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SuicideThe Last Great Stigma

Judy Gabert, M.Ed., MA CounselingSuicide Prevention Action Network of Idaho501 (c)3, only statewide suicide prevention

groupwww.spanidaho.org

Information about Assessment and the Nature of Suicide are cheerfully

Stolen from Dr. Thomas Joiner, FSUDr. David Rudd, U of T, formerly U of UMost information on pre-,post- and

intervention are at www.spanidaho.org

Objectives Idaho and suicide Understand what is known about suicide Youth Suicide Warning signs and risk and protective

factors Schools and suicide (pre-, inter-, and postvention)

Assessment Workplace Activities Resources

Myth sheet, what do you know about suicide? Take a few minutes to fill it out. When we finish, we will compare changes in your ideas about suicide.

Please let us know if at any time you become too uncomfortable with this subject.

A psychologist returned home from a conference in Aspen, where all the psychologists were permitted to ski for free. Her husband asked her how it went. She replied, "Fine, but I've never seen so many Freudians slips."

General Information Suicide is preventable. It is a permanent solution to temporary

problems. Prevention is everyone’s responsibility. Idaho has a Suicide Prevention Plan,

available at spanidaho.org The US rolled out its newest strategy in

June, as more than 40,000 people died by suicide in 2010.

National Suicide Prevention Day is Sept. 10.

Idaho Suicide Data In 2010 Idaho had the 6th highest

suicide rate in the nation--49% higher than the national average. In 2009, we were 4th in the nation.

Canyon County had the highest county per capita rate for deaths by suicide in 2011 with 37 deaths.

Note that the years are different on stats as SPAN re-does stats yearly.

Why are Idaho’s rates high?

Generally Idaho is in the top ten for deaths by suicide as are Wyoming, Montana, Alaska, Arizona, and Nevada. In 2010, Oregon joined us at 7th. Washington no longer dwells in the top 10. Other high rate states are Colorado, Utah, and New Mexico.

Why? Much rural/frontier area, aloneness Attitude about mental health (stigma and

rugged individualism) Access to affordable mental health High numbers of gun ownership; most

lethal means (In 2011, 59% of deaths in Idaho were by firearm)

Also, tend to have more males per capita in rural areas.

US Suicide rates

Although suicide is rare--in 2011, 284 people died by suicide--it’s impacts are powerful, affecting family, friends, communities, and work places and/or schools. However, if a 747 fell from the sky once a year killing this many people, how would we respond?

Idaho ranks 50th in the number of doctors per capita. From 40-45% of suicide victims see their primary care physician in the two months before they die. It’s debated that 70% see mental health clinicians in the year before they die.

Idaho ranks 51st for dollars spent on mental health. All of us are more likely to know someone who has died by

suicide than someone who died in a car accident; we are more likely to know someone who has made a serious attempt than someone who is seriously injured in a car accident.

Dr. Joiner’s Interpersonal Explanation of Suicide

Desire to Die

Perceived burdensomeness

Thwarted belongingness

Acquired Ability to

Self-harm (habituation to pain)

Learned ability Repeated self-harm--

whether accidental or intentional

Witnessing repeated emotional or physical pain

Abuse, especially when young

Sketch of Interpersonal Explanation for Suicide

PerceivedBurdensomeness

ThwartedBelongingness

Those Who Are Capable of Suicide

Acquired Ability for Self-Harm

Habituation to Physical Pain

Serious Attempt or Death by Suicide

Those Who Desire Suicide

Derived from Sketch of a TheoryPower Point presentation, 2009Thomas Joiner, PhD

People really don’t want to die; they want an end to pain--emotional or physical.

Most people (about 90%) who die by suicide have a treatable mental health issue, usually depression.

There are about 20-25 attempts for every death by suicide.

Although suicide is relatively rare, a family, friends, community and workplace (and/or school) are affected by a single death.

Suicide is a public health issue resolved by easily accessible, affordable, and culturally-appropriate mental health help.

Suicide is complex; it is not the result of one action or

interaction or one single factor.

It is a bit like the property of cohesion: a glass doesn’t run over even when water goes above the rim. However, one more drop (action) can make the difference.

Even so, drops can be removed with help and hope.

Youth Suicide

Suicide is the 2nd leading cause of death for adolescents and young adults in Idaho, which became true nationwide in 2011.

From 2007-2011, 78 school-age children (to age 18) died by suicide in Idaho.

