Emotionally Naked E-Book

Anne Moss Rogers

• Herausgeber: John Wiley & Sons
• Kategorie: Bildung
• Sprache: Englisch

Seitenzahl: 592

Veröffentlichungsjahr: 2021

Beschreibung

Discover effective strategies to help prevent youth suicide In Emotionally Naked: A Teacher's Guide to Preventing Suicide and Recognizing Students at Risk, trainer, speaker, and suicide loss survivor Anne Moss Rogers, and clinical social worker and researcher, Kimberly O'Brien, PhD, LICSW, empower middle and high school educators with the knowledge and skills to leverage their relationships with students to reduce this threat to life. The purpose of this book is not to turn teachers into therapists but given the pervasive public health problem of suicide in our youth, it's a critical conversation that all educators need to feel comfortable having. Educators will learn evidence-based concepts of suicide prevention, plus lesser known innovative strategies and small culture shifts for the classroom to facilitate connection and healthy coping strategies, the foundation of suicide prevention. Included is commentary from teachers, school psychologists, experts in youth suicidology, leaders from mental health nonprofits, program directors, and tudents. In addition, readers will find practical tips, and sample scripts, with innovative activities that can be incorporated into teaching curricula. You'll learn about: * The teacher's role in suicide prevention, intervention, postvention, collaboration * The different and often cryptic ways students indicate suicidality * What to do/say when a student tells you they are thinking of suicide * Small shifts that can create a suicide-prevention classroom/school environment * How to address a class of grieving students and the empty desk syndrome * Link to a download of resources, worksheets, activities, scripts, quizzes, and more Who is it for: Middle/high school teachers and educators, school counselors, nurses, psychologists, coaches, and administrators, as well as parents who wish to better understand the complex subject of youth suicide.

Leseprobe

Table of Contents

Cover

Title Page

Copyright

Dedication

Trigger Warning

Crisis Hotlines

About the Authors

Acknowledgments

Companion Website

Preface

ANNE MOSS ROGERS'S STORY

KIM O'BRIEN'S STORY

Introduction

NOTES

Chapter 1: Why Are We Seeing More Mental Health Problems with Students?

THE RISE IN TEEN MENTAL HEALTH PROBLEMS

MENTAL HEALTH DISORDERS

NOTES

Chapter 2: Adolescent Suicide: Risk Factors, Protective Factors, and Warning Signs

RISK FACTORS

AT-RISK STUDENT POPULATIONS

SOCIAL MEDIA, TEXTING, TEENS, AND SUICIDE

PROTECTIVE FACTORS

SUICIDE WARNING SIGNS

WHAT DO STUDENTS SAY WHEN THEY ARE THINKING OF SUICIDE?

NOTES

Chapter 3: Debunking Myths About Student Suicide

MYTH: TALKING ABOUT SUICIDE CAN GIVE THEM THE IDEA

MYTH: TEENS WHO SAY THEY ARE THINKING OF SUICIDE ARE JUST TRYING TO GET ATTENTION

MYTH: SUICIDE IS SELFISH

MYTH: YOU SHOULD USE A “NO-SUICIDE CONTRACT” WITH TEENS

MYTH: ONCE A TEEN GETS PAST A SUICIDE ATTEMPT, THEY'VE LEARNED THEIR LESSON

MYTH: TEENS WHO SELF-INJURE ARE TRYING TO KILL THEMSELVES

MYTH: THERE IS NO NEED TO SCREEN KIDS FOR SUICIDE BECAUSE THEY WON'T TELL ANYWAY

MYTH: IF SOMEONE IS SET ON TAKING THEIR OWN LIFE, NOTHING CAN BE DONE TO STOP THEM

MYTH: THE PARENT IS ALWAYS THE BEST PERSON TO TELL WHEN A STUDENT IS THINKING OF SUICIDE

MYTH: IF THEY DON'T HAVE A PLAN, THEY ARE NOT AT RISK FOR SUICIDE

MYTH: THE HOLIDAYS ARE PEAK TIMES FOR TEEN SUICIDE

MYTH: MOST STUDENTS WHO DIE BY SUICIDE HAVE BEEN BULLIED

NOTES

Chapter 4: Suicide-Related School Policies

PREPARE SCHOOL CRISIS PLAN

SCHOOL POLICY FOR SUICIDE PREVENTION

SCHOOL POLICY FOR COMMEMORATION AND MEMORIALIZATION

CONFIDENTIALITY POLICY

NOTES

Chapter 5: Prevention: The Educator's Role in Creating a Culture for Suicide Prevention

CREATING A CULTURE OF CONNECTEDNESS AND BELONGING

COLLABORATION IS THE KEY TO SUCCESS

CREATE A SAFE DIGITAL LEARNING ENVIRONMENT

CHOOSING THE RIGHT PROGRAM OR TRAINING

EDUCATOR/GATEKEEPER TRAINING

UNIVERSAL SCHOOL-BASED SUICIDE PREVENTION PROGRAMS

MENTAL HEALTH TRAINING PROGRAMS

PROGRAMS THAT BOLSTER PROTECTIVE FACTORS FOR STUDENTS

CUSTOMIZING/ADAPTING SUICIDE PREVENTION PROGRAMS

SCREENING FOR SUICIDE RISK

GETTING LEADERSHIP BUY-IN FOR SUICIDE PREVENTION EDUCATION

NOTES

Chapter 6: Suicide Prevention Activities for Schools

SIMPLE IDEAS/CONCEPTS ANYONE CAN INTEGRATE

CREATIVE ACTIVITIES FOR BOLSTERING PROTECTIVE FACTORS

AFFINITY GROUPS

STUDENT-LED MENTAL WELLNESS CLUBS

NOTES

Chapter 7: Intervention: They've Told You They're Thinking of Suicide. What Now?

KIDS WANT TO TELL

REMOVING MEANS

WHAT TO SAY, WHAT TO DO

ASSESSING SUICIDE RISK

SAFETY PLANNING

NOTES

Chapter 8: Reintegrating a Student into School After a Suicide Attempt or Family Loss

TRANSITION FROM THE HOSPITAL SETTING

RETURNING TO SCHOOL AFTER SUICIDE LOSS

NOTES

Chapter 9: Postvention: After a Student or Teacher Suicide

COMMUNICATION WITH THE IMPACTED FAMILY

PROTOCOL AND MAINTAINING STRUCTURE

EDUCATOR TALKING POINTS WITH STUDENTS AFTER SUICIDE

WHAT TEACHERS SHOULDN'T DO OR SAY

SCRIPTS ON HOW TO FACILITATE CONVERSATION WITH YOUR CLASS

MEMORIAL ACTIVITIES AND SUPPORT AFTER A STUDENT SUICIDE

THE EMPTY DESK SYNDROME AND TAKING CARE OF YOU

NOTES

Chapter 10: How Students Move Forward After a Suicidal Crisis

HOW DID THESE TEENS MOVE OUT OF A SELF-DEFEATING CYCLE?

