preventing suicide contagion in high schools...– step 1: the cultural understanding of suicide can...
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PreventingSuicide"Contagion"inHighSchoolsAnnaS.Mueller,PhDMA
© Anna S. Mueller. 2018. This presentation is made available under the CC-BY-NC-ND 4.0 licensehttps://creativecommons.org/licenses/by-nc-nd/4.0/
Department of Comparative Human Development
NationalSuicidePreventionLifeline:1-800-273-TALKanytimeIfyouorsomeoneyoucareaboutareinacrisis,callthelifeline
DepartmentofComparativeHumanDevelopment
Collaborators
MelissaOsborne,MA SanjaMiklin,MA
SethAbrutyn,PhD
DepartmentofComparativeHumanDevelopment
Overview
1. Overviewofsuicideinadolescence2. Definitions:– Suicideclusters– Suicidecontagion• Problematizetheword“contagion”
3. Whatdoweknowaboutcontagion?4. Whatissuesshouldschools,communities,
parents,andmentalhealthworkersconsiderwhenmanagingasuicidedeathinschool?
DepartmentofComparativeHumanDevelopment
BriefCommentonData/SourcesQuantitativeCausalModelingof
SuicideContagion
• Data:NationalLongitudinalStudyofAdolescenttoAdultHealth– 1994-2008– Nationallyrepresentativedata– N=15,170
• Publications:2014."AreSuicidalBehaviorsContagious?UsingLongitudinalDatatoExamineSuicideSuggestion."AmericanSociologicalReview79(2):211-27.
• 2014."CanSocialTiesBeHarmful?ExaminingtheSpreadofSuicideinEarlyAdulthood."SociologicalPerspectives.doi:10.1177/0731121414556544.
• 2015."SuicidalDisclosuresamongFriends:UsingSocialNetworkDatatoUnderstandSuicideSuggestion."JournalofHealthandSocialBehavior56(1):131-48.
• +Largerliteratureonexposuretosuicide/suicidality
QualitativeStudyofaCommunitywithaSuicideProblem
• Data:Ethnographyof“PoplarGrove”–N=124,2+yearsoffieldwork,youth,youngadults,parents,schoolpersonnel,mentalhealthworkersetc.– Allnamesarepseudonymsandidentifying
detailshavebeenchangedtoprotectprivacy
• Publications:2016."AdolescentsunderPressure:ANewDurkheimianFrameworkforUnderstandingAdolescentSuicideinaCohesiveCommunity."AmericanSociologicalReview81(5):877-99.doi:10.1177/0003122416663464.
• 2017."DoestheMediaMattertoSuicide?:ExaminingtheSocialDynamicsSurroundingMediaReportingonSuicideinaSuicide-ProneCommunity."SocSciMed180:152-59.doi:http://dx.doi.org/10.1016/j.socscimed.2017.03.019.
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AdolescentSuicide
• Recentdramaticincreasesinratesforyouth– Particularlyamong10-14yearolds(maleandfemales)and15-24yearoldfemales
• Whilesuicidedeathsarestillrare,suicidalityismuchmorecommon– 17%highschoolstudentshaveseriouslyconsideredattempting(22.4%offemales);13.6%madeaplan;8%attempted(10.6%offemales)• Source:CDCYRBS
DepartmentofComparativeHumanDevelopment
SuicideinSchools• 17%ofteenshavehadafriendattemptsuicide• 3%ofteenshadafrienddie
• Source:NationalLongitudinalStudyofAdolescenttoAdultHealth(1990s)
• 35%ofschoolpsychologistsreportthatastudentintheirschoolhaddiedbysuicide
• Source:AmericanAssociationforSuicidalitysurveyofschoolpsychologists(Berman2009)
• Dataisweak…
• Youthandyoungadultsare2-4timesmorelikelytodiebysuicidewithinapointsuicidecluster
• Source:Gouldetal.1990
DepartmentofComparativeHumanDevelopment
Whatisasuicidecluster?
