. Global and local epidemiological research reveals that suicidal behaviour is a complex phenomenon influenced by different intertwining factors, such as mental disorders, substance abuse, as well as other biological, familial, and situational factors (WHO, 2014). The prevention of youth suicides requires collaborated efforts of different parties of the

community to

building connection with our youth to create a supportive safety net

for them.

Did you know…

According to the World Health Organisation (WHO) Mortality Database, there were an estimated 804 000 suicide deaths worldwide in 2012, with an annual global age-standardised suicide rate of 11.4 per 100 000 persons. For youth between 15 to 29 years of age, suicide ranked as the second leading cause of death globally (WHO, 2014).

In Hong Kong, the Centre for Suicide Research and Prevention’s (CSRP) data showed that the age-standardised suicide rate was 9.3 per 100 000 persons in September 2015 and that the suicide rate for youth aged 15 to 24 was 8.5 per 100 000 persons (CSRP, 2015).

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As frontline teachers and workers at school, we need to be equipped with knowledge and skills in handling students’ suicidal behaviours; and act promptly to answer to their needs. International research findings show that over 80% of completed suicides have been preceded by warning signs (The Crisis Intervention and Suicide Prevention Centre of British Columbia, 2013; Granello &

Granello, 2007). Such findings highlight the importance of

timely intervention and support

for students who express suicidal ideation.

This Resource Handbook, serving as a more focused update of the previous document “An eBook on Student Suicide for Schools: Early Detection, Intervention & Postvention (EDIP)”, aims to provide teachers and other school personnel with a more thorough understanding of suicide including its risk and protective factors, knowledge and skills in detecting warning signs of suicide, and most importantly,

practical tips

for responding to suicidal behaviours. Information, strategies and illustrations provided in this Resource Handbook are based on local and global research and literature, as well as educational psychologists' frontline experiences in providing support to schools.

The 3-Tier Support Model

Based on the 3-tier support model suggested by the WHO (2014), this Resource Handbook focuses on the handling of

tier two

and

tier three

students who are at risk of suicide and display suicidal behaviours. It also provides information on how to support post-suicidal students re-entering the school environment and how to lessen the risk of contagion.

Furthermore, a list of resources for

tier one

universal prevention can be found in Chapter 7 to facilitate school-wide suicide prevention work.

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Adapted from World Health Organisation (2014). Preventing suicide: A global imperative.

All students

Students identified as being at risk

Students identified as high risk with signs of suicide and/or suicidal behaviours Mental Health Promotion

The 3-Tier Support Model for Suicide Prevention

Gentle Reminder

We hope that with early identification, appropriate intervention, and dedication in fostering a feeling of connectedness in schools, student suicides could be prevented.

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Chapter 1: Understanding Suicide 1.1 Categories of Suicidal Behaviours

Suicidal Ideation Any self-reported thoughts or fantasies about engaging in suicide-related behaviours.

Suicidal Threat Any action, verbal or non-verbal, expressing a self-destructive desire, but does not result in a real self-harmful act.

Suicide Attempt A non-fatal outcome for which there is evidence (either explicit or implicit) that the person believed at some level that the act would cause death. Attempted suicides include acts by persons whose determination to die is thwarted because they are discovered and resuscitated effectively, or the chosen method is not lethal.

Suicide Death Someone takes his or her own life with conscious intent by lethal means, for example, jump from height, injury, poisoning.

Adapted from Coleman & O’Halloran (2004)

Self-harm and Suicide

We should understand the complex relationship between self-harm and suicide. Self-harm behaviour could be seen as a maladaptive way of coping and refers to the direct and deliberate injury of one’s own body. It may include cutting, harsh scratching, overdosing on medication, punching walls, salt and ice burns and many others. Often students engaging in deliberate self-harm want to relieve psychological pain, anger or tension, to punish themselves, to numb themselves or to stop feeling numb. Some might deliberately hurt themselves to communicate their emotional turmoil or escape from distress. Nevertheless, some students might have an intention to die behind their self-harm behaviours.

Therefore, we should try to understand the motives of students’ self-harm behaviours to ensure that appropriate responses could be made. Research has also found that students displaying self-harm behaviours to be at a higher risk of committing suicide.

More information on supporting students with self-harm behaviours can be found in the “A Guide to Help Deliberate Self-harm” developed by the Hong Kong Jockey Club Center for Suicide Research and Prevention (http://www.mindmap.hk/featuring/dshguide/)[Chinese Version

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The Different Layers of the Ecological Model

1.2 Ecological Model for Understanding Suicidal Behaviours

An ecological approach is helpful in illustrating how an individual is encircled by environmental factors which impact the individual in interaction with his or her own personal factors. Our students live in and are affected by an ecological system formed by individual factors (e.g. mental health, personal experiences, personality), interpersonal relationships (e.g. families, peers), community (e.g. discrimination, living environment), the larger society (e.g. media, stigma of help-seeking) and the health system. These personal, interpersonal, and sociocultural factors interact and permeate through the layers to offer protection against or to increase their risk for suicide. The WHO (2014) has identified both

protective factors

and

risk factors

on different levels of the ecological system, with the former boosting one’s resilience to setbacks in life while the latter adding to the risk of one’s likelihood to take his or her life.

International research findings reveal that suicidal behaviours are complex, involving multiple contributing factors and causal pathways. Usually no single stressor could be sufficient to explain a suicide. Instead, a number of risk factors often act cumulatively and interactively to increase an individual’s vulnerability to

suicidal behaviour. At the same time, one’s protective factors could counterbalance the risk factors and improve one’s resilience. Suicide therefore involves complex interaction between one’s risk factors and protective factors.

