Preventing Suicide: Everybodys Business

1. Preventing Suicide: Everybody's Business Paul Quinnett, Ph.D. QPR Institute Spokane, Washington

2. Goals Scope of the problem The National Strategy for Suicide Prevention Suicide prevention is violence prevention Applying Social Network Theory to SP Enhancing consumer safety (Why Homer Simpson works in a nuclear power plant) Community solutions

3. Global Violence-Related DeathsWHO and IOM 2007 1 million people die by suicide 10-20 million attempt Leading cause of death in 1/3 of all countries Suicide accounts for 54% of all violence-related deaths More die by self-directed violence each year than by all other-directed violence in the world, including from all armed conflicts and homicides

4. Scope of the problem NZ 500 deaths per year More than all deaths by MVA 6th highest form of preventable death 11/100K (same as US) Males 3.61 greater than females 2,500 hospitalizations per year (not ED) Source: New Zealand Suicide Prevention Strategy 2006�2016

5. And yet�. �Suicide is our most preventable form of death.� Dr. David Satcher, former Surgeon General of the United States

6. Mental Illness & Suicide Over 90% of all people who die by suicide are suffering from a treatable major psychiatric illness or substance abuse disorder, or both. More teenagers and young adults die from suicide than from cancer, heart disease, AIDS, birth defects, stroke, pneumonia and influenza, and chronic lung disease, COMBINED. Effective, accessible, competent care could save thousands of lives. (NIMH, 2006)� And could save billions of dollars in healthcare costs! Speaks for itself � Source: NIMH.Speaks for itself � Source: NIMH.

7. What do we know? Mentally healthy, hopeful people don�t kill themselves If recovery is possible, suicide is preventable If treatment works, suicide is preventable (it does!) 78% of Americans believe many suicides are preventable (SPAN USA, 2007) 86% of Americans believe we should invest in suicide prevention (SPAN USA, 2007)

8. 4 Cornerstones for a Community Model: Theoretical Assumptions 1. Fundamentally, all communities care about human life and will go to great lengths to prevent and mitigate the human suffering that precipitates suicidal behavior and the agony and pain survivors experience in its aftermath.

9. Theoretical Assumptions 2. Once communities are equipped with specific knowledge, training, skills, and leadership, efforts to reduce suicidal behavior will be successful. US Air Force Ecological Approach

10. Theoretical Assumptions 3. Public health awareness efforts, gatekeeper training, and enhanced skills training across the spectrum of first responders, health and human services, correctional workers, and other provider organizations can dramatically lower the risk that an identified community member will attempt suicide.

11. Theoretical Assumptions 4. By building shared community responsibility, and individual and group competence, to identify, assess, manage and treat suicidal members of the community, communities can define themselves as caring, confident and competent in the prevention of suicidal behaviors among their members.

12. Simple truths� * Suicide prevention is too important a task to be left to government. * Because of the enormous emotional and economic loss to a community, it is essential that business, labor, religious and professional organizations be at the suicide prevention table. Everyone has a role and a responsibility

13. Theoretical Assumptions about Suicidal People Those who are most at risk for suicide are the least likely to ask for help. Thus, we must find our at-risk fellow citizens and help them where they are. If we require suicidal people to ask for help, they will continue to die.

14. What we know� Prior to making a suicide attempt, those in a suicide crisis are likely to send warning signs of their distress and suicidal desire and intent to those around them. Thus, learning these warning signs and taking quick, bold action during these windows of opportunity can save lives.

15. Simple truths� The person most likely to prevent you from dying by suicide is someone you already know! Thus, those around us must know what to do if we become suicidal.

16. Simple truths� When we solve the problems people kill themselves to solve, the reasons for suicide disappear. Thus, compassionate crisis intervention, problem resolution, and treatment will save lives.

17. Community-Based �Best Practices� Implementation of awareness-raising programs to gain community support. (the Belgrade story) Educate and train a broad range of community participates to better understand the causes of suicide, how intervention and treatment saves lives, and how to enhance protective factors.

18. Community-Based �Best Practices� Train law enforcement and other 1st responders, crisis line volunteers, mental health and other healthcare professionals, clergy, school counselors, teachers, those serving at risk populations in how to talk to suicidal people and to a) immediately reduce risk factors and b) immediately enhance protective factors.

