Also see Suicide Contagion and Clusters—Part 1: What School Psychologists Should Know

By Richard Lieberman, Scott Poland & Marina Niznik

In Part 1 of this series (Lieberman, Poland, & Niznik, 2019), we discussed the phenomena of contagion and identified adolescents as the most susceptible age group for imitating suicidal behavior. Beyond specifically suicidal behavior, we may be underestimating the full impact of being exposed to a death by suicide—a contention supported by Cerel and colleagues (2018), who found that of approximately 135 people exposed to a death by suicide, as many as 30% found it to be a life-changing event. Ultimately, the primary goal of postvention is to identify those now at risk and prevent the next suicide. Part 2 of this series focuses on limiting contagion and highlights the many potential roles of the school psychologist in suicide postvention. Frequently asked questions (FAQ) are addressed in a special section at the end of the article.

Postvention is defined as an intervention after a suicide. The term was coined by Schneidman (1973), whose basic view was, “the largest public health problem is neither the prevention of suicide nor the management of suicide attempts, but the alleviation of the effects of stress in the survivors whose lives are forever altered.” Research has shown that postvention efforts in the schools are often too short in duration and focus on too few children. While many districts have policies established for intervening with suicidal students, few spell out a process for postvention or how they will intervene in the aftermath of a student death by suicide. School psychologists play a critical role in guiding district policies and procedures, identifying and alleviating the distress of suicidal bereaved individuals, reducing the risk of imitative suicidal behavior, and promoting the healthy recovery of the impacted community (see FAQ 1).

We have assisted many school districts in the aftermath of point clusters (multiple student deaths by suicide, in geographical proximity, over a short period of time), and in each case the local school psychologist spearheaded the comprehensive district response. Working in collaboration with administrators and other school mental health personnel (such as counselors, social workers, and nurses), school psychologists provided guidance, resources, and ultimately, leadership. They helped their communities see this was not a school problem but a serious community crisis that required commitment and determination to respond (see FAQ 2). The remainder of this article provides suggestions regarding some of the key roles and actions that may be taken by school psychologists in these situations.

Immediate Actions

Respond immediately when a student suicide occurs. Confirm the facts and gather information. Verify that the death was by suicide, preferably by talking directly to the student's parents, law enforcement, or coroner. Work closely with the school administration and community resources to recognize the possibility of contagion and to identify students most at risk. Students at risk may include: students who were close to the student who died, students who have previously considered or attempted suicide, students who have been exposed to the suicide and have other risk factors, students who have major life events occurring, and students exposed via social media.

Mobilize a crisis response team (assist the principal in establishing this team before the crisis occurs!). Collaborate with team members to determine the impact of the crisis and advise the principal on how to proceed. Notify key district and community partners to increase screening and support of affected students.

Reach out to the family. Offer to accompany your principal to the home. Express sympathy and offer support. Identify the victim's siblings and friends who may need assistance. Discuss the school's postvention response. Identify details about the death that could be shared with outsiders. Discuss funeral arrangements and whether the family wants school personnel or students to attend. Communicate directly to parents and students, balancing the family's wishes for privacy and needs of the students (see FAQ 3). Utilize the After a Suicide: Toolkit for Schools (2nd ed.) for templates of statements for parents and students and share with your principal.

Next Steps

Triage staff first and notify them in person, if possible. Allow grieving staff to be relieved from the classroom. Conduct a faculty planning session to review the referral process and staff role in postvention. Remind staff that how they respond has great impact on potential traumatization, particularly in young children.

Share resources for students who need additional support. Share crisis hotline information via the school's social media page and send out information about safe messaging via the commonly used social media sites directly to adolescents. Post relevant support information, such as text line or crisis hotline numbers in visible locations for students and staff.

Conduct educational/psychological sessions (see FAQ 4). Avoid large assemblies or large groups (See Toolkit, p. 30) where students cannot ask questions or be easily monitored for their reactions (see FAQ 5). Provide support to students in small groups or in classrooms. Share facts, dispel rumors, allow students to share and then normalize a wide range of reactions, and look for students who may be showing signs that they are significantly impacted.

Identify and screen students for suicidal ideation/behavior. Conduct primary screening and triage students utilizing three factors: those physically proximal to the event, those emotionally proximal, and those with preexisting vulnerabilities. Train or refamiliarize faculty members, parents, and students on how to recognize warning signs and identify support services. Have mental health providers screen for suicidal ideation/behavior. Conduct secondary screening with students who may present an elevated risk for suicidal behavior or have been affected by the suicide to determine if interventions are necessary. Some exposed students will have sufficient ability to cope with loss.

Notify parents/guardians of those assessed with suicidal risk and recommend community-based mental health services as needed. Coordinate with community providers with appropriate signed releases to do so.