Health Systems

Society

Community

Relationships

Individual

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1.3 Protective Factors

Protective factors are characteristics believed to reduce the likelihood that an individual will engage in suicidal behaviour by promoting one’s resilience and connectedness (WHO, 2014). The WHO has highlighted three major categories of protective factors. They are presented in the following diagram:

Strong personal relationships supportive significant

others (e.g. best friends, parents, caregivers,

mentors, teachers)

satisfying social life (e.g. constructive use of leisure time & community

involvement)

family connectedness and cohesion (e.g. mutual

involvement, shared interests & emotional

support) Healthy religious , spiritual or cultural beliefs

socially cohesive and supportive community with a shared set of values

Positive coping strategies and well-being adaptive problem

solving skills

good social skills good conflict resolution skills

willingness to seek help when difficulties arise

positive self-esteem good sense of self-efficacy healthy lifestyle choices

e.g. regular exercises

effective management of stress

perceived connectedness to school

optimistic outlook & emotional stability developed self-identity

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1.4 Risk Factors

Risk factors refer to any aspect of an individual, either biological or environmental, that may increase possibility that an individual will engage in suicidal behaviour. Risk factors can also contribute indirectly to suicidal behaviours by influencing individual’s susceptibility to mental disorders (WHO, 2014). According to Granello (2010), more than 75 different child and adolescent suicide risk factors have been identified. In the following diagram, the most prevalent and well-researched risk factors are mentioned. In particular, risk factors under the Relationship and Individual categories are given in greater details as they can more effectively help school personnel identify at-risk students.

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Suicidal behaviour is regulated by the interplay of different risk factors. Among them, some inborn or early childhood factors (e.g.

genetic disposition, family history of suicide, early-life adversity) do not directly trigger suicidal behaviours, but may alter one’s responses to stress and other behavioural and emotional traits (e.g. increased impulsive aggression, increased anxiety) which could increase a person’s suicidal risk. When being faced with stressful events in life (e.g. loss of a family member, termination of a relationship, starting a new school year), one might feel depressed, anxious or hopeless;

suicidal thoughts or behaviours might also arise.

Among the risk factors, some research suggests that mental disorders have significant association with suicidal behaviours. Norquist and Magruder (2008) reported that more than 90% of completed suicide cases had one or more mental disorders. However, only 10-15% of young people with mental health problems received help from mental health services (WHO, 2010). In a local sample, only 18% of student suicide cases had been diagnosed with mental illnesses. There existed a reasonable basis to believe that some suicide cases with mental health problems in Hong Kong might have been unidentified (Committee on Prevention of Student Suicides, 2016). It is therefore of great importance for us to understand more about the warning signs of mental health difficulties so that we can identify students at risk and provide timely support for them (See

Appendix 1

for lists of warning signs of some major mental health difficulties experienced by young

people).

If your student exhibits signs of mental health difficulties for a period of time and the symptoms are affecting his/her daily functioning markedly, you should consult the school social worker (SSW) or educational psychologist (EP). Referral to mental health professionals for assessment and support may be needed.

Gentle Reminder

School personnel are encouraged to help identify students with risk factors for suicidal behaviours and strengthen students’ resilience by

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1.5 Myths & Facts about Suicide

There are numerous myths about suicidal behaviours.

Such myths should be dispelled. Understanding the facts about suicide will help us identify students who are at risk and provide the help and support needed.

Students who talk about suicide do not mean to do it and they just want to seek attention.

Talking about suicide can be a plea for help and it can be the final warning in the progression towards a suicide attempt. We must seriously take every precaution when our students talk about suicidal ideation, intent or plan.

People who have attempted suicide once seldom make a second attempt.

Past suicide attempts are a major risk factor for suicide death. Up to 50%

of individuals who die by suicide have made at least one previous attempt (Chehil & Kutcher, 2012). All suicide attempts must be treated as though the individual has the intent to die. Do not dismiss a suicide attempt as simply being an act to gain attention. This is why it is very important to provide continuous support for individuals with a history of suicide attempts.

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Most suicides happen suddenly without warning.

In Hong Kong, about 74% of children aged below 18 who committed suicide had expressed their suicidal thoughts implicitly or explicitly before actual attempts (Child Fatality Review Panel, 2015). Thus, it is important for us to know the warning signs of suicidal behaviours so that we can develop a higher level of sensitivity towards students at risk.

A marked and sudden improvement in mental state following a crisis indicates the suicide risk is over.

In the three months following an attempt, a student is still at highest risk of completing suicide. A sudden improvement could only mean an apparent lifting of the problems, that is, the person has made a decision to commit suicide and feels relieved because of this decision. It is of great importance to provide intensive support continuously and monitor the student closely following a crisis.

Suicide is always hereditary.

Suicide involves complex interaction between an individual’s risk factors and protective factors. Genetics may relate to one’s predisposition to psychiatric illness, which is a risk factor for suicidal behaviour. Family history of suicide is also a high risk factor for suicidal behaviour.

Members of family share the same emotional environment and the completed suicide of one family member may well give other family members a message that suicide is an option for solving problems.

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Children do not commit suicide since they do not understand the consequence of death and are cognitively incapable of engaging in a suicidal act.

Although rare, children do commit suicide; and hence, any suicidal gesture, at any age, should be taken seriously. They may have a distorted perception of their actual life situation and the solutions available for them to cope with the difficulties they are facing. They may perceive suicide as a means to make people feel sorry, to show how much they love someone, to escape from a stressful situation, etc.

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Chapter 2: Early Identification - Detecting the Warning Signs

Take any suicidal sign seriously.

It is indeed a cry for help.

