Mental Health: Class Action
An emerging philosophy of youth suicide prevention focuses on training peers and teachers to see warning signs. Can it solve Nevada’s teen suicide crisis?
On a late-June Las Vegas day, with the sun and wind roasting everything outdoors, eight College of Southern Nevada faculty and staff members hunkered down in an air-conditioned classroom for a full day of mental health alertness training. The instructor, Michele Howser, who teaches human behavior at the college, left the lights off, due to a pleasant ambient glow from the third-floor room’s window, which offered a view of Bonanza High School’s football field and the mountains of Red Rock Canyon beyond.
Howser, a brunette tennis player with aquamarine eyes and a dimpled chin, began by introducing herself: Ph.D. in social welfare, adoptive and foster care parent. “Mental health is my passion,” she said. “I love it. So, when they asked for volunteers, I was like, ‘Yeah! Pick me!’”
She laid out the day’s agenda, which would culminate in an exam and — for those who passed — certification in Mental Health First Aid, a citizen awareness and assistance program developed in Australia and brought to the U.S. in 2007. Howser used the adult version of the curriculum, tailoring it to CSN faculty and staff interactions with students. That’s because the training itself is part of the college’s larger goal: to refer more students to the Counseling and Psychological Services center.
The day’s lessons are laced with bleak facts: 18.5 percent of U.S. adults have a mental disorder, while only 41 percent of them get some kind of help with it. The median time of living with such a disorder before seeking help is 10 years. Howser explains the difference between signs and symptoms — symptoms are felt; signs are seen — by way of beginning a half-day survey of common mental health issues, from anxiety and depression, to substance abuse disorder and trauma. In the section on depression, we learn that loneliness is a symptom, while isolation is a sign. Howser notes that suicide and suicidal ideation are on the rise, despite an increase in services and decrease in stigma.
“Why?” she asks. “There’s a lot of work and study being done on that right now, much of it having to do with people’s self-esteem being built around likes on social media. But the research is still catching up with the way the world is changing. It’s not our role as early responders to sort that out. It’s our role to get people the help they need.”
And yet, suicide was the unspoken force behind the training that day at CSN and many other trainings like it taking place at schools all over the state. Suicide is currently the leading cause of death among Nevada teens and the second-most frequent cause of death among young adults. It claimed the lives of 32 Nevadans ages 15-19 in 2017, and another 45 in the 20-24 age bracket. Those numbers doubled over the previous decade, and they don’t include suicide attempts, which are more common than completions. Two CSN students will be included in those numbers for 2018, according to Daniel Alvarado, director of CSN’s CAPS and Disability Resources Center.
“Those incidents highlighted the need to do something about dealing with students in distress,” says Alvarado, “and what that meant for the faculty and staff, (their) knowing the early warning signs and handling it as part of classroom management. We already had some plans underway, and that moved things forward, as far as prevention goes.”
Shortly after Alvarado was hired last summer, his office applied for and won a federal grant. They’re using the $150,000, spread out over three years, to improve student awareness of and access to mental health services. Alvarado restructured CAPS, contracting with Mojave Counseling to offer more counselors for more hours. And the funding will cover materials and training costs for Mental Health First Aid, the program Howser was teaching that day in June.
CSN isn’t the only school using the Mental Health First Aid, or MHFA, curriculum. Through the Nevada Office of Suicide Prevention, several CCSD schools have offered the youth version of it, which teaches adults to help young people. And the pilot of a new version, geared toward teens helping teens, ran at eight U.S. high schools last year, including Valley High School in Las Vegas.
MHFA is response training for mental health emergencies. “It’s like a first-aid kit to identify when someone you love is struggling,” says Andrew Magness, a Valley social studies teacher who was one of the program’s five facilitators at the school. “You don’t have to be a therapist. It teaches you how to connect your friends to the correct people to get the help they need.”
Or, as Howser put it, “This is not about us leaving and saying, ‘I took a class for eight hours, and I think you’re bipolar.’ It’s about us knowing when someone needs help, and helping them get it.”