• Massclusters– whenamediastorycausesaspikeinsuicideratesinanationor
state• Pointclustersorspace-timeclusters
– CDC:“Agroupofsuicidesorsuicideattempts,orboth,thatoccurclosertogetherintimeandspacethanwouldnormallybeexpectedinagivencommunity”(Niedzwiedzetal.2014)• “Twoormore”minimumdefinition• Sometimestimeislonger(12monthsvs.1)butrelationshipsbetweenthe
peoplelosttosuicideareknown(e.g.,classmates/friends)
• Echo-suicideclustersorsuicide“hotspots”– Placeswheresuicideproblems/clustersre-emergerepeatedly– Laterdecedentswereexposedtoearlierdecedents(sometimes
muchearlier)
DepartmentofComparativeHumanDevelopment
Whatissuicide“contagion”?
• Suicide“contagion”– Afterexposuretothesuicidedeathorattemptofafriendorfamilymember,individualsareathigherriskofsuicideideationandattempts
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Whatissuicide“contagion”?OddsofReporjngSuicidality
0 0.7 1.4 2.1 2.8
2.23
2.77
NoExposureExposuretoSuicideAkemptorDeathofaFriend(Baseline)
SUICIDEIDEATION
SUICIDEATTEMPT
Source:(AbrutynandMueller2014)
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CritiqueofSuicideContagion
• Weselectfriendswhoaresimilartous– “homophily”or“assortativerelating”
• Ourfamiliesraiseustobesimilartothem– Andareoftengeneticallysimilartous(thoughnot
always!)
• Whatifpre-existingriskfactorsforsuicideexplaintheobserved“contagion”ofsuicide?– Requireslongitudinaldataandcausalmodeling
strategies
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Withcausalmodel:ExposurestillmatterstosuicideriskOddsofReporjngSuicidalityanerExposure
0 0.7 1.4 2.1 2.8
1.57
1.88
2.23
2.77
ExposuretoSuicideAkemptorDeathofaFriend(Baseline)Exposure(SaturatedModel)
SuicideAttempts
SuicideIdeation
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**ROBUSTFINDING**
• Usingeverycausalmodelingstrategypossible,researchersrepeatedlyfindthatexposuretosuicideincreasesriskofsuicideideationorattempts– Socialinfluence,notsocialselectionintofriendships
• Caveat:Notnecessarilydeaths– veryhardtoevaluatebecausedeathsaresorare– Causalmodelsrequirelongitudinaldata;cannotuseretrospectivedata
DepartmentofComparativeHumanDevelopment
Whatdoesthismean?
• Weshouldbeconcernedaboutyouthafterasuicidelossoreventhesuicideattemptofafriend
• However,youthcannotpassively“catch”suicidelikeacold
• Talkingaboutsuicidedoesnotincreaserisk– Experimentalevidenceshowsthis
• MattNock’steamatHarvard,MadelynGould’steamatColumbia…etc
– Exposuretothemereideaofsuicideisnotrisky
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SOWHATISSUICIDE“CONTAGION”?
IFITSNOTJUSTEXPOSURETOTHEIDEA,WHATISIT?
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Thestorieswetellmatter…
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ResearchonMassClusters
• WertherEffect–DavidPhillips– Whenastoryaboutsuicideisinthemedia,weseeaspikeinlocalsuicideratesabout1/3ofthetime(Stack2005)
– Certaindetailsamplifyriskofaspike• Sensationalisticcoverage• Informationaboutsuicidemethodormotive• Frontpagecoverage
– Seewww.reportingonsuicide.org
– Riskseemsmostamplifiedamongpeoplewhoaresimilartothedecedent
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ResearchonMassClusters
• PapagenoEffect– Positivecoverageofcopingwithsuicidalityoradversecircumstancescanlowersuiciderates!
– ThomasNiederkrotenthaleretal.(2010)
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Storieswetellaboutsuicideshapeourresponses
• Welearnfromoursocialworldshowtocopewithadversity– Ifthemessagesareprosocialorhelpful(gethelp!Don’tbeashamed!),that’sgreat!
