“The statistics show that one out of five adolescents experiences some type of behavioral and/or social, emotional concern that merits a need for mental and behavioral health interventions.”
“Any of us can provide that help, not just mental health experts, anyone can reach out and help.”
“That’s so important to train our youth because they’re the first line, often, of hearing the warning signs, when it’s another student.”
“When you utilize a framework of school-wide positive behavior interventions and support, it also increases your school climate. It increases your students’ success in their behaviors”
“Part of our training that’s crucial and important is that all of us are trained in risk assessment, and specifically, suicide risk assessment.”
“I think in order to address these needs, that we still see day-to-day, it’s going to take that commitment to make that investment in the school-based mental health personnel and the frameworks.”
“Understand there’s no shame in seeking out mental health help for yourselves…I think if we can reduce the stigma and say, “If I had bronchitis, guess what? I go to the doctor and I get help for it.” And it’s the same thing. If you’re feeling depressed or anxious, it’s okay to go get that help.”
Q: I’m going to jump right in, and if you would give us an overview of the mental health challenges. It’s a topic that’s right on the radar always, but particularly during this COVID pandemic. Give us a picture of the mental health challenges facing students today, and why there is a need to be talking about suicide prevention.
A: Sure. And thank you again to your organization for raising awareness for this topic as well. It is a critical need across the country for students and adults, just the needs of our mental health needs and the struggles that people are going through. And especially with the COVID crisis, we certainly have mental health concerns and needs. So I will say for years we have been seeing a steady increase in anxiety, depression and suicide in our nation’s youth. And the statistics show that one out of five adolescents experiences some type of behavioral and/or social, emotional concern that merits a need for mental and behavioral health interventions.
Why this topic is so important is because the majority of these adolescents do not receive mental or behavioral health services. And it is recognized only about 20% receive such support and services. And the vast majority of those are receiving those services in schools.
So it was a very large scope problem, one in five, but very few are receiving the support they need. And just to highlight some of our Pennsylvania data from our Pennsylvania youth survey, we do see over the last six years, there’s approximately, from our 6th to 12th grade youth, about 16.5% are reporting they seriously considered suicide. It’s a lot of students, when you think about how many students are across our state. And close to 10% over the last six years every year have attempted. So we really need to keep this topic at the forefront and talk about that. This is a need, it is a real need out there.
Q: It leads into what I’m going to ask next. It’s not an easy topic and perhaps it’s one that most people may just not want to think about, or may shy away from, but you can’t avoid talking about it if you want to prevent it is what I’m hearing. How do you address concerns from school leaders, parents, even teachers who may not simply be comfortable with the topic, how do you address that?
A: Absolutely. Well, first I think that validating that, yes, it’s an uncomfortable topic, but at the topic that can save lives. And I think it’s very important to address the myths around suicide and the myths around talking about suicide that we know about. So, if you don’t mind, I’ll run you through some of the myths and the facts behind it.
I mean, there is a myth that if a student is really intent on trying to die by suicide, that there is nothing that anybody can do to stop them. And the fact is suicide is preventable. And that youth or that teen that is expressing those suicide ideations, honestly, it’s more about wanting the pain to end. We call it psychache. They’re experiencing such a heavy psychache that they want that pain to end. And in their minds, often, death is the only way out. So if we can speak to them and address it and give them options for getting help to end that psychache, we can absolutely prevent it.
Another myth, another big one that addresses your question specifically is if we talk about suicide, we might give students the idea to kill themselves. This is such a myth. Research actually says the opposite that when we do talk about suicide, whether talking directly with the student, it does not put ideas in their head about suicide. It actually lessens the anxiety, especially when we talk about concerns. The key is talking in a non-judgmental way. Not placing judgment on if they’re thinking about suicide, but more of asking, “Are you okay? Or recognize it. “You seem really down. Are you having thoughts of suicide?” This just, again, validates the person’s feelings and opens that door to the conversation or opportunities to support them. They don’t feel alone then. And that may get them to the intervention they need. So it’s validating feelings and being a bridge for that person to get to the help for what they’re feeling.
Another myth is that those people who are talking about suicide are just looking for attention. This is not true. Most do give warning signs. That’s the thing. Most people give warning signs that they are contemplating suicide. So even if they are seeking attention, we need to get them help. They need help. They’re showing us they need help. And any of us can provide that help, not just mental health experts, anyone can reach out and help.
