Webinar presenter Greg Handleton answered a number of your questions after his presentation, Suicide Screening and Triage Systems for Juvenile Detention Centers. Here are just a few of his responses.
Audience Question: Are these forms only applicable to juveniles, or can they be used with adults, maybe with some modifications?
Gregory Handleton: So, my response to that would not be based so much from experience, obviously, as I’ve only been working and using this system here in our juvenile system. However, I think the beauty of it is that you can really use these forms as a guide to help you to develop your own screening and triage system with adults, on the basis of understanding that the Columbia is meant to be used in any setting both by and with people of all ages, with some versions being specific to children. So, all one has to do in the adult system is figure out the following three things in regards to a Low-risk, Moderate-risk, or High-risk individual: (1) where to physically place them (i.e., regular cell, out in the Pod/”Rec.,” an Isolation cell, or an intake holding cell), (2) which clothing, bedding, and mealtime implements to allow or restrict based on both the selected location as well as in regards to the individual’s recent and current threats and behaviors (or absence thereof), and (3) all of the steps involved in dealing with behavioral/mental health crises, including who to call and when/when not to transport to the hospital. The good news, in a way, is that there really are only so many options within any incarceration facility. Again, the central question always is, “Where do we put them physically within our facility, and then what kinds of protocols should also accompany that physical location?” So, for us, we decided that when a youth comes into our facility, even in the wintertime, that the youth is not going to be allowed to have a sweatshirt at night in a cell until they’re evaluated by a clinician because we want a trained clinician to “clear” them since the use of a sweatshirt’s arms for self-asphyxiation is a common and accessible means for self-harm. So, to compensate for this, we spent $10,000 on thick, quilted blankets that will keep an individual warm even if all they have on is a t-shirt and pants at night. So, when you think about clothing and trying to reduce the risk for self-strangulation, which is one of the typical things that people try to do if they’re going to hurt themselves within a detention facility, it’s just really a matter of deciding for your adult system what your protocols are going to be, depending on what you think really makes sense for your population.
Audience Question: Can you talk again about why some of the suicide-related questions were not included in your JVC assessment? Why you ended up excluding them?
Gregory Handleton: The tool that I was showing you with those slides was the longer versions of the C-SSRS, as there are indeed several longer versions of the Columbia. And so these “excluded” questions come from the longer versions. The reason I showed them in the presentation was because I just wanted you to see them and just know that they exist. And so typically, clinicians will be the ones asking those additional questions as part of a lengthier suicide-risk assessment. The screening version that we’re using as the core of our system is the official published C-SSRS screening tool and so, therefore, there isn’t really a need to use a longer tool when all you are asking your non-clinician staff members to do is a suicide screening – i.e., again, it’s called the C-SSRS Screen with Triage Points for Corrections. We’re just using that screener, and it does not contain all those other questions. So, Columbia University’s Lighthouse Project team are the ones who developed the longer versions and the screening version. For our non-clinicians, using the screening version just makes the most sense. So, there’s nothing wrong with that extra material. In fact, the full version is what really makes the Columbia an outstanding tool, as non-clinicians can also ask those additional questions as well. It’s not just for clinicians, but we’re using the screener because it fits our needs. So, showing you the additional C-SSRS questions was just for reference and to show you what’s out there.
Audience Question: Have you ever noticed that frequently detained youth might rush to answer questions? Because they remembered what they said last time?
Gregory Handleton: Absolutely. And so, knowing that that’s going to happen, my first response is, we can’t do anything about that. I mean, kids are going to get savvy and they’re going to get smart about just about any system that we would put in place. Our hope and I think what we have found, is that it’s still better to do a face-to-face interview. It’s no different with any tool, because our “frequent fliers” were also getting familiar with the questions on the MAYSI-2, as well, resulting in a lot of “faking good” on their responses to the questions that they knew would make them appear the most symptomatic. The point is that even if a kid says NO to everything, but we already know that they’ve had some suicidal history, there are some built-in safety nets to help compensate for this, safety nets that allow interviewers to relax and not feel like they have to magically coerce the truth out of a youth who is lying and minimizing. The key to success is that the staff member follows the directions in each step, period. When they do that and document their findings properly, then that plays the biggest role in limiting liability if a youth should still be placed at Yellow- or Orange-status but ends up harming or killing themselves. The safety net features of our system include: (1) Step 2’s questions about hallucinations and about extreme duress related to being in the detention facility, (2) the parent/guardian phone call using the same six questions, (3) asking the parent if they have concerns about their child’s safety in regards to suicidal ideation apart from the timeframes associated with the questions they just answered, (4) Step 3’s process of having the Shift Leader check the electronic database to see if the youth was on Orange- or Red-status during their last incarceration within the past 3 months, and (5) having the Shift Leader double-check the youth’s responses to a couple of questions related to past hospitalization/suicidal behavior from the OYAS Detention Tool questionnaire which is also part of the intake packet. So, in essence, we have built-into this screening packet all of the steps necessary to check additional sources of information, because it rarely makes sense to “just go with” what the youth is telling us, not when so many have such a propensity to lie, minimize, and try to look stronger and more competent than they really are. If we can’t reach the parent after hours at two in the morning, we document that, noting that we were unable to reach the parent. It’s right there in Step 3 in the different little checkboxes, such as, “A voicemail was left for the guardian …” or “guardian’s voicemail is not set up” or “guardian’s voicemail was full,” etc. If the youth lies about everything and then they end up hurting or killing themselves that night, we’ll be able to show that we attempted but couldn’t reach the parent; and so this becomes vital when documenting our efforts, especially when it involves a youth who is new to the system and, therefore, we have no previous information from the electronic database to check – i.e., we can’t see if they were on Orange- or Red-status within the past three months. So, these are all of the “safety net” features of this new system that help to cover us because we know that youth will often skim through it and not tell the truth.
