John Kennedy Toole: Recognizing the Person At Risk Of Suicide

1. John Kennedy Toole: Recognizing the Person At Risk Of Suicide 34th Annual I&R Training and Education Conference New Orleans, Louisiana Monday, May 21, 2012 3:15pm - 4:45pm John Plonski – Facilitator Director of Online Supervisors IMAlive National Hopeline Network jpnysairs@gmail.com Paper-free Workshop

2. Opening questions … What is your agency’s policy addressing the issue of suicide? Should we talk about suicide? Should we ask about suicide? Can we help the person at risk? How many people do you know whose lives have been by pandemic flu? Suicide?

3. In 2008 the population of the United States was 303,597,646. Of that number it is safe to say that the majority of the population… Likes Sports!

4. Reported deaths from suicide in 2008 was 36,035 For comparison the capacity of the new Marlins Park is 36,742 It is estimated that deaths from unreported suicides is 5% (37,837) to 25% (45,044)higher Oriole Park at Camden Yards seats 45,971 Boston’s Fenway Park seats 37,493

5. Reported suicides + Unreported Suicides = 81,078 (estimated) (By comparison the Mercedes-Benz Superdome seats 76,468)

6. It is estimated that, at any given time, 5% of the population (15,179,882People) have thoughts of suicide placing them at risk. From 2008 through 2011, 15,772,600 Race Fans attended NASCAR Sprint Cup Races

7. These numbers tell us that it is very possible we may interact with a person at risk of death by suicide. They also tell us something else.

8. The numbers not only tell us that the chances are great that we may encounter a person at risk of suicide but that there may be some of us whose lives have been affected by the suicide of another or we ourselves may have been at risk. With that in mind realize that there is help out there for us. The same skills we will talk about today are the same skills that a person can use to help any of us through the events that may place us at risk. Don’t keep a deadly secret. Please, be good to yourselves and reach out.

9. In 1999 the Surgeon General issued The Call to Action to Prevent Suicide. The Call to Action recommended: • Suicide be viewed in epidemiological terms as a major preventable cause of death, affecting gender, age, and ethnic groups in different ways. • Suggested the same preventive approach public health officials take to address disease and mental disorders. • Enhanced public awareness of risk factors for suicide. • Expanded mental health and drug rehabilitation services for those at risk. • The scientific study of suicide prevention.

10. Some general observations about persons at risk of suicide: • Death resulting from suicide is preventable through appropriate and timely intervention. • A suicidal person like any person in crisis • is faced with an intolerable life issue for • which they are seeking a solution. • The suicidal activity is not, in itself, a • crisis. In essence it is a maladaptive • coping response.

11. Additional observations when working with the person at risk of suicide: • Suicidal activity is both a means for resolving a situation and a method of communicating the intense feelings of hopelessness, helplessness and pain surrounding it . . . A cry for help • If you suspect a person is considering suicide, ask them in a direct manner. • The person at risk of suicide will seldom self identify. However they will offer hints or clues about their intention through their Thoughts, Feelings, and Behaviors.

12. It can be difficult to identify the person at risk of suicide. • As a society we are generally suicide denying. • We see suicide as something a person shouldn’t do. • Some may see the act as a weakness. • Some may cite religious or legal reasons forbidding the act. • In any case there exists a societal taboo • and stigma making it difficult for the person • at risk to state their intention openly.

13. This means the we will need to be aware of clues a person may be at risk. • Nearly everyone at some time in their • lives thinks about suicide. • Most decide to live because they come to realize that the situation is temporary but death isn’t. • Some will openly state their wish to die. • However, most offer hints and clues as to their intent hoping the listener will hear and interpret them, listen and provide help.

14. Direct Hints can be clues. • “I just can’t take it anymore”, • “I want to escape”, • “I want to go to sleep forever”, • “They’ll be sorry when I’m gone.” • “I can’t stand this pain anymore.” • “Nothing will ever get better,” • “My family would be better off if I were not around”

15. People will send hints by their Thoughts. • Escape/No escape • No future • Guilt • Loneliness • Being damaged • Helplessness • Preoccupation with talk of suicide/death • Planning for suicide

16. People at risk Feel they can’t... • Stop the pain • Make decisions • See any way out • Sleep, eat, or work • Get out of the depression • Make the sadness go away • See a future without pain • See themselves as worthwhile • Seem to get control

17. People will send hints by through their Feelings. • Desperation • Anger • Sadness • Shame • Worthlessness • Loneliness • Disconnection • Hopelessness • Unbearable Pain The intensity or long duration of painful feelings raise the volume of the hint.