19. Community-Based �Best Practices� Determine barriers to good treatment (cost, stigma, insurance coverage) and develop strategies to decrease barriers. Increase pathways to �Best Practices� treatment programs by securing organizational agreements, and referral network agreements. Who will see my suicidal brother today?

20. The Spokane Story Origins of QPR

21. QPR Chain of Survival What is QPR? stands for Question, 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.

22. Why QPR? Each letter in QPR represents an idea and an action step QPR intentionally rhymes with CPR � another universal emergency intervention QPR is easy to remember Asking Questions, Persuading people to act and making a Referral are established adult skills �Out of clutter, find simplicity�  Albert Einstein

23. QPR Is a simple, direct, behavioral intervention designed to produce a predetermined outcome: a referral for professional help Is designed to produce a helpful dialogue between someone at risk for suicide and a trained Gatekeeper Teaches Gatekeepers to immediately reduce risk factors, increase protective factors, and get the person to a professional

24. The QPR Chain of Survival(Think CPR) 4 links� Early recognition of warning signs Early application of QPR Early referral to professional care Early assessment and treatment Knowledge + Practice = Action

26. But Houston, we have a problem�

27. Our Challenge? Who will treat? Who will take QPR referrals from community members? How will at-risk people be evaluated for suicide risk? Who will provide services to youth high risk populations who will only accept help where they are? Work? Bars? Cyberspace? Services delayed are services denied Services delayed are services denied

28. Goal 6: �Implement training for recognition of at-risk behavior and delivery of effective treatment� 1. Who is qualified to conduct a suicide risk assessment? 2. What are these qualifications? 3. When is the risk assessment done? How often? 4. Where are staff trained in recognition of at-risk behavior? 5. How is this risk assessment documented?

29. It�s 2009�.and not much is happening�. Families are being taught suicide is preventable, so �Why did my brother die after I brought to your hospital, mental health center or substance abuse treatment program?� What�s coming round the corner������..

30. Suicide in Treatment Most people who die by suicide are not receiving any mental health service But of all suicide deaths in the US, 1/6th are in active care with a professional (1/2 if you include primary care) Of all suicides in the UK, 1/5 are in active care

31. Gatekeepers are the pitchers, professionals are the catchers But� Professionals don�t know what they don�t know about suicide risk detection, assessment, management and treatment of suicidal behaviors.�� Evidence?

32. What do clinicians know? 1,100 MHPs practicing in 13 states Standardized 25-item quiz (SRMI) covering suicide statistics, risk and protective factors, risk management and safety practices in clinical settings. Findings have been twice replicated (N>500 in >50 clinical settings) We wish to thank the Devereux Foundation for contributing to this database.

34. Type I errors: Failure to detect suicide * Of 100 ED severe attempters, 83 had seen PCP or MHP within 1 month and were considering suicide - 55 were not asked about suicide * Of 310 active care suicidal outpatients - 177 were not asked Odds of being screened for suicide if you are suicidal on a given visit = less than 50% (Hall, et al, Psychosomatics, 1999) ( Brown, et al, Crisis, 2003)

35. Would you�.? Return to a dentist that drilled and filled the right tooth � the time? Be satisfied with the surgeon who did a full hip replacement but on the wrong hip? Fly with a pilot only drunk half the time?

36. True story My son died by suicide in 1993 and in the process of suing the hospital and the doctor, the last professional to see my son for therapy was a Ph.D. in Psychology.�When this person was deposed, he reported that��he never asked him if he was suicidal (Todd was two days post discharge from a suicide attempt) and said that 'he was a bright young adult, if he was suicidal, he would have told me.'�Two days later, Todd hung himself.� �I won the case out of court without going to a jury! Sherry Bryant, LCSW, CADC, LMFT

37. Meet Our New Mental Health Patient Safety Officer

38. A glimmer of hope from Wyoming�. �I just wanted to share an experience that represents - hopefully a positive turn in suicide prevention. I took my 9 - year old son to his well-child visit with our pediatrician. During the exam our doctor asked my son what the #1 cause of death in people age 9- 20 something was and after some prompting my son said "accidents." He then told him that #3 was homicide and explained what that term meant. He then asked my son what he thought #2 was. My son said, "when someone dies on purpose?�

