Question Persuade and Refer QPR Introduction to Suicide Prevention Gatekeeper Training Before We Get Started I want you to check out the three people sitting nearest to you How are they doing ID: 735796
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Ben Camp, M.S.Ed.QPR Master Trainer
Question, Persuade, and Refer (QPR): Introduction to Suicide Prevention Gatekeeper TrainingSlide2
Before We Get Started I want you to check out the three people sitting nearest to you. How are they doing?
Do they look OK?
How do they appear?
2Slide3
Ben Camp, M.S. Ed.Faculty—Washington Institute for Mental Illness Research and TrainingOver 30 years experience in COD,
Inpt
, OP, Adult/
Adol, CD/MH at all levelsFormer Mental Health Commitment SpecialistFormer Director of Training: Suicide HelplineCommunity Intervention Specialist: Native Aspirations
Principal author
To Live To See The Great Day That Dawns: Preventing Suicide by American Indian and Alaska Native Youth and Young Adults
Faculty Eastern Washington UniversityNational Steering Committee SPRC
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Learning ObjectivesBy the end of this training and small group discussions, you will be able to:Discuss and articulate suicide as a national and Job Corps public health problem
List at least three reasons why people complete suicide
Describe
the theory and rational behind effective gatekeeper trainingIdentify the gatekeeper’s role in the chain of survivalPractice at least two QPR skills
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5 Suicide is PersonalSlide6
Raise Your Hand If…(Wait until all questions asked)You have ever thought about suicide? You know someone who has? You know anyone who has made a suicide attempt…
…or died by suicide?
You’re worried, right now, that someone you know is thinking about suicide?
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Big PictureThink, plan, attempt, die10 million adults think about suicide each year 1.2 million plan a method (gun, MVA, etc.)
840,000 attempt (minimum count
)
Approximately 33,000 dieSuicide is 11th cause of death overall3rd for young people (rate has almost tripled since 1950s)unexpected upturn 2003-2004
1
st
for young people in some states/communitiesSource: National Comorbidity study, CDC and NIMH7Slide8
Scope of the Problem14% of American youths 12-17 (3.5 million youth) experienced at least one episode of major depressive disorder (SAMSHA, 2004)
Over 7% (est. 1.8 million youths) thought about killing themselves at the time of their worst or most recent episode of MDD
Est. 712,000 youths tried to kill themselves during their worst or most recent major depressive episode (2.9% of all youth)
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9Scope of the Problem15-24 year olds 1st
, 2
nd
, 3rd cause of death (Utah, ID, College, the nation) 20% of teens seriously considers suicide each year (Grunbaum, 2002); 10% of college population (CHS) Slide10
A Few More NumbersBoys die 4X as often as girlsGirls attempt more than boys (3X)Youth: 100-200 attempts per 1 completionBoys use firearms more, girls OD moreLethality of method contributes to outcomes
90% of youth who die by suicide are suffering from an Axis I mental disorder (mood disorder, substance abuse and often both)
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Youth Especially at Risk?Highest suicide rate in US?
Native American males
Greatest increasing rate?
African American males (up 200%)
Highest rate of suicide attempts?
Hispanic youth (males & females)Highest rate of suicide attempts of any group?
Hispanic females
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All the Numbers…(CDC)Think, plan, attempt, die (last 12 months)19% of all high school students (1 in 5) thought seriously about suicide14% made suicide plan8.3% made an attempt
2,000 +/- die each year
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For Your Job Corps CenterOf 1,000 students this year –200 will think seriously about suicide140 will plan how to kill themselves80 will make a suicide attempt
Let’s work to make sure none die!
