Potential Harms of Responding to Youth Suicide Risk in Schools

Abstract

The potential harms related to interventions for adults with suicide-related risk, particularly hospitalization, have been well documented. Much less work has focused on the potential harms related to interventions with youth struggling with suicidal thoughts and behaviors. Young people are most likely to receive mental health services in schools, which are recognized as meaningful sites for effective suicide prevention work. However, no overviews have conceptualized the potential harms to youth when schools engage in ineffective suicide prevention efforts. In this article, we discuss three prominent overlapping areas of potential harms: (1) privacy-related, (2) relationship-related, and (3) mental health-related. We then discuss key factors thought to influence the development and maintenance of these potential harms. We conclude by noting ways in which school-based mental health providers may attempt to reduce unintentional harms in this area, with an overarching goal of helping support school mental health providers and the youth they serve.

Youth suicide and related behaviors are a pressing public health problem in the United States. Suicide is the second leading cause of death for the 14–18 year old age group, with over 1 in 10 high school students reporting a suicide attempt in the prior year (Centers for Disease Control and Prevention, 2023, 2024). Beyond the ethical imperative for suicide prevention work, schools face a legal obligation to attempt to prevent reasonably foreseeable harm to their students (Jacob et al., 2022). Failure to prevent suicidal behaviors by students has resulted in lawsuits against schools on the basis that the school did not meet their obligation to prevent foreseeable harm (D. N. Miller, 2014; Poland & Ferguson, 2022). As such, schools may be overzealous in their response to youth suicide risk in ways that can perpetuate harm. Although the many benefits of school-based suicide prevention have been covered extensively (see Erbacher et al., 2024; Miller, 2021; Singer et al., 2018), less attention has been given towards the ways in which school-based suicide prevention efforts may cause unintended harm. Thus, while acknowledging the importance of schools in supporting youth suicide prevention, the focus of this paper is to outline potential paths toward preventing these harms.

Schools are important sites for suicide prevention efforts as they provide mental health services that range from universal interventions to individualized crisis response across an entire local population of youth (Singer et al., 2018). Not only do most youth who receive mental health services typically receive them in schools (Duong et al., 2021), racially marginalized youth are also more likely to receive counseling services in school than at outpatient clinics (Green et al., 2020). Notably, Latino students were more likely to access school-based care following a suicide prevention gatekeeper program than outpatient care (Kataoka et al., 2007). School-based suicide prevention provides access to mental health care that may not otherwise be accessible to youth, especially for certain racially minoritized groups (Lyon et al., 2013).

Few existing reviews discuss potential harms in the youth suicide prevention literature broadly (c.f., Kuiper et al., 2019), or with regards to specific aspects of suicide prevention, such as trauma-informed approaches (c.f., O’Neill et al., 2021). A synthesis of various aspects of potential harms faced by youth experiencing suicidal thoughts and behaviors receiving services in the school setting is needed. Drawing from the literature, including adult literature in cases where the youth literature is sparse, we reviewed three overlapping domains of potential harms—privacy, relational, and mental health—in school-based efforts to address youth suicide risk. We then provide an overview of the factors that may lead to the development and maintenance of these harms in school settings, such as prioritizing legal risk management over authentic caring and an inaccurate understanding of suicide risk stratification and prediction. We conclude with a discussion of how school-based practitioners might attempt to mitigate these harms across four domains: intervention, assessment, referral to care, and postvention after a death.

Domains of Potential Harms

Privacy Harms

A potential unintended consequence of schools’ response to suicide risk is the breach of privacy or confidentiality. Although potential privacy harms are a possibility in all mental health settings, school settings can present unique concerns—especially when suicide risk is involved. For example, thousands of school districts use software that monitors students’ online activity and alerts the school to indicators of suicide risk—introducing substantial questions about student privacy and the legal responsibilities of these schools in the face of automated alerts (Krent et al., 2019). Student privacy may be compromised when safeguards are not in place to ensure that mental health-related information is protected in both formal records and informal interactions (e.g., conversations between school staff, how a student is pulled from class; Weist et al., 2003). Although there are potential benefits of disclosures (Bettis et al., 2024), such as referral to treatment and increased social support, non-collaborative breaches of confidentiality are associated with worse mental health outcomes, reduced quality of parent-child relationships, and reduced likelihood of making future disclosures related to suicide (Fox et al., 2022).

