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‘Choose Life’Website:The Development of a Self-Harm and Suicide Reduction and Prevention Website by Pupils Bereaved afterSuicide During a Critical Incident Involving a Suicide Cluster
LORRAINE SILVER
Educational Psychology Service
Introduction
Suicide is one of the leading causes of death amongst young people (Debski, Spadafore, Jacob, Poole Hixon, 2007).The Office for National Statisticsrecorded suicide as being the second most common cause of death after road accidents amongst 15 to 24 year olds in England and Wales during 2007 and 2008 (Street, 2010).Suicide constitutes a significant public health issue and given thegrowing concerns about adolescent and youth suicide an abundance of literaturehas been generated identifying potential risk factors.It is generally recognised that suicide is a complex issue, the cause of which is likely to be multifaceted.However, common themes in the suicide literature suggest that suicide ideation and suicide attempts are typicallyassociated with demographic and personal characteristics, behavioural changes, previous suicide attempts, family correlates and precipitating events,such as the break up of a boyfriend / girlfriend (Debski etal., 2007).
One precipitating event which has been the subject of much debate is the affect of news reports of other youth suicides in the same community,with thesuggestion of a causal relationship between the portrayal of suicide in the media and actual suicidal behaviour (Pirkis, Blood, Beautrais, Burgess Skehan, 2006). The effect is amplified when there are similarities in age and gender, where descriptions of the method are provided and where stories are of high impact (Pirkis et al., 2006). There is considerable evidence that heightened community awareness and glorification of the deceased leads to elevations in suicide,especially among adolescents (Hacker, Collins, Gross-Young, Almeida Burke, 2008). Communities affected by outbreaks of suicide involving young people have been well documented both nationally and internationally (e.g. Gould, 2003;Hacker et al., 2008). Hence, the term suicide cluster is commonly used to describe a group of suicides or suicide attempts, or both, which occur closer in time and space than is considered usual for the community(CDC, 1988).Previous studies suggest that suicide clusters may account for approximately 1% to 5% of adolescent suicides (Hacker et al., 2008).A community-wide coordinated response is vital to investigate, intervene and prevent suicide clusters (Hacker et al., 2008) and from the outset it is paramount that multidisciplinary prevention and postvention plans areput in place.
This paper describes how educational psychologists can work in diverse, unique and therapeutic ways with vulnerable young people affected by suicide.Background is provided to the suicide cluster in one LEA and how pupilsbecame involved in developinga self-harm and suicide reduction and prevention website. The paper provides an overview of the growing development of informationtechnology and the advancement of websites. Pupil participation and relevant ethical issues are discussed. The role of the educational psychologist in postvention activities and psychological approaches underpinning this work isconsidered. The engagement in multi agency workingandwithother professionals not normally associated with the role of educational psychologists is highlighted. Future directions will be considered and implications for the role of the educational psychologist.
Background
During 2008 a number of young people in the County Borough area took their own lives. The Child and Adolescent Mental Health Service (CAMHS) reported a statistically significant rise in referrals for depression and suicidal behaviour in 2008 compared with 2006 and 2007.There was wide media coverage and sensationalism linking the unexpected deaths. The suicide cluster affected many pupils attending local comprehensive schools,which placed tremendous strain on existing resources. In addressing the needs of groups of vulnerable young peoplethroughout this difficult period, particularly those who had suffered loss or made a suicide attempt,there was effective multi-agency working across a range of children’s services, including professionals working in the community with children and young people, their families and their carers. Throughout the critical incident educational psychologists prioritised work with vulnerable groups and became involved in a range of interventionsat individual, group and systemic levels.
It was during this time that three 15 year old pupilsattending a local comprehensive school in an area affected by the spate of suicidesbecame known tothe educational psychologist.Their lives had been changed by the loss of a young person very close to them and in the days following the event the pupils reported experiences ofpeople telling them how they should feel, rather than just listening to their feelings and accepting them. The pupils described the devastating effect that the loss had on them as well as their friends and family and members of the community and they expressed feelings of anger and frustration. Believing that there wasnot enough access to information about the affects of suicidetheyproposed the creation of an internet site which young people could access in order to help themselves.
By listening to the views of threepupils bereaved after suicide, support was offered to develop a self harm and suicide reduction and prevention website for the LEA.The ‘Choose Life’ website was designed as a messaging system to provide information to young people through survivors of their own age group, with the aim of progressing this to a wider audience via social networking sites.
The internet is becoming increasingly popular as a means of communicating information and can offer a valuable source of support. However, currently little is known about self harm and suicide reduction and prevention websites as limited research has been conductedinto the use of such sites, suggesting further evaluation is needed in this area.
