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Suicide is the second leading cause of death among college and university students, but it is also one of the most preventable causes of death. QPR (Question, Persuade, Refer), guided by certified trainers, is a program designed for everyone to learn what can be done to prevent suicide. The QPR curriculum is nationally recognized by the Joint Commission on Accreditation of Health Care Organizations as a "Best Practices" program. The training is an interactive presentation incorporating the basic QPR core curriculum, interactive case study, and opportunity for questions and discussion. Informational handouts are provided to program participants to be useful to participants in both their work and personal lives. The QPR presentation and materials are free.Of 1,000 students this year:• 200 will think seriously about suicide• 140 will plan how to kill themselves• 80 will make a suicide attemptMyth: Confronting a person about suicide will only make them angry and increase the risk of suicide.Fact: Asking someone directly about suicidal intent lowers anxiety, opens up communication.As a result of QPR Training:• You will be able to recognize a crisis and the warning signs that someone may be contemplating suicide.• You will be able to recognize the warning signs of suicide and how to apply three steps (question, persuade, and refer) with individuals in distress.• You will have the skills to act with confidence to make a difference.

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Page 1: Project LETS QPR Training

Project LETSQPR Training

Click the arrow to continue

Page 2: Project LETS QPR Training

Question 1

True or False: Adults between the ages of 65 and 70 are more likely to consider suicide than any

other age group. (click the box to select)

! !

TRUE !FALSE

Page 3: Project LETS QPR Training

Correct!

Young adults ages 18-24 think about suicide more than any other age group. In fact, 1 out of every 12 college students has made a plan to commit suicide at some point during their college career.

Page 4: Project LETS QPR Training

Actually…

Young adults ages 18-24 think about suicide more than any other age group. In fact, 1 out of every 12 college students has made a plan to commit suicide at some point during their college career.

Page 5: Project LETS QPR Training

Question 2

Approximately how many young people between the ages of 15 and 24 die every day from suicide?

8 !9 !10 !11

Page 6: Project LETS QPR Training

Correct!11 young people between 15 and 24 yours old commit suicide every day in the United States. It is ranked as the third leading cause of death for this age group

behind accidents and homicide. For every completed suicide, it is estimated that there are between 100

and 200 attempts. Suicide is the 2nd leading cause of death of college students with 7.5 out of every

100,000 taking their own lives.

Page 7: Project LETS QPR Training

Actually…11 young people between 15 and 24 yours old commit suicide every day in the United States. It is ranked as the third leading cause of death for this age group

behind accidents and homicide. For every completed suicide, it is estimated that there are between 100

and 200 attempts. Suicide is the 2nd leading cause of death of college students with 7.5 out of every

100,000 taking their own lives.

Page 8: Project LETS QPR Training

Question 3

Are females or males more likely to complete suicide?

MALES

!FEMALES !NEITHER

Page 9: Project LETS QPR Training

Correct!

In 2001, males 20 to 24 were approximately 6.6 times more likely than females to commit suicide and

males 15 to 19 were 4.8 times more likely than females to commit suicide. However, females are almost twice as likely to attempt suicide and suicide is the leading

threat to life for college women.

Page 10: Project LETS QPR Training

Actually…

In 2001, males 20 to 24 were approximately 6.6 times more likely than females to commit suicide and

males 15 to 19 were 4.8 times more likely than females to commit suicide. However, females are almost twice as likely to attempt suicide and suicide is the leading

threat to life for college women.

Page 11: Project LETS QPR Training

Question 4True or False: It’s better to not talk about suicide with

someone who may be thinking about it because you’ll just encourage them.

TRUE !FALSE

Page 12: Project LETS QPR Training

Correct!

Having a serious, compassionate conversation without passing judgment shows that you are concerned for the person’s well-being and want to understand their pain.

When talking with someone about suicide, keep an open mind to their problems and feelings, but don’t pretend

you have all the answers. Asking someone openly if they are thinking of killing themselves will not push them over the edge. The best thing you can do is to help the person

connect with resources.

Page 13: Project LETS QPR Training

Actually…

Having a serious, compassionate conversation without passing judgment shows that you are concerned for the person’s well-being and want to understand their pain.

When talking with someone about suicide, keep an open mind to their problems and feelings, but don’t pretend

you have all the answers. Asking someone openly if they are thinking of killing themselves will not push them over the edge. The best thing you can do is to help the person

connect with resources.

Page 14: Project LETS QPR Training

Question 5!

True or False: There is usually one sudden and traumatizing event that leads a person to attempt suicide.

TRUE !FALSE

Page 15: Project LETS QPR Training

Correct!