Audience Question: Is there any research out there regarding ways to keep youth detention who are potentially suicidal and keep them safe without inflicting even further harm?
Gregory Handleton: I’m not sure that I can speak to research, per se, but I feel like one of the primary motives of the Columbia Lighthouse Project, and of our staff here in Clermont County is, we’re trying to reduce risk. Each detention facility, depending on what state they’re in, has to follow state protocols, state-mandated protocols for what to do if kids are acting out violently toward themselves or others. Really, all state-mandated protocols are designed to maximize safety for both residents and staff, and now our suicide screening and triage system adds to that. The fact is, there are times where a kid is trying to scratch themselves so severely that staff has to use the belly belt which has the handcuffs and the belt so they can’t reach their face or can’t scratch their wrists and things like that. So, certainly, there are times like that where JDC staff have to use the tools available to them. But, one of the great things about this type of screening and triage system is that it is relationship-based which, in turn, helps to reduce the risk of implementing protocols “at” or “on” kids instead of “with” them, which is what we always want to do. If a youth has to be placed on Orange- or Red-status for one to three nights, there’s a better chance that they’re going to handle it better with our face-to-face interview-based system as compared to the past when a youth answered questions on a sheet of paper by themselves and then was told about the clothing and location restrictions that were going to be enforced. In addition, using a system like ours standardizes some things so that kids don’t feel like they’re just being arbitrarily placed, say, in an isolation cell or that a staff member is telling them on a whim that they can’t have a sweatshirt until cleared by a clinician. This system also gives staff a way to say to a youth, “Hey, I realize, you know, because of the screening, we’re going to be placing you in one of the isolation cells tonight, but please know it’s not a punishment, and you haven’t done anything wrong.” I’d like to now address the concepts of “keeping kids safe” and “without inflicting further harm”: First of all, yes, let’s always do all that we can to keep kids as safe as possible. At the same time, we must always remember that risk can never be completely eliminated in this life, in this world, or even in our own homes! The emphasis in this screening and triage system is to reduce risk, not to try to eliminate it completely, because the moment you go too far in trying to eliminate risk for one youth, I can guarantee that you’re somehow increasing risk for other residents and other staff at the same time or later that same day. Also, in order to make sure that protocols do not “inflict further harm,” we have to train our staff to have an attitude of Basic Respect at all times, even when they don’t like a particular resident at a particular time. The use of Basic Respect at all times, in addition to the principle of, “Never take a youth’s words or behaviors personally,” will go a long way in increasing the quality of the adult-youth relationships within the facility which, in turn, reduces risk and prevents “further harm” of an emotional or physical nature from happening. The last micro-skill I try to teach is that of Validation. So many times kids just want to be heard and understood, but all the adults in their lives both invalidate and misunderstand them based on partial listening or no listening at all. So, one thing both clinical and non-clinical staff members can work on is, when a youth says something, try to take a moment to (1) empathize with them, as well as (2) validate as much as possible without condoning destructive behaviors. The goal is to train staff to always listen and respond calmly and respectfully and, when a youth is badgering and being annoying, to set the appropriate boundary and/or consequence while still communicating ongoing support. Staff help themselves to step back from the “causing further harm” line every time they treat each youth with undeserved respect and kindness. In this way, then, youth learn that, “Even though I know that Shift Leader James doesn’t always like me, he still always treats me with respect, patience, and – now that I think about it – I do feel like he validates me and understands me better than most.” Think about it: If three staff members have to get a kid cuffed into a belly-belt and a helmet because they’re severely scratching themselves and banging their head dangerously against the wall, we can all appreciate that there’s a huge difference between staff barking commands and telling the kid to knock it off vs. staff verbally supporting the youth through the crisis by saying things in-vivo like, “We’re not mad at you, we’re just trying to help you to not actually injure yourself,” “Tell me if that’s too tight,” “We’re going to get through this together,” “We hate to see you feeling so upset,” “Once these are on, how can we help you to feel more comfortable?” or “Once these are on, is there anyone here that you would like to talk to?” So, when kids are helped to come to these kinds of positive conclusions about adult staff and when they are able to hear these kinds of supportive responses from adult staff even in highly confrontational situations, risk for self-harm and harm towards others within the facility goes down. The same would be true, I’m guessing, in the adult system. Of course, even with this system, it’s not perfect. Kids are going to end up sleeping out in the pod or in an isolation cell at times when they didn’t really need to be. But it’s better than what we had, and our non-clinicians are much better equipped than they were before. So, I think your question really speaks to how there’s really a system-wide movement now to try to reform Juvenile Justice so that there’s more of a Trauma-Informed Care (TIC) approach in handling youth. And that’s what we’re trying to do, which is to use a system like this to handle kids appropriately, to document our decisions within the use of the system itself, and to make sure that we’re not increasing risk unnecessarily.
Click Here to Watch a Recording of Suicide Screening and Triage Systems for Juvenile Detention Centers.