1 HEALTH SYSTEMS DIVISIONCoordinating Community Youth Suicide Response to Prevent Contagion Youth Suicide Prevention Conference 2016 Ann D. Kirkwood, MA Suicide Intervention Coordinator

2 HEALTH SYSTEMS DIVISIONChild and Adolescent Behavioral Health

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4 HEALTH SYSTEMS DIVISIONChild and Adolescent Behavioral Health

5 What is Postvention? Multiple interventions that occur after a suicide to assist in recovery and mitigate trauma. Address the care of bereavement/loss survivors, attempt survivors, caregivers and behavioral and medical health providers. Aims to destigmatize the tragedy of suicide, promote survivor recovery and strengthen suicide prevention efforts. Addresses Behavioral health Psychosocial factors Spiritual values Public health services HEALTH SYSTEMS DIVISION Child and Family Behavioral Health

6 Immediate Action is NeededYouth have access to social media and can communicate instantaneously. Adults need to be in a position to lead information-sharing so it is accurate, safe and complete. Delays in adults releasing information can cause distrust by youth and families. HEALTH SYSTEMS DIVISION Child and Family Behavioral Health

7 Goals of Postvention Help restore equilibrium and functioning within the school, agency, community Promote healthy grieving and commemorate the deceased in a safe manner Comfort those who are distressed and minimize adverse reactions Identify those most likely to need support, where and when Reduce risk of contagion Encourage self-care HEALTH SYSTEMS DIVISION Child and Family Behavioral Health

8 Categories of PostventionActive, early postvention (crisis response) Resources to guide survivors with practical tasks (handling memorial services, giving notices to survivors and their parents, possible media interviews, etc.) Therapy-centered techniques (immediate and over time) Encourage early treatment Manage current grief Proactively address and anticipate future concerns Containment strategies (for now and long term) Help youth/young adults identify risk in their peers Provide psychoeducation to staff and families Disseminate information on where to go for help Offer grief-management techniques Follow youth identified at risk for at least a year and offer resources HEALTH SYSTEMS DIVISION Child and Family Behavioral Health

9 Why a coordinated response to youth suicide?Responding to a suicide appropriately can: Comfort people suffering from traumatic grief due to the loss of a family or community member (loss survivors) or for people who previously attempted suicide (attempt survivors) at a time of high risk for them Provide an opportunity to educate and raise awareness in the community of the risk factors and warning signs for suicide Reduce chances that another person or persons in the community will attempt or complete suicide in the near future (contagion) Young people are more susceptible to contagion than older people HEALTH SYSTEMS DIVISION Child and Family Behavioral Health

10 Community Postvention Preparation: Before a SuicideReach agreements between agencies for accurate and timely information-sharing Reach agreements between agencies for responsibilities in responding Determine how a communication and response Lead person will be determined And what his/her/their role will be Prepare templates for public statements and safe messaging (e.g. letters home, media statements, etc.) Develop materials that can be distributed by first responders to the families of the deceased regarding reactions, resources, etc. HEALTH SYSTEMS DIVISION Child and Family Behavioral Health

11 People exposed to suicide can be ranked on a continuum, involving:Those with any connection to the deceased, Those who react in a mild, moderate or severe and self-limiting or ongoing way, Those with an attachment bond with the deceased and gradually adapt over time, and Those for whom grieving becomes a protracted struggle that includes diminished functioning in important aspects of their lives National Action Alliance (2015 April) Responding to Grief, Trauma, and Distress After a Suicide: U.S. National Guidelines HEALTH SYSTEMS DIVISION Child and Family Behavioral Health

12 Post-suicide intervention (postvention) and the appropriate response to suicide will vary by the person’s geographical, psychological and social proximity to the person who died by suicide and whether people are especially vulnerable themselves. Clinical Advisory Services Aotearo Ltd. (2011) Screening Using Circles of Vulnerability

13 Who is a “loss survivor?”Family and friends School mates School mates’ families Educators Law enforcement Medical examiner Religious communities Emergency medical providers (ambulance and hospital) Coworkers Youth and staff at recreation centers Youth and staff at other schools (e.g. football rivals) Behavioral health clinicians Others in your community? _____________________________ HEALTH SYSTEMS DIVISION Child and Family Behavioral Health