“They really emphasize that it’s not your responsibility to take care of this person,” says Lisette Vistal, a recently graduated senior who went through the Teen Mental Health First Aid training at Valley. “You direct them to an adult that can help them. I know if someone’s talking to me, I feel like I have to fix them. So, I liked how they emphasized that it’s not my job to do that.”
Another thing Vistal appreciated about the program was its frequent repetition of the slogan, “It’s okay not to be okay.” It struck a chord with her, a high-achieving student in the International Baccalaureate magnet program who’d been enduring a personal struggle without telling anyone for fear of appearing needy, weak, or ungrateful.
“It really helped me realize that it was okay to get help,” she says. “One day, during the training, I was having a bad day about that situation, that issue, and I found myself knocking on my teacher’s door and saying, ‘I need to talk to someone.’ After talking to my teacher, I felt like there was hope regarding my situation, that it could get better. And I wanted other people to have that feeling, too.”
Now a freshman in nursing at UNLV, she’s considering switching her major to psychology.
Vistal wasn’t the only student the program inspired, Magness says: “I can tell you, Valley’s counselors were busy in the following weeks … The whole summer is packed with appointments for kids who have graduated and are moving on. They want to take advantage of the wellness center while they still can. There were a lot of kids that stepped up and understood that it’s okay to ask for help.”
So, the program succeeded in getting kids at Valley to seek help much earlier than the 10-year median (so far, CSN’s first aiders have made no referrals to CAPS, according to the college’s spokesman Richard Lake). Then the question is: Can this success be repeated on a grand enough scale to reach every kid who’s considering killing himself? Can it help solve the problem of student suicide?
‘Most People Want to Stay Alive’
The authors of “A Review and Application of Suicide Prevention Programs in High School Settings,” from a 2011 edition of Issues in Mental Health Nursing, sort school suicide intervention programs into four categories: screening to single out at-risk students for help; protective skills, such as problem-solving and coping mechanisms, to help at-risk kids build resilience; curricula for educating entire student bodies on mental health issues; and gatekeeper training, for those who can offer or refer to help. Often, programs are hybrids of two or more categories.
As the study’s authors note, curriculum-based programs are a natural fit in schools. The Clark County School District requires that all eighth- and ninth-grade students complete such a program called SOS, for “Signs of Suicide.” In addition, as noted, the district works with the state Office of Suicide Prevention to offer teachers Youth Mental Health First Aid training (neither organization confirmed how many have actually undergone it). Although it also offers Adult MHFA, UNLV emphasizes an opt-in computer program called Kognito for improving general mental health literacy campus-wide. Kognito, like MHFA, is a hybrid gatekeeper/curriculum-based program.
MHFA’s curriculum includes a Power Point presentation, several group activities, such as role-playing, and a 130-page manual that covers the basics of common mental health disorders. As is often done with these programs, its essential skills are organized into an acronym, in this case ALGEE, which stands for Assess, Listen, Give reassurance and information, Encourage professional care, and Encourage self-care. At CSN’s training, Howser repeated the ALGEE steps in dozens of different scenarios. The idea is that you can always refer to the manual if you’re unsure whether something is cause for concern, but in a crisis, you need to be able to recall the intervention steps without having to think about them too hard. The acronym is supposed to help.
Does this approach work? It’s hard to say. For one thing, “You can’t measure something that doesn’t happen” — in other words, a crisis averted — says Tara Phebus, the head of the Nevada Institute for Children’s Research and Policy at UNLV’s School of Public Health. Phebus’ office and the Nevada Medical Center recently wrapped up an assessment of SOS to determine whether schools have everything they need (materials, training) to execute the program accurately and are doing so.
Phebus says the evidence of SOS’s efficacy comes from surveys of kids who’ve taken the curriculum, and comparisons of their suicide alertness with that of kids who haven’t taken it. This is similar to the approach behind evidence that the National Council offered of Mental Health First Aid’s success. A 2016 study in the International Journal of Mental Health Systems noted, “Teen MHFA appears to be an effective and feasible program for training high school students in Mental Health First Aid techniques. Further research is required with a randomized controlled design to elucidate the causal role of the program in the changes observed.”
