The document provides information on common warning signs, risk factors, and trajectories of youth suicide. It also outlines approaches to assessing suicide risk levels and how to assist youths at low, moderate, and high risk of suicide. The key points are: 1) Common warning signs of youth suicide include suicide threats, preoccupation with death, and changes in behavior, physical condition, thoughts or feelings. Risk levels increase based on factors like stress, symptoms, thoughts of suicide, and lack of social support. 2) Suicide risk is assessed based on a current suicide plan, prior suicidal behavior, and available resources. Risk is greater with a more detailed plan, prior attempts, and lack of support system. 3

1. Youth SuicideYouth Suicide
Lorna MartinLorna Martin
lormartin@gov.mb.calormartin@gov.mb.ca

2. Common Warning Signs ofCommon Warning Signs of
Youth SuicideYouth Suicide
 Suicide threatsSuicide threats (written, direct, indirect)(written, direct, indirect)
 Preoccupation with deathPreoccupation with death (making final arrangements, giving(making final arrangements, giving
away prized possessions, talking, reading, writing, drawing about death or aaway prized possessions, talking, reading, writing, drawing about death or a
dead person)dead person)
 Changes in behaviour, physical condition,Changes in behaviour, physical condition,
thoughts, or feelingsthoughts, or feelings (withdrawal, isolation, increased risk-taking,(withdrawal, isolation, increased risk-taking,
decreased performance, frequent lateness, unexplained absence, cryingdecreased performance, frequent lateness, unexplained absence, crying
jags, heavy use of alcohol or drugs, abrupt changes in appearance,jags, heavy use of alcohol or drugs, abrupt changes in appearance,
appetite, sleep patterns, exaggerated fears, irrationality/anxiety,appetite, sleep patterns, exaggerated fears, irrationality/anxiety,
hopelessness, increased irritability, moodiness, lethargy)hopelessness, increased irritability, moodiness, lethargy)
 StressStress (intolerable loss)(intolerable loss)

3. Four Indicators of Risk LevelsFour Indicators of Risk Levels
• StressStress
– Critical situational events, personal lossCritical situational events, personal loss
– Disruptive life eventsDisruptive life events
• SymptomsSymptoms
– Changes in behaviour, physical condition,Changes in behaviour, physical condition,
thoughts/feelingsthoughts/feelings
• Thoughts of SuicideThoughts of Suicide
– Direct/indirectDirect/indirect
• Loss/Lack of Social Network/SupportLoss/Lack of Social Network/Support
– Healthy connections to others missing or lostHealthy connections to others missing or lost

4. Assessment of RiskAssessment of Risk
• Current Suicide PlanCurrent Suicide Plan
– Method, preparation, means, time frameMethod, preparation, means, time frame
– The more detailed the plan, the greater the riskThe more detailed the plan, the greater the risk
• Prior Suicidal BehaviourPrior Suicidal Behaviour
– Prior attempt(s) reveal(s) acceptance of suicide as anPrior attempt(s) reveal(s) acceptance of suicide as an
alternativealternative
• ResourcesResources
– Risk decreases with personal support resources suchRisk decreases with personal support resources such
as a place to live, caring family, friends or teachers,as a place to live, caring family, friends or teachers,
access to helpaccess to help

5. Spectrum of SuicidalitySpectrum of Suicidality
• Not all youths follow the same trajectoryNot all youths follow the same trajectory
towards suicidetowards suicide
• Self-harm is not necessarily a precursor toSelf-harm is not necessarily a precursor to
suicidesuicide
• Not all suicidal youths are depressedNot all suicidal youths are depressed
• Not all youths indicate their feelings ofNot all youths indicate their feelings of
suicide prior to an attempt or completionsuicide prior to an attempt or completion

6. Sample 1 TrajectorySample 1 Trajectory
IDEATIONIDEATION
-thoughts of death-thoughts of death
-wishes never born-wishes never born
-life not worth living-life not worth living
-thoughts of killing self-thoughts of killing self
(general moving(general moving
towards specific)towards specific)
-sees suicide as-sees suicide as
retributionretribution
INTENTIONINTENTION
-writing notes/will-writing notes/will
-giving away-giving away
possessionspossessions
-subtle/overt threats-subtle/overt threats
-minor self-harm and-minor self-harm and
self-destructive risk-self-destructive risk-
takingtaking

7. Sample 1 Trajectory (cont’d)Sample 1 Trajectory (cont’d)
ATTEMPTATTEMPT
-pseudo-suicide attempt-pseudo-suicide attempt
(in a place and time(in a place and time
when interveners willwhen interveners will
be present)be present)
-minor attempt (failure is-minor attempt (failure is
distinct possibility)distinct possibility)
-major attempt (failure-major attempt (failure
remote)remote)
COMPLETIONCOMPLETION

