Described below are three key themes that consistently emerged from the interviews, contrasting how high and low implementation schools typically respond to students at-risk for suicide: 1) school-level organization and use of resources in response to a student at-risk for suicide (e.g., procedures, policies, structures); 2) school leadership and priorities; and 3) district-level training and support. Potentially informative exceptions are discussed, such as the one low implementation school in which the themes discussed by participants were similar to those consistently discussed in the high implementation schools, as well as the one high implementation school where the themes discussed by participants were similar to those that consistently arose in interviews with participants from the low implementation schools.
School-level organization and use of resources
Having plans with clear lines of communication, a team-based approach, and explicit procedures and protocols distinguished most high from low implementation schools. Generally, participants from high implementation schools described how communication about at-risk students occurred at their school and who participated in the communication chain. In addition to a communication plan, the procedures at high implementation schools usually involved clearly delineated and documented protocols and procedures for responding to at-risk students. These participants provided detailed descriptions of their schools’ procedures for handling at-risk students, often including recent examples of responses to at-risk students. As one participant who is “likely to handle” at-risk students related, “Knowing what to do and having structures and processes in place help make things easier. Everyone … knows what questions to ask and how to proceed. There is not anything the school or district does … that makes things more difficult.” Likewise, a teacher with prior involvement commented, “At this school we have such a complete system — so much better than I’ve seen anywhere else for handling student mental health.” At these schools, knowledge of the procedures also extended to participants “unlikely to handle” and those “with no prior involvement” with at-risk students. For example, a teacher with no prior involvement with at-risk students from the same high implementation school as above knew that there was a process in place: “I feel like we have a good process. I feel perfectly free to contact people and feel confident that cases will be handled competently.” Most of the high implementation schools were also more likely to have protocols, reference guides, or pamphlets that helped to ensure that all of the school’s teachers and administrators were familiar with the process. An administrator at another high implementation school stated, “I think we’ve fine-tuned our [system]. We’ve really got a good response team and we put out a response guide that we gave to people on campus so that when anything comes up, counselors, deans, school nurses, school psychologists — we can (all) pull down our quick reference guide and go through the flow chart…We list the different people and where they need to be or go in a crisis.” Even most individuals who are “unlikely to handle” at-risk students at high implementation schools were aware of their school’s referral and documentation process. For example, one such teacher described having filled out an assessment form and knowing the documentation process, including follow-up and maintenance of records.
In contrast, most low implementation schools appeared to lack such communication plans and formalized procedures. Instead of communication plans or teams, participants from these schools typically described one person at their school who was solely responsible for all aspects of responding to an at-risk student. Further, participants from these schools were typically unable to specifically describe how at-risk students were assessed and handled at their school. For example, an individual “likely to handle” an at-risk student from one school said that there were no “procedures in place” for handling at-risk students. She further explained that she was trying to respond in the best manner she could. This individual described being overwhelmed by “…the number of students I have. Most of the work [the school district] has us do is paperwork. I’m not a therapist. I can refer but they can’t see me once a week. I try to follow-up once or twice but that’s all I can do. If I give them the referral and they don’t go, that’s all I can do.” Many participants from these schools described little or no communication within the school about crisis responses to students who are at risk for suicide. As an administrator from another low implementation school related, “When I tell you that I’ve only dealt with one case in the past two years, I’m sure that there have been more than just that one case, but I haven’t known about it. Not that I’m left out of the loop, or that I’m left out of the loop intentionally, but…I just don’t know about it.” Participants from low implementation schools also tended to identify student confidentiality as an issue that impeded coordination of a systematic school response. One “likely to handle” participant from a low implementation school reported that confidentiality concerns prevented communication about at-risk students. When this individual was asked what he knew about suicide attempts at the school, he responded, “I don’t get any information other than verbal. They don’t give me a breakdown. It is considered confidential.” Further, participants from these schools often mentioned student confidentiality when discussing why they believed that they were unaware of prior attempted or completed suicides among students and why such events did not have an impact on the school’s response to at-risk students.
School leadership support and on-campus resources
The importance of school administrator support and on-campus resources to meet the needs of at-risk students emerged as another theme common to all types of schools and participants. At most high implementation schools, school leadership was interested and involved in the activities of the suicide prevention team. Administrators at these schools also ensured sufficient time for training of school staff in crisis response activities. Participants from these schools commonly mentioned the importance of attentive school administrators. As one participant “likely to handle” at-risk students described, “The (school) administration is extremely supportive of our children that have issues. If they see something … they’ll let me know that someone looked really sad today, or they’ll ask me to check in on a student.” A teacher with prior involvement stated, “I know that I have the resources here to get the students to help. I have an administration that I can tell that I need to have the student pulled, removed, or assessed.” The importance of administrative support was also apparent among those with no prior involvement or who were unlikely to respond to at-risk students. For example, a counselor said, “My administrators are very supportive. That helps a lot.”
Participants from most high implementation schools commonly discussed available on-campus resources, such as a multidisciplinary crisis intervention teams and other student support programs available to address the needs of students who are at risk for suicide. One participant “likely to handle” at-risk students described the school’s “pretty strong team”: “I work at a school that really sees itself as a team. The counselors, the psychologists, and I lean on each other. If I can’t follow up with a kid, they will. We also have teachers that will keep their eyes on a child, especially the teacher that may have brought the child in.” Another teacher at this school who had not had direct experience with at-risk students discussed the importance of above-average resources in creating a “very safe environment,” and the school’s administrator discussed his “network of resources,” which included a crisis team with a psychologist and a nurse.
