Preventing Suicide Contagion in High Schools...– Step 1: The cultural understanding of suicide can...

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


Overview

1. Overviewofsuicideinadolescence2. Definitions:– Suicideclusters– Suicidecontagion• Problematizetheword“contagion”

3. Whatdoweknowaboutcontagion?4. Whatissuesshouldschools,communities,

parents,andmentalhealthworkersconsiderwhenmanagingasuicidedeathinschool?


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.

http://dx.doi.org/10.1016/j.socscimed.2017.03.019


AdolescentSuicide

• Recentdramaticincreasesinratesforyouth– Particularlyamong10-14yearolds(maleandfemales)and15-24yearoldfemales

• Whilesuicidedeathsarestillrare,suicidalityismuchmorecommon– 17%highschoolstudentshaveseriouslyconsideredattempting(22.4%offemales);13.6%madeaplan;8%attempted(10.6%offemales)• Source:CDCYRBS


SuicideinSchools• 17%ofteenshavehadafriendattemptsuicide• 3%ofteenshadafrienddie

• Source:NationalLongitudinalStudyofAdolescenttoAdultHealth(1990s)

• 35%ofschoolpsychologistsreportthatastudentintheirschoolhaddiedbysuicide

• Source:AmericanAssociationforSuicidalitysurveyofschoolpsychologists(Berman2009)

• Dataisweak…

• Youthandyoungadultsare2-4timesmorelikelytodiebysuicidewithinapointsuicidecluster

• Source:Gouldetal.1990


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)


Whatissuicide“contagion”?

• Suicide“contagion”– Afterexposuretothesuicidedeathorattemptofafriendorfamilymember,individualsareathigherriskofsuicideideationandattempts


Whatissuicide“contagion”?OddsofReporjngSuicidality

0 0.7 1.4 2.1 2.8

2.23

2.77

NoExposureExposuretoSuicideAkemptorDeathofaFriend(Baseline)

SUICIDEIDEATION

SUICIDEATTEMPT

Source:(AbrutynandMueller2014)


CritiqueofSuicideContagion

• Weselectfriendswhoaresimilartous– “homophily”or“assortativerelating”

• Ourfamiliesraiseustobesimilartothem– Andareoftengeneticallysimilartous(thoughnot

always!)

• Whatifpre-existingriskfactorsforsuicideexplaintheobserved“contagion”ofsuicide?– Requireslongitudinaldataandcausalmodeling

strategies


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


**ROBUSTFINDING**

• Usingeverycausalmodelingstrategypossible,researchersrepeatedlyfindthatexposuretosuicideincreasesriskofsuicideideationorattempts– Socialinfluence,notsocialselectionintofriendships

• Caveat:Notnecessarilydeaths– veryhardtoevaluatebecausedeathsaresorare– Causalmodelsrequirelongitudinaldata;cannotuseretrospectivedata


Whatdoesthismean?

• Weshouldbeconcernedaboutyouthafterasuicidelossoreventhesuicideattemptofafriend

• However,youthcannotpassively“catch”suicidelikeacold

• Talkingaboutsuicidedoesnotincreaserisk– Experimentalevidenceshowsthis

• MattNock’steamatHarvard,MadelynGould’steamatColumbia…etc

– Exposuretothemereideaofsuicideisnotrisky


SOWHATISSUICIDE“CONTAGION”?

IFITSNOTJUSTEXPOSURETOTHEIDEA,WHATISIT?


Thestorieswetellmatter…


ResearchonMassClusters

• WertherEffect–DavidPhillips– Whenastoryaboutsuicideisinthemedia,weseeaspikeinlocalsuicideratesabout1/3ofthetime(Stack2005)

– Certaindetailsamplifyriskofaspike• Sensationalisticcoverage• Informationaboutsuicidemethodormotive• Frontpagecoverage

– Seewww.reportingonsuicide.org

– Riskseemsmostamplifiedamongpeoplewhoaresimilartothedecedent

http://www.reportingonsuicide.org/


ResearchonMassClusters

• PapagenoEffect– Positivecoverageofcopingwithsuicidalityoradversecircumstancescanlowersuiciderates!

– ThomasNiederkrotenthaleretal.(2010)


Storieswetellaboutsuicideshapeourresponses

• Welearnfromoursocialworldshowtocopewithadversity– Ifthemessagesareprosocialorhelpful(gethelp!Don’tbeashamed!),that’sgreat!