Finally, I would say, in Pennsylvania, Act 71 passed several years back and it mandates that educators are trained in suicide prevention. So, we certainly should be having these conversations, and to help educators be prepared because it’s uncomfortable, but at least it gives the tools of, “What do I do? What do I look for? What do I do?”
Q: Those are all great points. And those are certainly things that I’ve seen out there. The myths that you highlighted, I think that’s really important to break that apart. And especially that last one that you said about seeking attention, right? So if someone is seeking attention for that reason, I mean, isn’t that even all the more reason, really, to give them attention, right?
Q: I mean, that seems like that to me, but not being a mental health expert myself, obviously. What are the steps that school leaders can take to understand what might cause someone to take their own life and how to look for those risk factors and warning signs? You talked about most do give warning signs. And so, talk through, first of all, maybe just an understanding of what might cause a student to think that way, and then how we can spot those signs.
A: Sure. So there’s two categories. One’s the risk factors and then the other is the warning signs. Risk factors are different things that might be happening in a student’s life or different characteristics of a student that would put them at higher risk statistically for possibly attempting or dying by suicide. It doesn’t mean that it’s going to happen. It just puts them at risk. Warning signs are the signs out there that, “Yes, we need to act immediately. There is high probability that something could be happening. The student’s in danger.”
The risk factors that… And I think this helps educators and school leaders understand who are the groups of students we really need to look out for, especially, and try to put protective pieces and factors in place for them. So for instance, there’s higher risk factors for gender, age, race, and geography. So some examples, males are at higher risk. Ages, middle-aged males, White, Caucasian, are actually our highest risk population, but then also geography and certain areas of the country there’s higher risk. And actually, there’s a correlation between access to firearms and higher risk for suicide and the suicide rates in a state.
Another big risk factor is our LGBTQ youth are at much higher risk and not because of the LGBTQ part of things, but the bullying, rejection or lack of support that comes with being a youth that is part of that population. And that whole piece of making sure that they are safe is so important. Another big risk factor is having a psychiatric disorder or a mental illness, depression, anxiety, bipolar disorder, all those things put you at higher risk for suicide. And then there’s also addiction. And then, previous aggression or low self-esteem, low concept, all of these things put your risk.
Then there’s other risk factors: trauma, high pressure expectations that we see in some of our higher performing, high-intense academic settings, also exposure to suicide. There’s contagion effects that we need to be watching for, that’s a risk. And of course, students that are isolated or have a lack of connectedness. That is huge to watch out for. And family dysfunctions and other risk factors.
So, the warning signs, what we find is about them 50% to 75% of individuals give some warning of their intention to die by suicide or attempt suicide. So the warning signs, really things to look out for is big behavior changes or big life changes. So behavior changes, more anger and agitation, hostility, irritability that’s out of character. Youth that appear depressed, hopeless, expressing hopelessness, withdrawing from their social connections, withdrawing from their activities. Also warning signs where students or children are expressing doubt in reasons for living, feeling like they would be better off dead, feeling like a burden, if they are sharing these things.
And then, certainly, drug and alcohol use puts them at higher risk. If any child should express a plan of how to die by suicide, that is a huge warning factor. And then, definitely, if they have access or are seeking access to medication and firearms or other weaponry, very, very crucial, if they’re expressing that interest. Those would be the warning signs.
If anyone hears any of that. If a student… A teacher that’s where to reach out, to actively just listen to the student and then connect, offer the care, offer validation and connect them to support, or the individual that can then access the support. And the school-based mental health personnel would be the first stop in the building.
Q: And these are some of the things that the training includes, correct?
A: Yes, exactly. Training on warning signs and then training on what to do. And there’s trainings for the adult educators that’s so important to train our youth because they’re the first line, often, of hearing the warning signs, when it’s another student. And giving them the tools, one breaking down the stigma of you’re actually helping and caring for your friend. You’re not, I think this is an old-fashioned word, but narcing on your friend or telling on your friend, but you could potentially be saving their life. And then giving them the tools, or the steps of, “What do I do next?” And connecting them to an adult.
Q: So you advocate for school-wide positive behavior intervention and supports. Tell us about that.