14 The goal of effective postvention is to reach 100% of individuals immediately and over time, regardless of what circle of vulnerability they are in HEALTH SYSTEMS DIVISION Child and Family Behavioral Health

15 National Guidelines for PostventionFocusing only on the immediate aftermath can be insufficient for some people with longer-term reactions Need to include response over the long term as people respond and adapt to the “new normal” Postvention should include outreach to high-risk people over time, particularly around subsequent anniversaries of the death, birthdays or other notable occasions Assess for changing needs across time Ensure adequate and appropriate resources are available Need to reflect on lessons learned after a suicide HEALTH SYSTEMS DIVISION Child and Family Behavioral Health

16 Crisis Response Near-term: Adjust to “New Normal”Continuum for School & Community Suicide Attempt and Completion Response Crisis Response Activate School & Community Suicide Communication and Response Protocols Counselors Discuss With Students in Small Groups, Classroom by Classroom Make Counseling Services Available for a Month or Longer Manage Memorials/Funerals Appropriately Work with Media on Safe Reporting Bring in Peer and Family Support Specialists Near-term: Adjust to “New Normal” Safety for Vulnerable Youth and Families Continue Grief Counseling and Other Supports for At-Risk Individuals Create a Life-Affirming Culture Conduct Gatekeeper Training Continue to Monitor Welfare of Vulnerable Youth Consider Initiating Youth-Led Prevention Programs to Change the Culture, e.g.: Sources of Strength Lines for Life Youth MOVE Oregon Peer Support OFSN Family Support Long-term: Follow-up Postvention Activate Postvention Services Over Time to Accommodate Grieving Monitor at-risk youth and provide services as needed Pay Special Attention to: Anniversaries of Death Birthdays Holidays Graduation Resumption of classes in fall

17 Postvention Tasks Verify death and cause through the medical examinerCoordinate resources across agencies and systems Disseminate information rapidly Support those impacted by the death, one circle of vulnerability at a time Identify those at risk and prevent contagion; consider screening Tips for commemoration of the deceased: Do not require attendance Best if held off campus Allow memorials but encourage take-down within a week Treat all deaths (suicide or accidental) alike HEALTH SYSTEMS DIVISION Child and Family Behavioral Health

18 Safe messaging to youth, families, media, community Highlight help is available, treatment works Make help readily accessible as long as needed Avoid glamorizing the person who died or the suicidal act, e.g. “she is in a better place” Discourage a focus on the method of death Provide calm adult presence and structure (at school, work, home) that encourages healing HEALTH SYSTEMS DIVISION Child and Family Behavioral Health

19 Activities after a subsequent suicideForm, re-activate, re-invigorate community prevention task force/committee to elevate suicide prevention to the community level Include wide range of stakeholders: parents, youth/young adults, local and state leaders, clergy, child-serving agencies, schools behavioral health providers, physicians, etc. De-brief on the cross-systems response to the first and (any) subsequent suicide What went right? What could we do better? Identify safe prevention activities, including training, peer-led programs, awareness building, materials on how to identify at risk youth, etc. Identify needs and programs for building a more resilient community and school and culture of hope. HEALTH SYSTEMS DIVISION Child and Family Behavioral Health

20 Oregon Health Authority Plan SB 561SB 561 passed in 2015 addresses suicide response for individuals 24 years or younger As required, OHA has developed a plan for implementing SB 561 Community Mental Health Directors collaborated on developing the plan The plan suggests processes for developing local protocols for: Information-sharing & communication locally Local response processes to reduce contagion risks Informing OHA when a suspected suicide occurs of an individual 24 years or younger and planned postvention efforts OHA to offer technical assistance, as needed HEALTH SYSTEMS DIVISION Child and Family Behavioral Health

21 Advantages of SB 561 Harnesses strong community relationships and history of collaboration to reduce contagion risks Recognizes the expertise of local mental health programs in immediate, short- and long-term postvention efforts Assures youth, young adults and their families that they live in a wide community that will support them through the trauma of a suicide Provides schools with community supports and assistance to relieve them of the heavy responsibility for all suicide response HEALTH SYSTEMS DIVISION Child and Family Behavioral Health