39. A glimmer of hope�. Our pediatrician told him he was right and went on to talk to my son about suicide and the importance of having someone that you can trust to share your feelings with. Our doctor then turned to me and began to give me information on suicide prevention and the importance of our children having a true and non - judgmental connection with a parent. He gave statistics and examples. I was impressed with him and encouraged with this sign that some of the secrecy and shame of suicide is being lifted.� Chris Stoddard, RN

40. Ethical question to mental health leadership: �If not consumer safety, what matters more?�

41. PERSONAL PERSPECTIVE Question: �Why did this patient die by suicide?� Fatality reviews Psychological autopsy Motive Method Opportunity People, systems, or just bad luck?

42. What we did� Psychology interns & med records staff Pulled charts of all known suicides Pulled all �suicide event� incident reports Pulled all charts where patient named matched coroner report of suicide death Reviewed each chart with a standardized checklist

43. What we learned�on records review of the deceased: Suicide risk was not detected Suicide risk information was not collected 3rd party suicide risk data was not available 3rd party suicide risk data not sought Family risk observation input was minimized, denied or ignored There was little evidence of a competent, frank interview regarding self-destruction

44. Found 3 BASIC ERRORS TYPE 1: Failure to detect suicide risk TYPE 2: Failure to assess and reassess suicide risk TYPE 3: Failure to establish and monitor a suicide risk management plan

45. We tried to do better�. Developed QPR Developed advanced clinical training programs Developed college courses Developed competency based credentials Results are in and results are good

46. Devereux Results (a HRO) Training is mandatory for all 5,000 employees All staff trained in QPR � QPRT All clinical staff must pass a final test and demonstrate assessment skills Effects on suicide rate: Had a low base rate to begin with Significant reduction in completed suicides Significant reduction in life-threatening attempts Helped avert at least 5 staff suicides

47. Devereux Board Makeup Devereux is a good catcher for suicidal referrals � one of the best A chicken and pig go to breakfast Invite a suicide survivor on your board if you don�t have one already and get some skin the game

48. The Public Health Question How many gatekeepers must be trained to prevent one suicide event? Where suicide event = a suicide attempt or completion Per 10,000 adults and teenagers Question from public health leadership and funding sources � preventing attempts and completions providers a greater return on investment than preventing completed suicides alone.Question from public health leadership and funding sources � preventing attempts and completions providers a greater return on investment than preventing completed suicides alone.

49. If you do nothing� If you do nothing to recruit for self-referral, detect, intervene, refer, and assist those to be impacted by suicidal behavior in the next 12 months: - 1 person will have died by suicide - 25 will have attempted suicide - 1000 will have suffered from suicidal ideation and disorders that cause it - 1026 affected + survivors @ a cost of ? Probability outcomes if no actions are taken using the US average suicide rate for attempts and completions, 11/100K and 25 attempts per completion. These are statistical averages and assume all populations are the same, when they are not. But the general formula can be applied to any at risk group, e.g., 10,000 US soldiers where the suicide rate may be 40 per 100,000K Probability outcomes if no actions are taken using the US average suicide rate for attempts and completions, 11/100K and 25 attempts per completion. These are statistical averages and assume all populations are the same, when they are not. But the general formula can be applied to any at risk group, e.g., 10,000 US soldiers where the suicide rate may be 40 per 100,000K

50. To assist these 1,056 people you must first find them� - With a solid educational and social marketing outreach program, some will self-refer. These will be mostly females (at lower risk for death by suicide). - Let�s say of the 200 who self-refer, suicide risk is detected and assessed by professional counselors and no adverse events follow. Self referral rates will vary by gender and education, race and ethnicity of both the suicidal and the provider.Self referral rates will vary by gender and education, race and ethnicity of both the suicidal and the provider.

51. The 826 who do not self-refer - Males, minorities, some GLTB - Those who fear stigmatization - Those suffering serious psychiatric illness and early-onset dementia - Those too hopeless to believe in help - High profile males and females, e.g., doctors - Those using alcohol and other drugs, which a counselor is going to ask them to give up Those who will not self-refer are known to us, e.g., in differential health disparity data, and other markers.Those who will not self-refer are known to us, e.g., in differential health disparity data, and other markers.

