How to stop copycat suicides in students

Over the last two months three teenage students from the same Pune school have died by copycat suicide. 'Copycat’ suicides are frequent among adolescents aged 15-19 years. They occur more often than expected by chance alone. There has been an increase in teenage clusters in more recent years (Gould et al1990).

Patterns of ‘copycat’ suicide

There are two patterns of suicide clusters: point clusters, which are localised in both space and time (spatio-temporal), and mass clusters, which are localised in time only.

Point clusters

A point cluster is a temporary increase in the frequency of suicides within a small community or institution like a school or hospital. This differentiation is important as even limited resources can be effectively mobilised for prevention.

Mass cluster

A mass cluster is a temporary increase in the frequency of suicides within an entire population. Mass clusters are typically associated with high-profile celebrity suicides that are publicised and disseminated in the mass media. Prevention here is mainly by media restraint.

This article is concerned with point cluster copycat suicides that occur in schools.

Causes of ‘copycat’ suicide

Modelling

One of the causes of suicide is social learning. ‘Copycat’ suicides are caused at least in part by exposure to another individual's suicide and through the imitation of suicidal behaviour. Suicide modeling is a real phenomenon and there is ample evidence of its impact on suicide clusters (Mesoudi 2009, Insel and Gould 2003).

Homophily

Point clusters may also occur due to of homophily, the tendency for individuals with similiar interests and outlook to preferentially associate with one another. Students who are have poor academic performance, are delinquent or abuse drugs tend to associate together. These high-risk clusters may form suicide clusters due to each member's independently high risk of suicide (Joiner 1999).

Poverty

Community household poverty increases the risk of adolescent suicidal behavior. These communities place adolescents at a higher risk for associating with suicidal others. Adolescents brought up in poor communities would thus be subjected to the processes of both homophily and social modelling for suicide behaviour (Bernburg JG et al 2009 ).

Prevention of copycat suicide

One suicide in the school is tragic by itself. However, given the tendency for teenage suicides to occur in clusters urgent action needs to be taken to prevent further deaths. Successful suicide prevention programs have three general strategies - universal, selected and indicated. (Goldsmith et al 2002).

Universal approaches

These are strategies that target the entire school population. What the school does after the index suicide is important for prevention of point cluster suicides (Doan et al 2003).　
DO

• Respond within 24 hours of the suicide
• Show concern and empathy
• Inform all staff members about the suicide and provide a debriefing session where staff may voice their concerns, apprehensions, and any questions they may have.
• Inform school board members
• Ensure all teachers announce the death of the student by suicide to their first class of the day
• Provide counseling sites throughout the school for students
• Assign a school liaison to handle all media inquiries in order to avoid sensationalistic stories concerning the suicide
• Monitor the school’s emotional climate (Has there been an increase in fights or school delinquency following a death by suicide?).
• Evaluate all activities done following a death by suicide (How did your school respond? What worked and what did not work?).
• Utilize an established linkage system or community network in order to make referrals to the appropriate services as well to exchange information concerning the appropriate steps for treating those affected by the suicide.
• Utilize an established school response crisis team, which should include a diverse group of school professionals, such as the principal, counselor, teacher and possibly the school nurse.

DON'T

A major aspect of preventing cluster suicides lies in not glamourising or memorialising the act in any way. This would include attention to points as below.

• DON'T plant a tree or object in order to honor the student.
• DON'T hold a memorial service for the student at the school.
• DON'T describe in great detail the suicide (method or place).
• DON'T dramatise the impact of suicide through descriptions and pictures of grieving relatives, teachers or classmates.
• DON'T glamorise or sensationalise the suicide.

Selected approaches

Further specific strategies are for at-risk student groups. This would include screening and counselling of the student's known friends and group. Other at-risk children such as those with a previous history of attempted suicide, those known to have mood disorders, or substance use problems should also be specifically screened.

