The students who most need help are the least likely to ask for it. That is not a figure of speech. It is a measured effect with a name.
Help-negation
Help-negation is the finding that as suicidal thinking increases, the intention to seek help decreases. Not stays flat. Decreases.
The effect has been studied in adolescents and young adults, and it is associated with depression, anxiety and hopelessness. Which is to say, associated with precisely the things that make a student need help.
This is the mechanism underneath everything SAFER does.
Universal screening is how you find the students who would never raise their hand. Help-negation is why they never raise it.
A school that understands help-negation stops being surprised by the most common and most painful fact about youth suicide: that the student everybody later says "seemed fine" very often was not telling anybody anything, and the reason was not trust or stigma or not knowing where the office was.
Sources: Wilson CJ, Deane FP. Help-negation and suicidal ideation: the role of depression, anxiety and hopelessness. J Youth Adolesc. 2010;39(3):291-305. · Wilson CJ, Deane FP, Marshall KL, Dalley A. Adolescents' suicidal thinking and reluctance to consult general medical practitioners. J Youth Adolesc. 2010;39(4):343-56. · Wilson CJ, Thomas SDM, Furlong ST. Help-Negation. In: Encyclopedia of Adolescence. Springer; 2017.
What this means for how a school is designed
Three things, and the third is the uncomfortable one.
1. A referral pathway that waits to be used will be under-used. Posters, assemblies, an open counselling office door and a QR code all depend on a student acting. Help-negation says the students in most difficulty are the least likely to act.
2. Gatekeeper training is necessary and not sufficient. Training adults to notice and respond is valuable, and it still requires the student to be noticeable. A student who is quietly compliant, keeping their grades up and sitting at the back is not noticeable.
3. Asking everybody is the only method that does not depend on the student asking first. That is the whole case for universal rather than targeted screening, and it is why targeted screening, which asks the students an adult already suspected, finds the students the adults already suspected.
Every other pathway into care asks the student to overcome the exact thing that is wrong with them.
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Students tell a screen things they do not tell a person
A related and separate finding: in clinical trial settings, systematic questioning picks up suicidal thinking that was not disclosed in ordinary clinical contact.
Why that is plausible is not mysterious. A form does not react. A form does not look worried, does not know your mother, will not see you in the hallway tomorrow, and does not have to be told out loud.
Critical Reflection. Think of the last student at your school who disclosed suicidal thinking to an adult. How long had it been going on before they said anything? Now assume the same gap for every student who has not said anything yet.
Sources: Bridge JA, Barbe RP, Birmaher B, et al. Emergent suicidality in a clinical psychotherapy trial for adolescent depression. Am J Psychiatry. 2005;162(11):2173-5. · Vitiello B, Silva SG, Rohde P, et al. Suicidal events in the Treatment for Adolescents With Depression Study (TADS). J Clin Psychiatry. 2009;70(5):741-7.