While there may be a single event that triggers a person to attempt suicide, a person contemplating suicide typically has a history of depression, alienation, low self-esteem,

stress, and/or hopelessness. Among college students, those with a history of a significant and chronic mental health conditions pose the highest risks. The transition to a new

environment, academic and social pressures, cultural pressures, feelings of failure or decreased performance, a

sense of alienation, and lack of coping skills can cause the appearance of or increase the symptoms for suicide.

Page 16: Project LETS QPR Training

Actually…

While there may be a single event that triggers a person to attempt suicide, a person contemplating suicide typically has a history of depression, alienation, low self-esteem,

stress, and/or hopelessness. Among college students, those with a history of a significant and chronic mental health conditions pose the highest risks. The transition to a new

environment, academic and social pressures, cultural pressures, feelings of failure or decreased performance, a

sense of alienation, and lack of coping skills can cause the appearance of or increase the symptoms for suicide.

Page 17: Project LETS QPR Training

Question 6True or False: It is impossible to tell if someone

intends to commit suicide. !

TRUE !FALSE

Page 18: Project LETS QPR Training

Correct!Although individuals thinking about suicide may not share their intentions, there are numerous warning signs that are commonly

exhibited and recognizable. – Sudden worsening or lack of interest in school assignments – Fixation on death or violence – Unhealthy peer relationships such as individuals with no friends or suddenly rejecting close

friends – Significant mood swings or a sudden changes in personality – Involvement in a physically and/or emotionally abusive relationships – An eating disorder – Significant difficulty adjusting to a gender identity or sexual orientation – Withdrawing from extracurricular activities – Overreaction to criticism – Restlessness and agitation – Unprovoked episodes of crying – Sudden neglect of appearance and hygiene – Increased use of alcohol or other drugs

Page 19: Project LETS QPR Training

Actually…Although individuals thinking about suicide may not share their intentions, there are numerous warning signs that are commonly

exhibited and recognizable. – Sudden worsening or lack of interest in school assignments – Fixation on death or violence – Unhealthy peer relationships such as individuals with no friends or suddenly rejecting close

friends – Significant mood swings or a sudden changes in personality – Involvement in a physically and/or emotionally abusive relationships – An eating disorder – Significant difficulty adjusting to a gender identity or sexual orientation – Withdrawing from extracurricular activities – Overreaction to criticism – Restlessness and agitation – Unprovoked episodes of crying – Sudden neglect of appearance and hygiene – Increased use of alcohol or other drugs

Page 20: Project LETS QPR Training

There are also certain signs that can indicate a person is planning on attempting suicide soon.

!– Stating that one plans to kill him- or herself – Talking or writing about suicide or death – Statements such as:

• I wish I was dead • You will be better off without me • What’s the point of living? • You wont have to worry about me soon • Who cares if I’m dead?

– Choosing seclusion rather than spending time with friends – Saying that life is meaningless – Giving away important possessions – Obtaining a weapon or other means of harming oneself (including prescription

medication) !

These are not sure indicators of whether someone intends on harming him- or herself, but these warning signs can be a sign of a serious

problem and recognizing them moves you one step closer to helping.

Page 21: Project LETS QPR Training

Question 7!

How many suicides are estimated to occur on college and university campuses in the United States every year?

! 700

!900 !1100 !1300 !1500

Page 22: Project LETS QPR Training

Correct!!

1100 deaths occur every year on college campuses as a result of suicide.

Page 23: Project LETS QPR Training

Actually…!

1100 deaths occur every year on college campuses as a result of suicide.

Page 24: Project LETS QPR Training

Question 8!

Male college students under the age of 21 of which two ethnic groups are at a higher risk for suicide attempts and suicide ideation?

African American/Hispanic !White/Asian !Hispanic/Asian !Native American/White !Asian/African American

Page 25: Project LETS QPR Training

Correct!!

Hispanic and Asian males under the age of 21 are at a higher risk of attempting suicide and considering it as

an option.

Page 26: Project LETS QPR Training

Actually…!

Hispanic and Asian males under the age of 21 are at a higher risk of attempting suicide and considering it as

an option.

Page 27: Project LETS QPR Training

Question 9True or False: Once a person has started thinking about

suicide, there is little one can do to change his or her mind.

! TRUE

!FALSE

Page 28: Project LETS QPR Training

Correct!!

Many people considering suicide have not made a final decision on whether they want to live or

die. Talking with them about it shows that someone cares and can encourage them to get

the help they need.

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Actually…!

Many people considering suicide have not made a final decision on whether they want to live or

die. Talking with them about it shows that someone cares and can encourage them to get

the help they need.

Page 30: Project LETS QPR Training

Question 10!

True or False: If someone you and your friends know is considering suicide, it is best to not confront the

person all together.

TRUE !FALSE

Page 31: Project LETS QPR Training

Correct!!