In contrast, participants from most low implementation schools frequently mentioned the low priority of youth suicide on their administrators’ agendas. In one school, four out of five participants perceived suicide prevention as a low priority at their school. A counselor “unlikely to handle” at-risk students at one low implementation school said that youth suicide ranks “down at the bottom somewhere” among the school’s priorities. An individual “likely to handle” at-risk students from another school said that youth suicide is at “minus 20” in the school’s priorities because “no one has time to make it a priority so the counselors just deal with it.” When this individual was asked if he would contact the administration in a time of crisis, he responded, “Right now? No. I wouldn’t involve the administration.” Some were hopeful, however, that a new school principal could make a difference. As an individual “likely to handle” at-risk students related, “With the new administration, they’re going to try to get more agencies in the community involved to come in and do some counseling for us. Hopefully it doesn’t stay the same. Hopefully it’s going to improve.”
Participants from most of the low implementation schools also frequently discussed the absence of on-campus resources. When discussing the school’s resources to support at-risk students, a teacher “with prior involvement” from this school related, “There’s really nothing. It’s pretty pathetic, quite honestly.” An individual “likely to handle” at-risk students from one of the larger high schools with several thousand students described himself as the only on-campus suicide prevention resource. A counselor from this same school, who had not handled any cases recently, also remarked on the lack of available resources. He suggested that a crisis team could be pulled together if needed, but no such team met regularly. A lack of on-campus resources was not universal among all low implementation schools, however. One school did have a designated crisis counselor and other student support programs, but participants from this school indicated that despite these resources, little was in place to coordinate services for at-risk students.
District-level training and support
The school district’s role with respect to YSPP training and support was another theme that emerged, most commonly with individuals “likely to handle” at-risk students at most high implementation schools. Approximately equal numbers of staff from high implementation and low implementation schools receive YSPP training each year. However, participants at high implementation schools were likely to be aware of and have participated in YSPP training sessions and discussed completion of the YSPP assessment form as one of the steps in the crisis response protocol. For example, one experienced counselor from a high implementation school, trained in YSPP procedures, described how, when concerned about a student, she would “usually fill out [the YSPP assessment] form and submit that to the district. With that, I also refer the student to see the school’s psychiatric social worker.” However, she did not find the form particularly helpful, describing it as part of the “procedure” to document the actions taken to respond to the situation. An administrator at another high implementation school said that he and his team had been trained “over and over again” by the district and that his crisis team relies heavily on the district YSPP school psychologist.
Similar to participants in high implementation schools, staff from low implementation schools were variably familiar with the YSPP assessment form but had little understanding of its use or purpose. For example, a number of participants in low implementation schools observed that efforts to follow the formal YSPP protocols, such as properly completing and submitting the assessment form were not always associated with an effective response to students who are at risk for suicide. As one individual “likely to handle” at-risk students said, “I don’t know what follow-up is done with the assessment form. I’m not informed of that.” Participants at another low implementation school also commented that they did not know what happened after the forms were submitted to the district’s central office. Several indicated that they did not consistently complete the forms, as they did not see the value in doing so. For example, one individual “likely to handle” at-risk students, who has served as a YSPP trainer, remarked: “We don’t do a good job with [completing the forms]. I don’t do a good job. I try to do a good job with it. If you spent one day with me you would understand. If you close down your office for an hour there will be a backlog. So the [forms] are never done right away, ever. Most people are under the impression that the form is for someone’s master thesis. Using the bathroom is a luxury — the form is low on the totem pole.” Another theme of the low implementation schools was the perceived lack of district support for the YSPP. As a teacher with prior involvement from a low implementation school said, “(The district) needs to make it (YSPP) a priority. If they made it a priority and put health clinics on campus and funded [psychiatric social workers], if we had someone we could call anytime, that would help. We have one person in the entire district (running the YSPP); they call him the “Suicide Guy.” He is the suicide prevention unit. He’s awesome, but it’s only one man for the second largest school district in the U.S.”
Exceptions to the high/low implementation categories
As noted above, one low implementation school was similar to the high implementation schools in that respondents from this school indicated that they have a “good response team,” and a widely used resource guide. Respondents from this school indicated that they have a team approach wherein they look at each incident as a learning experience. Similar to most of the participants from the high implementation schools, participants from this one low implementation school indicated that their administration is highly supportive and involved. Thus, despite low implementation of the district protocol, this school (re)invented a comprehensive system that they perceived to be highly effective in addressing the issue of at-risk students.
In contrast, one high implementation school was more similar to the low implementation schools in that the school did not have an organized approach to at-risk cases. They had one person who seemed to be solely responsible for at-risk students; they did not describe a team or an integrated model. Four of the five participants from this school described multiple challenges, including poor staff communication and lack of cohesion. For example, when asked what makes her role more difficult, one experienced teacher said, “Resistance of the school to deal with the patience it takes to deal with a situation.” Participants from this school indicated that lack of school commitment to at-risk students is problematic. Most participants from this school indicated that suicide risk was not a priority for the school.