NOTE

Chapter 11: Resources

COMPREHENSIVE SUICIDE-RELATED SCHOOL-BASED MODELS AND TOOLKITS

SUICIDE-RELATED FACT SHEETS

BEST PRACTICES FOR STORYTELLING AND REPORTING ON SUICIDE

RECOMMENDED WEBSITES

EDUCATOR/GATEKEEPER TRAINING PROGRAMS MENTIONED IN THE BOOK

UNIVERSAL SCHOOL-BASED SUICIDE PREVENTION PROGRAMS MENTIONED IN THE BOOK

CRISIS AND MENTAL HEALTH TRAINING PROGRAMS MENTIONED IN THE BOOK

PROGRAMS THAT BOLSTER PROTECTIVE FACTORS FOR AT-RISK YOUTH

NONPROFITS AND GOVERNMENTAGENCIES

RECOMMENDED SUICIDE-RELATED BOOKS FOR SCHOOLS

Chapter 12: Quizzes, Worksheets, Handouts, Guides, and Scripts

WORKSHEET 1: HOW TO TELL SOMEONE YOU ARE THINKING OF SUICIDE

WORKSHEET 2: CREATING A SAFE DIGITAL LEARNING ENVIRONMENT

WORKSHEET 3: STUDENT WELLNESS SURVEYS

WORKSHEET 4: TRUE OR FALSE SUICIDE PREVENTION QUIZ

WORKSHEET 5: TRUE OR FALSE SUICIDE PREVENTION QUIZ: ANSWER KEY

WORKSHEET 6: SAMPLE CONFIDENTIALITY POLICY FOR STUDENTS

WORKSHEET 7: HOW EDUCATORS CAN HELP YOUTH BEREAVED BY SUICIDE

WORKSHEET 8: MANAGING A LOSS BY SUICIDE FOR MIDDLE AND HIGH SCHOOL STUDENTS

WORKSHEET 9: THE COPING STRATEGIES AND RESILIENCE BUILDING GAME

WORKSHEET 10: COPING SKILLS WORKSHEET

WORKSHEET 11: WHAT IS YOUR PASSION?

WORKSHEET 12: SAMPLE SCHEDULE OF STUDENT MENTAL WELLNESS EVENTS/IDEAS

WORKSHEET 13: SCRIPT FOR RESPONDING TO STUDENTS WHO THINK INFORMATION IS BEING WITHHELD

WORKSHEET 14: SCRIPT FOR ASKING PARENTS' PERMISSION TO DISCLOSE A SUICIDE DEATH

WORKSHEET 15: GUIDELINES FOR TELLING YOUR STORY

SEUSS-LIKE SCRIPTS: A SERIOUS MESSAGE IN AN ENGAGING FORMAT

WORKSHEET 16: BULLIES AREN'T THE BOSS OF YOU!

WORKSHEET 17: TOODLE-OO TO TABOO

WORKSHEET 18: EARS FOR YOUR PEERS

WORKSHEET 19: I'M ROOTING FOR YOU!

WORKSHEET 20: DON'T BALK, DO TALK

NOTES

Glossary

SUICIDE PREVENTION, INTERVENTION, POSTVENTION

DEFINITIONS IN ALPHABETICAL ORDER

NOTES

Index

End User License Agreement

List of Illustrations

Preface

Figure P.1 Charles on Homecoming Court, escorted by his favorite teacher, Ke...

Chapter 2

Figure 2.1 Text message from a teen (age 18) to his mother from a work relea...

Figure 2.2 Twitter post #1.

Figure 2.3 Twitter post #2.

Figure 2.4 Twitter post #3.

Figure 2.5 Twitter post #4.

Figure 2.6 Twitter post #5.

Figure 2.7 Messages between a teacher and Anne Moss Rogers.

Figure 2.8 From Emotionally Naked blog, note sent after 30 minutes on the we...

Chapter 5

Figure 5.1 Kognito uses simulated conversations to give educators talking po...

Figure 5.2 Signs of Suicide wallet card to remind students of the ACT Steps....

Figure 5.3 Sources of Strength

®

.

Chapter 6

Figure 6.1

Figure 6.2

Figure 6.3 Example of one of the license plate designs for the project. Spec...

Figure 6.4 Ms. Oz used the school 3D printer to render real-looking plates f...

Figure 6.5 Fishbowl Game.

Figure 6.6

Chapter 7

Figure 7.1 Some students will doodle dark thoughts in notebooks or the margi...

Chapter 9

Figure 9.1 Students may ask a lot of questions about what happens after we d...

Guide

Cover

Table of Contents

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Teachers play a central role in educating our youth but also serve as mentors and supporters. They are uniquely positioned to recognize children who are struggling emotionally. This excellent book provides a priceless resource in helping them to do this effectively and successfully. Every teacher needs to read and study this book.

—Victor Schwartz, MD, Former CMO of The JED Foundation, Founder of MindStrategies Advisors, Clinical Assoc. Professor, Dept. of Psychiatry, NYU School of Medicine

Rogers and O'Brien have created a book that brings out the heart and soul of suicide prevention. Reading Emotionally Naked is like having a conversation with the smartest person you know. Policy makers, administrators, educators, and parents will walk away hopeful, inspired, and better equipped to address suicide in schools

—Jonathan B. Singer, PhD, LCSW, President, American Association of Suicidology, Associate Professor, Loyola University Chicago, School of Social Work

Students of teachers who read this book are fortunate. It is filled with creative and feasible ways teachers can nurture the mental wellness of students and provides concrete and doable suggestions for asking directly about suicide, responding meaningfully, and shepherding classes compassionately after the death of a peer. It is an amazingly practical, accessible, and thoughtful resource.