It is much better to talk with the person alone and in a comfortable, private setting. Approaching someone as a group can make the person feel ganged-up on and may

not allow them to speak as freely as they would if it were just the two of you. If you feel that you need

support, ask a campus resource.

Page 32: Project LETS QPR Training

Actually…!

It is much better to talk with the person alone and in a comfortable, private setting. Approaching someone as a group can make the person feel ganged-up on and may

not allow them to speak as freely as they would if it were just the two of you. If you feel that you need

support, ask a campus resource.

Page 33: Project LETS QPR Training

Question 11!

Which is not the right way to ask someone if he or she is thinking about suicide? !A. “Have you been unhappy lately?” !

B. “You wouldn’t do anything stupid would you?” !A. “You’re not suicidal, are you?” !• “It sounds like you are feeling really upset and worried… Are you thinking about suicide?” ! Both A and C Both B and C ! Both C and D

Page 34: Project LETS QPR Training

Correct!!

Belittling someone or implying that she or he is crazy can make it seem like you do not think their thoughts

and feelings are legitimate. You can ask the question as directly or indirectly as you feel comfortable, but choose

your words carefully and remember to keep an open mind.

Page 35: Project LETS QPR Training

Actually…Both “you wouldn’t do anything stupid would you?” and “you’re not suicidal, are you?” are not the right ways to ask. Belittling someone or implying that

she or he is crazy can make it seem like you do not think their thoughts and feelings are legitimate.

You can ask the question as directly or indirectly as you feel comfortable, but choose your words

carefully and remember to keep an open mind.

Page 36: Project LETS QPR Training

Question 12!

True or False: If you think someone is in immediate danger, but are not sure, it is best to call a professional such as a counselor before calling emergency personnel.

!

TRUE !FALSE

Page 37: Project LETS QPR Training

Correct!If you think there is an immediate danger to a person’s life or safely, call 911 right a way. Immediate danger means that the

person… !

• has already injured him or herself

• has taken an overdose

• has a weapon and is threatening to use it

• is on a ledge, open stairway, rooftop

• is exhibiting other dangerous behavior

!Mere seconds can make all the difference, so go with your

instinct.

Page 38: Project LETS QPR Training

Actually…If you think there is an immediate danger to a person’s life or safely, call 911 right a way. Immediate danger means that the

person… !

• has already injured him or herself

• has taken an overdose

• has a weapon and is threatening to use it

• is on a ledge, open stairway, rooftop

• is exhibiting other dangerous behavior

!Mere seconds can make all the difference, so go with your

instinct.

Page 39: Project LETS QPR Training

Question 13True or False: Once I start to help someone who is

considering suicide, he or she becomes my responsibility.

!

TRUE !FALSE

Page 40: Project LETS QPR Training

Correct!

Your concern for a person’s well being shows them that you care and are willing to help them get help. You are not, nor should you ever be, responsible for making sure someone does not harm him or her self. Always seek support from a professional, or a service organization. Helping someone considering suicide can be emotionally draining for you too and it is okay to talk with someone about what you are going through physically and emotionally. Don’t forget to take care of yourself!

Page 41: Project LETS QPR Training

Actually…

Your concern for a person’s well being shows them that you care and are willing to help them get help. You are not, nor should you ever be, responsible for making sure someone does not harm him or her self. Always seek support from a professional, or a service organization. Helping someone considering suicide can be emotionally draining for you too and it is okay to talk with someone about what you are going through physically and emotionally. Don’t forget to take care of yourself!

Page 42: Project LETS QPR Training

Sources

American Association of Suicidology (2004), Youth Suicide Fact Sheet, http://www.suicidology.org/associations/1045/files/Youth2004.pdf. !Suicide Prevention Resource Center (2005), Information for College Students, http://www.sprc.org/featured_resources/customized/college_student.asp. !The Jed Foundation (2005), Suicide and America’s Youth, http://www.jedfoundation.org/articles/SuicideStatistics.pdf. !University of Connecticut (2008). QPR Training. !Project LETS (2013), Fact Sheets http://www.letserasethestigma.com

Page 43: Project LETS QPR Training

QUESTION PERSUADE REFER

PROJECT LETS QPR TRAINING

Page 44: Project LETS QPR Training

SUICIDE IS A MAJOR PUBLIC HEALTH ISSUE

Public health looks at data to identify which groups of people are at higher risk of suicide and uses research to develop interventions to address this risk. Suicide is a major public health issue, meaning: •Suicide affects large numbers of people. •Prevention is based on research that is mostly related to risk factors. !Suicide is a complex behavior, driven by multiple factors--individual, family, and social--that are more prevalent in people who die by suicide. Although risk factors related to suicide have been identified, there are no identified causes of suicide. Most people who die by suicide have mental illness and/or a substance use disorder. !