Suicide screening and assessment presents another juncture at which the risk of privacy harms can increase for students. First, youth concerns about confidentiality breaches are a key reason they may not disclose suicidal thoughts to a care provider (McGillivray et al., 2022). When suicide screening (or automated detection) suggests that a risk assessment is indicated, a positive screening result might be shared with multiple non-provider school staff to ensure safety despite the high level of false positives (Horowitz et al., 2009). Sharing screening results may call unnecessary attention to students or lead to students being treated differently given the stigma and high degree of alarm associated with suicidal thoughts and behaviors. If a student ultimately requires a risk assessment that identifies increased suicide risk, the risk assessment information may be recorded into the student’s educational records. Although students and families may assume such records will be treated as healthcare records covered by HIPAA, most data included in school records are governed instead by the Family Educational Rights and Privacy Act (FERPA; Jacob et al., 2022). FERPA is a federal law that protects the privacy of student education records that requires parent consent prior to school disclosure of the student’s records under ordinary circumstances—with the exception to situations when disclosure of information is needed to protect the safety of the youth or others (see U.S. Department of Education, 2021 for a comprehensive overview of FERPA protections and their exceptions). Therefore, students and families may be dismayed when information is shared without their consent or assent, and they can perceive this as a breach of privacy despite it being allowed by law in certain instances. Although youth and families likely expect the sharing of information regarding suicide risk (Bogart et al., 2024) youth have described concerns about suicide-related information being shared without their explicit permission (Bellairs-Walsh et al., 2020). Moreover, the labeling of students as “at risk” for suicide can lead to stigma, with youth conveying concerns about such labels being “reductionist” and “non-holistic” (Bellairs-Walsh et al., 2020).

When suicide risk is identified in school, professionals are encouraged to consider the best way to share information with parents and other professionals in a sensitive manner (Jacob et al., 2022). This applies to sharing information about suicide risk, but also to broader concerns the student may have shared during a risk assessment, such as bullying, romantic relationships, or substance use. Communicating issues related to marginalized sexual orientations and gender identities is further complicated by recently proposed and enacted state laws mandating that school staff out students of marginalized sexual orientations and/or gender identities to their parents—in direct contradiction of the ethics code of the National Association of School Psychologists (NASP, 2020). According to the American Civil Liberties Union (ACLU), 59 bills requiring forced outing in schools were proposed between January and September 2024, with three states passing such laws (Idaho, South Carolina, and Tennessee; ACLU, 2024). Such bills raise the potential for even greater harm to come from disclosures. Particular caution needs to be taken by schools when disclosing student suicide risk to parents and families when such disclosures would involve disclosing additional sensitive information.

Potential privacy harms may also stem from observations or reactions of the student’s peers. During the screening and assessment process, students may be called out of class for further assessment. If pulling a student out of class is not done discretely, there may be a risk of compromising privacy (Weist et al., 2003). Peers may also witness or hear rumors about a student’s suicide-related crisis occurring in school (or in the community), and students may discuss or spread rumors about suicide-related events between each other in an online environment, outside of the school building (Bell & Westoby, 2021). Such rumors and gossip may further the stress and social isolation of the student.

There are also ongoing risks related to privacy and confidentiality when students return to school after a suicide-related crisis. Students returning to schools following psychiatric hospitalization for suicide-related crises have reported concerns about answering peer questions and handling peer rumors (Marraccini & Pittleman, 2022). Other students may also have legitimate questions and concerns about another student’s crisis, asking teachers or other school staff about their health and recovery, with teachers and staff sometimes unsure how best to respond (Marraccini, Pittleman, Toole, et al., 2022). Schools may wish to dispel rumors by providing accurate information to reduce potential harms, but sharing accurate information about suicide-related student crises or deaths may be against the wishes of the family.

Ideally, school personnel who know about the crisis and will be able to help support the transition back to school; however, many reported not knowing about a student’s hospitalization, which serves as a barrier to enacting re-entry protocols (Marraccini, Pittleman et al., 2022). When schools are aware, there are frequently questions about who should know what and how much they should know (Marraccini, McGraw, et al., 2024). Administrators and school mental health professionals may receive the greatest amount of information, compared to teachers and other support staff, and help coordinate care within the school (Marraccini, Pittleman, Toole, et al., 2022). Although teachers may want to help support students, they may feel like they do not have the information that they need to be helpful, and face many different—oftentimes competing—responsibilities (Ekornes, 2015; Marraccini, Pittleman, Toole, et al., 2022). Depending on context, the potential harms of sharing information with teachers (e.g., loss of privacy, potential stigma) may need to be weighed against harms of teachers not having enough information to adequately support the student. Harms related to breaches of privacy and confidentiality overlap, and may result in, harms to important relationships with the student. These potential relation harms are noted next.

Relational Harms

Feelings of social and school connectedness are important protective factors for youth at risk of suicide (Arango et al., 2024); as such, we need to exercise caution against preventive measures that may strain relationships. For instance, when schools enact emergency procedures (e.g., police transport to the emergency department [ED]), there can be severe risks of harm to the relationship between that student and the school staff. Experiences among youth who present to the ED for suicide-related risk concerns are often fraught with additional stressors and intense emotions. Students previously hospitalized for suicide-related crises have described school referrals to the ED as “accusatory,” saying professionals were “just overly concerned” but not “really concerned about me” (Marraccini & Pittleman, 2022, p. 381; Pittleman, 2023, p. 89). Adolescents have described ED experiences as a violation of their control and autonomy and have expressed fearfulness resulting from experiences with restraints and police involvement (Salem et al., 2024). Within the ED, students are likely to experience difficult interpersonal interactions, as well as lengthy waits or delays in evaluations (Guzmán et al., 2020), further exacerbating distress. Hospitalized adolescents report similar concerns to those in the ED—emphasizing the potential for existing friendships to decay and the resulting stigma and strain they face in their peer relationships (Painter, 2008). Qualitative research has consistently pointed to an underlying mistrust among hospitalized youth. For example, a participant in a study exploring inpatient experiences shared (Jones et al., 2021, p. 2024):

…being [involuntarily hospitalized] that one time was enough to make me shut out all help from figures like therapists and school workers, my parents, for fear of going back to that place. I've had nightmares about it. So it really only caused me to shut in on myself further, and force out their help rather than look for it and accept it.