Assess high-risk students for suicidal ideation or behavior. “All school mental health professionals have the ethical and practical responsibility to conduct suicide risk assessment” (Singer, Erbacher, & Rosen, 2018, p. 8). Suicide risk assessment is an essential role of the school psychologist in suicide intervention and requires specialized training (Lieberman et al., 2014).

Risk assessment includes: identifying suicidal ideation, intent, and plan; assessing for risk and protective factors; assessing for access to lethal means and experience with self-injury to address habituation to pain; and creating a risk formulation. Many districts that we have consulted with have utilized the Columbia Suicide Severity Rating Scale for assessment.

Provide individual and group counseling to affected peers. Provide or refer students for individual counseling. This can include school-based counseling, safety planning, or referral to community agencies or mental health practitioners for treatment. Safety planning should include triggers, warning signs, thoughts, moods, coping strategies, agreement to remove access to means, and steps to take for help in a crisis. Parents should be involved in safety planning (Singer et al., 2018). Provide for students reentering from hospitalization (see FAQ 6).

Ensure Safe Messaging

Be aware of policies and procedures on social media sites. Appoint a Social Media Manager to assist the Public Information Manager. Utilize students as “cultural brokers” to help faculty and staff understand their use of social media. Train students in a gatekeeper role, and specifically identify what suicide risk looks like when communicated via social media. Have staff monitor social networks and provide safe messaging when important (this will require that districts not completely block these networks). Have parents get involved in their child's use of social media.

Support opportunities for memorialization. Assist your school district in developing memorialization policies (see FAQ 7 and consult the memorialization pages of the Toolkit for a host of suggestions). Encourage funeral participation with support from the family. Contribute to a suicide prevention effort in the community. Develop living memorials or primary prevention programs that will help students cope. Monitor all off campus memorial sites (see FAQ 8).

Ensure responsible media reporting and safe messaging (see FAQ 9). Educate everyone about safe messaging by adopting phrase “died by suicide” to replace “committed suicide.” Work with news reporters to inform, limit details, and share the resources listed at the end of this article. Educate students on safe messaging on social media. Encourage parents, staff, community members, and the students themselves to monitor communication that is concerning and to take action to get help for adolescents in need (via a trusted adult, crisis hotlines, crisis text lines, etc.).

Plan for the Long Term

Follow up with all referred students in the days, weeks, and months that follow, particularly with siblings and relatives of the victim. Be mindful of planning for anniversaries, birthdays, and graduation.

Debrief and evaluate the response. Collect data throughout the postvention on students referred, parent notifications, and student hospitalizations. Evaluate these data and update procedures.

Remember that postvention leads back to prevention. Implement evidence-based mental health promotion programs beginning in elementary school so that communication and seeking support for mental health is something that is accepted, encouraged, and supported. Train staff annually on how to respond to students seeking assistance. Have clear procedures in place with identified staff roles for getting students help. Update mental health and suicide prevention resources. Train peers, using gatekeeper programs such as Signs of Suicide (SOS) or Question/Persuade/Refer on how to respond when a peer needs assistance. Involve parents in all aspects of suicide prevention including policy development and gatekeeper training. Implement evidence-based suicide prevention curriculum such as SOS, Sources of Strength, or Riding the Waves (see FAQ 10).

Engage your community. Implement a comprehensive suicide prevention program that includes the entire community, including school officials, law enforcement officers, emergency room directors, funeral directors, clergy, public health administrators, representatives from mental health agencies, technology experts, and adolescents.

Communicate with other schools in the district or geographic area (including feeder schools) and groups with whom the student was involved (e.g., clubs, sports teams, jobs, and religious organizations) that can help support survivors and identify potential contagion. Ensure that school personnel, parents, and community members are monitoring social media and other forms of preferred communication among adolescents and empowering students to reach out for help and get help for their friends and classmates.

Resources

Utilize the newly released and updated, After a Suicide: Toolkit for Schools, Second Edition (2018), which is available at www.afsp.org and www.sprc.org. This resource was created in collaboration with suicide experts, school personnel, clinicians, and crisis responders, and provides guidance and tools to assist with postvention efforts in the schools that aim to provide support to students and staff and prevent additional trauma and deaths. The importance of community collaboration and partnership, well established prior to a crisis, is emphasized to enable good working relationships when necessary.

Be familiar with recommendations from the Centers for Disease Control (CDC) and the World Health Organization. The CDC (1988) recommends the preselection of a suicide task force, made up of trained and experienced gatekeepers from various helping professions, to assemble when an adolescent suicide has occurred and to oversee the implementation of the community-based postvention plan. Tasks include organizing local gatekeepers who may not all be familiar with the cluster phenomenon or the postvention plan; helping professionals to review the anticipated reactions from peer survivors so that they can swiftly, uniformly, and effectively respond; creating a statement within 24 hours of the suicide to be shared with gatekeepers, schools, churches, teen organizations, and news sources in order to control what is reported and to advertise public forums and emergent resources; and frequently reconvening while the cluster remains active to discuss any new developments and to review the postvention plans. More information from the CDC may be found at http://1.usa.gov/15wb5c0. Information from the WHO may be found at http://bit.ly/ZWSXoD and in Preventing Suicide: A Resource for Media Professionals (Update 2017).