Page 45: Project LETS QPR Training

DEFINING TERMSA suicide is a death from injury, including poisoning or suffocation, where there is evidence that the injury was self-inflicted and the person intended to kill himself or herself. A death such as a car accident or drug overdose is not considered a suicide if the person did not intend to kill himself or herself. However, it is often very difficult to determine intent. An attempted suicide is a potentially self-injurious act with at least some wish to die as a result of the act. The intent does not have to be 100%. If there is any intent or desire to die associated with the act, then it may be considered an actual suicide attempt. Non-suicidal self-injury, which we see a lot of, is done to relieve powerful emotions and is not a suicide attempt because there is not an intent to die. Self-injury is, however, a strong risk factor for suicide attempts. !Suicide ideation is a term that describes thoughts of suicide, including talking about suicide. Suicide ideation can range from fleeting thoughts and a vague “wish to be dead” to detailed planning and intent to act on the plan. !Suicidal behavior refers to all of the terms above. !

Page 46: Project LETS QPR Training

RISK + PROTECTIVE FACTORSSynergistic; dynamic; complex; modifiable and non-modifiable

•  Family'connectedness1'''''

•  Family'acceptance2'

•  Safe'schools1'

•  Caring'adult1'

•  High'self:esteem3'

•  Posi=ve'role'models3''

1.'Eisenberg'&'Resnick,'2006''2.'Ryan'et'al.,'2009'3.'Fenaughty'&'Harre,'2003'''

A risk factor indicates that an individual or population with a

particular characteristic is more likely to think about suicide, or attempt or die by suicide, but it cannot predict

any individual’s behavior. On the other hand, a protective factor indicates that an individual or population with a particular

characteristic is less likely to engage in suicidal behavior.

Page 47: Project LETS QPR Training

ECOLOGICAL MODEL

Individual)

Family)and)peers)

Ins1tu1onal)

Community)

Society)

Page 48: Project LETS QPR Training

Of 1,000 students this year

!• 200 will think seriously about suicide • 140 will plan how to kill themselves • 80 will make a suicide attempt !

“More teenagers died from suicide than from cancer, heart disease, AIDS, birth defects, stoke, pneumonia and influenza, and chronic lung disease combined.”

– US Public Health Service (’99)

Centers for Disease Control and Prevention. (20014). Web-based Injury Statistics Query and Reporting System (WISQARS). http://www.cdc.gov/injury/

wisqars/index.html

Page 49: Project LETS QPR Training

EACH DAY!

In the United States, there are 630 new suicide survivors each day.

!90% of youth who die by suicide are

suffering from an Axis I mental disorder (mood disorder, substance abuse and

often both).

Page 50: Project LETS QPR Training

0.000

1.250

2.500

3.750

5.000

1977 1980 1983 1986 1989 1992 1995 1998 2001 2004 2007

1 of every 62 Americans is estimated to be a suicide survivor

4,395,480 suicide survivors

732,580 deaths by suicide

SUICIDES IN THE UNITED STATES

Page 51: Project LETS QPR Training

Highly reliable school• Are not fooled by successful students • Trust their experts (the front line people in daily contact with

students) • Train everyone to identify and report possible problems • Have a smooth, practiced, crisis response plan when a student is

identified as in trouble • Have a smooth, practiced, crisis response plan when something

bad happens • Raise student awareness, encourage self-referral, train peers

to recognize and refer

Page 52: Project LETS QPR Training

GROUND RULES• Listen respectfully—respect others while they are

talking. • Speak from your own experience instead of

generalizing (Use “I” instead of “they”, “we,” and “you”).

• Do not be afraid to respectfully challenge one another by asking questions, but refrain from personal attacks. Focus on ideas.

• Participate to the fullest of your ability. Community growth depends on the inclusion of every voice.

Page 53: Project LETS QPR Training

Introduction To QPR Training

Page 54: Project LETS QPR Training

QPRMyth: Confronting a person about suicide will only make them angry and increase the risk of suicide Fact: Asking someone directly about suicidal intent lowers anxiety, opens up communication and lowers the risk of an impulsive act. Myth: Only experts can prevent suicide. Fact: Suicide prevention is everybody’s business, and anyone can help prevent the tragedy of suicide. !•Each letter in QPR represents and idea and an action step •QPR intentionally rhymes with CPR – another universal emergency intervention •Asking questions, persuading people to act and making a referral are established adult skills - offer hope through positive action.

Page 55: Project LETS QPR Training

QPR TRAININGRespond positively to someone exhibiting suicide warning signs and behaviors. !

!PRODUCES:

Changes in knowledge, attitude, perceived self-efficacy among adults Changes in detection rates Changes in referral sources

Changes in service utilization (crisis response and outside providers) !

SHOULD: Match level of training with level of duty

Be delivered in a standardized fashion Provide measurable outcomes

Be designed for busy adult learners Be culturally sensitive

Be low-cost, compared to other options !

