric Image

Crisis facilities need to provide easy access through evening hours, community location and immediate intervention. Further, they should project a non-psychiatric image by accenting a ‘problems in living’ or ‘trouble shooting’ focus. Terms such as ‘treatment’, ‘therapist’, and ‘patient’ should be consciously excluded from formal usage, in order to appeal to those who can benefit from professional assistance but are reluctant to identify their problem as ‘psychiatric’.

Attributional Implications

These structural facets may serve the function of bringing people to crisis centers before they have formed stable attributions about what has produced the crisis. It becomes possible, therefore, to receive help without redefining their problems as psychiatric. This eliminates the attributes of mystics and medication as causal to either crisis or help.

Time Limitation

Crisis intervention is provided for a limited time. This reflects the natural course of crisis which indicates that natural resolution, for better or worse, will occur within 4-6 weeks of the onset of the crisis. During this period of ‘disequilibrium’ intervention can maximally facilitate the adaptiveness of the crisis resolution.

Attributional implications

One important source of information a person has about his/her emotional problems is the nature and extent of help required to alleviate them. Acceptance into a time limited crisis situation provides validation for attributing the crisis to a problem in living, while the short course of intervention facilitates seeing the problem as quickly changeable. Brief help often leads to the conclusion that ‘very little must be troubling me’ and that, therefore, I am able to deal with the problem. Time limitation arouses an expectation of rapid restoration of internal control over problems, while long-term intervention may arouse an expectation of slow, effortful change.

Minimal Use Of Medication And Hospitalization

Resolution of the crisis through medication and hospitalization is seen as relatively maladaptive and should be reserved for instances where other alternatives prove ineffective.

Attributional Implications

This feature offers implications for attributions both about the source of the crisis and the source of crisis resolution. Attributing the crisis to severe psychopathology is made less likely when such culturally ‘strong’ forms of intervention such as psychotropic medication and hospitalization are avoided. But further, and perhaps more important, medication and hospitalization are highly salient ways of explaining any changes that occur during the intervention. Attributing improvement to such external sources is not likely to lead to internalization and maintenance of any new behavior patterns and attitudes that might have been established during the crisis resolution. Since changes in crisis disturbance occurs reliably within a few weeks of its onset, a person will be able to attribute this change to himself and the fact that s/he is a capable person, as long as no more salient explanatory source comes along to interfere. And, since the heart of crisis intervention involves the learning of new and better ways of dealing with stress, it is desirable that these changes are maintained and internalized.

STRUCTURE SUMMARY

The very way that crisis intervention is structured provides attributionally relevant information about both what has caused the crisis, and what has caused a change in the crisis state as it is resolved.

PROCESS FEATURES: THE CRISIS INTERVENTION SEQUENCE

The process of crisis intervention must follow a consistent sequence that, for present purposes, can be grouped into three [03] steps:

Clarification And Definition Of The Crisis Background

In the first stage of the intervention, the primary focus is on the events surrounding the onset of crisis. The goal is to identify the single recent stressor that precipitated the crisis. Following this identification, the individual’s patterns of dealing with stress are explored and their inadequacy in the present examined. This formulation includes a review of the crisis stress; the reasons for the failure of usual ways of coping; the learning, if necessary, of new coping mechanisms (behaviors or cognitive schema, etc); and the effects that the crisis has produced.

Attributional Implications

The initial intervention provides the worker with an understanding of the attributional state of the client, while providing the client with an attributionally ideal definition of the precipitating stress; one which externalizes the source of the crisis and makes it a single, recent event. This stage, as a whole, provides an excellent modeling process for thinking of the crisis in specific, recent, cause-effect terms. It sets a stage for cognitive and behavioral pattern development that can be used to avoid future crises by early stress identification or changing coping behaviors.

Restoration of functioning

The second phase of the intervention focuses on developing and implementing new strategies for handling the crisis stress. The role of the worker in this process is to facilitate the development and critical evaluation of all possible alternatives, but not to make the decision for the individual in crisis. Once the course of action has been decided on through a negotiated process of critical review, the worker helps to see that it is implemented as soon as possible.

Attributional Implications

This stage undermines any attempt to attribute the crisis to unalterable personal inadequacies, since the development of alternatives provides the evidence that change is possible and the implementation of an alternative demonstrates that this change can be produced by the client him/herself. Attributions about the locus of change in the crisis state are strongly influenced by the worker’s limited participation in decisions – about which alternative to adopt – or if strong negotiation is necessary to avoid continued maladaptive choices, through the teaching of skills that can be transported to new situations. The focus is always on the client’s ability to make his/her own decisions that increases the feeling of themselves as the source of change. By limiting participation to suggestion and reflection, the worker enables a self-attribution by the client to explain the change.

Consolidation of Change

During the final stage of the intervention, the value of changes that have been made are articulated to the client and the need to maintain these changes is emphasized. The entire process of the intervention is then reviewed, reinstating the role of the crisis precipitant in producing the crisis and the role of the client in producing constructive changes. Finally, the worker helps the client make plans that anticipate the best possible handling of potentially crisis-producing events that may occur in the future. These plans may include avoidance of stress by changes in environment; learning new behaviors by learning new coping skills; or by simply learning to identify potential crisis stressors early enough to effectively respond.

Attributional Implications

The review of the crisis keeps salient the external, specific, recent causal stressor that precipitated the crisis. The review of the client’s role in making changes increases his/her salience as the source of the resolution of the crisis. The use of anticipatory planning can be seen as a kind of ‘attributional inoculation’, in which attributions about future problems are directed in relatively useful ways well ahead of time.

CRISIS INTERVENTION SUMMARY

The structure and process of an intervention can be seen to interact in facilitating external attributions about the cause of the crisis and internal ones about the cause of the crisis resolution. This pattern of attributions can minimize the disruptive effects of the crisis and maximize maintenance and generalization of new behaviors and attitudes that were used in the crisis resolution.

DISCUSSION

Attribution analysis offers a valuable new way of conceptualizing the effects of crisis intervention on the cognitive processes of the client. A number of points of convergence can be seen between the realities of such interventions and analysis and the goals of the psychosocial rehabilitation process. This supports the need to further clarify the causal role of cognitive changes in the effective intervention and procedurally utilize attributional analysis in service design. The examination of crisis intervention is utilized to emphasize significant points in the structure and process of a psychosocial rehabilitation process. Two points might be underlined. First, it highlights the need for the worker to take an active role in helping the client to understand his/her experience in cause-effect terms. An over-eagerness to attribute any difficult but normal life experiences to psychopathology is a common clinical fact of life. This attribution seems to arise from a societal fascination with the fact of psychopathology that leaves people more than ready to find it lurking in many innocent corners. In light of such a potentially harmful predisposition, the worker has the task of helping the client recognize the contribution of precipitating external stressors in producing his/her state. S/he also has the task of helping the client to recognize, and use, his/her own resources in dealing effectively with the crisis.

Second, it strongly suggests the importance of how those in crisis cognitively structure their experience. If cognitive reorganization is an acknowledged method of resolving crisis, then greater emphasis needs to be placed on sensitivity to attributional implications of the work.

Steps to be considered include:

• identification of personality dimensions of clients; do they ascribe responsibility internally or externally and in what context?
• intervention through articulation and skill development in altering maladaptive attributions of responsibility.
• understanding of the implications of the structure and process of the intervention as it affects the maladaptive use of attributions.
• design of services to enhance corrective or remedial attributions of responsibility.

Further work may be developed in exploring the following hypotheses:

1. There exists, in the human organism, a drive to evaluate his/her opinions and abilities.

While opinions and abilities may, at first glance, seem to be quite different things, there is a close functional relationship between them. They act together in the manner in which they affect behavior. A person’s cognition (opinions and beliefs) about the situation in which s/he exists and his/her appraisals of what s/he is capable of doing (evaluation of abilities) will together have a bearing on behavior.

NOTE: see Expectancy Theory

2. To the extent that objective, non-social, means are not available, people evaluate their opinions and abilities by comparison, respectively, with the opinions and abilities of others.

In many instances, perhaps most, whether or not an opinion is correct cannot be immediately determined by reference to the physical world. Similarly, it is frequently not possible to assess accurately one’s ability by reference to the physical world. Even when there is a possible immediate physical referent for an opinion, it is frequently not likely to be employed.

If these hypotheses are correct, what are the implications of a significant other’s statement of a client’s deficiencies? What mental schema (see cognitive theory) are likely to develop? What attribution process can be expected? How must service interventions be structured to deal with these results?

PLANNING AND MANAGING A SCHOOL-BASED PROGRAM

The implementation of a successful comprehensive program in a school environment is contingent on three critical factors: establishing and fostering support, careful planning and effective management.

PART I. ESTABLISHING A NEED AND FOSTERING SUPPORT

Youth suicide has been, and to some extent still remains, a taboo subject in the minds of many individuals. Because of this mental barrier, the organizer(s) of a school program must make sure there is broad recognition of the need for the program and broad-based support for its implementation. It is vital that recognition and support are obtained before any attempts are made to implement program components.

