Project LETS

QPR Training

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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

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.

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.

Question 2
Approximately how many young people between the
ages of 15 and 24 die every day from suicide?

10

11

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.

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.

Question 3
Are females or males more likely to
complete suicide?
MALES

FEMALES

NEITHER

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.

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.

Question 4
True or False: Its better to not talk about suicide with
someone who may be thinking about it because youll just
encourage them.

TRUE

FALSE

Correct!
Having a serious, compassionate conversation without
passing judgment shows that you are concerned for the
persons well-being and want to understand their pain.
When talking with someone about suicide, keep an open
mind to their problems and feelings, but dont 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.

Actually
Having a serious, compassionate conversation without
passing judgment shows that you are concerned for the
persons well-being and want to understand their pain.
When talking with someone about suicide, keep an open
mind to their problems and feelings, but dont 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.

Question 5
!
True or False: There is usually one sudden and traumatizing
event that leads a person to attempt suicide.

TRUE

FALSE

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.

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.

Question 6
True or False: It is impossible to tell if someone
intends to commit suicide.
!
TRUE

FALSE

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

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

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
Whats the point of living?
You wont have to worry about me soon
Who cares if Im 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.

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

Correct!
!

1100 deaths occur every year on college

campuses as a result of suicide.

Actually
!

1100 deaths occur every year on college

campuses as a result of suicide.

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

Correct!
!

Hispanic and Asian males under the age of 21 are at a

higher risk of attempting suicide and considering it as
an option.

Actually
!

Hispanic and Asian males under the age of 21 are at a

higher risk of attempting suicide and considering it as
an option.

Question 9
True or False: Once a person has started thinking about
suicide, there is little one can do to change his or her
mind.

!
TRUE

FALSE

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.

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.

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

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.

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.

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 wouldnt do anything stupid would you?

A. Youre 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

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.

Actually
Both you wouldnt do anything stupid would you?
and youre 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.

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

Correct!
If you think there is an immediate danger to a persons 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.

Actually
If you think there is an immediate danger to a persons 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.

Question 13
True or False: Once I start to help someone who is
considering suicide, he or she becomes my
responsibility.

!
TRUE

FALSE

Correct!
Your concern for a persons 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. Dont forget to take care of yourself!

Actually
Your concern for a persons 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. Dont forget to take care of yourself!

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 Americas Youth, http://
www.jedfoundation.org/articles/SuicideStatistics.pdf.

!
University of Connecticut (2008). QPR Training.

!
Project LETS (2013), Fact Sheets
http://www.letserasethestigma.com

PROJECT LETS QPR TRAINING

QUESTION

PERSUADE

REFER

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.

DEFINING TERMS
A 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.

RISK + PROTECTIVE FACTORS

Synergistic; dynamic; complex; modifiable and non-modifiable

Family'connectedness1'''''
Family'acceptance2'
Safe'schools1'
Caring'adult1'
High'self:esteem3'
Posi=ve'role'models3''

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 individuals behavior. On the
other hand, a protective factor
indicates that an individual or

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

population with a particular

characteristic is less likely to engage
in suicidal behavior.

ECOLOGICAL MODEL

Individual)
Family)and)peers)
Ins1tu1onal)
Community)
Society)

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

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).

SUICIDES IN THE
UNITED STATES
5.000

4,395,480
suicide survivors

3.750
2.500

732,580
deaths by suicide

1.250
0.000

1977 1980 1983 1986 1989 1992 1995 1998 2001 2004 2007

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

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

GROUND RULES
Listen respectfullyrespect 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.

Introduction To
QPR Training

QPR
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 everybodys 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.

QPR TRAINING
Respond 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

QPR THEORY
Assumption: Passive systems dont 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

QPR CHAIN OF SURVIVAL

KNOWLEDGE + 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

QPR CHAIN OF SURVIVAL

1.
2.

3.

4.

Early recognition of suicide warning signs: The sooner warning

signs are detected, the sooner an intervention can be initiated
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.
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.
Early professional assessment and treatment: As with any lifethreatening crisis or illness, early detection, assessment and
treatment results in reduced morbidity and mortality.

IF OVERWHELMED BY
LIFE I WOULD
Strongly
agree or
agree with
-->

Would talk Believe

to counselor counselor
could help

Reported 20%
suicide
attempt
None
38%

Friends
would want
me to talk to
adult

Family
would want
me to talk to
adult

25%

35%

36%

47%

45%

53%

Q
Researchers 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?

Q
The 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 dont 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.

Q: SUICIDE WARNING
SIGN
!
A suicide warning sign is the earliest
detectable sign that indicates
heightened risk for suicide in the nearterm (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.