The above finding highlights the importance for adults to be able to detect warning signs that students might exhibit, and to take actions promptly. School personnel, who have regular contact with students, are in a good position to notice unusual changes or distress in students. Knowing

what

and

where

to look for the warning signs would help us notice students’ unusual changes or distress.

2.1 Warning Signs

Where to look?

The following are some useful strategies or sources to look for students’ suicidal warning signs:

 Daily observation

 Messages in students’ weekly journal/composition

 Regular small talk with students

 Information from peers / social network

Did you know…

For individuals who had either implicitly or explicitly expressed their suicide plan before their completed suicide, about 16% died within 24 hours of their identifiable suicidal thoughts, 14% from 1 to 7 days, 10% from a week to a month, and 11.3% from 1 to 2 months (Chen et al., 2006).

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 Student medical/mental health history

 Meeting with parents or arranging home visit on need basis

 Student survey (e.g. surveys to detect bullying and social isolation can be accessed from http://www.edb.gov.hk/tc/teacher/student-guidance-discipline-services/gd-resources/co- creating-harmonious-school.html [Chinese Version Only]. Schools may also use other school-based questionnaires.)

What to look for?

Below are some possible suicidal warning signs which can help school personnel determine when a student might need further attention and support:

Expressions related to Death and Suicide



Talking about, writing about or making artwork about death or suicide

Direct or indirect statements indicating a wish to die or escape or a final departure, e.g. ‘I wish I were dead.’ ‘I am going to kill myself.’

‘I am going to end it all.’ ‘I am so tired of it all.’

‘Very soon you won’t have to worry about me.’

 Seeking out lethal means

Exploring various lethal means such as sleeping pills, hanging, charcoal burning, etc. from different sources, e.g. peers, the internet, etc.

 Getting affairs in order

Making plans and/or final arrangements e.g. giving away prized possessions

 Saying goodbye to family and friends as if they won’t be seen again

Displaying Physical Symptoms

 Tiredness and fatigue

 Increased physical complaints, e.g. headache, stomachaches, body aches

 Change in sleep or eating patterns, nightmares, eating disturbances

 Unusual neglect of personal hygiene/physical appearance

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Change in Mood and Marked Emotional Instability

 Anger at self, irritability, moodiness, aggressiveness

 Pervasive sadness, sudden tearfulness

 Excessive fears or worries

 Overwhelming guilt, shame, and worthlessness

 ‘Flatness’ or numbness in mood

 Loss of motivation or enjoyment in things that used to be enjoyable

Change in Behaviours

 Deteriorated school performance

- Unexpected drop in grades and academic performance - Apathy in class

- Failure to complete assignments or handing in poorer work than usual - Increased absence or truancy

 Withdrawal from relationships - Loss of interests in surroundings - Drop out of sports and clubs - Withdrawal from friends and family

- Increased isolation and desire to be left alone

 Increased impulsivity and aggression, - Frequent trouble-making in school

- Increased conflicts with friends and family

 Engagement in high risk/self-destructive behaviours - Starting to participate in high risk activities - Increased use of drugs or alcohol

- Repeated self-injurious behaviours

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Decline in Cognitive Functioning/Negative Thinking

 Decreased cognitive functioning - Confusion in daily life

- Difficulty concentrating or thinking clearly - Disorientation, frequent accidents

 Hopeless and helpless thoughts

- Beliefs that things will never get better or change, e.g. ‘There’s no way out.’

- Seeing no sense of purpose in life or reason for living

 Self-critical thoughts

- Seeing no sense of self-worth, e.g. ‘I should never have been born.’,

‘Who cares if I’m dead?’

- Beliefs that they are a burden to others, e.g. ‘You will be better off without me.’

2.2 Understanding Individual Differences

Sometimes, it can be difficult to distinguish what are ‘normal’ adolescent behaviours and mood swings from those that require additional concerns. Moreover, there are individual differences in presentation of signs or symptoms. Even

when facing the same stressful events, some students may act out and ‘externalize’ their problems, while others may appear withdrawn and ‘internalize’ their difficulties.

Getting to know your students and their usual ways of

behaviour is the best way in helping you to decide if something is wrong with your students.

The following chapter will explain in details how to respond to students displaying suicidal warning signs.

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Gentle Reminder

 The more warning signs you notice, the more concerned you should be. But always act on the side of caution.

 Seek support and advice from appropriate school staff and/or mental health professionals if you are not sure of what action to take for any student suspected to be at risk of suicide.

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Chapter 3: Responding to Suicidal Behaviours

Offering your hand to someone in despair can save lives.

Although suicide can be an impulsive act in some cases, it often takes time for suicidal ideation to develop into actual plans and attempts. Students may first find themselves unable to cope with their problems. If they do not get help, they may eventually be in despair and see suicide as their only way out. Showing your care at an early stage is hence crucial in suicide prevention.

Sometimes your students may express directly that they are in great distress, other times it is you who observe worrying changes in them (see Chapter two for warning signs). Either way it is important to respond to your students’ needs. Talking through emotional issues with students can seem difficult and overwhelming, and you may feel uncomfortable or incompetent to do so. This chapter provides

practical tips

that help school personnel attend to students’ needs, provide immediate support and solicit appropriate follow-up support for them.

Did you know…

Young people prefer seeking help, when needed, from their friends, family and trusted adults such as school staff, more than to a health or mental health professional (Rickwood, Deane, Wilson & Ciarrochi, 2005).

Most young people report feeling relieved when they have a chance to talk about their problems, and are grateful that someone show concerns for them by asking if they are OK.

