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Reluctance To Require Suicide Prevention Education Could Cost Lives, But It's Complicated

QPR — shorthand for Question, Persuade, Refer — is one of several evidence-based curriculums recommended for use in schools by suicide prevention experts.
Mike Vanata
Hechinger Report
QPR — shorthand for Question, Persuade, Refer — is one of several evidence-based curriculums recommended for use in schools by suicide prevention experts.

Wyoming has the highest rates of suicide in the nation and some teens here say learning about prevention in schools is a "no-brainer," but adults are still debating how, and whether, to make it happen.

This story about suicide prevention educationwas produced by The Hechinger Report, a nonprofit, independent news organization focused on inequality and innovation in education. Sign up for the Hechinger newsletter.

It was clear to Soffy Anderson, 18, that the state needed to take action. She'd lost her sister to suicide and wished she'd known what signs to look for and how to intervene. When she took a break from class at Cody High School to testify to the Wyoming State Legislature, via Zoom, in favor of a bill that would have mandated suicide prevention education in schools, she was prepared for an easy win.

Soffy Anderson leans against a tree outside of Cody High School
Mike Vanata for the Hechinger Report
Hechinger Report
Soffy Anderson attributes Wyoming’s high suicide rates to "the cowboy up, get back on your horse" mentality. "It's ingrained, especially into the boys in our community, which I think is something we need to get rid of because you can't just cowboy-up from everything."

"I thought it would be a no-brainer," said Anderson of legislators voting "yes" on the bill.

Her state legislators disagreed. During discussion of the bill, lawmakers didn't deny suicide was a problem or that something needed to be done, but they disagreed on what to do and who should do it.

"From my freshman year till my senior year of high school I lost 13 friends to suicide," Rep. Landon Brown, a Republican representing Cheyenne in southeastern Wyoming, told fellow lawmakers. (Brown later said he wasn't certain about the number. A spokesperson for the Laramie County School District #1 could only find records of two students who died by suicide at East High school while Brown was enrolled there.)

Despite this history, Brown, like many of his colleagues, said a bill requiring schools to provide suicide prevention education to students was legislative overreach.

Ultimately, the bill failed. But the question of who should do something about preventing suicide in Wyoming, the state with the highest rates in the country, remains.

Anderson and her fellow student activists from Cody think legislators should take the lead on statewide prevention efforts. Some legislators think churches and families should be responsible for conversations about mental health. Others think schools could be an appropriate venue, but they're hesitant to add more to teachers' plates and look to the Wyoming Department of Health to do this work. Representatives from the health department say they are hamstrung by the state's local control policies, which make it difficult to administer statewide programming.

At the moment, the State Board of Education is the agency tasked with considering what to do about suicide prevention education. The board is currently reviewing the state's K-12 health standards, which mention suicide prevention parenthetically. Some on the board, which is accepting public comment on the health standardsthrough the end of July, say it's well past time to make age-appropriate suicide prevention education available to all kids.

"It just seems like a glaring omission in this state particularly, to not equip our youth who are in crisis with the most basic set of skills around this health topic," said Ryan Fuhrman, chairman of the Wyoming State Board of Education. "When kids are at the hospital because of an attempted suicide," he said, "they are in fact not learning, and we are behind the eight ball for getting them help."

The problem of suicide is so acute in the Mountain West that the region has been dubbed the "suicide belt"by experts. Wyoming, Alaska, Montana, New Mexico, Colorado and Utah - in that order - have the highest rates of suicide in the country, according to the Centers for Disease Control and Prevention. At about 29 deaths a year, per 100,000 people, suicide rates in Wyoming are more than twice the national average.

Nationally, suicide is the second leading cause of death among adolescentsand suicide rates for young women have doubled over the last 20 years.