Ultimately, adolescents describe ED and hospitalization experiences with a range of emotions (Haynes et al., 2011; Moses, 2011; Salamone-Violi et al., 2015), but consistently endorse a feeling of stigmatization (Rice et al., 2021). Feelings of stigma appear to remain upon return to school, wherein students may face questions about their absences and varying reactions from peers and adults (Marraccini, Pittleman, Toole, et al., 2022; Marraccini, McGraw, et al., 2024; Marraccini & Pittleman, 2022).

Similarly, parents have expressed confusion and dissatisfaction with school communication following risk assessments involving their child (Pittleman, 2023). School professionals themselves may feel unprepared to conduct risk assessments (Anderson et al., 2024), potentially influencing their ability to engage with students in an emotionally safe and caring way. A hurried, perfunctory, or visibly distressed completion of a risk assessment can inadvertently communicate to the student that they are a liability or problem to be solved or that adults cannot handle the student discussing suicide. A qualitative study by Kodish et al. (2020) found that parents and students had negative views of rigid school procedures related to decision making about suicide risk, but that conversely school staff believed these rigid protocols helped them know what to do and appear more professional. Taken together, rigid approaches to risk assessments and emergency transport, focused primarily on liability, may breach student and family trust with the school.

Caregivers who share information with school personnel may also violate their child’s trust. Parents may also feel hesitant to share detailed information as the varying training among professional roles and differences in school psychosocial climates may influence the capability of a school to appropriately handle information regarding psychiatric care (Marraccini, McGraw, et al., 2024; Marraccini, Middleton, et al., 2024; Vanderburg et al., 2023). Indeed, students returning to school following a suicide-related crisis identified the need for caring, affirming, and positive adult interactions, despite facing a mix of supportive and seemingly insensitive adults during their re-entry (Marraccini & Pittleman, 2022). For example, adolescents previously hospitalized for suicide-related thoughts and behaviors described feeling unwelcome when reaching out to their school counselors (Marraccini, Pittleman, Griffard, et al., 2022).These feelings align with the adult literature that suggests many community providers explicitly avoid clients experiencing suicidal thoughts and behaviors (Groth & Boccio, 2018).

Finally, school professionals report limited knowledge or preparation for handling postvention after a suicide despite the existence of national guidance (O’Neill et al., 2020). Unless accompanied with clear communication of the rationale, postvention guidance may be perceived by families and students as insensitive and schools may employ protocols and procedures that could lead to additional harm. A systematic review of postvention practices found no empirical support for protective effects of existing school-based postvention programs (Szumilas & Kutcher, 2011), with more recent reviews finding minimal evidence (Andriessen et al., 2019; Williams et al., 2022). However, existing postvention guidance aims to prevent harms associated with ineffective responses to a student’s suicide. For example, school postvention guidance advises against providing detailed descriptions of suicide methods or other communication that may glamorize or romanticize the death or installing permanent memorials (American Foundation for Suicide Prevention & Suicide Prevention Resource Center, 2018; Callahan, 1996). Although research regarding implementation of postvention practices is lacking, a recent article in the LA Times shared several painful anecdotes from parents about school responses they found to be harmful or lacking nuance following the death of their child (Sharp, 2023)—including being recommended to not speak to or accept any condolences from their child’s friends. Damaged relationships (between the youth and the school mental health provider, the youth and their friends, the family and the school, among others) resulting from attempts to intervene in youth suicide risk may ironically further exacerbate the youth’s mental health concerns, a potential harm that we next consider.

Mental Health Harms

At times, proactive interventions may also come at a cost to the mental health of those involved, including individuals experiencing suicidal ideation, their peers, and their caregivers. For instance, when a student is deemed at high risk of suicide, the de facto courses of action are often coercive (Alvarez et al., 2022; Balfour et al., 2022). Coercive actions may include involuntary hospitalization, police involvement, physical restraints, and disclosure to parents without involving or informing the youth in the process. Such actions can strip individuals of their autonomy and sense of control, amplify feelings of inadequacy and betrayal, undermine their trust in the school system, disrupt their relationships with peers, school personnel, and family, and make them less willing to disclose their suicidal intention (Edwards et al., 2015; Jones et al., 2021; Moses, 2011; C. Smith, 2017; Swartz et al., 2003). The disproportionate involvement of law enforcement for youth of color is particularly problematic and potentially traumatizing, especially considering their greater experience of violence within the criminal legal system compared to their White counterparts (Alvarez et al., 2022).