Once leadership is established, the process of gaining recognition and support can begin. There are many techniques that can be used to achieve this goal. The strategies chosen will depend on the individual styles of the key personnel, available and required resources, and the circumstances of the situation. However, any program effort requires the approval and, to varying degrees, the commitment of school- and district-level administrators, professional staff, parents, students, and ultimately the Board of Education.

A needs assessment can be administered to a sample of district parents, teachers, administrators, counselors, psychologists, and social workers to provide answers to two questions:

1. How much accurate information do people have about suicide?
2. Do people support the idea of a school-based suicide prevention project?

The needs assessment also creates an awareness of the problem and provides the Board of Education with a clear indication of the level of community support for the effort.

Presentations can be an effective means of developing awareness and support. Whether the presentation is formal or informal, the presenter must be knowledgeable about suicide prevention at both the national and local level and must be prepared to address the following types of difficult questions and statements.

• “Why do we need a project like this? We don’t have a suicide problem here.”
• “Isn’t this the parents’ responsibility? Our role in the schools is to teach student academics.”
• “This project will make our schools into mental health centers.”
• “If you have such a program in schools, it will give kids the idea of suicide.”
• “We don’t have the money.”
• “We can’t ask our staff to take on more responsibility.”

The following presentations might be considered.

Parent Teacher Organization: Present the results of the needs assessment to the Executive Council of the district Parent Advisory Committee and involve district parents in the planning of the project.

Student Council: The idea can be presented to the Student Council of the district high schools for endorsement.

School Principals: The idea can be presented to elementary and secondary principals.

Faculty: Several presentations concerning the goals and objectives of the project can be made at faculty meetings. These presentations help create an awareness of the efforts being made and gain support from teachers.

CEOs/Boards of MH Agencies: Reviewed the idea the executive directors of the mental health centers in the community, ask for suggestions for improvement and endorsement for the effort.

School Board: After gaining endorsements, present the idea to the School Board of Education.

When making presentations, it is helpful to have well-conceived and informative handouts. In addition, presentations may be more powerful if made by district psychologists, social workers, counselors, nurses and building principals.

Local media can provide a good method of disseminating information about the program. Proper use of local newspapers as a means of informing the public can be beneficial in generating support and providing information about the project. Many parents with concerns about their children can learn of the project through this means. However, articles describing the project may also spawn negative reactions. Project organizers must be prepared to respond in an informed way to such criticisms.

One should keep in mind that the topics of death and suicide may generate negative reactions and even withdrawal in audiences. When conducting efforts to build a support base for a suicide intervention program, organizers must be very knowledgeable about their subject and aware of their audience in order to deal effectively with any resistance. Moving too quickly with project activities before a sound support base has been established may have negative effects on the program.

PART II. ESTABLISHING A PROGRAM PLAN

Once a solid base of support has been established, the organizers can begin to focus on specific planning issues. The development of a program plan can be in progress simultaneously with some of the support activities. In fact, the process of soliciting school and community support can act as a mechanism to gather information critical in planning. Obviously, some preliminary planning is necessary to answer questions posed by staff and community and the materials contained in the Cognitive Behavior Protocol #06 can be used for this purpose.

The details of the program plan are, to a certain extent, contingent upon the circumstances of the school setting, resources available for the program, and the level of commitment to the intervention effort. The broader based the participation in the planning process the more likely the program will be accepted. While advocating broad based input, the most effective planning unit may be a small but representative committee.

The following issues must be detailed in the planning process:

• What intervention components will be implemented?
• What are the timeliness for the implementation of the various components?
• What resources (financial and manpower) will be committed to the project?
• How will the program interface with the available community resources and cooperate with existing community efforts?
• How will the program be coordinated?
• What are the specific roles of the participants?
• What formal procedures must exist for the program to operate smoothly?
• What communication channels exist for the participants?
• What training is necessary for the various groups involved?
• How and by whom will the training be conducted?
• What materials (information, guides, forms, etc.) are needed and where will they be obtained and/or developed?
• What public relations activities are needed?

ESTABLISHING A MANAGEMENT PLAN

Without a solid management plan and an individual to assume responsibility for coordination, any intervention effort cannot be totally effective. If at all possible, resources should be committed to support a project coordinator, even if only on a part-time basis. If resources for coordination are not available, someone must still take charge. The following represent some project management issues.

SELECTING A PROJECT COORDINATOR

In selecting a project coordinator, It is recommended that the following qualifications be considered. It may be impossible because of personnel availability and/or limited resources to match all of these recommendations.

• The coordinator should be someone from existing district staff. This will help create a sense of ownership and investment by the district.
• The coordinator should be knowledgeable about mental health issues (a clinical background is helpful). Obviously, a background in suicide prevention is a big advantage.
• The coordinator should have good organizational /communication skills.
• The coordinator should be dedicated to youth suicide prevention.

Management plans should also provide the coordinator with necessary support services. Such services may range from secretarial to additional professional staff.

MANAGEMENT DUTIES

Management plans should include specific tasks, who is responsible for the task, and how the task will be accomplished. Some examples follow:

• Planning and overseeing training and implementation.
• Keeping the cognitive behavioral principles uppermost in the minds of the various trainers and crisis intervention team members.
• Influencing the various mental health and crisis centers to reorganize around the cognitive behavioral management principles.
• Supervising school participants.
• Maintaining internal operational lines of communication with school staff, administration, parents, and student participants.
• Developing and maintaining a project evaluation.
• Ensuring that adequate materials are available for use (may include development efforts if existing materials are inadequate).
• Ongoing identification of training needs and coordination of training efforts.
• Maintaining ongoing public relations within the school district and with the community.

RATIONALE, FUNCTION, AND TEAM MEMBERSHIP

The notion of a collaborative or team approach to the suicide problem needs to be emphasized. Perhaps the most critical ‘team’ involved with the suicidal youngster is the crisis management team. This is the team that meets together when a youngster has been assessed by a team member as being at risk for suicide. The functions of the team are:

1. to evaluate the risk factors of the student,
2. to formulate an intervention plan (this plan is a menu of possible interventions that can be implemented or suggested by the team),
3. to act as an important liaison with the community agency (if referral is a decision made by the team) and family,
4. to provide support for the student at school,
5. to act as a resource for other staff members, and
6. to provide follow-up and guidance when the student re-enters the system (if the student was hospitalized).

There are several advantages that make the team approach more effective than others. Different people bring different perspectives to a single issue. Individuals may have had the opportunity to view the client in different settings and perhaps obtain varied information about the self-destructive teenager. In addition, the unique perspective of each individual creates a variety of possible alternatives.

A team approach brings a variety of professional backgrounds to a situation. A classroom teacher and a social worker each have their own unique skills to contribute.

Team members from different areas may have access to resources unavailable to a single person.

• When a decision is made by a team, an open network for the flow of consistent information, communication, and recommended intervention is established. In this way a consistent broad-based support system is built.
• A team approach to intervention provides each member with a built-in support system. This reduces the potential stresses that accompany interventions conducted by an individual.

Not to be overlooked is the fact that having a variety of people involved helps to change the culture of the district in terms of its attributions of causality to the crisis itself. Traditional approaches tend to verify the attributions of crisis and its resolution as being of external cause. The single most important factor in suicide prevention is to develop a culture in which people recognize themselves as responsible for both the interpretation and the resolution of crisis. By having members from many different factions of the culture involved and committed to this principle, there is the opportunity to effect cultural change across all domains.

Depending upon the school system and the availability of certain personnel, the team may consist of all or some of the following:

1. A principal
2. A psychologist
3. A social worker
4. A guidance counselor
5. A school nurse
6. The referring teacher
7. A member of the Student Council

The district will need to determine whether there is a team across the district or whether there is a team for each school within the district. For purposes of culture restructuring, the latter is the preferred position. This, however, may not be a possibility within certain districts because of human or financial resources.

CRISIS INTERVENTION TEAM PROCESS

The team process begins with a referral,¹ after which the child is assessed by the identified staff, using the philosophy and process of Psychological First Aid [PFA]. After the information is gathered and recorded, it is suggested that the team meet immediately to determine whether or what additional interventions are needed. It is assumed here that a process for notifying other team members is in place. The referred student should be under the supervision of an adult while the team is meeting. If the suicidal crisis does not seem serious and the youth wishes the information be held confidential, this should be considered. In cases where the youth is acutely suicidal, however, confidentiality should be waived. The team as a unit, however, should honor confidentiality in all cases.

CRISIS INTERVENTION

PROCESS

REFERRAL
Teacher
Parent
Peer
Self

ASSESSMENT
By team member

EVALUATE RISK
Crisis Intervention
Team meets to determine level of risk.

INTERVENTION PLAN
Determine Course of Action:
Inform parents
Outside referral
Inform social services
Inform police
Develop internal plan etc.