– Ifthemessagesdeliberatelyorinadvertentlypromotesuicide,thatcanbeharmful
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ParticularlySalientAfteraSuicideLoss
• Suicidebereavementorlossisaparticularlydisruptiveexperiencetoourunderstandingoftheworld
• RobertNeimeyer,clinicalpsychologist– (Currieretal.2015)
• http://www.robertneimeyerphd.com/
• Requiresnearcompulsorymeaningmaking– Incorporatetheexperienceintoourunderstandingofreality
– Intooursenseofself– Bigpartofthisismakingsenseof“why”
• Orcomingtopeacewithhowhardaquestionthatis
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Foreshadowing…
• ResearchQuestion:– Whatissuicide“contagion”?Howdoesithappen?
• Answer:Suicideisculturally“contagious”– Hypothesis:Exposurerenderssuicideamoresalientandaccessibleoptionforyouththroughstorytellingaboutsuicide
• WhatIwillshow:– Step1:Theculturalunderstandingofsuicidecanshiftundercertaincircumstances–whencertainstoriesgettold• Particularlywithregardtowhat“causes”suicideandwhensuicideisa“justified”action
– Step2:Linktheculturalunderstandingofsuicidetovulnerabilitytosuicide
DepartmentofComparativeHumanDevelopment
Whatdowebelieveaboutsuicide?
• BeforedelvingintothespecialcaseofPoplarGrove,needtoconsiderthegeneralbeliefsaboutsuicideintheU.S.– Specifically,thecausesofsuicide
• ComparebeliefsinPoplarGrovetomoregeneralbeliefsaboutsuicideintheU.S.
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GeneralizedBeliefsaboutSuicideintheU.S.
• “Atleast90percentofallpeoplewhodiedbysuicideweresufferingfromamentalillnessatthetime,mostoftendepression”à Mentalillnesscausessuicideà RootedinmedicalizedunderstandingofsuicidethatdominatestheU.S.(Marsh2005)
• 89%ofreferencegrouprespondents,presentedmentalillnessasthedominantframeforwhypeoplediebysuicide
• N=17outof19
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GeneralizedSuicideBeliefs
Susan,lostherbrothertosuicide(notfromPoplarGrove):
“IcompletelyunderstandthatJeremiahwassick,andnottojustify[hissuicide],butIgetthecomplexityofdepression….FromwhatIgather,inthewaythatthebrainworks,asfarasonceyougettoapointofdecidingthatyou’regoingtotakeyourownlife…So,Iget…whyhedidwhathedid.”
• Manyinourreferencegroupsituatedmentalillnessassomethingbiologicalor“inthebrain”
• Also“mentalillness”wasclearlyseenasaprimarycause
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MentalIllnessasCauseofSuicideInsightsfromPoplarGrove
• 88%Youth&YoungAdultsRespondentsreferencedamentalillnessframe– Mentalhealthorpsychologicalpaincausessuicide
• Leah,ateenwholostaclosefriend(Stella)tosuicide:– Ittakesacertaintypeofpersontogettothatpoint[suicide],andacertaintypeofdepressionthattheirexperiencing…It’sthechemicalsintheirmind,andittakesacertaintypeofpersontobepushedtotheedge,acertainkindofimpulsiveperson,orsomeotherqualitythatmakesthemmoreadepttoactingonarashterm…It’sthediseaseIthink.[emphasisadded.]
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MentalIllnesswithaTwist• Thus,forLeah,mentalillnessisrootedbothinbiology(“chemicalsin[the]mind”)andinsocialexperiences(“thepressure…aroundhere”).
• ShealsoattributedStella’sdeathtoboth:– Stella“[wouldwear]herselfraggedtryingtopleaseeverybodyandtryingtodothethingsthatshethoughtshehadtodo.”
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UnderstandingSuicideinPoplarGrove
• MentalIllnessFrame– Recall:88%ofyouthreported
• PressureFrame– 81%youthandyoungadultsreported–Manyadultsalsoheldthisbelief
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PressurebecameLocallyGeneralized
• Youthwithlessdirectexperiencewithsuicideadoptedthepressureframe
• Lily,anadolescentinPoplarGrovewholostaclassmate,illustratesthispatternafterbeingaskedwhyyouthdiebysuicideinafocusgroup:
– [F]romthebeginningofmiddleschool,westartthinkingaboutacareerpath,andIthinkthat'sreallyhard...especiallyforme,personally…Ifeellikealotofkidsfeelliketheydon'tknowwherethey'regoing…Andthen,theyrealizethatthereissomuchpressurearoundthemthatmaybethey'llnevergetoutofthepressure,orthetown,andthey'llnevergetarealjob,orareallifeoutsideoftheirteenagenightmare.
