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Shield of Care: Participant Workbook NAME: Shield of Care “System Policy & Protocol” “Connectedness to Youth” “Communication Between Protectors”

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S h i e l d o f C a r e : P a r t i c i p a n t W o r k b o o k

NAME:

Shield of Care

“System Policy & Protocol” “Connectedness to Youth”“Communication Between Protectors”

2 SHIELD OF CARE: Participant Workbook

SHIELD OF CARE: Participant Workbook

3

System Policy and Protocol

Connectedness to Youth

Communication Between Protectors

PROT

ECTOR PROTECTOR

P R O T E C T O R

PROT

ECTO

R PROTECTOR

4 SHIELD OF CARE: Participant Workbook

IndexIntroductory Letter and Self Care Resources ...........................................5

Section I: Introduction to the Shield of Care ..............................................6

Section II: Overview ................................................................................. 7

Section III: Shield of Care Model

Overview ........................................................................................... 9

Part A: “Seeing” ................................................................................ 10

Part B: “Protecting” .......................................................................... 19

Part C: “Listening” ............................................................................ 21

Part D: “Assessing” ...........................................................................24

Part E: “Networking” ........................................................................ 27

Section IV: After a Suicide ......................................................................30

Youth Story Cards

Victoria ...........................................................................................32

Jake ................................................................................................34

Haley ...............................................................................................36

David ...............................................................................................38

Section V: Glossary ................................................................................40

SHIELD OF CARE: Participant Workbook

5

Self Care Guide

Thank you for joining us in this suicide prevention training. We hope this training will be a beneficial experience for you.

In this training, we will be learning about the prevalence of suicide in juvenile justice facilities, reflecting on our attitudes about suicide, and learning strategies for preventing suicide in our facility.

We know that suicide can be a difficult topic to think about and discuss. Learning or talking about suicide prevention can be especially difficult for those who have lost a loved one to suicide. For this reason, if the topic gets too personal or intense for you, feel free to quietly step out of the training and regroup. The trainers may also be able to assist you briefly during a break and talk with you about additional resources available.

If you would like additional one-on-one time to talk with someone about the thoughts/emotions you experienced during this training, you may contact any of the resources below. These resources in your community may also be used to find out more information about suicide prevention and/or as referral resources if someone you know is thinking of suicide.

National Suicide Prevention Resources:

• NationalSuicidePreventionLifeline:1-800-273-TALK (8255) • AmericanAssociationofSuicidology(AAS):http://www.suicidology.org • AmericanFoundationforSuicidePrevention(AFSP):http://www.afsp.org Note: If you’ve lost a loved one to suicide, AFSP and AAS have a list of survivor support groups listed by state. • NationalOrganizationforPeopleofColorAgainstSuicide(NOPCAS): http://www.nopcas.com • SuicidePreventionResourceCenter(SPRC):http://www.sprc.org Additional National Resources:

• PoisonControl:1-800-222-1212 • NationalCenteronInstitutionsandAlternatives:http://www.ncianet.org • GatekeeperSupportTools:http://www.gatekeeperaction.org

Local Suicide Prevention and Referral Resources: * ________________________________________________________ * ________________________________________________________ * ________________________________________________________ * Yoursupervisor _____________________________________________ * Anothertrustedco-worker ______________________________________

Ifyouareunabletocompletethistrainingduetoanintenseemotionalconcern,pleasecoordinatealternativetrainingoptionswithyoursupervisor.

6 SHIELD OF CARE: Participant Workbook

Section I: IntroductionIntroduction_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

SHIELD OF CARE: Participant Workbook

7

Section ll: Overview

II

OverviewWhatisthepreventionpotentialofthisinformation?__________________________________________________________________________Howcanyoumaximizethepreventionpotentialofthisinformationgivenyourrole?__________________________________________________________________________

Whatisthepreventionpotentialofthisinformation?_____________________________________ _____________________________________Howcanyoumaximizethepreventionpotentialofthisinformationgivenyourrole?__________________________________________________________________________

Attention Deficit/Hyperactivity Disorder-isadevelopmentdisorder.“Symptomsincludedifficultystayingfocusedandpayingattention,difficultycontrollingbehavior,andhyperactivity(over-activity).”(NIMH)

Conduct Disorder –“isarepetitive,persistentpatterninchildrenoradolescentsofviolatingtherightsofothers,rules,orsocialnorms.”(SPRC)

Post Traumatic Stress Disorder–“Acommonanxietydisorderthatdevelopsafterexposuretoaterrifyingeventorordealinwhichgravephysicalharmoccurredorwasthreatened.“(WikEd)

Psychotic Disorder–“Amentaldisorderinwhichaperson’scontactwithrealityisimpaired.Duringapsychoticepisodeaperson’sthoughtpatternsareoftenconfusedanddisorganized.Theyfrequentlyexperiencesuchsignsandsymptomsasdelusions,hallucinationsandparanoia.”(Psychiatrynetworks.com).

(Source:SPRC/AFSPToolkitforSchools)

8 SHIELD OF CARE: Participant Workbook

Section ll: Overview

Whatisthepreventionpotentialofeachofthestatisticsonthisslide?

Statistic #1 _____________________________________________________________________________________________

Statistic #2 _____________________________________________________________________________________________

Statistic #3 _____________________________________________________________________________________________

Whatisthepreventionpotentialofthisinformation?__________________________________________________________________________Howcanyoumaximizethepreventionpotentialofthisinformationgivenyourrole?__________________________________________________________________________

Whatisthepreventionpotentialoftheinformationfromourownfacility?__________________________________________________________________________

Whatcanyoudoinyourroletomaximizethisinformation?__________________________________________________________________________

SHIELD OF CARE: Participant Workbook

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Section ll: Overview

II

10 SHIELD OF CARE: Participant Workbook

Section lll: Shield of Care ModelPART A:SEEING

1. SEEING ATTITUDES

A. Activity:SuicideAttitudesSurvey Directions:Below,youwillseeseveralstatementsaboutsuicide.Afterreadingeachstatement,decidewhetheryou1)StronglyDisagree,2)Disagree,3)NeitherAgreeNorDisagree,4)Agree,or5)StronglyAgree.Therearenorightorwronganswers,onlywhatyouthinkorbelieve.Usetheanswergridprovidedtorecordyourresponses.