Further, EDs are often ill-equipped to provide the care that a youth needs amid a suicidal crisis (Abid et al., 2014; Nordstrom et al., 2019). Experiences in EDs can lead to further feelings of helplessness and exacerbate distress for young people already struggling with suicidal thoughts (Kalb et al., 2019). Long wait times and limited staff with training in pediatric mental health (Dolan et al., 2011) may lead to further feelings of helplessness and exacerbate distress for young people already struggling with suicidal thoughts (Kalb et al., 2019).

Although less explored among children and adolescents, as summarized by Ward-Ciesielski & Rizvi (2021), there are a multitude of potential risks associated with psychiatric hospitalizations for individuals judged to be at risk for suicide in the adult literature. Risks include exacerbated distress and feelings of vulnerability during intake/hospitalization, coercion/loss of autonomy, and potentially traumatic experiences during hospitalization. In the adult literature, hospitalization has been shown to impact individuals’ ability to manage their external responsibilities, including financial obligations, familial caregiving, and other academic/occupational demands. Similarly, hospitalization for youth may interrupt social support networks, interfere with academic demands, extra-curricular involvement, employment, and family caretaking responsibilities. Fears of involuntary hospitalization, loss of autonomy, and stigma (Blanchard & Farber, 2020; Richards et al., 2019), as well as concerns about confidentiality breaches (McGillivray et al., 2022), are among some of the key reasons youth and adults report concealing suicidal thoughts. Unfortunately, nondisclosure of suicidal ideation is common, with up to 75% of individuals who die by suicide opting to deny suicidal ideation or intent in communications occurring immediately (i.e., within days) prior to their deaths (Berman, 2018; Busch et al., 2003). Although additional research is needed to fully understand the similarities and differences in experience between adults and youth regarding suicide-related hospitalization, many concerns raised in the adult literature are likely to occur among youth as well. Issues of hospitalization (and ED experiences) are particularly relevant to school-based harms as many school districts rely on hospitals and ED to complete a comprehensive risk assessment following a positive suicide risk screening whereas in outpatient treatment, the youth client might be able to receive a risk assessment from their clinician without relying on hospital resources.

Without attention to transition services following a psychiatric hospitalization, as well as ongoing outpatient or partial hospitalization services, the potential for mental harms following hospital discharge are elevated. The possibility for inpatient hospitalization and treatment to have iatrogenic effects on patients has long been debated, with research examining its causal effects limited by numerous research design and ethical factors (Ward-Ciesielski & Rizvi, 2021). Nonetheless, the effectiveness of inpatient hospitalization for preventing suicide remains questionable (Jobes, 2017; Jobes et al., 2008), and the psychological stress associated with these practices is well-documented. Thus, rather than defaulting to hospitalization for suicide risk in order to be “better safe than sorry,” it is imperative for school-based health providers to question “For whom is it better?” (Freedenthal, 2018, p. 112). Although research has yet to answer this question, recent work has shown that the only group that evidenced clear benefit from being hospitalized for suicide-related risk were patients who had attempted suicide within 24 hours of hospitalization (Ross et al., 2023).

Even well-intentioned and evidence-informed upstream preventive efforts involve risks that must be considered. A recent non-randomized controlled study examining the efficacy of a dialectical behavior therapy-based program shed light on the challenges of implementing universal interventions in school settings (Harvey et al., 2023). Contrary to expectations, the study revealed null effects and even deteriorations in the intervention group, marked by increased total difficulties, diminished quality of parent-child relationships, heightened depression, anxiety, and emotion dysregulation, as well as reduced emotional awareness and quality of life compared to the control group. Similarly, a recent large-scale school-based mindfulness study also appeared to result in iatrogenic outcomes (Montero-Marin et al., 2022). Although these studies did not address risk for suicide specifically and have their own methodological concerns, these examples underscore the necessity for cautious deliberation when employing early and universal intervention strategies to improve student mental health. Early universal suicide prevention programs in schools, especially those that portrayed suicide as an understandable response to stress, were criticized for potentially increasing suicidality and in one study, appeared to worsen outcomes for students who had previously attempted suicide (Shaffer et al., 1991).

It is also crucial to recognize the broader impacts of interventions that extend beyond the individual student experiencing suicidal thoughts and behaviors, including caregivers and peers who may also face heightened risks of mental health challenges. Parents or guardians often undergo significant distress witnessing their child in crisis, navigating complex healthcare systems and grappling with feelings of guilt or inadequacy (Smith et al., 2024). Heightened emotional turmoil disproportionately affects caregivers with preexisting mental health challenges, leading to a decline in overall well-being (Smith et al., 2024) and often results in reduced support from others due to stigma and shame (Daly, 2005; Trinco et al., 2017). Negative impacts on students’ caregivers may also have reciprocal negative effects on the student’s mental health or the caregiver-child relationship (Micol et al., 2024; Wagner et al., 2000).