Nation-wide youth suicide (15-24) occurs twice as frequently as it did 50 years ago.

Youth Suicide in Idaho Idaho has a 58% higher number of suicides for

youth (age 10-24) per capita than the national average.[i] In the most recent five-years for which national data is available (2006-2010), the suicide rate for youth age 10-24 nationally was 7 per 100k, and Idaho’s rate was nearly 11.2. Between 2007-2011, Idaho youth suicides increased 9% over the previous five-years 2006-2010.

[i] Data are calculated from CDC WISQARS. Retrieved May 24, 2013.

General info Suicide is often attributed to a mental health

issue and adolescents are more at risk for suicide at the onset of these disorders..

Every time someone is treated for a mental health or a non-specific health issue, suicide ideation should be addressed.

Most college/university mental and physical health programs do not include suicide assessment/prevention as part of the curricula. (Washington state is now a happy exception.)

Up to 70% of suicidal people had visited a mental health professional in the year before their death; about 40-45% had seen their general health practitioner for a physical ailment in the two months before their death.

What Youth Report The "

2011 Idaho Youth Risk Behavior Survey (YRBS): A Healthy Look at Idaho Youth" is based on a survey of 1,702 9th through 12th-graders in 48 public high schools across the state in the spring of 2011.

27.3% of high school students reported that in the previous 12 months they felt so sad or hopeless almost every day for two weeks or more that they stopped doing some usual activities, over in in 4.

One in seven high school students and one in four 9th grade females reported seriously considering suicide in the previous 12 months

During the previous year 13.2% of high school students reported having actually made a plan about how they would attempt suicide.

8.1% of high school females and 4.6% of high school males reported making a suicide attempt one or more times during the previous 12 months

An estimated 1 in 5 adolescents suffer from serious depression.

Suicide Warning Signs

(indicate suicide may be imminent)

Threatening to, talking or writing about suicide Previous suicide attempt Seeking methods to kill oneself (sudden interest in guns)

Feeling hopeless or trapped Withdrawing from friends, family, or society Dramatic mood changes Increased alcohol or drug use Inability to sleep or sleeping all the time Nightmares

Warning signs, continued Changes in weight or eating habits Withdrawal from friends or family or activities Agitation or anxiety or raging or risk-taking

(fights) Giving away favorite things or making final plans Neglecting school work or personal appearance Chronic headaches, stomach aches, fatigue

(stress) Recent loss of a friend, family member, or

significant relationship Sudden unexpected loss of freedom or fear of

punishment/humilation

Warning Signs in Youth

Youth may exhibit depression as anger or aggression.

Sometimes risk-taking behaviors can include acts of aggression, gunplay, and alcohol/substance abuse. While teens may not act “depressed,” their behavior suggests that they are not concerned about their own safety.

REMEMBER Any one sign alone doesn’t necessarily indicate a person is suicidal.  However, all signs are reason for concern and several signals may be cause for concern of suicide.  Warning signs are especially important if the person has attempted suicide in the past, isn’t sleeping, or is especially agitated or anxious.

For Youngsters and Beyond   Self-injury behaviors are warning signs

for young children as well as teenagers. Common self-destructive behaviors include running into traffic, jumping from heights, and scratching or cutting or marking the body. (Adolescent cutters are generally no more at risk than peers for suicide but still should have their issue addressed by competent mental health clinicians.)

Early Trauma May Increase Risk

Trauma disrupts development of the brain

Changes in ability to handle stressOverreaction to situations: fight or

flightUnderreact: seem numb or

paralyzedseek ways to hide

Disruption of trust in adults or others

Extra Concern for Teens

Continued trouble at school or work Incarceration or court-related

problems Inability to deal with problems or

disappointment (low emotional intelligence)

Raging or extremely angry reactions Shame or embarrassment within

peer groups or public settings

Bio-psychosocial Risk Factors

Mental disorders Alcohol and other substance use disorders Impulsive and/or aggressive tendencies Hopelessness History of trauma or abuse Some major physical illnesses Previous suicide attempt Family history of suicide

Environmental Risk Factors

Job or financial loss Relationship or social loss Easy access to lethal means Local clusters of suicide that have

a contagious influence

Psycho-social Risk Factors Lack of social support Sense of isolation Stigma associated with seeking help Barriers to accessing mental health care

and substance abuse treatment Certain cultural and religious beliefs

(those that believe suicide is noble) Exposure to, and influence of others

who have died by suicide

Harvard Study Information Adolescents (36% in the study) are more likely

to die the same day of a crisis. Number lowers to 24% for those in twenties.