StronglyDisagree

Disagree NeitherAgreeNorDisagree

Agree StronglyAgree

1.Thereisn’tmuchIcandotostopayouthfromkillinghim/herself.

1 2 3 4 5

2.Suicidalbehaviorsareirrational. 1 2 3 4 5

3.Youthinsecurefacilitieswhothreatenorattemptsuicideonlywantattention.

1 2 3 4 5

4.Suicideiswrong. 1 2 3 4 5

5.ImaychoosenottointervenewithasuicidalJJyouthsoIdonotbecomeliable.

1 2 3 4 5

6.IfayouthIworkwithinthefacilityconsidersorattemptssuicide,Ihavefailedathelpingthatyouth.

1 2 3 4 5

7.ThefacilityenvironmentincreasesJJyouth'sriskforsuicide.

1 2 3 4 5

8.SuicidepreventiontrainingcanhelpmesavelivesofJJyouth.

1 2 3 4 5

9.JJyouththinkaboutsuicidemoreoftenthannon-incarceratedyouth.

1 2 3 4 5

10.Youthinsecurefacilitieshavefewerreasonstolivethannon-offendingyouth.

1 2 3 4 5

11.Astaffpersonwhointerveneswhenayouthisconsideringsuicidebecomeslegallyresponsibleforthatyouth'slifeordeath.

1 2 3 4 5

12.IfeelcomfortablediscussingsuicideissueswithyouthinJJfacilities.

1 2 3 4 5

SHIELD OF CARE: Participant Workbook

11

Section lll: Shield of Care Model

III

PART A:SEEING

Once you’ve completed the survey, answer the following questions:

1. Doesattitude#1helporhinderacaregiver’sabilitytopreventsuicide? Why?/Whynot? _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________

2.Doesattitude#2helporhinderacaregiver’sabilitytopreventsuicide? Why?/Whynot? _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________

3.Doesattitude#3helporhinderacaregiver’sabilitytopreventsuicide? Why?/Whynot? _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________

4.Doesattitude#4helporhinderacaregiver’sabilitytopreventsuicide? Why?/Whynot? _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________

12 SHIELD OF CARE: Participant Workbook

Section lll: Shield of Care ModelPART A:SEEING

General Prevention Tips:

Develop

supportive

relationships

with youth

in general so

that it will

be easier

for them

to accept

your help

in a crisis

situation.

Help all

youth build

confidence

in their

ability to

solve smaller

problems. In

doing so, it

will be easier

for them to

solve larger

problems.

II. SEEING YOUTH

A. Thinking Patterns

1. Rigid thinking–Thisisanallornothingthinkingpattern.TypicallyifXdoesordoesn’thappen,IwilldoY.“Ifmydaddoesn’tcomeseemebymybirthday,I’mgivingup.”

2. Overgeneralizing–Takinganincident/experience/feeling,etc.andextendingittoanunreasonableconclusion.Forexample,afamilymembermayhavemissedavisitduetoanemergency,andyouheartheyouthsay,“See,shemissedthemeeting.Shedoesn’tgiveacrapandnooneelsedoeseither.”“Ican’tdothis.Ican’tdoanythingright.”“I’vebeeninthisstinkingplaceforyears,andnoonewillevertalktome.”

3. Catastrophizing–Takingsomethingandmakingitacatastrophe-“Ihavenothingtolookforwardto.Imightaswellbedead.”“Peopledon’tcareaboutanyoneexceptthemselves.”

4. Terminal statements–Anystatementthathintsofdeathorsuicide.“Imightaswelljustkillmyself,”“Ijustcan’ttakeitanymore.”

(Source:Maceetal.,2007)

SHIELD OF CARE: Participant Workbook

13

Section lll: Shield of Care Model

III

PART A:SEEING

III. SEEING RISK

Protectivefactorsarecharacteristicsthatmakeitlesslikelythatindividualswillconsider,attempt,ordiebysuicide.

Thesefactorsarelargelybiological,psychological,socialandenvironmental.

Biological:Intellectualability,personality/temperamentaltraits,andtoughness,Psychological:Resilience,motivation,humorandperceptionsofself;emotionalattributes-emotionalwell-being,lifesatisfaction,optimism,happiness,trust,optimism,hope;cognitive;spiritualattributes,andattributesofpost-traumaticgrowth.Social: Interpersonalskills,interpersonalrelationships,connectedness,andsocialsupportEnvironmental:Positivelifeeventsandsocioeconomicstatus.

(Bell,etal.,2005)

Formoreinformationonprotectivefactors,visit:http://www.giftfromwithin.org/html/promote.html

_________________________________________________________________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________

14 SHIELD OF CARE: Participant Workbook

Section lll: Shield of Care ModelPART A:SEEING

A. HIGH RISK PERIODS OF CONFINEMENT

(Sources:Hayes,2009;Hayes,2007)

RoomConfinementDeathofAnotherYouthintheFacilityParentsThreatof/FailuretoVisitFailureintheProgramRidiculefromPeersSevereGuiltorShameaboutOffenseSexual/PhysicalAssault

Roomconfinementisasanctionthatcanhavedeadlyconsequencesandshouldbecloselyscrutinizedandutilizedjudiciously.

Infact,over 50% of all juvenile suicides occur while the youth is under room confinement status.

Thisisaverysignificantfinding.Placementofayouthonconfinementstatusmaytriggerself-injuriousbehavior.

SHIELD OF CARE: Participant Workbook

15

Section lll: Shield of Care

III

PART A:SEEING

B. SUICIDE WARNING SIGNS (Sources:SPRC;AFSP;Joiner,2005)

Warningsignsarethosesignsthatindicatethepossibilityofanimminentsuicidalcrisis.Thislistincludeswarningsignsmostcommonlycitedinawidebodyofresearch.Takeallsuicidalbehaviorseriously.

Ideation -Thoughtsofsuicide.Ideationcanbeexpressedthroughtalking,gesturing,writinganddrawing.

MayalsobeexhibitedthroughTerminal Statements-“Iwon’tbeaproblemforyoumuchlonger.”“IwishIweredead.”“I’mgoingtokillmyself.”“It’snouse.”