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• Initiate conversation and build trust

• Be non-judgemental

• Help student to reduce stress

• Guide student to think of ways to look after oneself

• Create a list of coping strategies

• Safety Plan

 Gather more information

 Suicidal Risk Assessment:

 Suicidal ideation

 Suicidal intent

 Suicidal plan

 Past suicidal behaviours

• Explore student’s social and family support

• Understand the motives of student’s suicidal behaviours motives

• 了解學生的自殺動機

• Support from colleagues

• Professional support

• Referral

• As appropriate

• Ensure safety

• Seek emergency service

• Notify parents immediately

• Activate Crisis Management Procedure

3.1 Overall Strategies in Responding to Students with Suicidal Warning Signs

Walsh, Hooven and Kronick (2013) reported that a critical step in reducing youth suicide is to move beyond having a single responder in a school. When responding to students with suicidal warning signs, school should not rely solely on the SSWs or the guidance teachers.

As teachers have daily interactions with the students in the classroom, they can also serve as critical gatekeepers to detect students with warning signs and to provide support to them.

The diagram below lists the main aspects teachers might respond to students displaying suicidal warning signs. Teachers should

flexibly

decide the support measures student may need depending on his/her condition.

Response Measures

Support Express

Concerns

Initial Evaluation

Initial Intervention Crisis

Management Notify

Parents

At the same time:

＊ Conduct continuous and close monitoring

＊ Document the actions taken by school

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In response to students’ varying degrees of suicidal risks, teachers can take the following measures:

If you

notice marked or unusual changes

in your student…

You can first try to gather more information from different sources, such as other teachers who have regular contact with the student and his/her peers. You are also encouraged to

show concern

by talking to the student directly in a non-judgmental manner. This will enable you to

understand more about his/her situation

. If there are concerns after talking to the student and other teachers/peers, you should consult and/or refer the student to guidance personnel, SSW or EP for a more thorough assessment.

Please refer to sections: 3.2, 3.4

If the student

appears to have suicidal intent or thoughts

, or

appears to be in a state of despair

…

Besides the initial conversation to engage the student, more explicit questions should be asked directly to evaluate his/her suicidality. Professional assistance should be sought at the same time such that prompt support could be provided. Depending on the situation, you may also pair up with guidance personnel or SSW in conducting such

risk assessment

.

Please refer to sections: 3.2, 3.3, 3.4, 3.5

In cases where

imminent suicidal risk is suspected

(e.g. the student has verbally expressed concrete suicidal plan)

or the student is engaging in life-threatening behaviour

(e.g. the student is threatening to jump)…

The top priority is to ensure the student’s safety, which means it might be necessary to seek emergency support and contact parents immediately. The school’s

crisis management

procedure should be implemented.

Please refer to sections: 3.4, 3.6, 3.7

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3.2 General Principles When Talking with the Students

Before Talking with the Student

 Knowing your roles and limitations

Teachers/school personnel are not mental health professional.

Advice and support can always be sought from the school’s guidance personnel, SSW and EP. Teachers/school personnel should always be clear about their

roles and limitations

before talking to the students.

Talking with students is about Talking with students is NOT about

 Showing your concerns and letting them know they are not alone

 Trying to handle the issues alone without seeking support from other staff

 Helping them work through or resolve minor concerns

 Solving all the problems for them

 Linking them to professional help if issues are complex

 Trying to make diagnosis or ‘treating’

their mental health problems

Connecting with the Student

 Selecting the right time and place

Ensure that you find an appropriate

time

to talk, such that you and your student have enough time to talk through different issues. Avoid choosing a time when the student is emotionally charged by distress or anger. Allow time for student to settle from emotions that might arise from the discussion.

Gentle Reminder

No one needs to work with at-risk students alone. School personnel, SSW and EP should work as a team in supporting students at-risk.

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Choose a

place

where you can have private conversation with the student but additional support from other adults is available if necessary. To make the student feel more at ease, you can engage him/her in tasks such as art activities or games during the conversation.

 Active and reflective listening

Listen

patiently to what the student is saying. Reflecting back what you have heard can ensure that you have correctly understood what the student had said and make him/her feel accepted, e.g.

‘It sounds like you are having some very rough times and you don’t see any way to deal with this.’

 Being non-judgmental

Try not to express your own opinions, jump to conclusions, or argue with the student whether his/her views are right or wrong. Try to view the problems in his/her context will help you show

empathy

to the student, e.g.

‘I can see that you are very angry because you think people are treating you unfairly.’

 Acknowledging student’s feelings

Acknowledge

what the student is facing and convey that you are taking it seriously. It should precede and is more important than giving alternatives or directives, e.g.

‘I’m hearing that this feels hopeless to you and I’m thinking that there may be a way to deal with this that we haven’t thought yet.’

Initiating the Conversation

Building rapport and expressing your concerns

Let the student know that you have initiated the conversation because you

care

and worry about him/her. You can describe what you have noticed and invite the student to talk more about what is happening to him/her, e.g.

‘I notice you seem really unhappy lately…’

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‘Is something bothering you?’

‘It seems that things have been rough lately…’

‘It helps to talk things over with someone…’

‘I’ve noticed recently that you looked tired in class. I’m wondering if everything is OK?’

It is wise to

avoid

highlighting things that might sound critical or accusing to the student, e.g. ‘I found that your grades are dropping this term…’, or ‘You have missed schoolwork very frequently recently…’.

Using open-ended questions

Use open-ended questions to invite the student

talk more

about his/her situation. You can start with questions related to physical wellbeing or daily functioning, e.g.

‘How’s your sleep/appetite recently?’

‘How’s your headache/stomachache going recently?’

Understanding the motives of student’s suicidal behaviours

If the student expresses suicidal ideation, you can try to understand more about the student’s thoughts, especially the motives behind his/her suicidal behaviours.

