School – based suicide prevention strategies
Aikaterini Samiotou, MSc
The most common and widespread programs in a school base, are the psychoeducational programs (Shaffer & Gould 2000). Among their aims is to increase knowledge about the problem of suicide, educate on the identification of pupils who show “warning signs” and their referral to the appropriate services and encourage the suicidal students to ask for help themselves (Shaffer et al. 1991). Their functioning is both direct and indirect by educating the teachers and the other students to identify the pupils who are at risk (Shaffer & Gould 2000). Informing the participants of this program about the increase in subsequent suicide risk for the siblings and friends after a suicidal death as well as the different factors that can influence the suicide risk should be a part of the educational schedule. By demonstrating the familial, psychiatric and environmental vulnerability that these exposed groups present, the teachers and students can have an insight in the complexity of the cases and use this knowledge in the identification and management of students who present problems. Given that among the disadvantages of this school program is that the education in the warning signs may not represent the current research findings, the inclusion in the program of scientific knowledge that demonstrates the increased risk appears necessary (Shaffer et al. 1991). In addition the above evidence would increase the accuracy in the recognition of at risk cases. The accurate recognition remains a significant concern regarding the efficacy of these programs as studies demonstrate that a small number of teachers feel able to identify the students at risk (King et al. 1999).
Direct screening
This type of program includes the screening of all students and the use of self- report and interviews in order to identify the adolescents at risk for suicide related behavior. Depressive symptoms, substance abuse problems, suicide ideas and previous attempts are the targets of the screening (Gould et al. 2003). Given the high rates of mood symptomatology and the problems related to substance abuse and social functioning that siblings and friends survivors present, their immediate screening and appropriate referral are a major issue of a successful prevention strategy. This direct way of identifying the students at risk may lead to an over –identification of the students at risk and to an increased number of false- positive screening results but the cost of the over-identification remains low (Gutierrez et al. 2004).
Postvention strategy
The psychiatric sequelae after the loss of someone closed as a sibling or a peer is demonstrated and its devastating consequences have been reported. Apart from the increased risk for subsequent suicidal behavior, the siblings survivors present clinically significant depressive symptoms, new –onset of major depressive disorder, symptoms related to posttraumatic stress, anxiety, severe grief symptomatology and other components related to pathological bereavement (Pfeffer et al. 1997; Brent et al. 1993). The exposed friends were proved to be susceptible to new-onset of major depressive disorder, severe posttraumatic symptoms, clustering of traumatic grief components and engagement to risk situations such as behaviors related to drinking, drug abuse and physical fighting (Cerel et al. 2005; Brent et 1992; Bridge et al. 2003).
The task of the postvention strategy is to address and reduce the subsequent risk for suicidal behavior in the school environment and consists of a strategy that takes place timely after a suicide (Shaffer & Gould 2000). Given the evidence that support the suicide clustering and risk of contagion after a suicidal death, one of the principal tasks of a postvention program should be the identification and reduction of suicide contagion. However as this literature review demonstrated that the imitative nature of suicidal behavior still remains unclear, fundamental principle of an effective postvention strategy is the management of the psychiatric symptomatology and social impairment that the siblings and friends of suicide victims present. In the light of the high prevalence in personal and family psychopathology of these groups, the postvention strategy should address the psychiatric symptoms and the social dysfunction and refer these at risk groups in the appropriate psychiatric services for management and support.
The implementations of the evidence regarding the elevated risk that siblings and friends are exposed to, can be viewed not only in the school environment but in different settings too. Based on the complexity of suicide problem the development of strategies that incorporate the management of the risks following the aftermath of a suicide is crucial.
Media education
The presentation of a suicidal death by the media has been considered related to copycat suicidal behaviors in the public (Stack 2003). Increased outbreaks of suicidal behaviors and suicides after the publicity of a suicide by the media have been reported (Martin 1998). The association between the presentation of suicide in the media and the subsequent increased rates of suicide-related behavior has been considered as an imitation phenomenon. The greater vulnerability of teenagers in the suicide contagion and the clustering of adolescent suicides has been reported (Gould et al. 1990). In order to address the contagion effects guidelines for media and journalists have been developed (American Foundation for Suicide Prevention 2001).These guidelines include recommendations regarding the presentation of the suicides. The publicity of a suicide should avoid presenting the suicide as a romantic or inexplicable situation, ignoring the underlying psychiatric condition (Gould 2001). Interviews with the grieving relatives and detailed demonstration of the devastating effects on relatives and friends can also be considered as a way of seeking attention by others and lead to suicidal behaviors. Education of journalists regarding the way of presenting and the use of the appropriate language is recommended (American Foundation for Suicide Prevention 2001).