HavingaSuicide Plan

Actively Seeking Access to Suicide Means

Unbearable PainoftenasaResultofaLoss/Crisis-deathofalovedone,divorce,break-up,peerrejectionorthelossofanythingthatisofgreatvaluetotheteenespeciallyinconjunctionwithdepression

Perceived Lack of Resources–InternalandExternal Perceived Expendability–Beliefthatnoonewouldmisstheteen,theteen’sexistencedoesn’tmatter,orthatpeoplewouldbebetteroffwithouthim/her

Increased/PersistentorMore Pronounced Signs of Depression(especiallyanger,sadnesstomisery,withdrawal/isolation,lackofinterestinusualactivities)

Making final arrangements,sayinggoodbyeasifs/hewon’tseesomeoneelseagain

Giving Away Possessions Refusinghelp,feeling“beyond help” Becomingsuddenly cheerful afteraperiodofdepression–thismaymeanthat

16 SHIELD OF CARE: Participant Workbook

Section lll: Shield of Care ModelPART A:SEEING

theteenhasalreadymadethedecisiontoescapeallproblemsbyendinghis/herownlife Feelingsofhopelessnessorpurposelessness

Bullyingand/orharassmentand/orextremeembarrassment/humiliation

C. SUICIDE RISK FACTORS(Source:SPRC)

Riskfactorsarethosesignsthatpredisposesomeonetosuicide.Thefollowinglistincludesthoseriskfactorsmostcommonlycitedinresearch.

Biopsychosocial Risk Factors•Mentaldisorders,particularlymooddisorders,schizophrenia,anxietydisorders andcertainpersonalitydisorders• Alcoholandothersubstanceusedisorders• Hopelessness• Impulsiveand/oraggressivetendencies• Historyoftraumaorabuse• Somemajorphysicalillnesses• Previoussuicideattempt• Familyhistoryofsuicide• Environmentalriskfactors• Joborfinancialloss• Relationalorsocialloss• Easyaccesstolethalmeans• Localclustersofsuicidethathaveacontagiousinfluence

SHIELD OF CARE: Participant Workbook

17

Section lll: Shield of Care

III

PART A:SEEING

Is it Depression?

Likely if…the

changes persist

for longer than

two weeks; the

signs continue

to worsen;

attempts to

relieve the

symptoms are

unsuccessful;

and/or the

symptoms

interfere with

everyday

activities.

Sociocultural Risk Factors;• Lackofsocialsupportandsenseofisolation• Stigmaassociatedwithhelp-seekingbehavior• Barrierstoaccessinghealthcare,especiallymentalhealthandsubstance abusetreatment• Certainculturalandreligiousbeliefs(forinstance,thebeliefthatsuicideis anobleresolutionofapersonaldilemma)• Exposureto,includingthroughthemedia,andinfluenceofotherswho havediedbysuicide• Problemswiththelaw/involvementwiththejuvenilejusticesystem

Althoughthemajorityofpeoplewhohavedepressiondonotdiebysuicide,severedepressiondoessignificantlyincreasetheriskofsuicide.

D. SIGNS OF DEPRESSION

(Sources:DMVIV;NationalAssociationofSchoolPsychologists)

Behavioral Changes

• Depressed,angryorirritablemoodmostoftheday,nearlyeveryday• Diminishedinterestorpleasureinall,oralmostall,activities• Diminishedabilitytoconcentrate;orindecisiveness• Changeinschoolperformance(globaldropingrades)• Changeinattitudeaboutschool• Substanceabuse• Constantfeelingsofworthlessnessorexcessiveorinappropriateguilt• Problemsinrelationships• Recurrentthoughtsofdeath(notjustfearofdying),recurrentsuicidalideation, asuicideattemptoraspecificplanforcommittingsuicide• Refusaltoattendorparticipateinschool• Outburstsofshouting,complaining,unexplainedirritability,orcrying

18 SHIELD OF CARE: Participant Workbook

Section lll: Shield of CarePART A:SEEING

• Withdrawal,socialisolation,andpoorcommunication• Extremesensitivitytorejectionorfailure• Unusualtempertantrums,defiance,oroppositionalbehavior• Chronicboredomorapathy

Physical Symptoms• Significantweightlossorgainordecrease/increaseinappetite• Difficultysleepingorexcessivesleeping• Agitated-alwaysmoving• Psychomotorretardation• Mopingaroundnearlyeveryday• Vaguephysicalcomplaints;constantfatigueorlackofenergy

E. Challenging behavior

Depressedorsuicidalyouthmaychallengeyouwiththeirbehaviorparticularlyifangerisapredominantsignofdepression.Rememberthatthisbehaviormaybedrivenbyanillnessratherthanthedesiretomakeyourlifedifficultortochallengeyourauthority. F. Activity: Video Viewing Tasks

Please note any of the following:

1.Signsofdepression: ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________2.Riskfactorsofsuicide: ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________

3.Warningsignsofsuicide: ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________

G. Activity: Youth Story Cards–Refertothe“Seeing”QuestionsontheYouthStoryCardintheAppendixforthisExercise.

SHIELD OF CARE: Participant Workbook

19

Section lll: Shield of Care

III

PART B:PROTECTING

“PROTECTING”

I INTERVENTIONS

A. Responding to a Suicide Attempt

Roomconfinementisasanctionthatcanhavedeadlyconsequencesandshouldbecloselyscrutinizedandutilizedjudiciously.Infact,over50%ofalljuvenilesuicidesoccurwhiletheyouthisunderroomconfinementstatus.Thisisaverysignificantfinding.Placementofayouthonconfinementstatusmaytriggerself-injuriousbehavior.

NotesOnOurFacility’sObservationLevels:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

20 SHIELD OF CARE: Participant Workbook

Section lll: Shield of Care Model

PART B:PROTECTING

B. Activity: YouthStoryCards–Refertothe“Protecting”QuestionsontheYouthStoryCardintheAppendixforthisExercise.

C. Activity: PolicyReview

Pleasetakeoutyourcopyofthepoliciesandproceduresandstayinyourgroupstodiscussthefollowingexerciseandquestions:

Inwhatwaysarethesepolicieshelpfultoyouasacaregiverwhenthinkingaboutprotectingayouthatriskforsuicide?