—Julie Goldstein Grumet, PhD, Director, Zero Suicide Institute, Education Development Center

As suicide is the second leading cause of death for our young people, Emotionally Naked is a must-read for all who care for the well-being of our children. Sound information, practical advice, superb collection of resources, and written with compassion. We all have a role in suicide prevention and this book focusing on our youth is as informative as it gets.

—Jerry Reed, PhD, MSW, Senior Vice President for Practice Leadership, Education Development Center

EMOTIONALLY NAKED

A Teacher's Guide to Preventing Suicide and Recognizing Students at Risk

ANNE MOSS ROGERSAND KIMBERLY H. MCMANAMAO'BRIEN PhD, LICSW

Copyright © 2021 by John Wiley & Sons, Inc. All rights reserved.

Published by Jossey-BassA Wiley Brand111 River Street, Hoboken NJ 07030www.josseybass.com

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Library of Congress Cataloging-in-Publication Data is Available:

ISBN 9781119758303 (Paperback)ISBN 9781119758297 (ePDF)ISBN 9781119764823 (ePub)

Cover Design: Paul McCarthyCover Art: © Getty Images | A. Martin UW Photography

Anne Moss Rogers: To Randy, Richard, and my Emotionally Naked tribe, whose love and support helped keep that pilot light of hope burning after my youngest son Charles's suicide.

Kim O'Brien: To the loves of my life—Kevin, Taylor, Mac, Kelly, and Doug. You are the reason my life is full of purpose, love, and happiness.

Trigger Warning

This book tackles a tough topic and contains some emotional content. Most chapters that mention suicide method have a “trigger warning.” Teachers and other educators suffer from mental illness and have thoughts of suicide, too. So if you are struggling with mental illness and/or thoughts of suicide and if this is triggering, please stop or take breaks. There are a few instances where method is mentioned briefly in a story but there are no graphic details.

Your life is important. If you do experience thoughts of suicide, reach out to the prevention lifeline, a crisis text line, a trusted adult friend, a counselor, or find a support group.

There is only one you. If you left us, we'd be robbed of your potential, all your gifts, and what you could contribute to suicide prevention.

Crisis Hotlines

If you are experiencing thoughts of suicide, please reach out.

US National Suicide Prevention Lifeline: 1-800-273-8255 (By July 26, 2022, it will be simplified to the 3-digit crisis number 988.)

US and Canada Crisis Text Line: Text “help” to 741-741

US Trevor Project Crisis line for LGBTQ Youth: 1-866-488-7386

US Trevor Project Crisis text line for LGBTQ Youth 678-678

US Trans Lifeline 1-877-565-8860

Canada 1-833-456-4566

United Kingdom 116 123

Australia 13 11 14

For other countries: Search “suicide crisis lines”

UK: text 85258 | Ireland: text 50808

About the Authors

Anne Moss Rogers is an emotionally naked® TEDx storyteller, the 2019 YWCA Pat Asch Fellow for social justice, NAMI Virginia board member, and author of the award-winning book Diary of a Broken Mind. Despite her family's best efforts, Anne Moss's 20-year-old son, Charles, died by suicide June 5, 2015, after many years of struggle with anxiety, depression, and ultimately addiction. She chronicled her family's tragedy in a newspaper article that went viral and her blog, Emotionally Naked, has had millions of visitors. After receiving a message from a young lady who wrote that one of her articles saved her life, she sold her digital marketing business and followed her purpose of motivational speaking on the subjects of suicide, substance misuse, coping strategies, and grief. Originally from Fayetteville, North Carolina, and a graduate of UNC-Chapel Hill with a BA in journalism, she currently lives in Richmond, Virginia, with her husband, Randy. Her surviving son, Richard, works in Los Angeles as a screenwriter and filmmaker.

Kimberly O'Brien, PhD, LICSW, is a clinical social worker in the Sports Medicine Division and Female Athlete Program at Boston Children's Hospital, as well as a research scientist and assistant professor of psychiatry at Harvard Medical School. She received her BA from Harvard University, MSW and PhD from Boston College, and completed her postdoctoral fellowship at Brown University. Her research focuses on the development and testing of brief interventions for suicidal adolescents with and without substance use and their families, with an additional specialization on interventions that utilize technology. She has co-authored over 50 articles and book chapters related to adolescent suicide, substance use, and mental health, and was awarded the Young Investigator Research Award from the American Foundation for Suicide Prevention in 2019. She is also the founder and director of Unlimited Resilience, LLC, a private mental health practice for athletes by athletes.

Acknowledgments

Thank you to all who accepted our invitation to be interviewed for this book. These life-saving contributions, examples, and sharing are what makes this book a truly helpful guide. Special thanks to a few we emailed, reinterviewed, and called multiple times to review some of the worksheets and scripts, and to provide extra materials and images, including Jennifer Hamilton, LEP; Jessica Chock-Goldman, LCSW; Jim McCauley, LICSW; James Biela, LCSW; Desmond Herzfelder; and Lea Karnath.

We are grateful to the following people for the contributions and content from interviews conducted for this book (listed in alphabetical order).

Quoted Interviewees:

Melissa K. Ackley, LCSW (She/Her/Hers), Prevention Services Manager, Chesterfield Mental Health Support Services, Chesterfield Suicide Prevention Coalition

James Biela, LCSW (He/Him/His), Itinerant School Social Worker, Lower Kuskokwim School District, Bethel, Alaska

Sam Brinton (They/Them/Theirs), Vice President of Advocacy and Government Affairs at The Trevor Project, Rockville, Maryland,

TheTrevorProject.org

Doris (She/Her/Hers), Science Teacher, Colorado Public School

Dawn Gallagher (She/Her/Hers), Mother of Kiernan Gallagher who approved Kiernan's written excerpt about her father's suicide

Kiernan Gallagher, 14, middle school student, suicide loss survivor, Ocean, New Jersey

Jessica Chock-Goldman, LCSW (She/Her/Hers), Doctoral Candidate, School Social Worker, Stuyvesant High School, Manhattan, New York,

JessicaChockGoldman.com

Jennifer Hamilton (She/Her/Hers), School Psychologist, Director of Psychology and Counseling at Noble and Greenough, Independent School, Dedham, Massachusetts

Desmond Herzfelder (He/Him/His), Student Mental Wellness Club Founder, Psychology Major at Harvard University, Graduate of Noble and Greenough, Independent High School, Dedham, Massachusetts

Lea Karnath (She/Her/Hers), SOS Signs of Suicide Senior Program Manager, MindWise Innovations,