– Ifthemessagesdeliberatelyorinadvertentlypromotesuicide,thatcanbeharmful


ParticularlySalientAfteraSuicideLoss

• Suicidebereavementorlossisaparticularlydisruptiveexperiencetoourunderstandingoftheworld

• RobertNeimeyer,clinicalpsychologist– (Currieretal.2015)

• http://www.robertneimeyerphd.com/

• Requiresnearcompulsorymeaningmaking– Incorporatetheexperienceintoourunderstandingofreality

– Intooursenseofself– Bigpartofthisismakingsenseof“why”

• Orcomingtopeacewithhowhardaquestionthatis

http://www.robertneimeyerphd.com/

http://www.robertneimeyerphd.com/


Foreshadowing…

• ResearchQuestion:– Whatissuicide“contagion”?Howdoesithappen?

• Answer:Suicideisculturally“contagious”– Hypothesis:Exposurerenderssuicideamoresalientandaccessibleoptionforyouththroughstorytellingaboutsuicide

• WhatIwillshow:– Step1:Theculturalunderstandingofsuicidecanshiftundercertaincircumstances–whencertainstoriesgettold• Particularlywithregardtowhat“causes”suicideandwhensuicideisa“justified”action

– Step2:Linktheculturalunderstandingofsuicidetovulnerabilitytosuicide


Whatdowebelieveaboutsuicide?

• BeforedelvingintothespecialcaseofPoplarGrove,needtoconsiderthegeneralbeliefsaboutsuicideintheU.S.– Specifically,thecausesofsuicide

• ComparebeliefsinPoplarGrovetomoregeneralbeliefsaboutsuicideintheU.S.


GeneralizedBeliefsaboutSuicideintheU.S.

• “Atleast90percentofallpeoplewhodiedbysuicideweresufferingfromamentalillnessatthetime,mostoftendepression”à Mentalillnesscausessuicideà RootedinmedicalizedunderstandingofsuicidethatdominatestheU.S.(Marsh2005)

• 89%ofreferencegrouprespondents,presentedmentalillnessasthedominantframeforwhypeoplediebysuicide

• N=17outof19


GeneralizedSuicideBeliefs

Susan,lostherbrothertosuicide(notfromPoplarGrove):

“IcompletelyunderstandthatJeremiahwassick,andnottojustify[hissuicide],butIgetthecomplexityofdepression….FromwhatIgather,inthewaythatthebrainworks,asfarasonceyougettoapointofdecidingthatyou’regoingtotakeyourownlife…So,Iget…whyhedidwhathedid.”

• Manyinourreferencegroupsituatedmentalillnessassomethingbiologicalor“inthebrain”

• Also“mentalillness”wasclearlyseenasaprimarycause


MentalIllnessasCauseofSuicideInsightsfromPoplarGrove

• 88%Youth&YoungAdultsRespondentsreferencedamentalillnessframe– Mentalhealthorpsychologicalpaincausessuicide

• Leah,ateenwholostaclosefriend(Stella)tosuicide:– Ittakesacertaintypeofpersontogettothatpoint[suicide],andacertaintypeofdepressionthattheirexperiencing…It’sthechemicalsintheirmind,andittakesacertaintypeofpersontobepushedtotheedge,acertainkindofimpulsiveperson,orsomeotherqualitythatmakesthemmoreadepttoactingonarashterm…It’sthediseaseIthink.[emphasisadded.]


MentalIllnesswithaTwist• Thus,forLeah,mentalillnessisrootedbothinbiology(“chemicalsin[the]mind”)andinsocialexperiences(“thepressure…aroundhere”).

• ShealsoattributedStella’sdeathtoboth:– Stella“[wouldwear]herselfraggedtryingtopleaseeverybodyandtryingtodothethingsthatshethoughtshehadtodo.”


UnderstandingSuicideinPoplarGrove

• MentalIllnessFrame– Recall:88%ofyouthreported

• PressureFrame– 81%youthandyoungadultsreported–Manyadultsalsoheldthisbelief


PressurebecameLocallyGeneralized

• Youthwithlessdirectexperiencewithsuicideadoptedthepressureframe

• Lily,anadolescentinPoplarGrovewholostaclassmate,illustratesthispatternafterbeingaskedwhyyouthdiebysuicideinafocusgroup:

– [F]romthebeginningofmiddleschool,westartthinkingaboutacareerpath,andIthinkthat'sreallyhard...especiallyforme,personally…Ifeellikealotofkidsfeelliketheydon'tknowwherethey'regoing…Andthen,theyrealizethatthereissomuchpressurearoundthemthatmaybethey'llnevergetoutofthepressure,orthetown,andthey'llnevergetarealjob,orareallifeoutsideoftheirteenagenightmare.