Not a treatment !

Page 56: Project LETS QPR Training

QPR THEORYAssumption: Passive systems don’t work Those most at risk for suicide: 1. Tend to not self-refer 2. Tend to be treatment resistant 3. Dissimulate their level of despair 4. Go undetected and untreated !Assumption: Most suicidal people send warning signs 1. Warning signs can be taught 2. Gatekeepers can be trained to a) recognize these signs and b) know how to intervene 3. Gatekeepers must be fully supported by policy, procedure and professionals in their community

Page 57: Project LETS QPR Training

QPR CHAIN OF SURVIVALKNOWLEDGE + PRACTICE = ACTION Early recognition of warning signs Early application of QPR Early referral to professional care Early assessment and treatment !7 LIFE SAVING GOALS: 1. Detection of suicidal persons 2. Active intervention 3. Alleviation of immediate risk factors 4. Accompanied referral 5. Access to treatment 6. Accurate diagnosis 7. Aggressive treatment

Page 58: Project LETS QPR Training

QPR CHAIN OF SURVIVAL1. Early recognition of suicide warning signs: The sooner warning

signs are detected, the sooner an intervention can be initiated 2. Early QPR: Directly asking someone emitting suicide warning signs to

confirm or deny their meaning opens a potentially life-saving, caring dialogue which may a) immediately reduce anxiety and distress and, b) enhance protective factors and decrease risk factors; ex. Restore hope, decrease isolation, and increase social and spiritual support while removing the means of suicide.

3. Early referral: Linking the at-risk person to local resources for evaluation is essential to reducing immediate risk. As most people thinking about suicide are suffering from an undiagnosed and/or untreated mental illness or substance abuse disorder, accessible professional services are essential.

4. Early professional assessment and treatment: As with any life-threatening crisis or illness, early detection, assessment and treatment results in reduced morbidity and mortality.

Page 59: Project LETS QPR Training

‘Strongly agree’ or ‘agree’ with -->

Would talk to counselor

Believe counselor could help

Friends would want me to talk to adult

Family would want me to talk to adult

Reported suicide attempt

20% 25% 35% 36%

None 38% 47% 45% 53%

“IF OVERWHELMED BY LIFE I WOULD…”

Page 60: Project LETS QPR Training

QResearchers have frequently documented the presence of verbal, behavioral and situational “clues” or “warning signs” which precede suicide attempts

and completions.

!Some researchers have seen these warning signs as a “cry for help” and

while others have attributed motives to these communications ranging from warning others, to attempting to hold onto a relationship, to a

purposive act intended to bring about a change in the behavior of others. !

What do suicidal communications mean, and from a public health perspective, how might they be used effectively in preventing suicide?

Page 61: Project LETS QPR Training

QThe “talking about” preceding the “acting on” becomes a window of

opportunity to intervene, provided we understand the purpose, nature, and meaning of these suicidal communications and know what to do in their presence. This hesitation between idea and act, and provided suicide

warning signs are observable, provides the interpersonal opening into which an intervention like QPR can be inserted. But gatekeepers must be trained in the use

of the intervention, and the intervention must be supported by research to be safe and effective in its application.

!There is a common belief that people who talk or joke about suicide don’t do it.

With this belief, there is no duty or felt responsibility to take action. !

Suicide happens, and while rare, the public must believe that suicide is a possible cause of death in those they know and love, otherwise they will

never learn what is needed or what to do quickly when someone they know is contemplating suicide and sending suicide warning signs.

Page 62: Project LETS QPR Training

Q: SUICIDE WARNING SIGN!

“A suicide warning sign is the earliest detectable sign that indicates

heightened risk for suicide in the near-term (i.e., within minutes, hours, or days). A warning sign refers to some feature of the developing outcome of

interest (suicide) rather than to a distant construct (e.g., risk factor) that predicts

or may be casually related to suicide.”

Page 63: Project LETS QPR Training

IMMEDIATE SIGNS

•Threatening to kill/hurt themselves

•Someone looking for ways to kill themselves

•Talking or writing about death, dying, or suicide

NON-IMMEDIATE SIGNS

•Hopelessness •Rage, anger, seeking revenge •Acting reckless •Feeling trapped •Increasing alcohol/drug use •Withdrawing from friends, family or society •Anxiety, agitation, unable to sleep, or sleeping all the time •Dramatic changes in mood •No reason for living, no sense of purpose in life

weak signals: those easily lost in background nose or mistaken for benign communication (may intend to elicit a possible rescue) Signal Detection Theory (SDT): describes how we measure human decision making under condition of uncertainty these items listed are actually psychological

constructs, which define sets of behaviors - it does not address the actual or specific

behaviors or language a suicidal person might use to communicate his or her distress.