29 out of 100,000 — suicide rate in Wyoming, which is the highest in the country

Suicide prevention education aims to teach people how to identify signs that a person may be suicidal, how to talk to that person about their thoughts and where to turn for help. The goal is to offer hope. And research showsteaching people to intervene does lower suicide rates.

"If someone can get through the intense, and short, moment of active suicidal crisis, chances are they will not die by suicide," according to the American Foundation for Suicide Prevention.

Public schools seem like a logical place to teach when and how to intervene, since most people attend them at some point, but actually getting the classes into schools has not been easy.

"We've run into challenges where legislators are reluctant to pass an unfunded mandate," said Nicole Gibson, the senior director for state policy and grassroots advocacy at the American Foundation for Suicide Prevention. She said the foundation and other prevention organizations "have been able to offer educational and training materials at low or no cost in many states, which has helped to ease concerns around states/districts having to develop those resources on their own."

Suicide prevention for school-age kids evolved out of efforts to train teachers. According to an issue briefby the American Foundation for Suicide Prevention, 32 states require training for school personnel, and 20 of those states, including Wyoming, have passed a version of the Jason Flatt Act, which requires suicide prevention education for educators. The legislation, named for a 16-year-old Tennesseanwho died by suicide in 1997, passed in Tennessee in 2007 and became a model for other states. Research shows that training teachers and staff helps, but it has limitations.

"Young people really go to their peers for so much and really trust their peers, maybe more so than adults, depending on their age," said Gibson. "So making sure that [young people] are empowered to reach out for help when they notice those warning signs is so important. It's a sign of strength to seek help, it's a sign of strength to reach out."

Related: Another tool to improve student mental health? Kids talking to kids

Over the last 10 years, Gibson said, her organization has increased its efforts to get states to pass or amend current legislation to include suicide prevention education for students. Currently 12 states, including Texas and Vermont, require that education on suicide awareness and prevention be included in the curriculum, according to an email from Gibson. Additionally, several states require districts to have suicide prevention policies in place, but don't specify an education requirement. There are also states in which school identification cards must list suicide prevention resources like crisis hotline numbers.

Gibson said one of the foundation's policy goalsis to get evidence-based suicide prevention education into schools nationwide, much the same way all kids learn fire safety techniques like "stop, drop and roll." However, teaching teachers and students how to spot and act on warning signs won't be enough by itself, experts caution.

Increasing access to mental health care and limiting access to lethal means like firearms are also important pieces to the puzzle, according to the CDC. Suicide is a complicated phenomenon with a complex web of causes that no one person, no matter how well versed in mental-health triage, can be solely responsible for preventing.

"We can't just teach them to stop, drop and roll. We also need to understand why kids keep [figuratively] lighting themselves on fire."
Ryan Fuhrman, chairman of the Wyoming State Board of Education.

Two years ago, when Anderson was just 16, her half-sister died by suicide. Anderson said she didn't see it coming. She knows now that she is not responsible for her sister's death, but still wrestles with the idea that things might have been different if she'd known more.

"Since we never talk about it, I think people tend to put that thought aside, and they're like, 'That would never happen to me,'" said Anderson. "So they don't even consider it."

Her half-sister was 20 years older, but despite the age gap made an effort to build a relationship with Anderson and her brother. "On my birthday every year, she would send me a birthday card," Anderson said. "She kept doing that until she died. And that was something that I really appreciated."

Anderson, a spunky teen with a bright smile, was aware that her sister's mental health was fragile, but she hadn't considered that she was at risk of suicide.

"It just wasn't on my mind," said Anderson. "If it had been, maybe I would have been better at recognizing signs."

Anderson said her family still doesn't talk about her half-sister's death as a suicide. "We talk about it like it was an accident, like an unfortunate loss ... as if there was nothing we could have done about it."