52. 826 is not a needle in a haystack Case finding strategies: - Conduct mandatory depression screenings or mental health checkups - Open anonymous channels to help, e.g., texting - Require self-report of mental health records and medication use (public safety employees) - Accept that self-referral is a no-go and train community-based gatekeepers to recognize distress and suicide warning signs and intervene to bring about referral Case finding strategies come from public health, e.g., how do you find Typhoid Mary? Case finding strategies come from public health, e.g., how do you find Typhoid Mary?

53. Application of Social Network Theory to Gatekeeper Training Gatekeepers are existing members of the community of 10,000 who are trained to observe, detect, identify, and refer persons emitting recognizable suicide warning signs prior to engaging in behavior which could lead to a suicide event (attempt or fatality). We can teach warning signs Gatekeepers already exist � suicide warning signs are being sent daily � training closes this gap between recognition, intervention and referral.Gatekeepers already exist � suicide warning signs are being sent daily � training closes this gap between recognition, intervention and referral.

54. How will we find them? �No great misery goes unspoken� Estimates of those send detectable suicide warning signs to others in their immediate inner circle range from 60% to 90%. Of our 826 suicidal people, we can expect that between 496 (60%) and 743 (90%) will send warning signs before they attempt suicide to one or more persons within our community of 10,000. But which ones and to whom? Plenty of published data here, and more coming in. Psych autopsy studies reveal that as many as 90% tell someone what they are about to do.Plenty of published data here, and more coming in. Psych autopsy studies reveal that as many as 90% tell someone what they are about to do.

55. Social Network Theory According to dozens of sociological and anthropological studies on human communities there are two community construction rules to which all humans conform: The rule of 150 (Dunbar�s #) and, The rule of 12 These rules apply to military fighting units, churches, successful work groups, and even online social networks like Facebook� . Dr. Dunbar�s studies (Oxford) of primate brain size necessary to keep track of allies, enemies, who lusts after who and other such critical information to maintaining a stable social network found that the cognitive power of the brain limits the size of the of this network to a limited number. Primates with little brains can keep track of fewer brothers, sisters, cousins and such than can we. Extrapolating from the brain sizes of social networks of apes, he suggested the human brain allows stable networks of about 148 folks. Rounded to 150, this has become the �Dunbar number.� The Klung! of the Kalahari � group after group, run to 150. These are first-name-basis communities of common language, culture, ritual. From Neolithic villages to the maniples of the Roman Army, the Dunbar number holds.Dr. Dunbar�s studies (Oxford) of primate brain size necessary to keep track of allies, enemies, who lusts after who and other such critical information to maintaining a stable social network found that the cognitive power of the brain limits the size of the of this network to a limited number. Primates with little brains can keep track of fewer brothers, sisters, cousins and such than can we. Extrapolating from the brain sizes of social networks of apes, he suggested the human brain allows stable networks of about 148 folks. Rounded to 150, this has become the �Dunbar number.� The Klung! of the Kalahari � group after group, run to 150. These are first-name-basis communities of common language, culture, ritual. From Neolithic villages to the maniples of the Roman Army, the Dunbar number holds.

56. The Rule of 150 Average number of humans you know on a first name basis. (Think evolutionary theory and that we are all tribal) These 150 people are interdependent: share values, visions, ideas, enemies, kinships, likes, dislikes, etc. Our biological brain size and memory capacity is perfectly adapted to remember the names, faces, and interpersonal histories we�ve had with these 150 community-bonded, �like us� souls. Some sociologists suggest the number may be much higher, say, for social connectors like politicians.Some sociologists suggest the number may be much higher, say, for social connectors like politicians.

57. You in the middle of your village with your 150 closest family members, cousins, friends, and other humans you need to surviveYou in the middle of your village with your 150 closest family members, cousins, friends, and other humans you need to survive

58. The Rule of 12 Within each group of 150, there are approximately 12 people who you might call your �intimate others.� Women have more, men have fewer. These include your immediate family, dearest friends, lovers, spouses, and those with whom you routinely break bread. Each group of 150 has 12.5 sets of 12 people, but the overlap among the smaller groups is great, thus creating the �fabric� of a village. These are remarkably stable smaller networks � average man has 120 friends, but only 7 very close ones � Facebook research. In two-way conversations between men, it is as low as an average only 4 significant others, while for women is an average of only 6. These are remarkably stable smaller networks � average man has 120 friends, but only 7 very close ones � Facebook research. In two-way conversations between men, it is as low as an average only 4 significant others, while for women is an average of only 6.