Page 64: Project LETS QPR Training

direct verbal clues

•“I’ve decided to kill myself.”

•“I wish I were dead.”

•“I’m going to commit suicide.”

•“I’m going to end it all.”

•“If (such and such) doesn’t happen, I’ll kill myself.”

• “I’m tired of life, I just can’t go on.”

• “My family would be better off without me.”

• “Who cares if I’m dead anyway.”

• “I just want out.”

• “I won’t be around much longer.”

• “Pretty soon you won’t have to worry about me.”

behavioral clues

• Any previous suicide attempt

• Acquiring a gun or stockpiling pills

• Co-occurring depression, moodiness, hopelessness

• Putting personal affairs in order

• Giving away prized possessions

• Sudden interest or disinterest in religion

• Drug or alcohol abuse, or relapse after a period of recovery

• Unexplained anger, aggression and irritability

Page 65: Project LETS QPR Training

situational clues

• Being fired or being expelled from school

• A recent unwanted move

• Loss of any major relationship

• Death of a spouse, child, or best friend, especially if by suicide

• Diagnosis of a serious or terminal illness

• Sudden unexpected loss of freedom/fear of punishment

• Anticipated loss of financial security

• Loss of a cherished therapist, counselor or teacher

• Fear of becoming a burden to others

situational clues in a residential setting

• Feeling embarrassed or humiliated in a group session

• Being the victim of another patient’s assaults or bullying

• Being informed that their parents are getting a divorce

• Finding out that their parents do not want them to come back home

• Becoming aware of a financial crisis in the family

Page 66: Project LETS QPR Training

Gatekeeper does not respond

Gatekeeper does respond

Warning Sign Present

Miss Hit

Warning Sign Absent

Correct Rejection

False Alarm

The worst outcome of a Gatekeeper intervening would be a false alarm. The worst outcome of a Gatekeeper not

intervening is missing a warning sign, and a potential suicide occurring.

Page 67: Project LETS QPR Training

Conservative Bias vs. Liberal Bias

Conservative bias: failure to respond vigorously to weak suicide warning signs !

Liberal bias: respond to all possible warning signs vigorously. The cost of not responding may be death.

!Just as the signs of a pending heart attack may only signal indigestion, the

warning signs of a suicide attempt may produce false positives. But because the risk of a true positive in either case may lead to death, it is better

to act and be wrong than not act at all. !

Ex. Stop, Drop + Roll; Fire-drills; Ambulances coming to Brown for burnt toast.

Page 68: Project LETS QPR Training

RESPONSES FOLLOWING AN ATTEMPT

a) silence and increased tension in the relationship obvious ambivalence

c) visible indications of aggressiveness, anxiety, evasiveness

!most common response? total silence - “a verbal

vacuum” !

If the most common reaction to a direct verbal statement of intent to attempt suicide is silence, anger, and/or avoidance, how much easier might

it be for an observer to deny, ignore, or fail to respond to an indirect statement of intent?

Page 69: Project LETS QPR Training

Q: FEAR-INDUCING STATEMENTSIn some cases, a fear-inducing statement

motivated the recipient to demand a retraction or a denial of what the suicidal person had just said. As one frightened sister said to her brother after he threatened to ‘stop the suffering and get this over with’, “You wouldn’t do anything crazy, would

you!” Clearly upset by his statement, she responded not with a clarifying question, but with a fear-driven demand for a retraction and denial. In another case, a young boy being bullied at school overtly threatened to kill himself, to which the father said, “We don’t talk about suicide in this

house!” The boy died with a gunshot wound to the head one week later.

Page 70: Project LETS QPR Training

Q: INDIRECT VERBAL STATEMENTS

The following list of reasons was given by participants for issuing

an indirect verbal statement instead of a direct one:

!• I’d want to see if anyone was listening. • I’d want the person I told to care about

me enough to ask what I meant. • If they didn’t understand what I just threatened to do, perhaps they don’t

really care. • I wouldn’t tell anyone who I thought

couldn’t rescue me, provided I wanted to be saved.

• If I wasn’t sure I really wanted to die, I’d want to be able to later deny what I’d

said. • I know I’ve been a big problem for

them, so I wouldn’t want to force them to take notice of me.

- use indirect statements because person is

ambivalent about wanting to die

- appear to be testing a private hypothesis regarding

a would-be rescuer’s willingness and ability to

intervene; in which case the equivocal statement becomes a “test” of

commitment, confidence, caring or trust !

Page 71: Project LETS QPR Training

INDIRECT VERBAL STATEMENTS

• suicidal communications are a way for a suicidal sufferer to confirm, or disconfirm the accuracy of their perceptions that a) one is a “burden on loved ones” and b) one no longer belongs to a “valued group or relationship”

!• as a test of caring or willingness to rescue, an un-

responded-to suicide warning sign could be interpreted by the suicidal person experiencing burdensomeness as evidence that, indeed, he or she has been granted permission to proceed. !