Anderson chose to channel her grief into efforts to do something about it. Specifically, she'd like to get people to talk more openly about suicide. She found allies in that cause through Youth For Justice, a student group at Cody High School. Students in Youth For Justice, run by Deb White, a retired science teacher at Cody High, learn the basics of political activism and get real life experience advocating for both local and statewide policies. This past year the school's psychologist, Dan Cossaboon, enlisted their help to pressure the legislature to amend the state's Jason Flatt Act to provide suicide prevention education for students.

Daniel Cossaboon, the school psychologist at Cody High, discusses suicide prevention with students.
Mike Vanata for the Hechinger Report
Hechinger Report
Daniel Cossaboon, the school psychologist at Cody High, discusses suicide prevention with students. "It's a devastating thing" when a student dies by suicide, Cossaboon said. “Everything is put on hold as the entire school just mourns."

Cossaboon said that in the nine years he has been with Park County School District 6, which includes Cody, three students have died by suicide. In two of those cases, Cossaboon said he counseled kids who were close to the students who died.

"Warning signs were given, statements were made," and yet, Cossaboon said, those students "didn't know how to respond and kept that information to themselves thinking that they were doing the right thing and not betraying that person's trust."

Related: Nation's skeletal school mental health network will be severely tested

Suicide prevention education does not, of course, guarantee successful prevention. As with CPR, even if the person offering the emergency help does everything right, it may not work. This fact is also covered in prevention courses.

Still, kids need to be explicitly taught to reach out for adult help even if it means breaking a promise to a friend, said Cossaboon, who wears his grey hair close cut and sports a goatee. He said the kids he counseled felt it was their fault they didn't know what to do, even though they were never taught how to handle such situations.

It's a "really, really heavy burden" for surviving friends, said Cossaboon. "Those are some of the most difficult counseling sessions that I've ever done. And I've been doing this for 21 years now."

"If this is so important, why are the school boards not implementing this?"
Rep. Landon Brown, Wyoming State Legislature

The stress of the pandemic made the need for suicide prevention education in Cody seem even more urgent to Cossaboon, who said he was one of three counselors responsible for 22 suicide risk evaluations during the first week the high school re-opened last fall. He said he usually doesn't handle that many evaluations over the course of an entire school year.

In November, 2020, Cossaboon and the Youth For Justice students started their advocacy in their homedistrict before taking the issue to the legislature. They approached the school boardwith a plan to collaborate with local mental health experts to deliver prevention education in the schools. The proposal was approved and plans were made to provide an evidence-based program to all Cody High School students for the first time during the 2020-21 school year.

Cossaboon and the student activists had less luck with the state legislature.

"The simple question for me," said Brown, the Cheyenne legislator, "is 'What's stopping you from teaching these kids right now?' If this is so important, why are the school boards not implementing this?"

If Cossaboon had been able to get his district to offer suicide prevention education for students, Brown wondered why advocates couldn't achieve statewide suicide prevention education by working directly with districts.

During a suicide prevention workshop at Cody High school, students were encouraged to store the Crisis Text Line — text HELLO to 741741 — in their phones as a contact.
Mike Vanata for the Hechinger Report
Hechinger Report
During a suicide prevention workshop at Cody High school, students were encouraged to store the Crisis Text Line — text HELLO to 741741 — in their phones as a contact.

It's not an impossible political strategy, but it's one that could take a while to succeed, said Donna Birkholz, who serves on the board for Wyoming's chapter of the American Foundation for Suicide Prevention. Birkholz believes state leadership is necessary. She was recently part of a successful campaign to get the state to set up its own suicide hotline, which required legislative action. National hotlines can have long wait times and can't refer callers directly to local resources. Wyoming Lifeline, reached by calling 1-800-273-TALK (8255), isn't 24/7 yet, but Birkholz said it's a step in the right direction.