Beyond the family, the contagion effect of suicidal behaviors among youth are also of concern, persisting even when controlling for pre-existing risk factors (Abrutyn & Mueller, 2014a; Randall et al., 2015). Although the operationalization of contagion has been inconsistently used in research, the phenomenon generally refers to how suicidal behaviors may spread across individuals and communities (Cheng et al., 2014). Although there are several potential explanations or contributing factors for the phenomena, suicide contagion appears to be particularly pronounced in adolescent populations/high schools (Abrutyn & Mueller, 2014a; Lake & Gould, 2014; A. B. Miller & Prinstein, 2019). One overarching theory of suicide contagion defines an adolescent’s suicide propinquity as a combination of closeness/connection to suicide, social processes like suggestion and imitation, and cognitive processes such as priming and desensitization (Clayton et al., 2023) by drawing on the earlier work of sociologists (Abrutyn & Mueller, 2014b; Tarde, 1903). This theory may be a useful lens through which to consider potential harms related to social contagion when engaging in school-based suicide prevention. Therefore, it is imperative for schools to consider how their response to a student's suicidal thoughts and behaviors or death may impact the risk of their peers and ensure school responses do not deter peers from disclosing suicidal ideation to the school (Pisani et al., 2012).

Discussion

Having overviewed a range of potential overlapping harms, we now turn to discussing factors that may influence the development and maintenance of potentially harmful practices, followed by potential strategies for mitigating harms.

Factors Related to the Development and Maintenance of Potential Harms

Best efforts to mitigate and intervene on suicide may fall short of our expectations and potentially introduce harm where the intent is to ameliorate harm. In attempting to review practices that may cause harm, it is important to discuss factors that influence the development and maintenance of these practices. In addition to limited resources in schools, we posit that there are two key factors at play within school settings: prioritizing legal risk management over authentic caring (Mueller & Abrutyn, 2024) and an oversimplified understanding of suicide risk and its prediction, including failing to differentiate acute versus chronic risk.

Fears of legal consequence may produce rigid policies designed to manage legal risk that may not be appropriate for every student. School providers may then be left with two unsatisfactory paths: either follow policy (under the belief that this will reduce legal liability despite suspicions that it is not appropriate for the individual student) or respond based on the idiographic needs of the student (thus opening the practitioner and school to legal scrutiny for not following policy, but under the belief that such a response will be better for the student). At present, having the student transported for evaluation by emergency services may assuage fears of legal risk (and of student safety), but at the cost of the potential harms previously noted and suggested by the adult literature on the hospitalization of clients experiencing suicidal thoughts and behaviors (Ward-Ciesielski & Rizvi, 2021).

School policy and practice may also be influenced by an oversimplification of suicide risk and its prediction. Although one suicide is too many, it is a long-recognized challenge in the literature that the low base rate of suicide greatly limits the predictive value of any measure (e.g., Pokorny, 1983; Rosen, 1954), even for the most widely used and well-studied suicide risk assessment tools in the adult literature (Gutierrez et al., 2021). Despite the over-inclusiveness of the at-risk designations, across meta-analyses and reviews, around half of suicides came from individuals not identified as at-risk by screening/identification measures (Woodford et al., 2019). Suicide risk assessment measures fail to identify a large portion of suicides and a majority of those identified as “at-risk” are false positives. In one published example, a school ended its suicide screening program after nearly a third of their students were classified as at risk—an unacceptably high rate of false positives that could not be adequately and responsibly addressed by staff in a timely way (Hallfors et al., 2006). Additionally, a meta-analysis of longitudinal studies of suicide risk factors and suicide outcomes showed that no risk factor, or category of risk factors, predicted suicide substantially better than chance (Franklin et al., 2017). Simulations based on prevalence and outcome data across published studies similarly suggested that over 100 false positives could be expected for each true positive identification (Belsher et al., 2019). Given the high rates of false positives, acting on an “at-risk” result may outweigh the benefits—leaving school personnel to balance the willingness to do harm to many against the potential benefit of the few. However, assumption of the large benefits for the few rests on (1) the purported benefits of hospitalization or emergency evaluation (which, as described above, are contested) and (2) the belief that such action will shield the provider and school from legal liability (more so than appropriate clinical decision making).

An extension of the above prediction concern is that stratifying an individual’s risk as low, medium, or high has little validity and has been critiqued as being too imprecise to responsibly influence clinical decision making (Carter & Spittal, 2018). Such stratification may result in false confidence in the risk level and/or the stability of risk, and shifting the focus to risk management rather than on assessing for effective intervention based on client needs, which include, but are not limited to, client risk. One study of adults who died by suicide following contact with outpatient services found that, although over 70% of these decedents had received a suicide risk assessment, 75% were judged to be at low risk, and none of the decedents were judged as high risk (Wyder et al., 2021). Concerns about the validity of risk stratification have led the United Kingdom-based National Institute for Health and Care Excellence (NICE) to explicitly recommend against the use of standalone risk assessment measures and against risk stratification (NICE, 2022). Further, when done ineffectively, assessment focused on risk stratification may miss the narrative of the youth’s suicidal experience, resulting in the youth feeling unheard and placed "in a box." Relying on risk stratification to determine next steps and interventions causes schools to falsely identify suicide risk, misclassify student risk, and/or inaccurately overlook students who are at risk, all of which would lead to the harms we described above. This concern has also been noted by Simon (2009), who discusses the potential harms of strict adherence to risk assessment forms and that doing so may detrimentally prioritize “form over substance” (p. 290).