POLICIES AND PROCEDURES

Once a school suicide intervention team has been formed and trained, it is necessary to formalize the intervention procedure. The crisis team must be sure that each person and group understands their role and follows consistent procedures during the intervention process. These roles, responsibilities, and procedures should be formalized in writing. Specific issues to be addressed in the procedures are:

• What are the referral processes and who is involved?
• What information should be obtained from the referral source?
• What activity does the referral trigger with the team?
• Is a crisis interview necessary?
• How are assignments made for the crisis interview?
• What information is gathered during the crisis interview?
• How will the intervention plan be developed (short and long term)?
• Who should be notified and by what means (parents, social services, police, etc.)?
• What special arrangements are necessary, and how and under what circumstances will they be conducted (transportation, hospitalization, protective custody², etc.)?
• What policies should be adopted regarding confidentiality of information?

SETTING UP TRAINING WORKSHOPS

The training of various groups within the district and the community is a primary task in implementing school-based programs. Whether the training is for professional clinicians, teachers or parents, the workshop leader should have a solid background in cognitive behavior management. A certified psychologist working in the schools or a clinical psychologist acting as a consultant to schools from a local agency is probably the most qualified to act as the workshop facilitator. While the goal is to train all staff and students in the PFA process, if this is not possible, there should at least be methods developed to make such information available to everyone.

The facilitator should expect a range of different reactions to the workshop. The topics of death and dying, and more specifically, child and adolescent suicide, can bring about resistive behavior by the workshop participants. The facilitator should be aware that some of the participants may be highly sensitive to the content of the workshop as a result of their own experiences, or simply being made aware of their own vulnerability to death. The facilitator might troubleshoot this problem by making reference to the sensitivity of the topic being covered. S/he might make such a statement as “The topic of adolescent death is difficult for all of us to deal with“, which conveys an understanding of the audience’s sensitivities.

The workshop presenter should have a comprehensive guide to provide to the participants such as outline in CBP#06.

Selecting Program Components

There are several suicide intervention components that may be considered by schools. The minimum comprehensive effort should contain the following components:

• Teacher In-service Training
• Crisis Intervention Team Training
• A Student Curriculum
• Parent Training

It is important that districts consider the order in which they implement training components. The random implementation of project components may have undesirable effects. For instance, the implementation of a student curriculum without teacher training can create an unfair, if not potentially dangerous, situation. Once trained, students become good identifiers of other students in trouble. It is essential that informed students have trained school personnel with whom they can talk freely and who can provide assistance, if necessary.

Over and above the core program, there are other desirable components that a school may implement if given the necessary resources. For example, there are certain preventative measures that a school may take that are designed to reduce those cognitive responses that result in a crisis situation. The Chester County Intermediate Unit – Assessment & Clinical Services Department is prepared to offer technical assistance in the development of these preventative measures. The intent of this section is to discuss each of the training components individually, how these components may be implemented, and how each of the parts interact to form a schoolwide network.

TEACHER INSERVICE TRAINING

There are many format options for conducting teacher in-service training. The most productive format seems to be a two-part session. The first part covers information that will assist teachers in the identification of students who may be depressed and discusses pre-suicide symptomology. Part Two of the teacher in-service is conducted in small groups and deals with some of the personal, professional and operational issues of suicide prevention in schools. It is important in this section that the facilitator is competent to hear and respond to self-talk of the participants that may indicate areas of concern for implementation of a suicide management process.

The content of a teacher in-service might resemble the following outline:

Part One

I. Introductory Information

A. Statistics on child and adolescent suicide (attempts and completions)

1. National
2. State

B. Varying viewpoints on what can and should be done about the problem

C. The myths of suicide

D. Dealing with suicide as a community and defining a realistic role that schools can play in this effort

1. Prevention – cultural restructuring

a. Stop & think
b. Attribution training
c. Discipline without reward or punishment
d. Individual behavior learning packets
e. Teacher Expectations & Student Achievement

2. Development

a. Interpersonal cognitive problem solving
b. Emotional literacy
c. Thinking & feeling
d. Social skill development
e. Early identification – Sociometric

3. Remediation

a. Referral for evaluation
b. Referral for services

II. Examination of the Sociological Variables Involved in Child and Adolescent Suicide

A. Alienation (peer, family, other)

B. Mobility

C. Role models

D. Other

III. Examining Environment and the Cognitive Variables Involved in Depression and Suicide

A. Describing the ‘typical’ adolescent

B. Significant developmental issues

C. Looking more closely at the family

1 . Effects of devaluing children
2. Parenting styles
3. Violence, alcoholism, abuse, etc.
4. Divorce or separation
5. Loss from death or suicide
6. Cumulative stressors

D. Child and Adolescent Depression

1. As a symptom of suicide potential
2. Frequency of the disorder
3. Problems in defining child/adolescent depression
4. Depressive symptomology
a. Emotional
b. Cognitive
c. Physical
d. Masked symptoms
5. Coping – cognitive styles/processes of depressed youngsters

IV. Wrap-up

A. Questions and answers

B. Hand out teacher information pamphlet

Part Two

I. The Personal Side Of Suicide Prevention

A. Is suicide ever acceptable?
B. Right to die issues
C. Others

II. Professional Issues

A. Ethics
B. Limits of responsibility
C. Natural fears
D. Confidentiality

III. Practical Issues

A. Appropriate intervention strategies (CBP#06)

Cognitive Behavior Protocol #06 posits, among other things, that the way an individual copes with problems over the course of his/her life usually indicates whether the person is emotionally predisposed to suicide. It follows, therefore, that one needs to pay attention to how children cope with problems as a first step in identifying those children who are most likely to be prone to suicide when the second factor – seemingly obdurate ‘crisis’ – occurs.

It is not to great a leap to suggest, that as one identifies children with a propensity to see themselves as objects, interventions to change this perception would provide a preventative shield to future difficulty. Thus, an initial intervention could include both an ‘early warning system’ that identifies ‘victim’ attitudes and an early intervention system that changes these attitudes.

Psychological First Aid [PFA], is based on the concept of crisis as an essential building block in any structured understanding of human growth and development. Crisis theory is based on the idea that crises and major life transitions – similar in their components and varying only in degree and intensity – are the stuff of which life is made. This whole concept at once sets the stage for a thought process that is entirely different than the catastrophic approaches of traditional methodology.

PFA is a helping process aimed at assisting a person to move past an unsettling event so that the probability of debilitating effects [e.g., emotional scars, physical harm] is minimized, and the probability of growth [e.g., new skills, new outlook on life, more options] is maximized.

The focus is immediately shifted from prevention of the act of suicide to the future growth and development of the individual. The potential for good or bad outcomes lies in the disorganization and disequilibrium of crisis. A wealth of clinical data suggests that some form of reorganization will begin in a matter of weeks after the onset of crisis. The reorganization may be toward growth and positive development or toward psychological impairment or even death.

“An examination of the history of psychiatric patients shows that, during certain of these crisis periods, the individual seems to have dealt with his problems in a maladjusted manner and to have emerged less healthy than he had been before the crisis” [Caplan, 1964].

How the child will emerge from this crisis of potential suicide is at least, in part, dependent upon how the crisis is managed.

This is the CORE SECTION of all training and along with CBT#06, Districts may want to refer directly to Slaikeu’s book, Crisis Intervention, A Handbook for Practice and Research.

B. Referrals
C. How to network
D. Others
E. Wrap-up

The presenter should recognize the importance of conducting a post-in-service evaluation in order to assess: a) the participants’ knowledge of key adolescent suicide issues b) the comfort level of the participants in dealing with suicidal teenagers, and c) the degree to which the workshop met its goals.

PARENT TRAINING

Parents are a key group in any suicide intervention effort. Outside of their obviously strong position for identification, parents are integral in the intervention process and ultimately form the core of the community intervention effort. A number of parents who attend the training do so because of concerns about their children. In this way, the parent training goes beyond the awareness level to suicide intervention. It is helpful when organizing a parent training workshop to work through the PTO, PTA, or the appropriate school district parent advisory group. A suggested outline for parent training in suicide prevention follows.

I. Introductions

A. Brief description of the presenters.
B. Present an overview of the training workshop. Discuss why it is being offered (handouts of the presentation outline are helpful).

II. General Background Information

A. Statistics on suicide attempts and completions

1. National
2. State
3. Local (if possible)

B. Myths and facts about youth suicide (overheads work nicely)

III. Analysis of Self-Destructive Behavior in Youth

A. Sociological variables & interpretations

1. Changes in family: marriage, divorce, remarriage, role delineation, mobility
2. Religion versus spirituality
3. The drug culture: a medicine for everything
4. Information explosion: radio, television and the computer and the exposure to differing role models
5. The failure of authority: discipline as a verb/noun
6. Let the government do it: the absence of personal responsibility
7. Other

B. Psychological variables

1. Adolescent stressors
2. Cognitive factors

a) core beliefs
b) cognitive errors [self-talk]
c) attributions/expectancies

IV. Intervention and Prevention Strategies

A. Recognizing the potential

1. Child Management & Monitoring Strategies: Helping parents realize the importance of knowing what is going on in their child’s life – What disappointments are they facing? Do they have supports to help them?