59. Rule of 12 on a college campus Intimate others and frequent contacts example: Professor, father, mother, brother, sister, roommate, resident advisor, campus police, academic advisor, fraternity brother, sorority sister.. Intimate others and frequent contacts example: Professor, father, mother, brother, sister, roommate, resident advisor, campus police, academic advisor, fraternity brother, sorority sister..

60. Refinement of relationships within the Rule of 150 Suicidal people send warning signs not to strangers (although this happens), but to people within the circle of 150. They are especially likely to send warning signs to those in the circle of 12, or to those intimate 4 or 6 others (depending on gender) Threatened with isolation or a feeling one is burdening others, who is likely to know? But not all relationships are equal�. Who is likely to know is someone in a position to see or hear a suicide warning sign. If you have only one or two people in your innermost close group, and if this relationship is broken, it is no wonder that �isolation� becomes a risk factor for suicide.Who is likely to know is someone in a position to see or hear a suicide warning sign. If you have only one or two people in your innermost close group, and if this relationship is broken, it is no wonder that �isolation� becomes a risk factor for suicide.

61. Authority Ranking Relationship This is the pecking order � students, low-ranking soldiers, and employees all have someone in authority over them.This is the pecking order � students, low-ranking soldiers, and employees all have someone in authority over them.

62. Equality Matching Relationship Might a suicidal student send an oblique suicide warning sign to the barista? Maybe. Perhaps a big tip followed by, �Well, you won�t be seeing me again after Friday.�Might a suicidal student send an oblique suicide warning sign to the barista? Maybe. Perhaps a big tip followed by, �Well, you won�t be seeing me again after Friday.�

63. Communal Sharing Relationships Sharing is intimate, frequent, equal � family and close friends around a dinner table.Sharing is intimate, frequent, equal � family and close friends around a dinner table.

64. Do we teach different warning signs to different gatekeepers? No one has done this research But�.Pastors report rhetorical questions about afterlife consequences of suicide by parishioners - Administrative relief questions have surfaced from authority figures, HR directors, military clerks � and families report direct threats and clear statements of intent. General still-open questions.General still-open questions.

65. Assumptions� A single person among the 826 has 12 people in his/her intimate communication network. Let�s assume he/she sends warning signs to 25% of those 12 people, or 4 people. Let�s assume that of those 4 people at least one responds as trained in something like QPR The suicidal person could send warning signs to everyone, e.g., through a text message to their list or post in on their Facebook account. This would be a 100% blanket communication. I picked 25% just to be on the low side.The suicidal person could send warning signs to everyone, e.g., through a text message to their list or post in on their Facebook account. This would be a 100% blanket communication. I picked 25% just to be on the low side.

66. We can find these gatekeepers� Just ask 3 questions (LCH) Who can you count on to listen to you when you really need to talk? Whom can you count on to console you when you are very upset? Whom can you count on to help in a crisis situation even though they would have to go out of their way to do so? The Name Generation Exercise Source: Sarason et. al., 1983.Social Support Scale The �only blood matters� is a line from the film about the shootout at the OK corral when Sheriff Earp says to his family and cousins at the final meal before the showdown, that only we at this table matter � This is the �blood is thicker than water� evolutionary group survival dictum by which we all came to be humans. The Sarason study was done with aging male veterans.The �only blood matters� is a line from the film about the shootout at the OK corral when Sheriff Earp says to his family and cousins at the final meal before the showdown, that only we at this table matter � This is the �blood is thicker than water� evolutionary group survival dictum by which we all came to be humans. The Sarason study was done with aging male veterans.

69. Who�s got your back? Most of us have 3-7 intimate others whose names will be generated in this exercise, women more, men fewer. These 5 people will be inside our group of 12. - Train all 5, odds of survival high - Train 2 or 3, odds of survival good - Train 1 = odds of survival fair - Train 0 = odds of survival iffy to poor It�s all about surveillance! The 3-7 figure is very close to the 4-6 number (men = 4, women = 6) in the social network research.The 3-7 figure is very close to the 4-6 number (men = 4, women = 6) in the social network research.