22 Legislative Mandate for Coordinated Suicide ResponseThe OHA plan outlines the three responsibilities for Local Mental Health Authorities (LMHA): Communication Protocol – LMHAs and community partners identify local pathways and establish a protocol for information-sharing after a suicide of a person 24 years of age or younger Response Protocol – LMHAs and community partners develop a protocol for response to a suspected youth suicide for immediate, short- and long-term postvention OHA Notification – LMHAs in the area where the suicide occurred inform OHA of activities implemented or planned to support individuals affected by the suspected suicide within 7 days of the death HEALTH SYSTEMS DIVISION Child and Family Behavioral Health

23 Current Draft RulemakingCommunication Protocol Identify partners to the protocol and their roles and responsibilities for sharing information after a suicide of someone 24 or younger. State method for identifying a Lead person among the partners to serve as the hub for information-sharing after the suicide (may be same person or vary depending on circumstances of each suicide). Verify there’s an agreement among partners on what information will be shared and with whom. Not everyone needs the same information Anticipates medical examiners will share death information with the LMHA. De-brief after each suicide for lessons learned. Review and revise the protocol annually Submit the protocol to OHA initially and annual updates with lessons learned HEALTH SYSTEMS DIVISION Child and Family Behavioral Health

24 Activity Who are the partners in your community for information-sharing after a suicide of a youth or young adult? What do they need to know? May vary depending on their role. HEALTH SYSTEMS DIVISION Child and Family Behavioral Health

25 Current Draft RulemakingResponse Protocols Collaborate with medical examiner and other partners to create protocol for responding to suicides of individuals 24 or younger. Identify partners who are party to the protocol and their roles and responsibilities in response. Identify how a Lead person will be determined. Identify how partners will de-brief after each suicide on lessons learned and make revisions to the protocol as needed. Submit the protocol to OHA and provide annual updates based on lessons learned. HEALTH SYSTEMS DIVISION Child and Family Behavioral Health

26 Activity Who in your community needs to participate in suicide postvention activities? --What are their roles and responsibilities? --Who does what, when? Who in your community is situated to serve as a Lead person to keep response organized and coordinated? When will you meet as a group to de-brief on lessons learned? HEALTH SYSTEMS DIVISION Child and Family Behavioral Health

27 Current Draft Rulemaking: ReportingProvide name of contact person and back-up to OHA now. Notify of any staffing changes. Notify OHA of the death and crisis response within 7 days. Notify OHA of near- and long-term postvention within 45 days. The LMHA where the death occurred is responsible for reporting it to OHA. Advise if the deceased lived, worked, attended school and/or had significant family/social ties to another county. If another county is involved, both counties must report their respective postvention activities.

28 What’s in a Report? No protected health informationAvailable from medical examiner Name and contact information of person reporting. Date of death. Age of deceased. County/city where death occurred. School attended or facility where the deceased resided, if applicable. Available from LMHA/School or others Crisis response underway. Near-term postvention plans (have 45 days). Long-term postvention plans (have 45 days). e.g. anniversary, special dates, when school resumes, at graduation, in yearbook, etc. Any request for technical assistance If technical assistance is requested, OHA will seek additional information, as available at the time of the report. HEALTH SYSTEMS DIVISION Child and Family Behavioral Health

29 Why is Additional Information is Needed?Gender, gender identity and sexual orientation Name of agency with custody of the individual Location of death (public or private place) Evidence of bullying (cyber or in person) Manner in which social media were involved If within the previous year, the decedent’s family experienced another suicide If within the previous year, there were other traumatic deaths in the community Whether the decedent was receiving behavioral health services at time of death HEALTH SYSTEMS DIVISION Child and Family Behavioral Health

30 OHA Technical AssistanceReview and comment on protocols Provide information on best practices in postvention Serve as a conduit between impacted counties Offer training to LMHA staff and community partners on postvention best practices Prepare an annual report based on the LMHAs’ annual lessons learned reports and share it with all LMHAs, OHA and in the yearly Suicide Intervention/Prevention Plan report to the Legislature Activity What other technical assistance do communities need? HEALTH SYSTEMS DIVISION Child and Family Behavioral Health