Page 72: Project LETS QPR Training

INDIRECT VERBAL STATEMENTS

• Use clarifying questions: ex. What do you mean? what’s happening on Saturday? What do you mean take care of your dog?

!• The simple art of active listening, gentle

questioning and coming to a full understanding of a distressed persons communications lies at the heart of all successful healing trades, including the most sophisticated psychotherapies. !

Page 73: Project LETS QPR Training

But when do I know that what someone says might be a suicidal communication?

• These descriptions of emotional reactions are often used un the diagnostic workup of a symptomatic patient in clear distress. Many of these feelings were reported to have occurred in responses to thing the deceased said or did prior to a fatal suicide attempt. In short, the pre-suicide warning signs triggered a negative emotional response in the recipient.

!• Fear, silence and immobilization

are very primitive and protective human responses to perceived mortal threats; thus the challenge becomes responding in a competent, comfortable and effective manner.

!

Intuition is more trustworthy than rational thinking, and it is always correct

in two important ways: !

1. It is always in response to something 2. It always has your best interest at heart

!Fear is far quicker and more powerful than

logic, and a failure to trust the experience of it can lead to tragic outcomes. In order of importance, the top seven in his list of 13

“Messengers of Intuition,” are these:

!• Hunches

• Gut feelings • Doubt

• Hesitation • Suspicion

• Apprehension • Fear !

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Q: Asking The QuestionWhen in doubt, ask the question.

Don’t wait. !

If the person is reluctant, be persistent Talk to the person alone in a private setting

Allow the person to talk freely Give yourself plenty of time

Have resources ready. !

“You know, when I was this depressed I was frequently suicidal. Have you has any

thoughts?” !

“Have you thought about taking your life?”

!If you cannot ask the question, find

someone who can.

LESS DIRECT APPROACH: !

“Have you been unhappy lately?”

“Have you been very unhappy

lately?”

“’I’d like to talk to you a minute, I’m really worried, you seem like you’re a little down. Could we talk about that? I’m

here to help.”

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SUICIDE WARNING SIGNS

• are genuine, observable, produce strong emotional responses in an observer

• We cannot expect gatekeepers to take timely and effective remedial action if they cannot first validate that their experience of apprehension and fear in response to suicide warning signs are, in fact, confirming evidence for quick, positive action.

• there is no negative consequence in learning that someone is not suicidal !

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Q: DON’T MINIMIZE When talking to a person you think might be suicidal, it’s critical not to dismiss what they’re saying. While this makes sense, we might minimize a person’s pain without

even realizing it. !

For instance, in a training example, if the person says, “My life is so terrible right now,” it’s usually met with reactions like “Oh, it’s not that bad” or “I know you’d

never hurt yourself.” Even when the person mentions being overwhelmed, well-trained professionals

dismiss the comments. For instance, they say: ‘Things were awful for me last semester, too, and I got through it. Let me help you with your studying.” Although help

is being offered, this reaction still minimizes and discounts the person’s feelings and experiences. And

both slam the door on communication.

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The person most likely to prevent you from taking your own life is someone you already know.

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PPersuading the suicidal person to take positive, even-life saving action.

In reality, the ability to persuade a clinically depressed, alcohol abusing, or personality disordered person to accept professional evaluation and

treatment depends on at least the following: !

• The nature and quality of the relationship between the suicidal person and the gatekeeper

• The ability (competence) of the gatekeeper to motivate positive action through active listening and persuasive verbal skills

• The reasonable availability and accessibility of professional services, e.g., for a rural citizen a 100-mile drive to a professional

• The mental status of the suicidal person (intoxicated, paranoid, hostile, fearful, psychotic, belligerent, etc.)

• The suicidal person’s past history of success or failure with mental health or other professional services

• The degree of ignorance, stigma and fear the suicidal person associates with seeking and/or accepting professional help.

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P: TIMING = SUCCESSA suicide attempt does not begin when the pistol is pointed at the head

and fired, or when the gun is loaded. A suicide attempt begins with the idea that suicide is an acceptable solution to unendurable psychological

pain. The suffering is always more benign in the beginning than in the final hours before the attempt.

!The act of suicide is a process – the relative effectiveness of our ability to dissuade the person from suicide will vary with where we interrupt them

in their journey. !

•Re-knit the ties that bind people together to reduce the suicidal sufferer’s perception of being a burden on others.

!•Most likely to attempt suicide = least likely to self-refer

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P• Persuasion works best when commitment to a particular outcome remains

undecided

• Listen to the problem and give them your full attention

• Remember: suicide is not the problem, only a solution to a perceived insoluble problem

• Do not rush to judgement

• Offer hope in any form

!• “Will you go with me to talk to your therapist or clinician?”