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?’



• Therewassocialpressuretoavoidmentalillnesstoexplainsuicide– “Goodkids”werenotmentallyillanddidnotneedmentalhealthhelp

– Parents’suppressedinformationaboutmentalillnessintheirkids• (Mueller&Abrutyn2016;Mueller2017)

– Youthwhofitstereotypesaboutsuicide(e.g.,aperceiveddrugabuser)receivedmuchlessattention• Mourningrituals,gossip,media

• Activeworktocraftanarrativethatpreservedtheyoungsuicidedecedentsreputation– AsLilysaid“Noonetrashtalksthedeadkid.”



• Butthisscenariowasalsoterrifyingforyouth

– Amelia(teen):[LosingMichelle,myclassmate,tosuicideis]differentfromanythingelseI'veeverexperienced…Allyou'rethinkingaboutislike...Why?...Becausenoonejustdoesthat[referringtosuicide].Theyalwayshaveareasonfordoingit….Itmakesyoulookatthepeoplearoundyoucloser.Itmakesyouscared...scaredtoloseanyoneelse.Youfeellikeeverythingisjustfallingoff,andyou'retryingtocatcheverything.

• Ameliawasnotaloneinherfeelings


TheConsequencesforSuicideRiskforPoplarGrove

• ResearchQuestion:Howdoessuicide“contagion”occur?

• Hypothesis:Exposurerenderssuicideamoresalientandaccessibleoptionforyouth

– ThePoplarGroveculturalunderstandingofsuicideinvokesabroadlysharedexperience(pressure),thatmakesmanyyouthinthecommunitymiserable(Mueller&Abrutyn2016)

• Finaltask:Linktheculturalunderstandingofsuicidetovulnerabilitytosuicide



• 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.”



• Youthcouldturnthisperceivedmotiveforthesuicidesofothersintosomethingapplicabletothemselves;amotivetheycouldidentifywith

• Particularlytrueamongyouthwhoaresufferingunderthelocalpressureandwhowishedtheycoulddoabetterjoblivinguptoexpectations– Youthwhohadinternalizedlocalculturalexpectationsaboutwhatan

idealkidshouldbeintotheirsensesofself

• Notthesameasencouragingthecompletionofsuicide– Researchdoesshowthatpro-suicideattitudesareariskfactorforsuicide

deathandattempts


Withinthiscontext,motivesforsuicideareexpanded

Pressure

MentalIllness

Failure


Summary:

• Exposuretosuicidemayshapeyouth’sunderstandingofwhatsuicideisandwhatmakessomeonevulnerabletoit– Suggeststhatthemeaningofsuicidecontributestoitsdiffusion

• Individualandcollectiveprocesses– Watchingthecommunityreactalsoatrophieshealthycopingstrategies

• Communityadults’silenceleaveskidsto“figureout”suicideontheirown

• Structuraldimensionsmatter– Socialconnectednessofthecommunityfacilitatesthecollectivemeaningmaking

processes– Highsocialstatusofsomeofthesuicidedecedentsshapestheunderstandingof

suicide


InsightsforTheoriesofSuicide

ThwartedBelonging-

ness

PerceivedBurdensome-

ness

AcquiredCapacity

InterpersonalTheoryofSuicide



ThwartedBelonging-

ness


nessAcquiredCapacity-Exposuretoviolence

-Accesstolethalmeans




ThwartedBelonging-

ness


nessAcquiredCapacity

-NORMATIVECapacityExposuretonorms,

meanings,beliefsthatmakesuicideamoreimaginableoption




ThwartedBelonging-

ness


ness

Acquired(Normative)Capacity

Social-contextualfactors



SuicidehasSocialRoots


nessThwarted

Belonging-ness

AcquiredCapacity


Social-contextualfactors


PRACTICALIMPLICATIONS


PracticalImplicationsForSuicidePrevention(orPostvention)

• Ideally,communitiesshouldpromotenarrativesthatconstrainordiminishsuicidediffusion–Wehaveverylittleresearchonthistopic

• Basically,weneedtoknowmoreabouthowthemeaningofsuicidemattersandhowitcanbeleveragedforeffectiveinterventions–Mycontinuingresearchgoal


AdditionalImplicationsforPre/Postvention


AvoidPassiveLanguageforTalkingAboutSuicide

• Suicideisnot“contagious”likeavirus

• Suicidecannothappentoyouviaa“rippleeffect”


“Contagion”asProblematicMetaphor

• “Contagion”impliespassivecatchingofsuicide

• Metaphorsmatter– Neuroscienceshowstheyshapeourunderstandingandemotions!