31 Confidentiality Disclosure of information raises privacy concerns in the area of protected health information LMHAs and local partner organizations will consult their legal counsel Reporting requirements do not include protected information State vital statistics and public health laws appear to allow disclosure by LMHAs to OHA Public health laws include collection of vital statistics and public health surveillance, investigation and intervention OHA rules for implementing SB 561 ease concerns Postvention activities can occur appropriately without violating HIPAA Current threat assessment models allow providers to “listen” without disclosing protected health information Postvention activities can occur with respect for parental privacy rights In these cases, postvention can address a local tragedy in general Parties should explain the benefits of disclosure to other students and families

32 Sample Models… HEALTH SYSTEMS DIVISIONChild and Family Behavioral Health

33 Information-sharing Crisis Response PostventionSample Community Postvention Flowchart: Potential Communication & Response Pathways Suicide of Student Contact LMHA Notify OHA Activate Community Response Team Provide Longer-term Postvention Supports to School/Community Notify Students/Staff Contact Parent/Guardian Arrange for long-term grief services & prevention programs School Activates Crisis Response Protocol Medical Examiner Death Investigation Information-sharing Crisis Response Postvention Provide Crisis Response in School/Community HEALTH SYSTEMS DIVISION Child and Family Behavioral Health

34 Community Suicide Response: A Team-Based ApproachLocal Mental Health Authority Schools Medical Examiner Law Enforcement District Attorney Clergy Funeral Directors Youth and Parents Child-Serving Non Profits (providing mental health treatment/services and services to homeless & runaway youth, etc.) DHS, OYA, local Juvenile Justice Courts ________________ Other HEALTH SYSTEMS DIVISION Child and Family Behavioral Health

35 Sample: Community Suicide Postvention Response Team Responsibilities1. Sign Memorandum of Understanding Outlining Protocols for: Information-Sharing (Communication) Protocols Roles & Responsibilities for Suicide Response Protocol 2. Meet When a Suicide Occurs to: Offer Crisis Response Services to the School, Employer or Other Agencies Where Youth Received Services Coordinate Crisis Response and Postvention Responses Across Team Member Agencies Plan for Mid-term and Long-Term Postvention Activities to reach 100% of Individuals Impacted by Grief and Trauma 3. Debrief on Lessons Learned from Communication, Crisis and Postvention Response 4. Update Protocols as Needed

36 Collaboration: Considerations for a Memorandum of UnderstandingAgree to establish mutual Suicide Communication and Response Protocols Agree to common mission and values Agree to create a Community Suicide Postvention Response Team to: Agree to roles and responsibilities in information-sharing and response Share information to improve community response to reduce contagion Support the school with crisis response and postvention activities Support impacted community members/agencies Update protocols as needed 3. Each agency/group designates a representative Agree to immediately report to the team a suspected youth suicide Agree to strictly comply with matters of confidentiality and be sensitive to other agencies’ issues/concerns, chains of command, etc. HEALTH SYSTEMS DIVISION Child and Family Behavioral Health

37 Best Practice Resources for Community PostventionResponding to Grief, Trauma, and Distress after a Suicide: U.S. National Guidelines-- Connect of New Hampshire-- A best practice program for training, community building and coordinating suicide communication and response protocols Riverside Trauma Center Postvention Protocols– A best practice, nationally respected program in postvention Doughy Center– Training and consultation on traumatic grief, crisis planning and assisting families after murder, violent death or suicide Lifelines Postvention: Responding to Suicide and Other Traumatic Death-- Pathways to Purpose and Hope– A resource for grieving After a Suicide: A Toolkit for Schools-- Youth Suicide Prevention, Intervention and Postvention Guidelines: A Resource for School Personnel-- Sample Agency Practices for Responding to Client Suicide-- Postvention: A Guide for Response to Suicide on College Campuses-- Manager’s Guide to Suicide Postvention in the Workplace-- Black S & Guard A (n.d.) Guidelines for community response after suicide in rural areas.