Apart from the vulnerability of sibling survivors and friends in engaging in suicide risk behaviors and in developing psychiatric symptomatology, one of the findings that emerged in this literature review was the specific and different themes that the grief procedure includes in comparison to other types of death. The survivors of suicide present an initial shock and disbelief accompanied with a preoccupation with an explanation about the death (Ness & Pfeffer 1990). Anger, shame and feelings of rejection are also common among the suicide survivors (Reed & Greenwald 1991). The responsibility and the blame expressed by the survivors as well as the stigmatization are among the components of the social reaction to suicide (Allen et al. 1994). The reported lack of social support underlines the social stigma of suicidal death and the responsibilities attributed to the relatives and friends that complicate the bereavement procedure (Cvinar 2005).
The implication of these findings in the bereavement services is crucial. Counseling and psychoeducation regarding the different motivations behind the suicidal death would be extremely significant and should be incorporated to the program of these services. Given that an explanation for the death preoccupies the survivors, discussion about the reasons behind death and counseling regarding the allocation of responsibility consist of significantly beneficial resources (Jordan 2001).
Central component of the services offered to siblings and friends and families of adolescent victims should be the support against the social stigma that appears as a prevalent perception around suicidal death. Discussion and counseling regarding the management of social stigmatization should be offered as well as skills in order to prevent social isolation.
Group interventions including psychoeducational details regarding the definitions and causes of suicide, empowering the bereaved siblings and friends and providing the parents with the skills in order have an insight in the children’s bereavement procedure have also proved efficient in the control of psychosocial distress (Pfeffer et al. 2002; Cerel et al. 1999) and should be offered to the bereaved families.
The evidence of high rates of familial psychopathology among the siblings and friends of suicide victims and the association of the severity of their psychiatric symptoms and social impairment with the parental psychopathology and stressful life experiences (Pfeffer et al. 1997) indicates the importance of family-based intervention. Parents should be able to express their own feelings about the suicidal death and their possible psychiatric symptoms should be addressed as a part of the aim to reduce the siblings’ and friends’ vulnerability.
Apart from the risk for suicide-related behavior, a finding that deserves considerable attention is the high rates of psychiatric symptoms and social impairment that the siblings presented after the suicidal death. Similarly the exposed friends showed higher rates of psychiatric symptomatology and engagement in risk behaviors (drug use, drinking, fighting). Contrary to the initial hypothesis where friends were expected to show lower rates of psychiatric and social disregulation compared to siblings, the rates of psychopathology as well as the rates of pre-existing personal and familial psychopathology appeared similar between the two groups. With the exemption of one study that reported more severe and persistent grief symptomatology among the siblings (Brent et al. 1996) both groups developed clinically significant psychiatric symptoms (depressive and posttraumatic stress disorder symptoms), new–onset of depressive disorder and showed persistent social impairment. Contrary to the general belief the friends of suicide victims do suffer significantly and persistently and the implication of this evidence in the management and support of this group is really significant.
Among the aims of this literature review was the presentation of the increased rates of suicide risk that siblings and friends show after the suicidal death of an adolescent and discuss the possible mechanisms and factors that trigger this increase. However different questions still remain unanswered. Among the targets of future research should be to indicate and identify if there is a specific factor causally related to the suicide risk and suicide in general. There is still lack of knowledge regarding the way factors such as psychopathology, genetics and environment interplay and what is the contribution of each one of these factors in suicide. Additionally the research should be focused on the role of shared and non shared experiences and provide answers that can explain the individual differences regarding the suicide-related behaviors among the members of the same family. Furthermore, with respect to the exposed friends the research interest should be focused on the question whether the engagement to suicidal behavior consists of a contagious act or demonstrates their psychiatric vulnerability. Answers to the above questions will provide a better perception of suicide and its origins and can lead to the development of more effective and accurate prevention strategies.