Be familiar with safe messaging guidelines and share them with media professionals.

• A useful handout from Reporting on Suicide called Recommendations for Reporting on Suicide can be accessed at http://reportingonsuicide.org/wp-content/themes/ros2015/assets/images/Recommendations-eng.pdf
• Media guidelines for safe messaging are available at the Suicide Awareness Voices of Education (SAVE) website (www.save.org). SAVE also provides recommendations for blogging on suicide (https://docs.wixstatic.com/ugd/a0415f_0528cf9c81b64da2af583cbc595aabac.pdf).
• Guidelines for news and entertainment professionals for mental health promotion and suicide prevention can be found at Tools for Entertainment and Media (http://www.eiconline.org/teamup/wp-content/files/teamup-mental-health-social-media-guidelines.pdf).

Be familiar with state and local model programs and toolkits.

• Montana Crisis Action School Toolkit on Suicide (Montana CAST-S 2017; http://nebula.wsimg.com/20a4fe3556ac637a1c0f2612dc7cee4e?AccessKeyId=13EB78F20E6C59CB1790&disposition=0&alloworigin=1)
• Heard Alliance: Toolkit for Health Promotion and Suicide Prevention (2017; http://www.heardalliance.org/wp-content/uploads/HEARDToolkit2017.pdf)
• National Action Alliance for Suicide Prevention: Research Prioritization Task Force. (2014). A prioritized research agenda for suicide prevention: An action plan to save lives. Rockville, MD: National Institute of Mental Health and the Research Prioritization Task Force.
• The California Model Youth Suicide Prevention Policy (https://www.cde.ca.gov/ls/cg/mh/suicideprevres.asp)

Be familiar with grants to help recover from traumatic events. If your district has experienced a cluster, consider applying for Project SERV (School Emergency Response to Violence) short-term grants from the U.S. Department of Education. This program funds short-term and long-term education-related services for local educational agencies and institutions of higher education to help them recover from a violent or traumatic event in which the learning environment has been disrupted (https://www2.ed.gov/programs/dvppserv/applicant.html).