Despite these efforts, high-quality suicide prevention education is still not guaranteed, and information about what is happening in schools is sparse. When asked by The Hechinger Report for details about what is available to students in Wyoming, the staff at the Wyoming School Boards Association decided to conduct a surveyto find out. More than half the district's superintendents - 30 of 48 - responded. Of these, 67 percent said they provide suicide prevention programming of some kind to students. Some programs focus on character development and resilience while others focus on suicide prevention more directly. Of the districts that offer a suicide prevention program, 75 percent present the information in the classroom, although some may also use additional methods. The remaining 25 percent rely on other ways, such as special assemblies or extra-curricular activities.

In Cody's new program, suicide prevention education is presented in classrooms by a team of local volunteers led by Wendy Morris, the community prevention specialist with Healthy Park County, an organization that promotes health and wellness.

"All we need is 60 minutes and we have people come in to deliver the information that the kids need," Cossaboon said.

Although the pandemic stalled the plan to offer suicide prevention education at Cody High School, it finally happened in May 2021. Morris, who has blonde hair and a lot of energy, met with her volunteers in the school lobby to pass out flash drives with a slideshow that would help them walk students through a program called QPR - Question, Persuade and Refer.

"Like CPR, that you may have learned in health class, and like the Heimlich maneuver, this is a basic life-saving skill we're hoping to share with you today," Morris told students assembled in a social studies classroom, "because it very well could save a life."

Cody High students take a break from their social studies class to learn about QPR — question, persuade, refer — from Wendy Morris, the prevention specialist with Healthy Park County.
Mike Vanata for the Hechinger Report
Hechinger Report
Cody High students take a break from their social studies class to learn about QPR — question, persuade, refer — from Wendy Morris, the prevention specialist with Healthy Park County.

She started off with a list of myths. Among them, that asking someone if they are considering suicide could plant the seed of suicidal thought and cause that person to make a bad decision. In the past, educators in Wyoming and elsewhere have cited this as a reason not to offer suicide prevention education. For example, a Wyoming school psychologist was quoted almost 20 years agoas saying that providing information might "have the effect of glorifying suicide," and lead to more deaths. Morris explained that research now suggests the opposite: Open and frank conversations diffuse the situation and help people feel less alone.

Like stop, drop and roll, the purpose of question, persuade and refer is to reinforce an effective response that might run counter to instinct. If a person is on fire their instinct is to run to get away from the flames but that makes the problem worse, so we drill into kids that they need to get on the ground and smother the fire. Suicide prevention education normalizes uncomfortable conversations that might otherwise be avoided.

Morris encouraged students to be direct and ask people if they're OK, if they're thinking about suicide, and if they have a plan. The ultimate goal of the program is to make students comfortable referring someone to professional help and limiting access to lethal means for those who are considering suicide. Morris told the students they could use these skills to help friends, and also to help the adults in their lives - especially middle-aged white men, the group most at risk of dying by suicide.

Related: How one school is coping with mental health: Social workers delivering technology, food and counseling to kids at home, and open office hours all day - even when school is out

Paula Medina, another student who testified to the legislature in support of suicide prevention education, asked Morris: "How would you start a conversation with a family member as opposed to a friend?" Morris said to start the same way: Be curious. She suggested phrases like: "I noticed that you don't seem quite yourself lately. Everything good? What's going on?"

Paula Medina, a junior at Cody High School, staring at the camera and leaning on a brick wall
Mike Vanata for the Hechinger Report
Hechinger Report
Paula Medina, a junior at Cody High School, said before receiving suicide prevention education she felt like she might say the wrong thing to friends who are struggling. Medina said now she knows, "just asking is one of the most important steps. I got to learn a lot of stuff that seems common sense, but actually isn't."

Medina, 16, with wavy brown hair and black-framed glasses, recently moved from Queens, New York to Cody where she found mental health care more difficult to access. In New York City, kids can take public transportation to therapy, but in Cody they rely on their parents for rides.

"It's more like a family trip," she said "Sort of doesn't really work out when you're just trying to be private about it." For kids who don't have support from their family, she said, "I think it's about creating that culture in school where you can find a safe space."