8. Sample 2 TrajectorySample 2 Trajectory
IDEATIONIDEATION
- Thoughts of killingThoughts of killing
self (specific)self (specific)
INTENTINTENT
- Expresses threat inExpresses threat in
angry outburstangry outburst
- Threatens to harmThreatens to harm
others simultaneouslyothers simultaneously
ATTEMPTATTEMPT
- Major attempt (selectsMajor attempt (selects
time and method withtime and method with
little chance of failure)little chance of failure)
COMPLETIONCOMPLETION

9. Sample 3 TrajectorySample 3 Trajectory
IDEATIONIDEATION
- None expressedNone expressed
INTENTINTENT
- None observedNone observed
ATTEMPTATTEMPT
- None observed- None observed
COMPLETIONCOMPLETION

10. Sample 4 TrajectorySample 4 Trajectory
IDEATIONIDEATION
-Morbid ideation-Morbid ideation
-Preoccupation with-Preoccupation with
death and dyingdeath and dying
INTENTINTENT
-Writes songs-Writes songs
-Self-harms-Self-harms
ATTEMPTATTEMPT
- None observedNone observed
COMPLETIONCOMPLETION
-None to date-None to date

11. Early Family Influences onEarly Family Influences on
Suicidal BehaviourSuicidal Behaviour
ATTACHMENT
HISTORY
PSYCHOLOGICAL
RESPONSE
ATTACHMENT
BEHAVIOUR
ASSOCIATED
BEHAVIOUR
Insecure attachment Separation anxiety Protest
Despair
Detachment
Failure
Alternative
attachments
Persistent anxiety
Depression
Object hunger
Anxious
attachment
Emotional
detachment
Antisocial
behaviour
Behaviour disorder
School phobia
Illness behaviour
Impaired capacity
to form attachments
Loneliness
Low self-esteem
Depression
Relationship
difficulties
Marital
dysfunction
Personality disorder
Alcohol & drug
abuse
Threatened
attachments
Abandonment anxiety
Suicidal ideation
Suicidal threats
Suicide attempts
Alcoholic binge
Promiscuity
Phobic stages
Recurrent
attachment failure
Chronic anxiety
Severe depression
Persistent suicidal
ideation
Repeated
suicide attempts
Major affective
disorder
Chronic alcoholism
Social isolation Hopelessness
Depair
Suicide
Adam, K.S., Early family influences on suicidal behaviour

12. Assessing Risk LevelsAssessing Risk Levels
Ensure you are qualified to make risk decisions. If you haveEnsure you are qualified to make risk decisions. If you have
not been trained through a program such as ASIST ornot been trained through a program such as ASIST or
LivingWorks, seek assistance immediately. If you areLivingWorks, seek assistance immediately. If you are
trained, it is still important to debrief with a qualifedtrained, it is still important to debrief with a qualifed
colleague.colleague.
• Risk levels increase as resiliency factors decreaseRisk levels increase as resiliency factors decrease
• Risk levels increase withRisk levels increase with
– Current suicide planCurrent suicide plan
– Prior suicidal behaviourPrior suicidal behaviour
– Lack of available resources to act as a safety netLack of available resources to act as a safety net
• Risk levels further escalate if suicide plan has method,Risk levels further escalate if suicide plan has method,
means and established timeframemeans and established timeframe

13. If you are a trained intervener:If you are a trained intervener:
• The next slides are remindersThe next slides are reminders
• The next slides are for your information, toThe next slides are for your information, to
assist you providing details to a trainedassist you providing details to a trained
intervenerintervener
If you are likely to be a trustedIf you are likely to be a trusted
professional:professional:

14. Seeking Assistance andSeeking Assistance and
SupportSupport
• Use the school threat assessment and/or crisisUse the school threat assessment and/or crisis
intervention protocol to assist youintervention protocol to assist you
• Access the school psychologist, social worker,Access the school psychologist, social worker,
AFM worker or other qualified intervener withinAFM worker or other qualified intervener within
your systemyour system
• Access medical, RCMP, or mobile crisis unit ifAccess medical, RCMP, or mobile crisis unit if
there are no qualifed interveners within yourthere are no qualifed interveners within your
system.system.
• Contact parent(s)/guardian(s).Contact parent(s)/guardian(s).
• Document your actions.Document your actions.