Indicated approaches

Students who show signs of suicidal potential should not be left alone. They should be given empathic support until they can be assessed by a psychiatrist, psychologist or counsellor and more definitive measures instituted. The signs of suicide potential include

• statements about suicide or that things would be better if the student was dead
• talking or writing about death, dying, or suicide

Every Pune school should have a mechanism in place to deal with the aftermath of student suicide to prevent copycat suicides in teenagers.

References

1. Bernburg JG, Thorlindsson T, Sigfusdottir ID. The spreading of suicidal behavior: The contextual effect of community household poverty on adolescent suicidal behavior and the mediating role of suicide suggestion.Soc Sci Med. 2009 Jan;68(2):380-9. Epub 2008 Nov 18.
2. Doan, J., Roggenbaum, S., & Lazear, K.J. (2003). Youth suicide prevention school-based guide (c/p/r/s)—Checklist 7a: Preparing for and responding to a death by suicide: Steps for responding. Tampa, FL: University of South Florida, Louis de la Parte Florida Mental Health Institute. (FMHI Series Publication #219-7a).
3. Goldsmith SK, Pellmar TC, Kleinman AM, Bunney WE, eds. Reducing suicide: a national imperative. Washington, DC: National Academy Press; 2002.
4. Insel BJ, Gould MS. Impact of modeling on adolescent suicidal behavior. Psychiatr Clin North Am. 2008 Jun;31(2):293-316.
5. Joiner JTE. The clustering and contagion of suicide. Current Directions in Psychological Science. 1999;8:89–92
6. Mesoudi A. The cultural dynamics of copycat suicide. PLoS One. 2009; 4(9): e7252. Published online 2009 September 30. doi: 10.1371/journal.pone.0007252.

Manage exam stress: what Pune’s students need to do

Exams at St Germain's

Pune students need to differentiate true exam stress or test anxiety from rational test anxiety that occurs due to a lack of adequate preparation. Both conditions need to be addressed differently. True test anxiety is diagnosed when the student panics, "blanks out", or overreacts despite the following (Hanoski 2008):

• there is enough time for studying
• study strategies are adequate
• attendance is regular
• class material is understood

Managing rational test anxiety

(Morgan et al, 1986)
When there is adequate time for preparation effective learning habits minimise rational test anxiety.

Effective learning habits

We begin at this stage if the student comes to the clinic 6-8 weeks before the exams. Acquiring effective study skills is essential for all students.

• Plan and stick to a study schedule. This simple yet crucial first step is often neglected.
• Spend at least half the study time in elaborative rehearsal, thinking about what is being rehearsed and relating it to other things that are known or being learnt
• Organise the study material to form retrieval cues or reminders for recall
• Get feedback on how well things have been learnt and remembered
• Review before the exam in the same way things were learnt in the first place. Focus the review on the type of exam.
• Over learn the material. Go back and re-learn it after a few days.

Prior to the exam

 (University of Illinois)

These techniques are applied 1-2 weeks prior to the exam

• Avoid "cramming" for a test
• Combine all the information presented throughout the year. Work on mastering the main concepts.
• Anticipate questions that may be asked and try to answer them by integrating ideas from lectures, notes, texts, and supplementary readings
• Select important portions that can be covered well if you are unable to cover all the material given throughout the term, 
• Set a goal of presenting knowledge of this information on the test.

True (Classic) Test Anxiety

True or classic test anxiety occurs despite effort to study and requires further measures. Again these measures vary as per the phase of the examination.

Pre-test

These measures can be instituted at any time prior to the exam and should become routine for all students.