A: School-wide positive behavior intervention supports, it’s a framework, really, around teaching behavior, social skills in a school setting, but also addressing behavior and social skills in a school setting. A framework that is based on behavior research that shows us how to effectively increase positive behaviors and social interactions, and decrease the negative behaviors. So a couple decades ago, we were in much more of an exclusionary, disciplinary practices. And what we found is these did not necessarily change behavior. And it set up a lot of our at-risk youth to a lot towards that school to prison pipeline is what we’re seeing. So what we’ve done is, there’s been a lot of research behind putting around a framework that increases just the knowledge and instruction around. Thinking of social skills instruction, just how we do reading.
We teach explicitly students how to read. We also need to teach, a lot of times, students how to interact, and how to respond, and how to behave in the school. So it’s a lot of taking a broad-based approach of making sure you have a social, emotional, behavioral curriculum that we utilize. And then also getting data on how are students displaying their social and behavior skills? And then being able to, under a multi-tiered systems of support framework, this all fits in. So it’s looking at our data around who are our kids that are not at risk? Who are kids a little bit at risk? Who are a lot at risk? And then raising that level of intensity of intervention around different social skills or behavior needs that students might have. All of the system and framework. I mean, I could spend another hour talking about this, but really the purpose behind it and why I advocate for it is it is such a preventive method. When you utilize a framework of school-wide positive behavior interventions and support, it also increases your school climate. It increases your students’ success in their behaviors. And especially those students who struggle in that area. It increases the connectedness with adults. All of these things prevent bullying, therefore preventing students from suicide, or harm, or depression, or anxiety. It helps to reduce all of those outcomes that we have in a school setting that has a more difficult school climate. So it’s that link between the connectedness and relationships, and the positive morale and a building, the effect that can have on the adults and the students, and really help the mental health of all of those within that setting.
Q: We’ve already talked a bit about the role that the training plays, right? For staff and students, but what if that training is not available or our listeners don’t fall into that category that would be receiving that training? What can listeners do to educate themselves if they haven’t had access to this information, where can they go looking?
A: That’s a great question. There are a lot of really good resources out there, and I’ll highlight a couple of them. As far as some sites, the Substance Abuse and Mental Health Services Administration site has a lot of information about preventing suicide and suicide intervention. We also have, from NASP, on the National Association of School Psychologists, there’s plenty of resources around suicide prevention and intervention. Also, just mental health, in general, school-based mental health services. And NASP also provides for school districts the PREPaRE training. The acronym PREPaRE is a training course, and it addresses all areas of crisis prevention and intervention, and suicide is certainly within that, the training modules. And it is really probably the best model out there as far as crisis training and prevention and planning for schools. So, that’s through NASP.
Also, I would say, as far as our LGBTQ population, the Trevor Project is a wonderful resource online. It actually is a place where students can receive direct help if they are in crisis. There’s a connection point for them there with people that can help them. And then there’s all sorts of resources as well. For schools or school personnel, I’m going to highlight one book in particular. And it’s one of my very close colleagues, Dr. Terri A. Erbacher is one of the primary authors along with Jonathan Singer and Scott Poland. Scott Poland is one of our leading experts in the country on suicide prevention intervention. And the book is simply called Suicide in Schools.
I mean, it is my main resource of information for where we’ve been developing our intervention and prevention modules. This one’s really good especially for school personnel, but the training within, as a school mental health personnel. So a school psychologist, school counselor, a school social worker, and our school nurses also help with this. Part of our training that’s crucial and important is that all of us are trained in risk assessment, and specifically, suicide risk assessment.
We are the ones that can be in the buildings to determine at what risk level is the student. Is this a student that is at an immediate crisis, or is this a student that is more of a suicidal ideation perhaps, or something that we can address? Not an immediate, we need to have the student go to the hospital, but then also in there is training on suicide progress monitoring. Again, we progress-monitor everything, but having data, and much more of making sure that we are tapping in and checking in with the student regarding their suicidality, any ideations, and so that we can intervene.
Because we also know one of the risk factors is if the student has previously attempted, there is a much higher probability that they will attempt again. So it’s very important for us to have build those relationships and connections that we can monitor their progress and actually directly ask them about their thoughts related to suicide or their plans, so that if they become in crisis again, we can get it addressed and save them.
Q: That makes sense. So the ratio of students to school psychologists is quite high and some districts do not have a psychologist on staff, actually. So, how can school leaders advocate for appropriate and equitable access to school-based mental health professionals?