There’s the rub — causality. It seems odd to describe currently used mental health and suicide alertness efforts as successful while suicide is on the rise. Nevada’s prevention advocates often point out that the state is the only one in the U.S. where suicide rates declined from 1999 through 2016 (by half a percentage point); however, that’s overall. Among teens, the rate is rising.
But Mental Health First Aid is a recent innovation. Like much of what’s happening in Clark County, it may prove itself effective with time. Joe Roberts, coordinator of the school district’s crisis intervention team and a licensed school psychologist, rattles off a list of recent changes that have been made, from the 2011 implementation of mandatory SOS training to the 2014 establishment of mental health transition teams. In addition, there have been several state innovations, such as the free, round-the-clock Children’s Mobile Crisis Response Team and the Division of Child and Family Services’ Suicide Postvention Plan, both statewide efforts of the last five years. Also, a slate of suicide prevention bills passed in the 2019 legislative session, signaling that public attention on the issue isn’t going away.
Trends and best practices come and go in any field, and there’s some debate about the best way to tackle suicide prevention in a school setting. Citing evidence that suicide is actually rare as a percentage of the general population, and that it occurs in greater proportion among those with mental health issues, many experts advise an approach of screening students who exhibit signs of distress and referring those deemed at-risk to treatment for underlying issues. Others feel this isn’t enough, that widespread gatekeeper education is needed as well.
“Our current approach to suicide prevention simply isn’t working,” wrote Howard University psychiatry professor Donna Holland Barnes in 2014. “It is time we stop viewing suicide as a symptom of a mental health disorder and begin seeing suicide as a behavior — a behavior that must be addressed independently of any underlying disorders.”
LOOKING FOR SIGNS
Richard Egan of the state Office of Suicide Prevention. “Most people want to stay alive. I need people around our community members that are suicide alert, to recognize what somebody’s going through.”
This focus on what’s happening in the moment is at the heart of Richard Egan’s campaign to end suicide in Southern Nevada. As the state Office of Suicide Prevention’s head of training and outreach for the four lower counties, Egan sits on a well-stocked arsenal of programs, services, trainers, and volunteers that he can deploy to target just about any population, from gun owners and veterans, to first responders and school teachers.
“Suicide is preventable,” Egan says. “Even if it’s the No. 1 cause of death in people 12-19 years of age, they still had a choice. When they make that choice, I want somebody there to help them. Most people want to stay alive. I need people around our community members that are suicide-alert, to recognize what somebody’s going through, ask them about suicide, and connect them with resources in the community. That’s how we prevent it.”
Programs like Mental Health First Aid align with Egan’s goal of training everyone to be suicide alert. But, MHFA proponents add, it only works if the program is executed accurately and consistently — with “fidelity,” as they say. Think of their delivery model as a pyramid, with a few highly trained mental health professionals from the National Council at the top. They put a select group from a site that’s adopting the program — 12 CSN faculty and staff members, for instance, or five at Valley High School — through three days of in-depth workshops, qualifying them as facilitators. These facilitators then train large groups of individuals in the one-day program, making them first aiders. The Teen MHFA program at Valley trained more than 600 seniors; at CSN, 100 faculty and staff have completed the adult version of the training since March. Add those who have already done it in CCSD schools, through Egan’s office, and at UNLV — in addition to other programs besides MHFA — and you get potentially thousands of people roaming Las Vegas school halls and classrooms who are attuned to the signs of someone in crisis. The more people like this a community has, proponents believe, the more likely it becomes that suicidal students will be spotted and helped.
The million-dollar question is, helped by whom?
‘Can That Be a Bad Thing?’
Nevada’s lack of mental health services is a well-known problem. The situation is improving — albeit slowly — according to America’s Health Rankings, which reported that the number of mental health providers in Nevada increased 6 percent from 2017 to 2018. Still, the Nevada Association of School Psychologists estimates that 75-80 percent of school children in need of mental health services don’t get them.