Student may have different motives, such as to terminate or escape from pain, to stop burdening others, to atone, revenge or accuse, hoping to reunion with the deceased, or to have a new start in life etc. Understanding the motives behind student’s suicidal behaviours will provide crucial hints and direction for later intervention work.

Acknowledging the difficulty of talking about the issues

Let your student know that it is not easy to discuss one’s difficulties or negative feelings.

Some students may not be ready to talk at the time of the conversation. Unless you have noticed any immediate risks (see section below for initial evaluation of students’ suicidal risk), tell your student that it is OK if he/she does not want to talk at the

moment.

Reiterate

your care for the student, and let him/her know when, where or who he/she can approach to get support. It might take

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3.3 Initial Evaluation of Students’ Suicidal Risk

Do not hesitate to bring up the word “suicide”.

Direct questioning will not aggravate the risk of suicide but failure to respond may result in

losing the chance to prevent a suicide.

In most cases, suicide risk assessment is conducted by guidance personnel, SSW, EP or relevant mental health professionals. However, for more urgent situations when supporting staff is not available immediately and you suspect that the student may be at high risk for engaging in suicidal behaviour, you may have to evaluate the student’s suicidality on the spot such that immediate actions to ensure student’s safety can be taken (e.g., admission to hospital). The following consists of some key concepts to take note of when evaluating a student’s suicidality:

Did you know…

Ample literature and research (e.g. Chehil and Kutcher, 2012; Hall, 2002; Kalafat, 2003) show that asking individuals about suicidal thoughts, intent or plans does not plant or nurture these thoughts or wishes in one’s mind. Rather, the individual often feels relieved that he/she is given the opportunity to openly discuss these thoughts and feelings in a caring and non-judgmental environment (Hider, 1998; Meerwijk et al., 2010; Tatarelli et al., 2005).

Findings also show that acknowledging and talking about suicide may in fact reduce suicidal ideation (Dazzi et al., 2014). In contrast, if a student with suicidal risk feels that others may know his/her suicidality but avoid asking, his/her feelings of despair and helplessness may intensify (Capuzzi, 1994).

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Asking directly about suicide

While open-ended questions are generally encouraged to invite student talk more about his/her situation and problems, it is advisable to ask about suicide directly and clearly to find out whether the student is having suicidal thought, intent or plan.

Below are

four areas

that help to assess the immediate suicidal risk of the student.

When asking information related to the following areas, you should speak slowly, softly and calmly, while acknowledging the student’s pain.

Suicidal Ideation

The greater the magnitude and persistence of the suicidal thoughts, the higher is the risk for eventual suicide.

To determine the nature and potential lethality of the student’s suicidal thoughts, you should ask questions that elicit the

intensity, frequency, duration and persistence of the thoughts.

If your student initially denies thoughts of suicide, but you feel that he/she might be at high risk, you may ask additional questions to understand his/her feelings about the future and whether he/she has been anticipating future plans.

Students who are considering suicide may have conviction that things can never improve and express despair and a lack of hope.

Some sample questions are:

“Have you had thoughts about suicide?”

“How often do you think about killing yourself?”

“How long do these thoughts last when you have them?”

“When did you first have thoughts about suicide?”

“Do you ever feel that life is not worth living?”

Suicidal Intent

If your student has expressed suicidal ideation, ask direct and specific questions about suicidal intent and his/her expectation and commitment to die.

The greater and clearer the

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example, if a student expresses that he/she sees no reasons for living or believes nothing would change his/her mind, and the desire to die or leave the world is very strong, the risk for suicide is high.

“Have you felt that you or others would be better off if you were dead?”

“If you were alone right now, would you try to kill yourself? What about the near future?”

“How strongly do you want to end your life?”

Suicidal Plan

If your student expresses suicidal ideation and intent, you should ask direct and specific questions about a suicidal plan.

More detailed and specific plan is generally associated with a greater suicidal risk.

For example, if a student’s suicidal plan is well thought out;

knows when, where and how he/she will commit suicide;

has the means in hand; plans to act immediately; and has no one nearby or available if called upon, suicide risk is high in this case. You should consider the following regarding the suicidal plan:

 The chosen method (more lethal means relates to higher risk)

 The availability of means (easier access equals higher risk)

 The person’s belief about the lethality of the method (the person’s subjective belief of the method’s lethality reflects his/her intent to die even though the method may not be lethal objectively)

 The chance of rescue (the less likely that someone will intervene, the higher the risk)

 The steps he/she has taken to enact the plan (more concrete steps warrant higher risk)

 The person’s preparedness for death Some sample questions are:

“What have you thought about as a way to take your life?”

“What other ways have you considered?”

“Have you set a time or date or place for taking your own life?”

“Have you taken any steps to get the things you need to carry out your plan?”

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Past Suicidal Behaviours

A history of past suicide attempts is one of the most significant risk factors for suicide. You may ask questions to find out if the student has past suicide attempts before.

The higher lethality the means was, the more frequent or the more recent the attempts were, the higher the risk was for committing suicide.

“Have you tried to take your own life before?”

“When was this?”

“What sort of preparations did you make to carry out this plan?”

3.4 Issue of Confidentiality

When talking to a student with suicidal thoughts,

DO NOT

promise that you would keep this as a secret. The top priority is to keep the student safe, this means breaking confidentiality is needed to get someone else (e.g., parents, SSWs and EPs) involved so that support and help can be given to the student in a timely manner. If the student urges you to keep secret for him/her, explain that his/her privacy is important to you. While you will try your best to maintain their confidentiality, it is not always possible e.g., when students are at risk of hurting themselves or others, it will be necessary to share this information to relevant parties so that they can get the appropriate support immediately.