15. Acronyms to Aid in Assessing RiskAcronyms to Aid in Assessing Risk
To respond efficiently to a suicidal youth, itTo respond efficiently to a suicidal youth, it
is important to be calm, patient, andis important to be calm, patient, and
direction.direction.
To determine the degree of risk, you need toTo determine the degree of risk, you need to
learn answers to specific questions. Asklearn answers to specific questions. Ask
them. It may be a life-saving decision.them. It may be a life-saving decision.

16. Miller (1984) Acronym 1Miller (1984) Acronym 1
SS -- howhow specificspecific is the plan of attack? The moreis the plan of attack? The more
specific the details related the higher the degree ofspecific the details related the higher the degree of
present riskpresent risk
LL -- howhow lethallethal is the proposed method? How quicklyis the proposed method? How quickly
could the person die if the plan is implemented? Thecould the person die if the plan is implemented? The
greater the level of lethality, the greater the risk.greater the level of lethality, the greater the risk.
AA -- HowHow availableavailable is the proposed method? If theis the proposed method? If the
implement to be used is readily available, the level ofimplement to be used is readily available, the level of
suicidal risk is greater.suicidal risk is greater.
PP -- What is theWhat is the proximityproximity of helping resources?of helping resources?
Generally, the greater the distance the youth would beGenerally, the greater the distance the youth would be
from helping or supporting resources if the plan werefrom helping or supporting resources if the plan were
implemented, the greater the degree of risk.implemented, the greater the degree of risk.

17. Miller (1984) Acronym 2Miller (1984) Acronym 2
Four additional factors to aid in assessing the level of suicidal riskFour additional factors to aid in assessing the level of suicidal risk
when the youth has made a previous suicidal attempt:when the youth has made a previous suicidal attempt:
D – DangerousD – Dangerous – How dangerous was the prior attempt and– How dangerous was the prior attempt and
current plan? The greater the danger, the higher the current risk.current plan? The greater the danger, the higher the current risk.
I – ImpressionI – Impression – Even if the danger in the attempt or plan is not– Even if the danger in the attempt or plan is not
significantly high, if the impression is that the danger is high and willsignificantly high, if the impression is that the danger is high and will
surely cause death, the present risk is high.surely cause death, the present risk is high.
R – RescueR – Rescue – If the opportunity for rescue was great in the prior– If the opportunity for rescue was great in the prior
attempt or present plan, the risk is lower than if the opportunity forattempt or present plan, the risk is lower than if the opportunity for
rescue was remote. If the chances were or are poor that rescue willrescue was remote. If the chances were or are poor that rescue will
occur, the present risk is high.occur, the present risk is high.
T – TimingT – Timing – If the previous attempt was recent, the present risk is– If the previous attempt was recent, the present risk is
higher than if the previous attempt was long ago.higher than if the previous attempt was long ago.
If a youth may be at immediate risk, you must immediatelyIf a youth may be at immediate risk, you must immediately
implement any process necessary to protect that youth orimplement any process necessary to protect that youth or
to provide life-saving supports.to provide life-saving supports.

18. Safety ContractsSafety Contracts
• Many low to moderate risk youths respondMany low to moderate risk youths respond
positively and reliably to a safety contract.positively and reliably to a safety contract.
• The contract should includeThe contract should include
– A specific plan that prevents immediate riskA specific plan that prevents immediate risk
– A commitment to not engage in self-harm forA commitment to not engage in self-harm for
an agreed-upon timeframean agreed-upon timeframe
– Crisis support, including names and telephoneCrisis support, including names and telephone
numbersnumbers
• Ensure you have a ‘back-up’ plan inEnsure you have a ‘back-up’ plan in
addition to a safety contractaddition to a safety contract

19. Sample Safety ContractSample Safety Contract
PERSONAL SAFETY CONTRACT
Date:________________________ Time: ________________
I, (name), promise to keep myself safe until (date and time) when I see my
counsellor. I will not harm myself or others in any way. If I feel like I cannot
control myself or start to feel worried, or anxious, or that I might not keep
this promise, I will call:
(insert youth’s choice of trusted friend or family member and telephone number)
or
(insert youth’s alternative choice and telephone number) or
(insert name of hospital/RCMP/nursing station and telephone number)
_______________________ _______________________
Signature of Youth Signature of Counsellor
Ensure you have a ‘back-up’ plan in addition to a personal safety contract.
Contact resources.

20. Assisting Low Risk YouthsAssisting Low Risk Youths
• Listening empathicallyListening empathically
• Obtaining a specific, written promise toObtaining a specific, written promise to
seek help when neededseek help when needed
• Providing a promise of continued supportProviding a promise of continued support
““Will you be safe until Tuesday?”Will you be safe until Tuesday?”
““I’ll stay with you while you tell your parent how you’reI’ll stay with you while you tell your parent how you’re
feeling.”feeling.”
““Can you promise me that you will follow the instructionsCan you promise me that you will follow the instructions
we have agreed to in this contract?”we have agreed to in this contract?”
““Will you keep your appointment with me tomorrow?”Will you keep your appointment with me tomorrow?”

