As you explore these strategies, keep in mind that risk management should be2:
- collaborative - the clinical judgment of your community partners, the knowledge and experience of survivors, as well as the preferences of children, youth and families should carry weight in the risk-management management plan that you develop.
- culturally-informed - each young person may carry multiple, intersecting cultural identities. Some of these identities come with unique realities (e.g. FNIM youth, LGBTQ youth, rural and newcomer youth) so it’s important to be flexible in your approach to managing risk.
Also keep in mind that whatever the risk-management strategy being implemented, it’s crucial you remember why you do this work. Suicide prevention isn’t just about preventing death by suicide at a given moment in time. It’s about promoting life in its most wholesome, meaningful and sustainable form. Make sure this approach is foundational to your work.
Anyone can become aware of a suicide risk (e.g., peers, family members, educators, coaches, health and mental health service providers). However, everyone’s role in addressing the risk will be different. The first step in risk management is to know exactly what your role is (including its limits), should you ever suspect or learn that a youth may be experiencing suicidal thoughts or behaviours.
- Roles in risk management will vary according to levels of training in intervention and the specific role held by the individual within their organization (e.g. clinical support versus front line person interacting with youth such a teacher). Untrained staff should refer youth to personnel with formal training in risk assessment and/or crisis intervention. That key person may be another staff member within the organization or they may be an external resource – hence the importance of creating and sustaining connections with relevant community partners.
- Clear role definitions for each staff member should be captured in an open-access, readily-accessible document (for example, administrative staff and volunteer personnel should immediately notify a counsellor or supervisor if they become aware of a youth at risk). Staff members who have been trained in intervention and who can act as that key go-to person should be clearly highlighted.
- There is value in training people throughout the organization as gatekeepers. Youth may disclose to individuals regardless of their role. All people can and should be able to serve the role of bridge to more appropriate resources as the situation warrants.
Knowing what your role is in risk management doesn’t make conversations about suicide any easier. To help you anticipate these conversations, you should establish appropriate ways to deal with a youth’s initial disclosure about suicidal thoughts or behaviours.
- There are helpful and harmful ways to respond to a youth’s disclosure about suicidal thoughts or behaviours. This is important to highlight in your protocol. For more information on how to talk to youth about suicide, download this tip sheet.
- Determine how to deal with situations where a youth asks a staff/community member to keep their disclosure about suicidal thoughts or behaviours a secret. You should never swear to secrecy in conversations with youth about suicide.
- If you see a clear and imminent risk for a youth to engage in suicidal behaviour, it’s your responsibility to get the appropriate help to keep the youth safe (see recommendations in step 4 for responding to the risk for suicidal behaviour). You should discuss with the youth who that might be and how it will be done. Whenever possible, you should obtain the youth’s consent to disclose any information about them. However, if the youth is deemed at high-risk, information must be shared with appropriate parties regardless of consent.
How exactly should qualified personnel determine the level of suicide risk? It’s important that you determine what approaches and methods staff should use to conduct risk assessments.
- Determine exactly what the assessment should cover and how it should be carried out. What evidence-informed assessment tool(s) should be used in the assessment? What risk and protective factors should you look for? How should you document the assessment? Note: There are many instruments, checklists and scales for suicide risk assessments. Since there currently isn’t one globally-accepted measure that provides a perfectly accurate assessment of suicidality in youth, it’s important to assess their quality. Nothing is a substitute for clear, direct questions asked in a sensitive and supportive way.
- Determine in what cases it may be appropriate and/or necessary to contact additional sources of information (such as parents, roommates, friends or the youth’s mental health practitioner) to supplement the assessment within the realm of confidentiality.
A risk-assessment has been completed – what happens now? Deciding what to do at this stage can be particularly stressful and difficult because crucial decisions need to be made quickly. Setting clear guidelines and recommendations will help you make well-informed decisions.
- For any youth you suspect has a clear and active intent, plan and/or means available (or has already made an attempt), call a mental health crisis team, 911, or bring the youth to the emergency department yourself. Notify your supervisor as needed, and most importantly, don’t leave the youth alone - keep them under close supervision.
- There may be instances where further assessment for potential hospitalization is necessary (e.g., at an emergency room), but the youth refuses to go to the hospital. To be prepared for this difficult situation, develop a separate process for initiating involuntary hospitalization. This might include having to contact the police through 911.
- Think about the practical details of your procedures. Who accompanies the young person to the hospital? Who should establish and maintain communication with the hospital? How will the timing of the incident affect your response (e.g. weekend, evening, just before a vacation)? Who should be alerted (e.g., parents, caregivers, school, therapist already involved) and when should they be alerted (e.g., as part of the assessment, before or after decision to bring to the hospital)?
- There may be unclear intent as you assess the situation. Most youth have some level of ambivalence in these situations. The error should be on the side of extra evaluation in such circumstances.