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14Introduction to QPR Gatekeeper Training
QPR stands for
Q
uestion, Persuade and Refer, an emergency mental health intervention that teaches lay and professional Gatekeepers to recognize and respond positively to someone exhibiting suicide warning signs and behaviors. Slide15
15Why QPR?Each letter in QPR
represents an
idea
and an action stepQPR intentionally rhymes with CPR – another universal emergency interventionQPR is easy to remember Asking Questions, P
ersuading people to act and making a
R
eferral are established adult skills “Out of clutter, find simplicity” -Albert EinsteinSlide16
QPR Ask a Question, Save a Life
16
©Slide17
QPR Question, Persuade,
R
efer
17©Slide18
QPRQPR is not about learning to be a counselorQPR is
about offering hope by getting involved and doing
something
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©Slide19
Suicide Myths and
Facts
Myth
No one can stop a suicide, it is inevitable.Fact If people in a crisis get the help they need, they will probably never be suicidal again.Myth
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.
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Suicide Myths and Facts
Myth
Suicidal people keep their plans to themselves.
Fact Most suicidal people communicate their intent sometime during the week preceding their attempt.Myth
Those who talk about suicide don’t do it.
Fact
People who talk about suicide may try, or even complete, an act of self-destruction.Myth Once a person decides to complete suicide, there is nothing anyone can do to stop them.Fact
Suicide is the most preventable kind of death, and almost any positive action
may
save a life.
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©Slide21
Suicide and HomicideMore homicides or suicides per year?Is there any overlap between homicide and suicide? Discussion
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Suicidal BehaviorMeans someone is in extreme pain and sufferingMeans complex feelings and behaviorInvolves many reasons and factorsMeans approaching from many directions
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23Nature of Suicide and Joiner’s New Theory
Psychic suffering (Psyche-ache)
Hopelessness
Unbearable mental anguish
Cognitive constriction
Grossly impaired problem solving ability
Feeling a burden to others
Thwarted belongingness
Acquired capacity for self-injury and habituation to pain
(T. Joiner, Why People Die by Suicide, 2006)Slide24
Serious Attempt or Death by Suicide
Those Who
Desire Suicide
Those Who Are Capable of SuicideSlide25
Journey to SuicideAcquired Capacity for Self-InjuryLethality of method and seriousness of intent increase with attemptsPeople who have experienced or witnessed violence or injury have higher rates of suicide – prostitutes, self-injecting drug abusers, people living in high-crime areas, veterans, physicians
Those with a history of suicide attempt have higher pain tolerance than others
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Serious Attempt or Death by Suicide
Those Who
Desire Suicide
Those Who Are Capable of Suicide
Perceived
Burdensomeness
Thwarted
BelongingnessSlide27
27Perceived BurdensomenessFeeling ineffective to the degree that others are burdened is among the strongest sources of all for the desire for suicide.
Slide28
28Why do some people want to die?
Feel that I am a burden to my family
Feel that everyone will be better off without me
Darkness Calls: The Healthy Aboriginal NetworkSlide29
29Thwarted BelongingnessOur need to belong to valued groups and relationships is so powerful that, if frustrated or thwarted, serious negative health consequences follow – including suicide. Slide30
Why do some people want to die?30
Feel like I don’t belong
Feel like no one cares if I live or die
Darkness Calls:
The Healthy Aboriginal Network Slide31
Serious Attempt or Death by Suicide
Those Who
Desire Suicide
Those Who Are Capable of Suicide
Perceived
Burdensomeness
Thwarted
BelongingnessSlide32
DiscussionTake a few minutes to discuss this theoryDoes it have face validity?Does it seem to be inclusive?What are some ramifications?If this theory is valid, what impact would this have to self referrals?
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Our ChallengeMost youth don’t get treatment because they don’t self-refer or don’t even know they’re depressedSo, how do we find and help them before they make a suicide attempt?
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Suicide Clues And Warning SignsThe more clues and signs you notice, the greater the risk. Take all signs seriously.34
©
QPRSlide35
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.”
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©
QPRSlide36
Indirect Verbal Clues:“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.”
“I’m going to stay with my Grandfather” Who is dead.