Inwhatwaysisyourrolelimitedbypolicyinregardtoprotectingyouthatriskforsuicide?

SHIELD OF CARE: Participant Workbook

21

Section lll: Shield of Care Model

III

PART C:LISTENING

“LISTENING”

A. Reflection

B. Activity:Listening–IndividualWork

Directions:Paraphrasethefollowingstatement.Avoidpitfalls!

“Nooneunderstands.Noonewilleverunderstand.”

Paraphrasehere _____________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________

22 SHIELD OF CARE: Participant Workbook

Section lll: Shield of Care ModelPART C:LISTENING

C. Activity: Listening–PairWork

Objective:Thepersonintheroleoflistenerwillpracticelisteningskillsinthecontextofthespeaker’saggravationdrivingexperience.

Directions:Thelistenerwillpracticeparaphrasingthespeaker’sexperienceascloselyaspossiblewhileresistingthetemptationofofferingasolution,sharingasimilarexperienceorcriticizingtheotherdriver.

1.Individually–Thinkofsomethinganotherdriverdidthatreallymadeyoumad. Writeithere _______________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________

2.Begintheexercisewiththestatementbelow.

Open with “You look really [upset].”

3.Allowyourpartnertodiscusstheexperience

4.Practiceusingthefollowing:

“So you’re saying…” “What I hear you saying is …Mirror the statement – Near word for word restatement.

SHIELD OF CARE: Participant Workbook

23

Section lll: Shield of Care Model

III

PART C:LISTENING

5.Onceyou’vereflectedtheexperience,followitupwith.“I’msorrythathappenedtoyou.”

Wait for trainer to debrief

D. Activity: Youth Story Cards–Refertothe“Listening”QuestionsontheYouthStoryCardintheAppendixforthisExercise.

E. Activity: Policy Review

Pleasetakeoutyourcopyofthepoliciesandproceduresandstayinyourgroupstodiscussthefollowingexerciseandquestions:

Inwhatwaysarethesepolicieshelpfultoyouasacaregiverwhenthinkingaboutlisteningtoayouthatriskforsuicide?

24 SHIELD OF CARE: Participant Workbook

Section lll: Shield of Care ModelPART D: ASSESSING

“ASSESSING”

A. Asking about suicide

1.Whataresomewaystoaskdirectlyaboutsuicide?________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

B. Listening and Asking

Example of using listening skills and asking the question:S = Staff, Y = youth

S-Iseethatyou’rereallyangry.What’sgoingon?Y – Mymomdidn’tshowupagain.S–You’resayingthatyourmomdidn’tshowupagain.Icanunderstandwhy _ youwouldbeangryaboutthat.Y – Shedoesn’tcare.Noonedoes.Iwon’tbeaproblemforhermuchlonger.

Basedontheaboveexample,answerthefollowingquestions:

1.Whatmightleadyoutothinkthatsuicideisanissue? ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________

2.Woulditbetoosoontoaskaboutsuicide? ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________

3.Howwouldyoudoit? ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________

SHIELD OF CARE: Participant Workbook

25

Section lll: Shield of Care Model

III

PART D: ASSESSING

C. Activity: Video Viewing Tasks

Directions: Inyourgroups,decidewhowillbefocusingonseeing,whowillbefocusingonprotecting,whowillbefocusingonlisteningandwhowillbefocusingonassessing.Oncetheserolesareassigned,takenotesinyourassignedsectionbelow: “Seeing” Tricia1.Noteanysignsofdepression,riskfactors/warningsignsforsuicideorhighriskperiodsofconfinementhere. ________________________________________________________ ________________________________________________________ ________________________________________________________

“Protecting”Tricia2.Noteanyprotectingactionshere. ________________________________________________________ ________________________________________________________ ________________________________________________________

“Listening”toTricia3.NoteexamplesofhowDarlenelistenedhere ________________________________________________________ ________________________________________________________ ________________________________________________________

“Assessing” Tricia4.HowdidDarlenedetermineTriciawassuicidal? ________________________________________________________

26 SHIELD OF CARE: Participant Workbook

Section lll: Shield of Care ModelPART D: ASSESSING

5.Ifyourememberthequestion,pleasenoteithere. ________________________________________________________

When the video is over, wait for instructions from your trainer.

Discuss the following questions.

1.WhatpromptedDarlenetobegintalkingwithTricia? ________________________________________________________

2.HowdidDarlene“protect”Tricia’semotionalsafety? ________________________________________________________ ________________________________________________________

3.HowdidDarlenephysicallyprotectTricia? ________________________________________________________ ________________________________________________________ ________________________________________________________

4.WhatspecificwarningsigndirectlyaskingandledtoDarleneaskingdirectlyaboutsuicide? ________________________________________________________

D. Activity: Youth Story Cards –Refertothe“Assessing”QuestionsontheYouthStoryCardintheAppendixforthisExercise.

E. Activity: Policy Review

Please take out your copy of the policies and procedures and stay in your groups to discuss the following questions:

Whatdoesthepolicysayaboutassessingayouthatriskforsuicide?

Inwhatwaysarethesepolicieshelpfultoyouasacaregiverwhenthinkingaboutassessingayouthyouperceivetobeatriskforsuicide?

Inwhatwaysisyourrolelimitedbypolicyinregardtoassessingayouthyouperceivetobeatriskforsuicide?

SHIELD OF CARE: Participant Workbook

27

Section lll: Shield of Care Model

III

PART E: NETWORKING

“NETWORKING”

A. Activity: Video Viewing Tasks

1.HowdoesthestaffworktogethertohelpEddie’s? ________________________________________________________ ________________________________________________________

2.AtwhatpointdidSaldoesstandbackandletNickcontinue? ________________________________________________________ ________________________________________________________

3.HowdoesNickhelpprotectEddies’emotionalsafety? ________________________________________________________ ________________________________________________________ 4.HowdoesNickmakethereferraleasierforthementalhealthstaff? ________________________________________________________ ________________________________________________________

B. Activity: Youth Story Cards –Refertothe“Networking”QuestionsontheYouthStoryCardintheAppendixforthisExercise.

28 SHIELD OF CARE: Participant Workbook

Section lll: Shield of Care ModelPART E: NETWORKING

C. Activity: S-PLAN Review

FactsUsepromptsbelowtolistfivethingsyoueitherlearnedorreviewedinthistrainingthatcouldhelpyousavealife.Beasspecificaspossible.Anexampleisprovidedbelowtohelpyougetstarted.