SOSSignsofSuicide.org

Michelle Fortunado-Kewin, LCSW, PPSC (She/Her/Siya), School Social Worker and Program Coordinator, San Francisco Unified School District

Nora (She/Her/Hers), Ninth Grade Dean, East Coast High School

Scott LoMurray (He/Him/His), Executive Director, Sources of Strength,

SourcesofStrength.org

James Mazza, PhD (He/Him/His), Professor, University of Washington, Author of DBT Skills in Schools,

MazzaConsulting.com

Jim McCauley, LICSW (He/Him/His), Co-Founder and Associate Director of Riverside Trauma Center, Needham Heights, Massachusetts,

RiversideTraumaCenter.org

Sheila McElwee (She/Her/Hers), Chemistry Teacher, Noble and Greenough, Independent School, Dedham, Massachusetts

Keygan Miller, MEd (They/Them/Theirs), Senior Advocacy Associate at The Trevor Project, Washington, DC,

TheTrevorProject.org

Mr. Nigro, Public High School Teacher, World History II and Economics, Chester, Virginia

Tammy Ozolins (“Ms. Oz”), Middle School Health/PE Teacher, Pocahontas Middle School, Henrico, Virginia

Shirley Ramsey (She/Her/Hers), Founder of Virginia Chapter AFSP, Retired School Counselor,

More Than Sad

Presenter, Co-Facilitator of suicide loss support group

Mike Riekhof (He/Him/His), Survivor of Suicide Loss, Founder of The Peyton Riekhof Foundation, Fishers, Indiana,

ThePeytonRiekhofFoundation.com

Leigh Rysko (They/Them/Theirs), Spanish Teacher and World Languages Department Chair, Kansas Public High School

Jonathan B. Singer, PhD, LCSW (He/Him/His), President, American Association of Suicidology, author of

Suicide in Schools: A Practitioner's Guide to Multi-level Prevention, Assessment, Intervention, and Postvention

Sean Reilly (He/Him/His), retired teacher, Kansas Attorney General Suicide Coalition Task Force, The One Heart Project

Shelby Rowe (She/Her/Hers), Co-Chair, Indigenous Peoples Committee, American Association of Suicidology (AAS)

Victor Schwartz, MD (He/Him/His), Former CMO of The JED Foundation, Founder of MindStrategies Advisors, Clinical Associate Professor, Dept. of Psychiatry, NYU School of Medicine,

MindStrategies.com

Laura Stack, MBA (She/Her/Hers), Suicide loss survivor and Founder of Johnny's Ambassadors and Leadership USA, Inc.,

JohnnysAmbassadors.org

Dese'Rae L. Stage (She/Her/Hers), Suicide Attempt Survivor, Suicide Loss Survivor, Queer,

livethroughthis.org

Aurora Wulff (She/Her/Hers), Young Adult, Founder of

Active Minds

Student Mental Wellness Club, Graduate of Ithaca High School, student at Binghamton University

Interviewees who asked to remain anonymous

Beauregard, Young Adult, Graduate of all-boys school in eastern US (agreed name change to protect privacy)

Anonymous High School PE Teacher, Virginia

Anonymous High School Counselor, all-boys school in eastern US

Quotes from those underage whose names have been withheld for privacy

Many contributions from principals, teachers, school counselors, and students who asked that their names be withheld

Survivors of Suicide Loss Interviewees (adolescent child)

Kelly Sprecht (She/Her/Hers), Founder of Carl's Cause, Kansas City

Elaine Alpert (She/Her/Hers), CEO of Mindpeace Miracles, Atlanta

Ricky Rash (He/Him/His), Mechanicsville, Virginia

Companion Website

Since web links change, we've created a web page with links to resources mentioned in this book, with downloadable guides and resources for your school and classrooms.

wiley.com/go/emotionallynaked

Password is: 988preventsuicide

Preface

ANNE MOSS ROGERS'S STORY

Trigger Warning: Suicide method mentioned briefly

It was June 5, 2015, in Virginia—a warm day, but I was cold and shivering as I sat in the back of a police car in a parking lot. My husband was in the front passenger seat. The officer, dressed in a nicely tailored gray suit and yellow tie, made a quarter turn in the driver's seat so he could see both of us. On some other day, I would have thought him handsome.

“I have some sad news to share. Your son Charles has been found dead this morning… .” An electric shock surged though my body and air was siphoned out of my lungs. When my breathing recovered and my lungs remembered what to do, soul-crushing wails of agony and loss erupted. My chest burned, my ears filled with noise, and my mind was watery and unhinged as the unspeakable tragedy that forever changed our lives was delivered in a single sentence.

Moments later, my husband, Randy, paused and asked, “How did he die?” For some reason, this question stunned me. I thought, How do you think he died? He was addicted to heroin, for God's sake. I was prepared to hear “overdose.” But instead the officer said, “He hanged himself,” and my husband banged his fists on his lap and the glove box, wailing in inexplicable emotional pain as I stared at his explosion in shock, unable to move. The statement by the officer dangled in the air outside of my consciousness, trying to get in while confusion and denial obstructed its path. My first instinct was to find the escape route from the agony and slide into another life that was shiny and happy. Rocking back and forth and wailing guttural, inhuman sounds, I had the primal urge to grab the edges of yesterday and bring it back so we could do the day over and achieve a better outcome. We love him. How could he kill himself? I didn't understand why suicide and it would be a long time before I would.

There was an immediate and desperate longing in my soul for one more hug. My irrational disbelief that this couldn't be true curled around the edges of my trauma and the raw, naked pain of losing my son was forever imprinted on my soul. Bits and pieces of information floated about, screaming their importance with no place to land, only to be retrieved later when my mind had the ability to absorb them and put the pieces together.

I am the mother of a child who killed himself.

Struggling to make Charles's life count, I spent five months after his death writing a newspaper article about my family's tragedy that went viral, creating an audience for my newly minted blog, Emotionally Naked®. This is where I wrote in my public journal to work through my grief. Eighteen months later, my business partner and I sold our successful digital marketing company and I became an author and an emotionally naked speaker on subjects few want to talk about.