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©
QPRSlide37
Indirect Verbal Clues
37
Darkness Calls: The Healthy Aboriginal Network
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QPRBehavioral clues:Has made a suicide attempt in the past
Acquiring a gun or stockpiling pills
Is also depressed, moody, feels hopeless
Putting personal affairs in orderGiving away prized possessionsSudden interest or disinterest in religion or spiritualityDrug or alcohol abuse, or relapse after a period of recoveryUnexplained anger, aggression and irritability
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©Slide39
Non-Verbal Clues39
Darkness Calls: The Healthy Aboriginal NetworkSlide40
QPRSituational clues:Being fired or being expelled from schoolLoss of girl/boyfriend or other important relationship
Death of a best friend, aunt/uncle, especially if by suicide
Being told you have a serious or terminal illness
Sudden unexpected loss of freedom/fear of punishmentLoss of a favorite counselor, teacher, coach, or supportive personFear of becoming a burden to others40
©Slide41
Suicide ThreatsSuicide threats are warning signs, but not all suicide warning signs are threatsA suicide threat means (at the least) that the person has considered violence but has, for now, decided not to act
Only the living make threats
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Which of the Following is a Suicide Warning Sign?“I’m going to blow my brains out.”
“I just can’t stand it anymore.”
If either is a suicide warning sign, which statement requires immediate and urgent intervention?
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Content vs. Context“I’m going to blow my brains out!”
Is sitting in your office in a psychiatric hospital
“I just can’t stand it anymore.”
Is standing well out of arm’s reach on the edge of 10-story building
Now… which person needed immediate and aggressive intervention?
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45
Asking the suicide questionSlide46
46Scenario #118 Y.O. male showing signs of being disengaged, angry with low to no motivation. When questioned, states that he is just home sick and will be better soon. He stated to his roommate that he “just wanted everybody to leave him alone to do what he needs to do.” When questioned, he denies suicide. His mother has been calling for the past few days leaving messages with staff that she is greatly concerned.
DiscussionSlide47
47Why was mother concerned?This 18 Y.O. told his sister a few days ago that wanted to end it all and kill himself. Slide48
48Scenario #217 Y.O. female came in late to class and has been missing several of her assignments. The teacher asked her to stay after class where she found out that she has been depressed lately and lacks motivation for school. She is having trouble with some other girls on center and feels like she doesn’t belong. She ends the meeting by stating “I have learned my lesson.” She wants to do better in class and is asking how she can make up her assignments.
DiscussionSlide49
49Why was she late for class?This student took an overdose of 20 aspirin tablets and 4 sleeping pills she brought from home. After waking up she decided to come to class without telling anyone what she had done. Slide50
Last Words from Real CasesDepressed farmer to inpatient nurse on discharge, “Don’t worry about me, I’ll be six feet under by Friday.” Depressed boy to mother, “Do you think God has a place in heaven for a boy like me?”Father to son, “I’m going home soon.”
WWII vet to social worker, “Don’t worry, when the going gets tough the tough know what to do.”
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51Examples from Real CasesParishioner to Pastor, “Do people who kill themselves go to hell?”Catholic woman to best friend, “It’ll be fine, I’ve seen the virgin.”
Patient to pharmacist, “Are you sure this is enough medicine to cause death?”
Patient to doctor, “You’ve been a wonderful doctor. Thanks for everything.”Slide52
The 7 D’s of Suicide Risk AssessmentDid you?Develop an empathetic and respectful relationship?D
efine the problem(s) suicide would solve?
D
etect suicide ideation?Determine desire, capability, intent, and means availability?Detail risk and protective factors?Decide on level of acute risk present?Develop a collaborative crisis mitigation, means restriction and follow up plan?
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SRMI quiz (1,100+ practicing professionals)Slide54
Suicidal Communications Clump UpIf you were suicidal, who would you tell?How would you tell them?How many times would you tell them?What would you do if people did not respond?
How would you change your message if ignored?