DepartmentofComparativeHumanDevelopment
TheLimitsoftheMentalIllnessFrameforPoplarGrove
• ManysuicidedecedentsinPoplarGrovedidnotappear“mentallyill”orevenemotionallydistressed
• Manywereverypopular,“perfect”youth– Culturalincongruencebetweenexpectationsaboutvulnerabilitytosuicideand
whowasactuallydyingbysuicide• ThecaseofMichelle,whodiedbysuicide:
– Shannon(Michelle’sclassmate):• Fromtheoutside[Michelle]wasthispicture-perfectgirl–thesportsstar,andsupersmart,
anddefinitelygoingplaces,anddatingthisreallyawesomeguy.And[hersuicide]justseemedalittlebit—[it]wasconfusing;there'snotreallyanotherwordtouseforit.
• ThecaseofKennedy,whodiedbysuicide:– Harrison(amentalhealthworker):
• Ayounglady,Kennedy,who[diedbysuicide]andabsolutelydevastatedeverybodyaroundherbecauseshewasabright,articulate,intelligent,youknow,ifyoulookatjustsortofontheoutside,you’dsay,‘waitaminute,what’sgoingonthere?’
DepartmentofComparativeHumanDevelopment
TheLimitsoftheMentalIllnessFrameforPoplarGrove
• Therewassocialpressuretoavoidmentalillnesstoexplainsuicide– “Goodkids”werenotmentallyillanddidnotneedmentalhealthhelp
– Parents’suppressedinformationaboutmentalillnessintheirkids• (Mueller&Abrutyn2016;Mueller2017)
– Youthwhofitstereotypesaboutsuicide(e.g.,aperceiveddrugabuser)receivedmuchlessattention• Mourningrituals,gossip,media
• Activeworktocraftanarrativethatpreservedtheyoungsuicidedecedentsreputation– AsLilysaid“Noonetrashtalksthedeadkid.”
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TheLimitsoftheMentalIllnessFrameforPoplarGrove
• Butthisscenariowasalsoterrifyingforyouth
– Amelia(teen):[LosingMichelle,myclassmate,tosuicideis]differentfromanythingelseI'veeverexperienced…Allyou'rethinkingaboutislike...Why?...Becausenoonejustdoesthat[referringtosuicide].Theyalwayshaveareasonfordoingit….Itmakesyoulookatthepeoplearoundyoucloser.Itmakesyouscared...scaredtoloseanyoneelse.Youfeellikeeverythingisjustfallingoff,andyou'retryingtocatcheverything.
• Ameliawasnotaloneinherfeelings
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TheConsequencesforSuicideRiskforPoplarGrove
• ResearchQuestion:Howdoessuicide“contagion”occur?
• Hypothesis:Exposurerenderssuicideamoresalientandaccessibleoptionforyouth
– ThePoplarGroveculturalunderstandingofsuicideinvokesabroadlysharedexperience(pressure),thatmakesmanyyouthinthecommunitymiserable(Mueller&Abrutyn2016)
• Finaltask:Linktheculturalunderstandingofsuicidetovulnerabilitytosuicide
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TheConsequencesforSuicideRiskforPoplarGrove
• Becca,whoseclassmatediedbysuicideandfriendattempted,(whenasked‘whysuicide?’):
“I’vewantedtogetawayfromhavingalltheseproblems.Seeingalltheseotherpeoplegothroughalltheseproblems,theiranswerissuicidesowhycan’tmyanswerbesuicide.”
• Madison,whosefrienddiedbysuicide(whenasked‘whysuicide?’):
“[Mark]hadsomanyissuesofhisown,andnowhedoesn'thavethemanymore.Like,howgreatwouldthatbe?…So,it'sjustkindoflike,Whatagreatidea.Like,youdon'thavetolikedealwithanyofyourproblemsanymore.Like,youcouldjustbe.”