2. Identification & Intervention: Helping parents confront suicide threats by their youngsters. Elements of Psychological First Aid; risk assessment and referral. This is the CORE SECTION of all training and along with CBT#06, Districts may want to refer directly to Slaikeu’s book, Crisis Intervention, A Handbook for Practice and Research.

3. Cautions: Suicide attempts, gestures, etc., may be a form of manipulation. Until professional help is sought to define the youngster’s problems, perhaps it is best to allow the manipulation to occur. In other words, ignoring or discounting the behavior may prove dangerous and may even escalate the behavior to a more lethal level.

4. Testing the Model: How parents can assess the situation and intervene. Here is a good opportunity for the presenters to role-play a situation where the parent suspects things are not going well for the child or adolescent.

B. Getting help

1. Assessment: Know when a serious problem exists.
2. Resources: List kind of help available.
3. Getting Help: Know how to select a good clinician.

A STUDENT CURRICULUM

The student curriculum is a very important component of a school-based intervention effort. However, it is also one of the most controversial. The controversy is based on the fear that teaching such a unit will stimulate thoughts of suicide in class participants. For this reason, the reader should be cautioned that a student curriculum must be implemented in a well-planned manner by personnel specifically trained in the issues of adolescent suicide. If the curriculum is conducted in a professional and responsible way, it can have a very positive immediate as well as long-term impact.

There are a number of formats that can be utilized in the implementation of a student curriculum. The topic can be integrated into several existing curricula that address contemporary social issues such as drug and alcohol education, health education, living skills, etc. When integrated with existing courses, the objectives of a suicide curriculum can be attained more subtly than if they were presented in isolation.

The content of a suicide prevention curriculum may vary with the school setting. However, a minimum effort should include the following objectives:

1. To allow students to discover and express their own attitudes and beliefs about suicide.
2. To present the facts of suicidal behavior and to dispel the myths that shroud the subject.
3. To provide students with information that will help them better understand hopelessness and suicide ideation.
4. To teach strategies for their own ability to deal with stressors and/or disappointments.
5. To teach students to use the resources within their school and community.
6. To make students aware of their roles as potential support to a suicidal friend and the use of Psychological First Aid.
7. To provide students with appropriate courses of action to take if they encounter potentially suicidal peers. This is the CORE SECTION of all training and along with CBT#06, Districts may want to refer directly to Slaikeu’s book, Crisis Intervention, A Handbook for Practice and Research.

After exposing students to the curriculum, it is a good idea to assess their understanding of and feelings toward the issues.

PART III THE INTERVENTION PROCESS

The training of teachers, students and parents in the Psychological First Aid [PFA] process is a critical early identification and intervention process. In theory, after the training, any teacher, student or parent may act as a PFA agent when a student expresses intense concern. Entering into such a relationship may result in the identification of the potential for suicide. Depending upon the relationship, the comfort level and the skills learned in training, the PFA agent may be able to carry some of the process of risk assessment. But at any time s/he may refer to the Crisis Management Team [CMT] to a) take over the PFA process, assess risk, begin intervention or, if all options are to no avail, to refer to professionals in clinical suicide management. The process of referral to the CMT should be spelled out in detail in order to abide as closely as possible to the attribution theory underlying the intervention process.

The Crisis Management Team should be a specific group of people who have been trained in suicide assessment and prevention tactics and can be available whenever and wherever necessary. CMT agents should be trained in negotiation since the emergence of the suicidal intent will sometimes erupts without prior warning.

CRISIS INTERVENTION: A COMPREHENSIVE MODEL

Process	First Order Intervention Psychological First Aid	Second Order Intervention: Crisis Intervention
Time	Minutes to hours	Weeks to months
By Whom?	Front line caregivers [teachers, parents, friends]	Specially trained crisis intervention professionals
Where?	Anywhere	School clinic, Psychological clinic
Goals	Re-Establish Immediate Coping: give support; reduce lethality; link to helping resources	Resolve Crisis: work through crisis event; integrate event into fabric of life; establish openness/readiness to face future.
Procedure	Five components of Psychological First Aid	Multimodal Crisis Intervention

ASSESSMENT

Based on the information available today, screening of all students as a means of identifying potential for suicide is probably unwarranted and ineffectual. However, having teachers and students trained as Psychological First Aid agents means that the district has a large number of people who are prepared to intervene with people in crisis, and one result of this early intervention process may the identification of people at risk. The keenest observers may very well be peers as they are the ones who are most likely to recognize ‘uncharacteristic’ behaviors or behavioral changes. Once such a concern has surfaced, the agent will need to pursue the discussion effectively, using PFA guidelines, so as to know whether to make a referral to the CMT.

If the PFA agent feels the question of suicide in the air, a specific process needs to be followed. The PFA agent may, if comfortable, do the complete assessment of suicidal ideation and then, if necessary make the referral to the Crisis Management Team to assess lethality; or, if uncomfortable with pursuing the suicidal ideation past the first sense that it exists, s/he may make the referral at that time. In either case, how the referral is made is critical to the success of the intervention process. The District should consider the Attribution Theory elements and design a process that best meets these criteria. Discussion of the process of transfer that maintains the goal of re-establishing immediate coping and maintaining the subject as being in charge can be a major topic for discussion in the training sessions.

A. General Features

In order to assist the CMT agent in formatting a consistent and salient approach to effectively assess suicidal lethality, the following four general questions are provided for the clinician’s consideration.

Who should receive a suicide assessment?

A suicide assessment should be conducted on any student who meets DSM IV criteria for mental or substance use disorder, or who are known to have attempted suicide in the past. For students who fail to meet such criteria, a referral for an assessment is mandated when the PFA agent feels unable to help the student recover his/her coping ability and additional skills are needed. It should particularly be noted that students who have a pessimistic cognitive style should be of specific concern.

What are the components of a suicide assessment?

There are two components to the suicide assessment:

1. The elicitation and elaboration of suicidal ideation, and
2. The identification and quantification of risk factors for completed suicide.

At what point should such an assessment take place?

Ordinarily a suicide assessment should occur at the point of referral to the Crisis Management Team and periodically thereafter, as indicated. If, at the time of the initial assessment, the student meets the criteria for depressive disorders and/or manifest any degree of suicidal lethality, then the child should be monitored for suicidal lethality over a scheduled period of time.

How should such assessment be documented?

The clinical record should reflect the suicide lethality assessment has taken place, what the findings are, and what intervention plans are in place to contain, manage, or mitigate the identified suicidal lethality. The ideation and risk, along with the positive and negative findings, should be noted in the clinical record either in the mental status exam section or in a clinical note.

I. INTRODUCTION

The assessment of suicidality is among the most important functions exercised by clinical professionals. The imperative of keeping the person safe constitutes not only the most important clinical objective, but the core of good risk management as well. The principles outlined in this document represent best practice guidelines with regard to assessing and managing the child who presents with suicidal potential.

Ultimately, clinical judgement used consistently with the standards of good clinical practice will result in effective suicide assessment and management. The guidelines presented here are not meant to replace the clinician’s sense of good clinical judgement. The guideline principles are drawn from the scientific literature.

At the present time, professionals cannot predict a person’s potential for suicide with any degree of accuracy. Despite vast literature on the subject, there is no ‘gold standard’ and no single test or method of assessment that identifies the person most at risk to commit suicide. The basic goal of the assessment, therefore, is to identify, characterize, quantify, and manage those factors that constitute clinical risk. Along with proper documentation, such activities constitute the backbone of safe practice patterns. It should be recognized, however, that safety is a relative concept and risk is inherent in health care.

The establishment of a PFA intervention should provide the CMT agent with information about the child and aspects of the situation. A major source of information which can be provided by the school and the family concerns the cognitive style of the child in regard to conflict and crisis. If the child is one who consistently sees barriers as impossible to overcome and tends to catastrophize each difficult situation, the clinical staff should have a heightened awareness of risk and use the opportunity of crisis to establish new coping thoughts with the child.

Assessing Suicidal Ideation

The assessment of suicidal ideation should proceed along a gradient, from least to most severe, with a specific line of inquiry:

1. Beginning with general questions about the consideration of self harm, the agent should ask whether thoughts of death or suicide have occurred; if so, how often and how persistently? Are they fleeting, periodic, or constant? Do they occur under specific circumstances? Are they increasing, decreasing, or remaining constant?
2. Thoughts should be characterized as passive (i.e., “I would be better off dead”) or active (“Sometimes, I get the impulse to jump in front of a car”).
3. Any thoughts noted should then be elaborated upon using the person’s own language. Specifically, what are the thoughts?
4. The student should be asked whether there have been earlier suicidal impulses, whether there is current intent, and if so, is there a plan? Details of plan (method, time, and place) should be reviewed and documented for the record. The person should be asked about whether any rehearsal (mental or through action) has taken place and whether there have been any attempts made thus far.
5. Past history of similar thoughts, wishes, impulses, plans or attempts should be obtained.
6. The person with a plan should be asked about the availability of means and/or whether there is a plan/intent to obtain any means (i.e., to purchase a gun).
7. As part of the evaluation, the agent should make a determination about the person’s attitude toward suicide, which may range from acceptance of its inevitability or desirability (ego syntonic) to ambivalence or rejection (ego dystonic).
8. The person should be asked about barriers to suicide. What are the reasons for living and those for dying? How has the person managed to evade the act of suicide thus far?
9. Is there anything different now or anticipated to be different in the near future?
10. Has the suicidal ideation been shared with anyone else besides the agent? Who is or could be helpful in managing the ideation? This calls for the involvement of family and/or significant others. Family and/or significant others can assist in obtaining data about the person and provide containment and feedback during crisis management intervention. Studies indicate that suicidal communications may be made to family and/or significant others rather than to a professional. Optimally, such collaboration should be with the person’s permission as part of the safety plan.