Adopt a health-promoting lifestyle

Behavioural measures

• Assertiveness - claim space and environment for study, study materials, access to experts
• Time management - especially with a view to program adequate study hours by identifying periods in which time is spent on distractions
• Recreation and social activities - essential for maintaining concentration, and motivation. Should be programmed daily in small quantities

Physical measures

• Nutrition - don’t skip meals. Eat plenty of fruit and coloured vegetables
• Exercise - the amount can be varied. Incorporate some stretching exercises and some aerobics like skipping or same place jogging.
• Relaxation - use a muscle relaxation technique or any form of meditation that doesn't take more than a few minutes
• Sleep hygiene - for adequate, predictable and refreshing sleep

Cognitive and emotional measures

• Cognitive restructuring - see the exam as a means not an end. Keep in mind the ultimate goal you are working towards. This goal may differ from those of your parents and school. Aptitude testing, career guidance and counselling help match your expectations and capabilities with that of your family and school.
• Stress inoculation - take regular mock exams under the same conditions as the actual test
• Anxiety management techniques

Attention to practical aspects of the exam

• Find out where the test is scheduled to take place and how long it will take to get there
• Look at the buildingso that it feels more familiar.
• Know the rules as to what can be taken into the exam room etc [28].

The Day of the Test

• Begin the day with a moderate breakfast, avoid coffee
• Do something relaxing the hour before the test
• Plan to arrive at the test location early
• Avoid classmates who generate anxiety

During the Test

There are basic test taking strategies and specific anxiety management techniques that the student needs to learn (Hinton and Casey 2006).
Before answering

• Review the entire test and then read the directions twice.
• Think of the test as an opportunity to show what you know then begin to organise time efficiently.

Focusing exercise

• Take a deep breath. Look straight ahead at something inanimate (the wall, a picture, the clock)
• Focus the mind on the positive thought 'I CAN DO this exam' while breathing out.

Do the easiest parts first

• For essay questions start by constructing an outline.
• For short-answer questions answer exactly what is asked.
• If there is difficulty with an item involving a written response show some knowledge.
• If proper terminology evades you show what you know with your own words.
• For multiple choice questions read all the options first, then eliminate the most obvious. If unsure of the correct response rely on first impressions, then move on quickly. Be careful of qualifying words such as "only," "always," or "most."

Stick to time

• Do not rush through the test.
• Wear a watch and check it frequently
• If it appears you will be unable to finish the entire test, concentrate on parts you can answer well.

Recheck your answers only if you have extra time - and only if you are not anxious.

Anxiety management techniques

Learn a few of these techniques and stick to the ones that suit you. Use them whenever you panic while studying or during the exam. If problems persist despite using these techniques there are safe and effective medications that can be used just prior to the exam.
Thought-stopping

• Anxiety produces negative thoughts ('I can't answer anything', 'I'm going to panic' etc).
• Halt the spiralling thoughts by mentally shouting 'STOP!' Or picture a road STOP sign, or traffic lights on red.
• Once the thoughts are stopped continue planning, or practise a relaxation technique.

Mild pain

• Pain effectively overrides all other thoughts and impulses.
• Lightly press your fingernails into your palm
• Place an elastic band around your wrist and snap it lightly

Use a mantra

• A mantra is a self-repeated word or phrase.
• Repeatedly say 'calm' or 'relax' your breath

Distraction

• Distract attention from anxious thoughts and keep your mind busy
• Look out of the window, count the number of people with spectacles
• Count the number of desks in each row
• Make words out of another word or title

Bridging objects

• Carry something having positive associations with another person or place
• Touching the bridging object is comforting
• Allow a few minutes to think about the person

Self-talk

• In exam anxiety or panic there are often negative messages, 'I can't do this' 'I'm going to fail' 'I'm useless'. Consciously replace these with pre-rehearsed positive, encouraging thoughts:
• 'This is just anxiety, it can't harm me',
• 'Relax, concentrate, it's will be OK',
• 'I'm getting there, nearly over'.

After the Test

• Whatever the result of the test, follow through on a promised reward - and enjoy it!
• Try not to dwell on all the mistakes.
• Do not immediately begin studying for the next test. Do something relaxing for a while! (University of Illinois 2007).

Exam stress in students requires active management. State boards are taking exam anxiety and its adverse fallout seriously. The Central Board of Secondary Education (CBSE) has brought out a handbook, Knowing Children Better, offering information and advice on handling exam stress. When problems persist students and parents should not hesitate to seek psychiatric help (Malhotra 2007).