Given the idiographic nature of suicide risk (e.g., Kleiman et al., 2018), the ideal suicide risk screening and assessment should be conducted for the purpose of identifying opportunities for intervention and support that best suit the individual, such as identifying subgroups of individuals who experience suicidal thoughts and behaviors, which has stronger empirical support and point to different prognosis and intervention approaches (Au et al., 2021). Suicidal ideation (SI) differs between people and over time—some-one may experience low SI on average and then have a sudden sharp increase in SI (i.e., acute), or individuals may have relatively stable moderate SI over extended periods of time (i.e., chronic). Recent evidence suggests that chronic and acute suicidal ideation reflect different phenomena, as chronic and acute SI relate to different biological correlates, etiological pathways, risk indicators, and levels of risk for suicide behavior (Bernanke et al., 2017; Rizk et al., 2018). Most screening measures and practices fail to understand or assess for the differences between acute and chronic ideation and associated risk factors, which contributes to misunderstanding of student experiences, mis-classification of their suicide risk and inappropriate intervention efforts.

Both concerns of legal liability and the desire for clear decision-making guidance in the face of uncertainty, combined with provider fears of student suicide, align to create current paradigms that do not fully consider the potential harms of screening and assessment practices. Combined with stigma and a lack of services, the best efforts of school-based mental health providers may still involve the risk of potential harms that should be considered in decision making. Adequately describing the limitations of assessments and conclusions, as well as reviewing the likely benefits and potential harms of proposed interventions are essential in ethical service provision and informed consent—perhaps especially so with issues of suicide (American Psychological Association, 2017). We now turn to considerations for harm mitigation.

Potential for Mitigating Harms

Highlighting current shortcomings and potential harms is admittedly easier than envisioning ways to mitigate potential harms, update policies, and improve practices. Below, we attempt to sketch key considerations for reducing harm across several aspects of school-based service delivery: interventions, assessments, referrals to care, and postvention. We acknowledge that these considerations may involve substantial changes to practice that have many legitimate barriers. We recommend school staff begin with an inventory of their current practices, brainstorm potential benefits and harms of each practice, and work to consider possibilities for mitigating the harms listed in a stepwise manner. Although deciding what to do or knowing what to do can be challenging, implementing desired changes is often even more challenging and context specific.

Interventions

In addition to delivering all interventions in a culturally responsive manner, the review of potential harms above highlights that not all universal interventions are helpful—and indeed, some may do harm (Harvey et al., 2023; Montero-Marin et al., 2022). Thus, the key principle in addressing potential harms in interventions is to implement evidence-based interventions and monitor their impact. Three school-based interventions with evidence from randomized controlled trails for reducing suicide attempts are the good behavior game (GBG; Wilcox et al., 2008), Youth Aware of Mental Health (YAM; Wasserman et al., 2015), and Signs of Suicide (SOS; Schilling et al., 2016). YAM and SOS are suicide prevention programs that involve psychoeducation and increasing social supports/help-seeking behaviors, among other elements, delivered by trained facilitators or classroom teachers. The GBG is not designed as a suicide prevention program but is a teacher-delivered classroom management strategy based in behavior analytic techniques that has been shown to prevent suicide attempts in adolescence (in addition to other risk behaviors) for those that received the intervention in elementary school. Moreover, cultivating a culture of inclusiveness and emotional support, as well as addressing stigma related to mental health, is a key to mitigating relational harms.

To mitigate mental health harms associated with proactive interventions, it is imperative to adopt approaches that prioritize autonomy, support, and collaboration—which are key to the care of individuals experiencing suicidal thoughts and behaviors (Jobes, 2023; Østlie et al., 2018). Special consideration of the historical context of mistrust of the healthcare and legal system among youth of marginalized identities can help mitigate the potential of perpetuating trauma. In addition, school personnel should also recognize the broader impact of intervention efforts on caregivers and peers, including heightened distress and stigma associated with the youth’s suicidal behaviors.

Evidence-based clinical interventions for suicide risk such as dialectical behavior therapy (DBT; Linehan, 1993; A. L. Miller et al., 2017), brief cognitive behavioral therapy for suicide prevention (BCBT-SP; Bryan & Rudd, 2018), and the collaborative assessment and management of suicidality (CAMS; Jobes, 2023) may be beyond the capacity of many schools to currently provide (although, see A. L. Miller et al. 2023 for a successful example). However, school-based staff can prioritize connecting students with community resources that are able to provide these interventions (and indeed, may apply positive pressure on community mental health organizations to provide these evidence-based treatments). Brief interventions, often conducted as part of the assessment processes, such as safety planning (Stanley & Brown, 2012) and crisis response planning (Bryan et al., 2017)—both including efforts to reduce access to lethal means—are, however, promising approaches to be integrated into school-based practice.

Supporting student reintegration following a suicide-related absence requires consideration of the student within the broader school context, including their peer relationships and school psychosocial climate as a one-size-fits-all response is likely not feasible (Marraccini & Pittleman, 2022; Tougas et al., 2023). The reintegration period is a time where strategies of increased collaboration, appropriate autonomy, explicit discussions about addressing privacy concerns, and determinations of what accommodations and supports needed interact to potentially mitigate harms. Reintegration supports can be tailored to the degree of perceived stigma from close peers and from the school climate in general, the degree to which the student is comfortable being open about their experiences, the length of the absence, and whether the student will return to their normal schedule or a modified schedule.