In postmortem of 76% of decedents, only 4% of youth had drug/alcohol in system; 36 % for adults. (This study is being replicated, and these numbers seem to be holding close)

In 41% of cases, death investigation reports noted the youths had either made a prior attempt (21%) and/or told someone they were thinking of suicide in the days preceding their death (31%).

Youth and Means Nationally, 45% of suicide deaths in young

adults (to age 24) are by firearm, and 43% are by strangulation (biggest means in Idaho for youth)

Most young people who die by firearm use one found in the home, stored unlocked, though death reports show that adolescents often knew where to find the key or the combination numbers or broke the glass on the gun storage.

Most people die by firearms; women generally choose pills.

People who die by suicide are ambivalent until the last second. (bridge stories)

Often when the means are taken out of the suicide plan, the person chooses to live.

People who were restrained from jumping off the Golden Gate Bridge rarely went on to die by suicide. Ninety-four percent never attempted suicide again; 99% are still alive.

When barriers were placed on a Washington DC bridge, suicides did not go up at the sister bridge a mile away.

Humor time

My therapist told me the way to achieve true inner peace is to finish what I start. So far today, I have finished two bags of chips and a chocolate cake. I feel better already.

A 2010 study of Idaho high school and Jr. high school counselors and social workers showed that while 97% of respondents had experienced a potentially suicidal student, only 55% felt well prepared to handle such a student. The same study stated that 64% of school counselors felt ill prepared to deal with the aftermath of a student suicide, or postvention. 

Administrative Rules IDAPA 08.02.03.160 – SAFE

ENVIRONMENT AND DISCIPLINE

• Each school district will have a comprehensive district wide policy and procedure encompassing the following: School Climate � Discipline � Student Health � Violence Prevention � Gun-free Schools � Substance Abuse - Tobacco, Alcohol, and Other Drugs � Suicide Prevention� Student Harassment � Drug-free School Zones � Building Safety including Evacuation Drills �• Districts will conduct an annual review of these policies and procedures.

TITLE 33 EDUCATION CHAPTER 5 DISTRICT TRUSTEES 33-512B.Suicidal tendencies -- Duty to warn. (1) Notwithstanding the provisions of section 33-512(4), Idaho Code, neither a teacher nor a school district shall have a duty to warn of the suicidal tendencies of a student absent the teacher’s knowledge of direct evidence of such suicidal tendencies.

(2) "Direct evidence" means evidence which directly proves a fact without inference and which in itself, if true, conclusively establishes that fact. Direct evidence would include unequivocal and unambiguous oral or written statements by a student which would not cause a reasonable teacher to speculate regarding the existence of the fact in question; it would not include equivocal or ambiguous oral or written statements by a student which would cause a reasonable teacher to speculate regarding the existence of the fact in question. (3) The existence of the teacher’s knowledge of the direct evidence referred to in subsections (1) and (2) of this section shall be determined by the court as a matter of law.

Prevention Everyone learns the warning signs All staff and interested parents trained as

gatekeepers and have protocols for reporting Students learn that the code of silence doesn’t

apply School climate of inclusion and opportunity to

succeed Curriculum delivered as part of mental health

unit in small groups is best with at least two adults

Parents are forewarned and know warning signs

No assemblies presented by previously suicidal youth; no work done on prevention other than gatekeeper training within a year of death by suicide in the school community

Always have hope messages and ways for students to have easy access to help

Message that suicide is rare and result of easily treated mental health issue

Intervention Know easily accessible, competent mental health

(tip off mental health clinician about the student) Protocols to include community actions (EMT/police),

how parents will be notified, what to do if parent/guardian cannot be located, and pre-screened mental health professionals

Student never left alone nor sent home Home cleared of means Culturally-appropriate and confidentiality protocols Documentation of all actions taken De-briefing of those involved Follow up with parent and mental health (permission)

Postvention Use the protocols on website (IMPORTANT for

liability)

School teams are available Students are especially vulnerable

after a death of a classmate The school day should be kept as

normal as possible; do not let students leave unless their parents come to pick them up (not advisable)