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3.5 Responding to Students with Suicidal Ideation or Intent

After the initial evaluation, if you find that your student displays suicidal ideation or intent, but does not have concrete suicidal plan, you/other staff and professionals may….

Share your concern

Communicate that you care and he/she is not alone, and that you are there to help. Refer to section 3.2 on General Principles When Talking with the Students.

Guide the student to think of ways to look after oneself

Help the student to reflect on coping strategies and sources of support. Guide him/her to think of strategies and support that have helped him/her to cope with difficulties and suicidal ideation successfully in the past.

Create a list of coping strategies and sources of supprot

Guide the student to develop a list of coping strategies and sources of support that can be of assistance when he/she is having thoughts of suicide (See Appendix 3 for a safety plan template). Offer useful information of external resources e.g., local helplines to the student.

Connect the student with professional support in school

The school guidance team, the school social worker and the educational psychologist are there to support you in helping students with suicidal ideation or intent.

Conduct continuous and close monitoring

You should continue to monitor and observe the student's behaviour and mood changes. Keep a record of your observation and share the information with the support team.

Notify parents

Parents need to be contacted if there is any level of suicide risk. Refer to Chapter 5 for more details.

Document the actions taken by the school

Keep accurate records of the steps and actions taken by the school.

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Case Illustration for Responding to a Student with Suicidal Ideation

Student: Calvin (S.2) Observations by

Calvin’s Class

Teacher (Ms. Kwan):

 Appears lethargic and depressed recently

 No longer participates in class discussions, often rests his head on the table during lessons

 Frequently experiences headaches in the past few weeks

 Academic performance has declined tremendously

 Hands in poorer work than usual Observations by

Other Subject Teachers:

 Becomes withdrawn from his friends and prefers to be left alone

 No longer enjoys P.E lessons

 Expresses a sense of despair in his recent compositions e.g., seeing no purpose in life.

The following is an example of how school personnel and professionals can work together in supporting Calvin at school

Class Teacher

 Gathers more information from other subject teachers

 Talks to Calvin and shows her concerns (assess suicidality in urgent situation)

 Asks Calvin if it is okay to connect him with the guidance teacher / SSW / EP

 Provides support and accommodations for Calvin in class (Tier 1 Support)

 Conducts continuous and close monitoring

Subject Teacher

 Provides more information about Calvin’s behaviours

 Provides support and accommodations for Calvin in class (Tier 1 Support)

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Guidance Teacher

 Serves as the case manager, maintains close communication with different parties and documents the actions taken

 Notifies parents regarding Calvin’s situation and maintains close communication with parents

 Coordinates meetings with teachers, SSW and EP when needed

 Consults EP when needed

School Social Worker

 Meets with Calvin to evaluate his suicidality (in this case, he is found to have suicidal ideation without a concrete plan) and provides initial support, i.e. guides Calvin to think about coping strategies and resources available around him¹

 Meets with Calvin regularly and provides group training (Tier 2 Support) and/or individual counselling (Tier 3 Support) on relaxation techniques, coping skills, etc.

 Arranges appropriate school-based support and activities e.g.

buddy programmes

 Provides information of relevant community resources to Calvin

Educational Psychologist

 Provides consultation to teachers, guidance teachers and SSW on ways to support Calvin

 Conducts further assessment and intervention when needed

 Collaborates with school personnel and SSW in follow-up support

Referral for child and adolescent psychiatric services can be made if the student’s problems persist or deteriorate.

1 Some useful phrases to brainstorm coping strategies with the student are:

• ‘What have you done to overcome your negative feelings before?’

• ‘What other ways have you tried to deal with the situation?’

• ‘Do you have anyone you can trust and turn to for support?’

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The above case illustrates the need to adopt a team approach in responding to students with suicidal behaviour. The class teacher, subject teacher, guidance teacher, SSW and EP each has a role in supporting Calvin. It is important to note that the division of work would differ from case to case. For example, if the SSW is more familiar with the parents, he/she may be more suitable to be the main contact person with parents. For urgent situation, class teacher might need to assess student’s suicidal risk on the spot instead of the SSW. Schools are encouraged to be flexible in deciding the division of work among different parties.

Some Supportive Strategies in the Classroom (Tier 1 Support):

 Be flexible to provide learning support and/or accommodations to reduce stress, e.g. adjust academic demand, reduce homework or extend deadlines, adjust the learning pace etc.

 Give more individual attention or encouragement to student when he/she shows lowered level of concentration or engagement in class.

 Assign caring and supportive peers to provide assistance and support; arrange opportunities for positive interactions with peers.

 Be sensitive to student’s emotional needs and things that might trigger his/her negative feelings. Plan ahead and discuss with student what he/she can do when feeling distressed in class (e.g. take a break in the classroom or seek support from guidance teacher/SSW).

-

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3.6 Responding to Students with Imminent Suicidal Risks / Immediate Life-threatening Behaviours

If you find that your student displays imminent suicidal risks, e.g. the student has verbally expressed concrete suicidal plan, or exhibits immediate life-threatening behaviours e.g., the student is threatening to jump, you should seek support from other school personnel and professional staff in the school premise immediately and…

Ensure the student is not left alone and is being accompanied by an adult at all times.

Remove all means of harm and ensure the student’s immediate safety.

Ensure the safety of other students and staff.

Accompany the student to the hospital for emergency service support when there is imminent suicidal risks.

Seek help from emergency service immediately by calling 999 if it is a life-threatening emergency.

Notify parents immediately regarding the situation.

Provide accurate information to medical staff at the

hospital.