Example:

AnimportantFACTaboutsuicideis:SuicideistheTHIRDleadingcauseofdeathamongyouthages10-24.

In this training, I learned (or reviewed) that: . . .

1.AnimportantFACTaboutsuicideis: ________________________________________________________ ________________________________________________________2.MyOPINIONaboutsuicideincludestheattitude/beliefthat: ________________________________________________________ ________________________________________________________

3. YouthmaydemonstrateRISKFACTORS/WARNINGSIGNSofsuicide.Oneis: ________________________________________________________ ________________________________________________________

4.YouthmaydemonstratePROTECTIVEFACTORSagainstsuicide.Oneis: ________________________________________________________ ________________________________________________________

5.TheMOSTIMPORTANTthing(s)Ilearnedintrainingthatwillhelpmesavealifeis: ____________________________________________________ ________________________________________________________

Responding to Risk

Usethequestionsbelowtothinkaboutwaysyoucanapplywhatyoulearnedintrainingtorespondtoyouthatriskforsuicide.

SHIELD OF CARE: Participant Workbook

29

Section lll: Shield of Care Model

III

PART E: NETWORKING

1. HowissuicideriskmostlikelytobedisplayedintheJuvenileJustice populationatyourfacility?

a)Ayouthmightsaysomethinglike ____________________________

b)Ayouthmightdosomethinglike ____________________________ 2.Thinkaboutyourroleinyourparticularjuvenilejusticefacility(e.g.,“Security Officer;”CorrectionsTeacher).WhatpartsoftheShieldofCaremodelare youmostequipped/abletoperforminyourworkrole?Whatdoyourpolicies andproceduressayabouthelpingsuicidalyouth?

Shield of Care Action Plan

Anyoftheyouthwithwhomyouworkcouldbeatriskofsuicide.FillintheblankswithspecificinformationrelatedtotheS-PLANtodemonstratehowYOUwillhelpayouthatrisk.

1.S – ____________________________________________________

2.P – ____________________________________________________

3.L – ____________________________________________________

4.A – ____________________________________________________

5.N – ____________________________________________________

D. Activity: Busting Barriers

When I, (Your Name Here)

, encounter potential barriers to suicide prevention at

(Your Name Facility) , I will use these Barrier Busting Techniques to help save a life.

Potential Barrier to Helping Someone At Risk of Suicide:

1. ____________________________________________________________

2. ____________________________________________________________

30 SHIELD OF CARE: Participant Workbook

Section IV - After a Suicide

3. ____________________________________________________________

Barrier Busting Technique:

1. ____________________________________________________________

2. ____________________________________________________________

3. ____________________________________________________________

AFTER A SUICIDE

_________________________________

_________________________________

_________________________________

_________________________________

_________________________________

_________________________________

SHIELD OF CARE: Participant Workbook

31

Section IV - After a Suicide

IV

AFTER ASUICIDEA. Self Care - Watch for Signs of Stress

Tension: Physicalandemotionaltension,beingexcessivelyhyper,unabletorelaxorsitstillforverylong,muscletremorsortwitches.

Nausea: Especiallyduringorimmediatelyaftertheincident.

Body temperature regulation:Profusesweatingorchillsatunusualtimes.

Sleep disturbances:Eithertheinabilitytofallasleep,disruptivedreamsornightmaresorwakingupearlierthanusual.

Fatigue: Alwaystired.Nopeporenergy.Intrusive thoughts or memories: Thinkingabouttheincidentorsomerecurringmemoryobsessivethoughtsaboutwhenyoudon’twantto.

Negative feelings/Crying:Unpleasantfeelingsthatmaycomewithoutwarning,suchasprofoundsadness,helplessness,fear,anxiety,anger,rage,discouragement,frustrationordepression.

A feeling of vulnerability or lack of control:Feelingexposedtothreats,notincontrolofone’slife,experiencingparanoia.

Interpersonal problems:increasedirritability,insensitivity,blamingothers,distancingfromothers.

Substance Abuse:“Self-medication”canbeasymptomofstress.

Compulsive behavior:Increasedproblemssuchascompulsiveeatingorotheruncontrolled,repetitivebehaviors.

Self Blame:Usuallythisfixesonsomeparticularaspectoftheincident.Asenseofhavinglostself-valueordiminishedself-esteem.“Icouldhavedonethisorshouldhavedonethat.”

(UsedwithpermissionfromtheCaliforniaDepartmentofCorrectionsandRehabilitation)

32 SHIELD OF CARE: Participant Workbook SHIELD OF CARE: Participant Workbook

STORY

Victoria picked up her tray in the cafeteria line and looked for a place

to sit in the dining room. She saw a seat at a table near Jennifer,

Latisha and Monica, who always seemed to be having fun, but it

seemed like they suddenly stopped talking and looked down at their

trays as she approached, so she walked past and sat at the very next

table.

She couldn’t tell what they were whispering about, but they stopped

again when she got up to get more water. She was drinking a lot of

water the last day or so because her anti-depressant was making her

mouth so dry. She hasn’t had much appetite, and you’ve noticed that

she hasn’t been her chipper self recently or been interacting with staff

and other youth.

Victoria was just thinking of turning her tray in and heading back to her quarters when an officer walked up and

announced, “Come on, Vicky. The health clinic can take care of your request for a pregnancy test now.” Victoria could

hear the girls snickering as she stood up and looked at the officer, hissing “Thanks, bitch,” through clenched teeth. “Oh

yes you will get some ISO time for that mouth, Miss Taylor,” the officer replied. As they marched out of the cafeteria, she

could hear Monica’s distinctive voice: “You in trouble now, tricky Vicky. That rabbit done died!”

SEEINGIn groups: Identifysignsofdepression,riskfactorsorwarningsignsofsuicide,highriskperiodsofconfinementorotherworrisomebehavior.