How far this exploration is carried out by the PFA/CMT agent depends on the responses from the student. If each response builds on the prior response, s/he will want to pursue all ten areas and then make a determination about lethality and referral. On the other hand, if the student simply says that she has thought about suicide as a means to end suffering, but has not considered it further, the agent may want to continue building the coping responses of PFA.

Regardless of the ultimate decision about how severe the suicidal ideation is or was, it should be duly noted in the record and brought to the attention of the CMT team leadership. A student with continued crises who mentions suicide idly each time, probably should be seen by a trained CMT agent to make the determination about whether this is a real concern or simply a way of expressing frustration with being unable to cope.

Assessing Lethality

Three aspects of self-injury behavior influence the lethality of the vital outcome. These three are independent of each other and additive in yielding assessment of degrees of self-damage likely to occur. These three factors are

1. adequacy of planning;

2. effectiveness of self-injury methods;

3. efforts to prevent rescue.

Each can be rated on a scale of 0 to 6 by criteria provided here. All three ratings can be summed to yield total scores ranging from zero to eighteen. Average ratings for suicide attempts was 10.0. Average ratings among persons killed themselves was 13.3 with significant overlap in the two populations. Obviously, unless the agent is rating this lethality very low, 0 to 6 for all three factors, a referral should be made to the Crisis management Team to consider other actions.

Other risk assessment tools can be considered as well. While each district will need to determine its own tools, some information is available below.

Assessing Risk Factors

There is no certain way of predicting who will commit suicide. The assessment and weighing of risk factors alerts the clinician to those students who should be monitored. In addition, the determination that a patient is at risk, whether or not ideation is present, shapes the process by introducing the objective of risk reduction. The following section details general risks and those associated with specific diagnoses.

General Risk Factors

The presence of more than one risk factor increases the risk of suicide. The presence of a mental disorder may be regarded as a necessary factor in that over 90% of completed suicides are associated with the presence of such a disorder. Factors that may add increased risk for any patient with a mental disorder include:

• A psychiatric hospitalization within the past year;
• The presence of depression;
• Recent or impending loss, such as a job or an interpersonal relationship (including that with a clinician);
• The presence of substance or alcohol abuse;
• A history of impulsive or dangerous behavior, especially self-destructive behavior;
• Previous suicidal behavior or attempts;
• Access to guns;
• A family history of suicide;
• Social isolation; or
• The presence of a concurrent medical disorder characterized by chronicity, poor prognosis, or persistent pain.

There is vast information on adolescent suicidal behavior. The information reported here is offered as an overview on the subject. For further detail please refer to the citation and their cited references.

Bell and Clark (1998) studied adolescent suicidal behavior and provide a theoretical risk factor review for suicide in the adolescent population. They identify nine areas to consider when evaluating adolescents:

• Developmental psychopathology
• Social factors
• Psychological disorders
• Alcoholism and drug abuse
• Genetic factors
• Biological factors
• Physical illness
• Psychological factors
• Cycle of Violence

4. High risk diagnoses

Four diagnoses particularly associated with the risk of completed suicide are: 1) depression (primarily major depression, unipolar or bipolar, but including also the full range of depressive disorders listed in the DSM IV); 2) alcohol or other substance abuse or dependence; 3) schizophrenia (all forms, including schizophreniform disorders); and 4) borderline personality disorder. The risk factors associated with these disorders appear to vary with the diagnosis. They should be assessed as part of the treatment planning process.

a) Depression

The most commonly associated diagnosis is depression. It is present in over 60% of completed suicides (probably an underestimation of frequency). It is estimated that 15% of patients with major depression will eventually die by suicide. Counterintuitively, the severity of depression and the presence or absence of psychosis may not be a good indicator of suicidal risk. Therefore, all depressive disorders should be assessed for suicidal risk. The following factors have been found to increase risk and should be systematically queried and the response documented:

1) The concurrent presence of anxiety

• Anxiety, especially psychic (as opposed to somatic) forms
• Agitation, specify anxiety syndromes (obsessive compulsive symptoms, though not necessarily OCD)
• Turmoil (called by some, ‘perturbation’), especially when defensive breakdown is indicated
• The physical symptom of akathisia, occurring either alone or as a side effect of certain medications, may be characterized as a sense of inner agitation as well as motor restlessness. When present, such anxiety should be treated.

2) Concurrent substance abuse or dependence

• Ask about current use or abuse, whether or not these appear to constitute self-medication
• Many substances are disinhibiting and their use may increase the risk of impulsive acts or undermine judgment and restraint

3) Command hallucinations

• Hallucinations may be found in psychotic states and are thought to increase risk though this has not been proven conclusively
• The evaluator should ask whether the patient has received any signals or messages telling him/her to harm himself/herself

4) Rapid shifts in mood

• Ask about fluctuations and lability (i.e., from sadness to euphoria, irritability, and anger)
• There is some suggestion that bipolar II disorders, with hypomania alternating (or co-existing with) depression, along with rapid cycling bipolar disorder, may be associated with a high risk
• Irritability or anger associated with impulsivity may indicate a patient especially prone to take (self-destructive) action.

5) Certain aspects of the depressive diagnostic criteria appear ominous

• Severe insomnia, especially global insomnia, along with states of severe hopelessness, may increase risk
• Ask about these two symptoms in detail when they are present. Severe insomnia should be treated.

6) The presence of or access to a gun

• Ask about this routinely. If one is present, take steps to remove access during the episode of treatment and assess who is a safe person to restrict the patient’s access to the gun(s)
• Many suicides are impulsive, and national statistics indicate that over half of all suicides are committed with guns, especially handguns (see below, under treatment)
• Guns are especially likely to be associated with suicide in the very young (adolescents) and in the elderly

b) Alcohol/substance abuse or dependence

Although the characteristic suicide who carries a primary diagnosis of alcohol abuse has a pattern of drinking over many years and suicide is generally considered a chronic rather than acute risk, over half of completed suicides (and probably many events characterized as ‘accidents’ which may be covert suicides) involve drinking at the time of death. The clinician should routinely ask about substance abuse as part of any evaluation. In addition, inquire about:

1) The symptoms of depression, whether primary or secondary.

2) Jeopardy with regard to important relationships and job. The threat of jail, or severe financial or other loss may be considered within the same category.

The common use of substances at the time of suicide suggests that acute disinhibition may be an important contributing element. These factors should be routinely appraised as part of the initial intake and positive and negative findings noted in the record. The presence of multiple risk factors in a given patient is highly significant.

In a study by Gruenwald et al (1995), it was found that alcohol is related to suicide and suicide attempts through its use as a self- medication for the relief of depression. The alcohol is thought to disinhibit impulses to suicide. The article further suggests through data analysis that increases in spirits sales are related to increases in suicide rates.

Gruenwald et al suggest that this may be due to the preference among heavy drinkers and alcoholics for this type of beverage. Accordingly, heavy drinkers and alcoholics are more prone to suicide. The study does state that ‘here is no direct evidence connecting the preference for consuming spirits with the predisposition for suicidal behavior.

c) Schizophrenia

Between 20% to 40% of people with schizophrenia attempt suicide at some point in their lifetime (Meltzer, 1998). This disorder carries a lifetime suicide rate of approximately 10%. The risk for suicide is highest early in the onset of the illness. Suicide is most likely to occur in the young person with schizophrenia who has experienced a great decline in performance and, therefore, expectations with regard to the future.

Suicide often takes place during periods of remission, especially following hospitalization, rather than during acute psychotic states. A pattern of repeated exacerbation and remission, and especially the occurrence of depressive symptoms, carries high risk. The clinician should be alert to the presence of subtle or covert thought disorder and should ask about:

1) Dangerous behavior, perhaps under the influence of persisting delusions; i.e., overestimation of abilities, poor judgment in protecting self, and excessive risk-taking. Noncompliance with medication may represent one form of such behavior.