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TheConsequencesforSuicideRiskforPoplarGrove
• Youthcouldturnthisperceivedmotiveforthesuicidesofothersintosomethingapplicabletothemselves;amotivetheycouldidentifywith
• Particularlytrueamongyouthwhoaresufferingunderthelocalpressureandwhowishedtheycoulddoabetterjoblivinguptoexpectations– Youthwhohadinternalizedlocalculturalexpectationsaboutwhatan
idealkidshouldbeintotheirsensesofself
• Notthesameasencouragingthecompletionofsuicide– Researchdoesshowthatpro-suicideattitudesareariskfactorforsuicide
deathandattempts
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Withinthiscontext,motivesforsuicideareexpanded
Pressure
MentalIllness
Failure
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Summary:
• Exposuretosuicidemayshapeyouth’sunderstandingofwhatsuicideisandwhatmakessomeonevulnerabletoit– Suggeststhatthemeaningofsuicidecontributestoitsdiffusion
• Individualandcollectiveprocesses– Watchingthecommunityreactalsoatrophieshealthycopingstrategies
• Communityadults’silenceleaveskidsto“figureout”suicideontheirown
• Structuraldimensionsmatter– Socialconnectednessofthecommunityfacilitatesthecollectivemeaningmaking
processes– Highsocialstatusofsomeofthesuicidedecedentsshapestheunderstandingof
suicide
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InsightsforTheoriesofSuicide
ThwartedBelonging-
ness
PerceivedBurdensome-
ness
AcquiredCapacity
InterpersonalTheoryofSuicide
DepartmentofComparativeHumanDevelopment
InsightsforTheoriesofSuicide
ThwartedBelonging-
ness
PerceivedBurdensome-
nessAcquiredCapacity-Exposuretoviolence
-Accesstolethalmeans
InterpersonalTheoryofSuicide
DepartmentofComparativeHumanDevelopment
InsightsforTheoriesofSuicide
ThwartedBelonging-
ness
PerceivedBurdensome-
nessAcquiredCapacity
-NORMATIVECapacityExposuretonorms,
meanings,beliefsthatmakesuicideamoreimaginableoption
InterpersonalTheoryofSuicide
DepartmentofComparativeHumanDevelopment
InsightsforTheoriesofSuicide
ThwartedBelonging-
ness
PerceivedBurdensome-
ness
Acquired(Normative)Capacity
Social-contextualfactors
InterpersonalTheoryofSuicide
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SuicidehasSocialRoots
PerceivedBurdensome-
nessThwarted
Belonging-ness
AcquiredCapacity
InterpersonalTheoryofSuicide
Social-contextualfactors
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PRACTICALIMPLICATIONS
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PracticalImplicationsForSuicidePrevention(orPostvention)
• Ideally,communitiesshouldpromotenarrativesthatconstrainordiminishsuicidediffusion–Wehaveverylittleresearchonthistopic
• Basically,weneedtoknowmoreabouthowthemeaningofsuicidemattersandhowitcanbeleveragedforeffectiveinterventions–Mycontinuingresearchgoal
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AdditionalImplicationsforPre/Postvention
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AvoidPassiveLanguageforTalkingAboutSuicide
• Suicideisnot“contagious”likeavirus
• Suicidecannothappentoyouviaa“rippleeffect”
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“Contagion”asProblematicMetaphor
• “Contagion”impliespassivecatchingofsuicide
• Metaphorsmatter– Neuroscienceshowstheyshapeourunderstandingandemotions!
• Wedonotwantanyonethinkingpassivelyinthefaceofsuicide–Wewantaction
DepartmentofComparativeHumanDevelopment
“Contagion”asProblematicMetaphor
• InPoplarGrove:– Grace:Ithinkalotofthekidswerejustlike“Ohmygosh,that’sgonnabeus[meaningsomeonewhodiesbysuicide].We’reallgonnastressoutandloseit,evenifyourlifeisgreatyoucanstillsnaponeday.”
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“Contagion”asProblematicMetaphor
• Preferredlanguage:– Suicidediffusion– Exposuretosuicide
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ListentoYouth• What’smakinglifedifficultforyouthinyour
community?– Whatarethesocialrootsofpsychologicalpain?