Charles was complex, adorable, frustrating, hilarious, effervescent, electric, charming, eccentric, and a creative genius. From the time he came into the world to the time he left, his presence was all-consuming. He pushed boundaries past comfortable, questioned everything, and was relentless and persistent when he wanted something. When Charles waltzed in, the fun had arrived. Faces brightened, bodies turned toward him like he brought the sunshine in his pocket and he was there to hand it out. He was one of those bigger-than-life personalities who exceeded his allotment of space on earth despite his six-foot-two, 130-pound frame. Charles was the younger of my two sons, the funniest, most popular kid in school. Yet this funniest, most popular kid suffered from depression in middle school, and by high school was misusing drugs and alcohol to numb feelings of suicide we never knew about. His substance misuse led to deeper depression and an addiction to heroin, and he took his life while going through withdrawal.

Connection was Charles's gift and he demonstrated it over and over. No child ever entered his school and sat alone at lunch or felt friendless. He was the first to make new kids feel welcome. And given his popularity, that attention was like a social promotion.

It was a teacher who first suggested my child might be suffering from depression. It was a teacher who stars in one of my favorite photos of Charles (Figure P.1). And it was a teacher who wrote me the kindest, most heartfelt note after he died by suicide. My son's education shaped his writing and encouraged daily journal entries—a habit that evolved into his writing hundreds of hip-hop-style rhyme schemes that offered me a window into his tortured, artistic soul after his death. It was those notebooks he left behind that helped me understand the why behind his suicide. Some of these lyrics were included in my first book, Diary of a Broken Mind: A Mother's Story, a Son's Suicide, and the Haunting Lyrics He Left Behind.

Figure P.1 Charles on Homecoming Court, escorted by his favorite teacher, Kerry Fretwell.

While there are precious memories from his school days, there were horror stories, too. Zero-tolerance policies and rigid school administrators who defaulted to punitive measures perpetuated my youngest son's feelings of worthlessness, and unnecessary suspensions caused frustrating setbacks to his fragile progress with depression. Misunderstanding shaped their authoritarian responses when what was needed was empathy and compassion.

After students leave school, they rarely remember their test scores. They remember their interaction and experiences with peers, teachers, administrators, teammates, band leaders, school counselors, principals, drama teachers, janitors, bus drivers, cafeteria staff, librarians, school nurses, and coaches. Schools have something few other environments have, and that's opportunity for genuine human connection, which has gotten lost in the digital age. This is the most valuable currency in our universe today and a foundation for emotional wellness.

After Charles died, a young woman who suffered from depression reached out and told me a story that happened in high school. On one particular day, the dark fog of depression moved in and took her motivation hostage, but she made a Herculean effort to get out of bed and go to school. Later that day, she and her friends stood chatting in the hallway between classes. She was struggling to hold onto her mask of a clown, looked up, and was stunned to see Charles staring right at her. She said she knew Charles, since everyone did. But they had never met and she didn't know he knew her. As soon as eye contact was returned, my son walked towards her, stopped about two feet away, and broke out into a rap song he created on the spot, just for her (also known as freestyling). She and her friends were shocked at first but soon burst out laughing.

When he finished his song, he bent over, hugged her, and said, “Pretty girls shouldn't look so sad,” and then made his way down the hall. She told me she had never experienced such kindness and it was a moment she tucked away in her mental library of precious memories.

While I will always miss my son's beautiful curly hair and his sense of humor, his tall, skinny hugs and the way he altered his voice when he greeted his dog, what I miss most was his capacity for love. In a world where no one has time to listen, he did. In a disconnected world where no one has time to connect, he made time. As talented and funny as he was, this was his greatest gift—letting other people know they mattered. That is the legacy I carry forward in my son's name. And that is why today, educators invite me into their classrooms and auditoriums to share our family's story, the coping strategies that helped me find emotional healing, and the workshop that helps kids become aware of what defines healthy and unhealthy coping skills.

Many people ask me how I can work with suicide prevention and loss every day after losing a child to this cause of death. My answer is that the universe pushed me towards it. And even after the most devastating loss of my life, I have hope. Because more people survive thoughts of suicide than act on them. And your help and mentorship can prevent tragedy by integrating innovative strategies and small culture shifts in your classes that facilitate connection and healthy coping strategies. You have the relationships. And the goal of this book is to nurture those relationships, empower you with the tools and education to spot students at risk, listen, and introduce them to the next level of care.

There are days when I do want to give up this cause because it's like pushing a spiked ball uphill in a driving snowstorm. But then I get letters from students after a presentation and it reinforces my resolve and rekindles my passion to keep doing what I'm doing.

KIM O'BRIEN'S STORY

My passion for helping suicidal youth runs deep. People wonder how I could do something so dark, so depressing, and often ask me why I got into this field. But I see my work differently. When working with suicidal youth, I see hope and resilience. I see that in that place of darkness that seems never ending, there is a way out other than suicide. I know this because I've been there.

My kindergarten teacher told my parents I needed to see a psychologist. She said I always looked so sad and just stared out the window instead of playing with friends. And so began my journey with depression. Mental health was a foreign concept to my parents, for no fault of their own, so I endured this constant emotional struggle alone. Growing up, I never felt understood by others and never quite understood my sadness. I had two parents and three younger siblings who loved me and I always had a safe, beautiful home to live in. So why was I always so sad?

My childhood turned into an adolescence filled with anxiety and perfectionism, and my depression evolved into a secret source of shame and self-hatred. I would lie in bed at night wishing I could die. I endured some low moments, like when my college roommate died by suicide, when I seriously questioned why I was still living. Life was becoming increasingly too much to bear and I relied on the high moments—accomplishments, excitement, love, and laughter that continued to pull me through.

Shortly after I graduated college, I hit rock bottom. I became angry and sad, closed myself off to others, and drank more alcohol. I cried daily, sometimes all day. I didn't want to wake up in the morning yet I couldn't fall asleep at night. This continued for over a year and I remember going to the doctor one day for a well visit and I couldn't stop crying. She told me I needed antidepressant medication and I agreed. I figured, why not? At that point I didn't care about living any longer but I also thought I had nothing to lose. I was already lost and it was as if my soul had died and I was just going through the motions in a lifeless body.

With the little blue pills, I found myself crying a little bit less and the days became slightly more manageable. I started picking myself up, bit by bit, and began finding more reasons to go on living. There was no magical “aha” moment for me, just continuous introspection with professional support to guide me through. And now, decades later, I can say I live a life full of purpose, love, and even happiness. I still struggle emotionally every day, but I have the skills I need and the love and support around me to get through the difficult times that are a part of every human experience.