2) Concurrent substance abuse (it may be important to ask others, as well as the subject)

3) The presence of depression, which may center on the individual’s response to having such a disorder, as well as the family’s disappointment and/or anger.

d) Borderline personality disorder

This over-inclusive diagnosis is most likely to be associated with parasuicidal rather than suicidal acts, but approximately 8% of people who are diagnosed as borderline personality disorder eventually commit suicide. Usually after many previous suicidal or parasuicidal acts. Most commonly, those who commit suicide qualify for a concurrent Axis I diagnosis (depression, substance abuse) at the time of suicide. The fact that such people often use suicide as a manipulative threat and are litigious, accounts for a great many hospitalizations. Some of which may be counter therapeutic. Despite these observations, the clinician should take suicidal threats seriously and develop a plan for containment.

IV. MANAGING THE SUICIDAL CHILD

A. General Features

An important distinction exists between the acute risk and the eventual risk of suicide. The presence of pervasive anxiety with depression or thought disorder with persecutory delusions and/or command hallucinations with schizophrenia should alert the clinician to the need for rapid symptom reduction and containment whether or not suicidal ideation is acknowledged.

It is also significant, in the clinical relationship, to work to establish a strong alliance between the child and clinician. Developing and establishing this alliance could enhance the engagement between clinician and patient thus enabling for the clinical intervention to reduce suicidal lethality.

B. What intervention is best?

There are three distinct aspects to be considered:

1. Addressing the basic issues which underpin the person’s desire to die, and
2. Addressing the immediate issues which have causes the crisis, and
3. Ensuring that the person is safe.

At present, neither biological nor genetic markers are of everyday clinical use and the clinician should direct attention to the four strategies indicated below:

1. Conduct a thorough assessment;
2. Take steps to mitigate or eliminate identified risk factors [precipitating issues, access to weapons];
3. Strengthen barriers [coping skills, realistic alternative thoughts]; and
4. Address the basic personality issues.

C. Strategies

Suicide appears to occur when a basic cognitive style exist, a precipitating issue escalates the pain and suffering in the present, intent supervenes, and means are available. Additionally, either help in the form of clinical professionals, family, or significant others, is unavailable or rejected. Strategies that fall into the categories noted above include the following:

1. Address the immediate crisis using the PFA strategies and attempting to set the person back into control. Vigorously address anxiety or agitation associated with depression and/or thought disorder, if present
2. Identify and bring to bear significant others and/or professionals to support the client.
3. Ensure safety through providing ongoing supervision and observation, and if necessary through removal of access to weapons, especially guns
4. Address the abuse of substances in order to restore normal restraint and inhibition
5. Strengthen social resources through active involvement of family and friends in containment
6. Take steps to stabilize job and family situations that are in jeopardy
7. Consider cognitive restructuring to address the cognitive attribution style.
8. Employ family intervention to enhance effective family problem solving and conflict resolution.

D. When does suicidality require hospitalization?

The benefits of hospitalization should be compartmentalized and the question divided into two parts. First, is containment necessary? and second, are the unique medical resources of a hospital necessary to provide treatment? When both severity and imminence of suicidal risk are present, a hospital may be required. This situation is usually an emergency requiring immediate containment, where no other legitimate options exist. Resolution of the crisis through medication and hospitalization is seen as relatively maladaptive and should be reserved for instances where other alternatives prove ineffective.

When severity is present without imminence, such as when the person is ambivalent or rejecting of suicide as an option, if help is accepted and supports are present, other forms of containment may be considered (psychosocial and/or structural). It may be important for someone to stay with the child for 24 hour periods, but this can occur within the child’s own valued setting and may be provided by a family member.

It is important to note that risk may fluctuate during an episode of care and such decisions call for continual review and updating. The child must be aware that reassessment is available, including an ongoing emergency basis. The child and his/her family need to be instructed on how to access additional services in a timely fashion.

E. Should contracts for safety be used?

Contracts for safety should not be used in the absence of a strong alliance with the child and never as substitute for developing a safety plan. Contracts run the risk of communicating to the child that the clinician does not want to hear about suicidal ideation or wishes primarily to protect him/herself against liability. The risk under such circumstances is that the child will interpret the contract as a form of rejection. Contracts may be useful with some children following a thorough evaluation and based on evidence that the child may be relied upon to honor them, as part of a general strategy of risk sharing. Routine use of contracting may create a false sense of security to the clinician and maybe even the patient.

Shea (1998) reminds clinicians that safety contracts are no guarantee of safety. Safety contracts can act best as deterrents when there is a powerful bond between the person and the clinician. The more concrete the contract (written vs. oral), the more likelihood of a powerful deterrent. The sense of commitment and trust in a long-standing relationship between the child and clinician may cause the child to hesitate in breaking his/her word. However, the deterrent power of a safety contract made with a first time involvement is significantly less. In such a situation, a safety contracts may be more likely to be helpful if they are made between the child and the person s/he identifies as most significant to him/her. The clinician can help to develop the contractual arrangement and set up methods to monitor it.

Shea (1998) notes that for certain diagnoses it is best to avoid safety contracting. Individuals diagnosed with Borderline and passive – aggressive characteristics tend to manipulate around safety contracting issues.

F. Prevention

Depression is a foremost risk factor for suicide. Participation in self-help groups, particular grief counseling, appears to ameliorate depression, improve social adjustment, and reduce the use of alcohol and other drug abuse.

Primary care settings have been targeted to play a significant role in suicide awareness and intervention. Untreated/undiagnosed depression in primary care settings plays a significant role in suicide. Depression training for general practitioners reduces suicide. The role of the PFA training and the numbers of agents [teachers, students and parents] can have an impact on the number of children who consider suicide.

Suicide prevention is a much sought after result. Kessler et al (1999) offer some insight towards this outcome. The authors utilize data on prevalence and risk factors of attempted suicide from the National Comorbidity Survey (NCS). The results indicate the highest risks of initial suicide ideation, plans, and attempters are individuals in their late teens and early 20s. The progression from ideation to first onset of a plan, from a plan to first attempt, and from ideation to first attempt without a plan were all highest in the first year after onset of the earlier stage. However, risk of a first time attempt lacking a plan was limited to the first year after onset of ideation. Risk of a first attempt was substantially higher when a plan was involved. The authors note that risk of an attempt among ideators with a plan was very high in the onset year of plan and continued for many years.

Cognitive Behavior Management [CBM]

There is a major role for CBM in most cases of high suicidal risk, and we define a particular model of Multimodal Crisis Intervention for this purpose. An attitude of empathic acceptance, allying with the person’s pain and sense of desperation may be regarded as ancillary to other methods of intervention and basic to the establishment of the necessary alliance. The clinician should not try to avoid the issue of suicidality, but contain and manage it in conjunction with the child, significant other, and/or other helpers in his/her life structure, as indicated.

Multimodal Crisis Intervention, in this context, should focus on the suicide risk itself, as a prelude to reducing it and allowing for other treatment objectives to emerge. Often such involvement may be targeted and brief. These recommendations must be distinguished from questions about the role of CBM in addressing the underlying disorder. The way in which an individual copes with problems over the course of his or her life usually indicates whether the person is emotionally predisposed to suicide. Cognitive Behavior management is a method supremely designed to address the change of the child’s basic way of interpreting experiences and coping with outcomes.

Depending on the child’s preferred mode of learning and preference, suicidality may be contained and the student engaged in the process of recovery from the associated disorder through cognitive behavior management techniques.

J. Cultural Differences

In the current cultural climate of modern day America, it is of utmost importance, when considering intervention, that clinicians be educated, knowledgeable, and sensitive to cultural differences in the population. The information provided here addresses the issue of suicide with respect to the Asian-American, Native American, and African-American communities.

a) Asian

Purcell et al (1998) studied suicide in the elderly Asian population. Key factors for this population are depression, physical illness, and loss. Results from the study showed that the mean age for suicide was 75 years with the highest completion in the over 80 category.

The predominant method was hanging, followed by jumping, use of firearm, and poisoning. Almost half of the sample had seen a health care provider within six months of their deaths Seventy-nine percent of the sample committed suicide at home or on the surrounding property

Active depression was the most common psychiatric illness. Only 15% had contact with a mental health provider within one (1) month of their death. Fifty-eight percent had a history of suicidal behavior. Fifty-three percent made one or more active attempts. The authors found that males tended to be more violent (hanging, firearm, jumping) than females.

In Lester’s (1997) article on Chinese-American suicidal behavior the author found that Asian-American have a relatively low suicide rate compared to Caucasians. For example, in 1980 figures, 13.2 per 100,000 for Caucasians compared to 8.3 for Chinese Americans. Asian-Americans used hanging much more often the Caucasians and firearms less often. Cultural factors have been determined to have influence on suicidal behavior. Lester concluded that gender and age patterns seem to be affected strongly by ethnicity (older males more likely to suicide than females). The suicide rates and methods are effected by the nation in which the Chinese live.