- If you identify a youth with enough risk to warrant further assessment, the youth should be linked with appropriately trained staff (e.g. psychologist, school counsellor) to do further assessment, decide whether additional steps towards hospitalization are warranted (e.g.., youth being brought to an emergency room) and complete a safety plan together with the youth to come up with concrete strategies to address any future potential suicidal crises. For example, what are some adaptive thoughts and behaviours that can help the youth feel better when they are distressed? Who are the key people, organizations or institutions to contact if they felt suicidal again? Write this information down in the form of an action plan. This is an opportunity for the youth to, with help, problem-solve and learn to be pragmatic in ensuring their own safety. This can help them gain a sense of self-efficacy. A referral to mental health supports should also be made (see recommendations for facilitating the youth’s entry into support services in step 8).
- Make sure the youth knows what’s going on. Explain every step that you’re taking and why you are taking it. For example, don’t surprise the youth by taking them to a room with a group of people waiting. Explain every step that will occur and what they can expect at each step to avoid creating more chaos and confusion.
You’ll need to contact parents/caregivers as soon as you identify a youth as being at risk for suicide, regardless of whether hospitalization is required or not. Develop a process that allows for effective communication to take place.
- The person responsible for notifying the parents/caregivers about the situation should be the staff member who knows most about the youth’s situation or one that has a special relationship with the youth or family.
- Document all communications you have with the parents/caregivers. You can also develop a parent/caregiver contact or acknowledgment form for them to sign to confirm they have been notified of the suicidal thoughts or behaviours their child is experiencing.
- Acknowledge the parents’/caregivers’ emotions (e.g. anger, fear), let them know their presence is appreciated and emphasize that their involvement is paramount. Strong child-parent relationships are critical in helping youth cope with stress. In most cases, parents, caregivers and close family members are experts on their children, and their involvement in the risk-management process can be incredibly valuable.
- Be cautious about having parents solely make the decision about whether or not their child should be brought to an emergency room. They can add context and information, but stigma can often prevent parents from seeking help for their child even in a situation of perceived suicide risk.
- Develop a decision-making process for cases where the youth expresses concern, fear or complete resistance in regard to the involvement of their parents/caregivers. Keep in mind that suicide ideation is, in some cases, intimately tied with negative family contexts (e.g. abuse, conflict). In such cases, it may not be appropriate to initiate contact with the youth’s parents/caregivers right away. Think about the questions you should ask the youth in these circumstances and use your judgment: talk it out with the youth and try to gauge whether involving the family is an appropriate and beneficial strategy. This would include discussing not just if, but how and when to involve them.
- It’s important to bear in mind that some youth won’t have parents or caregivers that you can notify, either right away or at all. For example, you may run into an older youth who is living on their own entirely because their parents live outside the country or passed away. While the notification step may not apply in these situations, it’s important to support the youth in other ways (see recommendations for facilitating the youth’s return to school or other settings in step 7).
It’s crucial to manage the information you’ve gathered about the youth in your assessment confidentially. By doing so, you can promote the youth’s recovery by protecting them from the spread of rumours among peers and facilitating a more positive return to normal routines. Your protocol should include guidelines for the collection, use and disclosure of personal information.
- A child or youth can block information sharing if they can both understand and explain, in their own words, what information is being shared and to whom, as well as the realistic consequences of released vs. unreleased information.
- Whenever possible, you should obtain the youth’s consent to disclose any information about them. However, if the youth is deemed in imminent danger of harming themselves or others, information has to be shared to appropriate parties regardless of consent.
Following an intervention for suicidal behaviour, a youth might miss school, work or be absent from other settings. This could be because they’ve been hospitalized or simply because they needed to recuperate from the stress of the event. In either case, a youth’s absence from their usual settings warrants supportive re-entry arrangements. Think about how the youth’s first days back into their daily routine can be made easier and less nerve-racking.
- Coordinate a re-entry plan prior to the youth’s return to school in partnership with the youth, their parents/caregivers and relevant community partners (e.g. the youth’s case manager). Have the youth help identify who these people might be.
- Ask the youth about their particular concerns, anxiety around re-entry.
- In the re-entry plan, designate a person in the school to support the youth at the time of re-entry (for example, by discussing getting caught up on class work/academic expectations, coordinating modifications to their schedule in the first days back, etc.). This person should also set up a follow-up meeting with the youth once they have returned to school. The youth should help to identify this person. Ideally they can meet before re-entry.
- You should also find a safe school staff member that can act as the youth’s go-to person in the long-term, in the event that they need further support. This person should also be identified in consultation with the youth. They have to be comfortable with this person.
- School administrators should hold a staff debriefing session to address any circulating rumours or false information about the episode.
- School is not the only community setting that youth will be going back to – some youth don’t go to school at all. Think about ways to support youth in going back to community settings other than the school setting. What if the youth works a job on weekends? Plays on a sports team? Lives in a group home? These may not all require extensive re-entry plans, but this will be up to you and the youth to decide together.