That's exactly what experts in Utah have focused on.

"We require that there's a suicide prevention policy in every school," said Cathy Davis, the suicide prevention specialist for the Utah State Board of Education. It's her job to help schools create and implement those policies. Some schools focus on prevention education, while others focus more on helping kids build healthy supportive relationships. In more rural areas there's been a focus on limiting access to lethal means through gun lock distribution.

"There is a local control that way," Davis said. "We're not going to tell you that you have to do this curriculum. We're going to say you get to choose."

That's important in Utah, which shares a border and a good deal of culture with Wyoming. Both states are rural, offer residents liberal access to guns and prefer state government take a back seat to local authorities, or even better, to individuals. However, Utah, which has the sixth highest rate of suicide in the nation, has taken legislative action to create the choose-your-own-adventure program Davis oversees.

Cossaboon doesn't think his state should tell districts exactly what to do either, but he thinks it's time for Wyoming to do something.

Park County, home to Cody, where Cossaboon works, is in the northwest corner of the state near Yellowstone National Park. It's Wyoming's eighth largest county with about 30,000 residents. The area has more resources than smaller regions, which would have a harder time fulfilling unfunded mandates for new suicide prevention education programs, according to Brian Farmer, the executive director at the Wyoming School Boards Association.

"You get to those places that are more remote in Wyoming, and you've got that one school counselor who's trying to wear six different counselor hats," said Farmer. "And it becomes really challenging for that individual to deliver the same kind of program or same kind of service that there is in that community that has strong community resources."

The bill didn't address those kinds of disparities.

Deb White, a retired science teacher, coordinates Youth For Justice, which helped Wyoming pass the Jason Flatt Act in 2014, requiring suicide prevention education for teachers. In 2021 she tried — unsuccessfully — to get a law passed requiring suicide prevention education for students as well.
Mike Vanata for the Hechinger Report
Hechinger Report
Deb White, a retired science teacher, coordinates Youth For Justice, which helped Wyoming pass the Jason Flatt Act in 2014, requiring suicide prevention education for teachers. In 2021 she tried — unsuccessfully — to get a law passed requiring suicide prevention education for students as well.

Wyoming might be in a better position to target prevention efforts where they are most needed if the state still participated in the Youth Risk Behavior Survey, said Lindsay Martin, the injury and violence prevention program manager for the Wyoming Department of Health.

In 2016, the legislature halted Wyoming's participation in the survey, administered by the CDC, because it included questions about drug use and sexual activity, which some legislators deemed indecent.

"That makes it really difficult for us to know where the problem is," said Martin. "You know, are we seeing this issue more with male teens, or female teens or the LGBT population? We don't know that because we can't get that data right now."

During the 2020 legislative session Rep. Mike Yin, a Democrat representing Jackson, near the Grand Teton National Park, made an effort to restore participation in the survey - but failed.

Advocates grumble that legislators seem happy to unilaterally take away resources that would help them prevent suicide. And Cossaboon argues that legislators also create unfunded mandates when they want to, pointing to a 2018 law requiring that schools teach computer science. He has no problem with computers, but thinks the law begs the question: Why prepare kids for a high-tech future and not address a problem that prevents them from living that future?

Brown, who supported the computer science legislation, said the legislature voted to add computer science as one of the big subject areas that kids need to learn like math, language arts, science and health. Historically, the legislature decides what those big subjects are, but the content standards of those subjects are under the purview of the Wyoming State Board of Education. Brown and Farmer think that's where the responsibility for suicide prevention education belongs.

The state board "can solve some things without the legislature having a 'thou shall,'" Farmer said. He also pointed out that deciding a curriculum by legislative mandate opens the door for lawmakers to make other decisions about curriculum, like requiring schools to teach a particular version of U.S. history or a specific take on biology.