18. Behaviors can be hints or clues • Crying • Emotional outbursts • Alcohol/drug misuse • Recklessness • Fighting/law breaking • Withdrawal • Dropping out • Prior suicidal behavior • Putting affairs in order • Recent suicide attempt • Inability to think clearly

19. More Behavioral Clues • Trouble eating or sleeping • Withdrawal from friends and/or social activities • Loss of interest in hobbies, work, school, etc. • Writing a will and making final arrangements • Giving away prized possessions • Preoccupation with death and dying • Loss interest in personal appearance • Increase use of alcohol or drugs • Unnecessary risk taking

20. People will send clues by discussing their situations. • Losses – actual, perceived, or threatened • Relationship problems • Work problems/Failing grades • Trouble with the law • Family disruptions • Sexual or physical abuse • Recently publicized suicide/violence

21. Some other situations which serve as hints. • Death of a significant other (this can include an idol, role model, or a pet), • Breakup of a relationship, divorce or separation, • Loss of a job or housing. • Onset of illness for either the person or a significant other

22. Some more situational clues. • Anniversary of a loss • Move to a new area • Situation where a guardian is absent • Onset of physical or emotional disabilities • Successful resolution of past difficulties

23. The person’s discussion of Risk can be a clue. • Serious planning? • Active preparations? • Earlier self-harm? • What is stopping them?

24. Physical Changes can also be an Invitation. • Lack of interest/pleasure in all things • Lack of physical energy • Disturbed sleep • Loss of sexual interest • Loss of appetite • Increase in minor illnesses

25. The person’s manner of presentation can be a hint. • Very soft or loud voice • A voice that sounds weak or drained of energy • Long pauses between words or thoughts • Deep sighs • Depressed sounding voice • Speaking in an agitated manner

26. Our goal in working with the person at risk of suicide is twofold: 1. To assist them in focusing on the issue thus enabling them to communicate their feelings verbally instead of behaviorally; 2. To explore more adaptive resolutions to the precipitating issue presented.

27. There are 3 tasks involved in • assisting the person at risk: • 1. Establishing a relationship (Connecting/Questioning) • Evaluating the suicidal potential • (Understanding/Persuading) • 3. Formulating a plan and mobilizing Resources (Assisting/Referring)

28. Comparing the 5 Step I&R Process to Suicide Intervention

29. Establishing A Relationship • Bring the issue of suicide up for open • discussion. • If the person shares anything that gives • you the impression they are suicidal ask them, “Are you feeling suicidal?” • Be accepting, respectful, and empathic. • Present yourself as being patient, interested, self-assured, and knowledgeable. • Stay calm and sound confident Connecting/Questioning

30. Evaluation of Suicide Potential • Listen for, indicate, and support • any messages from the person at • risk that reflects a reluctance to die (ambivalence). • The Worker needs to make an evaluation of the seriousness of the person at risk’s suicidal intent. • This evaluation will determine the best plan of intervention: Calling an ambulance; Engaging significant others; A referral to a mental health agency, etc. Understanding/Persuading

31. Evaluation of Suicide Potential • A person’s degree of risk can be • accurately determined reviewing • the person at risk’s Risk Factors: • Current Plan • Pain • Resources • Prior Suicidal Behavior • Psychiatric History • Let’s look at each assessment criterion individually. Understanding/Persuading

32. Current Suicide Plan • The inherent lethality of the proposed • method; “How do you plan to kill • yourself?” • The availability of the means; “Where is the weapon, drugs or other implement that you plan to use?” • The specificity of the plan; “What have you done to prepare to die?” • The time frame of the plan; “When do you plan to die?” Understanding/Persuading

33. Assessing Pain Suicide is a maladaptive coping mechanism intended to relieve the pain of the hopelessness and helplessness precipitated by crisis. To assess that pain we need to ask; “Do you have pain that at time feels unbearable?” Understanding/Persuading

34. Assessing Resources • Internal; “What have you done to change things before you decided to attempt suicide? Do you think any of those things may work now?” • External; “Who have you talked to about what is going on for you? Is there anybody else you might consider?” • Communication with their external • resources; “Have you been able to talk • with people who have helped you in the • past?” Or “How do you get along with • people who have helped you in the past?” Understanding/Persuading

35. Prior Suicidal Behavior • Have there been previous attempts; “Have you attempted suicide before?” • The previous method; “What were your previous attempts?” • History of attempts by significant others; • “Has anybody you know attempted suicide?” • Response and treatment; “Following your • previous attempts did you get help? How • did that work out for you?” Understanding/Persuading