• Pastsuccessendingadolescentsuicideproblemsthroughthismethod– Gettingkidsinvolved,listeningtothem,lettingthemdesigninterventions• (MichaelKraletal.2009)
• Evidencebasedprogramstohelpdothis– SourcesofStrength– YouthAwareofMentalHealth(Y-A-M-S.org)
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Schools:Formulateaplanforhandlingasuicidedeathbeforeithappens
• SuicidePreventionResourceCenter’sAfteraSuicide,AToolkitforSchools– http://www.sprc.org/resources-programs/after-suicide-toolkit-schools
– Freeresource
Screenshot2018-05-1809.34.16
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BePrepared https://www.13reasonswhytoolkit.org
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AcknowledgeSuicideProblemswhentheyoccur…
• Helpschoolsunderstandwhenaproblemisaproblem
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Schoolisaveryimportantdenominator
• Wecalculatesuicideratesbycountyorzipcodes
• Butforyouth,schoolsmatter
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Howmuchisaproblem?
HighSchool-MalesSchoolSize (Approximate)
ExpectedNumberofDeathsper10years
500 <1[0.71deaths]
1000 <2
2000 3
3000 4
EstimatesmadeusingCDC’s2015suiciderates:14.2forboysages15-195.1forgirlsages15-19
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Howmuchisaproblem?
HighSchool-Males HighSchool-FemalesSchoolSize (Approximate)
ExpectedNumberofDeathsper10years
500 <1[0.26]
1000 <1[0.51]
2000 1
3000 <2[1.53]
SchoolSize (Approximate)ExpectedNumberofDeathsper10years
500 <1[0.71deaths]
1000 <2
2000 3
3000 4
Note:1femalesuicideper10yearseveninasmallschooldoesnotconstitutea“problem”
Challengewithrareevents
DepartmentofComparativeHumanDevelopment
Howmuchisaproblem?
HighSchool-Males HighSchool-FemalesSchoolSize (Approximate)
ExpectedNumberofDeathsper10years
500 <1[0.26]
1000 <1[0.51]
2000 1
3000 <2[1.53]
SchoolSize (Approximate)ExpectedNumberofDeathsper10years
500 <1[0.71deaths]
1000 <2
2000 3
3000 4
PoplarGroveHighwhichhasaschoolpopulationofapproximately2,000haslost4adolescentgirlsinpast10years
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Alsoconsiderrecentgraduates
• PoplarGrovealsolost8recentgraduates(allmale)overthesame10yearperiod
– 1-5yearsaftergraduation
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Teachyouthsignsofsuicide&wheretogethelp
• Useexistingevidencebasedsuicidepreventiontrainingprograms– SafeTALK&ASIST– SignsofSuicide(SOS)– Question,Persuade,&Respond(QPR)– www.SPRC.orgforinfo
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EducateYourselvesaboutSuicide
• Intheeventofasuicidedeath,talkclearlyandnon-judgmentallyaboutsuicide– Giveaccurateinformation– Avoidblamingorscapegoating– Donotfocusonthemethodorprovidegraphicdetails– Addressanger– Addressfeelingsofresponsibility– Encouragehelp-seeking
Source:SuicidePreventionResourceCenter’sAfteraSuicide,AToolkitforSchools
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Askdirectquestionsaboutsuicide
• Ifyou’reworriedaboutsomeone,askthemdirectlywhethertheyareconsideringharmingthemselves– Youmaysavetheirlife– Butbecarefultobecoolandnotfreakout– Mostpeoplewithsuicidalthoughtsneverescalatetoanattempt• Mostsuicideattemptsdonotresultindeath• Buttheyaresignsofsuffering• TheyareNOT“criesforattention;”theymaybecriesforhelp
– SOHELP!
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Thankyou
www.AnnaSMueller.com
Manyofthestudiesonwhichthispresentationisbasedareavailableforfreeonmywebsite,alongwiththingsIhavewrittenforabroadaudience(e.g.,
blogs)
NationalSuicidePreventionLifeline:1-800-273-TALKanytimeIfyouorsomeoneyoucareaboutareinacrisis,callthelifeline
DepartmentofComparativeHumanDevelopment