The most common and widespread programs in a school base, are the psychoeducational programs (Shaffer & Gould 2000). Among their aims is to increase knowledge about the problem of suicide, educate on the identification of pupils who show “warning signs” and their referral to the appropriate services and encourage the suicidal students to ask for help themselves (Shaffer et al. 1991). Their functioning is both direct and indirect by educating the teachers and the other students to identify the pupils who are at risk (Shaffer & Gould 2000). Informing the participants of this program about the increase in subsequent suicide risk for the siblings and friends after a suicidal death as well as the different factors that can influence the suicide risk should be a part of the educational schedule. By demonstrating the familial, psychiatric and environmental vulnerability that these exposed groups present, the teachers and students can have an insight in the complexity of the cases and use this knowledge in the identification and management of students who present problems. Given that among the disadvantages of this school program is that the education in the warning signs may not represent the current research findings, the inclusion in the program of scientific knowledge that demonstrates the increased risk appears necessary (Shaffer et al. 1991). In addition the above evidence would increase the accuracy in the recognition of at risk cases. The accurate recognition remains a significant concern regarding the efficacy of these programs as studies demonstrate that a small number of teachers feel able to identify the students at risk (King et al. 1999).
Direct screening
This type of program includes the screening of all students and the use of self- report and interviews in order to identify the adolescents at risk for suicide related behavior. Depressive symptoms, substance abuse problems, suicide ideas and previous attempts are the targets of the screening (Gould et al. 2003). Given the high rates of mood symptomatology and the problems related to substance abuse and social functioning that siblings and friends survivors present, their immediate screening and appropriate referral are a major issue of a successful prevention strategy. This direct way of identifying the students at risk may lead to an over –identification of the students at risk and to an increased number of false- positive screening results but the cost of the over-identification remains low (Gutierrez et al. 2004).
Postvention strategy
The psychiatric sequelae after the loss of someone closed as a sibling or a peer is demonstrated and its devastating consequences have been reported. Apart from the increased risk for subsequent suicidal behavior, the siblings survivors present clinically significant depressive symptoms, new –onset of major depressive disorder, symptoms related to posttraumatic stress, anxiety, severe grief symptomatology and other components related to pathological bereavement (Pfeffer et al. 1997; Brent et al. 1993). The exposed friends were proved to be susceptible to new-onset of major depressive disorder, severe posttraumatic symptoms, clustering of traumatic grief components and engagement to risk situations such as behaviors related to drinking, drug abuse and physical fighting (Cerel et al. 2005; Brent et 1992; Bridge et al. 2003).
The task of the postvention strategy is to address and reduce the subsequent risk for suicidal behavior in the school environment and consists of a strategy that takes place timely after a suicide (Shaffer & Gould 2000). Given the evidence that support the suicide clustering and risk of contagion after a suicidal death, one of the principal tasks of a postvention program should be the identification and reduction of suicide contagion. However as this literature review demonstrated that the imitative nature of suicidal behavior still remains unclear, fundamental principle of an effective postvention strategy is the management of the psychiatric symptomatology and social impairment that the siblings and friends of suicide victims present. In the light of the high prevalence in personal and family psychopathology of these groups, the postvention strategy should address the psychiatric symptoms and the social dysfunction and refer these at risk groups in the appropriate psychiatric services for management and support.
The implementations of the evidence regarding the elevated risk that siblings and friends are exposed to, can be viewed not only in the school environment but in different settings too. Based on the complexity of suicide problem the development of strategies that incorporate the management of the risks following the aftermath of a suicide is crucial.
Media education
The presentation of a suicidal death by the media has been considered related to copycat suicidal behaviors in the public (Stack 2003). Increased outbreaks of suicidal behaviors and suicides after the publicity of a suicide by the media have been reported (Martin 1998). The association between the presentation of suicide in the media and the subsequent increased rates of suicide-related behavior has been considered as an imitation phenomenon. The greater vulnerability of teenagers in the suicide contagion and the clustering of adolescent suicides has been reported (Gould et al. 1990). In order to address the contagion effects guidelines for media and journalists have been developed (American Foundation for Suicide Prevention 2001).These guidelines include recommendations regarding the presentation of the suicides. The publicity of a suicide should avoid presenting the suicide as a romantic or inexplicable situation, ignoring the underlying psychiatric condition (Gould 2001). Interviews with the grieving relatives and detailed demonstration of the devastating effects on relatives and friends can also be considered as a way of seeking attention by others and lead to suicidal behaviors. Education of journalists regarding the way of presenting and the use of the appropriate language is recommended (American Foundation for Suicide Prevention 2001).