36. Psychiatric History A mental health history can be a contributing factor in a person at risks suicidal ideation. “Are you receiving or have you received mental health care?” Understanding/Persuading

37. Formulating a Plan and Mobilizing Resources Anytime a person says they are thinking about suicide, regardless of the level of risk, the worker will develop a Safeplan with the client. • All Safeplans include: • Keep Safe • Safety Contacts • Addressing safe use of alcohol or drugs • Link to resources Assisting/Referring

38. Risk Specific Safeplans Current Suicide Plan: Disable the plan Pain: Ease the pain Resources: Link to resources Prior Suicidal Behavior: Protect against the current danger and support past survival skills Psychiatric History: Link to mental health worker Assisting/Referring

39. When working with the person at risk. • Don’t go it alone! • Don’t take responsibility for “saving” the caller. • Don’t debate whether suicide is right or wrong. • Don’t moralize or judge the person’s feelings or situation. • Don’t allow yourself to be sworn to secrecy. • Don’t minimize the person’s pain or situation. • Don’t avoid talking about suicide. s

40. More things to remember when working with the person at risk. • Avoid statements such as , “It could be worse”, “Don’t worry, things will get better.” • Don’t give advice • If you suspect a person is at risk ask them directly, “Are you feeling suicidal?” • Keep in mind that now is NOT the time to solve all of their problems. Now is the time to do something that allows the person at risk to keep safe.

41. Suicide: General thoughts • In interacting with the suicidal person we operate under the assumption that the person at risk is ambivalent about their decision to die. This bestows upon us the moral right and responsibility to attempt to intervene. • Make contact at a feeling level. • Be patient and listen carefully. • Listen for hints or clues to discuss suicide. • Identify and reflect the person at risk’s feelings.

42. Suicide: General thoughts • Let the person tell their story in their own words and time. Be patient. • Simply note any factual information about possible resources that the person may share. You can clarify the particulars once openness and trust are established. • Control your personal feelings of stress and anxiety by reflecting them to the person at risk (Parallel Process). • Avoid any sermons about suicide or policy.

43. John Kennedy Toole (December 17, 1937 – March 26, 1969) • Thelma Toole, mother, was a cultured, controlling woman involved her her son’s affairs for most of his life. She picked his friends and interests. Thelma has been described as a ostentatious, shrill, loud voiced, bossy, bragging woman • John Toole, father, was less involved in his son’s life and frequently complained about his lack of influence in his son’s life.

44. John Kennedy Toole (December 17, 1937 – March 26, 1969) • Excellent student. • Worked on school newspaper and was in the debate club. • Well received locally as a stage performer. • Enjoyed the French Quarter, albeit secretly as his mother viewed it as a place for low life individuals.

45. John Kennedy Toole (December 17, 1937 – March 26, 1969) • Received a full scholarship to Tulane at age 17 and graduated in 1958 • Woodrow Wilson Fellowship to Columbia University – Completed Masters in English Literature in one year. • In 1959 Assistant Professor of English at University of Southwestern Louisiana.

46. John Kennedy Toole (December 17, 1937 – March 26, 1969) • During this time friends noticed he became sullen and withdrawn when his Mother would visit. • Began to frequent country bars and drink beer. • 1960 offered a 3-year fellowship to the University of Washington – Seattle for a Ph.D. in Renaissance Literature which he left to teach at Hunter College and study at Columbia.

47. John Kennedy Toole (December 17, 1937 – March 26, 1969) • Developed apprehension about regarding the liberal views of his students. • Drafted into the Army in 1961 teaching English to Spanish speaking recruits in Puerto Rico. • Began to drink excessively. • A Marilyn Monroe fan devastated by her suicide

48. John Kennedy Toole (December 17, 1937 – March 26, 1969) • Became withdrawn following the death by suicide of fellow instructor who was gay. • Began working on what would become A Confederacy of Dunces. • Hardship discharge in 1963 to care for his father suffering from dementia

49. John Kennedy Toole (December 17, 1937 – March 26, 1969) • Begins teaching at Dominican College. • Several love relationships over the years end in rejection • Becomes severely depressed following the Kennedy assassination in 1963 • February 1964 completes A Confederacy of Dunces.

50. John Kennedy Toole (December 17, 1937 – March 26, 1969) • Dunces rejected several times by several publishers over the intervening years. • Becomes angry with Mother over her insistence he continue to see the book published. • Beginning in 1967 friends notice increased paranoiac behavior.