Preparetoshareanoverviewofthiscase,discusswhichelementsofS-PLANareapriority,andanswerthefollowingquestion:

WhatdoyouseethatmaypossiblyputVictoriaatriskforsuicide?Discussanyworrisomebehavior.Whyisitworrisome?Whatcouldbedoneaboutit,ifanything?_____________________________________________________________________________

PROTECTINGHowwillyouprotectVictoria?_____________________________________________________________________________ _____________________________________________________________________________

LISTENINGInpairs,practiceyourlisteningskillsandavoidthecommonpitfalls.OnepersonwilltaketheroleofcaregiverandtheothertheroleofVictoria.Remembertomakeeyecontactandmaintainanopenbodyposture.

1

VICTORIA

SHIELD OF CARE: Participant Workbook 33

NOTES: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

DecideonanegativeemotionthatwouldlikelybedemonstratedbyVictoriaandareasoncontainedinthestoryforthatemotion.

Thepersonintheroleofcaregiverwillsimplyreflectthatemotion,thereasonandacknowledgethefeeling.

Use the following example dialogue. Change the details to relate to your story. S = Staff, Y=Youth

S – Iseethatyou’rereallyangry.What’sgoingon? Y – Mymomdidn’tshowupagain. S – You’resayingthatyourmomdidn’tshowupagain.Icanunderstandwhyyou wouldbeangryaboutthat.

ASSESSING

UsingthesamenegativeemotionandreasonforthatemotionwithinVictoria’sstory,you’regoingtoaddawarningsignforsuicideandaskdirectlyaboutsuicide.

Inpairs,practiceyourassessingskillswithonepersonactingintheroleofcaregiverandtheotherintheroleofVictoria.

Use the following example dialogue. Change the details to relate to your story, and ask about suicide. S = Staff, Y=Youth.

S–Iseethatyou’rereallyangry.What’sgoingon? Y – Mymomdidn’tshowupagain. S – You’resayingthatyourmomdidn’tshowupagain.Icanunderstandwhyyou wouldbeangryaboutthat. Y– Shedoesn’tcare.Noonedoes.“Iwon’tbeaproblemforhermuchlonger.” S – Sometimeswhenpeoplesaythat,theyarethinkingaboutsuicide.Areyou thinkingaboutsuicide?

NETWORKING

UsingtheReferralResponseGuideforyourfacility,determinethepersonwithwhomyouwillnetworkandhowtocontactthisperson.

Who: ____________________________________________________________________________________________________________

How to contact: ___________________________________________________________________________________________________________________________________________________________

JAKESTORY

You hear Jake and Matt talking about Jake’s upcoming transfer to

another facility and “CTB” catches your attention. You begin listening

closely now and hear Matt asking Jake whether he “has a ticket.”

You’re listening closely because you recognize these terms from a

suicide prevention training. During the training, you learned that

people will sometimes use the phrase “catch the bus” to mean suicide,

and that “having a ticket” means that a person has the means and a

plan to complete suicide.

You don’t want to let them know you’re listening, but you move

closer because you want to hear what Jake says in response to Matt’s

question.

You can’t hear what Jake said in reply to Matt’s question, but Matt

moves away, leaving Jake sitting at a table with his head down. Jake approached you last week and told you that his

father had died. He also said that he has a hard time talking to anyone about it.

SEEINGIn groups: Identifysignsofdepression,riskfactorsorwarningsignsofsuicide,highriskperiodsofconfinementorotherworrisomebehavior.

Preparetoshareanoverviewofthiscase,andanswerthefollowingquestion:

WhatdoyouseethatmayindicateJakeisthinkingaboutsuicide?Discussanyworrisomebehavior.Whyisitworrisome?Whatcouldbedoneaboutit,ifanything?__________________________________________________________________________________________________________________________________________________________

PROTECTINGHowwillyouprotectJake?_____________________________________________________________________________ _____________________________________________________________________________

LISTENINGInpairs,practiceyourlisteningskillsandavoidthecommonpitfalls.OnepersonwilltaketheroleofcaregiverandtheothertheroleofJake.Remembertomakeeyecontactandmaintainanopenbodyposture.

DecideonanegativeemotionthatwouldlikelybedemonstratedbyJakeandareasoncontainedinthestoryforthatemotion.

2

34 SHIELD OF CARE: Participant Workbook SHIELD OF CARE: Participant Workbook

Thepersonintheroleofcaregiverwillsimplyreflectthatemotion,thereasonandacknowledgethefeeling.

Use the following example dialogue. Change the details to relate to your story. S = Staff, Y=Youth.

S – Iseethatyou’rereallyangry.What’sgoingon? Y – Mymomdidn’tshowupagain. S – You’resayingthatyourmomdidn’tshowupagain.Icanunderstandwhyyou wouldbeangryaboutthat.

ASSESSING

UsingthesamenegativeemotionandreasonforthatemotionwithinJake’sstory,you’regoingtoaddawarningsignforsuicideandaskdirectlyaboutsuicide.

Inpairs,practiceyourassessingskillswithonepersonactingintheroleofcaregiverandtheotherintheroleofJake.

Use the following example dialogue. Change the details to relate to your story, and ask about suicide. S = Staff, Y=Youth.

S–Iseethatyou’rereallyangry.What’sgoingon? Y – Mymomdidn’tshowupagain. S – You’resayingthatyourmomdidn’tshowupagain.Icanunderstandwhyyou wouldbeangryaboutthat. Y– Shedoesn’tcare.Noonedoes.“Iwon’tbeaproblemforhermuchlonger.” S – Sometimeswhenpeoplesaythat,theyarethinkingaboutsuicide.Areyou thinkingaboutsuicide?

NETWORKING

UsingtheReferralResponseGuideforyourfacility,determinethepersonwithwhomyouwillnetworkandhowtocontactthisperson.

Who: ____________________________________________________________________________________________________________

How to contact: ___________________________________________________________________________________________________________________________________________________________

SHIELD OF CARE: Participant Workbook 35

NOTES: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

HALEYSTORYAt 17, Haley was raised in a family with money.