The growth in information technology and the advancement of self-harmandsuicide reduction and preventionwebsites
It is widely recognised that the use of technology is a growing 21st centuryphenomenon. The recent 2008 annual report of the American Psychological Association Policy and Planning Board entitled ‘How Technology Changes Everything (and Nothing) in Psychology’, provides an overview ofthe positive and negative implications that technology has for the science and practice of psychology. The report highlights the opportunities for the internet to potentially harm others due to ease of access, anonymity, disinhibition and lack of restrictions on what people say on line with few consequences. Needless to say that perceived risks are greater with unprotected sites where there is exchange of information, opinions and views.The report also emphasises the benefits of information technology, in particular the availability of online therapy,support groups and self–help programmes. The rapid growth of the internet means that information is available for anyone seeking help, advise and support whether they are feeling suicidal or have been bereaved after suicide. However, presently there is a lack of research and clear guidelines onprecisely how to improve communication to reduce rates of suicideand suicide attempts. One recommendation is to provide supportive information on suicide prevention websites(Aldrich and Cerel, 2009).
Internet websites have been dedicated to the issues of self harm and suicide as sources of information, some provide the facility for people to communicate to each other via internet chat or message boardsand others provide support and advice.General categoriesof sites include: support for the bereaved and support for those with suicidal feelings (Lipczynska, 2009). Despite a lack of knowledgeaboutsuch sites and the benefits to users,websiteshave been overlycriticised as being potentially harmful. More concerning is the implicationthat websites encourage self-harming and suicidal behaviours.For this reason Baker and Fortune (2008) interviewed users of self-harm and suicide websites to gain further understanding of the websites that they use in order to inform future research. They concluded that the users found them to be sources of empathy, understanding and friendship, indicating that they offered a way of coping with social and emotional distress.This would suggest that for some people self-harm and suicide websites offer an ‘accessible and effective alternative to conventional psychotherapeutic and pharmacological interventions’ (Baker Fortune, 2008, p.121). This is especially the case forthose who are reluctant to seek out help through more traditional methods. Furthermore, as only a minority of bereaved attend group interventions or therapies (Andriessen, 2009) and drop out rates are known to be high (Baker Fortune, 2008), other forms of support such as internet websites are needed to give people a choice.
Importantly website messages ought to be tailored to meet the needs of this vulnerable group. Therefore,it seems reasonable that the views of young people bereaved after suicide be obtained when considering effective messages for self-harm and suicide reduction and prevention websites. Particularly if intervention by close others is fundamental to prevention(Aldrich & Cerel, 2009).
Pupil participation
Increasingly over the past two decades national and internationallegislation has aimed to promote the ‘voice’ of the child. TheChildren Act 1989 in England and Walesencouraged local authorities to ascertain the wishes and feelings of children before making any decisions relating to them. Article 12 and 13 of the United Nations Convention on the Rights of the Child(1989) recognised that children should be given the opportunity to seek and receive information and ideas of all kinds and be allowed to expresses their views freely on all matters affecting them.
The ‘Every Child Matters’ (ECM) agenda (DfES, 2004b) encourages children and young people to make a ’positive contribution’,giving them confidence to become more actively involved in decision making, including reviewing, evaluating and developing services and policies (Burton, Smith Woods,2010).From a service perspective, the report ‘A Review of the Functions and Contribution of Educational Psychologists in England and Wales in light of Every Child Matters: Change for Children’ (Farrell, Woods, Lewis, Rooney, Squires O’Connor, 2006) reviewed how effective educational psychologists are in contributing to the five outcomes of ECM, recommending that on a day to day basis educational psychologists should monitor, record and where appropriate communicate this contribution. Subsequent examples of good practice have been documented whereeducational psychologistshave empowered pupils to participate in research projects to help inform school improvements (Burton et al., 2010) and children and young people have contributed to educational psychologists’ understanding of the factors that act as barriers to effective pupil participation (Aston Lambert, 2010).
More recently, at a national level,Waleshas placed the principles of the United Nations Convention on the Rights of the Child at the heart of its 5 year rolling plan for children and young people in the Getting it Right(2009)agenda. Priority 8 aims‘to increase the opportunities for all children and young people in Wales to participate in decision making on issues that affect them’ and Article 12 to ensure that ‘children have the right to say what they think should happen when adults are making decisions that affect them and to have their opinions taken into account’. This concurs with the ECM framework for change.
Legislation promoting pupil participation is relevant to the practice of educational psychologists when working with children and young people and it follows that if pupils are to become more involved in decision making processes then their views should be elicited onissues that affect them. However, careful considerationshould be made with regard to the age, maturity and capability of the young person(DfES, 2001) as it can not be assumed that children and young peoplehave the relevant skills and knowledge on all issues affecting them. Hence,they should not be overwhelmedwith determining outcomes,nor should the decision-making process be completely passed over to them.In practice there is a need to balance the responsibility afforded to pupils in decision making whilst adhering to ethical guidelines to maintain confidentiality and protect them from potential risk of harm.
Involving pupils in the development of a self-harm and suicide reduction and preventionwebsite raises ethical issues because by its very nature the subject of suicide evokes emotions. How to overcome potentialethical issues needs to be considered carefully and sensitively.