• “Would you like me to tell your therapist that you would like to talk to him/her?”

• If they say “yes,” continue to monitor them closely.

• If they say “no,” say “I understand - it might be too hard right now. But if I feel like you aren’t safe, I will have to tell somebody.”

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PIncluded in the reluctant referral group are some of our brightest and most able

citizens, including doctors, lawyers, military officers, political and business leaders, students, etc.

Reluctant referrals at elevated risk for suicide are, frequently, high profile, successful people who do not typically call hotlines, seldom avail themselves of mental health

services, and who are generally resistant to seeking professional mental health treatment. (Institute of Medicine)

• Fear

• Stigma

• Prejudice

• Cost

• Shame

• All therapists are crazy

• Cultural expectation that one should be able to solve one’s own problems without assistance

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P: TIMING = SUCCESSGoal is not to produce therapists

• faith and hope • accurate empathy and empathetic listening • how to provide immediate support and reflection • the nature of ambivalence and facilitating behavior change !

• must happen immediately and not require a lot of time • especially with reluctant referrals: “the relief experienced by

these individuals from a single therapeutic session appears to motivate commitment to additional treatment and behavior change.”

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LIABILITY

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RMake the most reliable referral possible and follow up with a visit, a phone call, a card, or in whatever way feels comfortable to you,

to let the young person know you care about what happens to them.

1. Accompany the suicidal person to the resource 2. Secure an agreement from the suicidal person to see a professional and follow up to see that the appointment was kept 3. Secure an agreement to see a professional, or accept help, even if in the future 4. Secure an agreement to stay alive !

Referrals are only successful 50% of the time. Access is not about admission policy or distance, but about stigma, fear and

shame.

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RWhere no mental health services exist, and in some rural

communities and on Native American reservations, the “go to” person – who is known to be understanding, reliable, a good

listener, strong and respectful, and able to deescalate a suicide crisis – may not be a licensed healthcare professional at

all, but rather a mature community spiritual leader. !• Community-based professionals vary greatly in their clinical competence to assess, manage, and treat suicidal consumers. !• There may be a high level of shared responsibility and community competence needed to assist suicidal members

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R

The presence of a suicide risk is confirmed by the gatekeeper, following the emission of a

warning sign and clarified with one or more S questions; Persuasion is made less difficult because stigma has been reduced, access to

service is straightforward; and all parties know that the local community of care providers is willing and able to accept a

referral for professional assessment and care.

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R• As part of the R in QPR, gatekeepers are provided the names, phone numbers,

addresses, and where appropriate, maps to emergency rooms, mental health centers, and college counseling centers.

!Who would you be willing to talk to?

Who else needs to know you are in this much pain? !

• Address issues of perceived burdensomeness and lack of belonging by assisting significant others to rally critical emotional support and understanding, thus challenging ideas of burdensomeness and lack of belonging

• Offer hope in any form that works for them

• “I’m on your side”

• “We’ll get through this” !The purpose of life-affirming, supportive statements and encouraging their use during an intervention are to a) set the gatekeepers expectations for survival high

while expressing confidence in a positive outcome and b) survival is expected.

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R!

Properly carried out, QPR training should help accomplish three sympathetic goals: a) mass public health awareness and basic education about suicide and its causes, b) an

effective gatekeeper intervention to help prevent suicide, and c) the employment of voluntary gatekeepers

to recruit high-risk suicidal reluctant referrals to treatment (SIT). Should the QPR intervention prove

effective in increasing the detection and referral of community-dwelling new cases of undiagnosed and

untreated psychiatric disorders, it could be considered a success.

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RClearly, detection and treatment are only a part of the solution to

preventing suicide. Gatekeeper training, while it has key role to play, is an incomplete answer to the much larger social, psychological, and

cultural strategies that might move entire populations toward less risk and lower suicide rates. Perhaps the positive but limited role gatekeepers

are trained to play in detecting at-risk persons in the general population should be expanded to include, more directly, skills to enhance mental

health literacy and understanding, the breaking down of stigma, and the immediate provision of known protective factors against suicide before

someone becomes suicidal.

!To this end, much more is needed to be learned about those positive,

protective, hope-instilling, faith-affirming words, acts, deeds, events and activities that make life much too precious to even consider ending it by

suicide.

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R- An e-mail of confirmation stating you attended QPR Training

- Access to the Google Drive containing Mental Health resources on campus and in the Providence community

- An overview/review of the skills taught in QPR - Any questions: [email protected]

!Project LETS meets every Friday at 4:30 in

the Sarah Doyle First Floor Lounge! !

Please sign in if you haven’t!