That kindergarten teacher spotted something in me that no one else noticed, not even my family. How did she know I was so sad, so tortured inside? And as my emotional state kept getting worse as the years went on, why was no one aware of it? None of my middle or high school teachers ever noticed it. I wonder why but as I look back and ponder, I'm actually not sure I showed too many signs. I was bright, athletic, and relatively social. On the surface I had friends—people to talk to in class and teammates to joke with on the field and ice. So how would they even have known? But the fact remains that no one ever asked me how I was feeling inside. No one inquired about my emotional state or what it felt like to be me. I don't blame my teachers for this—it simply wasn't in the culture back then to address mental health in such a direct way.

But it is now. Today, we are finally beginning to recognize how inextricably linked our physical and emotional health actually are, and how important it is to take care of our mental health. We owe it to our youth to teach them how to identify what they are feeling and what they can do to help themselves when they experience distressing and unwanted emotions. We also need to teach our youth how to recognize when their friends may be struggling, what they can do to help them, and when they need to tell a trusted adult.

Our educators play an integral role in how we can and will affect change amidst this cultural shift where the mental health of our youth is being increasingly prioritized. Many argue that no one knows youth better than their teachers, the adults who are with them every day. Our goal for this book is to help educators see their critical role in suicide prevention, and acquire the knowledge and skills they need to save lives.

Introduction

Trigger Warning: Suicide method mentioned briefly

“The Colorado school where I teach went on lockout and we didn't know why. With our school so close to Columbine, it's hard not to think the worst when this happens. I kept teaching in an effort to distract the students. And myself. Thirty minutes into the lockout I'm looking at my student Emily as a look of horror crosses her face, which triggers a visceral internal response. Then one by one I see other students with their phones out and the same look of shock appears on all their faces. One of them shares that they'd all been sent a picture via the social media platform called Snapchat. It was a body bag photo of a student who had killed himself just minutes before. I never saw the picture. I couldn't. And although we didn't hear it, the rifle shot was heard by many of the classes. Earlier that day, a male who had been in my class as a freshman was in his welding class and referring to his welding helmet, he quietly told another student, ‘I won't be needing that anymore.’ He then asked the teacher if he could be excused to go to the bathroom. He crossed the football field, went home, got his weapon, then went to a public park near the school. That suicide rocked the community. It was the first one of three student suicides. It was one of the worst teaching days of my life.”

Doris, Science Teacher, Colorado Public School

After a death by suicide at a school, tissues are passed around in staff meetings, teachers are encouraged to contain gossip, productivity is arrested by shock and confusion, and in a desperate rush to force premature normalcy in the wake of devastation, the healing step is disregarded or abbreviated. Unresolved grief is a risk factor for suicide but teachers are rarely given tips on supporting grieving students, creating an additional layer of emotional chaos on a school campus that is already hurting. Sometimes lawyers will instruct administrators to say nothing, so they don't engage with the family, which can result in anger, blame, tempestuous lawsuits, and unwanted media attention that can brand the school as a rigid and uncaring. Once the school is moving forward again, administrators resist revisiting the topic.

With this population especially, suicide contagion, also known as copycat suicide, is a real threat and the desperation to contain the chatter and take control of the situation often motivates educators and administrators to act in ways they believe to be safeguarding their school community, when in fact it may be doing the opposite.

Suicide is the number two cause of death for ages 10–34 in both the United States and Canada after accidents, and the leading cause of death for ages 14–15 in the US.1

Despite this alarming public health threat, educator training for prevention is inconsistent and school districts tend to implement a plan for suicide prevention only after a student or teacher takes their own life. As one principal said, “It's tragic that a kid with great potential had to die for that to happen.” Policies and protocols for identifying students at risk for suicide, information on how to support grieving students, or a commemoration policy on how to handle a death from any cause are not commonplace even though free resources are available.

Overall, researchers have noted that 50–69% of those who die by suicide communicate suicidal thoughts or suicidal intent to others in some way before they die, providing a window of opportunity for intervention and prevention if we know what to look for and what to do.2 And because youth spend more time in school than any other place in their lives, there is an opportunity to prevent this cause of death and encourage the coping strategies that offer students the tools to manage adversity before it becomes a crisis.

Education has become a frenzy of test taking with little emphasis on students' emotional health. A lot is expected of educators today and the job keeps evolving and becoming more complex. Add to that rapid changes in technology and its influence on students and the teaching profession. The education world can be slow to adapt, leaving gaps in the system and administrators trying to play catch-up, but the good news is that teachers can integrate small culture shifts that are part of a foundation of suicide prevention and student wellness.

“When I graduated in 2000, there was no suicidal ideation happening. For today's students, suicide is embedded in their normal thought processes. It's just part of their language now which is why it should be part of ours, too. I've learned to ask every student that comes by my office if they are thinking of suicide. Because our student population is talking about it all the time. If they are talking about it, so should we.”

Jessica Chock-Goldman, LCSW (She/Her/Hers), Doctoral Candidate, School Social Worker, Stuyvesant High School in Manhattan, New York

While the conversation on mental health should be open and educators should listen and show empathy, Jessica Chock-Goldman also emphasizes that there is no need for teachers to be heroes but instead they can refer students to school counselors and those who know how to handle the situation since there are many nuances with this age group and even among specific ethnic populations. Sometimes the teacher joins that conversation with the student and counselor if the pupil is showing resistance, since it's only natural that they'd want to connect with the person with whom they have a relationship.

“We had a situation where a student who was quietly struggling with severe depression went on a school trip at the end of the year. One of the teachers who was chaperoning the trip sensed that this kid was really having a difficult time. She continually and gently reached out and kept reaching out, even though the student always responded that she was fine. But then on the last day when they were at the airport, at the last possible moment, the student just opened up and told her teacher how much she was struggling. The teacher called me from the airport and we began the conversation about how to connect this student with support when she returned from the trip. We worked together to help the student open up to her parents and get the help that she needed.”

Jennifer Hamilton (She/Her/Hers), School Psychologist, Director of Psychology andCounseling at Noble and Greenough, Independent School, Dedham, Massachusetts

Jennifer Hamilton collaborated on what needed to happen next and the student was unwilling to talk with a counselor, having established a trusted relationship with the teacher. This is often the case, which is why it is important to empower teachers with basic talking points on what to say or do to dispel the fear related to those conversations. Because that's all it is. Students want to talk to the person with whom they have a relationship, and that warm handoff sometimes needs to include the person they originally connected with because the pupil is afraid of the process. In this case, the counselor and teacher worked together to talk about what needed to happen next, and it was suitable to contact and inform the parents. After talking with her parents, she agreed to talk to the school counselor with the teacher present. From there, the goal was to include the student in conversations regarding options, which for her included outpatient treatment.