70. Having a cardiac event in public? Your survival depends on a trained observer recognizing the warning signs and quickly applying CPR and/or defibrillation paddles. Odds of surviving: Average US city = less than 5% Seattle, King County = +-25% Any gambling casino = ????+% Awareness + surveillance + action saves lives! In Seattle King Country one in 4 adults is trained in CPR - In casinos every customer is under constant surveillance, recognition/intervention occurs in less than 3 minutes. In Seattle King Country one in 4 adults is trained in CPR - In casinos every customer is under constant surveillance, recognition/intervention occurs in less than 3 minutes.

71. Probability of intercepting a suicide warning sign? Detection is a function of frequency of observation: Who is a daily observer? Who is a weekly observer? Who is a monthly observer? Those with the highest frequency of contact or observation have the best chance of detecting a suicide warning sign and intervening.Those with the highest frequency of contact or observation have the best chance of detecting a suicide warning sign and intervening.

72. Public health approaches Universal = train all 10,000 (must be affordable, accessible, available and adequate to the job of detection of new cases) Selective = Train some or all key gatekeepers Indicated = Train key gatekeepers with power and authority for intervention, treatment and care. Match the level of training with the level of responsibility With QPR training online now available a five or fewer dollars, affordability, accessibility and availability have become realities. We know the intervention is adequate to detect new cases. With QPR training online now available a five or fewer dollars, affordability, accessibility and availability have become realities. We know the intervention is adequate to detect new cases.

73. You in the middle of your village with your 150 closest family members, cousins, friends, and other humans you need to survive. In this graphic, only 25% of the people know QPR (estimated). Imagine it 100%You in the middle of your village with your 150 closest family members, cousins, friends, and other humans you need to survive. In this graphic, only 25% of the people know QPR (estimated). Imagine it 100%

74. Strategies to maximize the odds of finding the 826 in 10,000 in 12 months 1. Train as many of 5-7 intimate others whose names are generated by the exercise 2. Train as many of those in the circle of 12 as possible via the name generation exercise 3. Train those in strategic, frequent contact in Authority Ranking relationships 4. Train those in strategic, frequent contact in Equality Exchange relationships Probation officers working with high risk youth� - pharmacists, exchange, - everyone a veteran names in the intimate other name generationProbation officers working with high risk youth� - pharmacists, exchange, - everyone a veteran names in the intimate other name generation

75. You in the middle of your village where everyone is trained in QPR but the guy in the blue dot above your head � he just moved into town and is on schedule to be trained. You in the middle of your village where everyone is trained in QPR but the guy in the blue dot above your head � he just moved into town and is on schedule to be trained.

76. Remember� Preventing suicide may be easier than overcoming our fear to try. and a few words on hope�..

77. The numbers� Since 2001 � 1,000,000+ gatekeepers trained More than 3,750 active Certified QPR Instructors 10,000+ gatekeepers per month Each has an average of 5.2 conversations with others who did not attend the training Total impact = 50,000 people per month. 5 million new conversations!

78. The power of the web Technology transfer QPR online Advanced training online Robust research agenda Global network of online Suicide Crisis Risk Mitigation Specialists Launching now!

79. Let�s start an epidemic of hope A new conversation The Law of the Few � you are perfectly placed to influence others. Create a �tipping point� - A movement that begins small and then everything changes at once. Let�s infect people around us with the idea that suicide is preventable, �One life is too many,� that �Preventing suicide is everybody�s business.�

80. Another bloody optimist� You may never know what results come from your action. But if you do nothing, there will be no result. ����������������������� Mahatma Gandhi �

81. What if? We are the ones we�ve been waiting for�.

82. Contact Information In New Zealand QPR is delivered by Clinical Advisory Services Aotearoa (CASA) � www.casa.org.nz. QPR New Zealand Freephone: 0800-448 909 Email: stephen.lisk@casa.org.nz Web: www.qpr.org.nz Please visit our web site and download the free e-book: Suicide: the Forever Decision and share it widely�..

83. Believe it will happenand it will �The time is always right to do what is right.� Martin Luther King, Jr.