In the Asian population, under reporting is a real possibility. Suicide is viewed as ‘shameful’.

b) Native American

In the Native-American culture, suicides were often honored. The concern is that today’s youth hope for attention and acceptance in their own suicides. Acculturation is a factor thought to contribute to the suicide rate. Resulting pressure from the dominant culture leads to a variety of changes in the non-dominant culture, Native Americans who attempted or completed suicide mention causes such as grief over loss and quarrels with relatives and friends. Rarely is cultural conflict mentioned. Problems related to acculturation may raise the stress level so much that stressors now precipitate suicide.

c) African American

Research on African-American suicide has yielded the following suicide risk factors: the combination of male gender, early adulthood, and substance abuse may be associated with a greater risk for suicide among African Americans. Additional precipitants identified were depression, family dysfunction, interpersonal discord/marital conflict, acting out/delinquency, psychiatric disorders, and homosexuality/AIDS (Gibbs, 1997). Conversely, the combination of strong religious beliefs, social supports, and ethnic neighborhoods is purported to help reduce the effects of aging and poverty, thus reducing the suicide risk. In contrast to African-Americans, Caucasians tend to report suicidal ideation. This suggests that clinicians should use caution when relying on patient self reports of depression and suicidal ideation as predictors of suicidal behavior in African American youth.

d) Hispanic

While there are implications of cultural factors and their role in suicide, we were unable to uncover significant Hispanic cultural factors in our literature review. It is apparent there is a need for further study and research of cultural factors and suicide in this population.

K. Liability

Because of the high incidence of claims against clinicians following a suicide, specific precautions are in order when treating the suicidal patient:

1. Documentation

The cornerstone of sound risk management is record keeping. Clinical records should be a clear indicator of the thought process of the clinician, especially with regard to decisions made about managing lethality. Shea (1998) writes that documenting a safety contract in the initial assessment provides some forensic support in a lawsuit by demonstrating that the clinician inquired about patient safety in some detail. This purportedly would make it harder to prove negligence on the part of the clinician.

Sound lethality assessments, as described above, including not only lethal ideation but risk assessment as well, are important safeguards against later claims of negligence or lack of care. Contacts with family, other treatment providers, and the patient (phone calls and letters as well as sessions): responses to failed appointments; noncompliance with treatment requirements, and impasses in treatment should all be documented.

2. Collaboration

Consultation and/or collaboration with other helpers as well as with the child and his/her family, and communication among principals in the interventions are important elements of good treatment as well as good risk management.

3. Assessment of competence and provision of Informed consent

People will often fail to inform their counselors about lethality. It may be important to review lethality with the child the risks of not doing so. Also, associated with this strategy, assess the person’s competence with regard to this issue: i.e., does s/he understand the risks of failing to keep the clinician informed? The result of this process should be documented in the record.

When the person’s competence is in question (i.e., actively psychotic), other forms of containment may need to be considered (i.e., hospitalization, and guardianship).

4. Post prevention

Following a suicide it is both humane clinical practice and sound risk management to maintain contact with the decedent’s family, to attend the funeral, and to offer (at least brief, supportive) services to survivors. When treatment beyond brief support is required, referral to another clinician should be considered. Since requirements for confidentiality do not cease with the death, the provider should limit the amount of information communicated to only what is necessary.

PART IV. MULTIMODAL CRISIS COUNSELING [For a complete discussion see Chapter 8 of Crisis Intervention by Slaikeu.

Multimodal crisis counseling picks up where psychological first aid leave off by assisting the client in the process of rebuilding a life shattered by external events. The uniqueness of the intervention lies in the fact that everything the clinician does is aimed at helping the client deal with the impact of the crisis event on each on each area of the client’s life. Working through the crisis event so that it become functionally integrated into the fabric of life, leaving the client open, instead of closed, to facing the future. Remember also that not everyone who experiences a life crisis needs multimodal crisis counseling to resolve it. Many individuals work through crises on their own, profiting from the experience.

Crisis counseling is most effective when it coincides with the period of disorganization [six or more weeks] of the crisis itself. The intent is to offer assistance at that time to increase the probability that the reorganization is toward growth and away from debilitation. Counseling energies are geared toward helping the client to a) physically survive the crisis experience, b) identify and express feelings that accompany crisis, c) gain cognitive mastery over the crisis, and d) make a range of behavioral and interpersonal adjustments necessitated by the crisis.

Districts will need to decide whether the multimodal crisis counseling is done by school personnel [psychologist, social workers trained in the techniques] or by clinical professionals from the outside. In either case, it is worth considering having the counselors identified with the school to avoid the terms such as ‘treatment’, ‘therapist’, and ‘patient’ which should be consciously excluded from formal usage, in order to appeal to those who can benefit from professional assistance but are reluctant to identify their problem as ‘psychiatric’. Clinical professionals can be under contract to provide the services within the district and be identified as part of the CMT.

The assessment and intervention framework was inspired by the work of Lazarus and others who have taken a multidimensional approach and starts with a modified version of the Five Person Subsystem. The main differences are: 1) the elimination of the drugs category, coding the taking of tobacco, alcohol, medication and other substances as a behavioral activity, and 2) including all physical functioning variables [including the sensations of vision, touch, taste, smell and hearing] under somatic functioning.

BASIC Personality Profile

Modality/ System	Variables/Subsystems
Behavioral	Patterns of work, play, leisure, exercise, diet [eating and drinking habits], sexual behavior, sleeping habits, use of drugs and tobacco, presence of the following: suicidal, homicidal or aggressive acts.Customary methods of coping with stress.
Affective	Feelings bout any of above behaviors; presence of feelings such as anxiety, anger, joy, depression, etc.; appropriateness of affect to life circumstances. Are feelings expressed or hidden?
Somatic	General physical functioning, health.Presence or absence of tics, headaches, stomach difficulties and any other somatic complaints; general state of relaxation/tension; sensitivity of vision, touch, taste, hearing.
Interpersonal	Nature of relationship with family, friends, neighbors, and co-students [workers]; interpersonal strengths and difficulties; number of friends, frequency of contact with friends and acquaintances; role taking with various intimates [passive, independent, leader, co-equal]; conflict resolution style [assertive, aggressive, withdrawn]; basic interpersonal style [congenial, suspicious, manipulative, exploitive, submissive, dependent].
Cognitive	Current day and night dreams; mental pictures about past or future; self image; presence of any cognitive errors, hallucinations, irrational self talk, rationalizations, paranoid ideation; general [positive/ negative] attitude toward life.

Assessment Assumptions

Assessment in crisis counseling is built on the following suppositions:

1. We must be able to assess the impact of the crisis event on all five areas of the child’s functioning.
2. The BASIC subsystems, though assessed separately, are interrelated so that change in one can be expected to lead to change in others.
3. It is important to assess both strengths as well as weaknesses in BASIC functioning during the crisis and whenever possible to mobilize the former to shore up the latter.
4. Assessment of an individual’s crisis must include the contextual variables of family/social environment, community and culture, since these suprasystem variables have a direct bearing on the success or failure of intervention strategies.
5. Assessment procedures must be organized to allow for evaluation at the end of counseling and at various follow up points.
6. The goal of assessment is not to create a diagnostic label, but rather to provide a profile of pre-crisis functioning in the context of similar profile of post-crisis functioning, both of which will yield concrete guidelines for selection of intervention strategies.

It is important that data be secured in each of the following areas:

Precipitating Event(s)

It is important to know what happened to touch off the crisis. Was there one major event such as the unexpected death of a loved one or was the precipitating event of the ‘last straw’ variety. Particular attention is give when the event occurred and who was involved, as a backdrop for how the event interacts with the client’s self-image, life structure and life goals. Does the client view the event as a loss? Threat? Challenge?

Presenting Problem

This is essentially a summary of the client’s difficulties at the time of the referral. What complaints does the client bring to the intervention? What does the client want from crisis counseling? How does the client presently describe the difficulty and what is the client’s view of what s/he needs most at that time?

Context Of Crisis

It is important to determine the effect of the crisis on the immediate family and/or social group and vice versa. Assessment of context looks at how the original crisis [e.g., the diagnosis of cancer] is perceived by the community and how this perception might possible precipitate another crisis. What resources are available in the community to assist the client in working through the crisis?

Pre-Crisis BASIC Functioning

A brief developmental history is necessary in order to fully appreciate the disorganization and disequilibrium that follows a particular precipitating event. The primary concern is to identify the most salient aspects of the client’s BASIC functioning during childhood, puberty, and adolescence as they may relate to the crisis event. This includes emphasis on the following:

• previous means of coping and solving problems
• most obvious person and social resources
• most noticeable strengths and weaknesses in BASIC functioning
• unresolved conflicts or unfinished business which might be touched off by the crisis event
• relative satisfaction or dissatisfaction with life
• pre-crisis developmental stage
• excesses and deficits of any of the BASIC modalities
• life goals and life structure to achieve goals
• goodness of fit between life style and suprasystems
• other stresses before crisis event

In sum, our concern is to determine how well the individual was functioning before the crisis event. Particular attention is given to determining previous coping patterns and unresolved personal conflicts.

Crisis BASIC Functioning

Our chief goal here is to determine the impact of the precipitating event in all five of the individual’s BASIC functioning.