• Wedonotwantanyonethinkingpassivelyinthefaceofsuicide–Wewantaction



• InPoplarGrove:– Grace:Ithinkalotofthekidswerejustlike“Ohmygosh,that’sgonnabeus[meaningsomeonewhodiesbysuicide].We’reallgonnastressoutandloseit,evenifyourlifeisgreatyoucanstillsnaponeday.”



• Preferredlanguage:– Suicidediffusion– Exposuretosuicide


ListentoYouth• What’smakinglifedifficultforyouthinyour

community?– Whatarethesocialrootsofpsychologicalpain?

• Pastsuccessendingadolescentsuicideproblemsthroughthismethod– Gettingkidsinvolved,listeningtothem,lettingthemdesigninterventions• (MichaelKraletal.2009)

• Evidencebasedprogramstohelpdothis– SourcesofStrength– YouthAwareofMentalHealth(Y-A-M-S.org)


Schools:Formulateaplanforhandlingasuicidedeathbeforeithappens

• SuicidePreventionResourceCenter’sAfteraSuicide,AToolkitforSchools– http://www.sprc.org/resources-programs/after-suicide-toolkit-schools

– Freeresource

http://www.sprc.org/resources-programs/after-suicide-toolkit-schools

http://www.sprc.org/resources-programs/after-suicide-toolkit-schools

Screenshot2018-05-1809.34.16


BePrepared https://www.13reasonswhytoolkit.org

https://www.13reasonswhytoolkit.org

https://www.13reasonswhytoolkit.org


AcknowledgeSuicideProblemswhentheyoccur…

• Helpschoolsunderstandwhenaproblemisaproblem


Schoolisaveryimportantdenominator

• Wecalculatesuicideratesbycountyorzipcodes

• Butforyouth,schoolsmatter


Howmuchisaproblem?

HighSchool-MalesSchoolSize (Approximate)

ExpectedNumberofDeathsper10years

500 <1[0.71deaths]

1000 <2

2000 3

3000 4

EstimatesmadeusingCDC’s2015suiciderates:14.2forboysages15-195.1forgirlsages15-19


Howmuchisaproblem?

HighSchool-Males HighSchool-FemalesSchoolSize (Approximate)


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


Howmuchisaproblem?

HighSchool-Males HighSchool-FemalesSchoolSize (Approximate)


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


Alsoconsiderrecentgraduates

• PoplarGrovealsolost8recentgraduates(allmale)overthesame10yearperiod

– 1-5yearsaftergraduation


Teachyouthsignsofsuicide&wheretogethelp

• Useexistingevidencebasedsuicidepreventiontrainingprograms– SafeTALK&ASIST– SignsofSuicide(SOS)– Question,Persuade,&Respond(QPR)– www.SPRC.orgforinfo

http://www.sprc.org/


EducateYourselvesaboutSuicide

• Intheeventofasuicidedeath,talkclearlyandnon-judgmentallyaboutsuicide– Giveaccurateinformation– Avoidblamingorscapegoating– Donotfocusonthemethodorprovidegraphicdetails– Addressanger– Addressfeelingsofresponsibility– Encouragehelp-seeking

Source:SuicidePreventionResourceCenter’sAfteraSuicide,AToolkitforSchools


Askdirectquestionsaboutsuicide

• Ifyou’reworriedaboutsomeone,askthemdirectlywhethertheyareconsideringharmingthemselves– Youmaysavetheirlife– Butbecarefultobecoolandnotfreakout– Mostpeoplewithsuicidalthoughtsneverescalatetoanattempt• Mostsuicideattemptsdonotresultindeath• Buttheyaresignsofsuffering• TheyareNOT“criesforattention;”theymaybecriesforhelp

– SOHELP!


Thankyou

[email protected]

www.AnnaSMueller.com

Manyofthestudiesonwhichthispresentationisbasedareavailableforfreeonmywebsite,alongwiththingsIhavewrittenforabroadaudience(e.g.,

blogs)

NationalSuicidePreventionLifeline:1-800-273-TALKanytimeIfyouorsomeoneyoucareaboutareinacrisis,callthelifeline

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