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55QPR TheoryAssumption: passive systems don’t work
Those most at risk for suicide:
tend not to self-refer for treatment
tend to be treatment resistantoften abuse drugs and/or alcoholdissimulate their level of despair go undetectedgo untreated (and remain at risk for suicide)Slide56
QPR TheoryMost suicidal people send warning signsWarning signs can be taughtGatekeepers can be trained to a) recognize suicide warning signs and, b) intervene with someone they know
Gatekeepers must be fully supported by policy, procedure and professionals in their community
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Goals for QPR Gatekeeper TrainingEffective Gatekeepers:Are alert to the possibility of suicide Know suicide risk factors
Recognize symptoms of distress
and depression
Recognize suicide warning signsKnow what to say, when to say it, and what to do57Slide58
The QPR Chain of Survival4 links…Early recognition of warning signs Early application of QPR
Early referral to professional care
Early assessment and treatment
Knowledge + Practice = Action 58Slide59
59Seven Life-Saving GoalsDetection of suicidal persons
Active intervention
Alleviation of immediate risk factors
Accompanied referralAccess to treatmentAccurate diagnosisAggressive treatment“Ask the question, save a life.”Slide60
60QPR Prevention Strategy
AWARENESS SURVEILLANCE DETECTION
Suicidal Thoughts
Suicidal Warning Signs
Suicide Attempt
Suicide injury or death
Perceived Insoluble Problem
INTERVENTION
OPPORTUNITIES
Question
Persuade
Refer
TreatSlide61
61A Simple TruthThe person most likely to prevent you from taking your own life is someone you already know Slide62
62Clear Verbal Threats
& Uncoded Clues
Untrained Detection Network
Teacher
Job Corps Site counselor
Student in crisis
Job Corps Site nurse
Girlfriend
Pastor
Parents
Best friend
No Clues
Coded Clues
Self-referral unlikely
Hotline call unlikely
Intervention unlikely
Coded Clues
Coded Clues
Coded Clues
Consultation
No Clues
Source: Paul Quinnett, Ph.D., QPR for Suicide Prevention
Diagram 1Slide63
63QPR Gatekeeper Network
Teacher applies QPR
Student gets support
Parents
Depression/alcohol
screening
Nurse
Counselor
Food service staff
Teachers
Best
friend
Network Trained to detect suicidal students
Q
uestion
Asked
P
ersuaded
R
eferral
Completed
Suicide
attempt averted
Referral
Referral
QPR Intervention
Source: Paul Quinnett, Ph.D., QPR for Suicide Prevention
Diagram 2
GirlfriendSlide64
64Research QuestionsDoes QPR Training Produce….
Changes in knowledge, attitude, perceived self-efficacy among adults?
Yes.
Changes in detection rates? Yes.Increases in referrals? Yes.Changes in service utilization (crisis response and outside providers)?
Yes.
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65If Overwhelmed by Life….Georgia high school students with suicide attempts were 2 to 3 times less likely to endorse help-seeking when in crisis
Conclusion: those students at highest risk, and the most hopeless, are the least likely to ask for help!
Solution? WE MUST GO TO THEM!
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66Complete ResearchGo to http://www.qprinstitute.com/
Click Evidence of QPR on left hand side of pageSlide67
We Feel that Suicide Prevention Training Should… Match level of training with level of duty Be delivered in a standardized fashion Provide measurable outcomesEmbrace technology
Be culture-sensitive and acceptable to learners
Be low-cost, compared to other options
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68Advanced Online Training
Training
from EWU for
Job Corps Center Counselors, Psychologists, Nurses and Social Workers Suicide risk detection, assessment and management training
University
based - CEU or college credit
APA approved (6 hours)Blended DVD, study guide, + online
CertificateSlide69
69Take Out Your BookletsOn the back side is a website, user ID, and password
http://www.qprtraining.comSlide70
Change Organization for Alternative
70Slide71
71ResourcesFree book for downloadSuicide: The Forever Decision
qprinstitute.comSlide72
Resources72Slide73
Contact InformationPaul Quinnett: 509-235-8823www.qprinstitute.com
Ben Camp: 509-939-7001
Bcampsight@aol.com
Please visit our web site and download the free e-book:
Suicide: the Forever Decision
and share it widely…..
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