- There may also be instances where the youth shouldn’t go back to these settings, either immediately or ever (e.g. high stress job, abusive family setting). Plan for an appropriate response in these cases.
- If you’re helping to support an older youth (e.g. that has graduated high school, lives alone), ensure your re-entry plan is age-sensitive and not overbearing.
You’ve mobilized an immediate response to a crisis – it’s now time for you to think about long-term support. What kind of professional support might help to minimize the risk of the youth experiencing future suicidal thoughts or behaviours? How can you enable an effective pathway to care for this youth?
- Have your options ready. Develop a list of support services that youth can readily access in their community. Make sure this list includes a variety of different options (e.g. specialized services for a particular population or problem, different levels of treatment, affordability options).
- Discuss these treatment options with the youth and their parents/caregivers, and provide them with support service options in their community. Stress the importance of getting the youth the appropriate help. The youth may already be receiving treatment. If so, do they have a strong therapeutic alliance keeping them motivated and engaged in treatment? If possible, call to make an appointment together with the youth and their parents/caregivers.
- Your community-based protocol should include safe referral processes (i.e. how are cross-agency referrals carried out, when needed?).
- You can also ask the youth to identify other people they think could be helpful and supportive based on past experience (e.g. family members, friends, elders, etc.). These people could be mobilized as part of their circle of care for this current situation.
- Don’t just give the youth a name or a telephone number. Try to serve as an active bridge to service (e.g. help with the initial call, check out resource in advance, use existing networks to facilitate a referral).
- If a child (under the age of 16) is in imminent danger, and parents/caregivers refuse to seek support or treatment services for their child, then you have a duty to report this to child protection services.
It’s not unlikely that you or another community partner may need to re-visit information about the case at a later time. What information about the youth was written down? What should be recorded? How can you keep readily-accessible records of the episode?
- Staff should be reminded to keep records of all steps of the response to suicidal behaviour, including the assessment, management and referral plans.
- Develop a format or template that staff can use to record information in. You can also include reminders of the protocol steps in this template. This is a way to prompt people to actually follow the protocol and keep it up to date.
Make sure you evaluate, review and update your protocol. Think about ways to track how well your procedures are working once they’ve actually been put into action. For example, you could have a feedback component built into the protocols themselves where people could write down thoughts, issues they ran into, things that worked for them and things that didn’t. This could also be used as an opportunity for the various caregivers involved in using the protocol to debrief, and if needed, get support. For guidance on how to evaluate, refer to the evaluation section of the toolkit.
Your protocol should evolve with new knowledge from your experience in using it as well as from the emerging research literature. A planned review (e.g., annual, every two years) can ensure that material is kept fresh and can also serve as a teaching/training opportunity.
- 1. Strategies were adapted from the following resources with input from Dr. Ian Manion and Dr. Simon Davidson:
- The Jed Foundation. (2006). Framework for developing institutional protocols for the acutely distressed or suicidal college student. New York, NY: The Jed Foundation.
- Substance Abuse and Mental Health Services Administration (2012). Policies and Protocols Addressing the Needs of Youths Who Have Attempted or Are Considering Suicide. Retrieved at: http://www.sprc.org/sites/sprc.org/files/library/LLWG_Policies%20and%20Protocols_2012.pdf
- Queensland Government, Department of Communities. (2008). Principles for developing organisational policies and protocols for responding to clients at risk of suicide and self-harm. Retrieved at: http://www.togethertolive.ca/sites/default/files/principles-for-developing-protocols.pdf
- School Mental Health Assist. (2014). Youth Suicide Prevention at School: A Resource for School Mental Health Leadership Teams. Retrieved at: https://drive.google.com/a/uottawa.ca/file/d/0Bx9WOcdOlVzNQkp4WUdLeGs0SDg/view
- White, J. (2013). Preventing Youth Suicide: A Guide for Practitioners. British Columbia Ministry of Children and Family Development. Retrieved from: http://www2.gov.bc.ca/assets/gov/health/managing-your-health/mental-heal...
- Doan, J., LeBlanc., A., Roggenbaum, S., & Lazear, K.J. (2012). Youth Suicide Prevention School-Based Guide. Issue brief 3a: Risk factors: Risk and protective factors, and warning signs. Tampa, FL: University of South Florida, College of Behavioural and Community Sciences, Louis de la Parte Florida Mental Health Institute, Department of Child and Family Studies (FMHI Series Publication #218-3a-Rev 2012).
- Children’s hospital of Eastern Ontario (CHEO). (2012). What you need to know about Helping Children and Youth who are feeling suicidal - Information for Parents and Caregivers. Retrieved from: http://www.cheo.on.ca .
- 2. White, J. (2013). Preventing Youth Suicide: A Guide for Practitioners. British Columbia Ministry of Children and Family Development. Retrieved from: http://www2.gov.bc.ca/assets/gov/health/managing-your-health/mental-health-substance-use/child-teen-mental-health/preventing_youth_suicide_practitioners_guide.pdf