“I believe this teacher saved this kid's life with all my heart. She did. It was so rewarding to see how that all played out because she had a comfort level around knowing what to do when worried about a student. She also knew when she needed some backup. I am so grateful.”

Jennifer Hamilton (She/Her/Hers), School Psychologist, Director of Psychology and Counseling at Noble and Greenough, Independent School, Dedham, Massachusetts

The purpose of this book is not to make the job of the educator harder, but to make it more meaningful. Our hope is that this book will arm you with the knowledge, tools, resources, and ideas to inspire administrators to integrate new policies and encourage impactful shifts in your school culture and curriculum to prevent suicide and promote health and wellness. It will make you aware of resources for crisis response, as well as give you tips on getting school leadership and the community behind social emotional teaching and suicide prevention, which can mean adding more staff trained in mental health to support those efforts. A lot of what you'll read here is not a teacher's responsibility to implement, but having knowledge of what that collaborative process might look like helps complete your understanding of how it should work and a teacher's role as part of a team effort. So while this book is not intended solely for teachers, that is the point of view from which we will speak. Our intention is to make you more comfortable with an uncomfortable subject because it's one that very few feel qualified to address. But given the pervasive public health problem of suicide in our youth, it's a critical conversation that all educators need to have in order to feel ready and able to effectively engage with their students. Although we refer to students who are at risk of suicide in this book, that's not to exclude educators who might be at risk. They can. And it is our hope that the information delivered will also help you recognize any colleagues, friends, and family members who are struggling and connect them with life-saving and supportive resources in the school and community.

This book is also not meant to train you as an interventionist or a counselor. Enough is asked of you. Instead we hope to help you see, notice, and pick up on which students need intervention. Learning to say, “Tell me more,” and actively listen is a powerful first step to help a suicidal student open up. And even if you are not comfortable with that, you can simply look after your students and make the school social worker or counselor aware of your concerns. Mastering the art of listening and empathically connecting to people is underrated in today's busy culture and we are often unaware of how important even the smallest gestures and acts of kindness mean to another human being. One empathetic adult is all it takes to have a positive impact on a student and change the trajectory of their life. Throughout this book we want you to ask yourself, “What kind of educator do I want to be?”

NOTES

1.

  Kann, L., McManus, T., Harris, W.A., Shanklin, S.L., Flint, K.H., Queen, B., Lowry, R., Chyen, D., Whittle, L., Thornton, J., Lim, C., Bradford, D., Yamakawa, Y., Leon, M., Brener, N., Ethier, K. (2018) Youth Risk Behavior Surveillance — United States, 2017. MMWR

Surveillance Summaries

67(8):1–114.

2.

  Coombs et al., 1992; Robins, Gassner, Kayes, Wilkinson, Murphy, 1959, p. 9.

https://www.qprinstitute.com/uploads/QPR%20Theory%20Paper.pdf

Chapter 1Why Are We Seeing More Mental Health Problems with Students?

“In order to achieve, you have to put wellness first.”

Jennifer Hamilton (She/Her/Hers), School Psychologist, Director of Psychology andCounseling at Noble and Greenough, Independent School, Dedham, Massachusetts

Mental health includes our emotional, psychological, and social well-being. It affects how we think, feel, and act and drives how we handle stress, relate to others, and make choices.1 This can be impacted by the home and social environment, economic status including homelessness and food instability, early childhood adversity or trauma, physical health, and a family history of mental health diagnoses and suicide. Mental health concerns, such as depression, anxiety disorders, self-harm, post-traumatic stress disorders, and substance use disorders, significantly impact one's daily functioning, and those are the signs that educators need to look out for.

Many psychiatric disorders have their onset at adolescence. So right at the phase when their brains are still maturing and hormones are driving behavior, teenagers can develop a mental illness, making adolescence that much more challenging. Mental illness often makes teens more susceptible to suicide risk, and family history, medical history, and social stressors like trauma, grief, transitions, and relationship disruption can add to that vulnerability.

THE RISE IN TEEN MENTAL HEALTH PROBLEMS

A study by Twenge and colleagues (2019)2 found that between 2008 and 2017, mental health problems, including self-harm behaviors, grew substantially for the youth subset of the population. They found that by 2017, 13% of youth had symptoms consistent with major depression in the previous year, which represented a 62% increase in eight years. Scholars and advocates posit a variety of reasons for the rise in mental health issues among today's youth. Technology and too much screen time, constant social comparison exacerbated by social media, emphasis on happiness and nonacceptance of difficult emotions, the academic and extracurricular rat race, helicopter parenting, transitions, and the disruption of relationships (whether that's a family divorce, death of a loved one, or loss of a romantic partner) all contribute.

When the digital age moved in, that which we thought would connect us more instead pushed us apart in many ways. It was during the early 2000s that we began to see an increase in student mental health problems. Poor sleep hygiene, the result of increased screen time and 24/7 Internet access via mobile phones, exacerbated those issues because youth sacrificed precious slumber time for late-night chats and video watching. As the digital revolution has grown, each generation has less face time with friends than the one before, which means youth are getting fewer opportunities to learn, fail, and problem solve. Add to that the fact that extended family often lives out of town and community programs and interactions have a reduced role in our lives, further fracturing the community of connection and support. Humans crave contact with each other, and lack of it can leave teenagers feeling anxious, small, insignificant, and devoid of opportunities to develop important life skills.

If you are an adult who grew up before 1995, think about how much you learned when you played games outside with friends in your neighborhood. You learned to negotiate, compromise, and argue in an effective way. There was no referee other than the peer-appointed kid who lived on the corner, so you had to work it out. Failure is a part of life and a learning opportunity, but so many students have no idea how to manage it because what little unstructured time they do have is now spent on digital screens. Victor Schwartz, MD, Clinical Associate Professor, Department of Psychiatry, NYU School of Medicine, points out that there are fewer community centers, religious-based organizations, and clubs like 4-H or Girl Scouts in today's culture (in some cases for very good reasons). These gathering places and clubs were commonplace in earlier generations and were settings where youth picked up a lot of life skills. This is where kids learned to run a program, organize something, learned how to deal with other people in planning a project. It's not the schools' fault that we've lost the whole notion of community centers, but are there ways to bring more of those skill-building opportunities in a more intentional way into academics? In Chapter 6, “Suicide Prevention Activities for Schools,” we present specific strategies and ideas that teachers from different regions are integrating into their curriculums to build that skillset. The effect of doing so reduces unhealthy coping such as self-harm, substance misuse, and suicide, and promotes more positive experiences in school and beyond.