References

1. Geetanjali Kumar. Knowing Children better. CBSE. New Delhi. 2005.
2. Hanoski TD. Test anxiety: what it is and how to cope with it. http://www.ualberta.ca/~uscs/counselling_links.htm Accessed 27-Jul-08.
3. Hinton A, Casey M. Managing Exam Anxiety and Panic-A guide for students. 18-Sep-2006. http://www.brookes.ac.uk/. Accessed 27-Jul-08.
4. Malhotra S. Dealing with exam stress amongst students: Challenge for psychiatrists. Abstracts of 59th Annual National Conference of Indian Psychiatric Society. Indian J Psychiatry 2007;49:1-60. Available from: http://www.indianjpsychiatry.org/text.asp?2007/49/5/1/33280
5. Morgan CT, King RA, Weisz JR, Schopler J. Introduction to psychology. 7th Edition. New York. McGraw-Hill Book Company, 1986
6. University of Illinois. Test Anxiety. 2007. http://www.counselingcenter.uiuc.edu/. Accessed 27-Jul-08.

How to refuse alcohol - keepin' it REAL

How to refuse an alcohol containing drink? The lead up to the festive season comes with a slew of articles on how to consume alcohol without experiencing a hangover. Then come the lessons on managing a hangover. Finally by New Year, come the statistics on drunken driving and police action on youngsters partying in rural Pune hideouts. Nothing about how to refuse alcohol while partying.

Alcohol refusal strategies

MN Gosin(2003) has classified drug resistance strategies into four types summarised by the acronym REAL
R - Refuse: say no.
E - Explain: decline with an explanation
A - Avoid: stay away from situations where alcohol is offered
L - Leave: exit situations where alcohol is offered

Don't reach for it

10 tactics to resist alcohol at a party

These tried and tested ways to politely resist alcohol are classified along REAL lines. Remember you have the right to choose not to consume alcohol at any time. If that’s not respected you are probably in the wrong company. Once you take your stand don’t hold back. Participate, then you are less likely to be singled out to have a drink forced on you.

1. Firmly decline alcohol. Ask for a soft drink. Don’t apologise. When your friends recognise you mean it this time they will not press you. (R)
2. Go for a soft drink ‘to start with’. ‘Stick with this’ if your friends remember to ask later. Grab a soft drink and don’t let go. Once you have a soft drink in your hand it is easier to just wave the alcohol offer away. (R)
3. In the initial stages keep a glass constantly in your hand. Make sure its at least a third full at all times. (R)
4. Don’t reach for any glass of alcohol, even if it’s paid for by one of your friends. There are enough people around who will drink it gladly. (R)
5. Volunteer to be the ‘designated driver’. If there are more than one of you claiming this position your task is easier. See point 8. (E)
6. Insist that you’re on medication that reacts with alcohol (eg Tiniba for a stomach problem). If you are known to have diabetes or hypertension say your doctor advised you not to drink alcohol (He did, didn’t he?). (E)
7. Say you have to work on a presentation/ pick up your mother after the party. Any plausible reason for the need to remain sharp will do.(E)
8. Stick with a known tee-totaller in the group. Its easier to resist exhortations to drink alcohol when you have a partner.(A)
9. When invited inform that you won’t be drinking alcohol. They’ll say its for the pleasure of your company. Hold them to it at the party (A)
10. Leave when you suspect your soft drink may be spiked. (L)

Do these strategies work?

(Kulis et al, 2008)

• Refusal - significantly reduces binge drinking.
• Explanation - may not be so effective, at least in teenagers.
• Avoidance - significantly reduces alcohol use
• Leaving - significantly reduces binge drinking

What worked for you?