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In situations where the school has called 999 for emergency support, school personnel can follow the 3C strategy to manage the crisis situation.

The 3Cs refer to

Control

,

Containment

and

Communication

.

Control

 Try to maintain control of the situation by minimising the number of witnesses and preventing individuals from entering the crisis spot unnecessarily. Some examples of management strategies are as follow:

Block entrance and access to staircase or hallways

Draw down the window blinds in the classrooms

Evacuate students / Ensure students stay in the classrooms as appropriate Rearrange recess and lunch

Rearrange or stop school activities when needed Plan end of school arrangement

Containment

 Two members of school staff (e.g., the teacher and the SSW whom the suicidal student is familiar with) should engage the student in a dialogue. There should also be designated staff members nearby to provide stand-by support.

 Do not provide mobile phone to the student in a crisis situation. This is to prevent the student from engaging in phone conversation with individuals who may trigger the escalation of his/her emotions.

 Listen to the student attentively and show that you are willing to solve the problem together.

 Be directive and say to the student,

“Don't do that”, “Stand there and talk with me”, “I'm listening”.

 Provide drinks, food and extra clothing to the student if needed.

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Communication

 It is very important to ensure there is close communication between different parties (e.g., the School Crisis Management Team, parents of the suicidal student, the principal, the school personnel and professionals managing the crisis situation) so that all individuals involved, including the police/fire service personnel

when they arrive, can obtain updated and accurate information about the crisis event.

Adapted from 香港警務處警察談判組及香港基督教服務處學校社會工作服務(2007). 校園危機談判

— 校方與香港警務處談判組的合作建議

3.7 Points to Note When Speaking to Students in Life-threatening Situations

The following might be helpful for school personnel at critical times when handling a student’s life-threatening suicidal behaviour, such as sitting on the balcony threatening to jump. Words that show genuine concern and offer to help are more likely to bring comfort to a suicidal student.

I'm listening. I care.

I'm not walking away. I won't abandon you.

You must be in a lot of pain going through this.

It must be hard to be feeling the way you do.

I care about you and want to get you the help you need.

Get back down. (Be directive)

Say...

I know exactly how you feel.

I have been depressed before.

I understand how you feel.

Stop whining and being so depressed.

You're luckier than most people!

Others in worse situations don't want to die.

You're ungrateful and selfish.

How would your parents feel?

You don't really mean to die.

I won't tell others. Tell me what you're thinking.

Don't say...

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3.8 Responding to Suicidal Threats on Social Media

You may come across messages on social network sites that suggest possible suicidal threats. The principles for responding to these messages are similar to sections above.

However, school personnel need to

note

the following:

 Start by reaching out and showing your concerns via the social media platform / by phone.

 Avoid using emoji, graphics or “likes” as responses because the receiver may misinterpret what you mean.

 Ask questions directly to evaluate suicidality. Find out the student’s current location and situation (e.g. access to lethal means for suicide and whether someone nearby can provide support for him/her).

 If the student is at imminent danger…

 Contact the emergency service immediately

 Notify the student’s parents as soon as possible

 Ask his/her friends or family members to accompany the student until emergency service arrives

 If no one is nearby, try to keep the communication going until emergency support arrives

 If the student is NOT at imminent danger…

 Guide him/her to think of strategies that have previously helped him/her cope with suicidal ideation e.g., talking to close friends, relaxation strategies

 Offer further information about useful external resources, including local suicide prevention helplines

 Tell the student you will connect him/her to the support needed (e.g., the SSW, the EP or other mental health professionals)

 Notify the student’s parents as soon as possible

Gentle Reminder

 Understand your limits when you try to help someone in crisis.

You can only offer support and hope, but you can’t always “fix”

problems faced by someone.

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Chapter 4: Making Referral

You can play a role in facilitating students at risk to seek help.

4.1 Barriers that Prevent Young People from Seeking Help

When you try to engage students in seeking further support, it is not uncommon to encounter some forms of hesitation or resistance. Below are some commonly reported

barriers

that may deter young people from seeking help:

 Concern about what others might think of them, (e.g.

laugh at them, think that they are weak or ‘crazy’)

 Worry that what they disclose will become known to others (e.g. parents, teachers, peers)

 Fail to recognise own distress or do not see it as serious enough to seek help

 Lack knowledge of services available

 Prefer to handle problems on their own

 Do not believe that anyone can help with their problems

 Have difficulties articulating their feelings

 Uncertain about what would happen when meeting helping professionals

 Have negative past experiences working with helping professionals

Did you know…

Studies from different countries have found that only about 18 to 34% of young people with high level of depression or anxiety symptoms seek professional help (Gulliver et al., 2010). You can play a role in promoting help-seeking behaviours in young people.

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4.2 Encouraging Students to Seek Help

Young people prefer to seek informal help before they turn to formal sources (Boldero & Fallon, 1995). Often, they will need encouragement and support from trusted adults in order to reach out and seek help. If students feel being understood and supported

when they approach you for support, they are much more likely to be willing to seek further help from other professionals. Your open and positive attitude towards receiving services from helping professionals will be essential in facilitating them to seek help.