Ten Faqs From the Field Answered

1. What is the one essential resource I need if a student in my school dies by suicide? If you do one thing after reading this series, we hope it is to download After a Suicide: Toolkit for Schools, Second Edition from the Suicide Prevention Resource Center and American Foundation for Suicide Prevention. It is easily accessed, completely electronic, and, at a time when you will find it hardest to think, it will provide you with best practice suggestions on how to proceed. Arrange to review the Toolkit with your principal in “prevention/preparedness” mode, particularly the section on “Crisis Response.” You could also share the “Helping Students Cope” section to highlight mental health services you provide.
2. What have you learned from consulting with school districts that have experienced point clusters? Each district:
   • Realized they were in it for the long haul (minimum of 2 years).
   • Created an intradistrict suicide prevention task force to inform their school boards in establishing best practice policies and procedures.
   • Collaborated with and assisted in developing county-level task forces to consolidate suicide prevention resources and data tracking in the community.
   • Provided specialized training to mental health personnel in suicide risk assessment, parent notification, collaborating with law enforcement and community mental health agencies, and safety and reentry planning for students returning from hospitalization.
   • Created district-level suicide prevention/wellness coordinator positions to implement primary prevention programs such as Signs of Suicide: Depression Screening Program; Sources of Strength; and Riding the Waves.
   • Coped with contagion due to unsafe messaging in television and other news media.
3. What if the parents do to not want the cause of the death of their child to be acknowledged as a suicide? We have faced this situation many times and sometimes we have been successful in explaining to parents that no one will be theorizing about the reasons that their child died by suicide. In fact, the reasons for their suicide have died with them, but if we can simply acknowledge that the death was a suicide, this gives us an opportunity to talk truthfully with all staff and students about their important role in preventing further suicides. If the parents do not give permission to disclose the cause of the death, then the school crisis team is encouraged to read in the Toolkit the sample templates for student and parent communications that address this situation. It will be up to the crisis team and administration to determine whether or not to adapt the template letter, which essentially states that the parents have asked that the cause of their child's death not be disclosed but still emphasizes that suicide is a leading cause of death for students and that everyone needs to know what to look for and what to do if someone is suicidal. It is worthwhile to mention there are two other templates for letters, one for when the parent is cooperative with the team in acknowledging the suicide and another for when you do not know if the victim's death was accidental or intentional.
4. What are the most common questions that students ask in the aftermath of a suicide?
   • Students always want to know why the suicide occurred, and it is important for the school psychologist to emphasize, “The answers have died with him/her and we will never know why, which is why it is so hard to grieve.”
   • Students often asked directly about the method that was used to die by suicide. We have found it best to simply acknowledge the method if it is factually known but not to dwell on any graphic details. Always focus the conversation back to helping students.
   • Students also often ask why God did not stop him or her. We do not claim to be religious experts; however, numerous members of the clergy have stated, “Unfortunately, God could not stop him or her but God has embraced them in whatever afterlife you believe in. But God is sad that they did not stay on this earth and do God's work over their natural lifetime.” We like this approach because it emphasizes that the victim has been embraced but was not chosen at a young age to die.
5. Why don't you support an assembly after a suicide? We very much believe that suicide prevention must be discussed with students and a death by suicide acknowledged, but in a classroom or an even smaller group setting. An assembly is dramatic and glamorizes the suicide, students will be reluctant to ask questions, and school staff will not be able to ascertain how individual students are coping with the tragedy.
6. What do you do when the parent just drops the student off at school the day after their hospitalization? Can you tell the first period teacher? This question comes up frequently and is known in “prevention phase” as reentry planning. In a perfect world, the parent would accompany the student back and meet with the psychologist to share the records from the hospital and develop a safety plan that includes trusted adults at school. Additional components of reentry planning include:
   • Monitor the student to ensure that no bullying takes place as a result of hospitalization.
   • Collaborate with members of the team and determine which staff members, including teachers, need to be apprised of the situation to ensure the student's safety.
   • Do not deny entry to any student standing at the front door of the school. They are much better served at school then alone at home.
   • Check in frequently the first few weeks, particularly if monitoring medications.
7. What is the key recommendation in the Toolkit about memorials? The Toolkit strongly recommends that school districts establish one policy that treats all deaths the same regardless of the cause of death. The school psychologist could advocate for such a policy while in prevention phase before a death by suicide occurs.
8. What if students arrive at school the day after the suicide with T-shirts with a picture of the deceased and they want to wear them at school? This is the scenario that we have encountered quite often and the Toolkit stresses the importance of being compassionate and understanding that students are expressing the loss of their friends through wearing the T-shirt. We believe it is best to allow the T-shirt for that first school day and then meet with students, remind them of the school's dress regulations, and guide them toward more appropriate prevention and memorialization activities referenced in the Toolkit.
9. What are some examples of the safest messages that I can communicate to my students, staff, and parents?
   • Suicide and the grief that follows a death by suicide are complex and no one person, no one thing, is ever to blame. Additional safe messages include:
   • While some suicides cannot be prevented, most can.
   • Everyone plays a role in suicide prevention.
   • There are evidence-based treatments for all the risk factors of youth suicide.
   • Kids are resilient and they can get better.
10. What are some available applications to help me with suicide assessment and safety planning? One application to assist with suicide assessment is SUICIDE SAFE from SAMHSA (https://store.samhsa.gov/apps/suicidesafe). Three applications to assist with safety planning are: Virtual Hope Box (https://play.google.com/store/apps/details?id=com.t2.vhb&hl=en_US); A Friend Asks from the Jason Foundation (http://jasonfoundation.com/get-involved/student/a-friend-asks-app); and My3, developed with funding from the California Mental Health Services Act (http://my3app.org).

References

Centers for Disease Control. (1988). CDC recommendations for a community plan for the prevention and containment of suicide clusters. MMVR, 37(s-6), 1–12.

Cerel, J., Brown, M. M., Maple, M., Singleton, M., Van de Venne, J., Moore, M., & Flaherty, C. (2018). How many people are exposed to suicide? Not six. Suicide and Life-Threatening Behavior. doi:10.1111/sib/sltb.12450

Lieberman, R., Poland, S., & Kornfeld, C. (2014). Best practices in suicide intervention. In P. L. Harrison & A. Thomas (Eds.), Best practices in school psychology: Systems-level services (pp. 273–288). Bethesda, MD: National Association of School Psychologists.

Lieberman, R., Poland, S., & Niznik, M. (2019). Suicide contagion and clusters—Part 1: What school psychologists should know. Communiqué, 47(5), 1, 21–23.

Singer J., Erbacher T., & Rosen P. (2018). School-based suicide prevention: A framework for evidence-based practice. School Mental Health. Retrieved from http://work.bepress.com/terri_erbacher/1

Richard Lieberman, NCSP, is a lecturer in the Graduate School of Education at Loyola Marymount University in Los Angeles, California. Scott Poland, EdD, NCSP, is a professor and the codirector of the Suicide and Violence Prevention Office at Nova Southeastern University. Marina Niznik, PhD, earned her doctorate in school psychology from The University of Texas at Austin and consults with school districts in Northern California.