21. Assisting Moderate Risk YouthsAssisting Moderate Risk Youths
without a specific planwithout a specific plan
• Require more intervention and directionRequire more intervention and direction
• Written and verbal commitment requiredWritten and verbal commitment required
• Refer to school psychologistRefer to school psychologist
• Contact parent(s)Contact parent(s)
““I’m not positive you’re going to be okay after you leave here.”I’m not positive you’re going to be okay after you leave here.”
““Will you keep the promises you made in our contract?”Will you keep the promises you made in our contract?”
““Here’s a telephone number where I can be reached, the suicide crisisHere’s a telephone number where I can be reached, the suicide crisis
line and the clinic number. Promise me now that you will call me orline and the clinic number. Promise me now that you will call me or
any of these other numbers for help before you decide to take anyany of these other numbers for help before you decide to take any
action that might harm you. Even when the idea enters your headaction that might harm you. Even when the idea enters your head
and you’re not sure….phone. Can you promise?”and you’re not sure….phone. Can you promise?”
““Can I telephone you this evening to make sure you’re all right? I’mCan I telephone you this evening to make sure you’re all right? I’m
very concerned and I want us to talk again to make things better forvery concerned and I want us to talk again to make things better for
you.”you.”
““Will you be safe if you leave here now? Are you positive?”Will you be safe if you leave here now? Are you positive?”

22. Assisting High Risk YouthsAssisting High Risk Youths
• Youth is in crisisYouth is in crisis
• Do not leave the youth unsupervised.Do not leave the youth unsupervised.
• Support cannot be withdrawn for any reasonSupport cannot be withdrawn for any reason
• Be assertive and directive.Be assertive and directive.
““I can’t leave you here alone. I want you to come with me now so weI can’t leave you here alone. I want you to come with me now so we
can get you more help than I can give you here.”can get you more help than I can give you here.”
““You can’t promise that you won’t kill yourself and that concerns me.You can’t promise that you won’t kill yourself and that concerns me.
Let’s go together to the hospital where we can get more support.”Let’s go together to the hospital where we can get more support.”
• Do not take ‘no’ for an answer. Follow schoolDo not take ‘no’ for an answer. Follow school
protocol for threat assessment/crisisprotocol for threat assessment/crisis
intervention.intervention.
• Contact parent(s). Dial 911 if necessary.Contact parent(s). Dial 911 if necessary.

23. Summary of Typical RiskSummary of Typical Risk
FactorsFactors
• Recent attemptsRecent attempts
• Recent lossesRecent losses
• Critical incidentsCritical incidents
• Prior traumasPrior traumas
• Isolation/withdrawalIsolation/withdrawal
• Substance abuseSubstance abuse
• Destructive copingDestructive coping
stylesstyles
• Poor problem solvingPoor problem solving
skillsskills
• DisorientationDisorientation
• Inadequate supportInadequate support
• Hopelessness/Hopelessness/
helplessnesshelplessness

24. Summary of Protective FactorsSummary of Protective Factors
• Support from family andSupport from family and
friendsfriends
• Perceived connection toPerceived connection to
family and friendsfamily and friends
• Strong cultural tiesStrong cultural ties
• Good physical andGood physical and
mental healthmental health
• Strong spiritual tiesStrong spiritual ties
• Positive self-esteemPositive self-esteem
• Early identification andEarly identification and
treatment of psychiatrictreatment of psychiatric
illnessillness
• Good school performanceGood school performance
• Positive attitude towardsPositive attitude towards
schoolschool
• Skills in stressSkills in stress
management,management,
communication, problem-communication, problem-
solvingsolving
• Fear of suicide andFear of suicide and
objections to suicideobjections to suicide
• Sense of belongingnessSense of belongingness

25. Risk vs Imminent DangerRisk vs Imminent Danger
PHASE ONEPHASE ONE
Is there a plan and means?Is there a plan and means?
Risk factors – five of the following (1-4=risk,Risk factors – five of the following (1-4=risk,
5 or more=danger):5 or more=danger):
a)a) MaleMale
b)b) Past attemptPast attempt
c)c) More than one attemptMore than one attempt
d)d) Antisocial behaviourAntisocial behaviour
e)e) Friend or family who has committed suicideFriend or family who has committed suicide
f)f) Drug and/or alcohol abuseDrug and/or alcohol abuse
g)g) DepressionDepression
h)h) Difficulty socially, especially family problemsDifficulty socially, especially family problems