Apart from the vulnerability of sibling survivors and friends in engaging in suicide risk behaviors and in developing psychiatric symptomatology, one of the findings that emerged in this literature review was the specific and different themes that the grief procedure includes in comparison to other types of death. The survivors of suicide present an initial shock and disbelief accompanied with a preoccupation with an explanation about the death (Ness & Pfeffer 1990). Anger, shame and feelings of rejection are also common among the suicide survivors (Reed & Greenwald 1991). The responsibility and the blame expressed by the survivors as well as the stigmatization are among the components of the social reaction to suicide (Allen et al. 1994). The reported lack of social support underlines the social stigma of suicidal death and the responsibilities attributed to the relatives and friends that complicate the bereavement procedure (Cvinar 2005).
The implication of these findings in the bereavement services is crucial. Counseling and psychoeducation regarding the different motivations behind the suicidal death would be extremely significant and should be incorporated to the program of these services. Given that an explanation for the death preoccupies the survivors, discussion about the reasons behind death and counseling regarding the allocation of responsibility consist of significantly beneficial resources (Jordan 2001).
Central component of the services offered to siblings and friends and families of adolescent victims should be the support against the social stigma that appears as a prevalent perception around suicidal death. Discussion and counseling regarding the management of social stigmatization should be offered as well as skills in order to prevent social isolation.
Group interventions including psychoeducational details regarding the definitions and causes of suicide, empowering the bereaved siblings and friends and providing the parents with the skills in order have an insight in the children’s bereavement procedure have also proved efficient in the control of psychosocial distress (Pfeffer et al. 2002; Cerel et al. 1999) and should be offered to the bereaved families.
The evidence of high rates of familial psychopathology among the siblings and friends of suicide victims and the association of the severity of their psychiatric symptoms and social impairment with the parental psychopathology and stressful life experiences (Pfeffer et al. 1997) indicates the importance of family-based intervention. Parents should be able to express their own feelings about the suicidal death and their possible psychiatric symptoms should be addressed as a part of the aim to reduce the siblings’ and friends’ vulnerability.
Apart from the risk for suicide-related behavior, a finding that deserves considerable attention is the high rates of psychiatric symptoms and social impairment that the siblings presented after the suicidal death. Similarly the exposed friends showed higher rates of psychiatric symptomatology and engagement in risk behaviors (drug use, drinking, fighting). Contrary to the initial hypothesis where friends were expected to show lower rates of psychiatric and social disregulation compared to siblings, the rates of psychopathology as well as the rates of pre-existing personal and familial psychopathology appeared similar between the two groups. With the exemption of one study that reported more severe and persistent grief symptomatology among the siblings (Brent et al. 1996) both groups developed clinically significant psychiatric symptoms (depressive and posttraumatic stress disorder symptoms), new–onset of depressive disorder and showed persistent social impairment. Contrary to the general belief the friends of suicide victims do suffer significantly and persistently and the implication of this evidence in the management and support of this group is really significant.
Among the aims of this literature review was the presentation of the increased rates of suicide risk that siblings and friends show after the suicidal death of an adolescent and discuss the possible mechanisms and factors that trigger this increase. However different questions still remain unanswered. Among the targets of future research should be to indicate and identify if there is a specific factor causally related to the suicide risk and suicide in general. There is still lack of knowledge regarding the way factors such as psychopathology, genetics and environment interplay and what is the contribution of each one of these factors in suicide. Additionally the research should be focused on the role of shared and non shared experiences and provide answers that can explain the individual differences regarding the suicide-related behaviors among the members of the same family. Furthermore, with respect to the exposed friends the research interest should be focused on the question whether the engagement to suicidal behavior consists of a contagious act or demonstrates their psychiatric vulnerability. Answers to the above questions will provide a better perception of suicide and its origins and can lead to the development of more effective and accurate prevention strategies.
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