Ethical issues
If someone bereaved after suicide provides a better understanding of suicide and its prevention (Andriessen et al., 2009) then it is feasible that theircontribution to postvention activities could enhance the lives of others.Whilst it is recognised that ethics should be considered when involving vulnerable groups in activities or research on sensitive issues that personally affect them,there is lack of clarity about the precise nature of the ethical problems and how to overcome them (Lakeman FitzGerald, 2009). Historically this has resulted in many services developing ‘passive’ models of postvention, whereby people bereaved after suicide are provided with information about available resources to help them (Campbell, Cataldie, McIntosh Millet, 2004) with limited interactiontaking place,or dialogue,to establish their views and opinions. Consequently, there is little documented in the suicide literature about children and young people actively participating in areas of work involving suicide prevention and postvention. Intuitively, Lakeman and FitzGerald (2009, p.15) propose that the process of participants actively contributing to postvention activities such as suicide researchmay be therapeutic providing:
‘the opportunity for participants to exercise altruism, by conveying hope, by gaining personal insight (into own psychology and situation), by gaining a sense of universality (they are not alone and others suffer similarly) and by being listened to (having the opportunity to talk and be heard)’.
This would suggest that contributingto postvention activities may be a positive experience for participants whohaveexperienced loss.
For practicing educational psychologists the British Psychological Society(2006) Code of Ethics and Conduct provides ethical guidelines to protect participants from harm. Ethical issues can be dealt with by obtaining informed consent, making assessments of risk and providing appropriate support. More recently Lakeman and FitzGerald (2009) providegeneral ‘normative guidelines’ concerning the ethics of involving children and young people in suicide research. The guidelines weregenerated from an online survey completed by members of the Human Research Ethics Committee identified through web-based lists in the United Kingdom, Ireland, Australia, Canada, and New Zealand. Recommendations include consulting with other experienced professionals during the process, establishing procedures to identify participants who may be at risk, ensuring support is available,providing information about the consequences of participation,acknowledging the vulnerability of participants and responding with care.Lakeman and FitzGerald (2009) also recommend that researchers make use of supervision with experienced professionals for the purpose of problem solving and debriefing.These guidelines are helpful and provide greater specificity of the ethics involved in suicide research which can be generalised to other postvention activities and projects involving children and young people.
Media guidelines have also been developed by a number of countries to promote responsible reporting of suicide. The guidelines stress the importance of challenging the myths about suicide and recommend providing information about help services. However, further evaluation of the effectiveness of these guidelines is recommended (Pirkis et al., 2006).
Ethical and media guidelines have been adapted and refined over time to help inform courses of actionwhich may affect the wellbeing of others.The current guidelines helped inform theeducational psychologist’s postventionwork with pupils, families, members of the community, multi agency teams and other professionals, as part of an ongoing negotiated process during the development of the Choose Life self-harm and suicide reduction and prevention website.
The role of the educational psychologist in postvention
According to Andriessen (2009, p.43) postvention involves ‘activities developed by, with, or for suicide survivors in order to facilitate recovery after suicide.’ During critical incidents involving suicide a range of postvention activities are undertaken by educational psychologists. At a systemic level educational psychologists are primarily involved in building capacity in schools through empowering school staff to support vulnerable young people affected by suicide. Triage work and the process of referring ‘at risk’ pupils to external agencies such as CAMHS is also an important aspect of crisis intervention work (Debski et al., 2007), highlighting that collaborative multi agency working plays an important role. Moreover, with the newly established children’s services there is increased emphasis placed on educational psychologists working in a multi–agency context.When working with individuals and groups educational psychologists generally intervene by applying psychological first aid as well as therapeutic and counselling approaches. Whilst it is recognised that postvention work is paramount in the aftermath of suicide, due to limited evaluative research there is insufficient information about treatment, programmes and appropriate group formatsacross different subgroupsof survivors (Andriessen, 2009). This poses a challenge to educational psychologists as one of the most frequently encountered crisis situations experienced in the school setting is intervention with potentially suicidal young people.
Educational psychologists’ distinctive contribution when working with children and young people is the application of psychological theory to practice, which is a fundamental principle underpinning all aspects of educational psychologists’work. Of relevance is the theory of Social Constructionism (Burr, 1995) which maintains that different people hold different constructions of reality, suggesting that the perspective of young people may differ from professionals but is equally valid. To effectively work with vulnerable people bereaved after suicide a number of theoretical perspectives may also be drawn upon, including theories on loss and bereavement (e.g. Kubler-Ross,1970) and specific approaches can be employed, such as solution-focused brief therapy (De Shazer, 1985).
Moreover, as the grief response differs between individuals it makes sense that importance should be placed on helping the survivor find his/her own, unique way to deal with the loss (Andriessen, Beautrais, Grad, Brockman, Simkin, 2007). To support this process West (2008) advocates ‘child-centred negotiation’ using a person–centred approach with its roots based in humanistic psychology, which places direct emphasis on the ‘client’. Its philosophy is to give the client a voice by eliciting personal thoughts and feelings about issues in their life. For this approach to be effective opportunities need to be developed for children and young people to gain the skills and knowledge to make informed decisions. Agenuine belief should also be held that children and young people can be involved in collective decision making processes, whilst at the same time flexibility is required to modify plans if appropriate (West, 2008).