A: I’m so glad you asked this question. And this certainly is an issue that hits close to home for so many of us as school psychologists. It is true. Our recommended ratio is 1:500 students. And the average, one study that was just recently completed by Ackland et al. in 2019, found that across the nation, we’re averaging about one to 1,500 to 2,000 students per school psychologist. In Pennsylvania, the Association of School Psychologists, Pennsylvania, recently we did some research and found it’s about 1:1,200 plus students in Pennsylvania. So it’s still very high. And what the research also found, Ackland et el, they found the higher the ratio, the less likely that school psychologist is delivering mental and behavioral health services. There tend to be more just sticking to doing evaluations to determine if children are in need of special education services.
Whereas in our roles as school psychologists, we are certainly and recognized through the Affordable Care Act and the Every Student Succeeds Act, we’re explicitly referenced as mental and behavioral health providers. We have the capability of providing intervention and counseling, and broad intervention services across the building. Again, related to that school-wide positive behavior intervention support, helping to consult and design those kinds of frameworks and programs, and monitor the data, and help develop interventions. We are those professionals trained to do those roles.
So yes, it is crucial that we advocate and try to increase the number of school psychologists in the field and in the buildings, so that students have better access to the mental health services. As I said in the beginning, they’re having a hard time accessing them. If we are there, there’s more of a chance that they will be able to access them. I thought of this, a couple of things, one, I think it’s clarifying, and I think raising understanding of the role of school psychologists, that we are not just people that give tests, that we do have the mental and behavioral health background.
And that within the hiring process in school districts, to make sure that their job descriptions of school psychologists align with the certification guidelines that Pennsylvania now has because we’d recently had them updated through NASP to match the NASP practice model, which is a broad model, including our school mental health capabilities and service deliveries. The other thing I think is just sharing the stories. And we have stories from both ends, unfortunately. And we have stories of students who didn’t have access, and there’s tragic outcomes from students that didn’t have access to the mental health services that they needed.
We also have students that have had access and lives have been saved. And I can speak from my own experience. I have certainly intervened several times for students that were in crisis and were contemplating and had a plan. And because I was able to be involved, we were able to get them to a safe place. I think sharing those stories of the importance of having school psychologists, school counselors, school social workers in an accessible to address these needs.
And I understand, trust me, I’ve been doing this almost 25 years now. I know it’s really tough to make those budget decisions for districts. And I completely empathize with that and understand that. I think in order to address these needs, that we still see day-to-day, it’s going to take that commitment to make that investment in the school-based mental health personnel and the frameworks. The MTSS frameworks, the school-wide positive behavior intervention supports frameworks, so that we can prevent the issues. And then also then be able to address the issues to make sure that we are meeting the mental health and social and emotional developmental needs of our students in Pennsylvania.
Q: And so, you mentioned a few ratios, I heard 1:1,200, 1:1,500. Say again, what is the more ideal scenario? One to what number?
A: The National Association of School Psychologists recommends one school psychologist to 500 students.
Q: I just wanted to remind everybody of that. Well, that’s quite a vast gap difference there. What are some everyday practices that listeners can incorporate into their day to support their own mental wellbeing? Whether it be student educators, whomever.
A: Another great question. I think first off, it’s important to recognize the phenomenon of secondary trauma. It’s a relatively new concept that is being discussed. That is for those of us, or a lot of us teachers and educators, we work with students who have been through trauma or experienced trauma, or when traumatizing events come up or situations, or even micro traumas, we take that on as adults that are interacting or caring and we carry a secondary trauma.
So I think it’s important for us to recognize that, that it does exist and happens. And to find those ways that you are able to balance and support yourselves. So I think the importance of, and I go back to again, because it matters for adults too, finding those personal connections. Even if one person that you can trust and connect with to support each other and to share out what you’re feeling, what you’re experiencing to problem solve together and having that validation of, “You know what? This is hard stuff that we have to deal with.” Just having that understanding is huge.
I’m also a big proponent of the mind-body connection. I think this is a lot of where the self-care… We’ve had a lot of talk about self-care lately too. We’re school psychologists. We’re loving this movement as well, but really importance of being okay with taking care of ourselves in order to take care of others. It’s the airplane analogy. We need the oxygen mask first before we can give it to the other people. So really making sure that we’re taking care of our own sleep nutrition, exercise, or interest activities, mindfulness practice, whatever it might be that helps us to calm, to find that healthy balance within our lives.