1. Gosin M, Marsiglia FF, Hecht ML. Keepin' it R.E.A.L.: a drug resistance curriculum tailored to the strengths and needs of pre-adolescents of the southwest. J Drug Educ. 2003;33(2):119-42.PubMed
   
2. Kulis S, Marsiglia FF, Castillo J, Becerra D, Nieri T. Drug resistance strategies and substance use among adolescents in Monterrey, Mexico. J Prim Prev. 2008 Mar;29(2):167-92.PubMed

Caregivers of mentally ill persons - Do's and Don'ts

Caregivers of persons with chronic mental illness are usually family members, 'individuals whose own happiness is entwined with the well-being of people who are dear to them'. The burden of care is associated with significant stress. For one family the stress was unbearable. They abandoned their mentally ill daughter in a hospital. This story is repeated often enough in urban areas like Pune.

How can a caregiver help a relative with mental illness?

DOs

Follow the treatment

See to it that the person takes the prescribed dosage of medication regularly. Failure to keep to the dosage may lead to a relapse of the illness.

Watch for a relapse

A person in your care may suffer a relapse for no obvious reason. Watch out for early signs such as sleeplessness, restlessness, and irritability. Take the person immediately to a psychiatrist, so that medication may be adjusted.

Take interest and appreciate

Talk to the person. Show an interest in what he or she is doing. Appreciation of the smallest task is important. Try to prolong normal talk and conversation.

Assign small responsibilities

Get the person to perform simple tasks around the house. Keep these tasks small and uncomplicated.

Supervise
The need for supervision varies.

• Constant supervision: Persons who are chronically ill or who express suicidal thoughts and seem very depressed.
• Periodical supervision: To ensure that drugs are taken, personal hygiene is maintained and that there are no signs of depression.
• Minimal supervision: As patients become self-sufficient they can be trusted to function alone safely.

Acceptance

The family must realise limitations and weaknesses of the person being cared for. Caregivers can minimize frustration by learning not to expect the impossible the ill relative. The patients condition will improve – but slowly.

Support services

Do utilise support services available in the community. Mental illness is included in the Persons with Disabilities Act (1995). This act has sections related to education and employment of individuals with mental illness.

Ensure some ‘ME’ Time

While caring for a loved one it is easy to neglect oneself. Stick to a routine for meals and sleep. Arrange for someone to care for the relative at least once or twice a week. Preserved health will ensure continued care for the dependent relative. Caregivers who spend some time away from their ill relatives express more satisfaction in caring for them.

DONTs

Don’t criticise
Derogatory criticism, taunting or disbelieving can have a traumatic effect on the mentally ill person who is in a very sensitive state. Arguing and harassing only adds to the stress and may lead to a return of acute symptoms.
Refrain from over-involvement
Sometimes the person being cared for may interpret interest and support as interference and meddling. In that case it is better to back off. Stand by in case of need, rather than getting involved actively.
Don’t exert social pressure
Do not try to make the person aware of social and financial responsibilities while undergoing treatment. Show that you believe in and value their efforts. As the person improves, he or she should be allowed to grow slowly into a realisation of abilities and responsibilities.

What are the factors related to caregiver satisfaction?

(Kartalova-O’Doherty and Doherty, 2010)
Finding caring services. A caring psychiatrist plays a crucial role in caregiver satisfaction.
Being accepted as a partner in caring for the ill person. Satisfied caregivers see their role as an additional source of social support for rehabilitation or recovery for their relative. They feel this role is accepted by the mental health services.
Interrelated factors

• Supportive and non-intrusive relationships between carers and their ill relatives
• Supportive community. A supportive community is essential to reduce stigma associated with chronic mental illness.
• Suitable family support programmes. Caregivers are left to fend for themselves or when they give up, to leave their relatives at some soul-less 'home'.

Caregivers have a major role to play in re-socialization, vocational and social skills training of a relative with mental illness. There is a shortage of rehabilitation professionals to deliver these services in Pune. The lack of infrastructure, funds and political support for mental heath care places almost the entire burden of caring for persons with mental illness on their families (Avasthi, 2010).