For the board's current review of the state's health standards, Laurie Hernandez, the director of standards and assessment at the Wyoming Department of Education, helped convene a committee of 30 members, including educators, business people, parents, school nurses and school counselors. Midway through the process, Hernandez said the committee was informed of the conversation in the legislature, and the members were asked to consider the possibility of adding suicide prevention education to the standards.

"There was a lot of discussion about whether or not every single health teacher is the most appropriate person to teach those things," said Hernandez. "And there was a lot of discussion about the external resources needed to be brought in, you know, the mental health experts."

Like the legislature, the Health Standards Review Committee decided against requiring suicide prevention education, again leaving it up to school districts to prioritize. Hernandez said the committee didn't want to be too prescriptive.

"If someone can get through the intense, and short, moment of active suicidal crisis, chances are they will not die by suicide."
American Foundation for Suicide Prevention

That concern does not seem to have been a problem for the committee in setting other standards.

In the proposed revised standards, students must be taught to identify three different forms of bullying: cyber, physical and verbal. They also need to know the three different roles in a bullying scenario: aggressor, victim, and bystander. The standards also require that kids be able to describe the impact of bullying on physical, mental, emotional and social health. The examples given are listed in parentheses: "(depression, violence, avoidance, suicide, physical illness, etc.)" That's one of three times suicide is mentioned in the health standards document; in each instance, it is simply included in a list of suggested topics.

Multiple interview requests were put out to members of the health standards committee asking for an explanation of why bullying prevention is worth a more prescriptive approach than suicide prevention education. Several members were willing to speak off the record, but none wanted to share their thoughts publicly about why suicide prevention education is not explicitly included in the proposed standards.

"I'll just be honest," Fuhrman, the board chair, said when he saw the proposed new health standards. "I'm a little dismayed to see not a more targeted standard around this topic, equipping our youth to help each other." Fuhrman is a junior high vice principal; he said three kids at his school attempted suicide and required medical treatment this year. He said kids need more resources.

"I'm much more comfortable having uncomfortable conversations" since getting suicide prevention education for educators, Fuhrman said. "That has helped me out in my day job and it's helped me out as a dad."

He believes in taking personal responsibility - a strong tenet of Western culture - but reasons that "parents won't know how to have that conversation if they themselves haven't been taught how to have those conversations."

Fuhrman said the training will help kids now, "but also, I'm hoping that kids will benefit from the training when they're in my shoes as parents as well."

Without a change in the state's health standards, whether or not Wyoming students get the benefit of suicide prevention education will depend on their zip code. The proposed new health standards are now out for an informal public comment period. There are two virtual meetings scheduled in July, as well as a Health Education Standards Public Survey, to allow for public input.

Fuhrman said the problem of high suicide rates cannot be resolved by prevention education alone. He told the State Board of Education, "We can't just teach them to stop, drop and roll. We also need to understand why kids keep lighting themselves on fire."

Anderson, the Cody high student, said whether suicide prevention education gets to schools as a new law or as part of revised state health standards doesn't matter to her. What she cares about is that kids across Wyoming learn that "it's okay to not be okay" and how to reach out for help.

If you or someone you know is having suicidal thoughts, you can call The National Suicide Prevention Lifeline at 1-800-273-8255 or reach the Crisis Text Line by texting HELLO to 741741.

This story about suicide prevention educationwas produced by The Hechinger Report, a nonprofit, independent news organization focused on inequality and innovation in education. Sign up for the Hechinger newsletter.

Tennessee -- despite what the name might make you think -- was born and raised in the Northeast. She most recently called Vermont home. For the last 15 years she's been making radio -- as a youth radio educator, documentary producer, and now reporter. Her work has aired on Reveal, The Heart, LatinoUSA, Across Women's Lives from PRI, and American RadioWorks. One of her ongoing creative projects is co-producing Wage/Working (a jukebox-based oral history project about workers and income inequality). When she's not reporting, Tennessee likes to go on exploratory running adventures with her mutt Murray.

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