And then I think the other thing is to recognize and seek professional help when you need it. And understand there’s no shame in seeking out mental health help for yourselves. Personally, I think it takes more courage to get help than to not. It’s okay. I think if we can reduce the stigma and say, “If I had bronchitis, guess what? I go to the doctor and I get help for it.” And it’s the same thing. If you’re feeling depressed or anxious, it’s okay to go get that help. It’s something that you need and to seek that out if needed.
Q: And certainly, this is a time where the school community is impacted by a lot of stress in this past year. And as you mentioned, the educators themselves, as they’re looking to support and serve the students, need to kind of focus on taking care of themselves as well.
A: Absolutely. I think that’s what stood out to me the most. I mean, I work in two elementary buildings, I’ve never seen teachers work harder or pour more of themselves. And they’re the hardest working people I’ve seen before COVID, and even more so now. And I think, I know for myself, I just wanted my office to be a place… It’s certainly a place where kids come that need help or if I’m working with kids, but it’s also a place where adults know they can come if they need an ear or a six-foot distance shoulder, it’s there. We have to do that for each other.
Q: For sure. I do want to thank you so much for joining us on this episode. I know that there is so much more that we could talk about, but we will include resources with the podcast post so that folks can go looking for additional information in the places that you referenced. So, thank you so much. And also, congratulations again on your acknowledgement. That’s wonderful news, so congratulations, but thank you, Dr. Szarko for joining us.
A: Oh, you’re very, very welcome. I will end with the other important resource and hopefully, everyone will get this ingrained in their brains, but there’s now two lifelines so that people can call the National Suicide Prevention lifeline 1-800-273-TALK. That’s 1-800-273-TALK, or text “help” to 741741.
Thank you again for bringing this topic to light and the importance of it. And I encourage all of your listeners to access the resources. And then, I’ll just leave you with, even just the smallest act of kindness can make a huge difference in someone’s life. So find those ways every day to just drop an act of kindness to even just a stranger. It makes a difference.
Q: Important to remember, and you might not even have any sense of the impact it could make before or after doing it.
Julia E. Szarko, PhD, NCSP
Julia E. Szarko, PhD, NCSP, is currently a school psychologist in the Central Bucks School District in Doylestown, PA. Julia completed an MS and PhD in School Psychology from The Pennsylvania State University in 1996 and 2000, respectively. She has a background in testing performance and behaviors of children with autism and related developmental disabilities, and she has extensive experience in student and system level intervention and support.
Julia has served on the Association of School Psychologists of Pennsylvania (ASPP) legislative board since 2007, including positions of Legislative Chair, President, Secretary, and organizer for the association’s annual conventions. Her most recent work includes being actively involved in updating the PA State Certification as well as the evaluation rubric to mirror the 2020 NASPPractice Model. Additionally, on behalf of ASPP, she represented school psychologists’ expertise in school safety and mental health, serving on Pennsylvania Governor Wolf’s School Safety Task Force and working with State Senator Jay Costa’s office in supporting language for SB 997, legislation outlining ratios for school mental health professionals. At the national level, Julia routinely participates in “Hill Day” in Washington, DC as an ASPP representative. Julia also facilitated the development of a Pennsylvania school psychologist “Hill Day” in conjunction with PSEA that took place in June 2019. Julia has also been actively involved in the collaborative drafting of legislative bills to address the school psychologist shortage and, most recently, the federal Mental Health in Schools Excellence Program Act of 2019.
In addition to her effectiveness as an advocate, Julia has received awards and honors in recognition of her dedication, service, and advocacy on behalf of students, families, and the profession of school psychology. She was named Pennsylvania School Psychologist of the Year in 2019. Additionally, in 2011, the National Association of Social Workers in Pennsylvania named her the Colleague of the Year, attesting to her strength as a collaborator.
Julia was selected as the National Association of School Psychologists 2021 School Psychologist of the Year for her commitment to the profession through her advocacy work addressing not only the needs of the children, families, and schools she works with, but for also working on improving systems to better schools and the profession.
NASP suicide prevention resources
NASP PREPaRE Training
Substance Abuse and Mental Health Services Administration
The Trevor Project
National Suicide Prevention lifeline: 1-800-273-TALK or text “help” to 741741