Remember to monitor social media Announcement made within classrooms Be very aware of students’ reactions and

offer safe place to talk Prescreen close friends and vulnerable

youth No memorial at locker Counselor or other professional to

monitor classrooms throughout the day and bus after school

De-brief and self-care meetings for staff during the days after the death

Continue to monitor friends of deceased and other vulnerable students/staff

No permanent memorials; ask students to write notes to the family (pre-read), take up a collection for flowers or for the family, or other such activities

Contact family about coming to get personal items after the funeral

Have at least one school representative at the funeral; have mental health people available after

Encourage the family to have the funeral after school

Laughter as Medicine  APsychology Today article entitled “

Happily Ever Laughter” cites a study which shows that the average child in kindergarten laughs some 300 times a day whereas the typical adult laughs a measly 17 times a day. If you haven’t laughed in awhile maybe it is time you did. There is much research to show that laughter really is the best medicine for a lot of different types of maladies including depression.

Humor Time A young woman took her troubles to a

psychiatrist. "Doctor, you must help me," she pleaded. "It's gotten so that every time I date a nice guy, I end up in bed with him. And then afterward, I feel guilty and depressed for a week." "I see," nodded the psychiatrist. "And you, no doubt, want me to strengthen your will power and resolve in this matter." "For goodness sake, NO!" exclaimed the woman. "I want you to fix it so I won't feel guilty and depressed afterward."

For Clinicians:1. Complete a comprehensive assessment for every

patient where suicidality is an issue.2. A thorough diagnostic interview and history must

be completed as a part of the assessment process.3. Always cover the targeted domains identified

including: precipitant(s), suicidal thinking and past behavior, symptom presentation, hopelessness, impulsivity and self-control, and protective factors.

4. The use of simple 1-10 patient ratings are useful to gauge the patient--not only current severity across identified symptoms but also can be used to monitor a

patient's functioning.5. Be sure to consider co-morbidity.

Liability Issues DOCUMENT, DOCUMENT, DOCUMENT Write the client’s words specifically as

you can. CONFER, COLLABORATE Interview collateral sources Read and memorize Dr. Rudd’s The

Assessment and Management of Suicidality available by pdf request to Linda Haroldson or me.

Be Aware

Many people kill themselves in the first few days after an emergency room evaluation for suicide or after getting out of in-patient treatment or after a mental health diagnosis

Provide a crisis plan to your clients ahead of time for this occurrence

The Nature of Suicide Intent Current ideation frequency,

intensity, and duration (FID) Presence of suicidal plan (increased

risk with specificity-European vacation idea) Availability of means Lethality of means Active suicidal behaviors Explicit suicidal intent

Previous Suicidal Behavior Frequency and context of previously

suicidal behaviors Perceived lethality and outcome Opportunity for rescue and help-

seeking How did you save yourself before? What can you do next time you feel this

way? Preparatory behaviors

Emotional Regulation

Objective self-control—substance abuse, aggressive behavior, impulsivity, control of others, co-dependence on others

Subjective self-control—ability to self-adjust at advent of a precipitating event and to modify thinking

Emotional Regulation Tactics Relaxation training

Mindfulness training

Reasons for living list

Survival kit (Hope Kit) Including Reasons for Living

Sleep hygiene / stimulus control

If someone, especially youth, is highly suicidal, she or he may be unable to self-regulate. At this point, 911, ER, or other emergency services should be involved. Never leave someone alone in this state.

Protective Factors Presence of social support. Support

needs to be both present and accessible. Make sure the relationships are healthy. Problem-solving skills and history of

coping skills Active participation in treatment Presence of hopefulness Parents/children present in the home Religious commitment or spiritual beliefs

Protective factors continued

Intact reality-testing Fear of suicide or death. This suggests

that the patient has not yet habituated to the idea of death, a very good sign.

Feeling hopeful and capable Doing well in several activities/school Strong wish not to let others down No access to means

Humor Time

A guy goes to a psychiatrist. "Doc, I keep having these alternating recurring dreams. First I'm a teepee; then I'm a wigwam; then I'm a teepee; then I'm a wigwam. It's driving me crazy. What's wrong with me?" The doctor replies: "It's very simple. You're two tents."

NO NO-SUICIDE CONTRACTSInstead use Commitment to Treatment Statements (CTS)

and Safety Plan

Here is an example of a CTS (Rudd, Joiner, & Rajab, 2004). It is necessarily brief and straightforward and probably best handwritten with the client.