Assessments

Regarding the tension between the desire for standard operating procedures and the inherently idiographic nature of risk assessment and response, policies could be written to explicitly include clinically appropriate flexibility in responding to the student and their context. Like the NICE guidelines, district policy may also be written in a way that emphasizes assessment for effective intervention in response to students’ specific needs rather than on stratification of student risk. Such a paradigm could empower providers to do what is effective while staying within the defined boundaries of district policy. Such policies could emphasize transparency, collaboration and shared decision making, and discussions of courses of action that adequately note potential harms. Policies should also be developed with considerations of how they may affect already marginalized students and families. Such policies vary across districts, states, and regions in the United States, and also across the world, with additional research examining the positive and iatrogenic effects of these policies sorely needed.

As with intervention, assessments should be conducted in a culturally sensitive manner (Molock et al., 2023). When communicating with families, it is important to consider family culture and values and approach caregivers with respect when communicating about sensitive issues such as LGBTQ + status and suicide risk (Burke et al., 2021; Marraccini, Ingram, Naser, et al., 2022). In states with laws mandating forced outing of gender and sexual minority students, discussing these laws in the context of informed consent with a student during the risk assessment may reduce harms related to feeling disempowered or betrayed and potentially increase safety at home.

To truly mitigate privacy risks, policies are needed that go beyond the bare minimum requirements put forth by local, state, and federal laws. For example, even though FERPA states that health-related documentation is a part of the educational record, additional protections could be put into place for sensitive mental health records. Careful attention must thus be paid to what goes into the student’s educational record related to suicidality. School staff must engage in clear and timely communication with students and families about information disclosures, and this is particularly true in emergency situations when prior consent was not sought. Youth and families should also be allowed some autonomy when communicating about suicide risks and other mental health concerns. For example, the school point person (e.g., counselor) should collaborate with students and families to determine what is necessary for other school personnel (e.g., teachers) and even peers to know. Identifying and using such a point person is particularly critical after a hospitalization or a mental health crisis in determining what and how sensitive information is shared (Vanderburg et al., 2023).

As noted in the prior section on privacy harms, thoughtful disclosures to guardians and school staff have the potential to positively increase support and understanding for the student (Sheehan et al., 2019). Although parent “notification” is a common phrasing of this task, the process of sharing the youth’s suicidal thoughts and/or behaviors with staff and educators is considerably more involved than mere notification. Additionally, when parents are advised to pick up their child from school and transport them to immediate treatment due to elevated suicide risk, some schools require parents to sign a document stating that they have been informed of their child’s suicidality and the need for immediate treatment (Erbacher et al., 2024). However, the potential positive or negative impact of this practice is not well-studied. On the one hand, this may help parents understand the seriousness of the situation, clarify their responsibilities, and/or provide the school some measure of legal defense following a suicide. Conversely, this may also move the conversation with the parent to a legalistic frame and increase parent perception that the school is primarily concerned with protecting itself rather than providing authentic care during a difficult and stressful conversation. Thus, in situations where school staff ask parents to sign documents about their responsibility to their child, school staff should take the time to carefully review both the content and purpose of the document with the parent in a collaborative manner emphasizing authentic caring for the youth and their family.

Beyond policy and privacy, increasing provider competence in assessing and intervening with youth with suicidal thoughts and behaviors is essential. Unacceptably high numbers of mental health providers (both school-based and clinic-based) report inadequate training in assessing and intervening with clients thought to be at risk for suicide (Anderson et al., 2024; Dexter-Mazza & Freeman, 2003; Schmitz et al., 2012). There is also evidence that providers rely more on their own emotional reactions to client risk when making treatment decisions than to objective client risk (Barzilay et al., 2022). To ensure ethical treatment of youth experiencing suicidal thoughts and behaviors, providers must ensure their competency to work with this population without perpetuating harm (Jobes & Barnett, 2024). If schools lack the staff qualified to conduct risk assessments and must outsource this service, priority should be given to options that reduce cost and avoid unnecessary police, emergency medical service, or ED involvement. Such options include mobile crisis outreach teams or telehealth assessments. Telehealth risk assessments by hospital or community providers may also reduce potential financial harms by avoiding an ED visit with long wait times and potentially associated transport costs (Godleski et al., 2008; Holland et al., 2021). Moreover, to maintain positive relationships with their students, school providers must navigate these assessments in a sensitive and caring manner, and maintain connections beyond times of liability and risk. Specific training in school-based suicide prevention, assessment, and intervention is well outlined in Erbacher, Singer, and Poland (2024) and in Miller (2021).