26. Risk vs Imminent DangerRisk vs Imminent Danger (cont’d)(cont’d)
PHASE TWOPHASE TWO
Can the youth complete tasks incompatible with suicidalCan the youth complete tasks incompatible with suicidal
states?states?
1.1. Written promise to abstain from suicidal behaviour forWritten promise to abstain from suicidal behaviour for
specified timespecified time
2.2. Ability to compliment self and othersAbility to compliment self and others
3.3. Ability to assess their own emotional state (e.g,Ability to assess their own emotional state (e.g,
develop hierarchy of situations that would raise suicidaldevelop hierarchy of situations that would raise suicidal
thoughts)thoughts)
4.4. Capacity to plan ahead (e.g., being prepared forCapacity to plan ahead (e.g., being prepared for
stressors, positive imagery, relaxation, develop socialstressors, positive imagery, relaxation, develop social
support systemsupport system
(Inability to accomplish these four tasks indicates possible(Inability to accomplish these four tasks indicates possible
imminent danger)imminent danger)

27. ReferralsReferrals
• Report suicidality and refer to a trainedReport suicidality and refer to a trained
professional (e.g., psychologist, medical doctor,professional (e.g., psychologist, medical doctor,
Salvation Army Mobile Crisis Unit). WhileSalvation Army Mobile Crisis Unit). While
awaiting the professional,awaiting the professional,
• Remove access to means of suicideRemove access to means of suicide
• Use protocols for threat assessments/crisisUse protocols for threat assessments/crisis
interventionintervention
• Inform parent that referral has been madeInform parent that referral has been made
• Maintain supervision of youthMaintain supervision of youth

28. Formal AssessmentsFormal Assessments
There are several instruments available toThere are several instruments available to
trained professionals to detect suicidality.trained professionals to detect suicidality.
Some of the most commonly used are:Some of the most commonly used are:
• Suicide Probability Scale (SPS)Suicide Probability Scale (SPS)
• Suicidal Ideation Questionnaire (SIQ)Suicidal Ideation Questionnaire (SIQ)
• ISO-30ISO-30
• Children’s Depression Rating ScaleChildren’s Depression Rating Scale
• Beck Hopelessness Scale (BHS)Beck Hopelessness Scale (BHS)
• Index of Potential SuicideIndex of Potential Suicide

29. Making the ConnectionMaking the Connection
• You’ve recognized the signs and symptoms.You’ve recognized the signs and symptoms.
• You’ve asked the questions directly.You’ve asked the questions directly.
• You’ve documented the interview and yourYou’ve documented the interview and your
actions.actions.
• You’ve made a connection with the youth.You’ve made a connection with the youth.
• You may be the difference between recoveryYou may be the difference between recovery
and imminent death.and imminent death.
• The youth is trusting you to be a reliable,The youth is trusting you to be a reliable,
responsible adult.responsible adult.

30. Keeping the ConnectionKeeping the Connection
• Stay focused.Stay focused.
• Stay calm.Stay calm.
• Stay with the youth.Stay with the youth.
• Err on the side of caution.Err on the side of caution.
• Trust your ‘gut’.Trust your ‘gut’.
• Get help. Create a helping network with theGet help. Create a helping network with the
youth.youth.
• Document events.Document events.
• Debrief with a trusted colleague following theDebrief with a trusted colleague following the
initial resolution of the event.initial resolution of the event.

31. This presentation has been anThis presentation has been an
overview of commonly heldoverview of commonly held
principles and practices whenprinciples and practices when
dealing with suicidal clients.dealing with suicidal clients.
It is intended as an informationIt is intended as an information
session only.session only.
This presentation does notThis presentation does not
provide training for suicideprovide training for suicide
intervention.intervention.
For information on training in interventionFor information on training in intervention
and postvention, please contact:and postvention, please contact:

32. Centre for Suicide PreventionCentre for Suicide Prevention
Suite 320, 1202 Centre Street S.E.Suite 320, 1202 Centre Street S.E.
Calgary, Alberta Canada T2G 5A5Calgary, Alberta Canada T2G 5A5
Phone: 403 245-3900 Fax: 403 245-0299Phone: 403 245-3900 Fax: 403 245-0299
sptp@suicideinfo.casptp@suicideinfo.ca
oror
Lorna MartinLorna Martin
Manitoba Education, Citizenship andManitoba Education, Citizenship and
YouthYouth
Phone: 204 945-7964 Fax: 204 948-2291Phone: 204 945-7964 Fax: 204 948-2291
lormartin@gov.mb.calormartin@gov.mb.ca