I, ________________ agree to make a commitment to the treatment process. I understand that this means that I have agreed to be actively involved in all aspects of treatment including:

1) attending sessions (or letting my therapist know when I can’t make it),

2) setting goals,3) voicing my opinions, thoughts, and feelings honestly and

openly with my therapist (whether they are negative or positive, but most importantly my negative feelings),

4) being actively involved during sessions,5) completing homework assignments,

6) taking my medications as prescribed,7) experimenting with new behaviors and new ways of doings

things,8) and implementing my crisis response plan when needed (see the

attached crisis response plan card for details). I also understand and acknowledge that, to a large degree, a

successful treatment outcome depends on the amount of energy and effort I make. If I feel like treatment is not working, I agree to discuss it with my therapist and attempt to come to a common

understanding as to what the problems are and identify potential solutions. In short, I agree to make a commitment to living. This agreement will apply for the next three months, at which time it will be reviewed and modified.

Signed: ____________________________Date: _____________________________Witness: _____________________________

As should be evident, this agreement is very different than the notion of an informed consent statement.

It targets the patient’s motivation and commitment to the treatment process, outlining core elements and expectations.

The CTS can be as brief as the one noted above or more detailed, depending on the patient and the context.

In many ways, it is a living document, one that changes as the patient makes progress in treatment

and the dynamics of therapy evolve.

Defined as a commitment to Living

Treatment and care incorporates a crisis management or response plan

Specifically identifies responsibilities of patient and clinician

Elements of Good Agreements

Defined as a commitment to Living

Treatment and care incorporates a crisis management or response plan

Specifically identifies responsibilities of patient and clinician

Safety Plan Connection with family/friends (may need a consent

form)

Crisis Response Card (3x5 handwritten) include at least three or four of the most powerful reasons for living

Hope/Survival Kit (must be monitored with therapist)

Contains copy of crisis response card Photos of those cared for including pets Reasons for living Items that generate hopeful, productive

thoughts and feelings

Practice use of Survival Kit Review each item and ask patient

to describe and tell a little about it What is the client thinking? What is the client feeling? How much more hopeful does each

item make the client feel?

Crisis Plan When I’m acting on my suicidal thoughts by trying to find a gun(or another method to kill myself), I agree to take the following steps:Step 1. I will try to identify specifically what’s upsetting me.Step 2. Write out and review more reasonable responses to my suicidal thoughts,including thoughts about myself, others, and the future.Step 3. Review all the conclusions I’ve come to about these thoughts in the past in

my treatment log. For example, that the sexual abuse wasn’t my fault and I don’t have anything to feel ashamed of.

Step 4. Try and do the things that help me feel better for at least 30 minutes (listening to

music, going to work out, calling my best friend).Step 5. Repeat all of the above at least one more time.Step 6. If the thoughts continue, get specific, and I find myself preparing to dosomething, I’ll call the emergency call person at (phone number: XXXXXXX).Step 7. If I still feel suicidal and don’t feel like I can control my behavior, I’ll go to

theemergency room located at XXXXXXX, phone number; XXXXXXX.

Signed

Thought Self-Correction Diary

Triggering event Thoughts about that event and severity and

duration Feelings (anger, frustration, etc.) Severity and Duration Behavioral Response New Belief and how much I believe it

Forms are free at http://media.psychologytools.org/Worksheets/English/CBT_Thought_Record.pdf

Treatment JournalsJournals have been demonstrated to be a useful intervention in treatment,

particularly to improve self-awareness, understanding of change over time and as tool for relapse prevention. Your journal will provide an easy and ready reference for what you’ve done in treatment, identifying what’s worked and what has not, with an emphasis on becoming more efficient and effective in problem solving, regardless of the situation. Here are the ground rules for keeping your journal:

Journal for 15-30 minutes per day. Try to do it at the same time each day, it’s important to make this part of your daily routine. I want you to write only as much as I can reasonably read and cover with you in treatment. This is particularly important early in the treatment process. I’ll make copies of your journal to keep and review.

For the first month I’d like for you to journal about things that are important to you. That is, what’s on your mind? What’s upsetting you? How are you feeling about yourself? How are you feeling about other people? When you write about these things, please try to identify specifically what the problem is so that we can target it in treatment. We’ll talk about a specific approach to problem solving.