Lastly, risk assessments that prioritize an ideographic understanding of suicidality (rather than prioritizing risk stratification) have several avenues through which harm may be reduced. As noted above, a collaborative approach to risk assessment that allows clients to tell the story of their suicidality leads to greater reductions in suicidal ideation than checklist approaches (Lohani et al., 2024). This approach also naturally allows for the assessor to encourage the client to identify the drivers, or perceived proximal causes, of suicidality for the client—which are essential for intervention (Jobes, 2023). Interviews that incorporate functional assessments (or chain analysis in DBT parlance; Rizvi & Ritschel, 2014) of suicidal thoughts and/or behaviors provide information about what types of responses from school staff may inadvertently be reinforcing suicidal thoughts and/or behaviors and thus actually serve to increase student risk (A. L. Miller et al., 2023)

Referrals to Care

Given the literature on the potential iatrogenic effect of hospitalization for suicidality in some adults, hospitalization should be viewed as an intervention of last resort in schools. This includes voluntary or involuntary transport to the ED for assessment. Potential harm can be avoided by capacity building among school mental health providers, policy changes that discourage the use of emergency services for routine assessment, or community partnerships that can provide telehealth or in-person risk assessments. Reducing reliance on ED assessment could also reduce financial harms to families. School mental health staff should directly enquire about community providers’ training in evidence-based interventions for suicide and prioritize providers with additional training in evidence-based care for individuals experiencing suicidality when making referrals.

Yet, support for youth with suicide-related risk cannot stop at referral. Schools are still expected to support these students after these initial referrals and oftentimes feel ill-equipped to do so (Marraccini et al., 2019). They can partner with community agencies and families to ensure networks are established (Marraccini, Middleton, et al., 2024) and employ strengths-based and trauma-informed approaches to re-entry planning and to accommodations and supports throughout their recovery (Marraccini, Pittleman, Toole, et al., 2022; O’Neill et al., 2021). Because school and teacher relationships have been shown to relate to recovery after psychiatric referrals (King et al., 2019; Marraccini, Resnikoff, Brick, et al., 2022) maintaining and reinforcing ongoing relationships is essential to mitigating such relational harms.

Postvention Following a Suicide

Historically, much more attention has been paid to suicide prevention and intervention than postvention (DeHart, 2019; Williams et al., 2022). As such, there is very little guidance on maintaining privacy during suicide postvention efforts and even less on avoiding potential harms. The primary recommendation related to privacy and suicide postvention in schools is that school staff should respect the privacy of the deceased and their family while also sharing accurate information with the school community (American Foundation for Suicide Prevention & Suicide Prevention Resource Center, 2018). Oversharing or sharing before communicating with the family could create a rupture between the school and the student’s loved ones during what is already an extremely stressful time or be seen as a violation of the parents’ privacy rights. The "After a Suicide: Toolkit for Schools” provides guidance on how to balance the privacy and wishes of the student’s family with the need to communicate a loss to the school community and provide resources related to suicide (American Foundation for Suicide Prevention & Suicide Prevention Resource Center, 2018). For example, in the event that a family does not want to share that their child died by suicide, but students are aware, it is recommended that students are notified about the death of a student and also provided with relevant psychoeducation about suicide. This advice, however, arguably does not resolve the tension of speaking about suicide in relation to a death for which the family does not want the cause of death shared. As noted previously, however, research examining the effectiveness of these postvention practices is lacking and sorely needed.

Schools find themselves in a very difficult position when undertaking postvention activities for several different reasons, such as (1) the general lack of empirical research, b) the pain experienced by many following a suicide, (2) the different needs of various school community members, (3) fears of legal consequences, (4) guidance documents that cannot account for every specific situation or need of the school following a suicide, and (5) fears of contributing to contagion (Mueller & Abrutyn, 2024). While following the postvention guidance documents cited previously is likely to help mitigate harm and avoid common mistakes, there will doubtless be occasions where such guidance will be inadequate to a given situation or situations where guidance could be implemented improperly. Prioritizing interpretations of postvention guidance through the lens of what would be most “authentically caring” to students who have just experienced a tragic loss is a guiding principle that may serve to negate unintended harms (Mueller & Abrutyn, 2024, p. 159).

Conclusion

In this conceptual overview, we presented potential harms identified in the school literature and from the clinical literature where relevant, noting that there is little direct evidence that studies these harms. We then reviewed key factors that perpetuate and maintain these harms and discussed potential ways to reduce these harms while engaging in suicide prevention and postvention work in schools.

Although we focused on the potential harms of school-based suicide prevention work, we in no way deny the benefits (and indeed, ethical imperative) of engaging in school-based suicide prevention. More research is needed to inform best practices for schools to respond to suicide risk, and the present paper should be considered in light of the vast limitations of the literature. For example, additional research examining the effectiveness of culturally grounded risk assessments, postvention practices, and policies across the world will better inform how we approach suicide prevention in schools. Although the potential harms faced by adult experiencing suicidal thoughts and behaviors, particularly in response to hospitalization, have received some research attention—very little attention has been paid to youth in schools or clinic settings. There are many remaining questions regarding harms related to suicide prevention in schools, including whether these harms vary across locations (e.g., across states, between countries), or by how well-resourced certain schools are compared to others. The majority of research informing this paper was conducted within the United States, limiting generalization. We hope providing an initial conceptualization of these concerns in the school settings can spur future research aimed at providing effective suicide prevention in schools in ways that purposefully consider and attempt to account for known potential harms.