1. Avasthi A. Preserve and strengthen family to promote mental health. Indian J Psychiatry 2010;52:113-26
2. Yulia Kartalova-O’Doherty and Donna Tedstone Doherty. Satisfied Carers of Persons With Enduring Mental Illness: Who and Why? Int J Soc Psychiatry. 2009 May; 55(3): 257–271. doi: 10.1177/0020764008093687.

Schools, punishment and suicide - teenagers dying of shame

A Pune school joined the ranks of those in which a punished and humiliated teenager committed suicide. A teenage life snuffed out by the psychological pain of humiliation. It was apparently over his talking with a girl student. He was thrashed by the school principal, two teachers and the girl's uncle. This was not punishment - it was physical abuse. The boy did not return home after school. His father, a labourer, went to the school to look for him. The next morning the teenager’s body was found on the railway tracks.

Labourers moving to their work-site

Behaviours perceived as undesirable by teachers

The chain of events in this suicide apparently begins with the teenager talking to a girl student - normal adolescent behaviour. It is in the stage of adolescence that opposite-sex social interaction begins. A co-ed school would be the ideal place for this adolescent interaction. Yet this behaviour was perceived as seriously undesirable by the school authorities. Let’s look at other behaviours perceived as undesirable by teachers (Borg MG, 1998).

• Teachers perceive drug abuse, bullying and destruction of property as the most serious problem behaviours. Inquisitiveness and whispering are rated as the least serious
• Cheating, lying, masturbation and heterosexual activity are considered as more serious in girls. In boys, dreaminess, disorderliness, silliness, quarrelsomeness, and restlessness are considered to be more problematic.
• Female teachers perceive masturbation and obscene notes as more serious than male teachers. Male teachers perceive disorderliness to be more serious.

Punishment in schools

In the next step of the chain of events the teenager was punished for his normal adolescent behaviour.

Punishment is the application of an adverse stimulus after an unacceptable behaviour has occurred. The goal is to reduce the probability that the behaviour will recur. However, punishment, especially in public will also result in loss of self-esteem and humiliation. Public humiliation is known to promote further aggression - not reduce it.

In a school system there are better ways to induce behavioural change while preserving the child’s dignity. All behavioural measures start with defining the problem behaviour. Talking to a girl-student in a co-ed school is only problem behaviour when it is viewed on social class lines. School authorities and teachers need to realise their role as promoters and nurturers of responsible freedom and equality. As educators they need to go beyond their own personal biases.

Humiliation

A major interpersonal risk factor for suicide in India is humiliation (Bhatia et al, 1987). Humiliation is strongly related to aggressive behaviour. Suicide is nothing other than aggression turned inward (Freud. 1919). Middle class status protects the individual against aggression when humiliated (Aslund et al, 2009). That protection was not available for this lower socio-economic status labourer's son.

The outskirts of Pune are a churn of economic activity sucking in people with the promise of opportunity for work. In the mornings the roads from surrounding villages are lined by labourers walking with tiffin in hand to the nearest transport hub. Many among these house their families in one room shacks. It is a tribute to our system that at least for some among them the education of their children in a proper school is not just a dream. It is a shame on us that ten years of education and commitment of parents and the state can be cut short by insensitive punishment and humiliation by parents and educators. One labourer’s child died of that shame.

Top

1. Aslund C, Starrin B, Leppert J, Nilsson KW. Social status and shaming experiences related to adolescent overt aggression at school. Aggress Behav. 2009 Jan-Feb; 35(1):1-13.
2. Bhatia SC, Khan MH, Mediratta RP, Sharma A. High risk suicide factors across cultures. Int J Soc Psychiatry. 1987 Autumn; 33(3):226-36.
3. Borg MG. Secondary school teachers' perception of pupils' undesirable behaviours. Br J Educ Psychol. 1998 Mar; 68 (Pt 1):67-79.
4. Freud S. Mourning and Melancholia. 1919