If you write about suicidal thoughts, feelings and plans, we’ll target these directly in treatment. If you write about reasons for dying, I’m going to ask you to always include your reasons for living. If you have trouble identifying them, I’ll help you.

Within the first couple of weeks, I’m going to ask you to identify the problem specifically when you write, generate and write about alternative responses, practice implementing the alternatives (we’ll role play these to help you), evaluate whether or not it’s working, and if it’s not, identify a new one and try again.

Finally, I’m going to ask you to always close your writing each day by adding a single sentence about what your hopeful about in treatment and life.

What Parents/Adults Can Do Listen nonjudgmentally (take walks, go for drives) Learn the warning signs Ask your child if he or she has considered suicide Analyze how much pressure the student feels Request that your family doctor or mental health

provider assesses for depression (tip them off)

Be sure your child finds success at some things Be sure that your child knows that she or he is never a

burden Prepare and eat dinner together at least 4-5 times a

week Rid your house of means--bank guns, lock away extra medication but avoid statistics or means discussion with children.

Parents and Schools Get to know your child’s teachers/principal Be sure that you alert them if your child is

bullied and follow up to see that it ends Check to see what the school does to ensure

that all students feel as if they belong If your child is struggling with school, find out

why. Ask the school for help. Make sure your child and his or her friends

know not to keep the “code of silence.”

For Men For Sure; Others, Too Yoga helps with PTSD symptoms and depression Outdoor exercise for everyone: walk, bike, or

run Men learning to build relationships may be of

import (Lonely at the Top by Dr. Joiner) Calling someone daily—friend or family member Being responsible to plan a small event Learning a new skill—cooking--with a group of men

(bbq; gardening) Reading group to discuss a book or movie Volunteerism, especially with animals and children Back to nature: find peaceful activities together

Workplace and Suicide

Know the warning signs Other signs in the workplace

Absenteeism General malaise Disconnectedness, inability to concentrate Anger, Anxiety, and/or Unusual Irritability

Revenge statements Ask the worker if he or she is considering

suicide In case of a suicide death, go to

http://www.suicidology.org/c/document_library/get_file?folderId=272&name=DLFE-822.pdf for a comprehensive best practice guide

Workplace, continued Promote mental health as health. Advertise EAP’s and health insurance

benefits for mental health Have the expectation that people will

seek mental health help. Promise and insure confidentiality. Provide healthful options: nutritious

food, exercise, togetherness activities and education on various helpful subjects

Communities and Prevention Take opportunities to talk about suicide at all

types of meetings. Provide resources (spanidaho.org) Join mental health forums; be sure suicide

prevention is part of the discussion Ask businesses and organizations to host

suicide awareness events Join with mental health providers to be sure

suicide is addressed and clinicians trained Look at activities in the State Plan

(spanidaho.org)

Myths Discussed T or F 1. Suicide deaths spike around

the holidays. ________ T or F 2. Suicide often happens on a

whim. ________ T or F 3. More men than women die by

suicide. ________ T or F 4. People who die by suicide are

cowards. ________

T or F 5. Most suicidal people really want to live. ________

T or F 6. Youth die by suicide more than older people. ________

T or F 7. Suicide is more common among minorities. ________

T or F 8. Poor countries have higher suicide rates. ________

T or F 9. If people want to die, we can’t stop them. ________

T or F 10. People who die by suicide are selfish. ________

T or F 11. Most suicidal people have mental health issues. ________

T or F 12. People who attempt just want attention. ________

T or F 13. Most victims of suicide have substances in their system. ________

T or F 14. Most victims leave notes. ________

T or F 15. Suicidal people make future plans. _______

More? http://training.sprc.org/course/desc

ription.php#course4

On line training in areas of suicide prevention (CEU’s available)

Psychological Autopsy (perhaps the only way to determine why)

Survivor packets and groups Questions and comments?

Resources Idaho Suicide Prevention Plan: A Call to Action

(spanidaho.org) Suicide Prevention Action Network of Idaho

(spanidaho.org) American Association on Suicidology (suicidology.org) American Federation on Suicide Prevention (afsp.org) Suicide Prevention Resource Center (sprc.org) Substance Abuse and Mental Health Services Admin.

(samhsa.org) Idaho Dept. of Health and Welfare The Trevor Project (thetrevorproject.org) NAMI.org Idaho Suicide Prevention Hotline: 800-273-8255 (talk)

Thanks for caring about suicide prevention.