“That’s the unfortunate part of the state of our mental health system in Nevada: inadequate support for our community as a whole,” says CCSD’s Joe Roberts. “We are educators. We’re not mental health experts. Our role is to educate. We do the best we can to care for our students during the day. Parents are made aware when risk assessments are conducted, and depending on the level of severity, they’re one-half of the interview process. … But, for mental health supports in the community, we’re in a better situation than we were a few years ago.”
Roberts says every school in his district has an intervention team, comprising a school psychologist, nurse, counselor, and social worker, all licensed. Some may have social workers as well. Rotating among the schools are more than 650 school counselors and 150 social workers, along with 160 psychologists and another 195 nurses — nearly 1,200 mental health professionals total for the district’s 367 schools. Roberts’ staff of 14 trains the mental health professionals in risk assessment and handles crisis intervention and postvention, activities that facilitate recovery from an incident.
A CULTURE OF HELP
CSN professor Michele Howser trains teachers and students in mental health alertness. “Mental health is my passion,” she says.
As principal of Valley High School, Ramona Esparza decided she needed more mental health support than the current budget could provide for, and she didn’t want to wait. So, she applied for outside grants, teamed up with third-party providers, and opened up a wellness center at her school. It provides mental health counseling on-site through a nonprofit called United Citizens Foundation. Since opening at Valley, the operation has expanded to the Basic Academy of International Studies and Western High School, as well.
“The district was questioning why I wanted to open up a clinic, and I said to them, because if you want student achievement to increase, we have to address this first,” Esparza said. “Mental health is the elephant in the room. We have to embed it in our curriculum today. Those services don’t exist to the degree we need. Should I wait for the community to provide what we need? If I do, then my students’ needs aren’t being addressed and learning is impeded.”
Esparza learned of the opportunity to participate in the Teen Mental Health First Aid pilot program through Nevada Congresswoman Susie Lee, whom she knew from Communities in Schools. Valley was one of the eight schools chosen to participate nationwide because of its diverse demographics and inner-city location, says Lacey Rosenbaum, director of curricula and research for Mental Health First Aid at the National Council on Behavioral Health. The council is currently gathering and analyzing data from the pilot, but it already plans to expand the teen program next year. The number of schools hasn’t been determined yet, Rosenbaum says, but Valley will participate, training its sophomore class this time around.
What then? Will Valley be able to keep the program going? The National Council shares costs with the schools that adopt the program; Well Being Trust and Lady Gaga’s Born This Way Foundation are funding the pilot. But it’s unrealistic to expect any nonprofit to pay to put the program in every CCSD school. So, Esparza will have to stay on the lookout for other resources. “I need more therapists,” she says. Those she currently has are available five days a week, and they have waiting lists.
Barry Corcoran could have used an on-site therapist when he was a senior at Coronado in 2015. Starting in his sophomore year, Corcoran acted out in ways that he thought would draw the attention of teachers, based on what he’d seen in the SOS curriculum’s vignettes. But nothing came of it, and the bad behavior perpetuated a downward spiral. By the time Corcoran’s parents understood what was going on, he was deeply depressed and making plans to end his own life. Barry’s mother, Chantal Corcoran, wrote about her family’s struggle in a 2016 Desert Companion story, “I Swear I Will.” Unable to get appropriate treatment in Las Vegas, Barry Corcoran went through a 30-day residential treatment in Southern California.
He’s doing well now, living in Los Angeles and pursuing an acting career. He’s learned to pay as much attention to his mental health as his physical health, and he’s acquired skills to help him through the times when it seems like death is the only way to end his pain. Asked whether he thought a program like Teen Mental Health First Aid could have helped him, if it had been available back when he was a sophomore at Coronado, Corcoran said he wasn’t sure. It would have depended on who reached out to him, what kind of counseling was available at his school, and, most importantly, in the community.
“But anything that teaches people to be more aware of mental health issues is a positive step,” he says. “The more we lessen the stigma, the more we get people talking about it, the better we’ll all be. … And any time someone wants to help, how can that be a bad thing?”