After an abusive event on vacation with her father 6 months prior to entering the facility, Haley had attempted to kill herself by jumping in front of a car on a busy highway near her home. Although she had several broken bones, she lived through the attempt. She was recently arrested outside a pawn shop after stealing jewelry from a high end store. She told the arresting officer that she needed the money to buy a gun because she “was just done with her miserable existence.”

Once she entered your facility, other youth avoided her. She spoke and acted very differently than others. The remark about getting a gun to kill herself was not conveyed by the arresting officer, and she denied any suicidal thoughts or behaviors on intake, so she was not placed on suicide watch.

However, she became extremely upset whenever staff discussed either her upcoming visit with her mom and younger brother or her court date. As the family visit approached, Haley began to refuse meals. When asked about it, she said that she wanted to see her family, but that she was extremely embarrassed to be there, and that she felt torn between seeing them and being seen in “juvenile jail.” A few days prior to the visit, she would nod off in the day room and had to be reminded that sleeping was not allowed. The third time she put her head down and slept, staff placed her on room confinement for the rest of the day.

Despite the fact that Haley wasn’t on suicide watch, you get a strong feeling that you should probably check on her. When you do, you discover that she had obtained a radio cord, had wrapped it around her neck, and is barely responsive.

SEEINGIn groups: Identifysignsofdepression,riskfactorsorwarningsignsofsuicide,highriskperiodsofconfinementorotherworrisomebehavior.

Preparetoshareanoverviewofthiscase,andanswerthefollowingquestion:

WhatdoyouseethatmayindicateHaleyisthinkingaboutsuicide?Discussanyworrisomebehavior.Whyisitworrisome?Whatcouldbedoneaboutit,ifanything?__________________________________________________________________________________________________________________________________________________________

PROTECTINGUsingtheSuicideInterventionandPrecautionGuide,howwillyouprotect her?_____________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________

3

36 SHIELD OF CARE: Participant Workbook SHIELD OF CARE: Participant Workbook

LISTENINGInsteadofconfininghertoherroom,youtooksometimetolistentoHaley.

Inpairs,practiceyourlisteningskillsandavoidthecommonpitfalls.OnepersonwilltaketheroleofcaregiverandtheothertheroleofHaley.Remembertomakeeyecontactandmaintainanopenbodyposture.

DecideonanegativeemotionthatwouldlikelybedemonstratedbyHaleyandareasoncontainedinthestoryforthatemotion.

Thepersonintheroleofcaregiverwillsimplyreflectthatemotion,thereasonandacknowledgethefeeling.

Use the following example dialogue. Change the details to relate to your story. S = Staff, Y=Youth.

S – Iseethatyou’rereallyangry.What’sgoingon? Y – Mymomdidn’tshowupagain. S – You’resayingthatyourmomdidn’tshowupagain.Icanunderstandwhyyou wouldbeangryaboutthat.

ASSESSING

ImaginethatyouhadtheopportunitytoassessHaleypriortoherattempt.UsingthesamenegativeemotionandreasonforthatemotionwithinHaley’sstory,you’regoingtoaddawarningsignforsuicideandaskdirectlyaboutsuicide.

Inpairs,practiceyourassessingskillswithonepersonactingintheroleofcaregiverandtheotherintheroleofHaley.

Use the following example dialogue. Change the details to relate to your story, and ask about suicide. S = Staff, Y=Youth.

S–Iseethatyou’rereallyangry.What’sgoingon? Y – Mymomdidn’tshowupagain. S – You’resayingthatyourmomdidn’tshowupagain.Icanunderstandwhyyou wouldbeangryaboutthat. Y– Shedoesn’tcare.Noonedoes.“Iwon’tbeaproblemforhermuchlonger.” S – Sometimeswhenpeoplesaythat,theyarethinkingaboutsuicide.Areyou thinkingaboutsuicide?

NETWORKING

UsingtheReferralResponseGuideforyourfacility,determinethepersonwithwhomyouwillnetworkandhowtocontactthisperson.

Who: ____________________________________________________

How to contact: ____________________________________________________________________________________________________

SHIELD OF CARE: Participant Workbook 37

NOTES: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

DAVIDSTORY

David, 15, did not have a history of conflict with other youth at the

facility, but lately, he has been spending quite a bit of time in room

confinement for physical and verbal conflicts with youth and staff.

After he was discharged from room confinement for yelling at staff

again earlier this week, David became particularly upset after a

phone call from his father canceling his visit for the second time that

month.

David had been outspoken prior to the call, but hasn’t said much

since. Once an active participant in class he has started to do the bare

minimum. A teacher saw him drawing a noose in the margins of his

notepaper today and alerts you immediately. While you are waiting

for mental health staff, you talk with him and discover that although

his girlfriend broke up with him, he seems disturbingly cheerful.

SEEINGIn groups: Identifysignsofdepression,riskfactorsorwarningsignsofsuicide,highriskperiodsofconfinementorotherworrisomebehavior.

Preparetoshareanoverviewofthiscaseandanswerthefollowingquestion:

WhatdoyouseethatmayindicateDavidisthinkingaboutsuicide?Discussanyworrisomebehavior.Whyisitworrisome?Whatcouldbedoneaboutit,ifanything?__________________________________________________________________________________________________________________________________________________________

PROTECTINGIsDavid’sphysicaloremotionalsafetyapriority?UsingtheSuicideInterventionandPrecautionGuide,howwillyouprotecthim?_____________________________________________________________________________ _____________________________________________________________________________

LISTENINGInpairs,practiceyourlisteningskillsandavoidthecommonpitfalls.OnepersonwilltaketheroleofcaregiverandtheothertheroleofDavid.Remembertomakeeyecontactandmaintainanopenbodyposture.

DecideonanegativeemotionthatwouldlikelybedemonstratedbyDavidandareasoncontainedinthestoryforthatemotion.

4

38 SHIELD OF CARE: Participant Workbook SHIELD OF CARE: Participant Workbook

Thepersonintheroleofcaregiverwillsimplyreflectthatemotion,thereasonandacknowledgethefeeling.

Use the following example dialogue. Change the details to relate to your story. S = Staff, Y=Youth.

S – Iseethatyou’rereallyangry.What’sgoingon? Y – Mymomdidn’tshowupagain. S – You’resayingthatyourmomdidn’tshowupagain.Icanunderstandwhyyou wouldbeangryaboutthat.

