1. QPR GATEKEEPER TRAINING Rural Health Association of Tennessee Mental Health Awareness & Suicide Prevention Alliance Mary Beth Blevins, RN, BSN Anna Shugart, MSSW, LCSW

2. Question, Persuade, Refer Ask A Question, Save A Life QPR ©

3. The Golden Gate Bridge Kevin Hines

4. Suicide is an equal opportunity destroyer, heedless of race, economic status or religious affiliation.

5. QPR QPR is not intended to be a form of counseling or treatment. QPR is intended to offer hope through positive action. ©

6. National Suicide Rate: 1 death every 13.7 minutes = 105 per day

7. National View Someone aged 10 – 24 dies by suicide approximately every two hours in the U.S. The highest suicide rate is in the 45 – 54 age group. More teenagers and young adults die from suicide than from cancer, heart disease, AIDS, birth defects, stroke, pneumonia, influenza, and chronic lung disease combined Each week about 100 young people die from the Silent Epidemic in the United States.

8. Tennessee View Tennessee is above the national average Tennessee rate is 14.7 suicide deaths per 100,000 of population National rate is 12.2 suicide deaths per 100,000 of population In TN in 2010 death by suicide was: 2nd leading cause of death for age 25-34 3rd leading cause of death for age 15-24 2/3 of all suicides in TN involve a firearm

9. Suicide in Rural Areas Access to Treatment Stigma Drug & Alcohol use Historical Trauma Economy Firearms Veterans

10. QPR - Suicide Myths and Facts MythNo one can stop a suicide, it is inevitable. FactIf people in a crisis get the help they need, they may never be suicidal again. Myth Confronting a person about suicide will only make them angry and increase the risk of suicide. FactAsking 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 ©

11. QPR - Suicide Myths and Facts MythSuicidal people keep their plans to themselves. FactMany suicidal people communicate their intent sometime during the week preceding their attempt. Myth Those who talk about suicide don’t do it. FactPeople 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. How can I help? Ask the Question... ©

12. QPR – Suicide Risk Factors Young People Young brains Disenfranchised Antisocial behavior All Ages Mental illness diagnosis and addiction Recent suicide attempt History of sexual and/or physical abuse Chronic medical illness or chronic pain Socio-demographic factors Life pressures

13. The more clues and signs observed, the greater the risk Take ALL signs seriously QPR - Suicide Warning Signs ©

14. “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.” QPR – Direct Verbal Clues ©

15. “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 just want to go to sleep forever.” “If someone dies by suicide do they still go to heaven?” © QPR – Indirect Verbal Clues

16. 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/irritability or sudden mood improvement without treatment QPR – Behavioral Clues ©

17. 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 by suicide Diagnosis of a serious or terminal illness Sudden unexpected loss of freedom/fear of punishment Anticipated loss of financial security Change in relationship with a counselor, teacher or coach Fear of becoming a burden to others QPR – Situational Clues ©

18. Mental illness is linked to suicide Population without mental illness: 234 M Population with mental illness: 78 M 90% of those who die by suicide have a diagnosable mental illness 3,636 suicides 32,728 suicides

19. The Many Paths to Suicide Underlying RisksTriggers Means Crisis in Relation Loss of Freedom Fired/ Expelled Illness Major Loss ? Poison Gun Hanging Autocide Jumping ? Hopelessness PROTECTIVE FACTORS GeneticsSex Race Age Biological Drugs or Alcohol Child Abuse Loss of Parent Culture Shock/ Shift Values Religion Beliefs Personal Season of year Geography Model for Suicide Environmental Urban vs. Rural

20. Protective Factors Self Esteem Personal Control Internal Constraints (faith, hope) External Constraints (family/children) Coping Skills Good Attachments to Others Distress Tolerance Acute Risk May Override Protective Factors  Most people are planning for the future while contemplating specific suicide plans  Married people die by suicide  Religious people die by suicide  Psychiatric disorders can impair resilience and coping, amplify distress, and decrease the value of protections

21. QPR - Tips for Asking the Suicide Question If in doubt, don’t wait, ask the question If the person is reluctant, be persistent Arrange for privacy and plenty of time Allow the person to talk freely Have resources handy; QPR Card, phone numbers, counselor’s name and any other information that might help Remember: How you ask the question is less important than that you ask it ©

22. Q QUESTION Less Direct Approach: “Have you been very unhappy lately?” “Have you been so very unhappy lately that you’ve been thinking about ending your life?” “Do you ever wish you could go to sleep and never wake up?” “Do you feel that everyone would be better off if you were not here?” ©

23. Q QUESTION Direct Approach: “You know, when people are as upset as you seem to be, they sometimes wish they were dead. I’m wondering if you’re feeling that way, too?” “You look pretty miserable, I wonder if you’re thinking about suicide?” “Are you thinking about killing yourself?” NOTE: If you cannot ask the question, find someone who can. ©

24. How Not to Ask the Question “You’re not suicidal, are you?” ©

25. P PERSUADE Listen to the problem and give them your full attention Remember, suicide is not the problem, only the solution to a perceived insoluble problem Do not rush to judgment Offer hope in any form Question for the group: what are ways to offer hope? How to Persuade Someone to Stay Alive: ©

26. P PERSUADE Then Ask: “Will you go with me to get help?” “Will you let me help you get help?” “Will you promise me not to kill yourself until we’ve found some help?” ©

27. R REFER Suicidal people often believe they cannot be helped, so you may have to do more. The best referral involves taking the person directly to someone who can help. The next best referral is getting a commitment from them to accept help, then making the arrangements to get that help. The third best referral is to give referral information and try to get a good faith commitment not to complete or attempt suicide. Any willingness to accept help at some time, even if in the future, is a good outcome. ©

28. Situation Imminent Threat Person has a plan/means You are very alarmed High Threat Person hopeless, distressed You are worried Unclear Threat Person is depressed You are concerned Referral Options Call 911, take to ER Treat as a medical emergency Take to ER, Call BMH mental heath Call therapist, EAP, family Get others involved EAP, therapist, physician, family, friends R REFER

29. REMEMBER Since almost all efforts to persuade someone to live instead of attempt suicide will be met with agreement and relief, don’t hesitate to get involved or take the lead. ©

31. What Would You Do About Kevin Hines? If you were his Dad and you… Noticed his behavior Knew his mental health status Knew about the current stressors If you saw a stranger and… Witnessed obvious signs of distress

32. Questions & Answers