Behavioral

• what activities [going to school, sleeping, eating, etc.) have been most affected by the crisis event?
• which areas have been unaffected by the crisis?
• which behaviors have been increased or possibly strengthened by the crisis?
• what coping strategies have been attempted and what was the relative success/failure of each.

Affective

• how does the individual feel in the aftermath of the crisis event> [Anger, sadness, numbed, hopeless, helpless?]
• are feelings expressed or hidden?
• does affective state give any clues at to the stage of working through the crisis?

Somatic

• are there physical complaints associated with the crisis event?
• if crisis stems from physical loss [loss of limb, surgery, disease], what is the exact nature of the loss and what are its effects on other bodily functioning?

Interpersonal

• impact of crisis on immediate social world of family and friends.
• current social network and supports.
• interpersonal stance taken during the time of crisis, for example, withdrawn, dependent, etc.

Cognitive

• expectancies or life goals violated by the crisis event.
• current ruminations or intrusive thoughts.
• the meaning of the precipitating event in overall life.
• presence of ‘shoulds’ such as “I should have been able to handle this”.
• illogical thought patterns such as inevitable outcomes (“she left me, therefore I’ll never find another”).
• current self talk patterns.
• day and night dreams.
• images of impending doom.
• destructive fantasies.
• use of humor as a way of coping with the crisis.

The cognitive modality captures the heart of the crisis experience since it focuses on the meaning of the crisis event(s) to the individual. Crisis theory suggests that it is critical to discover the individual’s expectations, goals and dreams that have been shattered by the crisis event and to assess current style of cognitive functioning [e.g., blaming self, overgeneralizing, catastrophizing]. Perhaps more than any other, the cognitive modality is viewed by theorists as critical to understanding the crisis experience.

Special emphasis should be given to ‘disruptions’ in each modality when determining the impact of the crisis event on BASIC functioning.

FOUR TASKS OF CRISIS RESOLUTION

Physical Survival In The Aftermath Of The Crisis

Offer PFA. Consult with client about nutrition, exercise and relaxation. [See Technique #4 Relaxation and Technique #26 The Calm Technique]

Expression of feelings related to the crisis

The central premise behind expression of feelings as a task of crisis resolution grows from experience with people who have not resolved earlier lifetime crises.

The chief strategy for identifying client feelings is active listening wherein the clinician listens both for what happened to the client and how s/he feels about the events. Heavy doses of empathic understanding can often help clients admit to a range of troublesome and uncomfortable feelings. By listening carefully to the verbalizations that accompany the expression of feelings, the counselor gains valuable information on specific explorations that will be necessary for the client in order to gain full cognitive mastery over the crisis. Emotions give similar clues to anticipated behavioral changes. Some clients will need to be given ‘permission’ to express feelings, to be reassured that feelings are normal and that it is all right to be angry during the crisis.

The counselor should look for client misconceptions and at times offer rules or guidelines for expression of feelings. It should be stated to directly to the client that there are many ways to express feelings and that each person can find his/her own place, time and company (or the absence thereof) to do so. Feelings are a psychological reality during a crisis and deserve express in some form or another. The counselor’s chief responsibility is to assist the client in sorting thought the various feelings, finding ways to identify and express them and at the same time, finding out what they really mean to the client in terms of past experience, current expectations and future plans, all as a lead-in to full cognitive mastery.

Cognitive Mastery Of The Entire Experience

Cognitive factors are the mechanism by which external events turn into personal crises. The first aspect of cognitive mastery is that at some point the client must gain a reality-based understanding of the crisis event. The counselor will essentially ask the client to tell the story of what happened, what led up to the crisis, who was/is involved, the outcome(s) and any other related details, listening all the while for gaps in information , possibly deliberate omissions, distortions, generalizations, etc. [See Meta Model – Appendix ]. The premise is that in order for a crisis client to move through and pest the crisis even, s/he must have some understanding of what happened and why.

The second aspect is for the client to understand the meaning the event has for him/her, how it conflicts with expectations and cognitive maps, life goals/dreams and religious beliefs. In listening for what the event means to the client, the counselor notes also any apparent cognitive errors [See CBT#02 – Altering Limited Thinking Patterns for a list of these errors], misconceptions or irrational beliefs. The counselor will use questions and reflective [clarifying] statements to draw the client’s thought processes out for examination. Essentially, the questions shift from ‘how-do-you-feel– about-that’ questions to ‘how-do-you-think-about-that’ questions.

Interpretations run a far better chance of being accepted by the client when it is the client who first ‘discovers’ them. The counselor should aim to generate considerable data about cognitions, thereby increasing the probability of the client drawing the conclusions him/herself, or at least being receptive to the counselor’s interpretation. Minimally, any interpretations should be based on data that both the counselor and client have generated and reviewed together. Our key concern is with whether these cognitions are realistic, rational and conducive to future growth and development.

The third cognitive mastery activity involves rebuilding, restructuring or replacing cognitions, images and dreams that have been destroyed by a crisis event. The objective is to assist the client in developing new cognitions, perhaps amending an overall philosophy of life and defining new goals/dreams that both square with the available data and equip the client to face the future.

Clinicians should be familiar with CBT#01 – Perceiving Reflex Thoughts, CBT#02 -Altering Limited Thinking Patterns & CBT#03 – Changing Distressing Thoughts as the basic techniques for carrying out this portion of the Multimodal crisis Intervention.

Behavioral/Interpersonal Adjustments Required For Future Living

The final crisis resolution task is based on the idea that behavioral change is the ‘bottom line’ for crisis resolution. Central to this task is the question of whether the person can eventually return to school, work, engage in play and participate in meaningful relationships, in spite of the fact that nay or all of these activities may have been brought to an abrupt halt or thrown into tremendous disarray for a period of time. A comparison of crisis function in the behavioral and interpersonal modalities with pre-crisis functioning will serve as a guide in identifying the specific client activities necessary to negotiate this task. Some issue will require immediate attention, while others will stretch over a period of months. The main consideration should be to help the client deal first with behavioral steps that, if neglected, will severely reduce options later on. Counselors and clients should discuss these decisions together, with the counselor taking responsibility for raising the issues of priorities, as well as introducing strategies for change.

CRISIS GROUPS

These groups usually focus on the immediate needs of clients in crisis [PFA] and assist in charting a path for survival in the days and weeks following a traumatic event. A more generic form of group intervention can be offered over a period of months to a wider range of crisis clients, including those facing developmental transitions and also situation cries. The chief focus in these groups is in providing group support and ‘coaching’ as clients negotiate the risks and behavior changes associated with unexpected illness, injury, financial reversals, separation/divorce and other issues.

FAMILY INTERVENTIONS

Family crisis intervention has a rich history built on the assumption that families in crisis are more amenable to help than during more stable times, and that counseling is likely to produce faster results in the early stages of the crisis than it might after the crisis is over. The same four tasks of crisis intervention can provide a structure for family interventions. This is accomplished by considering the family’s physical functioning [financial security], the family’s management of feelings [mood, tone] , the family’s cognitive mastery [myths, identify, rules, decision-making, power structure], and the family’s behavioral/interpersonal adjustments [communication, coalitions, use of power, and other influences of family members on one another.

DETERMINING PRIORITIES

Counselors should assess task progress with each client during each contact and endeavor to make some progress [or lay the ground work] for each task during every session. Beyond this general guideline, the manner of which topics will be discussed and which adjustments begun grow from a negotiation process with the client. In deciding how to allocate clinical energies the following should be considered.

• determine which issue are most salient to the child at the moment
• consider beginning with a crisis resolution activity that is the easiest to address; one most amenable to change
• look for the crisis resolution activity that seems to account for the most variance in the client’s overall disorganization
• devote attention in the early sessions to any activity that, if neglected, might reduce a client’s options in subsequent weeks, months and years.

EVALUATION OF OUTCOME

At followup, several key variables need to be assessed. This includes more than simply checking on the state of each of the personality modalities or subsystems, although this is where followup assessment begin.

• Has there been a return to equilibrium and a reorganization of the BASIC personality subsystems? By checking the state o the various modalities and their relationship with one another, crisis theory’s constructs of equilibrium regained and openness to the future are examined.
• We need to assess the extent to which coping capabilities have been regained – to what extent is a) problem solving now possible, and b) subjective discomfort being managed?
• To what extent have any pre-crisis unresolved issued been worked through or finished at follow up?
• Has the event been integrated into the fabric of life?
• Is the person open to facing the future, equipped and ready to work, play and relate to others?

CONCLUSION

The focus on a multimodal perspective of crisis intervention built on a model first developed by Lazurus is recommended for clinical use. Appropriate attention should be paid to all of the attributional concerns identified in the opening of this workbook.

This workbook is presented to help school districts determine whether they wish to pursue a suicide management program and, if so, suggest how to proceed. It is not intended that the workbook is able to present all of the issues that might need to be addressed. If the district decides to pursue such a program and is committed to the process defined in CBP#06, they should seek further information from their State or County Educational units.