IMMEDIATE
SIGNS

NON-IMMEDIATE
SIGNS

Threatening to kill/hurt themselves

Hopelessness

Someone looking for ways to kill

themselves

Rage, anger, seeking revenge

Acting reckless

Talking or writing about death, dying, or

suicide

Feeling trapped

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

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
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.

direct verbal clues

behavioral clues

Ive decided to kill myself.

I wish I were dead.

Any previous suicide attempt

Im going to commit suicide.

Im going to end it all.

Co-occurring depression, moodiness,

hopelessness

If (such and such) doesnt happen, Ill kill

myself.

Putting personal affairs in order

Im tired of life, I just cant go on.

My family would be better off without
me.

Sudden interest or disinterest in religion

Who cares if Im dead anyway.

I just want out.
I wont be around much longer.
Pretty soon you wont have to worry
about
me.

Acquiring a gun or stockpiling pills

Giving away prized possessions

Drug or alcohol abuse, or relapse after a
period of recovery
Unexplained anger, aggression and
irritability

situational clues

situational clues in
a residential setting

Being fired or being expelled from school

A recent unwanted move
Loss of any major relationship

Feeling embarrassed or humiliated in a

group session

Death of a spouse, child, or best friend,

especially if by suicide

Being the victim of another patients

assaults or bullying

Diagnosis of a serious or terminal illness

Being informed that their parents are

getting a divorce

Sudden unexpected loss of freedom/fear

of punishment
Anticipated loss of financial security

Finding out that their parents do not

want them to come back home

Loss of a cherished therapist, counselor or

teacher

Becoming aware of a financial crisis in

the family

Fear of becoming a burden to others

Gatekeeper does Gatekeeper

not respond
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.

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.

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?

Q: FEAR-INDUCING STATEMENTS
In 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 wouldnt 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 dont talk about suicide in this
house! The boy died with a gunshot wound to the
head one week later.

Q: INDIRECT VERBAL
STATEMENTS
The following list of reasons was
given by participants for issuing
an indirect verbal statement
instead of a direct one:

Id want to see if anyone was listening.

Id want the person I told to care about
me enough to ask what I meant.
If they didnt understand what I just
threatened to do, perhaps they dont
really care.
I wouldnt tell anyone who I thought
couldnt rescue me, provided I wanted to
be saved.
If I wasnt sure I really wanted to die, Id
want to be able to later deny what Id
said.
I know Ive been a big problem for
them, so I wouldnt 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 rescuers
willingness and ability to
intervene; in which case the
equivocal statement
becomes a test of
commitment, confidence,
caring or trust

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 unresponded-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.
!

INDIRECT VERBAL
STATEMENTS
Use clarifying questions: ex. What do you mean?
whats 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.
!

But when do I know that what someone says

might be a suicidal communication?
Intuition is more trustworthy than
rational thinking, and it is always correct
in two important ways:

These descriptions of emotional

reactions are often used un the
diagnostic workup of a symptomatic
!
patient in clear distress. Many of
1. It is always in response to something
these feelings were reported to have
2. It always has your best interest at heart
occurred in responses to thing the
!
deceased said or did prior to a fatal
suicide attempt. In short, the preFear is far quicker and more powerful than
logic, and a failure to trust the experience of it
suicide warning signs triggered a
can lead to tragic outcomes. In order of
negative emotional response in
importance, the top seven in his list of 13
the recipient.
Messengers of Intuition, are these:

Hunches
Gut feelings
Doubt
Hesitation
Suspicion
Apprehension
Fear

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.

Q: Asking The Question

When in doubt, ask the question.
Dont 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?
Id like to talk to you a
minute, Im really worried, you
seem like youre a little down.
Could we talk about that? Im
here to help.

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
!

Q: DONT MINIMIZE
When talking to a person you think might be suicidal, its
critical not to dismiss what theyre saying. While this
makes sense, we might minimize a persons pain without
even realizing it.

!
For instance, in a training example, if the person says,
My life is so terrible right now, its usually met with
reactions like Oh, its not that bad or I know youd
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 persons feelings and experiences. And
both slam the door on communication.

The person most likely to prevent you from taking

your own life is someone you already know.

P
Persuading 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 persons 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.

P: TIMING = SUCCESS
A 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 sufferers
perception of being a burden on others.

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

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 arent safe, I will have to tell somebody.

P
Included 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 ones own
problems without assistance

P: TIMING = SUCCESS
Goal 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.

LIABILITY

R
Make 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.

R
Where 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

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.

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
Im on your side
Well 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.

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.

R
Clearly, 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.

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: stefanie_kaufman@brown.edu

Project LETS meets every Friday at 4:30 in

the Sarah Doyle First Floor Lounge!
!

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