This article is part of State of Health, a series about how Michigan communities are rising to address health challenges. It is made possible with funding from the Michigan Health Endowment Fund.

When Jenison Public Schools nearly lost a student to suicide, the issue of youth suicide transformed from statistic to traumatic reality for Kristin Graham, then a principal in the district.

"We had a really close call," says Graham, who is now principal of Macatawa Bay Middle School in West Ottawa Public Schools. "I think that personal experience I had drove me to want to find a program that could help with suicide prevention."

Today, all of the West Ottawa district’s schools take part in the Corewell Health School Blue Envelope suicide prevention program. Blue Envelope originated as a suicide prevention program that trained more than 5,000 Corewell employees to quickly communicate about a patient with suicide risk by using the code words "blue envelope." In collaboration with the Ottawa County Department of Public Health (OCDPH) and the Ottawa County Suicide Prevention Coalition, Ottawa was the first county to request the new School Blue Envelope program. The program trains all school employees how to respond to a student expressing thoughts of suicide.

"We actually brought it all the way down to the elementary school. We're seeing ideation as young as first and second grade," Graham says. "With students, there's even the verbiage 'KMS,' [for] 'kill myself.' It's part of the dialogue. We have to determine whether this is just a joke or truly is a risk."

Since the inception of School Bue Envelope in 2019, 13,500 school personnel have been trained over 367 sessions in the Western Lower Peninusla. In 199 schools spread over 55 school districts and 12 counties, 20,629 preventive Blue Envelope conversations with students took place. In 2023, 6,119 school personnel were trained and 1,053 Blue Envelope events happened, meaning that students were potentially saved from suicide. Macatawa Bay Middle School was asked to pilot the School Blue Envelope program in 2018.

"We're a higher-needs building," Graham says. "We have a really diverse demographic with high socio-economic needs. They thought we would be a good place to start."
Kristin Graham.
School Blue Envelope is one of a suite of programs Macatawa Bay Middle School has initiated to support students’ mental health and prevent suicide prevention. 

"We are constantly telling our students that their behavior, their words, how they treat other people matters," Graham says. "Some of that cruelty we see is more a defense mechanism. I don't think kids have a bad nature. We have to teach them to look beyond that, even if you are in defense mode, to respond to people without cruelty."

Suicide is everyone’s responsibility

According to Dr. Subodh Jain, Corewell Health vice president and behavioral health department chief, suicide is a public health epidemic. He shares that one in three children in middle and high school struggle with a mental health condition. One in five have expressed suicidality or self-harm. The national and statewide shortage of mental health counselors and child psychiatrists means communities must find other ways to prevent suicides.
Dr. Subodh Jain.
"Instituting these kinds of preventative programs actually helps us identify suicidality and intervene immediately," Jain says. "Suicide is an episodic event. And if we prevent one event, we have prevented one suicide."

Jain describes Blue Envelope as a "risk stratification" protocol.

"A patient or a student who expresses a suicidality or a risk of harm to self in any way has to go through an evidence-based screening process, the Columbia Suicide Severity Scale," Jain says. "Based on how they score, low, moderate, or high, that's where we find out what interventions they would need at that time."

School Blue Envelope has two different levels of training. The first, for all school staff, teaches how to identify and report a student in crisis. The second level of training is for counselors, administrators, and teachers who learn how to conduct the screening protocol. After determining the severity level, a corresponding intervention is made. Jain describes Blue Envelope as using a "train-the-trainer model." After Corewell staff conduct initial trainings, they identify champions within the school system who can take over as trainers, so the program becomes sustainable.
Kristin Graham (right) checks in with a member of her team.
"Implementing any suicide prevention program, irrespective of whether it is Blue Envelope or others, reduces stigma in the school systems to actually talk about this," Jain says. "When your staff and teachers are confident in addressing a child's immediate crisis or needs, they can immediately attend to the child's needs. They're comfortable after they've been trained."

As part of the protocol, the person identifying a student with a need stays with them, validates their feelings, and eliminates lethal means.

"When you're taking all the steps, you help to prevent any future incident that helps with completing suicide," Jain says. "The difficult part about suicide prevention is we do not know how many suicides we prevent. But once the entire school is well trained, then the students who come forward are often getting the right kind of help."

Children who score at the highest level of risk can be taken to a hospital, crisis unit, or a mental health professional immediately.

"This program is extremely successful because it doesn't further stigmatize children who bring their mental health issues forward," Jain says. "As they're addressed within schools, not every child with low to moderate risk is having to go through hospitals or inpatient units. It prevents an excessive burden on families. And children can be integrated back within their daily lives once the early intervention is done if they're not at high risk."

Encouraging results in Ottawa County

When staff at the OCDPH looked at community assessment survey results in 2017, they were shocked by the number of middle and high school students identifying as having suicidal thoughts.
Amy Sheele.
"In a classroom of 25 students, five had had thoughts of killing themselves," says Amy Sheele, an OCDPH program supervisor who also works with the Ottawa Area Suicide Prevention Coalition. "We decided we wanted to make sure that we have really good suicide prevention happening."

While the collaborative partners making up the Suicide Coalition had done a lot around suicide prevention in general, they decided a focus was needed in the county’s schools. Members of the coalition were aware of the Blue Envelope program from its success in the health care sector. With help from Spectrum Health, the group figured out how to roll out the program in multiple schools, train staff, and collect data for the first years of the program.

"We partnered up with other community organizations and schools and got together to figure out how can we translate this program from health care settings into schools," Sheele says. "Other communities had been interested in doing this, but I think that we really had the infrastructure around the table."

The Ottawa Area Intermediate School District also uses the be nice. program, which enlists students as leaders in breaking down stigma and leading conversations about mental health. With the School Blue Envelope program, all trusted adults working in the schools have been trained to respond to students in need.

"It really works to make sure that everyone can help identify and rally behind these students," Sheele says. "Really early intervention is important to better identify what students need some extra help, support, and resources and then make sure they get it."

While the health department is no longer a partner in the School Blue Envelope program, Sheele reports seeing good results during the first years it was implemented. The Suicide Coalition has continued to track the data. In 2023, 84 Ottawa area schools were using the program, reaching 42,000 students. 375 incidents, i.e., cases of students accessing the intervention, were reported. Sheele notes that the impact of these numbers can multiply exponentially because family members, classmates, and others in the community also experience a traumatic loss when a suicide happens.

"It's just such an important thing for us to pay attention to so that we can make sure that the youth have the resources that they need to be successful in their schooling and also as they move into adulthood," Sheele says. "It’s a really important initiative."

Estelle Slootmaker is a working writer focusing on journalism, book editing, communications, poetry, and children's books. You can contact her at Estelle.Slootmaker@gmail.com or www.constellations.biz.

Kristin Graham photos by Tommy Allen. All other photos courtesy of the subjects.