ASSESSING

UsingthesamenegativeemotionandreasonforthatemotionwithinDavid’sstory,you’regoingtoaddawarningsignforsuicideandaskdirectlyaboutsuicide.

Inpairs,practiceyourassessingskillswithonepersonactingintheroleofcaregiverandtheotherintheroleofDavid.

Usethefollowingexampledialogue.Changethedetailstorelatetoyourstory,andaskaboutsuicide.

Use the following example dialogue. Change the details to relate to your story, and ask about suicide. S = Staff, Y=Youth.

S–Iseethatyou’rereallyangry.What’sgoingon? Y – Mymomdidn’tshowupagain. S – You’resayingthatyourmomdidn’tshowupagain.Icanunderstandwhyyou wouldbeangryaboutthat. Y– Shedoesn’tcare.Noonedoes.“Iwon’tbeaproblemforhermuchlonger.” S – Sometimeswhenpeoplesaythat,theyarethinkingaboutsuicide.Areyou thinkingaboutsuicide?

NETWORKING

UsingtheReferralResponseGuideforyourfacility,determinethepersonwithwhomyouwillnetworkandhowtocontactthisperson.

Who: ____________________________________________________________________________________________________________

How to contact: ___________________________________________________________________________________________________________________________________________________________

SHIELD OF CARE: Participant Workbook 39

NOTES: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Section V - Glossary

40 SHIELD OF CARE: Participant Workbook SHIELD OF CARE: Participant Workbook

Anchor–Afixedobject,suchasawindowframeorcamerahousing,fromwhichtohangoneself.

Causal factor-Afactorlinkedtothecausationofadiseaseorhealthproblem.

Contagion -Aprocessbywhichexposuretothesuicideorsuicidalbehaviorofoneormorepersonsinfluencesotherstocommitorattemptsuicide.

HIPAA–Enactedin1996,HIPAAortheHealthInsurancePortabilityandAccountabilityActhelpsworkersretainhealthinsurancewhentheychangeorlosetheirjobsandprotectstheprivacyofpersonallyidentifiablehealthinformation.

Ligature –Anythingthatcanbeusedtohangoneself.Thismaybearag,plasticbag,shoelaceoranyothermaterialthatcanbeusedaroundtheneckandthatcanwithstandtheweightofabody.

Mortality review –Aninvestigationfollowingasuicidewherebythedetailsprecipitatingasuicidearedocumentedanddiscussedwiththeintentofpreventingadditionalsuicides.

Postvention -TheAmericanAssociationofSuicidePreventiondefinessuicidepostventionasthe“provisionofcrisisintervention,supportandassistanceforthoseaffectedbyacompletedsuicide.”

Precipitating factor-Thecatalystforanillness,symptom,orepisode.Thismaynotbetheunderlyingcauseofanillness,ratheritiswhatleadsuptoit.

Protective factor-Protectivefactorsareskills,strengths,orresourcesthathelppeopledealmoreeffectivelywithstressfulevents.Protectivefactorsmaybepersonal,external,orenvironmental.

Room confinement –Definedasabehavioralsanctionimposedonyouththatrestrictsmovementforvaryingamountsoftime.Itincludes,butisnotlimitedto,isolation,segregation,time-out,oraquietroom[Hayes,2009].

Risk factor–Anindividual’scharacteristics,circumstances,historyandexperiencesthatincreasethestatisticalriskforsuicide.

Suicide-Deathcausedbyself-directedinjuriousbehaviorwithanyintenttodieasaresultofthebehavior.(Source:CDC)

Section V - Glossary

V

SHIELD OF CARE: Participant Workbook 41

Suicide attempt-Anonfatalself-directedpotentiallyinjuriousbehaviorwithanyintenttodieasaresultofthebehavior.Asuicideattemptmayormaynotresultininjury.

Suicidal ideation –Thoughtsofharmingorkillingoneself.Ideationcanbeexpressedthroughtalking,gesturing,writingordrawing.MayalsobeexhibitedthroughTerminalStatements-“Iwon’tbeaproblemforyoumuchlonger.”“Nothingmatters.”“IwishIweredead.”“I’mgoingtokillmyself.”“It’snouse.”

Suicide precaution-Anobservationalstatusplaceonsuicidalyouthrequiringincreasedstaffsurveillanceandmanagement.(Hayes,2005)

Warning signs -Variablesthatsignalthepossiblepresenceofsuicidalthinking

42 SHIELD OF CARE: Participant Workbook

TheTennesseeDepartmentofMentalHealth(TDMH)istheauthor/ownerofthismaterialdevelopedaspartoftheTennesseeLivesCountJuvenileJusticeproject fundedviaagrant(#2U79SM057400-04)fromtheSubstanceAbuseandMentalHealthServicesAdministration(SAMHSA),U.S.DepartmentofHealthandHumanServices(HHS).Theviews,policies,andopinionsexpressedarethoseof theauthorsanddonotnecessarilyreflectthoseofSAMHSAorHHS.TheTennesseeDepartmentofMentalHealth(TDMH)istherecipientofthisgrantmadepossiblethroughtheGarrettLeeSmithMemorialActof2004.TheTLC/JJprojectiscollaborativelyimplementedwithMentalHealthAmericaofMiddleTennessee,theCenterstoneResearchInstitute,andtheTennesseeSuicidePreventionNetwork.

ShieldofCare™CopyrightStatementAllmaterials,trainermanuals,workbooks,logoandvideopresentationsoftheShieldofCare™arethesolepropertyoftheTennesseeDepartmentofMentalHealthTDMH,StateofTennessee,andshallnotbereproducedorpresentedinpartorinwholewithoutexpresswrittenpermissionofTDMH.ContacttheDivisionofMentalHealthServicesat(615)253-5078orwriteto:LygiaWilliams,Project

Director,10thFloor,AndrewJohnsonTower,710JamesRobertsonParkway,Nashville,Tennessee27243.©2012,FirstEdition

PublicationAuthorization339523;50copies@$4.48ea.March,2012,TennesseeDepartmentofMentalHealth

For more information visit:

www.tn.gov/mental (click on suicide prevention)

www.tspn.org/shield-of-care