Barriers to Mental Health Treatment for Teens

Neither teens nor the adults who are close to them recognize the symptoms of their treatable illness.

Fear of what treatment might involve.

Belief that nothing can help.

They don't see help-seeking as a sign of strength.

They are embarrassed.

Belief that adults won't understand.

Limited access to resources (money, insurance, transportation, healthcare).

Source: From the American Foundation for Suicide Prevention, More Than Sad for Parents.

Standardized testing is a measurement strategy that many school systems use. Wherever you stand on the issue, it siphons considerable instructional time and resources during the school day and the casualties of that effort have been innovation, creativity, practical skills, opportunities to build connection, and social emotional skills. In short, there is not enough time. More trigonometry will not help a student learn how to cope with the loss of a sibling. Integrating skills to help students learn and manage life goes a long way in minimizing substance misuse, self-harm, eating disorders, promiscuity, and other unhealthy coping strategies, as well as preventing suicide during the school years and throughout a student's lifespan. What we do know is that several studies have shown that suicide rates increase during the school year and drop off during the summer when most students are out of school and during academic breaks, suggesting that social and academic pressure may play a role in student suicidal behavior.

In a 2018 study, Gregory Plemmons and his colleagues found that the rate of hospitalization of school-aged children for suicidal ideation and attempts increased by almost 300% from 2008 to 2015.3 Each year the rate of psychiatric hospitalizations is significantly higher in the school months than in the summer. A decrease occurred not just during summer vacation, but also during school vacation weeks, too. So in schools where parents are more involved and academic success and college prep are paramount, for example, the pressure of grades and college acceptance can be a contributor to student suicide risk and attempts.

Social media is another factor that can either boost student well-being or crush it. It's the lollipop land of shiny faces and perfect families, and in our accomplishment-obsessed culture, this highlight reel of influencers, likes, and comments can alter a student's feelings of self-worth. Positive interactions, social support, and connectedness on social networking sites are consistently related to lower levels of depression and anxiety. Conversely, negative interaction and social comparisons on social networking sites are related to higher levels.4 Extended time spent on these sites results in negative mental health outcomes.5 With an adolescent population, feelings of inclusion can shift fast, triggering impulsive thoughts and actions. For example, a student who is experiencing a great day can see a status update by another student that includes pictures to a party she wasn't invited to and her mood can transform from happiness to despair in seconds. Teens are more susceptible to social influence, the need for peer approval, and the conformity effect, which drives some adolescents to agree with or engage with what their friends have already commented on or liked.

Teen Worries

What are you and your friends most worried about?

College is scary and a lot of work.

Friends feel like they need to do everything every second of the day: volunteering, activities, etc.

Pressure to get perfect grades.

Getting acclimated to high school, feeling overwhelmed, figuring out feelings, figuring out who they are, can be very stressful.

Getting into varsity or JV teams.

Really worried about junior year, AP classes, preparing for the next year.

A lot of homework, a lot of pressure.

Getting along with others.

Personal appearance, hygiene, being made fun of.

Gender identity.

Middle school is a big popularity contest, with nobody winning and everybody losing.

Gossip, drama, rumors.

You're in that stage where you're trying to figure it out, but it feels risky to be open about that.

Feeling threatened threats of violence on social media and in person.

Not feeling safe at home.

Source: Survey question for teens and sample of comments from Signs of Suicide Youth Focus Group for reviewing new video content.

The trouble lies in how the teenage brain matures. The “let's party now” parts, the hippocampus and amygdala, which are associated with impulsivity, thrill seeking, and emotions, mature way ahead of the “cockpit” or prefrontal cortex part of the brain. That cockpit is responsible for regulating all that emotion as well as planning, focusing attention, following instructions, and juggling multiple tasks. Throughout the adolescent years and up through age 25, this executive portion of the brain lags behind. It's during this period of brain development that kids often act out based on their moods and impulses, misuse substances, and engage in self-harm. Half of all mental health concerns start by 14 years of age but most cases are undetected and untreated.6 So at an age when their brains are not yet fully equipped, teens with immature coping skills are trying to manage a multitude of complex mental health, social, and life issues.

Teenagers who feel less connected, with underdeveloped coping skills and executive functions, may resort to drugs and alcohol to numb feelings and/or experience highs. People don't heal if they can't feel and this concept is especially unknown to teenagers. The late 1990s and early 2000s brought on a period of normalization for using substances to treat both physical and mental pain. Meanwhile pain clinics that used alternative methods of pain management shut down. And the US, which makes up 4.4% of the world's population, started consuming 80% of the world's prescription painkillers and became the number one consumer of prescription pain medication.7 The overprescribing meant there were more unused drugs available in medicine cabinets that often ended up in the hands of teenagers more susceptible to dependence and addiction than adults. When adolescents try something and it runs out, they find alternatives in over-the-counter substances that can be bought in drug stores. They get those ideas from online collaboration and sometimes these students will stalk peers at school for their medications after wisdom teeth removal or athletic surgery.

Just because adults and schools rarely address subjects of mental illness, grief, self-harm, and substance misuse doesn't mean young people aren't seeking answers. Given the gap in that education, young people go online to search for answers on sensitive and taboo topics, the sources of which are not always reliable. This is where they learn to turn cough medicine into a substance to get high and where they look up and find specific ways to kill themselves, often with step-by-step instructions and even videos. Still the most frequently misused substances in this age group are alcohol and marijuana, the effects of which are detrimental to the developing adolescent brain.8,9 In 2018, marijuana use among middle and high school students remained steady, but the number of teens in eighth and tenth grades who said they used it daily increased.10 Teens vape it, roll it, smoke it in pipes, cook it into baked goods, and often migrate to waxy-looking globs of high-THC concentrates known as hashish oil extracts, commonly referred to as dabs, wax, shatter, or crumble.

The problem is that parents and students are ill-informed about the detrimental effects and not only consider marijuana and derivatives as harmless but as a viable option to help kids with anxiety and sleep. Compared with conventional marijuana, hashish oil extracts may be associated with a greater risk of psychosis.11