Rickwood et al. (2005) described four key stages in the help-seeking process:

Consider the following

to facilitate your students’ help-seeking process:

Give recognition to the problems they are facing

Guide them to express feelings and difficulties in ways they feel comfortable Work together in accessing information about services available

Help to identify concerns they have about seeking help Clarify misconceptions about help seeking if feasible

Encourage them to raise their concerns when meeting with helping professionals Offer to accompany them when making initial contact

From a broader perspective, school-wide programmes that promote students’

mental health literacy

, including understanding and beliefs about mental health problems as well as proper attitudes towards help-seeking behaviours, will surely help to reduce the stigma effect and encourage students to look for support at an early stage. More

Willing to seek out and disclose

Knowing where they can get help Being able to express

their difficulties

Recognising they have a problem that need help

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4.3 Referring Out for Professional Support

A student displaying suicidal behaviours is likely to need more intensive and long-term support, including support from the family and school, and in many cases, support from helping professionals. As long as you have concerns about a student’s emotional and/or mental wellbeing, especially when suicidal risk is suspected, you should immediately

consult

the guidance personnel of your school.

Depending on the risk and needs of the student, the School Guidance Team can

make referral

and solicit support from specialised helping professionals (such as SSWs, EPs, psychiatrists, medical and/or police officers) to ensure that appropriate intervention measures will be taken.

A list of community support for suicide prevention, counseling services for youth and children, and services for mental health problems can be found in the below website (http://www.edb.gov.hk/en/student-parents/crisis-management/helpline-community-resourc es/index.html).

4.4 Record Keeping

It is a good practice for school to have records of student’s suicidal behaviours as well as action(s) taken by school. It can serve as an important source of information when making referral to medical and/or mental health professionals. An example of ‘Suicidal Risk Record Form’ is included in

Appendix 2

for school’s reference.

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Chapter 5: Communicating with Parents

Parents are a valuable resource in supporting the students at times of crises.

5.1 Communicating Concerns to Parents

If sufficient level of concerns is raised after talking with the student, his/her parents should be notified of what has happened. Preferably, a meeting should be arranged with parents to communicate school’s concerns and to come up with safety and support measures the student may need. It would be ideal to notify the student’ about meeting with his/her parents, so that he/she would feel respected and involved.

** News of their child’s suicidal behaviour is likely to be alarming and difficult for parents to comprehend or accept. Showing parents your

genuine empathy and concern

would help make the communication easier when you approach them.

Choosing the right time and contact preferences

The type and level of concerns also determine how urgent you should contact the parents. Check if there is a preferred time or way for the parents to be contacted, such that concerns can be communicated to the parents in a timely

Collecting necessary information

Try your best to gather information about the family (e.g. family background and dynamics, difficulties the family may be facing, school’s previous communication with the family etc.). It is also helpful to prepare information of local services (e.g.

counselling hotlines, community services) to be shared with parents when necessary.

Choosing the right person

Think about the best person to communicate the concerns with parents.

Usually, parents will be easier to relate to staff who have already built up certain level of trust with them. Sometimes it may be beneficial to involve guidance personnel and/or senior school staff in the discussion.

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5.2 Addressing the Needs of Parents

Parents differ individually in how they might react to hearing their child being suicidal. It is important to understand that parents might also need support in handling their child’s crisis. These phrases might be helpful when you find parents at shock or distressed at any point of the conversation:

Key messages to be communicated to parents

State your concerns clearly with concrete examples and express in a caring way to avoid sounding like criticising the student and/or the parents. Invite parents to talk about their perspectives, e.g.

‘I’m wondering whether you share similar concerns?’

‘Have you noticed similar changes/behaviours at home?’

‘Do you have any ideas about what might be happening?’

Allow some time for the parents to digest the information. After addressing their concerns, it is important to carry a positive, solution-focused message to parents so that they would feel hopeful and supported. Discuss with parents different ways of supporting the student, be it from family members or relatives, from school personnel, or from external professional agencies. Engage the student in devising any support plans as far as possible and let parents know that follow-ups/check-ins will be arranged.

 “How can I help?”

 “How are you coping?”

 “Who can you talk to? Would it help if I call them for you?”

 “What can I do better to help you?”

 “I understand how this has turned your world upside down. It is great you have been willing to get help. Nobody can do this alone.”

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Besides informing parents about their child’s suicidal behaviours or thoughts and enlisting their support for the child, the school is also encouraged to help parents:

 feel emotionally supported

 understand the seriousness of the situation

 dispel myths about suicide

 recognise their key role in helping their child

 recognise the importance of finding help

 understand the importance of removing access to means of suicide (e.g.

storing medicine safely, locking window grills)

 identify personal coping mechanism (e.g. ways to deal with stress) and support systems (e.g. support from friends, relatives and the community)

 understand their limits

 establish hope

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Chapter 6: Re-entry Support for Students

6.1 Formulating a Re-entry Plan

Careful planning should be made for any student who has survived a suicide attempt and is about to re-enter school after having been temporarily withdrawn from school or hospitalised. Efforts should be focused on making the student’s return to school

smooth and comfortable

and re-establishing the student’s

social support network

. Devising a comprehensive re-entry plan requires the collaboration from professionals, school personnel, the student and the parents.

Before Reintegration into School



Designate a liaison person for the following purposes:



to be the case manager;



to communicate with parents and other service providers;



to coordinate the implementation of the re-entry plan; and



to monitor progress.



Obtain parent consent for “release of information” so school and medical personnel could share information and communicate to better support the student.



Attend the discharge meeting to seek aftercare recommendations from the doctor if the student was hospitalised for the incident.



Jointly work out a re-entry plan with specialists (e.g. EP and medical professionals) and school personnel concerned and, if possible, involve the student.



Schedule a meeting with parents and the student to discuss and agree on re-entry arrangements at an appropriate time. Review the student’s safety plan or develop

Did you know…

Persons having attempted suicide are often at greater risk for another attempt in the months following. So it is important to closely monitor the student’s re-entry into school after his/her suicide attempt and to maintain close contact with his/her parents, caregivers and other supporting specialists. School personnel should be reminded to be accepting, sensitive and encouraging to these students.

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